Background The choice of empiric antibiotics for the treatment of gram-negative bacilli (GNB) bloodstream infections (BSIs) in patients presenting with a β-lactam (BL) allergy is often a difficult ...decision given that these agents are first-line treatment in many guidelines. Objective We sought to compare rates of clinical failure between patients with a history of BL allergy who received either a BL or a non–β-lactam (NBL). Methods Adult patients with a past medical history of BL allergy and receipt of antibiotics for treatment of a GNB BSI were included from 3 academic medical centers. Treatment groups were classified as BL or NBL groups based on the empiric antibiotics received. Clinical failure was assessed 72 to 96 hours after initiation of empiric antibiotics. Hypersensitivity reactions during receipt of antibiotic therapy for the index BSI were recorded. Results A total of 552 patients were included for analysis: 433 patients in the BL group and 119 patients in the NBL group. Clinical failure was higher in the NBL group compared with the BL group (38.7% vs 27.4%, P = .030). The most common cause of clinical failure was a temperature of greater than 38.0°C 72 to 96 hours after receipt of empiric antibiotics (NBL group: 22.7% vs BL group: 13.9%, P = .016). Hypersensitivity occurred in 16 (2.9%) of 552 patients. Thirteen (2.5%) of 552 patients experiencing hypersensitivity reactions were exposed to a BL during treatment for GNB BSI. Conclusion Among patients with a BL allergy, use of BL antibiotics is associated with a lower rate of clinical failure. The low rate of hypersensitivity provides further evidence about the risk of cross-reactivity between BL classes. These results support the practice of using a BL from an alternative class for patients in need of gram-negative antibiotic coverage.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Pseudomonas aeruginosa nosocomial pneumonia (Pa-NP) is associated with considerable morbidity, prolonged hospitalization, increased costs, and mortality.
We conducted a retrospective cohort study of ...adult patients with Pa-NP to determine 1) risk factors for multidrug-resistant (MDR) strains and 2) whether MDR increases the risk for hospital death. Twelve hospitals in 5 countries (United States, n = 3; France, n = 2; Germany, n = 2; Italy, n = 2; and Spain, n = 3) participated. We compared characteristics of patients who had MDR strains to those who did not and derived regression models to identify predictors of MDR and hospital mortality.
Of 740 patients with Pa-NP, 226 patients (30.5%) were infected with MDR strains. In multivariable analyses, independent predictors of multidrug-resistance included decreasing age (adjusted odds ratio AOR 0.91, 95% confidence interval CI 0.96-0.98), diabetes mellitus (AOR 1.90, 95% CI 1.21-3.00) and ICU admission (AOR 1.73, 95% CI 1.06-2.81). Multidrug-resistance, heart failure, increasing age, mechanical ventilation, and bacteremia were independently associated with in-hospital mortality in the Cox Proportional Hazards Model analysis.
Among patients with Pa-NP the presence of infection with a MDR strain is associated with increased in-hospital mortality. Identification of patients at risk of MDR Pa-NP could facilitate appropriate empiric antibiotic decisions that in turn could lead to improved hospital survival.
Background: Recent studies have suggested that early goal-directed resuscitation of patients with septic shock and conservative fluid
management of patients with acute lung injury (ALI) can improve ...outcomes. Because these may be seen as potentially conflicting
practices, we set out to determine the influence of fluid management on the outcomes of patients with septic shock complicated
by ALI.
Methods: A retrospective analysis was performed at Barnes-Jewish Hospital (St. Louis, MO) and in the medical ICU of Mayo Medical Center
(Rochester, MN). Patients hospitalized with septic shock were enrolled into the study if they met the American-European Consensus
definition of ALI within 72 h of septic shock onset. Adequate initial fluid resuscitation (AIFR) was defined as the administration
of an initial fluid bolus of ⥠20 mL/kg prior to and achievement of a central venous pressure of ⥠8 mm Hg within 6 h after
the onset of therapy with vasopressors. Conservative late fluid management (CLFM) was defined as even-to-negative fluid balance
measured on at least 2 consecutive days during the first 7 days after septic shock onset.
Results: The study cohort was made up of 212 patients with ALI complicating septic shock. Hospital mortality was statistically lowest
for those achieving both AIFR and CLFM and higher for those achieving only CLFM, those achieving only AIFR, and those achieving
neither (17 of 93 patients 18.3% vs 13 of 31 patients 41.9% vs 30 of 53 patients 56.6% vs 27 of 35 77.1%, respectively;
p < 0.001).
Conclusions: Both early and late fluid management of septic shock complicated by ALI can influence patient outcomes.
Objective: To identify predictors of 30-day mortality and hospital costs in patients with ventilator-associated pneumonia (VAP) attributed
to potentially antibiotic-resistant Gram-negative bacteria ...(PARGNB) Pseudomonas aeruginosa , Acinetobacter species, and Stenotrophomonas maltophilia .
