Publications (5)10.83 Total impact
- [Show abstract] [Hide abstract] ABSTRACT: Background: Using serum PCT levels to help guide antibiotic duration in adult intensive care units reduced antibiotic use without adversely affecting survival or other outcomes in randomized controlled trials. We assessed the clinical utility of real-world PCT testing in two Chicago teaching hospital MICUs. Methods: Concurrent PCT testing and teaching/guideline interventions deployed in reverse sequence in the two MICUs were approved as quality improvement projects by both hospital IRBs, with waiver of patient consent. Recipients of systemic antibacterials were targeted for daily PCT testing only while in the MICU; results appeared in patients' electronic records; MICU physicians (MDs) used published interpretive criteria to integrate PCT results with clinical data in making antibiotic prescribing decisions. We assessed MD prescribing decision/PCT level adherence over all PCT levels and for the last PCT measurement for each episode of care. Results: PCT was measured 1240 times in 630 care episodes (median 2 tests/episode) for 540 patients over 10 months in MICU A. Over 5 months of ongoing testing in MICU B, PCT was measured 531 times during 131 episodes of care (median 3 tests/episode) for 121 patients. PCT results and patient-level trends generally mirrored infection severity and response to therapy. At hospital A, of 173 initially low PCT values, MDs stopped antibiotics 49 (28%) times; at hospital B, initial PCT values were not responded to. Adherence to PCT-generated recommendations for all PCT levels and for the last PCT levels is displayed in Figure 1 and Figure 2. Conclusion: The distribution of PCT values above and below the threshold for recommending antibiotic stopping was similar at our two academic MICUs, but MD adherence to these recommendations differed markedly, suggesting variable test acceptance. Only 20% of patients in the MICU with higher rates of adherence had PCT levels below the threshold to recommend stopping antibiotics. PCT testing after ICU discharge and improved MD education may be needed to take full advantage of PCT testing in this population.
- [Show abstract] [Hide abstract] ABSTRACT: The development and implementation of an extended-infusion piperacillin-tazobactam program at an urban teaching hospital are described. A multidisciplinary team was formed to address the feasibility of converting from the standard 30-minute infusion to an extended infusion of piperacillin- tazobactam. Before hospitalwide implementation, feasibility studies were performed in a subset of patients to identify potential barriers to program implementation. On the day of hospitalwide conversion, the orderables for piperacillin-tazobactam were reprogrammed in the computerized prescriber-order-entry system to allow separate options for the 30-minute infusion (for pediatric patients) and the extended-infusion regimen. After selecting the orderable for the extended-infusion regimen, an electronic message appeared to remind prescribers of the rationale for this change and recommended indications for piperacillin-tazobactam. Program success was prospectively evaluated on 11 weekdays after hospitalwide conversion for all 96 adult inpatients receiving piperacillin-tazobactam. Of the 194 piperacillin-tazobactam doses observed, 90% were appropriate, with compliance increasing to 100% by the end of the observation period. There was near-complete cessation of the every-6-hour dosage interval and a marked increase in the every-8-hour and every-12-hour dosage intervals. The number of piperacillin-tazobactam doses per 1000 patient-days significantly decreased during the postimplementation period. During the postimplementation period, pharmacy expenditures related to piperacillin-tazobactam decreased by 18% and the total number of grams of piperacillin-tazobactam purchased decreased by 24%. A hospitalwide program for the administration of extended-infusion piperacillin-tazobactam was safely and successfully implemented using a multi-disciplinary approach in an urban teaching hospital.
