Pharmacotherapy the Journal of Human Pharmacology and Drug Therapy, Mar 1, 2003
To assess central nervous system (CNS) penetration of cefepime in adults with external ventricula... more To assess central nervous system (CNS) penetration of cefepime in adults with external ventricular drains and to compare the achieved cerebrospinal fluid (CSF) concentrations with the usual minimum inhibitory concentrations (MICs) of common pathogens. Open-label, prospective study. University-affiliated medical center. Seven patients with external ventricular drains and normal renal function (documented creatinine clearance > 60 ml/min) who received cefepime 2 g intravenously every 12 hours for treatment of nosocomial pneumonia. Serial serum and CSF samples were obtained concurrently after the fourth dose during one dosing interval. The concentration-time profiles in serum and CSF were comodeled by using a two-compartment model with zero-order infusion to the central compartment. The CSF concentration-time profiles of the individual patients were compared with published MIC90 of common pathogens isolated in nosocomial meningitis. Our model reasonably characterized the disposition of cefepime in serum and CSF. Penetration into the CNS was 4-34% based on area under the curve and was 5-58% based on minimum concentration. Penetration of cefepime into the CNS was variable among the patients (4-34%) but appeared similar to that reported for other cephalosporins given to treat meningitis. The concentrations attained by most patients in this study were above the MIC90 of many common nosocomial organisms.
Although some of the variables associated with adherence (eg, patient age, place of residence) ca... more Although some of the variables associated with adherence (eg, patient age, place of residence) cannot be influenced, others are very amenable to modifications. Levels of adherence correlate with the convenience of dosage regimens, as shown in a number of clinical trials. Therefore, antimicrobial agents that are well accepted by patients should be considered whenever feasible. Such agents include those that enable shortterm therapy with the fewest daily doses and shortest effective treatment regimens. DOT, a cost-effective and clinically effective approach for certain chronic conditions, may also have practical implications for the treatment of acute infectious diseases, such as CAP, AECB, and otitis media. Although there are a number of challenges to the implementation of DOT for these conditions, such an approach may be beneficial, particularly when short-course antibiotic therapy is indicated and appropriate candidates are identified for treatment.
Oral antibiotic therapy can reduce complications and costs compared with intravenous (IV) therapy... more Oral antibiotic therapy can reduce complications and costs compared with intravenous (IV) therapy. The object of this study was to determine the health economic and resource utilization effects of outpatient treatment with oral linezolid relative to IV vancomycin. Longitudinal claims data from 80 health care plans were used. Patients 18 years and older, who did not have osteomyelitis, with a pharmacy claim for linezolid or vancomycin between January 1, 2002 and March 31, 2004 were eligible. Clinical and resource utilization data were collected for 12 months before and 35 days after treatment. Patients treated with linezolid were matched with controls treated with vancomycin, based on propensity scoring. Direct medical costs paid by health plans were compared. A total of 1,048 matched pairs were identified. Demographic and clinical characteristics were comparable between groups. Patients with linezolid claims had lower resource utilization versus those with vancomycin claims during follow-up, including fewer mean physician office visits (4.1+/-5.7 vs. 8.4+/-13.8 visits; P< .001); lab/diagnostic claims (6.3+/-18.0 vs. 10.4 +/-15.2 claims; P< .001); pharmacy claims (7.3+/-8.1 vs. 13.6+/-17.4 claims; P< .001); emergency room visits (9.7% vs. 13.9%; P= .003) and hospitalization (15.3% vs. 19.1%; P= .024). Patients receiving vancomycin were more likely to be hospitalized or have an emergency room visit than patients receiving linezolid. Mean total adjusted cost was 4,707 dollars less for linezolid compared with vancomycin (8,401dollars vs. 13,108 dollars; P< .001). Similar trends were observed for patients matched based on complicated skin and soft tissue infection diagnosis. Outpatient treatment with oral linezolid was associated with significantly lower resource utilization and total medical costs compared with IV vancomycin.
