Antimicrobial stewardship in long term care facilities: what is effective?

Intense antimicrobial use in long term care facilities promotes the emergence and persistence of antimicrobial resistant organisms and leads to adverse effects such as C. difficile colitis. Guidelines recommend development of antimicrobial stewardship programs for these facilities to promote optimal antimicrobial use. However, the effectiveness of these programs or the contribution of any specific program component is not known. For this review, publications describing evaluation of antimicrobial stewardship programs for long term care facilities were identified through a systematic literature search. Interventions included education, guidelines development, feedback to practitioners, and infectious disease consultation. The studies reviewed varied in types of facilities, interventions used, implementation, and evaluation. Comprehensive programs addressing all infections were reported to have improved antimicrobial use for at least some outcomes. Targeted programs for treatment of pneumonia were minimally effective, and only for indicators of uncertain relevance for stewardship. Programs focusing on specific aspects of treatment of urinary infection – limiting treatment of asymptomatic bacteriuria or prophylaxis of urinary infection – were reported to be effective. There were no reports of cost-effectiveness, and the sustainability of most of the programs is unclear. There is a need for further evaluation to characterize effective antimicrobial stewardship for long term care facilities

A Review of the Rationale for Additional Therapeutic Interventions to Attain Lower LDL-C When Statin Therapy Is Not Enough

Statins alone are not always adequate therapy to achieve low-density lipoprotein (LDL) goals in many patients. Many options are available either alone or in combination with statins that makes it possible to reach recommended goals in a safe and tolerable fashion for most patients. Ezetimibe and bile acid sequestrants reduce cholesterol transport to the liver and can be used in combination. Niacin is very effective at lowering LDL, beyond its ability to raise high-density lipoprotein and shift LDL particle size to a less atherogenic type. When statins cannot be tolerated at all, red yeast rice can be used if proper formulations of the product are obtained. Nutrients can also be added to the diet, including plant stanols and sterols, soy protein, almonds, and fiber, either individually or all together as a portfolio diet. A clear understanding of how each of these strategies works is essential for effective results

Protocol for a randomized controlled trial to compare bone-loading exercises with risedronate for preventing bone loss in osteopenic postmenopausal women

BACKGROUND: In the United States, over 34 million American post-menopausal women have low bone mass (osteopenia) which increases their risk of osteoporosis and fractures. Calcium, vitamin D and exercise are recommended for prevention of osteoporosis, and bisphosphonates (BPs) are prescribed in women with osteoporosis. BPs may also be prescribed for women with low bone mass, but are more controversial due to the potential for adverse effects with long-term use. A bone loading exercise program (high-impact weight bearing and resistance training) promotes bone strength by preserving bone mineral density (BMD), improving bone structure, and by promoting bone formation at sites of mechanical stress. METHODS/DESIGN: The sample for this study will be 309 women with low bone mass who are within 5 years post-menopause. Subjects are stratified by exercise history (≥2 high intensity exercise sessions per week; < 2 sessions per week) and randomized to a control or one of two treatment groups: 1) calcium + vitamin D (CaD) alone (Control); 2) a BP plus CaD (Risedronate); or 3) a bone loading exercise program plus CaD (Exercise). After 12 months of treatment, changes in bone structure, BMD, and bone turnover will be compared in the 3 groups. Primary outcomes for the study are bone structure measures (Bone Strength Index [BSI] at the tibia and Hip Structural Analysis [HSA] scores). Secondary outcomes are BMD at the hip and spine and serum biomarkers of bone formation (alkaline phosphase, AlkphaseB) and resorption (Serum N-terminal telopeptide, NTx). Our central hypothesis is that improvements in bone strength will be greater in subjects randomized to the Exercise group compared to subjects in either Control or Risedronate groups. DISCUSSION: Our research aims to decrease the risk of osteoporotic fractures by improving bone strength in women with low bone mass (pre-osteoporotic) during their first 5 years’ post-menopause, a time of rapid and significant bone loss. Results of this study could be used in developing a clinical management pathway for women with low bone mass at their peak period of bone loss that would involve lifestyle modifications such as exercises prior to medications such as BPs. TRIAL REGISTRATION: Clinicaltrials.gov NCT02186600. Initial registration: 7/7/2014. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12905-016-0339-x) contains supplementary material, which is available to authorized users

Hyponatremia after initiation and rechallenge with trimethoprim&ndash;sulfamethoxazole in an older adult

Ashley M Huntsberry,1 Sunny A Linnebur,1 Maria Vejar2 1University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA; 2Division of Geriatrics, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA Purpose: The purpose of this study is to describe a case report of a patient experiencing hyponatremia from trimethoprim&ndash;sulfamethoxazole (TMP&ndash;SMX) upon initial use and subsequent rechallenge.Summary: An 82-year-old woman presented to the emergency department with altered mental status thought to be due to complicated cystitis and was treated with TMP&ndash;SMX 160 mg/800&nbsp;mg orally twice daily for 7 days. Her basic metabolic panel prior to initiation of TMP&ndash;SMX was within normal limits, with the exception of her serum sodium of 132 mmol/L (range 133&ndash;145&nbsp;mmol/L). The day after completing her 7-day course of TMP&ndash;SMX therapy the patient was evaluated by her primary care provider and another basic metabolic panel revealed a reduction in the serum sodium to 121 mmol/L. The patient&rsquo;s serum sodium concentrations increased to baseline 7 days after completion of the TMP&ndash;SMX therapy, and remained normal until she was treated in the emergency department several months later for another presumed urinary tract infection. She was again started on TMP&ndash;SMX therapy empirically, and within several days her serum sodium concentrations decreased from 138 mmol/L to a low of 129&nbsp;mmol/L. The TMP&ndash;SMX therapy was discontinued upon negative urine culture results and her serum sodium increased to 134 mmol/L upon discharge. Based upon the Naranjo probability scale score of 9, TMP&ndash;SMX was the probable cause of the patient&rsquo;s hyponatremia.Conclusion: Our patient developed hyponatremia from TMP&ndash;SMX therapy upon initial use and rechallenge. Although hyponatremia appears to be rare with TMP&ndash;SMX therapy, providers should be aware of this potentially life-threatening adverse event. Keywords: hyponatremia, trimethoprim&ndash;sulfamethoxazole combination, aged, drug-related side effects and adverse reaction

Medication regimen complexity in ambulatory older adults with heart failure

Michael R Cobretti,1 Robert L Page II,2 Sunny A Linnebur,2 Kimberly M Deininger,1 Amrut V Ambardekar,3 JoAnn Lindenfeld,4 Christina L Aquilante1 1Department of Pharmaceutical Sciences, 2Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, 3Division of Cardiology, School of Medicine, University of Colorado, Aurora, CO, 4Advanced Heart Failure and Cardiac Transplant Program, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA Purpose: Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in &ldquo;young-old&rdquo; (60&ndash;74 years) versus &ldquo;old-old&rdquo; (75&ndash;89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM).Patients and methods: Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60&ndash;89 years with heart failure. Medications were categorized into three types &ndash; heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications &ndash; and scored using the pMRCI tool.Results: The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73&plusmn;7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1&plusmn;14.4, range 3&ndash;84) and total medication counts (13.3&plusmn;4.8, range 2&ndash;30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2&plusmn;4 young-old versus 7.8&plusmn;5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5&plusmn;15.2 versus 28.8&plusmn;12.7, P=0.009; medication count 14.1&plusmn;4.9 versus 12.2&plusmn;4.5, P=0.008), which was largely driven by other prescription medications.Conclusion: Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population. Keywords: medication complexity, heart failure, elderly, geriatric, age