Hemostatic Efficacy and Safety of 4-Factor Prothrombin Complex Concentrate in Doac-Associated Intracranial Hemorrhage.

Background: Factor Xa (FXa) inhibitor use has increased over the last decade and though associated rates of major bleeding are lower compared to warfarin, outcomes from intracranial hemorrhage (ICH) are still significant. Targeted FXa inhibitor reversal agent became available in 2018, however use of 4-factor prothrombin complex concentrate (4F-PCC) for FXa inhibitor-associated ICH continues at many institutions. Objective: Evaluate the safety and hemostatic efficacy of 4F-PCC for FXa inhibitor-associated ICH. Methods: Single-center, retrospective study of patients who received 4F-PCC for FXa inhibitor-associated ICH. The primary efficacy endpoint was hemostasis and thrombosis was the main safety endpoint. Secondary endpoints included in-hospital mortality and discharge disposition. Results: 76 patients on apixaban or rivaroxaban were included. Good or excellent hemostasis was achieved in 80.3% of patients. Five patients experienced a thrombotic event. Favorable discharge disposition and lower in-hospital mortality was more likely in patients who achieved excellent hemostasis. Conclusion: 4F-PCC is safe and effective for FXa inhibitor associated ICH.

Prevalence and Health Outcomes of Clostridioides difficile Infection During the Coronavirus Disease 2019 Pandemic in a National Sample of United States Hospital Systems.

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented emphasis on infection control procedures; however, it is unknown whether the pandemic altered Clostridioides difficile infection (CDI) prevalence. This study investigated CDI prevalence before and during the COVID-19 pandemic in a national sample of United States (US) hospitals. Methods: This was a retrospective cohort study using the Premier Healthcare Database. Patients with laboratory-confirmed CDI from April 2019 through March 2020 (pre-COVID-19 period) and April 2020 through March 2021 (COVID-19 period) were included. CDI prevalence (CDI encounters per 10 000 total encounters) and inpatient outcomes (eg, mortality, hospital length of stay) were compared between pre-COVID-19 and COVID-19 periods using bivariable analyses or interrupted time series analysis. Results: A total of 25 992 CDI encounters were included representing 22 130 unique CDI patients. CDI prevalence decreased from the pre-COVID-19 to COVID-19 period (12.2 per 10 000 vs 8.9 per 10 000, P < .0001), driven by a reduction in inpatient CDI prevalence (57.8 per 10 000 vs 49.4 per 10 000, P < .0001); however, the rate ratio did not significantly change over time (RR, 1.04 [95% confidence interval, .90-1.20]). From the pre-COVID-19 to COVID-19 period, CDI patients experienced higher inpatient mortality (5.5% vs 7.4%, P < .0001) and higher median encounter cost ($10 832 vs $12 862, P < .0001). Conclusions: CDI prevalence decreased during the COVID-19 pandemic in a national US sample, though at a rate similar to prior to the pandemic. CDI patients had higher inpatient mortality and encounter costs during the pandemic.

Clostridioides difficile Infection Treatment and Outcome Disparities in a National Sample of United States Hospitals.

Clostridioides difficile infection (CDI) disproportionately affects certain populations, but few studies have investigated health outcome disparities among patients with CDI. This study aimed to characterize CDI treatment and health outcomes among patients by age group, sex, race, and ethnicity. This was a nationally representative, retrospective cohort study of patients with laboratory-confirmed CDI within the Premier Healthcare Database from January 2018 to March 2021. CDI therapies received and health outcomes were compared between patients by age group, sex, race, and Hispanic ethnicity using bivariable and multivariable statistical analyses. A total of 45,331 CDI encounters were included for analysis: 38,764 index encounters and 6567 recurrent encounters. CDI treatment patterns, especially oral vancomycin use, varied predominantly by age group. Older adult (65+ years), male, Black, and Hispanic patients incurred the highest treatment-related costs and were at greatest risk for severe CDI. Male sex was an independent predictor of in-hospital mortality (aOR 1.17, 95% CI 1.05−1.31). Male sex (aOR 1.25, 95% CI 1.18−1.32) and Black race (aOR 1.29, 95% CI 1.19−1.41) were independent predictors of hospital length of stay >7 days in index encounters. In this nationally representative study, CDI treatment and outcome disparities were noted by age group, sex, and race.

National Disparities in Antibiotic Prescribing by Race, Ethnicity, Age Group, and Sex in United States Ambulatory Care Visits, 2009 to 2016.

