Previous 90days Research Articles

1419. High Prevalence of Fluoroquinolone-Resistant Urinary Tract Infection Among US Emergency Department Patients Diagnosed with UTI, 2018-2020

BackgroundUropathogen resistance, Fluoroquinolone-resistance (FQR) and Extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. We sought to determine recent resistance prevalence from a geographically diverse sample of US Emergency Departments (ED).MethodsWe conducted a multi-center, observational cohort study utilizing a network of 15 geographically diverse US EDs. Patients ≥ 18 years of age with the primary international classification of diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or urinary tract infection (UTI) and were discharged home from the ED from 2018-2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with fluoroquinolone (FQ)-resistant Escherichia coli. ResultsAmong 3,779 patients who met inclusion criteria, median age was 62.9 years (IQR: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (40.9%) and uncomplicated cystitis (39.4%). Six hundred and forty-five (17%) patients reported receiving antimicrobials in the previous 90-days. E. coli was the most common pathogen (62.9%), followed by Klebsiella pneumoniae (13%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 4.4%, ranging from 2.3% to 8.6% by site. Previous IV or oral antimicrobial use in the last 90-days and complicated vs. uncomplicated UTI were associated with FQ-resistant E. coli (OR 1.69, 95% CI: 1.33-2.14, and OR 1.60, 95% CI: 1.26-2.02, respectively). Of the most prescribed oral antibiotics upon patients discharged from the ED, E. coli resistance to nitrofurantoin and cephalexin was 1.8% and 0.9%, respectively.ConclusionFQ-resistant E. coli is widely prevalent and ESBL-mediated resistance appears to be emerging across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments. Disclosures Brett Faine, PharmD, Spero Therapeutics (Research Grant or Support) Megan A. Rech, PharmD, MS, BCCCP, FCCM, Spero (Research Grant or Support) David A. Talan, MD, AbbVie (Consultant)GSK (Consultant)SPERO Therapeutics (Grant/Research Support)

Spontaneous rupture of middle fossa arachnoid cysts: surgical series from a single center pediatric hospital and literature review.

Arachnoid cysts may present with symptoms deriving from cyst rupture, usually causing intracystic hemorrhage and subdural hematoma or hygroma. Rupture is usually caused by minor trauma, spontaneous rupture is an exceptional event, and 57 cases have been described in literature. We here present and discuss the largest series of spontaneously ruptured middle fossa arachnoid cysts in order to investigate clinical presentation and best treatment available. We report a retrospective series of 17 pediatric patients surgically treated for middle fossa arachnoid cyst with signs of cyst rupture without a history of trauma in the previous 90days. We describe clinical presentation, treatment, and outcome at follow-up discussing our results with a literature review including all reported cases of spontaneous rupture of middle fossa arachnoid cysts. In our experience patients most frequently presented with subdural hygroma, in literature, a chronic hematoma was most frequently reported. Headache is the most reported symptom at presentation. Neurological deficits and consciousness alterations are rare. Surgical treatment may resolve brain compression only or reduce rupture recurrence risk. Conservative treatment has also been proposed. Different treatments are reported and discussed focusing on indications, contraindications, risks, and expected benefits. We propose, when safely possible, microsurgical cyst fenestration in skull base cisterns as the treatment of choice for these patients as long as it addresses both immediate decompression and risk of rupture recurrence. We report good outcomes and low incidence of complications from our series with a mean postoperative follow-up of 30months.

Device-detected congestion is associated with worse patient-reported outcomes in heart failure

BackgroundCongestion is a common cause of symptoms in heart failure (HF). Yet, intrathoracic impedance, an objective marker of cardiopulmonary congestion, has not been examined in relation to HF symptoms. ObjectiveTo determine whether device-detected cardiopulmonary congestion is a predictor of physical and psychological symptoms and health-related quality of life (HRQOL) in adults with HF over 3 months. MethodsMultivariate generalized linear modeling was used to quantify the association of cardiopulmonary congestion (Optivol® Index exceeding 60 Ω threshold) with HRQOL (12-item Kansas City Cardiomyopathy Questionnaire) and both physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early & Subtle Symptoms subscales) and affective symptoms (9-item Patient Health Questionnaire; 6-item Patient-Reported Outcomes Measurement Information System Anxiety Scale). ResultsThe mean age of the sample (n = 49) was 62years old, 39% were women, and 63% had NYHA class III/IV HF. Participants who experienced threshold crossings in the previous 90days reported on average, 130% higher dyspnea (p = 0.017; confidence interval (CI) 10.2%, 437%), 40% higher early & subtle symptoms (p = 0.029; CI 3.4%, 89.7%), 106% higher depressive symptoms (p = 0.003; CI 19.1%, 257%) and 40% higher anxiety (p = 0.028; CI 3.7%, 89.1%). Threshold crossings in the previous 90days were also significantly associated with a clinically meaningful decrease in HRQOL (β = −16.16 ± 6.32; p = 0.01). ConclusionsIntrathoracic impedance measured with the Optivol Index can provide additional information regarding the patient experience of hallmark physical and psychological HF symptoms and HRQOL over 3months.

