RESUMEN
OBJECTIVES: Due to antimicrobial resistance in Streptococcus pneumoniae, national guidelines recommend a respiratory fluoroquinolone or combination antimicrobial therapy for outpatient treatment of community-acquired pneumonia (CAP) associated with risk factors for drug-resistant S. pneumoniae (DRSP). The objectives of this study were to assess the prevalence of these risk factors and antibiotic prescribing practices in cases of outpatient CAP treated in the acute care setting. METHODS: This was a retrospective cohort study of adult outpatients treated for CAP in the emergency department (ED) or urgent care center of an urban, academic medical center from May 1, 2009, through October 31, 2009, and comparison of antibiotic therapy in cases with and without DRSP risk factors. RESULTS: Of 175 patients, 90 (51%) had at least one DRSP risk factor, most commonly asthma (n = 28, 16%), alcohol abuse (n = 24, 14%), diabetes mellitus (n = 18, 10%), chronic obstructive pulmonary disease (n = 16, 9%), age > 65 years (n = 16, 9%), and use of antibiotics within 3 months (15, 9%). Antibiotic prescriptions were similar among cases with and without DRSP risk factors: a macrolide (62% vs. 59%, respectively, p = 0.65), doxycycline (27% vs. 28%, p = 0.82), or a respiratory fluoroquinolone (9% vs. 9%, p = 0.90). Concordance with national guideline treatment recommendations was significantly lower in cases with DRSP risk factors (9% vs. 87%, p < 0.0001). CONCLUSIONS: DRSP risk factors were present in approximately half of outpatient CAP cases treated in the acute care setting; however, guideline-concordant antibiotic therapy was infrequent. Strict adherence to current guidelines would substantially increase use of fluoroquinolones or combination therapy. Whether the potential risks associated with these broad-spectrum regimens are justified by improved clinical outcomes requires further study.
Asunto(s)
Antibacterianos/uso terapéutico , Farmacorresistencia Bacteriana/efectos de los fármacos , Neumonía Neumocócica/tratamiento farmacológico , Streptococcus pneumoniae/efectos de los fármacos , Centros Médicos Académicos , Adulto , Estudios de Cohortes , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Servicio de Urgencia en Hospital , Hospitales Urbanos , Humanos , Servicio Ambulatorio en Hospital , Neumonía Neumocócica/complicaciones , Pautas de la Práctica en Medicina , Estudios Retrospectivos , Factores de RiesgoRESUMEN
INTRODUCTION: Traditional medical training focuses on ameliorating disease states but not on the underlying socially determined causes. The LEADS (Leadership Education Advocacy Development Scholarship) program at the University of Colorado Denver School of Medicine was designed to train medical students to become effective advocates and to promote health at the community level. METHODS: Participants in the LEADS Track complete courses in advocacy skills, perform a summer internship, and complete a mentored scholarly activity addressing population health. Students are paired with a faculty mentor and a community-based organization. RESULTS: Students report empowerment, improved self-efficacy, and increased likelihood of future engagement in leadership and health advocacy. Community sponsors also rate the experience as highly valuable. CONCLUSIONS: A curriculum in advocacy and leadership skills that includes an intensive, community-based service learning experience is effective at increasing student empowerment and disposition toward community service.
Asunto(s)
Curriculum , Educación Médica/métodos , Promoción de la Salud , Aprendizaje Basado en Problemas , Estudiantes de Medicina , Colorado , Servicios de Salud Comunitaria , Humanos , Liderazgo , Defensa del Paciente , Poder Psicológico , AutoeficaciaRESUMEN
BACKGROUND: Cellulitis and cutaneous abscess are among the most common infections leading to hospitalization, yet optimal management strategies have not been adequately studied. We hypothesized that implementation of an institutional guideline to standardize and streamline the evaluation and treatment of inpatient cellulitis and abscess would decrease antibiotic and health care resource utilization. METHODS: A retrospective preintervention-postintervention study was performed to compare management before and after implementation of the guideline (January 1, 2007-December 31, 2007, and July 9, 2009-July 8, 2010). RESULTS: A total of 169 patients (66 with cellulitis, 103 with abscess) were included in the baseline cohort, and 175 (82 with cellulitis, 93 with abscess) were included in the intervention cohort. The intervention led to a significant decrease in use of microbiological cultures (80% vs 66%; P = .003) and fewer requests for inpatient consultations (46% vs 30%; P = .004). The median duration of antibiotic therapy decreased from 13 days (interquartile range [IQR], 10-15 days) to 10 days (IQR, 9-12 days) (P < .001). Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). Clinical failure occurred in 7.7% and 7.4% of cases (P = .93), respectively. CONCLUSION: Implementation of a guideline for the management of inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes.