Eric W Mueller

University of Cincinnati, Cincinnati, Ohio, United States

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Publications (29)63.18 Total impact

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    ABSTRACT: Low anti-factor Xa (anti-Xa) concentrations with twice-daily enoxaparin are associated with venous thromboembolism (VTE) in high-risk trauma patients. Concerns have been raised with once-daily dalteparin regarding effectiveness and achievable anti-Xa concentrations. The purpose of this before-and-after study was to evaluate the effectiveness of a VTE prophylaxis protocol using anti-Xa concentrations and associated dalteparin dose adjustment in high-risk trauma patients. Adult trauma patients receiving VTE chemoprophylaxis and hospitalized for at least 3 days were prospectively followed during two 6-month epochs before (PRE) and after (POST) implementation of anti-Xa monitoring. In both groups, high-risk patients received dalteparin 5,000 U subcutaneously once daily; low-risk patients received subcutaneous unfractionated heparin. High-risk POST patients with anti-Xa less than 0.1 IU/mL 12 hours after initial dalteparin dose received dalteparin every 12 hours. All patients underwent routine VTE ultrasound surveillance of the lower extremities. The primary outcome was incidence of VTE. A total of 785 patients (PRE, n = 428; POST, n = 357) were included. Demographics, injury patterns, Injury Severity Score (ISS), red blood cell transfusions, intensive care unit and hospital stays, and mortality did not differ between groups. Overall, POST patients had lower VTE (7.0% vs. 13%, p = 0.009) including acute VTE (6.4% vs. 12%, p = 0.01) and proximal deep vein thromboembolism (2.2% vs. 5.7%, p = 0.019). Between high-risk patients, VTE occurred in 53 (16.3%) PRE compared with 24 (9.0%) POST patients (p = 0.01); there was no difference in VTE between low-risk patients (PRE, 2.0% vs. POST, 1.1%; p = 0.86). Among 190 high-risk POST patients with anti-Xa, 97 (51%) were less than 0.1 IU/mL. Patients with low anti-Xa had higher rates of VTE (14.0% vs. 5.4%, p = 0.05) and deep vein thromboembolism (14.4% vs. 3.2%, p = 0.01). Younger age (odds ratio, 0.97; 95% confidence interval, 0.95-0.99) and greater weight (odds ratio, 1.02; 95% confidence interval, 1.00-1.03) predicted low anti-Xa on multivariate regression. A VTE prophylaxis protocol using anti-Xa-based dalteparin dosage adjustment in high-risk trauma patients was associated with decreased VTE. Once-daily dalteparin 12-hour anti-Xa concentrations are suboptimal in a majority of patients and associated with VTE. Therapeutic study, level IV.
    The journal of trauma and acute care surgery. 02/2014; 76(2):450-6.
  • Annals of Pharmacotherapy 10/2013; 47(10):1374-1375. · 2.92 Impact Factor
  • Molly E Moore, Eric W Mueller
    Respiratory care 08/2012; 57(8):1348-9. · 2.03 Impact Factor
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    ABSTRACT: To describe the pharmacokinetic profile and clinical outcome associated with high-dose ciprofloxacin therapy in a patient with the triad of extreme obesity, multiple organ failure, and deep-seated infection. A 45-year-old, class 3 obese (185 kg; body mass index 53.7), critically ill trauma patient receiving continuous venovenous hemodiafiltration (CVVHDF) was treated with ciprofloxacin 800 mg intravenously every 12 hours for presumed Enterobacter aerogenes (ciprofloxacin minimum inhibitory concentration [MIC] ≤1 μg/mL) lumbar spine osteomyelitis. Four sequential plasma ciprofloxacin samples were obtained and analyzed to determine the steady-state pharmacokinetic profile. The observed steady-state maximum (C(max)) and calculated minimum (C(min)) ciprofloxacin plasma concentrations measured on treatment day 8 were 13 μg/mL and 4.8 μg/mL, respectively, corresponding to an estimated half-life, area under the curve (AUC(0-24)), total systemic clearance, and clearance by CVVHDF of 7.6 hours, 192 μg·h/mL, 139 mL/min, and 26 mL/min, respectively. These concentrations produced AUC(0-24)/MIC ratios >125 and plasma C(max)/MIC ratios >10 for MICs ≤1 μg/mL. Intravenous colistin and polymyxin B lumbar wound irrigation were initiated on ciprofloxacin days 12 and 15, respectively, for concomitant multidrug-resistant Acinetobacter baumannii infection. Lumbar tissue cultures on day 24 of ciprofloxacin therapy demonstrated no growth, coinciding with overall improvement of the invasive wound. A week later, the patient developed worsening septic shock and died secondary to an occult subdiaphragmatic abscess. Pharmacodynamic outcome studies suggest that AUC(0-24)/MIC ratios >125 and plasma C(max)/MIC ratios >10 are good predictors of clinical and microbiologic success of ciprofloxacin against gram-negative pathogens. These pharmacodynamic goals were achieved in the plasma with high-dose ciprofloxacin for MICs ≤1 μg/mL. Critically ill obese patients with deep-seated infection involving organisms with MICs >0.5 μg/mL likely require ciprofloxacin dosages greater than traditional daily doses of 400-800 mg during CVVHDF to achieve optimal pharmacodynamic targets.