While efforts have been made in the United States (US) to optimize antimicrobial use, few studies have explored antibiotic prescribing disparities that may drive future interventions. The objective of this study was to evaluate disparities in antibiotic prescribing among US ambulatory care visits by patient subgroups. This was a retrospective, cross-sectional study utilizing the National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was described as antibiotic visits per 1000 total patient visits. The appropriateness of antibiotic prescribing was determined by ICD-9 or ICD-10 codes assigned during the visit. Subgroup analyses were conducted by patient race, ethnicity, age group, and sex. Over 7.0 billion patient visits were included; 11.3% included an antibiotic prescription. Overall and inappropriate antibiotic prescription rates were highest in Black (122.2 and 78.0 per 1000) and Hispanic patients (138.6 and 79.8 per 1000). Additionally, overall antibiotic prescription rates were highest in patients less than 18 years (169.6 per 1000) and female patients (114.1 per 1000), while inappropriate antibiotic prescription rates were highest in patients 18 to 64 years (66.0 per 1000) and in males (64.8 per 1000). In this nationally representative study, antibiotic prescribing disparities were found by patient race, ethnicity, age group, and sex.

Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016.

BACKGROUND/OBJECTIVES: With an aging population suffering from increased prevalence of chronic conditions in the United States (U.S.), a large portion of these patients are on multiple medications. High-risk medications can increase the risk for drug-drug interactions and medication nonadherence. This study aims to describe the prevalence of polypharmacy and high-risk medication prescribing in U.S. physician offices. METHODS: This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. All patients over 65 years old were included. Polypharmacy was categorized as no polypharmacy (< 2 medications), minor polypharmacy (2-3 medications), moderate polypharmacy (4-5 medications), and major polypharmacy (>5 medications). Medications were further categorized into high-risk medication categories (anticholinergics, cardiovascular agents, central nervous system (CNS) medications, pain medications, and other). Comparisons between the degrees of polypharmacy were performed utilizing chi-square or Wilcoxon rank-sum tests with JMP Pro 14® (SAS Institute, Cary, NC). RESULTS: Over 2 billion patient visits were included. Overall, Polypharmacy was common (65.1%): minor polypharmacy (16.2%), moderate polypharmacy (12.1%), and major polypharmacy (36.8%). Patients with major polypharmacy were older compared to those with moderate or minor polypharmacy (75 vs. 73 years, respectively) and were most frequently prescribed pain medications (477.3 per 1,000 total visits). NSAIDs were the most frequently prescribed, with 232.4 per 1,000 total visits resulting in one high-risk NSAID prescription, while 21.9 per 1,000 total visits resulted in two or more high-risk NSAIDs. CONCLUSION: Most patients over 65 years experienced some degree of polypharmacy, with many experiencing major polypharmacy. This indicates an increased need for expanded pharmacist roles through medication therapy management and safety monitoring in this patient population.

National Prevalence of Influenza Diagnoses and Vaccination Rates Among Patients Presenting to United States Physician Offices and Hospital Outpatient Departments, 2009 to 2016.

BACKGROUND: Influenza health resource utilization studies are important to inform future public health policies and prevent outbreaks. This study aimed to describe influenza prevalence, vaccination, and treatment among outpatients in the United States and to evaluate population-level characteristics associated with influenza health resource utilization. METHODS: Data were extracted from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (2009 to 2016). Prevalence rates were described as influenza visits (defined by International Classification of Diseases, Ninth Revision, Clinical Modification or International Classification of Diseases, Tenth Revision code) per 1000 total visits overall and by flu year, month, region, race, and age group. Influenza vaccination and antiviral treatments were identified by Multum code(s) and presented as vaccination visits per 1000 total visits and the percentage of patients diagnosed with influenza receiving antiviral treatment. RESULTS: In more than 19.2 million patient visits, an influenza diagnosis was made with rates ranging from 1.2 per 1000 during 2014-2015 to 3.7 per 1000 during 2009-2010. Rates were highest in the South (3.6 per 1000), in December (5.2), among black patients (2.8), and those less than 18 years (6.8). Vaccination rates were highest during 2014-2015 (29.3 per 1000) and lowest during 2011-2012 (15.5 per 1000), in the West (23.4), in October (69.2), among "other race" patients (26.2), and age less than 18 years (51.4). Overall, 39.4% of patients with an influenza diagnosis received an antiviral. CONCLUSIONS: Overall, there were no major changes in influenza diagnosis or vaccination rates. Patient populations with lower vaccination rates had higher influenza diagnosis rates. Future campaigns should promote influenza vaccinations particularly in underserved populations.

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016.

