Development of Antibiogram for Management of Aerobic Bacterial Infection in Diabetic Foot Ulcer

VA L U E I N H E A LT H 1 9 ( 2 0 1 6 ) A 8 0 7 – A 9 1 8

PDB48 Comparisons of Treatment Patterns for Type 2 Diabetes Mellitus (T2DMm) in Japan and in the United States Anabuki K1, Irwin DE2, Winer I3, Iizuka R1, Nishikino R1, Palmer LA4 Medical Data Center Co.,Ltd., Tokyo, Japan, 2Truven Health Analytics, Chapel Hill, NC, USA, 3Truven Health Analytics, Ann Arbor, MI, USA, 4Truven Health Analytics, Bethesda, MD, USA

1Japan

Objectives: Compares real world treatment patterns for T2DM in Japan and the United States (US).  Methods: Retrospective analysis was conducted using administrative claims data from MarketScan® Commercial and Medicare and JMDC Claims Database databases (1/1/2009-12/31/2014). Adult T2DM patients (MarketScan n= 233,058; JMDC n=  18,006) were included if they were newly treated with oral hypoglycemic agents. The index date was the date of first treatment. First and second line treatment patterns are compared during a 6-month follow-up.  Results: Patients were predominately male (52% US; 72% Japan) with mean age of 58 years in the US and 51 years in Japan. The majority of patients initiated treatment with a monotherapy (US 87%; Japan 85%). In the US, biguanides (74%), sulfonylureas (14%) and dipeptidyl-peptidase inhibitors (DPP4-i) (6%) were the most common monotherapies compared to Japan where DPP4-i (45%) was the most common followed by biguanides (22%), sulfonylureas (12%) and alpha-glucosidase inhibitors (12%). The majority of patients remained on their index therapy for the entire follow-up (54% US; 60% Japan);16% of the US and 23% of Japanese patients switched to a different treatment. Second line therapy predominantly used ≥ 2 drug combinations (US 71%; Japan 73%) with the most common being biguanides/sulfonylureas (40%) and biguanides/DPP4i (19%) in the US and biguanides/DPP4-i (26%) and DPP4-I/sulfonylureas (16%) in Japan.  Conclusions: In Japan and the US, T2DM oral hypoglycemic treatment was initiated most often as monotherapy; however, the types of drugs used differed between the countries. Despite initiating monotherapy with dissimilar medications, the majority of patients in both countries remained on their initial therapy during the entire 6 months of follow-up. Patients switching medications during the follow-up period predominantly used combination therapy. Whether in combination or monotherapy, the most commonly used class of oral hypoglycemic agents in the US was biguanides and was DPP4-i in Japan. PDB49 Development of Antibiogram for Management of Aerobic Bacterial Infection in Diabetic Foot Ulcer Miraj SS1, MK U1, Rodrigues GS2 College of Pharmaceutical Sciences, Manipal, India, 2Kasturba Medical College, Manipal, India

1Manipal

Objectives: To determine antimicrobial susceptibility (AMS) pattern of aerobes in diabetic foot infections (DFIs).  Methods: A cross-sectional study was conducted for a period of 3 years at the Department of Surgery, Kasturba hospital, Manipal, India, with 260 DFUs patients. These patients’ culture specimens (swab/pus/tissue) were observed as Gram-stained smears and cultured aerobically on blood agar and MacConkey agar plates. AMS test was performed by disc diffusion technique according to CLSI guidelines.  Results: A total of 354 microbes were isolated from the ulcer wounds of 213 DFU patients, with an average of 1.7 organisms per lesion. Monomicrobial infections were less common (n= 81; 31.2%) than polymicrobial infections (n= 132; 50.7%). Gram-negative bacteria were the most common among the isolates (n=  192; 54.2 %). Aerobic Gram-positive Cocci accounted for 162 (45.8%) of all isolates. On the other hand, Staphylococcus aureus was the most frequently isolated aerobe (n= 106; 29.9%) followed by Pseudomonas aeruginosa (n= 91; 25.7%). AMS data from our study recommends that doxycycline would be the appropriate choice as single drug for empirical coverage for Gram-positive organisms. Second choices are TMP/SMX (except for Enterococcus spp.) and gentamicin (except for MRSA) for Gram-positive organisms. The most appropriate antibiotic for Gramnegative organisms is meropenem. Second choices for Gram-negative pathogens are amikacin (except for E.coli), cefoperazone/sulbactam (except for Acinetobacter) and piperacillin/tazobactam (except for K.oxytoca). One of the critical observations is the presence of Acinetobacter, an MDR isolated from DFIs, which is either relatively or totally resistant to all the AMAs tested.  Conclusions: The cumulative AMS patterns (Antibiogram) show that there is no single effective AMA for treating all aerobic bacteria inDFIs. Hence we recommend the implementation of antimicrobial stewardship program in hospitals for improving individual patient outcomes, reduce the overall burden of AMR and save healthcare cost, especially in resource poor settings like Indian healthcare system.