    Annals of Pharmacotherapy 10/2010; 44(10):1660-4. · 2.92 Impact Factor
  • The Journal of trauma 02/2010; 68(2):E35-8. · 2.35 Impact Factor
  • Eric W Mueller, Bradley A Boucher
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    ABSTRACT: Extended-interval dosing strategies have been developed to exploit the concentration-dependent bactericidal activity and time-dependent host toxicity associated with aminoglycoside the therapy. The ability of published extended-interval dosing nomograms to achieve optimal pharmacodynamic endpoints may be limited in certain critically ill surgical patients. Review of pertinent English language literature. Presentation of descriptive, graded recommendations for extended-interval aminoglycoside dosing in critically ill surgical patients. Aminoglycoside dosing considerations in critically ill surgical patients should attempt to maximize the bacterial and host pharmacodynamic attributes of these agents. Empirically, extended-interval aminoglycoside doses proposed by published nomograms are reasonable for most patients; however, because of clinically meaningful variations in aminoglycoside pharmacokinetics, routine use of published extended-interval aminoglycoside dosing nomograms to determine an appropriate dosage interval is discouraged in many critically ill surgical patients. Critically ill surgical patients receiving extended-interval aminoglycoside dosages should undergo individualized pharmacokinetic analysis to characterize efficiently and more effectively plasma concentration-to-bacterial minimum inhibitory concentration (MIC) relationships and determine an appropriate dosing interval, considering site and severity of infection, plasma clearance, and the apparent post-antibiotic effect. The use of extended-interval aminoglycoside dosage regimens in critically ill surgical patients should be based on pharmacodynamic endpoints and patient-specific pharmacokinetic assessment.
    Surgical Infections 12/2009; 10(6):563-70. · 1.87 Impact Factor
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    ABSTRACT: Purpose: Current evidence shows that outpatient treatment of venous thromboembolism (VTE) with low molecular weight heparin is a cost effective and safe alternative to inpatient treatment with unfractionated heparin. This study evaluated the process, effectiveness, and safety of a long-standing pharmacist-driven anticoagulation discharge process. Methods: Any patient discharged from The University Hospital on an injectable anticoagulant between December 2008 and February 2009 was evaluated. The primary endpoint was the percent of patients discharged on an injectable anticoagulant who were counseled by a pharmacist. Secondary endpoints included the duration of patient counseling and medication procurement; length of hospital stay for patients with a primary diagnosis of VTE; and VTE recurrence rates and bleeding events at 3 months. Results: Two-hundred and seven patients discharged on an injectable anticoagulant (3.4 discharges per day) were included. Pharmacist counseling was documented for 180 (87%) patients. Overall, pharmacists spent 37.6±25.5 minutes per patient including 19.4±9.6 minutes for counseling and 19.7±19.7 minutes for medication procurement; 150 (83%) patients required complete medication procurement lasting 21.4±19.6 minutes. The length of hospital stay for patients with a primary diagnosis of VTE was 3.2±2.4 days. At 3 months, 5.3% and 15.9% of patients had a recurrent VTE or bleeding event, respectively, with a major bleed rate of 1.4%. Patients with major bleeding experienced intracranial hemorrhage (n=2) and gastrointestinal bleeding (n=1) all beyond the first two weeks after discharge. Conclusions: System wide education is needed to ensure all patients are counseled on their injectable anticoagulant prior to discharge. Continued evaluation of discharge criteria is encouraged to identify the most appropriate candidates to minimize recurrent VTE and bleeding events. Consideration needs to be given to outsourcing the procurement portion, as this requires a significant amount of pharmacists’ time.
