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Biomedical subjects

Joshua P Metlay

Publications and source records attributed to Joshua P Metlay.

At least 19 recordsLinked to original sources
PubMed2006

Duration of outpatient fecal colonization due to Escherichia coli Isolates with decreased susceptibility to fluoroquinolones: longitudinal study of patients recently discharged from the hospital.

Among 10 subjects colonized with Escherichia coli isolates with reduced susceptibility to fluoroquinolones, the median duration of colonization following hospital discharge was 80 days (range, 8 to 172 days). Colonization was longer for isolates demonstrating organic-solvent tolerance than for isolates that were not organic-solvent tolerant (151 versus 29 days, respectively; P = 0.07) but was not associated with other resistance mechanisms, demographics, or antibiotic use.

Adult↗
PubMed2006

Inaccurate communications in telephone calls to an antimicrobial stewardship program.

BACKGROUND: Antimicrobial stewardship programs (ASPs) decrease unnecessary antimicrobial use, decrease antimicrobial resistance, and improve patient outcomes. The effectiveness of a prior approval system--that is, the requirement that approval be obtained from ASP practitioners before certain antimicrobials can be used--depends on the accuracy of the patient data communicated from the primary service. OBJECTIVES: To determine the incidence of inaccurate communication of patient data during ASP interactions, describe examples of inaccurate communications, and identify risk factors for inaccurate communication. DESIGN: We used a retrospective cohort design. We evaluated the communicated patient data for clinically important inaccuracies, using the patients' medical records as the gold standard. SETTING: A tertiary care medical center that has a prior approval system for restricted antimicrobials. PATIENTS: Inpatients discussed in telephone ASP interactions. INTERVENTION: Observational study. RESULTS: Of telephone calls requesting prior approval from ASP practitioners, 39% (95% confidence interval [CI], 31%-48%) contained an inaccuracy in at least 1 type of patient data (eg, current antimicrobial therapy); the incidence varied widely between data types. Examples of inaccuracies are given to demonstrate their clinical relevance. In multivariable analysis, inaccurate communications were more common for telephone calls from surgical services (versus calls from nonsurgical services: odds ratio, 2.1 [95% CI, 1.1-3.9]) and for calls received by Infectious Diseases fellows (versus pharmacists: odds ratio, 2.0 [95% CI, 1.1-3.8]). CONCLUSIONS: A high proportion of ASP calls requesting prior approval included patient data inaccuracies, which have the potential to affect the prescribing of antimicrobials. Although risk factors were identified, these communication errors were common across the different types of ASP interactions. Inaccurate communications may compromise the utility of ASPs that use a prior approval system for optimizing antimicrobial use.

Academic Medical Centers↗
PubMed2006

The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction.

BACKGROUND: Antibiotics within four hours of arrival for patients with pneumonia and percutaneous intervention (PCI) within two hours for patients with acute myocardial infarction (AMI) are standard measures of emergency department (ED) quality. OBJECTIVES: To assess the institutional-level association between measures of ED crowding and process measures for pneumonia and AMI. METHODS: The authors used summary data from 24 academic hospitals in the University Health Consortium. Analysis included the 2004 ED cycle time survey and performance data from January to December 2004 regarding the Joint Commission for Accreditation of Healthcare Organizations' PN-5b (initial antibiotic administration within four hours) for pneumonia and AMI-8a (PCI received within 120 minutes). Spearman correlation coefficients were used to determine associations between crowding and performance measures. RESULTS: Across all institutions, 59% (range 43%-77%) of pneumonia patients received antibiotics within four hours, and 57% (range 22%-95%) of AMI patients received PCI within two hours. An increase in overall ED length of stay (-0.44, p = 0.04) and for admitted patients (-0.37, p = 0.08) was associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. An increase in chest x-ray turnaround time (-0.83, p < 0.001) and an increase in the left-without-being-seen rate (-0.51, p = 0.01) were also associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. No measures of crowding exhibited an association with time to PCI for AMI patients. CONCLUSIONS: Administrative measures of ED crowding showed an association with poorer performance on pneumonia quality of care measures but not with AMI quality of care measures. Hospitals might consider improving ED throughput, reducing boarding times for admitted patients, and reducing chest x-ray turnaround times to improve pneumonia care.

Angioplasty, Balloon, Coronary↗
PubMed2006

Phenotypic and genotypic characterization of fecal Escherichia coli isolates with decreased susceptibility to fluoroquinolones: results from a large hospital-based surveillance initiative.

