BACKGROUND Our objective was to determine if oral vancomycin, fidaxomicin, and oral metronidazole use in the United States changed after publication of revised clinical practice guidelines for Clostridium difficile infection (CDI) in February 2018. METHODS We obtained US antibiotic prescription data (IQVIA) from 2006-August 2019 and used guideline-recommended dosing regimens to estimate monthly numbers of 10-day treatment courses of vancomycin, fidaxomicin and metronidazole. Interrupted time-series analyses were performed, adjusted by month. We compared linear trends for monthly numbers of treatment courses in different time periods. RESULTS Cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% (n = 226 166) and 48% (n = 18 518), respectively, in 18 months following guidelines compared with 18 months before; those of oral metronidazole decreased by 3% (n = 238 372). Monthly vancomycin and fidaxomicin use significantly increased throughout the period following revised guidelines (P < .0001 and P = .0002, respectively), whereas that of metronidazole decreased significantly (P < .0001). Monthly vancomycin use increased and metronidazole use decreased to a significantly greater extent after publication of revised guidelines than after publication of clinical trials establishing superiority of vancomycin over metronidazole (P < .0001). CONCLUSIONS Revised practice guidelines have had a significant impact on CDI treatment in the US. Clinical trial data used for the revised guidelines were available since 2007-2014 and 2011-2012 for oral vancomycin and fidaxomicin, respectively. Guidelines or guidance documents for treating CDI and other infections should be updated in more timely fashion.

Impact of revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America clinical practice guidelines on the treatment of Clostridium difficile infections in the United States.

The incorporation of evidence-based practice (EBP) is widely recognised as a necessary process for entry-level health professional training. Accreditation documents reflect the practice standards of health professions. No previous study has assessed the extent to which EBP has been taken up by chiropractic regulatory/licencing authorities, known as Councils on Chiropractic Education (CCEs), around the world. The purposes of this study were to examine CCEs’ educational standards for signs of a positive and negative approach to EBP as indicated by the prevalence and use of the words evidence, research, subluxation and vitalism, and to make recommendations if significant deficiencies were found. We undertook a systematic audit of the educational standard documents of the various CCEs. CCEs were selected on the basis of the World Health Organisation. Two investigators identified the occurrences of terms explicitly related to EBP: evidence, evidence-based, research, subluxation and vitalism. This information was tabulated for comparative purposes. The date of the study was March 2016. Occurrences of the term evidence, as it related to EBP, was highest in the CCE-Europe (n = 6), followed by CCE-Australia (n = 2), and CCE-USA (n = 1). None were found in the CCE-International or CCE-Canada documents. The term research appeared most frequently in the CCE-Europe documents (n = 43), followed by CCE-USA (n-32), CCE-Australia (n = 29), CCE-Canada (n = 9) and CCE-International (n = 8). The term subluxation was found only once (CCE-USA) and vitalism did not appear in any educational standard documents. Accreditation bodies are powerfully positioned to act as a driver for education providers to give greater priority to embedding EBP into entry-level programs and shaping future directions within the profession. Terminology relating explicitly to EBP appears to be lacking in the educational standard documentation of CCEs. Therefore, future revisions of accreditation standards should address lack of terminology.

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How comprehensively is evidence-based practice represented in councils on chiropractic education (CCE) educational standards: a systematic audit.

Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.

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Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management.

Maytenus erythroxylon Reissek (Celastraceae) ethanol extract presents antidiarrheal activity via antimotility and antisecretory mechanisms