Background: Oral antibiotic therapy has been associated with reduced complications and decreased ... more Background: Oral antibiotic therapy has been associated with reduced complications and decreased costs compared with IV therapy. The impact of outpatient treatment with oral linezolid relative to IV vancomycin on resource utilization and direct medical cost was evaluated. Methods: A retrospective cohort study was performed utilizing longitudinal claims data from > 80 healthcare plans. Patients ≥18 years, excluding osteomyelitis, with a pharmacy claim for linezolid or vancomycin between 1/2002 and 3/2004 were eligible. Demographic, clinical, and resource utilization data were collected for 12 months prior and 35 days after treatment. A propensity score for linezolid therapy was constructed using multivariate analysis. To control for confounding, 1048 patients treated with linezolid were matched with 1048 controls treated with vancomycin, based on closest propensity score. Costs were calculated from the paid amount by health plans. Results: Demographic and clinical characteristics ...
Background: In clinical trials of DAP for cSSSI a trend was observed toward faster resolution of ... more Background: In clinical trials of DAP for cSSSI a trend was observed toward faster resolution of symptoms and decreased IV therapy, yet these trends have not been verified nor have economic implications of DAP use for cSSSI been evaluated. We assessed the impact of DAP on the outcome of patients with cSSSI with risk of MRSA. Methods: Prospective, open-label study of pts with cSSSI and risk for MRSA treated with DAP 4mg/kg IV q24 vs controls treated with VAN. DAP and VAN pts were matched 1:4 on age, APACHE II, Charlson score, and infection type. Outcomes: blinded assessments of clinical resolution, duration of tx and costs. Results: 47 DAP and 188 VAN pts. Average age, 45; APACHE II, 3; Charlson, 1; cellulitis 31%, abscess 21%, ulcer 8%, cellulitis + abscess 35%, other 13% (P >.05 for all). Microbiology in DAP, VAN - no organisms: 36%, 2%; S. aureus only: 36%, 62%; other Staph: 6%, 6%; Streptococcus spp: 6%, 4%; Other: 0%, 4%; Polymicrobial: 11%, 21%. Patients with complete resolu...
Background: Rates of nosocomial pneumonia (NP) due to SA are increasing. Initial inappropriate an... more Background: Rates of nosocomial pneumonia (NP) due to SA are increasing. Initial inappropriate antibiotic treatment is a risk factor for mortality in patients (pts) with NP. There is growing literature suggesting that vancomycin (VANC) may not be optimal for treatment of MRSA NP. Objectives: To describe outcomes of bacteremic NP due to SA (NBSAP) and to determine if delay in treatment, MRSA v. MSSA, or empiric use of β-lactams vs VANC are risk factors for negative outcomes. Methods: A retrospective cohort analysis was performed. Patients identified as having NBSAP were identified. Demographics, comorbidities, empirical therapy and outcomes were evaluated. Results: Of 159 pts identified over a 4-yr period with both blood and sputum cultures for SA, 45 met strict clinical, radiographic, and microbiologic criteria for NBSAP. Overall: Age: 58.5, APACHE II: 18; ICU at onset; 88.9%; mechanical ventilation: 77.8%. Length of stay (LOS) prior to SAP: 10 [2-81] days. Hospital and infection-re...
Background: Complicated skin and skin structure infections (cSSSI) are associated with considerab... more Background: Complicated skin and skin structure infections (cSSSI) are associated with considerable morbidity, mortality and cost. Daptomycin (DAP) is a novel lipopeptide with rapid in vitro bactericidal activity against MSSA and MRSA that was recently approved for cSSSI. Overall response rates in clinical trials were demonstrated to be equivalent to comparators (semi-synthetic penicillins (SSP) or vancomycin (VAN)). It is unclear if certain subsets of patients may benefit from the rapid bactericidal activity of DAP. Outcomes including rate of improvement and required duration of therapy have not yet been compared. Methods: DAP 4mg/kg IV q24h was compared to SSP or VAN for treatment of cSSSI in two large phase III clinical trials. Treatment duration was at the discretion of the primary investigators based on clinical response. To compare rates of improvement and study treatment duration between DAP and comparators, study data was examined for daily signs of improvement and for durat...