    2009 American College of Clinical Pharmacy Annual Meeting; 10/2009
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    ABSTRACT: Purpose: Few data exist to guide appropriate antibiotic dosing in critically-ill obese patients receiving continuous veno-venous hemodiafiltration. We present a case of an obese critically ill, multiple trauma patient who received high-dose ciprofloxacin for lumbar spine osteomyelitis following spinal fixation. Methods: Pharmacokinetic analysis and chart review Results: Pharmacokinetic and pharmacodynamic profiles were determined for ciprofloxacin 800 mg IV every 12 hours in a class 3 extreme obesity (185 kg; body mass index = 53.7), critically ill, trauma patient with Enterobacter aerogenes (ciprofloxacin minimum inhibitory concentration [MIC] ≤ 1 mcg/mL) lumbar spine osteomyelitis receiving continuous veno-venous hemodiafiltration (CVVHDF). Steady-state ciprofloxacin plasma concentrations measured on treatment day 11 revealed plasma area under the curve (AUC)-to-MIC ratios > 125 and plasma peak-to-MIC ratios > 8 across organism MICs ≤ 1 mcg/mL. Estimated ciprofloxacin bone concentrations (published reports suggest 35-48% of plasma concentration) for this dosage met these pharmacodynamic targets for organism MICs ≤ 0.5 mcg/mL. Lumbar spine cultures on day 24 of ciprofloxacin therapy demonstrated no growth coinciding with overall improvement of the invasive wound. A week later, however, the patient developed worsening septic shock and expired secondary to an unrelated occult subdiaphragmatic abscess. Conclusions: Critically ill, obese patients with deep-seated infection receiving CVVHDF likely require ciprofloxacin dosages greater than 400-800 mg per day to achieve optimal pharmacodynamic targets.
    2009 American College of Clinical Pharmacy Annual Meeting; 10/2009
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    ABSTRACT: A major unanswered question in ventilator-associated pneumonia (VAP) management relates to patient response to therapy. We investigated the use of pulmonary cytokines as biomarkers for response to antibiotic therapy for VAP. Prospective, observational pilot study of 12 critically ill trauma patients with VAP using a bronchoscopic bronchoalveolar lavage (BAL) (> or =100,000 colony-forming units [cfu]/mL). All patients underwent repeat BAL after three days of adequate antibiotic therapy. Changes in pulmonary effluent interleukin (IL)-8 and tumor necrosis factor (TNF)-alpha concentrations measured on diagnostic and repeat BAL were evaluated on the basis of the presence of a microbiologic response (<10,000 cfu/mL on repeat BAL). Six post-therapy BAL samples showed a microbiologic response. In responders, IL-8 and TNF-alpha concentrations decreased significantly (1,303 +/- 1,150 ng/mL in diagnostic BAL sample vs. 309 +/- 448 ng/mL after response; p = 0.08 and 9.9 +/- 18.4 ng/mL in diagnostic vs. 0.1 +/- 0.1 ng/mL in post-treatment sample; p = 0.06, respectively). In non-responders, IL-8 (449 +/- 426 ng/mL vs. 326 +/- 319 ng/mL; p = 0.59) and TNF-alpha (1.2 +/- 1.9 ng/mL vs. 0.3 +/- 0.3 ng/mL; p = 0.31) did not change significantly. Clinical response measures did not change or increased in responders, whereas these parameters did not change or decreased paradoxically in non-responders. This pilot study indicates pulmonary concentrations of IL-8 and TNF-alpha decrease in microbiologic responders with VAP. Conversely, clinical response parameters were discordant with the microbiologic response. The utility of pulmonary cytokine behavior in evaluating the effectiveness of antibiotic therapy for VAP should be studied further.