Design: A retrospective, single-center, observational cohort study.
Setting: Barnes-Jewish Hospital, a 1,200-bed urban teaching hospital.
Patients: Adult patients requiring hospitalization with microbiologically confirmed VAP attributed to PARGNB.
Interventions: Retrospective data collection from automated hospital, microbiology, and pharmacy databases.
Measurements and main results: Seventy-six patients with VAP attributed to PARGNB were identified over a 5-year period. Nineteen patients (25.0%) died during
hospitalization. Patients receiving their first dose of appropriate antibiotic therapy within 24 h of BAL sampling had a statistically
lower 30-day mortality rate compared to patients receiving the first dose of appropriate therapy >24 h after BAL (17.2% vs
50.0%; p = 0.005). VAP due to Acinetobacter species was most often initially treated with an inappropriate antibiotic regimen,
followed by S maltophilia and P aeruginosa (66.7% vs 33.3% vs 17.2%; p = 0.017). Overall, total hospitalization costs were statistically similar in patients initially
treated with an inappropriate antibiotic regimen compared to an appropriate regimen ($68,597 ± $55,466 vs $86,644 ± $64,433;
p = 0.390).
Conclusions: These data suggest that inappropriate initial antibiotic therapy of microbiologically confirmed VAP attributed to PARGNB
is associated with greater 30-day mortality. High rates of VAP attributed to antibiotic-resistant bacteria ( eg , Acinetobacter species) may require changes in the local empiric antibiotic treatment of VAP in order to optimize the prescription
of appropriate initial therapy.
antibiotic treatment
Gram-negative bacteria
mortality
ventilator-associated pneumonia
OBJECTIVE:To evaluate the impact of weekly feedback to clinicians and the activation of a sepsis response team on the process of care and hospital mortality in patients with severe sepsis or septic ...shock.
DESIGN:Prospective, interventional cohort study.
SETTING:The medical intensive care unit of a tertiary, academic medical center.
STUDY SUBJECTS:Patients with severe sepsis or septic shock consecutively treated in a medical intensive care unit.
INTERVENTIONS:Daily auditing and weekly feedback, and sepsis response team activation.
MEASUREMENTS AND MAIN RESULTS:During a 33-month study period, from January 2007 through September 2009, we performed daily screening of patients for severe sepsis or septic shock. Study periods were divided into baseline (screening only), daily auditing with weekly feedback, and sepsis response team activation. Comparisons among the three periods were made by using univariate and multiple logistic regression analyses. Compliance with the overall sepsis resuscitation bundle and its individual elements and hospital mortality were used as outcome measures. A total of 984 episodes of severe sepsis and septic shock were identified during the study periods, severe sepsis in 52 (5.3%) and septic shock in 932 (94.7%). The compliance rate with all elements of the sepsis resuscitation bundle increased from 12.7% at baseline to 37.7% and 53.7% during the weekly feedback and sepsis response team activation periods, respectively (p < .001). Overall hospital mortality rate was 30.3%, 28.3%, and 22.0% during baseline, weekly feedback, and sepsis response team periods, respectively (p = .029). Multiple logistic regression analysis showed that the sepsis response team was associated with reduced risk of hospital death (odds ratio, 0.657; 95% confidence interval, 0.456–0.945; p = .023) whereas hepatic cirrhosis, hepatic failure, leukemia, multiple myeloma, transfer from the same hospital ward, do-not-resuscitate status at the recognition of severe sepsis/septic shock, and lactate level were associated with increased risk of death.
CONCLUSIONS:In septic shock, the activation of the sepsis response team in combination with weekly feedback increases the compliance with the process of care and reduces hospital mortality rate.
OBJECTIVE:The first goal of this investigation was to determine the rate of appropriate initial antimicrobial administration to patients with methicillin-resistant Staphylococcus aureus (MRSA) ...sterile-site infections. Our second goal was to evaluate the influence of appropriate initial treatment of MRSA sterile-site infection on outcome.
DESIGN:A retrospective, single-center, observational cohort study.
SETTING:Barnes-Jewish Hospital, a 1200-bed urban teaching facility.
PATIENTS:Adult patients requiring hospitalization identified to have an MRSA sterile-site infection.
INTERVENTIONS:Retrospective data collection from automated hospital and pharmacy databases.