Background: Initial antibiotic treatment of cSSSIs is often empiric, and is based on presumed sou... more Background: Initial antibiotic treatment of cSSSIs is often empiric, and is based on presumed source of infection, probable pathogens, patient characteristics, and treatment guidelines. Current real world patterns of initial therapy in cSSSI have not been well-documented. Methods: Using a database with information from >100 hospitals, we identified all admissions between 1/1/2007 and 6/30/2010 of persons aged ≥18y with ICD-9-CM diagnoses of skin infection (e.g., cellulitis, decubitus ulcer, postoperative wound infection). We constituted 3 cohorts, based on presumed infection source (community-acquired [CA], healthcare-associated [HCA], nosocomial [N]). For each admission, we ascertained time when antibiotic treatment for cSSSI began, and characterized initial antibiotic therapy based on all parenteral agents received within the next 36hr. Patterns of initial antibiotic therapy were examined by cohort, including use of agents with activity against methicillin-resistant S. aureus (...
Background: Bacteremia (BSI) may complicate SSTI. Clinicians should consider patient-specific ris... more Background: Bacteremia (BSI) may complicate SSTI. Clinicians should consider patient-specific risk for BSI. This study examines outcomes of pts with SSTI BSI treated with DAP. Methods: All pts with SSTI BSI in CORE 2005-8 a retrospective, multicenter, observational registry were studied. Primary outcome (success, failure, nonevaluable) was investigator-assessed at the end of DAP therapy; a secondary outcome was sponsor-assessed where DAP d/c due to adverse event (AE), death (any cause), and /or evidence for lack of clinical response were evaluated as failures. Demographics and efficacy were based on investigator-evaluable population; all pts were included for safety. Results: 111/2269 (5%) pts with SSTI had concomitant BSI. 88/111 (79%) pts were evaluable for primary outcome; 32% were >65 yrs; 41% were diabetic and 9% had peripheral vascular disease. 69% had complicated SSTI, 31% uncomplicated SSTI; 19% had CrCl <30 ml/min. 75% of pts had Staphylococcus sp., 48% of which was M...
Using a previously described computer algorithm to prospectively identify diabetics, we observed ... more Using a previously described computer algorithm to prospectively identify diabetics, we observed the adherence to published guidelines for treatment of dyslipidemia in diabetics. Despite national guidelines, dyslipidemia remains widely under-treated. Further interventions are needed to improve lipid-lowering treatment in appropriate candidates.
Purpose: Despite well established evidence-based guidelines for dyslipidemia in diabetic patients... more Purpose: Despite well established evidence-based guidelines for dyslipidemia in diabetic patients, statin therapy remains underutilized. We evaluated whether rates of dyslipidemia screening (LDL-cholesterol testing) and adherence to guidelines for lipid-lowering therapy in patients with diabetes mellitus (DM) admitted to a community hospital are improved using a technology-assisted pharmacist intervention. Methods: The study was conducted between June 2006-April 2008. Hospitalized patients with DM were identified using an automated clinical prediction rule. Alerts were generated for DM patients without LDL-c testing, or with an LDL-c greater than or equal to 100mg/dl. Medicine and cardiology practices were randomized to intervention or control groups. For patients with no LDL-c in the intervention group, the pharmacist recommended lipid profile testing. Statin therapy was recommended for intervention group patients with an LDL-c greater than or equal to 100mg/dl when no contraindica...
To facilitate healthcare quality improvement initiatives, we previously developed an algorithm to... more To facilitate healthcare quality improvement initiatives, we previously developed an algorithm to identify diabetes mellitus (DM) patients using only electronically available administrative data. In this study, we have validated our prediction model, screening over 28,000 admissions and determining factors associated with false positive assignment. These factors will be incorporated into a revised algorithm.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 15, 2014
We conducted a survey to compare antimicrobial stewardship outcomes considered to be most importa... more We conducted a survey to compare antimicrobial stewardship outcomes considered to be most important with those used in practice as metrics. Respondent opinion of important outcomes compared with those collected as metrics were antimicrobial use (15% vs 73%), antimicrobial cost (10% vs 73%), appropriateness of antimicrobial use (56% vs 51%), infection-related mortality rate (34% vs 7%), and antibiotic-associated length of stay (22% vs 12%). Patient outcomes are important to many practitioners but are rarely used as metrics.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 15, 2014
Partnership between clinicians and the pharmaceutical industry with a focus on antimicrobial stew... more Partnership between clinicians and the pharmaceutical industry with a focus on antimicrobial stewardship research initiatives is a necessary step toward meeting the shared goals of combating inappropriate antimicrobial use, improving patient outcomes, and minimizing resistance development. Achieving these goals requires outcomes-focused data collection and monitoring tools for antimicrobial stewardship programs (ASP) that consider real-world data about how antimicrobials are used to treat patients. Here we highlight the experiences and challenges associated with the development and implementation of an industry-sponsored electronic antimicrobial stewardship data collection and analysis tool (AS-DCAT). The benefits and risks of the industry-sponsored AS-DCAT from the perspectives of the sponsoring company and participating sites are discussed. Barriers encountered as well as general considerations and recommendations for preventing or overcoming those barriers for future studies and ...