    Surgical Infections 09/2009; 11(2):161-7. · 1.87 Impact Factor
  • Shaun P Keegan, Neil E Ernst, Eric W Mueller
    Critical care medicine 07/2009; 37(6):2139; author reply 2139-40. · 6.37 Impact Factor
  • International anesthesiology clinics 01/2009; 47(4):55-64.
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    ABSTRACT: Critically ill patients often require therapeutic argatroban dosages lower than those recommended in package labeling. The magnitude of dosage alteration in relation to severity of organ failure is unknown. To compare therapeutic argatroban dosages between critically ill and noncritically ill patients with confirmed or suspected heparin-induced thrombocytopenia and investigate the relationship between total Sequential Organ Failure Assessment (SOFA) score and therapeutic argatroban dosage. This retrospective cohort study was conducted at an urban academic medical center. Adults without Child-Pugh class C hepatic dysfunction who received argatroban for more than 24 hours over a 3-year period were included. Therapeutic argatroban dosage was that resulting in 2 consecutive activated partial thromboplastin time (aPTT) values 1.5-3 times the patient-specific baseline obtained at least 4 hours apart. Initial argatroban dosages were at the discretion of the managing service. Fifty-three patients (critically ill, n = 34; noncritically ill, n = 19) were included. Critically ill patients had higher median [interquartile range] Acute Physiology and Chronic Health Evaluation (APACHE II) (17 [12-21] vs 10 [3.25-17.75]; p = 0.007) and SOFA (11 [7-13] vs 2 [0-2.75]; p < 0.001) scores. Critically ill patients required lower mean +/- SD therapeutic argatroban dosage (0.6 +/- 0.5 vs 1.4 +/- 0.9 microg/kg/min; p < 0.001). There was no significant difference in time to therapeutic aPTT or proportion of aPTTs within therapeutic range. Argatroban dosage was inversely related to SOFA score tertiles (<6: 1.34 +/- 0.82 microg/kg/min; 6-9: 0.93 +/- 0.54; > or =10: 0.40 +/- 0.27; p < 0.001). Total SOFA score at the time of argatroban initiation was independently associated with an argatroban dosage less than 0.75 microg/kg/min (OR 1.5, 95% CI 1.2 to 1.8; p < 0.001). Adverse events were similar between groups. Critically ill patients with single or multiple organ failure require lower therapeutic argatroban dosages compared with noncritically ill patients. Because of an inverse relationship with SOFA score, initial argatroban dosage in critically ill patients should be based on the presence and magnitude of organ failure.
    Annals of Pharmacotherapy 01/2009; 43(1):19-27. · 2.92 Impact Factor
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    ABSTRACT: More than one half of lower respiratory cultures are negative for ventilator-associated pneumonia (VAP) and final reporting requires 72 hours to 96 hours. A previous retrospective study concluded that preliminary bronchoalveolar lavage (BAL) culture results (pBAL), reported at approximately 24 hours, accurately predicted final BAL culture results (fBAL). Our objective was to verify the predictive value of pBALs for fBALs, and evaluate the use of insignificant (1-99,999 cfu/mL) pBALs for rapid discontinuation of empirical antibiotics. All BALs performed in the intensive care unit (ICU) of the Presley Regional Trauma Center were used to compare pBALs with fBALs. Trauma intensive care unit patients whose antibiotics were discontinued using pBALs (study group), were compared with a historical control group who had their antibiotics discontinued using fBALs. Preliminary and final results of 474 prospectively collected BALs were compared. Significant pBALs had a positive predictive value of 100%, whereas the negative predictive values of "no growth to date" and insignificant pBALs were 99% and 95%, respectively. Study patients (n = 176) were similar to control patients (n = 112) except for a higher median injury severity score (34 vs. 29; p < 0.001). The median (interquartile range) duration of empirical antibiotic therapy in patients without VAP was shorter for study patients [1.5 (1.25, 2) vs. 3 (3, 4) days, p < 0.001]. Empirical antibiotics were temporarily interrupted in four patients with VAP because of falsely negative pBALs without adverse clinical sequelae. Preliminary BALs were highly predictive for final results. Using insignificant pBALs appears to be a safe strategy for promptly discontinuing empirical antibiotics in trauma patients with suspected VAP.