BACKGROUND: Prior studies have found that outpatient antibiotics are commonly prescribed for non-bacterial conditions. It is unclear if national prescribing has changed in recent years given recent public health and antimicrobial stewardship initiatives. This study aimed to describe antibiotic prescribing in United States (U.S.) physician offices. MATERIALS/METHODS: This was a cross-sectional study of all sampled patient visits in the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was defined as at least one oral antibiotic prescription during the visit as identified by Multum code(s). Patient visits were categorized by U.S. geographic region and season. ICD-9-CM and ICD-10 codes were used to assess diagnoses and categorize antibiotic use as appropriate, possibly appropriate, or inappropriate. RESULTS: Seven billion visits were included for analysis, with 793,415,182 (11.3%) including an antibiotic. Prescribing rates were relatively stable over the study period (102.9-124.9 prescriptions per 1000 visits); however, 2016 had one of the lowest prescribing rates (107.7 per 1000 visits). The most commonly prescribed antibiotic class was macrolides (25 per 1000 visits). The South region and winter season had the highest antibiotic prescribing (118.2 and 129.7 per 1000 visits, respectively). Of patients who received an antibiotic, 55.9%, 35.7%, and 8.4% were classified as inappropriate, possibly appropriate, and appropriate, respectively. The most common conditions in which antibiotics were prescribed inappropriately included those with no indication in any of the predefined diagnosis codes (40.1%), other skin conditions (17.3%), and viral upper respiratory conditions (13.3%). CONCLUSIONS: There was no significant reduction in outpatient antibiotic prescribing rates among U.S. outpatients from 2009 to 2016 and prescribing varied by region and season. These data suggest that more than half of antibiotics were prescribed inappropriately, with the majority of antibiotics prescribed with no indication. However, these findings need to be confirmed with robust prospective studies.

GABAergic but not Antidepressant Medications Increase Risk for Clostridioides difficile Infection in a National Cohort of Veterans.

BACKGROUND: Clostridioides difficile infection (CDI) is primarily mediated by alterations in the host gut ecosystem. While antibiotic use is the primary risk factor for CDI, other medications that modulate the gut ecosystem, particularly those targeting the gut-brain axis, could impact CDI risk. This study aimed to investigate the association between recent antidepressant and gamma-aminobutyric acid (GABA)-ergic medication use with CDI risk in a national cohort of United States veterans. METHODS: This was a retrospective case-control study of patients seen in Veterans Health Administration facilities from October 2002 to September 2014. CDI and non-CDI control patients were propensity score matched 1:1 using a maximum caliper of 0.0001. Antidepressant and GABAergic medication use 90 days before cohort inclusion were analyzed for CDI association using bivariable and multivariable logistic regression models. RESULTS: A total of 85 831 patients were included, and 9287 CDI and 9287 control patients were propensity score matched. Antidepressant use overall was not significantly associated with CDI risk (odds ratio [OR], 1.05; 95% CI, 0.98-1.12), although GABAergic medication use was associated with increased risk (OR, 1.81; 95% CI, 1.70-1.92). In multivariable models of individual medications/classes, benzodiazepines had the strongest CDI association (OR, 1.91; 95% CI, 1.77-2.07). SSRIs (OR, 0.88; 95% CI, 0.81-0.95) and bupropion (OR, 0.67; 95% CI, 0.57-0.78) were negatively associated with CDI. CONCLUSIONS: In this national study of veterans, GABAergic medication use was a positive predictor of CDI risk, though antidepressant use was not. Further research is needed to understand biological mechanisms, and confirmatory studies are needed to validate these findings.

Can oral health and oral-derived biospecimens predict progression of dementia?

Growing evidence indicates that oral health and brain health are interconnected. Declining cognition and dementia coincide with lack of self-preservation, including oral hygiene. The oral microbiota plays an important role in maintaining oral health. Emerging evidence suggests a link between oral dysbiosis and cognitive decline in patients with Alzheimer's disease. This review showcases the recent advances connecting oral health and cognitive function during aging and the potential utility of oral-derived biospecimens to inform on brain health. Collectively, experimental findings indicate that the connection between oral health and cognition cannot be underestimated; moreover, oral biospecimens are abundant and readily obtainable without invasive procedures, which may help inform on cognitive health.

A possible association between statin use and improved Clostridioides difficile infection mortality in veterans.

Clostridioides difficile infection (CDI) is the most common cause of nosocomial diarrhea and places a significant burden on patients and the health care system. Statins could lead to improvements in CDI clinical response due their pleiotropic effects, including immunomodulatory and lipid-lowering effects; however, few studies have assessed this association. The primary objective of this study was to compare CDI health outcomes in statin users and non-users in a national cohort of patients. This was a retrospective cohort study of all adult CDI patients receiving care from the Veterans Health Administration from 2002 to 2014. Patients were divided into two groups based on statin exposure 90 days prior to and during their first CDI encounter. CDI health outcomes, including mortality and CDI recurrence, were compared using a propensity-score matched cohort of statin users and non-users and multivariable logistic regression. A total of 26,149 patients met study inclusion criteria, of which 173 statins-users and 173 non-users were propensity score matched. Thirty-day mortality was significantly lower among statins users with CDI (12.7%) compared to non-users (20.2%) (aOR 0.34; 95% CI 0.16-0.72). Sixty-day CDI recurrence was non-significantly lower among statin-users (9.0%) compared to non-users (16.6%) (aOR 0.68; 95% CI 0.29-1.59). In this nationally-representative study of veterans with CDI, statin use was associated with lower 30-day mortality compared to non-use. Statin use was not associated with 60-day CDI recurrence.