Associations between the smoking-relatedness of a cancer type, cessation attitudes and beliefs, and future abstinence among recent quitters.

Smoking after a diagnosis of cancer can negatively impact treatment outcomes and quality of life. It is important that patients quit smoking and remain abstinent regardless of cancer type. Some cancer types (eg, lung) have stronger links to smoking as a cause than do others (eg, colorectal). The aims of this study were to (1) assess associations between smoking-relatedness of the cancer type with beliefs and attitudes concerning smoking abstinence (eg, confidence, self-efficacy), and (2) assess these variables as predictors of future abstinence. In this secondary analysis, cancer patients (N=357) who quit smoking within the previous 90days were assigned a code of 3, 2, or 1 according to the cancer type's level of smoking-relatedness: Very related (n=134, thoracic and head and neck), Somewhat related (n=93, acute myeloid leukemia, bladder, cervix, colorectal, esophageal, kidney, liver, pancreas, and stomach), and Unlikely related (n=137, all other cancer types). Smoking-relatedness was positively associated with plan to stay smoke-free, maximum confidence in being smoke-free in 6months, higher abstinence self-efficacy, and lower expected difficulty in staying smoke-free. Each of the 4 beliefs and attitude variables predicted abstinence 2months later. Smoking-relatedness also predicted abstinence in a univariate model, but not in a multivariable model with the belief and attitude variables. Using backwards stepwise procedures, the final model included plan to stay smoke-free, confidence in being smoke-free, and abstinence self-efficacy. These results are consistent with our conceptualization of cessation motivation differing by smoking-relatedness of the cancer type and predicting future abstinence.

Clinical predictors of methicillin-resistant Staphylococcus aureus in nosocomial and healthcare-associated pneumonia: a multicenter, matched case-control study.

The situations in which coverage for methicillin-resistant Staphylococcus aureus (MRSA) in the empirical treatment of nosocomial pneumonia (NP) or severe healthcare-associated pneumonia (HCAP) is needed are poorly defined, particularly outside intensive care units (ICUs). Our aim was to characterize if the risk of MRSA NP/HCAP can be defined by clinical variables. We designed an observational, retrospective, multicenter, case-control study to analyze the association between defined clinical variables and risk of MRSA NP/HCAP in non-ICU patients using conditional multivariable logistic regression. Cases and controls (1:2) with microbiological diagnosis were included. Controls were matched for hospital, type of pneumonia (NP or HCAP), and date of isolation. A total of 140 cases (77 NP and 63 HCAP) and 280 controls were studied. The variables associated with the risk of MRSA pneumonia were: (i) respiratory infection/colonization caused by MRSA in the previous year [odds ratio (OR) 14.81, 95% confidence interval (CI) 4.13-53.13, p<0.001]; (ii) hospitalization in the previous 90days (OR 2.41, 95% CI 1.21-4.81, p=0.012); and (iii) age (OR 1.02, 95% CI 1.001-1.05, p=0.040). The area under the receiver operating characteristic (ROC) curve for the multivariable model was 0.72 (95% CI 0.66-0.78). The multivariate model had a sensitivity of 74.5% (95% CI 65.3-83.6), a specificity of 63.3% (95% CI 56.0-70.6), a positive predictive value of 52.5% (95% CI 43.9-61.2), and a negative predictive value of 82.0% (95% CI 75.3-88.8) for the observed data. Clinical predictors of MRSA NP/HCAP can be used to define a low-risk population in whom coverage against MRSA may not be needed.

A comprehensively quantitative method of evaluating the impact of drought on crop yield using daily multi-scale SPEI and crop growth process model.

The quantitative evaluation of the impact of drought on crop yield is one of the most important aspects in agricultural water resource management. To assess the impact of drought on wheat yield, the Environmental Policy Integrated Climate (EPIC) crop growth model and daily Standardized Precipitation Evapotranspiration Index (SPEI), which is based on daily meteorological data, are adopted in the Huang Huai Hai Plain. The winter wheat crop yields are estimated at 28 stations, after calibrating the cultivar coefficients based on the experimental site data, and SPEI data was taken 11 times across the growth season from 1981 to 2010. The relationship between estimated yield and multi-scale SPEI were analyzed. The optimum time scale SPEI to monitor drought during the crop growth period was determined. The reference yield was determined by averaging the yields from numerous non-drought years. From this data, we propose a comprehensive quantitative method which can be used to predict the impact of drought on wheat yields by combining the daily multi-scale SPEI and crop growth process model. This method was tested in the Huang Huai Hai Plain. The results suggested that estimation of calibrated EPIC was a good predictor of crop yield in the Huang Huai Hai Plain, with lower RMSE (15.4%) between estimated yield and observed yield at six agrometeorological stations. The soil moisture at planting time was affected by the precipitation and evapotranspiration during the previous 90days (about 3months) in the Huang Huai Hai Plain. SPEIG90 was adopted as the optimum time scale SPEI to identify the drought and non-drought years, and identified a drought year in 2000. The water deficit in the year 2000 was significant, and the rate of crop yield reduction did not completely correspond with the volume of water deficit. Our proposed comprehensive method which quantitatively evaluates the impact of drought on crop yield is reliable. The results of this study further our understanding why the adoption of counter measures against drought is important and direct farmers to choose drought-resistant crops.