We tested whether a technology-assisted pharmacist intervention improved physician adherence to g... more We tested whether a technology-assisted pharmacist intervention improved physician adherence to guidelines for lipid-lowering therapy in diabetic patients. Computerized alerts identified diabetic patients above LDL-Cholesterol (LDL-C) goal. During Period 1 prescribing behavior was observed in both control and intervention physician groups without intervening. In Period 2, pharmacists conducted academic detailing with intervention group physicians. Control group physicians were observed. The intervention significantly improved the proportion of diabetic patients discharged on statin therapy.
Staphylococcus aureus is among the most prevalent pathogens isolated from hospitalized patients; ... more Staphylococcus aureus is among the most prevalent pathogens isolated from hospitalized patients; those infected with methicillin-resistant strains have longer hospital stays and higher total costs compared with those infected by methicillin-susceptible strains. A multidisciplinary team of health care providers, including hospitalists and other hospital-based physicians, clinical pharmacists, infectious disease specialists, infection control professionals, and case managers, is key to improving treatment and outcomes in these patients. Optimizing transitions of care for hospitalized patients with S aureus infections can improve quality and reduce total costs of care. Hospital length of stay can be shortened by initiating timely, appropriate empiric therapy and by transitioning suitable patients to outpatient antimicrobial therapy. The number of hospitalizations can be reduced by identifying patients who are suitable candidates for initial outpatient antimicrobial therapy. Consistent with good antimicrobial stewardship, the risk of resistance can be minimized by de-escalating empiric therapy to a more narrow-spectrum agent once culture and susceptibility testing results are known. There are several antimicrobial agents available for the management of S aureus infections, including methicillin-resistant S aureus. Consideration of these agents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; characteristics may facilitate optimal transition of patients through health care settings.
International journal of chronic obstructive pulmonary disease, 2014
Early identification of patients with a prolonged stay due to acute exacerbation of chronic obstr... more Early identification of patients with a prolonged stay due to acute exacerbation of chronic obstructive pulmonary disease (COPD) may reduce risk of adverse event and treatment costs. This study aimed to identify predictors of prolonged stay after acute exacerbation of COPD based on variables on admission; the study also looked to establish a prediction model for length of stay (LOS). We extracted demographic and clinical data from the medical records of 599 patients discharged after an acute exacerbation of COPD between March 2006 and December 2008 at Oslo University Hospital, Aker. We used logistic regression analyses to assess predictors of a length of stay above the 75th percentile and assessed the area under the receiving operating characteristic curve to evaluate the model's performance. We included 590 patients (54% women) aged 73.2±10.8 years (mean ± standard deviation) in the analyses. Median LOS was 6.0 days (interquartile range [IQR] 3.5-11.0). In multivariate analysis...
A continued increase in the expression of resistance among bacterial pathogens has prompted the d... more A continued increase in the expression of resistance among bacterial pathogens has prompted the development of a variety of new compounds directed against resistant strains of bacteria. Recently, the most dramatic increase in resistance has been among gram-positive organisms, and the predominant areas of development have been within a few classes of agents. Expanded spectrum fluoroquinolones offer advantages against many resistant gram-positive organisms, including S. pneumoniae and S. aureus. Newly developed classes of antimicrobials offer some unique activity against resistant staphylococci and enterococci. The first classes approved for use in the US are the streptogramins, specifically quinupristin/dalfopristin (Synercid), and the oxazolidinone linezolid (Zyvox). Other new classes of agents, including the ketolides, everninomycins, and newer glycopeptides, such as LY-333328, are in the early stages of development.
