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1.  Effects of Clinical Pathways for Common Outpatient Infections on Antibiotic Prescribing 
The American journal of medicine  2013;126(4):327-335.e12.
Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use.
Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all eight conditions during a 2-year baseline and 1-year intervention period.
In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (p <.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (p=0.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively, (14.4% relative reduction) (p <.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (p=0.35). There were significant differences in the trends of prescriptions for acute respiratory infections (p<.0001) and broad-spectrum antibiotic use (p=0.001) between the study and control groups during the intervention period, with greater declines in the study group.
This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.
PMCID: PMC3666348  PMID: 23507206
Clinical pathways; guidelines; antimicrobial stewardship; antibiotic prescribing; primary care; acute respiratory infection
2.  Targets for Antibiotic and Health Care Resource Stewardship in Inpatient Community-Acquired Pneumonia: A Comparison of Management Practices with National Guideline Recommendations 
Infection  2012;41(1):135-144.
Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the U.S. The objective of this study was to evaluate management practices for inpatient CAP in relation to IDSA/ATS guidelines to identify opportunities for antibiotic and health care resource stewardship.
This was a retrospective cohort study of adults hospitalized for CAP at a single institution from April 15, 2008 – May 31, 2009.
Of 209 cases, 166 (79%) were admitted to a medical ward and 43 (21%) to the intensive care unit (ICU). 61 (29%) cases were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. 110 sputum cultures were ordered; however, an evaluable sample was obtained in 49 (45%) cases, median time from antibiotic initiation to specimen collection was 11 (IQR 6–19) hours, and a potential pathogen was identified in only 18 (16%). Blood cultures were routinely obtained for both non-ICU (81%) and ICU (95%) cases, but 15 of 36 (42%) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone plus azithromycin (182, 87% cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66%), most commonly levofloxacin (101, 55%). Treatment durations were typically longer than suggested with a median of 10 (IQR 8 – 12) days.
In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations revealing potential targets to reduce unnecessary antibiotic and health care resource utilization.
PMCID: PMC3567260  PMID: 23160837
pneumonia; community-acquired pneumonia; guidelines; Infectious Diseases Society of America; antimicrobial stewardship; Streptococcus pneumoniae; fluoroquinolones
3.  Introducing standardized “readbacks” to improve patient safety in surgery: a prospective survey in 92 providers at a public safety-net hospital 
BMC Surgery  2012;12:8.
Communication breakdowns represent the main root cause of preventable complications which lead to harm to surgical patients. Standardized readbacks have been successfully implemented as a main pillar of professional aviation safety for decades, to ensure a safe closed-loop communication between air traffic control and individual pilots. The present study was designed to determine the perception of staff in perioperative services regarding the role of standardized readbacks for improving patient safety in surgery at a single public safety-net hospital and level 1 trauma center.
A 12-item questionnaire was sent to 180 providers in perioperative services at Denver Health Medical Center. The survey was designed to determine the individual participants’ perception of (1) appropriateness of current readback processes; (2) willingness to attend a future training module on this topic; (3) specific scenarios in which readbacks may be effective; and (4) perceived major barriers to the implementation of standardized readbacks. Survey results were compared between departments (surgery versus anesthesia) and between specific staff roles (attending or midlevel provider, resident physician, nursing staff), using non-parametric tests.
The response rate to the survey was 50.1 % (n = 92). Respondents overwhelmingly recognized the role of readbacks in reducing communication errors and improving patient safety. There was a strong agreement among respondents to support participation in a readbacks training program. There was no difference in the responses between the surgery and anesthesia departments.
There was a statistically significant difference in the healthcare providers willingness to attend a short training module on readbacks (p < 0.001). Resident physicians were less likely to endorse the importance of readbacks in reducing communication errors (p = 0.01) and less willing to attend a short training module on readbacks (p < 0.001), as compared to staff providers and nursing staff.
The main challenge for respondents, which emanated from their responses, appeared to relate to determining the ideal scenarios in which readbacks may be most appropriately used. Overall, respondents strongly felt that readbacks had an important role in patient handoffs, patient orders regarding critical results, counting and verifying surgical instruments, and delegating multiple perioperative tasks.
The majority of all respondents appear to perceive standardized readbacks as an effective tool for reducing and/or preventing adverse events in the care of surgical patients, derived from a breakdown in communication among perioperative caregivers. Further work needs to be done to define the exact clinical scenarios in which readbacks may be most efficiently implemented, including the definition of a uniform set of scripted quotes and phrases, which should likely be standardized in concert with the aviation safety model.
PMCID: PMC3418160  PMID: 22713158
4.  Complement C3 serum levels in anorexia nervosa: a potential biomarker for the severity of disease? 
Anorexia nervosa carries the highest mortality rate of any psychiatric disorder. Even the most critically ill anorexic patients may present with normal 'standard' laboratory values, underscoring the need for a new sensitive biomarker. The complement cascade, a major component of innate immunity, represents a driving force in the pathophysiology of multiple inflammatory disorders. The role of complement in anorexia nervosa remains poorly understood. The present study was designed to evaluate the role of complement C3 levels, the extent of complement activation and of complement hemolytic activity in serum, as potential new biomarkers for the severity of anorexia nervosa.
Patients and methods
This was a prospective cohort study on 14 patients with severe anorexia nervosa, as defined by a body mass index (BMI) <14 kg/m2. Serum samples were obtained in a biweekly manner until hospital discharge. A total of 17 healthy subjects with normal BMI values served as controls. The serum levels of complement C3, C3a, C5a, sC5b-9, and of the 50% hemolytic complement activity (CH50) were quantified and correlated with the BMIs of patients and control subjects.
Serum C3 levels were significantly lower in patients with anorexia nervosa than in controls (median 3.7 (interquartile range (IQR) 2.5-4.9) vs 11.4 (IQR 8.9-13.7, P <0.001). In contrast, complement activation fragments and CH50 levels were not significantly different between the two groups. There was a strong correlation between index C3 levels and BMI (Spearman correlation coefficient = 0.71, P <0.001).
Complement C3 serum levels may represent a sensitive new biomarker for monitoring the severity of disease in anorexia nervosa. The finding from this preliminary pilot study will require further investigation in future prospective large-scale multicenter trials.
PMCID: PMC3110119  PMID: 21542928

Results 1-4 (4)