Use Of Second-line Antibiotics Research Articles

Prolonged outpatient parenteral antimicrobial treatment: frequency and evolution over a six-year period in a Swiss University Hospital

BackgroundEmerging research indicates the potential for early transition from intravenous to oral antimicrobial therapy in certain infections. This trend may have implications for outpatient parenteral antibiotic therapy (OPAT) programs, as the demand for prolonged intravenous treatment could decrease. The objective of this study was to evaluate the frequency and evolution of OPAT courses of ≥ 14 days over the years and determine the medical justification for those prolonged treatments.MethodsAll patients treated intravenously for ≥ 14 days by the OPAT program at Lausanne University Hospital, Switzerland, between 2017 and 2022 were included in the study. Data were extracted from a prospectively established OPAT database. Prevalence of prolonged antibiotic treatment and its clinical and microbiological information were identified.ResultsDuring the study period, a total of 2,448 treatment courses were administered: 1,636 intravenous (IV) and 812 oral treatments. Of the IV treatments courses, 749 (36%) were of a duration of ≥ 14 days, without discernible trend over the 6-year study period. The most common type of infections needing prolonged treatment were bone and joint infections (31%), endovascular infections (18%), complicated intra-abdominal infections (15%), and urinary tract infections (11%), with only minor fluctuations in these proportions during the study period. Finally, the use of second-line antibiotics (piperacillin-tazobactam, carbapenems and vancomycin) did not increase over the years, suggesting that prolonged intravenous antibiotic therapy is not linked to an increase of anti-microbial resistance in our cohort.ConclusionsDespite the general trend towards shorter intravenous treatment courses in infectious diseases, our OPAT unit did not observe a decline in the use of prolonged intravenous antibiotic therapy between 2017 and 2022, suggesting that OPAT units will probably not see a decrease in their activities in the near future.

Penicillin Allergy in China: Consequences of Inappropriate Skin Testing Practices and Policies.

Penicillins are the most frequently prescribed class of medications worldwide and first-line antibiotic of choice for most bacterial infections. They are also commonly labelled as the culprit of drug 'allergy'; leading to obligatory use of second-line antibiotics, suboptimal antibiotic therapy and increased antimicrobial resistance. However, the majority of reported penicillin 'allergy' labels are found to be incorrect after allergy testing, emphasising the importance of proper drug allergy testing and evaluation. Penicillin skin testing (PST) remains an important component of drug allergy diagnosis; however, its practice and policies significantly differ across the world. Inappropriate and non-evidence-based PST practices can lead to consequences associated with allergy mislabelling. Even within different regions of China, with a population exceeding 1.4 billion, there are marked differences in the implementation, execution and interpretation of PST. This review aims to examine the differences in PST between Mainland China, Hong Kong and the rest of the world. We critically analyse the current practice of 'pre-emptive' PST in Mainland China, which has a significant false-positive rate leading to high levels of penicillin allergy mislabelling. Non-evidence-based practices further compound the high false-positive rates of indiscriminatory PST. We postulate that inappropriate PST policies and practices may exacerbate the mislabelling of penicillin allergy, leading to unnecessary overuse of inappropriate second-line antibiotics, increasing antimicrobial resistance and healthcare costs. We advocate for the importance of more collaborative research to improve the contemporary workflow of penicillin allergy diagnosis, reduce mislabelling and promote the dissemination of evidence-based methods for allergy diagnosis.

A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively

Study objectiveTo characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use. DesignQuasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated. SettingOutpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center. Patients670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively. InterventionA paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use. MeasurementsAntibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 – April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants. Main resultsOf 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09–2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42–0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35–0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention. ConclusionsA simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.

2738. Two-step sulfonamide antibiotic challenges in patients who require treatment with trimethoprim-sulfamethoxazole at an academic medical center: Outcomes in a largely immunocompromised population