Pharmacotherapy the Journal of Human Pharmacology and Drug Therapy, Mar 1, 2003
To assess central nervous system (CNS) penetration of cefepime in adults with external ventricula... more To assess central nervous system (CNS) penetration of cefepime in adults with external ventricular drains and to compare the achieved cerebrospinal fluid (CSF) concentrations with the usual minimum inhibitory concentrations (MICs) of common pathogens. Open-label, prospective study. University-affiliated medical center. Seven patients with external ventricular drains and normal renal function (documented creatinine clearance &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 60 ml/min) who received cefepime 2 g intravenously every 12 hours for treatment of nosocomial pneumonia. Serial serum and CSF samples were obtained concurrently after the fourth dose during one dosing interval. The concentration-time profiles in serum and CSF were comodeled by using a two-compartment model with zero-order infusion to the central compartment. The CSF concentration-time profiles of the individual patients were compared with published MIC90 of common pathogens isolated in nosocomial meningitis. Our model reasonably characterized the disposition of cefepime in serum and CSF. Penetration into the CNS was 4-34% based on area under the curve and was 5-58% based on minimum concentration. Penetration of cefepime into the CNS was variable among the patients (4-34%) but appeared similar to that reported for other cephalosporins given to treat meningitis. The concentrations attained by most patients in this study were above the MIC90 of many common nosocomial organisms.
Although some of the variables associated with adherence (eg, patient age, place of residence) ca... more Although some of the variables associated with adherence (eg, patient age, place of residence) cannot be influenced, others are very amenable to modifications. Levels of adherence correlate with the convenience of dosage regimens, as shown in a number of clinical trials. Therefore, antimicrobial agents that are well accepted by patients should be considered whenever feasible. Such agents include those that enable shortterm therapy with the fewest daily doses and shortest effective treatment regimens. DOT, a cost-effective and clinically effective approach for certain chronic conditions, may also have practical implications for the treatment of acute infectious diseases, such as CAP, AECB, and otitis media. Although there are a number of challenges to the implementation of DOT for these conditions, such an approach may be beneficial, particularly when short-course antibiotic therapy is indicated and appropriate candidates are identified for treatment.
Oral antibiotic therapy can reduce complications and costs compared with intravenous (IV) therapy... more Oral antibiotic therapy can reduce complications and costs compared with intravenous (IV) therapy. The object of this study was to determine the health economic and resource utilization effects of outpatient treatment with oral linezolid relative to IV vancomycin. Longitudinal claims data from 80 health care plans were used. Patients 18 years and older, who did not have osteomyelitis, with a pharmacy claim for linezolid or vancomycin between January 1, 2002 and March 31, 2004 were eligible. Clinical and resource utilization data were collected for 12 months before and 35 days after treatment. Patients treated with linezolid were matched with controls treated with vancomycin, based on propensity scoring. Direct medical costs paid by health plans were compared. A total of 1,048 matched pairs were identified. Demographic and clinical characteristics were comparable between groups. Patients with linezolid claims had lower resource utilization versus those with vancomycin claims during follow-up, including fewer mean physician office visits (4.1+/-5.7 vs. 8.4+/-13.8 visits; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001); lab/diagnostic claims (6.3+/-18.0 vs. 10.4 +/-15.2 claims; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001); pharmacy claims (7.3+/-8.1 vs. 13.6+/-17.4 claims; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001); emergency room visits (9.7% vs. 13.9%; P= .003) and hospitalization (15.3% vs. 19.1%; P= .024). Patients receiving vancomycin were more likely to be hospitalized or have an emergency room visit than patients receiving linezolid. Mean total adjusted cost was 4,707 dollars less for linezolid compared with vancomycin (8,401dollars vs. 13,108 dollars; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Similar trends were observed for patients matched based on complicated skin and soft tissue infection diagnosis. Outpatient treatment with oral linezolid was associated with significantly lower resource utilization and total medical costs compared with IV vancomycin.