INDIVIDUAL’S HEALTH – Clinical Outcomes Studies PIH1 A Comparison of Long-Term Anticholinergic Burden Derived from Different Risk Scales with Adverse Clinical Outcomes in the Elderly Hsu W1, Lin C1, Wen Y2, Chen L3, Hsiao F1 University, Taipei, Taiwan, 2Chang Gung University, Taoyuan, Taiwan, 3Taipei Veterans General Hospital, Taipei, Taiwan

1National Taiwan

Objectives: No consensus has been reached regarding which anticholinergic scoring system works most effectively in clinical settings. The aim of this populationbased cohort study was to compare the impact of anticholinergic burden, as defined by different scales, on emergency room visits, all-cause hospitalization, fracturespecific hospitalization and incident dementia among older people.  Methods: From Taiwan’s Longitudinal Health Insurance Database, we retrieved monthly information about anticholinergic drug use measured by the Anticholinergic Risk Scale (ARS), Anticholinergic Cognitive Burden Scale (ACB) and Drug Burden Index Anticholinergic component (DBI-Ach) for 116,043 people aged 65 and older during a 10-year follow-up. We used generalized estimating equations (GEE) to examine the association between anticholinergic burden and adverse outcomes, and strati-

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fied by age (65-74, 75-84, 85+).  Results: In the first year after cohort enrollment, the average monthly anticholinergic burden measured by the ARS, ACB and DBIAch was 0.26, 0.60 and 0.04, respectively. Compared to the ARS and DBI-Ach, the ACB showed a strong dose-response relationship with risk for each of the adverse outcomes, particularly in people aged 65-84. For example, in people aged 65-74, ACB scores =  1-4+, emergency room visits: adjusted odds ratio (aOR) ranged from 1.41-2.25, all-cause hospitalization: aOR ranged from 1.32-1.92, fracture-specific hospitalization: aOR ranged from 1.10-1.71, incident dementia: aOR ranged from 3.13-10.01).  Conclusions: The ACB scale is more selective than the ARS and the DBI-Ach in identifying medications likely to cause adverse outcomes, including emergency room visits, all-cause hospitalization, fracture-specific hospitalization and incident dementia in the elderly. PIH2 Effect of Virus Hepatitis During Pregnancy on Maternal and Perinatal Adverse Outcomes: A Systematic Review Based on Observational Studies Tan J1, Sun X2 1School of West China Public Health, Sichuan University, Chengdu, China, 2West China Hospital of Sichuan University, Chengdu, China