BACKGROUND: The prevalence of fecal colonization with Escherichia coli that has reduced susceptibility to fluoroquinolones is unknown. A detailed characterization of such isolates is limited. METHODS: We conducted 3 annual fecal surveillance initiatives at 2 hospitals from 2002 to 2004. All E. coli isolates with reduced susceptibility to fluoroquinolones (minimum inhibitory concentration [MIC] to levofloxacin, > or = 0.125 microg/mL) were identified. We characterized gyrA and parC mutations and organic solvent tolerance (OST). Isolates were compared using pulsed-field gel electrophoresis. RESULTS: Of 789 fecal samples, 149 (18.9%) revealed E. coli with reduced susceptibility to fluoroquinolones. Of 149 isolates, 102 (68.5%) had a MIC > or = 8 microg/mL, 138 (92.6%) had > or = 1 gyrA mutation, 101 (67.8%) had > or = 1 parC mutation, and 59 (39.6%) demonstrated OST. Isolates with a MIC > or = 8 versus <8 microg/mL had more target mutations (median, 3 vs. 1; P<.001) and more often exhibited OST (51% vs. 15%; P<.001). Of 149 isolates, 144 (96.6%) demonstrated a MIC > or = 16 microg/mL to nalidixic acid. The prevalence of OST differed across study years (P = .01). There was no clonal spread of isolates. CONCLUSIONS: Colonization by E. coli with reduced fluoroquinolone susceptibility is common, and fluoroquinolone-resistance characteristics differ significantly over time. Resistance to nalidixic acid may be useful in the identification of E. coli with early resistance mutations.

Anti-Bacterial Agents↗
PubMed2006

Population antibiotic susceptibility for Streptococcus pneumoniae and treatment outcomes in common respiratory tract infections.

PURPOSE: Antibiotic-resistant Streptococcus pneumoniae potentially threatens the successful treatment of common respiratory tract infections (RTIs); however, the relationship between antibiotic resistance and treatment outcomes remains unclear. We aimed to test the hypothesis that higher in vitro penicillin and erythromycin nonsusceptibility levels among clinical isolates of S. pneumoniae are associated with higher risk of treatment failure in suppurative acute otitis media (AOM), acute sinusitis, and acute exacerbation of chronic bronchitis (AECB). METHODS: We conducted a population-level analysis using treatment outcomes data from a national, managed-care claims database, and antibiotic susceptibility data from a national repository of antimicrobial susceptibility results between 1997 and 2000. Treatment outcomes in patients with suppurative AOM, acute sinusitis, or AECB receiving selected macrolides or beta-lactams were assessed. Associations between RTI-specific treatment outcomes and antibiotic nonsusceptibility were determined using Spearman correlation coefficients with condition-specific paired outcome and susceptibility data for each region and each year. RESULTS: There were 649 552 available RTI outcomes and 7252 susceptibility tests performed on S. pneumoniae isolates. There were no statistically significant trends across time for resolution proportions following treatment by either beta-lactams or macrolides among any of the RTIs. Correlation analyses found no statistically significant association between S. pneumoniae susceptibility and RTI treatment outcomes apart from a significant positive association between of erythromycin nonsusceptibility in ear isolates and macrolide treatment resolution for suppurative AOM. CONCLUSION: On the population level, in vitro S. pneumoniae nonsusceptibility to macrolide or beta-lactam antibiotics was not associated with treatment failure in conditions of probable S. pneumoniae etiology.

Acute Disease↗
PubMed2006

Antibiotic treatment of acute respiratory infections in acute care settings.

OBJECTIVES: To examine the patterns of antibiotic use for acute respiratory tract infections (ARIs) in acute care settings. METHODS: Chart reviews were performed retrospectively on a random sample of adult ARI visits to seven Veterans Affairs (VA) and seven non-VA emergency departments (EDs) for the period of November 2003 to February 2004. Visits were limited to those discharged to home and those with primary diagnoses of antibiotic-responsive (pneumonia, acute exacerbation of chronic bronchitis, pharyngitis, sinusitis) and antibiotic-nonresponsive conditions (acute bronchitis, nonspecific upper respiratory tract infection [URI]). Results are expressed as adjusted odds ratios with 95% confidence intervals. RESULTS: Of 2,270 ARI visits, 62% were for antibiotic-nonresponsive diagnoses. Seventy-two percent of acute bronchitis and 38% of URI visits were treated with antibiotics (p < 0.001). Stratified analyses show that antibiotic prescription rates were similar among attending-only and housestaff-associated visits for antibiotic-responsive diagnoses (p = 0.11), and acute bronchitis (76% vs. 59%; p = 0.31). However, the antibiotic prescription rate for URIs was greater for attending-only visits compared with housestaff-associated visits (48% vs. 15%; p = 0.01). Antibiotic prescription rates for total ARIs varied between sites, ranging from 42% to 89%. Patient age, gender, race and ethnicity, smoking status, comorbidities, and clinical setting (VA vs. non-VA) were not independently associated with antibiotic prescribing. CONCLUSIONS: Acute care settings are important targets for reducing inappropriate antibiotic prescribing. The mechanisms accounting for lower antibiotic prescription rates observed with housestaff-associated visits merit further study.