    The Journal of trauma 12/2008; 65(6):1271-7. · 2.35 Impact Factor
  • Justin K. Rak, Neil E. Ernst, Eric W. Mueller
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    ABSTRACT: Purpose: Carbapenem-resistant Acinetobacter baumannii (CRAB) is increasingly associated with nosocomial infection. We sought to describe local definitive antibiotic regimens and evaluate clinical and microbiologic outcomes in critically ill medical and surgical patients with CRAB bacteremia or pneumonia. Methods: Adult medical and surgical ICU patients admitted to The University Hospital between August 2005 and February 2008 with blood or significant lower respiratory cultures positive for CRAB and clinical signs/symptoms of infection were reviewed. Pregnant, hospice, and cystic fibrosis patients were excluded. Clinical and microbiologic cure, as well as in-hospital outcomes, were recorded. Results: Twenty-eight patients were included (13 pneumonia, 10 pneumonia/bacteremia, 5 bacteremia). Twenty-one (75%) patients were male and had surgical diagnoses. Median [range] ICU admission APACHEII score was 20[11-33], infection day SOFA 8[5-16], and mean ICU length of stay 3522 days. Eleven (39%) patients had recent hospital admission, 28(100%) required mechanical ventilation, and 16(57%) required vasopressors. Time from hospital admission to infection was 149 days; 27(96%) infections were polymicrobial. Of tested isolates, susceptibility rates were: colistimethate 100% (n=14), tobramycin 31% (n=54), ampicillin/sulbactam 11% (n=54), and tigecycline (MIC £ 2) 0% (n=15). Seven (25%) patients received adequate empiric antibiotic therapy. Of treated patients (n=26), 13(50%) received combination antibiotic therapy; 15(58%) received a colistimethate-based regimen (6 IV only, 7 inhaled only, 2 both). Duration of definitive antibiotic therapy was 9.55.6 days. Of treated patients, 8(31%) demonstrated clinical cure and 11/13 (85%) patients with follow-up cultures had microbiologic cure; 10(36%) patients experienced reinfection. Overall, 5(18%) patients died. Conclusions: Critically ill patients with CRAB bacteremia or pneumonia have moderate-high severity of illness, polymicrobial infections, and extended duration of ICU stay. Colistimethate demonstrated the highest in vitro activity, whereas tigecycline resistance was high among tested isolates. Continued research is needed to identify effective antibiotic strategies for CRAB-related infections in critically ill patients.
    2008 American College of Clinical Pharmacy Annual Meeting; 10/2008
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    ABSTRACT: Analgesics and sedatives are required to maintain a calm and comfortable mechanically ventilated injured patient. Continuous sedative infusions have been shown to lengthen mechanical ventilation and hospital length of stay. Daily interruption of sedative infusions may reduce both of these variables. Implementation of an Analgesia-Delirium-Sedation (ADS) Protocol using objective assessments with a goal of maintaining an awake and comfortable patient may obviate the need for daily interruption of infusions in critically ill trauma patients. We examined the effects of such a protocol on ventilator duration, intensive care unit (ICU) length of stay, hospital slength of stay, and medication requirements. A multidisciplinary team designed the protocol. Objective measures of pain (visual/objective pain assessment scale-VAS/OPAS), agitation (Richmond Agitation-Sedation Scale-RASS), and delirium [Confusion Assessment Method {CAM-ICU}] were used. Medications were titrated to a RASS of -1 to +1 and VAS/OPAS <4. Haloperidol was used to treat delirium in CAM-ICU positive patients. Retrospective review of the local Project IMPACT database for a 6-month period in 2004 was compared with the same seasonal period in 2006 in which the ADS protocol was used. All mechanically ventilated trauma patients receiving infusions of narcotic, propofol, or benzodiazepine were included. Age, APACHE II score, Injury Severity Score, ventilator days, ventilator-free days at day 28, ICU length of stay, and hospital length of stay are reported as median values (interquartile range). Medication usage is reported as mean values (+/-SD). Differences in data were analyzed using Wilcoxon's rank-sum test or t test, as appropriate. Gender, mortality, and mechanism of injury were analyzed using chi analysis. A total of 143 patients were included. Patients who died during their hospitalization were excluded except in the analysis of ventilator-free days at day 28. After exclusions, 61 patients were in the control group and 58 in the protocol group. The median duration of mechanical ventilation in the protocol group was 1.2 days (0.5-3.0) which was significantly reduced compared with 3.2 days (1.0-12.9) in the control group (p = 0.027). Analysis of ventilator-free days at day 28 found that the protocol group had 26.4 ventilator-free days (13.9-27.4) compared with 22.8 days (10.5-26.9) in the control group (p = 0.007). The median ICU length of stay was 5.9 days (2.3-18.2) in the control group and 4.1 days (2.5-8.3) in the protocol group (p = 0.21). Hospital length of stay was 12 days (7-17) in the protocol group in contrast to 18 days (10-27) in the control group (p = 0.036). Opiate equivalents and propofol use per patient was significantly reduced in the protocol group from 2,465 mg (+/-1,242 mg) to 1,641 mg (+/-1,250 mg) and 19,232 mg (+/-22,477 mg) to 10,057 (+/-14,616 mg), respectively (p < 0.001, p = 0.01). An objective assessment- based ADS protocol without daily interruption of medication infusion decreases ventilator days and hospital length of stay in critically ill trauma patients.