Abstract Background Sulfonamide antibiotic allergy is the second most reported medication allergy. The allergy label limits the use of trimethoprim-sulfamethoxazole (TMP-SMX), the antibiotic of choice for pneumocystis jirovecii pneumonia (PJP), Toxoplasma, and many types of urinary tract infections. Immunocompromised patients, including solid organ transplant recipients, are considered to be at a higher risk for developing an infection. While penicillin allergies are commonly tested and patients delabeled, sulfonamide challenges are not as prevalent. Patients who are tested following a transplant may be on medications that lower the negative predictive value of the challenge, raising questions about whether they truly passed the challenge or whether mild reactions were masked. Methods: Thirty-seven patients labeled with a sulfonamide allergy who were evaluated and challenged with two doses of TMP-SMX were included. Adults (≥18 years) with a sulfonamide antibiotic allergy were evaluated and challenged between June 2020 and May 2023. Data collection included the number of patients challenged and delabeled, number of patients who had reactions and what type of reaction, and proportion of patients who completed the treatment or prophylaxis course for which TMP-SMX was the first-line antibiotic. Results Thirty-seven patients were challenged, of which twenty-seven patients were immunocompromised (73%). Thirty-four (92%) passed the sulfonamide challenge and were delabeled, and thirty-two (86%) completed the full course of TMP-SMX prophylaxis or treatment. Nineteen patients (51%) were tested following immunosuppression or antihistamine treatment due to a new transplant. Five patients were not able to be delabeled due to mild or delayed reactions to the challenge or treatment, including two patients that passed the sulfonamide challenge and were delabeled but had a mild reaction during SMX-TMP therapy and were relabeled. Conclusion The benefits of sulfonamide antibiotic allergy testing can have great effects in immunocompromised patients in preventing the use of second-line antibiotics. Sulfonamide challenges were shown to be safe and effective in immunocompromised patients in delabeling the sulfonamide antibiotic allergy and leading to the completion of treatment with TMP-SMX. Disclosures Shyam Joshi, MD, Cogent: Honoraria|Leo Pharma: Honoraria|Nectar Allergy: Advisor/Consultant|Nectar Allergy: Stocks/Bonds|Sanofi/Regeneron: Advisor/Consultant|Sanofi/Regeneron: Honoraria|Takeda: Honoraria

The Role of Stakeholders' Understandings in Emerging Antimicrobial Resistance: A One Health Approach.

The increasing misuse of antibiotics in human and veterinary medicine and in agroecosystems and the consequent selective pressure of resistant strains lead to multidrug resistance (AMR), an expanding global phenomenon. Indeed, this phenomenon represents a major public health target with significant clinical implications related to increased morbidity and mortality and prolonged hospital stays. The current presence of microorganisms multi-resistant to antibiotics isolated in patients is a problem because of the additional burden of disease it places on the most fragile patients and the difficulty of finding effective therapies. In recent decades, international organizations like the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) have played significant roles in addressing the issue of AMR. The ECDC estimates that in the European Union alone, antibiotic resistance causes 33,000 deaths and approximately 880,000 cases of disability each year. The epidemiological impact of AMR inevitably also has direct economic consequences related not only to the loss of life but also to a reduction in the number of days worked, increased use of healthcare resources for diagnostic procedures and the use of second-line antibiotics when available. In 2015, the WHO, recognising AMR as a complex problem that can only be addressed by coordinated multi-sectoral interventions, promoted the One Health approach that considers human, animal, and environmental health in an integrated manner. In this review, the authors try to address why a collaboration of all stakeholders involved in AMR growth and management is necessary in order to achieve optimal health for people, animals, plants, and the environment, highlighting that AMR is a growing threat to human and animal health, food safety and security, economic prosperity, and ecosystems worldwide.

Approach for delabeling beta-lactam allergy in children.

A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.

Pharmacist-led improvement in perioperative antibiotic selection for patients with a penicillin allergy label.

Surgical patients with a penicillin allergy label (PAL) are less likely to receive β-lactams for surgical site infection (SSI) prophylaxis and more likely to receive second-line antibiotics, which may increase the risk of SSI, drug toxicities, and associated costs. We assessed the impact of implementing a pharmacist-led quality improvement project to increase the use of cefazolin as a first-line agent in this population. After implementation of a pilot project in December 2021, all patients with a PAL and orders for preoperative antibiotics were risk stratified into high- or low-risk categories by a pharmacist. For the low-risk group, cefazolin was recommended. For the high-risk group, cefazolin was avoided and a second-line agent was administered. Our analysis compared 422 preintervention patients (August 15 to November 15, 2021) to 492 postintervention patients (December 15 to March 15, 2022). During the postintervention period, β-lactam usage increased (from 12.6% to 37.8%, P < 0.001), while usage of vancomycin (45.5% vs 29.5%, P < 0.001) and other second-line antibiotics (87.4% vs 62.2%, P < 0.001) declined. There were no adverse reactions reported in the preintervention cohort, with 2 potential adverse reactions reported after the intervention (0% vs 0.4%, P = 0.190). Medication costs based on claims data were 50% to 80% lower for patients receiving cefazolin. In our cohort, a pharmacy-led antibiotic selection algorithm for patients with a PAL receiving perioperative antimicrobial prophylaxis resulted in increased use of β-lactam antibiotics, decreased use of second-line antibiotics, and decreased costs without a significant change in the incidence of adverse reactions.