Background: Oral antibiotic therapy has been associated with reduced complications and decreased ... more Background: Oral antibiotic therapy has been associated with reduced complications and decreased costs compared with IV therapy. The impact of outpatient treatment with oral linezolid relative to IV vancomycin on resource utilization and direct medical cost was evaluated. Methods: A retrospective cohort study was performed utilizing longitudinal claims data from > 80 healthcare plans. Patients ≥18 years, excluding osteomyelitis, with a pharmacy claim for linezolid or vancomycin between 1/2002 and 3/2004 were eligible. Demographic, clinical, and resource utilization data were collected for 12 months prior and 35 days after treatment. A propensity score for linezolid therapy was constructed using multivariate analysis. To control for confounding, 1048 patients treated with linezolid were matched with 1048 controls treated with vancomycin, based on closest propensity score. Costs were calculated from the paid amount by health plans. Results: Demographic and clinical characteristics ...
Background: In clinical trials of DAP for cSSSI a trend was observed toward faster resolution of ... more Background: In clinical trials of DAP for cSSSI a trend was observed toward faster resolution of symptoms and decreased IV therapy, yet these trends have not been verified nor have economic implications of DAP use for cSSSI been evaluated. We assessed the impact of DAP on the outcome of patients with cSSSI with risk of MRSA. Methods: Prospective, open-label study of pts with cSSSI and risk for MRSA treated with DAP 4mg/kg IV q24 vs controls treated with VAN. DAP and VAN pts were matched 1:4 on age, APACHE II, Charlson score, and infection type. Outcomes: blinded assessments of clinical resolution, duration of tx and costs. Results: 47 DAP and 188 VAN pts. Average age, 45; APACHE II, 3; Charlson, 1; cellulitis 31%, abscess 21%, ulcer 8%, cellulitis + abscess 35%, other 13% (P >.05 for all). Microbiology in DAP, VAN - no organisms: 36%, 2%; S. aureus only: 36%, 62%; other Staph: 6%, 6%; Streptococcus spp: 6%, 4%; Other: 0%, 4%; Polymicrobial: 11%, 21%. Patients with complete resolu...
Background: Rates of nosocomial pneumonia (NP) due to SA are increasing. Initial inappropriate an... more Background: Rates of nosocomial pneumonia (NP) due to SA are increasing. Initial inappropriate antibiotic treatment is a risk factor for mortality in patients (pts) with NP. There is growing literature suggesting that vancomycin (VANC) may not be optimal for treatment of MRSA NP. Objectives: To describe outcomes of bacteremic NP due to SA (NBSAP) and to determine if delay in treatment, MRSA v. MSSA, or empiric use of β-lactams vs VANC are risk factors for negative outcomes. Methods: A retrospective cohort analysis was performed. Patients identified as having NBSAP were identified. Demographics, comorbidities, empirical therapy and outcomes were evaluated. Results: Of 159 pts identified over a 4-yr period with both blood and sputum cultures for SA, 45 met strict clinical, radiographic, and microbiologic criteria for NBSAP. Overall: Age: 58.5, APACHE II: 18; ICU at onset; 88.9%; mechanical ventilation: 77.8%. Length of stay (LOS) prior to SAP: 10 [2-81] days. Hospital and infection-re...
Background: Complicated skin and skin structure infections (cSSSI) are associated with considerab... more Background: Complicated skin and skin structure infections (cSSSI) are associated with considerable morbidity, mortality and cost. Daptomycin (DAP) is a novel lipopeptide with rapid in vitro bactericidal activity against MSSA and MRSA that was recently approved for cSSSI. Overall response rates in clinical trials were demonstrated to be equivalent to comparators (semi-synthetic penicillins (SSP) or vancomycin (VAN)). It is unclear if certain subsets of patients may benefit from the rapid bactericidal activity of DAP. Outcomes including rate of improvement and required duration of therapy have not yet been compared. Methods: DAP 4mg/kg IV q24h was compared to SSP or VAN for treatment of cSSSI in two large phase III clinical trials. Treatment duration was at the discretion of the primary investigators based on clinical response. To compare rates of improvement and study treatment duration between DAP and comparators, study data was examined for daily signs of improvement and for durat...