    The Journal of trauma 10/2008; 65(3):517-26. · 2.35 Impact Factor
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    ABSTRACT: Drug-induced hepatotoxicity is an infrequent but life-threatening complication. Sunitinib is a multitargeted receptor tyrosine kinase inhibitor approved for treatment of renal cell carcinoma and gastrointestinal stromal tumor. However, results from preapproval clinical trials suggest an equivocal hepatic risk profile for sunitinib. We describe a 75-year-old woman with renal cell carcinoma who was admitted to the intensive care unit after experiencing fulminant hepatic failure during sunitinib therapy. The patient's hepatic and renal chemistries had been within normal limits throughout four previous cycles of sunitinib therapy spanning 9 months. After the fifth cycle, she complained of a 3-day history of severe diarrhea and dehydration. Her abnormal laboratory test results included the following: total bilirubin level 5.9 mg/dl, aspartate aminotransferase level 3872 U/L, alanine aminotransferase level 3332 U/L, ammonia level 897 microg/dl, and an international normalized ratio of 4.8. Use of the Naranjo adverse drug reaction probability scale indicated a possible relationship between sunitinib and hepatotoxicity. Supportive care including aggressive intravenous hydration and reversal of coagulopathy was successful. The patient was discharged home on hospital day 7 without apparent longstanding sequelae. Clinicians should be aware of this possible adverse effect of sunitinib, and continued pharmacovigilance is imperative to accurately quantify the possible risk of sunitinib-related hepatotoxicity.
    Pharmacotherapy 08/2008; 28(8):1066-70. · 2.31 Impact Factor
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    ABSTRACT: PURPOSE: Controversy persists regarding the accurate identification of relative adrenal insufficiency (RAI) in septic shock patients. Given suspected variability at our institution, this study was performed to assess the processes of care related to the diagnosis of RAI and associated outcomes of management with corticosteroids (CS). METHODS: Patients with septic shock admitted to The University Hospital between September 1, 2005 and December 31, 2006 were reviewed. Concurrent CS use and total cortisol concentrations were assessed. RAI was defined as either an ACTH-induced cortisol change £9 mcg/dL from baseline or a random cortisol <25 mcg/dL. Evaluation of RAI, and patient outcome between CS and non-CS patients were compared. Patients with preadmission or concomitant disease state CS use were excluded. RESULTS: One hundred patients were included. Overall mortality was 67%. Patient assessment for RAI included ACTH testing (58%), random cortisol only (27%), or no test (15%). Corticosteroids were administered to 64%, 30%, and 47% of these patients, respectively, for 6.75.6 days. CS (n=53) and non-CS (n=47) patients were as likely to be tested for RAI (89% vs. 85%; p=0.759); however, CS patients more often underwent ACTH testing (70% v 45%; p=0.019). CS patients were more often diagnosed with RAI (64% v 36%; p=0.01), and had lower ACTH-induced change (8.616.3 vs 13.38.5 mcg/dL; p<0.001) and random (27.026.1 v 31.815.5 mcg/dL; p=0.007) cortisol levels. Overall, the discordance rate between presence or absence of RAI and CS use was 36%. Mortality rates were similar between CS and non-CS RAI (74% v 65%; p=0.744) and non-RAI (72% v 58%; p=0.494) patients. CONCLUSIONS: Variation in RAI diagnostic methods and subsequent CS use was evident. The utility of ACTH-directed CS to improve patient outcome was not observed. Further study is required to refine outcome-focused strategies for the diagnosis and management of RAI in septic shock patients.