Nursing home-acquired pneumonia presenting at the emergency department.

Nursing home-acquired pneumonia (NHAP) is one of the most common infections arising amongst nursing home residents, and its incidence is expected to increase as population ages. The NHAP recommendation for empiric broad-spectrum antibiotic therapy, arising from the concept of healthcare-associated pneumonia, has been challenged by recent studies reporting low rates of multidrug-resistant (MDR) bacteria. This single center study analyzes the results of NHAP patients admitted through the Emergency Department (ED) at a tertiary center during the year 2010. There were 116 cases, male gender corresponded to 34.5% of patients and median age was 84years old (IQR 77-90). Comorbidities were present in 69.8% of cases and 48.3% of patients had used healthcare services during the previous 90days. In-hospital mortality rate was 46.6% and median length-of-stay was 9days. Severity assessment at the Emergency Department provided CURB65 index score and respective mortality (%) results: zero: n=0; one: n=7 (0%); two: n=18 (38.9%); three: n=26 (38.5%); four: n=30 (53.3%); and five; n=22 (68.2%); and sepsis n=50 (34.0%), severe sepsis n=43 (48.8%) and septic shock n=22 (72.7%). Significant risk factors for in-hospital mortality in multivariate analysis were polypnea (p=0.001), age≥75years (p=0.02), and severe sepsis or shock (p=0.03) at the ED. Microbiological testing in 78.4% of cases was positive in 15.4% (n=15): methicillin-resistant Staphylococcus aureus (26.7%), Pseudomonas aeruginosa (20.0%), S. pneumoniae (13.3%), Escherichia coli (13.3%), others (26.7%); the rate of MDR bacteria was 53.3%. This study reveals high rates of mortality and MDR bacteria among NHAP hospital admissions supporting the use of empirical broad-spectrum antibiotic therapy in these patients.

Arsenic and ultraviolet radiation exposure: melanoma in a New Mexico non-Hispanic white population.

Cases of cutaneous melanoma and controls were enrolled in a New Mexico population-based study; subjects were administered questionnaires concerning ultraviolet (UV) and inorganic arsenic (iAs) exposure. Historical iAs exposure was estimated. UV exposure estimates were also derived using geospatial methods. Drinking water samples were collected for iAs analysis. Blood samples were collected for DNA repair (Comet) and DNA repair gene polymorphism assays. Arsenic concentrations were determined in urine and toenail samples. UV exposures during the previous 90days did not vary significantly between cases and controls. Mean (±SD) current home iAs drinking water was not significantly different for cases and controls [3.98μg/L (±3.67) vs. 3.47μg/L (±2.40)]. iAs exposure showed no effect on DNA repair or association with melanoma. Results did not corroborate a previously reported association between toenail As and melanoma risk. Arsenic biomarkers in urine and toenail were highly significantly correlated with iAs in drinking water. A UV-DNA repair interaction for UV exposure over the previous 7-90days was shown; cases had higher DNA damage than controls at low UV values. This novel finding suggests that melanoma cases may be more sensitive to low-level UV exposure than are controls. A UV-APEX1 interaction was shown. Subjects with the homozygous rare APEX1 DNA repair gene allele had a higher risk of early melanoma diagnosis at low UV exposure compared with those with the homozygous wild type or the heterozygote. Notably, a UV-arsenic interaction on inhibition of DNA repair was not observed at iAs drinking water concentrations below 10ppb (μg/L).

