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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: May 7, 2014
Expiration Date: May 7, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 13.0 contact hour(s) of continuingeducation by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237A

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Oncology
Section Editor of Specialty Content

DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

Last week 556 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 282 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Compared to Amoxicillin, Levofloxacin and Azithromycin Each Associated With Increased Mortality and Risk of Serious Cardiac Arrhythmia in Older Men
Reference: Ann Fam Med 2014 Mar-Apr;12(2):121 full-text (level 2 [mid-level] evidence)

Several macrolide antibiotics, particularly erythromycin and clarithromycin, have been shown to cause QT interval prolongation and increase the risk of cardiac arrhythmias such as torsades de pointes (Curr Drug Saf 2010 Jan;5(1):85). Azithromycin was initially thought to have minimal cardiotoxicity, but was later shown to increase the risk of cardiovascular death compared to amoxicillin in a large Medicaid cohort in the United States (N Engl J Med 2012 May 17;366(20):1881 full-text). The U.S. Food and Drug Administration subsequently revised the prescribing information for azithromycin to strengthen the Warnings and Precautions section with information related to the risk of QT interval prolongation and torsades de pointes (FDA Press Release 2013 Mar 12). In addition, QT interval prolongation is considered a class effect of fluoroquinolone antibiotics, and quinolone-related torsades de pointes has been described for sparfloxacin, levofloxacin, and grepafloxacin (J Antimicrob Chemother 2000 May;45(5):557 full-text). A recent large retrospective cohort study of Veterans Affairs medical centers in the United States evaluated the risk of all-cause mortality and serious cardiac arrhythmia in persons receiving levofloxacin, azithromycin, or amoxicillin.

A total of 1,757,689 treatments with levofloxacin, azithromycin, or amoxicillin to United States veterans (mean age 57 years, 89% male) between September 1999 and April 2012 were evaluated. Azithromycin was dispensed mostly for 5 days, whereas amoxicillin and levofloxacin were each dispensed mostly for ≥ 10 days. Compared to other antibiotics, azithromycin was more often prescribed for COPD, and levofloxacin was more often prescribed for genitourinary infection (no p values reported). Crude mortality and serious cardiac arrhythmia rates were assessed, with analyses adjusted for multiple clinical and demographic characteristics at baseline, including indication for antibiotic prescription.

At 5 days, the adjusted mortality per million antibiotics dispensed was 384 with levofloxacin (p < 0.001 vs. amoxicillin), 228 with azithromycin (p < 0.003 vs. amoxicillin), and 154 with amoxicillin. At 10 days, the adjusted mortality per million antibiotics dispensed was 714 with levofloxacin (p < 0.001 vs. amoxicillin), 422 with azithromycin (not significant vs. amoxicillin), and 324 with amoxicillin. Levofloxacin was also associated with an increased risk of serious cardiac arrhythmia vs. amoxicillin at 5 days and 10 days, while azithromycin was associated with an increased risk of serious cardiac arrhythmia vs. amoxicillin at 5 days but not 10 days.

These data show that in a U.S. population, predominantly older men, both levofloxacin and azithromycin were associated with an increased risk of all-cause mortality and serious cardiac arrhythmia during the typical dosing cycle for each drug (10 days for levofloxacin and 5 days for azithromycin). This conclusion is strengthened by the large sample size and the use of actual pharmacy dispensing data, rather than prescriptions. However, it is limited by its observational design, particularly due to imbalanced patient characteristics within the cohort. Although the study used a multivariable model to adjust for a wide variety of baseline characteristics, including antibiotic indication, these differences may still have biased the results. Nonetheless, these findings suggest that physicians should consider prescribing medications other than levofloxacin and azithromycin for older patients when multiple antibiotic choices are available, particularly for those with cardiac comorbidities.

For more information see the Levofloxacin (Systemic) and Azithromycin topics in DynaMed.

Earn CME Credit for reading this e-Newsletter. For more information on this educational activity, see the CME sidebar.

News About Mobile Access

On April 16, 2014, Physicians Interactive launched Omnio® 3 for iPhone/iPad/iPod touch as a free update for the existing Skyscape Medical Resources (SMR) app. The Android version will be available by the end of the month. DynaMed is compatible with Omnio 3 on both platforms.

Those users who have Skyscape Medical Resources running on iOS 7 will receive the Omnio 3 update automatically, using the background app update feature that Apple has built into the operating system. Please note that Omnio for iOS supports iOS 7 or higher; Omnio for Android will support version 2.2 or higher.

DynaMed has been moved to the new “References » Library” section. A video showing how to access the Library and to navigate a resource is available in a blog post on omnio.com.

Physicians Interactive have partnered with the original founders of Skyscape at Skyscape Medpresso, Inc., to relaunch SMR as Skyscape Medical Library (SML) – a new app focused on education, and with support for DynaMed on iOS 5 or higher. Users who prefer to continue to use DynaMed within the existing Skyscape interface, should download SML. Learn more about Skyscape Medical Library at Skyscape.com/SML.

For more information and technical support, visit the DynaMed Mobile Access page

DynaMed Events
May 30-June 3, 2014

DynaMed Founder and Vice President Brian Alper, MD, will be attending the American Society of Clinical Oncology(ASCO) 50th Annual Meeting, held at McCormack Place in Chicago, Illinois. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the ASCO website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at any of our conferences, please contact us at DyndMedCommunity@ebscohost.com.

PEMSoft Mobile is Now Live

Access the definitive resource for pediatric clinical information right from your Apple or Android device.

  • Access topics using A-Z index
  • Search content using intuitive navigation
  • View images easily

For more information and technical support, visit the PEMSoft Mobile Access page

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.