Acute Disease↗
PubMed2006

Antimicrobial drug resistance, regulation, and research.

Innovative regulatory and legislative measures to stimulate and facilitate the development of new antimicrobial drugs are needed. We discuss research approaches that can aid regulatory decision making on the treatment of resistant infections and minimization of resistance selection. We also outline current and future measures that regulatory agencies may employ to help control resistance and promote drug development. Pharmacokinetic/pharmacodynamic research models offer promising approaches to define the determinants of resistance selection and drug doses that optimize efficacy and reduce resistance selection. Internationally, variations exist in how regulators use drug scheduling, subsidy restrictions, central directives, educational guidelines, amendments to prescribing information, and indication review. Recent consultations and collaborations between regulators, academics, and industry are welcome. Efforts to coordinate regulatory measures would benefit from greater levels of international dialogue.

Anti-Bacterial Agents↗
PubMed2006

Macrolide resistance in adults with bacteremic pneumococcal pneumonia.

We conducted a case-control study of adults with bacteremic pneumococcal pneumonia to identify factors associated with macrolide resistance. Study participants were identified through population-based surveillance in a 5-county region surrounding Philadelphia. Forty-three hospitals contributed 444 patients, who were interviewed by telephone regarding potential risk factors. In multivariable analyses, prior exposure to a macrolide antimicrobial agent (odds ratio [OR] 2.8), prior flu vaccination (OR 2.0), and Hispanic ethnicity (OR 4.1) were independently associated with an increased probability of macrolide resistance, and a history of stroke was independently associated with a decreased probability of macrolide resistance (OR 0.2). Fifty-five percent of patients with macrolide-resistant infections reported no antimicrobial drug exposure in the preceding 6 months. Among patients who reported taking antimicrobial agents in the 6 months preceding infection, failure to complete the course of prescribed drugs was associated with an increased probability of macrolide resistance (OR 3.4).

Adolescent↗
PubMed2005

Changes in veterans' use of outpatient care from 1992 to 2000.

OBJECTIVES: During the mid-1990s, the Veterans Health Administration (VHA) reorganized and placed greater emphasis on high-quality primary care. To determine whether the reorganization was associated with changes in patterns of out-patient VHA use, we sought to evaluate changes in characteristics of veterans who use VHA outpatient services between 1992 and 2000. METHODS: We merged 2 waves of the National Survey of Veterans to determine changes in patterns of outpatient care use. We evaluated the extent to which veterans who received outpatient care received that care from the VHA. RESULTS: The odds ratio for VHA-only outpatient care relative to non-VHA-only care in 2000 relative to 1992 was 1.75 (95% confidence interval [CI]=1.51, 2.04), and the odds ratio for dual relative to non-VHA-only care was 1.22 (95% CI=1.08, 1.37). Veterans who were older, had low incomes, and had no additional health insurance coverage were most likely to increase their use of VHA outpatient care. CONCLUSIONS: Our results suggest that the VHA is increasingly serving veterans who have trouble accessing the private health care system.

Ambulatory Care↗
PubMed2005

Association between fluoroquinolone resistance and mortality in Escherichia coli and Klebsiella pneumoniae infections: the role of inadequate empirical antimicrobial therapy.