Venous thrombosis and risk of cancer in patients with arterial cardiovascular disease

IntroductionPatients with acute myocardial infarction or stroke are at high risk of venous thromboembolism, which is traditionally considered a complication rather than a marker of occult cancer. We examined the association between venous thromboembolism and cancer in patients with acute myocardial infarction or stroke. MethodsWe used medical databases to conduct a population-based cohort study including all patients with a first-time venous thromboembolism from 1978 through 2011 who also had a diagnosis of acute myocardial infarction (n=2,878) or stroke (n=1,971) recorded on the same day or within the previous 90days. We followed patients until a first-time cancer diagnosis, emigration, death, or December 31, 2011, whichever came first. We computed 1-year absolute risks and standardised incidence ratios for cancer based on national incidence rates. ResultsThe 1-year absolute cancer risk was 2.7% in the acute myocardial infarction cohort and 3.7% in the stroke cohort. The corresponding standardised incidence ratios were 3.22 (95% confidence interval [CI]: 2.54–4.03) and 3.76 (95% CI: 2.95–4.74), respectively. For cancers diagnosed in the first year, the estimated number of venous thromboembolism patients needed to examine to detect one excess cancer was 25 in the acute myocardial infarction cohort and 19 in the stroke cohort. ConclusionAmong acute myocardial infarction and stroke patients, venous thromboembolism can be a marker of occult cancer. We suggest that current guidelines for cancer screening in patients with unprovoked venous thromboembolism could be applied to this group of patients.

Use of Benzodiazepines and Association with Falls in Older People Admitted to Hospital: A Prospective Cohort Study

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes. This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls. A prospective cohort study was undertaken of patients aged over 70years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90days prior to admission). Of 1,412 patients, 146 (10.3%) were taking BZDs at admission and 155 (11.3%) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95% confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1%; p=0.002), particularly when compared with oxazepam users (70.8 vs. 25.0%; p<0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95% CI 1.1-8.5; p=0.036). Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

A prospective cohort study of healthcare visits and rehospitalizations after discharge of patients with community‐acquired pneumonia

The aim of this study was to identify the frequency of, reasons for, and risk factors associated with additional health-care visits and re-hospitalizations (health-care interactions) among patients with community-acquired pneumonia (CAP), within 30days of discharge from hospital. This was an observational analysis of a prospective cohort of adults hospitalized with CAP at a tertiary hospital in 2007-2009. Additional health-care interactions were defined as visits to a primary care centre or emergency department, and hospital readmissions within 30days of discharge. Of the 934 patients hospitalized with CAP, 282 (34.1%) had additional health-care interactions within 30days of discharge from hospital; 149 (52.8%) required an additional visit to a primary care centre and 177 (62.8%) attended the emergency department. Seventy-two patients (25.5%) were readmitted to hospital. The main reasons for additional health-care interactions were worsening of signs or symptoms of CAP and new or worsening comorbidities that were unrelated to pneumonia, mainly cardiovascular and pulmonary diseases. The only independent factor associated with visits to a primary care centre or the emergency department was alcohol abuse (OR 1.65; 95% CI: 1.03-2.64). Hospitalization in the previous 90days (OR 2.47; 95% CI: 1.11-5.52) and comorbidities (OR 3.99; 95% CI: 1.12-14.23) were independently associated with re-hospitalization. Additional health-care visits and re-hospitalizations within 30days of discharge from hospital were common among patients with CAP. This was mainly due to worsening of signs or symptoms of CAP and/or comorbidities. These findings may have implications for discharge planning and follow up of patients with CAP.

The Coulee Region Community Pharmacy Asthma Intervention Study

To determine whether community pharmacist-initiated interventions containing a recommendation to adjust prescribed asthma therapy are more helpful to prescribers than similar communications without such a recommendation. Prospective, multicenter, quasi-experimental design with posttest. Wisconsin and Minnesota. 33 community and clinic pharmacies throughout the Coulee Region of Wisconsin and Minnesota enrolled eligible patients from October 1, 2004, to January 31, 2005. Patients were between 12 and 60 years of age, had used three or more short-acting beta-agonist (SABA) canisters with-in the previous 90 days, and did not meet any exclusion criteria. Based on an evaluation of each patient's inhaler technique and adherence to controller medications, pharmacists sent to the prescriber a fax containing a recommendation (for patients with proper technique and appropriate adherence to prescribed controller medications) or information (for those who had any combination of inappropriate inhaler technique or inappropriate adherence). Health care professionals' yes-or-no response to the question, "Do you find this form helpful for making clinical decisions?" Pharmacists offered to enroll 235 patients who were identified as meeting preliminary inclusion criteria. Of those, 112 people met exclusion criteria, 28 were not interested in their pharmacists' involvement, 13 stated that they did not have time to participate, 11 took the forms home but did not return them, and 11 other patients were excluded by the pharmacists for other reasons. The remaining 60 patients were in enrolled in the study, 60 faxes were sent from 16 pharmacies, and 40 of those were analyzed further. For 24 recommendation faxes sent, prescribers rated 15 as helpful (62.5%) and 4 as not helpful (16.7%). Of 16 informational faxes sent, 10 were marked helpful (62.5%) and 2 were marked not helpful (12.5%). Recommendation and informational faxes were overall helpful to health care professionals in making clinical decisions. Respondents found the two types of faxed interventions as equally helpful, suggesting that pharmaceutical care initiated by community pharmacists is helpful to prescribers.