Patterns and trends of antibacterial treatment in patients with urinary tract infections, 2015–2019: an analysis of health insurance data

BackgroundUrinary tract infections are among the most common reason for encounter and subsequent antibiotic prescriptions. Due to the risk of collateral damage and increasing resistance rates, explicit recommendations against the use of fluoroquinolones like ciprofloxacin in uncomplicated urinary tract infections have been issued. However, to what extent these recommendations were followed and if there are relevant differences between the disciplines involved (general practitioners, urologists, paediatricians and gynaecologists) are unknown.MethodsWe used anonymized data from a local statutory health insurance (SHI) company, which covered about 38% of all SHI-insured persons in the federal state of Bremen, Germany between 2015—2019. Data included demographics, outpatient diagnoses and filled prescriptions on an individual level.ResultsOne-year prevalence of urinary tract infections was 5.8% in 2015 (females: 9.2%, males: 2.5%). Of all 102,715 UTI cases, 78.6% referred to females and 21.4% to males, 6.0% of cases were younger than 18 years. In females, general practitioners were the most common diagnosing speciality (52.2%), followed by urologists (20.0%) and gynaecologists (16.1%). Overall, fluoroquinolones were most often prescribed (26.3%), followed by fosfomycin (16.1%) and the combination of sulfamethoxazole and trimethoprim (14.2%). Fluoroquinolones were most often prescribed by urologists and general practitioners, while gynaecologists preferred fosfomycin. During the study period, shares of fluoroquinolones decreased from 29.4% to 8.7% in females and from 45.9% to 22.3% in males.ConclusionsDespite a clear trend toward a more guideline adherent prescription pattern, there is still room for improvement regarding the use of second-line antibiotics especially fluoroquinolones. The choice of antibiotics prescribed differs between specialities with higher uptake of guideline-recommended antibiotics by gynaecologists, mainly because of higher prescription shares of fosfomycin.

Relabeling of penicillin drug allergy after evaluation in a drug allergy clinic

Penicillins are a commonly labeled drug allergy, and yet, many patients are inappropriately labeled with this allergy status.1 Medical staff may not have adequate training or time to evaluate a patient's drug allergy history to determine if a labeled allergy is a true allergy. Implications of having a penicillin allergy label include the use of second-line antibiotics, risk of adverse effects, antibiotic resistance, increased inpatient/outpatient costs, and increased mortality.2 Therefore, it is important to prevent erroneous relabeling of penicillin allergy labels.

Economic Burden of Patient-Reported Penicillin Allergy on Total Hip and Total Knee Arthroplasty

IntroductionSelf-reported penicillin allergies in patients undergoing total joint arthroplasty often results in the use of second-line prophylactic antibiotics. A higher risk of prosthetic joint infection (PJI) is associated with suboptimal antibiotics vs first generation cephalosporins, which have historically been grouped with other beta-lactam antibiotics such as penicillin for potential allergic reactions. This study evaluates the economic burden of self-reported penicillin allergies in total joint arthroplasty (TJA). MethodsData from studies reporting true incidence of IgE-mediated penicillin allergies, infection-free survivorship of TJA, and cost of PJI attributed to use of second-line antibiotics were obtained. Projected cost of preoperative penicillin allergy testing and potentially avoidable PJI associated with second-line antibiotic usage were calculated. This was compared with projected cost of PJI in the current state to estimate cost savings. ResultsImplementation of preoperative penicillin allergy testing leads to a potential savings of nearly $37 million to payors in the first year based on 1-year survivorship. This savings increases to $411.6 million over a 10-year span and $1.18 billion over a 20-year span. ConclusionPreoperative penicillin allergy testing or risk stratification via thorough history should be implemented as standard of care for patients with self-reported penicillin allergies before TJA and would result in decreased cost of PJI.

A Streamlined Approach to Optimize Perioperative Antibiotic Prophylaxis in the Setting of Penicillin Allergy Labels

Patients with penicillin allergy labels often receive alternative antibiotics for perioperative prophylaxis, as opposed to first-line cephalosporins (cefazolin/cefuroxime). Provider misconceptions about the risk of cross-reactivity likely drive this prescribing behavior, which is problematic because of its association with increased risk of surgical-site infections. To develop, implement, and assess the safety of a streamlined approach to perioperative antibiotic selection for surgical patients with a penicillin allergy label, to reduce the use of second-line antibiotics. A multidisciplinary task force developed an institutional algorithm for antibiotic selection in penicillin-allergic surgical patients. The percentage of patients receiving a first-line cephalosporin was compared before and after algorithm utilization. The safety of this approach was assessed via chart review of all patients who received epinephrine or diphenhydramine in the operating room, or diphenhydramine within 24hours postoperatively, assessing for any adverse reactions to cephalosporin administration. Between September 2016 and May 2019, 9.3% of surgical patients had documented penicillin allergy (n= 2296). At baseline, 22% of these patients received a cephalosporin, with an increase to more than 80% after algorithm implementation (P< .0001). Among 551 patients with penicillin allergy label who received a cephalosporin after algorithm implementation, no immediate allergic reactions requiring epinephrine were identified; 1 patient had a delayed rash that did not require cephalosporin discontinuation. Three patients received diphenhydramine for "itching" without rash in the setting of concomitant narcotic administration. Using a streamlined algorithm, we were able to significantly reduce the use of second-line antibiotics in penicillin-allergic surgical patients without severe adverse reactions.

Extending the use of the World Health Organisations' water sanitation and hygiene assessment tool for surveys in hospitals - from WASH-FIT to WASH-FAST.

Poor water sanitation and hygiene (WASH) in health care facilities increases hospital-associated infections, and the resulting greater use of second-line antibiotics drives antimicrobial resistance. Recognising the existing gaps, the World Health Organisations' Water and Sanitation for Health Facility Improvement Tool (WASH-FIT) was designed for self-assessment. The tool was designed for small primary care facilities mainly providing outpatient and limited inpatient care and was not designed to compare hospital performance. Together with technical experts, we worked to adapt the tool for use in larger facilities with multiple inpatient units (wards), allowing for comparison between facilities and prompt action at different levels of the health system. We adapted the existing facility improvement tool (WASH-FIT) to create a simple numeric scoring approach. This is to illustrate the variation across hospitals and to facilitate monitoring of progress over time and to group indicators that can be used to identify this variation. Working with stakeholders, we identified those responsible for action to improve WASH at different levels of the health system and used piloting, analysis of interview data to establish the feasibility and potential value of the WASH Facility Survey Tool (WASH-FAST) to demonstrate such variability. We present an aggregate percentage score based on 65 indicators at the facility level to summarise hospitals' overall WASH status and how this varies. Thirty-four of the 65 indicators spanning four WASH domains can be assessed at ward level enabling within hospital variations to be highlighted. Three levels of responsibility for WASH service monitoring and improvement were identified with stakeholders: the county/regional level, senior hospital management and hospital infection prevention and control committees. We propose WASH-FAST can be used as a survey tool to assess, measure and monitor the progress of WASH in hospitals in resource-limited settings, providing useful data for decision making and tracking improvements over time.

A 5-year retrospective review of outpatient graded drug challenges

Drug allergies are commonly over-reported. These inaccurate drug allergy labels adversely impact patient care because first-line medications are unnecessarily avoided. For penicillin allergy, use of second-line antibiotics is associated with increased adverse reactions, cost, hospital length of stay, and bacterial resistance in both children and adults.1-3 Despite the harm of unnecessarily avoiding first-line medications, there is limited validated diagnostic testing for drug allergy. Graded drug challenges (GDCs) are the gold standard for the diagnosis or exclusion of IgE-mediated drug allergy in the office, and delayed reactions outside of the office.