    2008 American College of Clinical Pharmacy Spring Practice and Research Forum; 04/2008
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    ABSTRACT: Bronchoalveolar lavage (BAL) is recommended to facilitate the diagnosis of ventilator-associated pneumonia (VAP). It is unclear if bilateral sampling improves the accuracy of BAL. Consecutive patients with clinical suspicion for VAP were analyzed. All patients underwent bilateral BAL. A threshold of >10(4) colony-forming units (cfu)/mL was diagnostic for VAP (VAP positive). Samples were concordant if the organism(s) and thresholds from both lungs were diagnostically consistent. Organisms </=10(4) cfu/mL with growth on the contralateral sample >10(4) cfu/mL were considered false-negative samples. Between November 2005 and April 2006, 73 patients were considered clinically suspicious for VAP. Forty-four (60%) patients were VAP positive. Twenty-eight (64%) VAP patients had concordant samples. Overall, there were 15 false-negative samples. Sole use of the unilateral samples to guide treatment would have inappropriately directed antibiotic avoidance and/or discontinuation in 25% of VAP patients. Influence of the chest radiograph was equivocal because of the presence of bilateral infiltrates in 80% of discordant samples. Bilateral BAL improves the accuracy of bronchoscopy in diagnosing VAP. Unilateral BAL may be insensitive in patients with clinically significant contralateral infection.
    American journal of surgery 02/2008; 195(2):159-63. · 2.36 Impact Factor
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    ABSTRACT: Using an arbitrary day cutoff or clinical signs to decide the duration of antibiotic therapy for ventilator-associated pneumonia (VAP) may be suboptimal for some patients. We sought to determine whether antibiotic duration for VAP can be safely abbreviated in trauma patients using repeat bronchoalveolar lavage (BAL). This was an observational case-controlled pilot study. Fifty-two patients were treated for VAP using a repeat BAL clinical pathway. Definitive antibiotic therapy for VAP was discontinued if pathogen growth was <10,000 colony forming units/mL on repeat BAL performed on day 4 of antibiotic therapy (responder), otherwise therapy was continued per managing team. A matched control group of 52 VAP patients treated before (immediately consecutive) the pathway was used for comparison. Antibiotic duration in pathway patients was shorter than control patients (9.8 days +/- 3.8 days vs. 16.7 days +/- 7.4 days; p < 0.001), including nonfermenting gram-negative bacilli VAP (10.7 days +/- 4.1 days vs. 14.4 days +/- 4.2 days; p < 0.001). There were no differences in pneumonia relapse, mechanical ventilator-free intensive care unit (ICU) days, ICU-free hospital days, or mortality. Of study group isolates, 86 (82.7%) responded on repeat BAL and were treated for 8.8 days +/- 3.3 days. Of these without concomitant infections (n = 65), antibiotic duration was 7.3 days +/- 1.2 days compared with 14.4 days +/- 2.6 days for nonresponding isolates (n = 18) (p < 0.001). Repeat BAL decreased the duration of antibiotic therapy for VAP in trauma patients. More adequately powered investigations are needed to appropriately determine the effects of this strategy on patient outcome.
    The Journal of trauma 01/2008; 63(6):1329-37; discussion 1337. · 2.35 Impact Factor
  • Eric W Mueller, Neil E Ernst
    Critical Care Medicine 06/2007; 35(5):1430-1. · 6.12 Impact Factor

Publication Stats

248 Citations
63.18 Total Impact Points

Institutions

  • 2004–2012
    • University of Cincinnati
      Cincinnati, Ohio, United States
  • 2009
    • University of Tennessee
      • Department of Clinical Pharmacy
      Knoxville, TN, United States
  • 2003–2008
    • The University of Tennessee Health Science Center
      • • Department of Clinical Pharmacy
      • • College of Pharmacy
      Memphis, TN, United States