Over the past 20 years, various authors have addressed the question of the future of chiropractic. Most were positive about the future, with some advocating evidence-based practice and integration with mainstream healthcare, some advocating continued separation with an emphasis on subluxation-based care or the traditional/historical paradigm of chiropractic, and some calling for tolerance and unity. No papers were found specifically inquiring about the future of chiropractic radiology. The study population consisted of all current members of the American Chiropractic College of Radiology (ACCR), estimated at 190 people, known as chiropractic radiologists or Diplomates of the American Chiropractic Board of Radiology (DACBRs). An internet-based, anonymous survey using SurveyMonkey was implemented, supplemented by hard copies distributed at a conference. The main point of interest for this paper is the final item of the overall questionnaire. This item inquired about the future of chiropractic radiology. Thematic analysis was used on the responses, coded in both constructionist and inductive ways to extract both a general outlook and more specific themes. The inductive themes were also assigned secondarily to a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The overall response rate to the survey was 38% (73/190); within the group of respondents, 71 of 73 (98%) answered the item that is the subject of this paper. Opinions on the outlook for chiropractic radiology in the future were more negative than positive, with 14 respondents giving a positive outlook, 26 negative, and 14 non-committal. 28 respondents advocated integration with the wider healthcare community, 11 recommended emphasising separateness or a focus on working within chiropractic, and 15 did not express an opinion on this issue. Ten strengths were noted, 11 weaknesses, 57 opportunities, and 30 threats. The increasing necessity of demonstrating evidence for diagnostic and therapeutic procedures in healthcare makes it likely that chiropractic radiologists and the wider chiropractic profession will need to take a more active position on evidence-based practice. Re-evaluation of guidelines and legislation as well as enforcement policies and practices will be necessary. The consequences of failing to do so may include increased marginalisation and reduced viability as a profession.

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Historical influence on the practice of chiropractic radiology: part II - thematic analysis on the opinions of diplomates of the American Chiropractic College of Radiology about the future.

Objectives Clostridium difficile infection (CDI) is the most common healthcare-associated infection in the United States. Clinical practice guidelines for the treatment of CDI were updated in 2010 by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. An institutional guideline for the classification and management of CDI in accordance with the 2010 Society for Healthcare Epidemiology of America/Infectious Diseases Society of America guideline was developed and provided to attending physicians and medical residents in multiple formats. Methods We sought to determine the impact of an evidence-based guideline for the treatment of CDI at a community teaching hospital. A retrospective chart review was conducted to identify length of stay (LOS), readmission rates, direct cost, mortality, and physician adherence to guidelines in patients with International Classification of Diseases, Ninth Edition codes and laboratory confirmation of CDI between February 1, 2013 and January 31, 2014. Endpoints included LOS after diagnosis of CDI, 30-day readmission rates, direct cost after diagnosis of CDI, and mortality. Results A total of 351 patient encounters were included in the study. Although not statistically significant, it was found that guideline-based therapy (n = 131) was associated with a lower median LOS (6 days vs 8 days; P = 0.06). Thirty-day hospital readmission (25.2% vs 29.5%; P = 0.39) and median cost after diagnosis of CDI ($7238.48 vs $8794.81; P = 0.10) also were lower but not statistically significant. Patients with mild-to-moderate infection were found to have a significantly lower median LOS (5 days vs 7 days; P = 0.03) and median cost after diagnosis ($5257.85 vs $7680.56; P = 0.03) when treated with guideline-based therapy. Overall physician adherence to guidelines was low, at 38%. Conclusions Treatment with guideline-based therapy for CDI was associated with a trend toward a significantly lower LOS and cost. Barriers to physician adherence to guidelines still exist, despite education and guideline availability. Electronic health record-based order sets or clinical decision tools may improve recognition of and adherence to guidelines.

Impact of Evidence-Based Guidelines on Outcomes of Hospitalized Patients With Clostridium difficile Infection

Legionnaires' disease may present with a broad spectrum of illnesses and nonspecific extrapulmonary symptoms including diarrhea. To our knowledge, bowel obstruction has not been reported as a manifestation of Legionella. We present a unique case of Legionnaires' disease contributing to a small bowel obstruction.

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Wesley Prichard

Papers

Impact of Evidence-Based Guidelines on Outcomes of Hospitalized Patients With Clostridium difficile Infection

When Diarrhea Can Become Deadly: Legionnaires' Disease Complicated by Bowel Obstruction.