Antibiotic prescription for febrile children in European emergency departments: a cross-sectional, observational study

Prevalence of serious bacterial infections in children in countries in western Europe and the USA is low. Antibiotic stewardship aims at a more rational use of antibiotics but information on the frequency of antibiotic prescription to children in emergency departments is scarce. We aimed to quantify and explain variability in antibiotic prescription in children attending European paediatric emergency departments. We did a cross-sectional, observational study of children aged between 1 month and 16 years who presented with fever to one of 28 European emergency departments on one random sampling day per month between Nov 1, 2014, and Feb 28, 2016. The surveyed sites were spread across 11 countries and included 17 academic hospitals with 3000 to up to 80 000 annual visits to their paediatric emergency departments. We determined the proportion of children without comorbidities who received antibiotic prescriptions by country, focus of infection, and type of antibiotic. We then did a detailed analysis of the same population, using a multilevel logistic regression analysis, into the variability in prescriptions across hospitals, focusing particularly on respiratory tract infections and correcting for a combination of result-dependent factors. Random group assignment was done by computer randomisation. Of 5177 children in total, 617 children had comorbidities. Of the 4560 children without comorbidities, 1454 (32%) received antibiotics. This percentage varied from 19% to 64% across countries. Of these 1454 prescriptions issued, 893 (61%) were second-line antibiotics. Antibiotic prescription for respiratory tract infections, the most common infection type, in children without comorbidities was most variable across countries (15-67% for upper respiratory tract infections and 24-87% for lower respiratory tract infections) and was associated with age (odds ratio [OR] 1·51, 95% CI 1·08-2·13), fever duration (OR 1·45, 1·01-2·07), blood concentrations of C-reactive protein (OR 2·31, 1·67-3·19), and chest x-ray results (OR 10·62, 5·65-19·94, for focal abnormalities; OR 3·49, 1·59-7·64, for diffuse abnormalities). After correcting for patient characteristics, diagnostic assessment, and hospital characteristics, antibiotic prescription for respiratory tract infections remained highly variable across emergency departments (standardised antibiotic prescription ratio 0·49-2·04). Antibiotic prescription in European emergency departments is highly variable, with frequent use of second-line antibiotics. To ensure successful antibiotic stewardship initiatives in Europe aimed at reducing unnecessary prescription of antibiotics, variability of prescription across hospitals should be considered, drivers of suboptimal antibiotic prescription at the local level need to be identified, and European guidelines need to be devised. None.

Inpatient β-lactam test-dose protocol and antimicrobial stewardship in patients with a history of penicillin allergy

BackgroundPenicillin allergy is the most commonly reported drug allergy in hospitalized patients, resulting in increased second-line antibiotic use, nosocomial infections, and health care use. Given that most patients are not truly allergic, a safe strategy that empowers the admitting physician is needed. ObjectiveTo assess the effect on antibiotic prescribing practices for hospitalized patients with penicillin allergy using a validated intervention. MethodsAn intervention was implemented to educate health care professionals on management of patients with penicillin allergy using a validated risk stratification algorithm to guide testing and antibiotic use. Thirty days of control data using current standard of care was compared with 60 days of postintervention data measuring documentation of penicillin allergy history and antibiotic selection. ResultsThe relative use of cephalosporin and penicillin antibiotics increased by 121.2% (P = .03) and 256% (P = .04), respectively, without an increase in adverse drug reactions. There was a decrease in the use of broad-spectrum antibiotics: vancomycin, 67.2% (P = .04); quinolones, 33.3% (P = .31); carbapenems, 81.9% (P = .08); and aztreonam, 73.8% (P = .18). ConclusionThe antibiotic choice in patients admitted to the hospital with a reported penicillin allergy can be improved by better evaluation of the allergy history and the use of a risk stratification guideline.

Use of a Penicillin Allergy Screening Algorithm and Penicillin Skin Testing for Transitioning Hospitalized Patients to First-Line Antibiotic Therapy

Penicillin allergy is the most commonly reported antibiotic allergy. Avoidance of β-lactam antibiotics in hospitalized patients leads to the use of second-line therapies. The utility of a penicillin allergy history algorithm (PAHA) and subsequent penicillin skin testing (PST) in transitioning hospitalized patients from second- to first-line antibiotic therapy is described. Through an electronic medical record report, pharmacists identified adult inpatients with penicillin allergy receiving moxifloxacin, intravenous vancomycin, aztreonam, daptomycin, or linezolid, in which a β-lactam antibiotic was preferred. The PAHA was administered to identify patients for PST. Skin-test negative patients were transitioned to first-line β-lactam antibiotic therapy. Fifty patients consented to the study. Historical reactions included hives (16 patients, 32%), angioedema (15, 30%), anaphylaxis (6, 12%), unknown (6, 12%), rash (6, 12%), and dyspnea (1, 2%). Pre-PST antibiotic regimens included vancomycin (82%), aztreonam (22%), moxifloxacin (6%), daptomycin (4%), and/or linezolid (2%). Forty-seven patients (94%) were skin-test negative and were subsequently transitioned to a β-lactam antibiotic. Two patients were skin-test positive and one was histamine nonreactive. No patients experienced an immediate adverse reaction when challenged with a penicillin-based antibiotic. A total of 982 days of second-line antibiotic therapy and at least 23 hospital days to administer the antibiotic were avoided. The use of the PAHA and subsequent PST is a safe, effective multidisciplinary intervention that facilitates the transition to β-lactam antibiotics. Our approach is unique in that it prioritizes patients based on the use of second-line antibiotics, and then applies an algorithm to determine eligibility for PST.

Overall and second-line antibiotic use in the community in Israel - a call for action

Overall and second-line antibiotic use in the community in Israel - a call for action

Implementing a urinary tract infection clinical practice guideline in an ambulatory urgent care practice

A clinical practice guideline for uncomplicated urinary tract infections in an ambulatory urgent care practice was implemented. Aims were to increase the number of first-line antibiotics prescribed to treat uncomplicated urinary tract infections, increase the use of second-line antibiotics prescribed when appropriate, and decrease the number of unnecessary urine cultures.

Penicillin Skin Testing: Potential Implications for Antimicrobial Stewardship

As the progression of multidrug-resistant organisms and lack of novel antibiotics move us closer toward a potential postantibiotic era, it is paramount to preserve the longevity of current therapeutic agents. Moreover, novel interventions for antimicrobial stewardship programs are integral to combating antimicrobial resistance worldwide. One unique method that may decrease the use of second-line antibiotics (e.g., fluoroquinolones, vancomycin) while facilitating access to a preferred β-lactam regimen in numerous health care settings is a penicillin skin test. Provided that up to 10% of patients have a reported penicillin allergy, of whom ~10% have true IgE-mediated hypersensitivity, significant potential exists to utilize a penicillin skin test to safely identify those who may receive penicillin or a β-lactam antibiotic. In this article, we provide information on the background, associated costs, currently available literature, pharmacists' role, antimicrobial stewardship implications, potential barriers, and misconceptions, as well as future directions associated with the penicillin skin test.

Acute urinary retention increases the risk of complications after transurethral resection of the prostate: a population‐based study

Study Type--Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Higher mortality and morbidity rates in men presenting with AUR have been reported in previous studies. This study has comprehensive comparisons of post-TURP complications between patients with and without AUR. Furthermore, it shows that AUR is associated with increased risk of complications after TURP. • To assess the association between a history of acute urinary retention (AUR) and complications after transurethral resection of prostate (TURP). • We conducted a retrospective, national, population-based study using Taiwan's National Health Insurance Research Database. • We included men > 50 years old, diagnosed with benign prostatic hyperplasia (BPH) and divided these into two groups: an AUR(+) group--those with AUR who underwent TURP between 2002 and 2004; and an AUR(-) group--those without AUR who underwent TURP between those dates. • Prostate cancer, Parkinsonism and multiple sclerosis were exclusion criteria. • Postoperative complications, e.g. re-catheterization, haematuria or urinary tract infection (UTI), were compared using crude odds ratios (ORs), 95% confidence intervals (CIs), and Student's t-test. • A chi-squared test was used for potential confounding factors: preoperative UTI and anticoagulant use. • Univariate and multivariate analysis on medical expenses were conducted. • The AUR(+) group contained 3305 men; the AUR(-) group contained 1062. • Re-catheterization (13.8%), septicaemia (1.1%) and shock (0.3%) were found only in the AUR(+) group. • The AUR(+) group had more UTIs (18.9% vs. 15.6%, OR: 1.26, 95% CI: 1.05-1.52), more lower urinary tract symptoms (22.8% vs. 16.9%, OR: 1.45, 95% CI: 1.21-1.73), fewer blood transfusions (3.2% vs. 1.5%, OR: 2.19, 95% CI: 1.29-3.72) and higher medical expenses. • There were no significant differences in haematuria, lower urinary tract stricture, or re-surgical intervention of the prostate and second-line antibiotic use. • Patients in Taiwan with BPH with AUR who were treated by TURP were associated with a higher risk of complications, longer hospital stay and more comorbidities than those without AUR and a preoperative warning is warranted for these patients.