Background: Initial antibiotic treatment of cSSSIs is often empiric, and is based on presumed sou... more Background: Initial antibiotic treatment of cSSSIs is often empiric, and is based on presumed source of infection, probable pathogens, patient characteristics, and treatment guidelines. Current real world patterns of initial therapy in cSSSI have not been well-documented. Methods: Using a database with information from >100 hospitals, we identified all admissions between 1/1/2007 and 6/30/2010 of persons aged ≥18y with ICD-9-CM diagnoses of skin infection (e.g., cellulitis, decubitus ulcer, postoperative wound infection). We constituted 3 cohorts, based on presumed infection source (community-acquired [CA], healthcare-associated [HCA], nosocomial [N]). For each admission, we ascertained time when antibiotic treatment for cSSSI began, and characterized initial antibiotic therapy based on all parenteral agents received within the next 36hr. Patterns of initial antibiotic therapy were examined by cohort, including use of agents with activity against methicillin-resistant S. aureus (...
Background: Bacteremia (BSI) may complicate SSTI. Clinicians should consider patient-specific ris... more Background: Bacteremia (BSI) may complicate SSTI. Clinicians should consider patient-specific risk for BSI. This study examines outcomes of pts with SSTI BSI treated with DAP. Methods: All pts with SSTI BSI in CORE 2005-8 a retrospective, multicenter, observational registry were studied. Primary outcome (success, failure, nonevaluable) was investigator-assessed at the end of DAP therapy; a secondary outcome was sponsor-assessed where DAP d/c due to adverse event (AE), death (any cause), and /or evidence for lack of clinical response were evaluated as failures. Demographics and efficacy were based on investigator-evaluable population; all pts were included for safety. Results: 111/2269 (5%) pts with SSTI had concomitant BSI. 88/111 (79%) pts were evaluable for primary outcome; 32% were >65 yrs; 41% were diabetic and 9% had peripheral vascular disease. 69% had complicated SSTI, 31% uncomplicated SSTI; 19% had CrCl <30 ml/min. 75% of pts had Staphylococcus sp., 48% of which was M...
Using a previously described computer algorithm to prospectively identify diabetics, we observed ... more Using a previously described computer algorithm to prospectively identify diabetics, we observed the adherence to published guidelines for treatment of dyslipidemia in diabetics. Despite national guidelines, dyslipidemia remains widely under-treated. Further interventions are needed to improve lipid-lowering treatment in appropriate candidates.
Purpose: Despite well established evidence-based guidelines for dyslipidemia in diabetic patients... more Purpose: Despite well established evidence-based guidelines for dyslipidemia in diabetic patients, statin therapy remains underutilized. We evaluated whether rates of dyslipidemia screening (LDL-cholesterol testing) and adherence to guidelines for lipid-lowering therapy in patients with diabetes mellitus (DM) admitted to a community hospital are improved using a technology-assisted pharmacist intervention. Methods: The study was conducted between June 2006-April 2008. Hospitalized patients with DM were identified using an automated clinical prediction rule. Alerts were generated for DM patients without LDL-c testing, or with an LDL-c greater than or equal to 100mg/dl. Medicine and cardiology practices were randomized to intervention or control groups. For patients with no LDL-c in the intervention group, the pharmacist recommended lipid profile testing. Statin therapy was recommended for intervention group patients with an LDL-c greater than or equal to 100mg/dl when no contraindica...
To facilitate healthcare quality improvement initiatives, we previously developed an algorithm to... more To facilitate healthcare quality improvement initiatives, we previously developed an algorithm to identify diabetes mellitus (DM) patients using only electronically available administrative data. In this study, we have validated our prediction model, screening over 28,000 admissions and determining factors associated with false positive assignment. These factors will be incorporated into a revised algorithm.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 15, 2014
We conducted a survey to compare antimicrobial stewardship outcomes considered to be most importa... more We conducted a survey to compare antimicrobial stewardship outcomes considered to be most important with those used in practice as metrics. Respondent opinion of important outcomes compared with those collected as metrics were antimicrobial use (15% vs 73%), antimicrobial cost (10% vs 73%), appropriateness of antimicrobial use (56% vs 51%), infection-related mortality rate (34% vs 7%), and antibiotic-associated length of stay (22% vs 12%). Patient outcomes are important to many practitioners but are rarely used as metrics.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 15, 2014
Partnership between clinicians and the pharmaceutical industry with a focus on antimicrobial stew... more Partnership between clinicians and the pharmaceutical industry with a focus on antimicrobial stewardship research initiatives is a necessary step toward meeting the shared goals of combating inappropriate antimicrobial use, improving patient outcomes, and minimizing resistance development. Achieving these goals requires outcomes-focused data collection and monitoring tools for antimicrobial stewardship programs (ASP) that consider real-world data about how antimicrobials are used to treat patients. Here we highlight the experiences and challenges associated with the development and implementation of an industry-sponsored electronic antimicrobial stewardship data collection and analysis tool (AS-DCAT). The benefits and risks of the industry-sponsored AS-DCAT from the perspectives of the sponsoring company and participating sites are discussed. Barriers encountered as well as general considerations and recommendations for preventing or overcoming those barriers for future studies and ...