BACKGROUND: The prevalence of fluoroquinolone (FQ) resistance among Escherichia coli and Klebsiella pneumoniae has increased markedly in recent years. However, the impact of FQ resistance on mortality remains unknown. METHODS: To identify the association between FQ resistance and mortality, we conducted a retrospective cohort study of hospitalized patients with infections due to FQ-resistant strains and FQ-susceptible strains of E. coli and K. pneumoniae between 1 January 1998 and 30 June 1999. RESULTS: Of 123 patients with FQ-resistant infection, 16 (13.0%) died, compared with 4 (5.7%) of 70 patients with FQ-susceptible infection (odds ratio [OR], 2.47; 95% confidence interval [CI], 0.75-10.53). After adjustment for other significant risk factors and confounders, there remained an independent association between FQ-resistant infection and mortality (adjusted OR, 4.41; 95% CI, 1.03-18.81). Patients with FQ-resistant infection were significantly less likely to have received antimicrobial therapy with activity against the infecting pathogen within the first 24 h and 48 h of infection (P=.002 and P<.001, respectively). The association between FQ resistance and mortality was no longer significant, after adjusting for inadequate empirical therapy. CONCLUSIONS: FQ resistance is an independent risk factor for mortality in patients with health care-acquired E. coli and K. pneumoniae infections. This may be explained, at least in part, by a delay in the initiation of appropriate antimicrobial therapy in patients with FQ-resistant infection. These results highlight the grave clinical consequences of FQ resistance and emphasize the importance of efforts designed to curb the increase in the prevalence of resistance to these agents.

Adult↗
PubMed2005

Impact of pediatric vaccination with pneumococcal conjugate vaccine on the risk of bacteremic pneumococcal pneumonia in adults.

Invasive pneumococcal disease in adults may be declining, reflecting a form of herd protection from a new pediatric pneumococcal conjugate vaccine. Our aim was to determine whether vaccination of children protects adults in the same home from bacteremic pneumococcal pneumonia. We conducted a case-control study with 43 participating hospitals across a five-county region in Pennsylvania. Eligible cases were adults with bacteremic pneumococcal pneumonia identified by the microbiology laboratories at participating hospitals. Controls were healthy adults from the region identified through random digit dialing. Cases and controls were interviewed by telephone. We analyzed vaccine protection in those adults who reported living in homes with at least one child < or =6 years of age. From April 2002 through June 2004, there was a significant decline in the proportion of adult pneumococcal bacteremia due to any of the seven serotypes in the conjugate vaccine (p=0.006). Within this time period, 17% of cases and controls reported living in homes with at least one child < or =6 years of age. In adjusted analysis, vaccination of the youngest child in the home was associated with an 80% reduction in the odds of bacteremic pneumococcal pneumonia among adults with children in the home (OR=0.2, 95% CI 0.1-0.8). We conclude that introduction of a pneumococcal conjugate vaccine for children has reduced the population rate of adult pneumococcal bacteremia due to vaccine serotypes and is associated with a reduced risk of bacteremic pneumococcal pneumonia for adults with children in the home.

Adult↗
PubMed2005

Role of computerized physician order entry systems in facilitating medication errors.

CONTEXT: Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. OBJECTIVE: To identify and quantify the role of CPOE in facilitating prescription error risks. DESIGN, SETTING, AND PARTICIPANTS: We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders. MAIN OUTCOME MEASURE: Examples of medication errors caused or exacerbated by the CPOE system. RESULTS: We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. CONCLUSIONS: In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

Clinical Pharmacy Information Systems↗
PubMed2005

Accuracy of adult reported pneumococcal vaccination status of children.

PURPOSE: A pneumococcal conjugate vaccine was licensed in 2000 for use in children. To evaluate the accuracy of an adult's recall of children's vaccination status with the pneumococcal vaccine, the authors conducted a cross-sectional survey of adults in Philadelphia County from January to December 2003. METHODS: Subjects were identified by random digit dialing and interviewed regarding the age and vaccination status of all children 6 years old or younger with whom they had significant contact. The gold standard for determining the accuracy of vaccine status reports was the Kids Immunization Database/Tracking System (KIDS) at the City of Philadelphia Department of Public Health. RESULTS: One hundred twenty-two interviews were completed with vaccination data collected on 185 children. One hundred sixty-six children (90%) were matched with records in the KIDS registry. The sensitivity and specificity of adult reported child vaccine status were 0.65 (95% CI, 0.55, 0.74) and 0.47 (95% CI, 0.34, 0.61), respectively. Agreement between adult report and the KIDS registry was 59%. Significant variation in agreement was not found to be related to demographic characteristics of the adult subjects. CONCLUSION: Adult report of the pneumococcal vaccination status of children was found to be relatively inaccurate and did not vary by known demographic characteristics.

Adult↗
PubMed2005

Facility-level variation in antibiotic prescriptions for veterans with upper respiratory infections.