MEASUREMENTS AND MAIN RESULTS:Five hundred forty-nine patients with S. aureus sterile site infections were identified during a 3-yr period (January 2002 through December 2004). One hundred twenty-seven (23.1%) died during hospitalization. Hospital mortality was statistically greater for patients receiving inappropriate initial antimicrobial treatment (n = 380) within 24 hrs of a positive culture than for those receiving appropriate initial treatment (n = 169) (26.1% vs. 16.6%; p = .015). Multiple logistic regression analysis identified inappropriate initial antimicrobial treatment (adjusted odds ratio AOR, 1.92; 95% confidence interval CI, 1.48–2.50; p = .0134), vasopressor administration (AOR, 5.49; 95% CI, 4.08–7.38; p < .001), and increasing age (1-yr increments) (AOR, 1.03; 95% CI, 1.02–1.04; p < .001) as independent determinants of hospital mortality.
CONCLUSIONS:Inappropriate initial antimicrobial treatment of MRSA sterile-site infections is common and is associated with an increased risk of hospital mortality. Appropriate antimicrobial treatment of MRSA sterile-site infections may be maximized by increased use of initial empirical antimicrobial treatment regimens targeting MRSA in patients at risk for this infection until organism identification and susceptibility become known.
LEARNING OBJECTIVESOn completion of this article, the reader should be able to:Dr. Kollef has disclosed that he is/was the recipient of grant/research funds from Merck, Elan, Pfizer, and Bard. All remaining authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity.Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
To describe the employment of an automated text messaging text-bot during the 2019 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting Residency Showcase and its impact on ...the number of applications received for the postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) pharmacy residency programs at a medium-sized community hospital.
Visitors at the residency showcase booth were asked to text a code word to a program number. The text-bot collected the visitor's contact information and program of interest (PGY1 or PGY2). A series of automated messages were sent to all visitors following the showcase and up until the residency application deadline.
71% (20/28) of visitors to the program's showcase booth registered with the text-bot and of these, 65% (13/20) submitted applications to the residency program in phase I of the match. Both the PGY1 and PGY2 programs saw an increase in the amount of applications received compared to previous year.
A text messaging text-bot may be a useful residency recruitment tool.
To promote early detection of AKI, recently proposed pretest probability models combine sub-Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria with baseline AKI risk. The primary objective ...of this study was to determine sub-KDIGO thresholds that identify patients with septic shock at highest risk for AKI.
This was a retrospective analysis of 390 adult patients admitted to the medical intensive care unit (ICU) of a tertiary, academic medical center with septic shock between January 2008 and December 2010. Hourly urine output was collected from the time of septic shock recognition (hour 0) to hour 96, urine catheter removal, or ICU discharge (whichever occurred first). All available serum creatinine (SCr) measurements were collected until hour 96. The AKI pretest probability model was assessed during the first 12 hours of resuscitation and included the initial episode of oliguria, increase from baseline to peak SCr level, and Acute Physiology and Chronic Health Evaluation (APACHE) III score in a multivariable receiver-operator characteristic (ROC) analysis. The primary outcome was the incidence of stage II or III (stage II+) AKI defined by KDIGO criteria. Secondary outcomes included the need for RRT and 28-day mortality.
Ninety-eight (25%) patients developed stage II+ AKI after septic shock recognition. APACHE III score and increase in SCr level in the first 12 hours were not statistically associated with stage II+ AKI in multivariable ROC analysis. Consecutive oliguria for 3 hours had fair predictive ability for achieving stage II+ AKI criteria (area under ROC curve, 0.73; 95% confidence interval 95% CI, 0.68 to 0.78), and oliguria for 5 hours demonstrated optimal accuracy (82%; 95% CI, 79% to 86%).
Three to 5 hours of consecutive oliguria in patients with septic shock may provide a valuable measure of AKI risk. Further validation to support this finding is needed.
PURPOSE.The development, implementation, and evaluation of a pharmacogenomics education program for pharmacists in a large, integrated multicampus health system are described.
...SUMMARY.Pharmacogenomics has been described as tailoring medications to each patientʼs unique genetic sequence with the goals of minimizing harmful effects and optimizing therapeutic effects. Pharmacists are uniquely trained to lead the implementation of pharmacogenomics in clinical care. After assessment of pharmacistsʼ comfort with pharmacogenomics, different approaches were explored to develop, pilot test, and disseminate pharmacogenomics education across a multicampus academic medical center. Limited success with large-audience, single-lecture didactic education led to development and delivery of targeted, competency-based online modules using the institutionʼs academic virtual learning environment and course management system. Implementation steps included (1) collaboration with the Mayo Clinic Center for Individualized Medicine to create an interprofessional development team and project charter, (2) galvanizing pharmacy leadership support across multiple campuses, (3) development of competency-based interactive modules, and (4) assessment of the quality of and learner satisfaction with the modules. Significant improvements in competency scores were observed with each module and across the multiple campuses. Satisfaction with the education program was assessed at the end of a 4-module series.
CONCLUSION.A pharmacogenomics educational program targeting pharmacists was developed through interprofessional collaboration and provided a novel opportunity to construct an educational infrastructure to support enterprise health-system campuses with limited educational resources.
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DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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