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Kate Setzler 1264

Inpatient Insights

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Antibiotics prevalent in nursing homes

Nursing home care staff faces cheerful elderly couple

While promoting antibiotic stewardship is important to the health of all patients, overprescribing of antibiotics is a particular problem among nursing home patients. According to a recent paper published on April 5, 2023, in the Journal of Infectious Diseases, antibiotics are among the most frequently prescribed medications in nursing homes, and up to 85% of prescribed antibiotics are inappropriate or unnecessary.

Nursing home residents are particularly vulnerable to adverse outcomes from antibiotic use, such as Clostridioides difficile infection, which not only affects residents who are prescribed antibiotics, but can be transmitted to other residents in the facility.

Researchers at the Brown University School of Public Health studied a national cohort of older adults residing long-term in U.S. nursing homes between 2013 and 2017 and calculated period prevalence estimates for antibiotic prescribing, rates of prescribing, and days of therapy. They found that among 1,375,062 residents, 66.2% were prescribed at least one antibiotic during the nursing home stay. The median number of antibiotic courses per resident was two and overall, residents received 41.6 days of antibiotic treatment per 1,000 days of care.

The most prevalent antibiotic classes were ­fluoroquinolones, sulfonamides and related agents, and first-generation cephalosporin. Sulfamethoxazoletrimethoprim, levofloxacin, and ciprofloxacin were the most prevalent antibiotics.

The authors suggest that their results can inform antibiotic stewardship interventions to reduce antibiotic overprescribing, improve appropriateness, and reduce related adverse outcomes in nursing homes. ■


Comparing the efficacy of antibiotics for spontaneous bacterial peritonitis

colorful bacteria

For patients with liver cirrhosis, spontaneous bacterial peritonitis (SBP) is one of the most serious complications of the disease. Initial treatment consists of the use of antibiotics, including cefotaxime, ceftriaxone, and ciprofloxacin. Increasing antibiotic resistance, however, has led researchers to question if the three antibiotics are comparable and still appropriate for clinical treatment of SBP. A recent study, published in the April 2023 issue of the American Journal of Gastroenterology, compared the current efficacy of cefotaxime, ceftriaxone, and ciprofloxacin for the treatment of SBP in patients with cirrhosis with ascites.

Researchers from eight universities in Korea conducted a multicenter, prospective, randomized controlled trial that included 261 patients with liver cirrhosis with ascites randomized to receive one of the three subject antibiotics.

A follow up paracentesis was performed after 48 hours of treatment to allow a change of antibiotic in the absence of an initial response, defined as a >25% decline in polymorphonuclear cell count. Further evaluations were done after 120 hours (the primary endpoint) and 168 hours of treatment.

Resolution rates at the primary endpoint were 67.8%, 77.0%, and 73.6% in the cefotaxime, ceftriaxone, and ciprofloxacin groups, respectively, and the 1-month mortality was similar among the groups. The authors concluded that the efficacy of the three antibiotics was not significantly different when using response-guided therapy and that they are still efficacious as the initial treatment for SBP, especially in patients with community-acquired infections. ■


Bisphosphonate use OK after long-bone fractures

molecular model

Fragility fractures among older patients often necessitate initiation of osteoporosis treatment. While the use of bisphosphonates is the current standard of care for medical management of osteoporosis, it’s unclear if osteoporosis medications increase the risk of nonunion when administered after surgical treatment of an acute fracture.

In a recent study published in the April 2023 issue of the Journal of Bone and Joint Surgery, researchers investigated whether bisphosphonates or selective estrogen receptor modulators/hormone replacement therapy (SERM/HRT) are associated with nonunion following fracture in a population of older adults.

The authors conducted a retrospective analysis of Medicare claims from 2016 to 2019 to identify patients more than 65 years old who had a surgically treated long-bone fracture and successive claims were linked for each beneficiary through one year following the fracture to determine fracture union status. Multivariable logistic regression models were specified to identify the association between medications and fracture union status while controlling for age, sex, race, Charlson Comorbidity Index (CCI), and fracture type.

Of the more than 110,000 fractures included in the study, only 9.4% were associated with a diagnosis of nonunion within one year. Bisphosphonate use was more common in the nonunion group (12.2% vs. 11.4%), but when controlling for race, age, sex, and CCI, neither bisphosphonates nor SERM/HRT were associated with nonunion. Bisphosphonate use within 90 days post-fracture was not significantly associated with nonunion and the timing of medication administration did not influence fracture union status.

The authors concluded that orthopedic surgeons should not withhold or delay initiation of bisphosphonate or SERM/HRT for osteoporosis after acute fracture out of concern for nonunion. ■


LDC medications effective for initial management of hypertension

a person takes their blood pressure using a pressure cuff

Low-dose combination (LDC) medications consisting of three or four antihypertensive drugs have emerged as a potentially important therapy for the initial management of hypertension. Researchers at the University of New South Wales, Royal Prince Alfred Hospital, the University of Sydney, Northwestern University, Washington University in St. Louis, and the University of Kelaniya (Sri Lanka) conducted a systematic review and meta-analysis of seven trials enrolling 1,918 patients and found that LDC antihypertensives were more efficacious than monotherapy, usual care, or placebo in terms of mean BP reduction and achieving a BP target. Four trials involved triple-component LDC and four involved quadruple-component LDC.

The researchers found that at 4 to 12 weeks’ follow up, LDC medications were associated with a greater mean reduction in systolic BP than initial monotherapy, usual care, and placebo. LDC medications were also associated with a higher proportion of participants achieving BP <140/90 mm Hg at 4 to 12 weeks compared to monotherapy, usual care, and placebo.

They found no significant heterogeneity between trials enrolling patients with and without baseline BP-lowering therapy. Results from two trials indicated that LDC medications remained superior to monotherapy or usual care at 6 to 12 months. LDC medications were associated with more dizziness but no other adverse effects nor treatment withdrawal.

The authors concluded that the study, published on April 26, 2023, in JAMA Cardiology, showed evidence that LDC medications may be an effective strategy for the early management of hypertension. ■

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