BACKGROUND: Programs have targeted individual patient and physician behaviors to reduce the use of antibiotics for upper respiratory infections (URIs), but such efforts have had limited success to date. OBJECTIVE: The aim of this study was to measure the extent of variation in antibiotic prescribing patterns at the hospital-facility level to determine whether organizational factors may be associated with patterns of antibiotic prescribing. METHODS: This was a cross-sectional study using linked pharmacy and encounter data to measure hospital-level variation in patterns of antibiotic prescribing at US Department of Veterans Affairs (VA) medical centers between October 1, 2000, and September 30, 2001. The main outcome measure was the proportion of visits for URIs or acute bronchitis with an antibiotic dispensed within 1 day before to 3 days after the encounter, restricted to primary-care and emergency/urgent care clinics at VA medical centers with > or =100 annual visits for URIs. RESULTS: A median of 523 visits for URIs occurred across 108 medical centers. The median proportion of visits with an antibiotic dispensed was 52% (range, 14%-88%). Hospitals in the South had increased odds of prescribing antibiotics for veterans with URIs compared with hospitals in the Northeast (odds ratio, 1.8 [95% CI, 1.2-2.5]). Among facilities with <200,000 visits per year, an increase in the percentage of unscheduled outpatient visits increased the odds of prescribing antibiotics for veterans with URIs (odds ratio per 10% increase, 1.3 [95% CI, 1.1-1.5]). CONCLUSIONS: Our results suggest variation in antibiotic prescribing for URIs at the hospital-facility level within the VA health care system. Organizational factors, such as time pressure, may be important targets for future interventions designed to reduce inappropriate antibiotic use in ambulatory care settings.

Acute Disease↗
PubMed2005

Medication safety in older adults: home-based practice patterns.

OBJECTIVES: To identify the current state of medication-taking practices of community-dwelling older adults on high-risk medications. DESIGN: Telephone survey of older adults filling prescriptions for warfarin, digoxin, or phenytoin from May 2, 2002, through June 30, 2003. SETTING: The Pennsylvania Pharmacy Assistance Contract for the Elderly (PACE) Program, a state-run program providing prescription drug coverage for poor older adults. PARTICIPANTS: PACE members. MEASUREMENTS: Patients self-reported sources of information on current medications as well as home-based practices for organizing medication regimens. RESULTS: Four thousand nine hundred fifty-five PACE members were interviewed. Thirty-two percent of the sample reported that they had not received any specific instructions about their medications, 35% reported that they received instructions from their primary care provider, and 46% indicated they received them from a pharmacist. Fifty-four percent of participants indicated that they used a pillbox for organizing their medications. Older adults prescribed warfarin were more likely to report receiving instructions than those prescribed digoxin or phenytoin. CONCLUSION: A substantial proportion of older adults on high-risk medications do not recall receiving instructions for the use of their medications and do not take advantage of existing systems for organizing medication regimens. Improved patient education and delivery of medication organization systems are immediate opportunities to potentially reduce the risk of medication errors in older people.

Aged↗
PubMed2005

Test characteristics of perirectal and rectal swab compared to stool sample for detection of fluoroquinolone-resistant Escherichia coli in the gastrointestinal tract.

Among 63 patients enrolled in a prospective cohort study of gut colonization with fluoroquinolone-resistant Escherichia coli, the sensitivity of perirectal swab compared to stool sample was 90% (95% confidence interval [CI], 70 to 99%) and the specificity was 100% (95% CI, 91 to 100%). For rectal swab, the sensitivity was 90% (95% CI, 68 to 99%) and the specificity was 100% (95% CI, 91 to 100%).

Adult↗
PubMed2005

Assessing the suitability of intervention sites for quality improvement studies in emergency departments.

OBJECTIVES: As an initial step in disseminating an emergency department (ED)-based quality improvement program (QIP) to improve antibiotic prescribing for patients with acute respiratory infections, the authors conducted a nationwide survey to assess the value and feasibility of the QIP. METHODS: Directors of EDs at 119 Veterans Administration hospitals and 160 non-Veterans Administration hospitals (identified based on the existence of accredited emergency medicine training programs and/or participation in an existing ED-based research network) were surveyed. The survey included questions on the current existence of an antibiotic QIP in the ED, enthusiasm for an antibiotic QIP program, and the existence of physical features in the ED that would support the QIP intervention. RESULTS: Overall, 77% of ED directors reported they did not have an existing antibiotic QIP and 84% reported they would benefit from having such a program (either new or in addition to their current program). In addition, 63% of respondents indicated that improving antibiotic prescribing was an intermediate to high priority in the ED. Forty-five percent reported that they did not have a suitable location for a key component of the intervention (an interactive computer kiosk), and 26% reported that they could not display educational posters on the walls of the examination room. CONCLUSIONS: Many EDs identify barriers to implementing an antibiotic QIP. Perceived and real barriers are important factors to consider in translating successful QIPs into routine clinical practice.

Anti-Bacterial Agents↗