We tested whether a technology-assisted pharmacist intervention improved physician adherence to g... more We tested whether a technology-assisted pharmacist intervention improved physician adherence to guidelines for lipid-lowering therapy in diabetic patients. Computerized alerts identified diabetic patients above LDL-Cholesterol (LDL-C) goal. During Period 1 prescribing behavior was observed in both control and intervention physician groups without intervening. In Period 2, pharmacists conducted academic detailing with intervention group physicians. Control group physicians were observed. The intervention significantly improved the proportion of diabetic patients discharged on statin therapy.
Staphylococcus aureus is among the most prevalent pathogens isolated from hospitalized patients; ... more Staphylococcus aureus is among the most prevalent pathogens isolated from hospitalized patients; those infected with methicillin-resistant strains have longer hospital stays and higher total costs compared with those infected by methicillin-susceptible strains. A multidisciplinary team of health care providers, including hospitalists and other hospital-based physicians, clinical pharmacists, infectious disease specialists, infection control professionals, and case managers, is key to improving treatment and outcomes in these patients. Optimizing transitions of care for hospitalized patients with S aureus infections can improve quality and reduce total costs of care. Hospital length of stay can be shortened by initiating timely, appropriate empiric therapy and by transitioning suitable patients to outpatient antimicrobial therapy. The number of hospitalizations can be reduced by identifying patients who are suitable candidates for initial outpatient antimicrobial therapy. Consistent with good antimicrobial stewardship, the risk of resistance can be minimized by de-escalating empiric therapy to a more narrow-spectrum agent once culture and susceptibility testing results are known. There are several antimicrobial agents available for the management of S aureus infections, including methicillin-resistant S aureus. Consideration of these agents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; characteristics may facilitate optimal transition of patients through health care settings.
International journal of chronic obstructive pulmonary disease, 2014
Early identification of patients with a prolonged stay due to acute exacerbation of chronic obstr... more Early identification of patients with a prolonged stay due to acute exacerbation of chronic obstructive pulmonary disease (COPD) may reduce risk of adverse event and treatment costs. This study aimed to identify predictors of prolonged stay after acute exacerbation of COPD based on variables on admission; the study also looked to establish a prediction model for length of stay (LOS). We extracted demographic and clinical data from the medical records of 599 patients discharged after an acute exacerbation of COPD between March 2006 and December 2008 at Oslo University Hospital, Aker. We used logistic regression analyses to assess predictors of a length of stay above the 75th percentile and assessed the area under the receiving operating characteristic curve to evaluate the model's performance. We included 590 patients (54% women) aged 73.2±10.8 years (mean ± standard deviation) in the analyses. Median LOS was 6.0 days (interquartile range [IQR] 3.5-11.0). In multivariate analysis...
A continued increase in the expression of resistance among bacterial pathogens has prompted the d... more A continued increase in the expression of resistance among bacterial pathogens has prompted the development of a variety of new compounds directed against resistant strains of bacteria. Recently, the most dramatic increase in resistance has been among gram-positive organisms, and the predominant areas of development have been within a few classes of agents. Expanded spectrum fluoroquinolones offer advantages against many resistant gram-positive organisms, including S. pneumoniae and S. aureus. Newly developed classes of antimicrobials offer some unique activity against resistant staphylococci and enterococci. The first classes approved for use in the US are the streptogramins, specifically quinupristin/dalfopristin (Synercid), and the oxazolidinone linezolid (Zyvox). Other new classes of agents, including the ketolides, everninomycins, and newer glycopeptides, such as LY-333328, are in the early stages of development.
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Papers by Peggy McKinnon