Objectives: This systematic review was planned to explore the association between viral hepatitis (HBV and HCV) during pregnancy and multiple maternal/perinatal adverse outcomes.  Methods: Databases of MEDLINE (Ovid), EMBASE (Ovid), Web of Science, Chinese Biomedical Database Disk, China National Knowledge Infrastructure and Wanfang Platform were searched with Mesh terms and keywords from inception till Jan 1st, 2015. Random effect model and revised NewcastleOttawa Scale (NOS) were used to pool studies and assess risk of bias respectively. Furthermore, meta-regression was used to investigate heterogeneity sources of the association between viral hepatitis and adverse outcomes. Covariates included hepatitis types, publication languages, population sources, prospective collection of data and publication times. All statistics analyses were performed with STATA12.0 software.  Results: A total of 113 studies were included from 17,611 searched references. The maternal HBV positivity showed higher risk of postpartum hemorrhage (RR 3.56, 95% CI 2.93-4.31), gestational diabetes (1.54, 1.26-1.87), cholestasis (2.0, 1.73-2.45), maternal death (1.73, 1.57-32.45), premature birth (2.40, 2.02-2.86), low birth weight (1.65, 1.34-2.04), premature rupture of fetal membranes (1.76, 1.44-2.14), fetus growth restriction (1.47, 1.06-2.03) and perinatal death (2.10, 1.46-3.03). And the significant associations of maternal HCV and adverse outcomes were present on postpartum hemorrhage (4.99, 1.64-15.22), antepartum hemorrhage (1.8, 1.342.58), gestational diabetes (1.46, 1.23-1.73), cholestasis (26.33, 14.86-46.67), premature birth (1.61, 1.27-2.04), low birth weight (2.08, 1.32-3.28), premature rupture of fetal membranes (2.04, 1.33-3.11), congenital malformation (1.35, 1.02-1.80). Hepatitis types, publication languages and population origins were primary sources of heterogeneity.  Conclusions: Pregnant women with viral hepatitis could significantly increase the risk of several maternal and perinatal adverse outcomes. Such findings might provide helpful evidence for comprehensive understanding of viral hepatitis during clinical practice and thus take efficient prevention and treatment to reduce maternal and perinatal harm. PIH3 Prevalence, Pharmaceutical Expenditures and Patient’s Factors of High-Risk Medication used among Elderly Inpatients at a District Hospital in the South of Thailand Jantakanangkoon C, Ninlamote W, Pannoi T Walailak University, Nakhorn-Sri-Thammarat, Thailand

Objectives: Most Thai elderly had multiple diseases that high-risk medications (HRM) were subsequently used. In this study, HRM was defined as any medications which posed more risks than benefits in elderly, and those might be replaced by other medications. The study aimed to obtain the prevalence of HRM, pharmaceutical expenditures and patient’s factors associated with HRM.  Methods: A 65-yearold inpatient and older, who had at least an admission during the fiscal year 2013 at the study hospital, was systematically sampled. All inclusive 393 elderly inpatients were selected. A country-specific HRM screening tool developed by Ploylueamsang and colleagues was applied in this cross-sectional study. Logistic regression was to analyze the association between patient’s factors and HRM.  Results: Of all 393 elderly inpatients, 74.3 per cent [292/393] received at least one HRM. Moderate to severe HRM was given by one fifth of all elderly inpatients. Moreover, 7.6 per cent [30/393] of those patients had experienced the use of all mild, moderate, and severe HRM during the study period. The pecentage of HRM expenses to overall medication expenses across all study inpatients was 3.5% [1,030/29,501, monetary unit: US$]. However, the difference of overall medication expenditures between HRM and nonHRM was insignificantly observed (p> 0.05). Gastrointestinal drugs accounted for by a half of all HRM expenditures. Patient who had more frequent hospital visits was a likelihood of given HRM (> 2 vs. 1-2: OR= 5.440, 95%CI= 1.249-23.690, p= 0.024). The more number of medications was given, the higher HRM was observed. (6-10 vs. 1-2: OR= 2.414, 95%CI= 1.150-5.068, p= 0.020; > 10 vs. 1-2: OR= 5.152, 95% CI= 2.31511.466, p< 0.01).  Conclusions: A prospective population-based study of HRM and its adverse event should be further conducted in Thailand. Ultimately, the safety and vigilance of HRM given among the elderly inpatients, in particular those who used polypharmacy and had more frequent hospitalizations should be monitored by hospital pharmacists. PIH4 Prevalence of Low Birthweight and its Correlates from 2008 to 2014 in Xindu County of Chengdu, China Zhu P, Pan X, Wang Y, Li C, Chen J Sichuan University, Chengdu, China

Objectives: Low birthweight is associated with adverse short-term and longterm health outcomes. We aimed to examine the trend in the prevalence of low