Current patterns of overuse of antimicrobials and of the antianaerobic spectrum of activity were prospectively investigated in 129 adult patients hospitalized in a university-affiliated medical center. Thirty percent of all antimicrobial days of therapy were deemed unnecessary. The most common reasons for unnecessary therapy included administration of antimicrobials for longer than recommended durations, administration of antimicrobials for noninfectious or nonbacterial syndromes, and treatment of colonizing or contaminating microorganisms. Antianaerobic agents accounted for 35% of the unnecessary antimicrobial days of therapy, and these agents were frequently prescribed when equally efficacious alternative regimens with minimal antianaerobic activity were available. Hecker et al identified several common clinical scenarios associated with unnecessary use of antimicrobials that might be amenable to intervention.
Overview of decisions regarding necessity of antimicrobial therapy.
To determine whether use of central nervous system active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases fracture risk in elderly community-dwelling women, Ensrud et al ascertained use of these 4 categories of medications in a cohort of 8127 older women and followed up the participants prospectively for incident nonspine fractures, including hip fractures. During an average follow-up of 4.8 years, 1256 women (15%) experienced at least 1 nonspine fracture, including 288 (4%) with first hip fractures. After adjustment for multiple potential confounding factors, women taking narcotics had a 1.4-fold increase in the risk for any nonspine fracture and those taking antidepressants had a 1.3-fold increase in risk for nonspine fracture and a 1.7-fold increase in risk for hip fracture. The authors conclude that antidepressant use and narcotic use are independent risk factors for fractures in community-dwelling older women.
Dunn and Turpie performed a systematic review of the literature to determine the safety and efficacy of various management strategies for patients receiving oral anticoagulation (OAC) who need to undergo surgery or invasive procedures and identified 31 reports, which were of generally poor quality. Overall, 29 thromboembolic events, including 7 strokes, were experienced among 1868 patients. Major bleeding while receiving therapeutic OAC was rare for dental procedures (0.2% [4/2014]), arthrocentesis (0% [0/32]), cataract surgery (0% [0/203]), and upper endoscopy or colonoscopy with or without biopsy (0% [0/111]), indicating that most patients can undergo these procedures without alteration of their regimen. The authors state that for other invasive procedures and surgical procedures, OAC needs to be withheld and the decision whether to pursue an aggressive strategy of perioperative administration of intravenous heparin or subcutaneous low-molecular-weight heparin individualized. Further and more rigorous studies are needed to better inform this decision.
The proper stroke prophylaxis in patients with atrial fibrillation (AF) requires the determination of stroke risk. van Walraven et al studied 2501 patients with AF treated with aspirin in 6 clinical trials to derive and internally validate a simple clinical prediction rule to identify AF patients whose stroke risk while taking aspirin is low enough that oral anticoagulation is unnecessary. In the derivation, patients with no previous stroke or transient ischemic attack, no treated hypertension or systolic blood pressure exceeding 140 mm Hg, no symptomatic coronary artery disease, and no diabetes experienced 1.0 strokes or transient ischemic attacks per 100 person-years (PYs). The expected event rate for an age- and sex-matched population is 1.2 events per 100 PYs. Low-risk patients in the validation set also had low rates (observed 1.1 events per 100 PYs; expected 1.2 events per 100 PYs). Low-risk patients who were randomized to therapeutic warfarin experienced 1.5 events per 100 PYs. Irrespective of age, AF patients taking aspirin with none of these 4 clinical features had stroke rates comparable with age-matched community cohorts and would not benefit substantially from anticoagulation.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2003;163(8):875. doi:10.1001/archinte.163.8.875