ANTIBIOTIC RESISTANCE
Interventions enhance antibiotic stewardship
In EDs and urgent care centers (UCCs), antibiotics are often inappropriately prescribed to treat acute viral respiratory infections. Antibiotic stewardship interventions are designed to reduce inappropriate prescriptions, which contribute to antibiotic resistance. A pragmatic, cluster-randomized clinical trial was conducted in three academic health systems to compare an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) with a stewardship intervention that additionally incorporated behavioral nudges (enhanced intervention) with the goal of reducing inappropriate prescriptions. Five adult and pediatric EDs and four UCCs participated in the study.
The adapted intervention consisted of education for patients and providers based on the CDC's Get Smart campaign (currently called Be Antibiotics Aware) adapted for the acute care setting. The enhanced intervention was more intensive, incorporating the adapted Get Smart campaign along with individualized audit, feedback, and peer comparisons. Delivered monthly via email, peer comparisons compared individual prescribers with top-performing peers, a strategy that has proven effective in prior studies. The main outcome was the proportion of antibiotic-inappropriate acute respiratory infection (ARI) diagnosis visits that received an outpatient antibiotic prescription by individual providers. The periods studied were the influenza seasons for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).
The researchers identified 4,820 ARI visits among 292 providers. During the study period, antibiotic prescribing for ARI visits dropped from 6.2% to 2.4%. However, they found no significant difference in prescribing between the two interventions. They concluded that implementation of simple antibiotic stewardship protocols for ARI is both feasible and effective in the ED and UCC settings, and that implementing more intensive interventions was not more effective.
Source: Yadav K, Meeker D, Mistry RD, et al. A multifaceted intervention improves prescribing for acute respiratory infection for adults and children in emergency department and urgent care settings. Acad Emerg Med. 2019;26(7):719-731.
MEDICATION SAFETY
Many grandparents do not secure drugs properly
The University of Michigan National Poll on Healthy Aging asked a sample of about 2,000 adults ages 50 to 80 about how they store medications at their own homes and when visiting the homes of their grandchildren. The results show that many grandparents routinely keep their medications in easy-to-open containers and easy-to-reach locations, placing their grandchildren at risk for accidental poisoning or intentional misuse.
The poll revealed that about two-thirds of grandparents provide care for their grandchildren: 42% care for them monthly, 18% care for them weekly, and 10% live with them year-round.
Over 80% of the grandparents said they keep their medication in the same place as usual when their grandchildren visit their house. Common locations included a cupboard or cabinet, tabletop, or purse. Only 5% reported routinely locking up their medications at home. In addition, 72% said they keep their medications in a purse or bag when they visit their grandchildren, and nearly one-third said they store their prescription medications in something other than the container they came in, primarily easy-to-open containers.
According to the CDC, about 40% of children treated in EDs for medication-related poisoning took a grandparent's medication. Poll director Preeti Malani, MD, notes that prescription medicines, over-the-counter products, and supplements can harm children who find them in a purse or a kitchen table, and teenagers may divert opioids and sleep medicines for recreational use. "No matter how old your grandchildren are, you need to think about medication safety."
Source: University of Michigan. Institute for Healthcare Policy & Innovation. Many grandparents' medicines not secure enough around grandchildren, poll suggests. News release. July 1, 2019.
ALZHEIMER DISEASE
Androgen deprivation therapy raises risk
In many patients with prostate cancer, androgen deprivation therapy (ADT) is prescribed to reduce the likelihood of cancer progression and lower mortality risk. However, ADT therapy may also have long-term health effects that can reduce quality of life.
To investigate the possible association between ADT and dementia, researchers conducted a retrospective cohort study using data from a National Cancer Institute database liked to Medicare. The study included 154,089 men age 65 and older who were newly diagnosed with prostate cancer between 1996 and 2003 and who received ADT within 2 years of prostate cancer diagnosis. During a mean follow-up of 8.3 years, they found that exposure to ADT was associated with a diagnosis of Alzheimer disease and dementia. The hazard ratio was significant regardless of the number of ADT doses a patient received, which ranged from one to eight or more. Noting the growing list of ADT drugs, which now includes androgen synthesis inhibitors and second-generation antiandrogens, the authors conclude that "clinicians need to carefully weigh the long-term risks and benefits of exposure to ADT in patients with a prolonged life expectancy and stratify patients based on dementia risk prior to ADT initiation."
Source: Jayadevappa R, Chhatre S, Malkowicz SB, Parikh RB, Guzzo T, Wein AJ. Association between androgen deprivation therapy use and diagnosis of dementia in men with prostate cancer. JAMA Netw Open. 2019;2(7):e196562.
ECULIZUMAB INJECTION
Treatment for debilitating autoimmune disorder
The FDA has approved eculizumab injection (Soliris) to treat neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody-positive. An autoimmune disease of the central nervous system, NMOSD mainly affects the optic nerves and spinal cord and can be associated with antibodies that bind to the AQP4 protein. The disorder causes permanent vision loss and paralysis in about 50% of patients and is thought to affect 4,000 to 8,000 people in the US.
In a placebo-controlled clinical trial of 143 patients, the new drug reduced the number of NMOSD relapses by 94% over 48 weeks. It also reduced the need for hospitalizations and the need for treatment of acute attacks with corticosteroids and plasma exchange.
Eculizumab is administered I.V. It carries a boxed warning about the risk of life-threatening meningococcal infections, which can become rapidly fatal if not recognized and treated promptly. Monitor patients for early signs and symptoms of meningococcal infections, such as moderate to severe headache with nausea or vomiting, and use caution in patients with any other infection.
Eculizumab is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS). Providers must enroll in the REMS program to prescribe the drug.
Source: US Food and Drug Administration. FDA approves first treatment for neuromyelitis optica spectrum disorder, a rare autoimmune disease of the central nervous system. News release. June 27, 2019.