- [Show abstract] [Hide abstract] ABSTRACT: While propofol is associated with an infusion syndrome (PRIS) that may cause death, the incidence of PRIS is unknown. Determining the incidence of PRIS and the frequency of PRIS-related clinical manifestations are key steps prior to the completion of any controlled studies investigating PRIS. This prospective, multicenter study sought to determine the incidence of PRIS and PRIS-related clinical manifestations in a large cohort of critically ill adults prescribed propofol. Critically ill adults from 11 academic medical centers administered an infusion of propofol for [>/=] 24 hours were monitored at baseline and then on a daily basis until propofol was discontinued for the presence of 11 different PRIS-associated clinical manifestations and risk factors derived from 83 published case reports of PRIS. Among 1017 patients [medical (35%), neurosurgical (25%)], PRIS (defined as metabolic acidosis plus cardiac dysfunction and [>/=] 1 of: rhabdomyolysis, hypertriglyceridemia or renal failure occurring after the start of propofol therapy) developed in 11 (1.1%) patients an average of 3 (1-6) [median (range)] days after the start of propofol. While most (91%) of the patients who developed PRIS were receiving a vasopressor (80% initiated after the start of propofol therapy), few received a propofol dose >83 mcg/kg/min (18%) or died (18%). Compared to the 1006 patients who did not develop PRIS, the APACHE II score (25 +/- 6 vs 20 +/- 7, P = 0.01) was greater in patients with PRIS but both the duration of propofol use (P = 0.43) and ICU length of stay (P = 0.82) were similar. Despite using a conservative definition for PRIS, and only considering new-onset PRIS clinical manifestations, the incidence of PRIS slightly exceeds 1%. Future controlled studies focusing on evaluating whether propofol manifests the derangements of critical illness more frequently than other sedatives will need to be large. These studies should also investigate the mechanism(s) and risk factors for PRIS.
Conference Paper: Continuation of High Dose Vancomycin (HDV) Despite Nephrotoxicity (Nftx)[Show abstract] [Hide abstract] ABSTRACT: Background: Studies have reported Nftx in 12-40% of patients (pts) receiving HDV (trough [Tr] ≥15 mg/L). The purpose of this study was to examine the clinical outcomes and rate of Nftx in patients receiving greater than 5 days of HDV. Methods: Clinical and laboratory data was collected in adult inpatients receiving supervised HDV for treatment of severe MRSA infections. Nftx was defined as increase in serum creatinine (SCr) of 0.5 mg/dL or 50% from baseline. Results: Thirty-five patients were included. The mean duration of vancomycin (V) therapy was 19.7 ± 11 (range 6-43) days. A total of 185 V concentrations (Cp) were measured with a mean of the average V Tr per patient being 18.7 ± 5 mg/L. Nftx developed in 10 (29%) pts (Table). Age, weight, ICU stay at initiation of HDV, comorbidities, exposure to other nephrotoxins, baseline SCr and V Tr were similar for pts with or without Nftx. Pts who developed Nftx achieved mean V Tr of 16.8 ± 5.4 mg/L before and 17.8 ± 5.2 mg/L after onset of Nftx. Seven pts who developed Nftx continued to receive HDV with close monitoring of V dose and Cp. At discharge, SCr returned to within 0.5mg/dL or 50% of baseline in 3 pts and was trending down in 6. No pts required hemodialysis. Pt Days to Nftx onset from V initiation Indication for HDV Baseline SCr (mg/dL) Peak SCr (mg/dL) SCr before discharge (mg/dL) Days on HDV after Nftx Outcome 1 3 Empiric, pneumonia 1.8 2.7 2.3 12 Completed HDV, discharged. SCr at follow-up was 1.7 mg/dL. 2 4 MRSA bacteremia, osteomyelitis, pneumonia 0.9 3.1 1.1 35 Transferred to nursing home for 7 more days of HDV. 3 6 MRSA bacteremia, osteomyelitis 0.8 1.4 1.3 37 Completed HDV, discharged. 4 7 Empiric, retroperitoneal abscess 1.5 2.2 1.5 0 Abscess grew VRE, V discontinued 5 13 MRSA tenosynovitis 0.4 0.7 0.6 10 MRSA MIC=2 mg/L, patient switched to daptomycin. 6 14 Empiric, osteomyelitis 0.9 1.5 1.2 29 Completed HDV, discharged home. 7 15 MRSA bacteremia 1 1.5 1.5 0 Stopped V treatment 2 days earlier. 8 17 MRSA bacteremia, endocarditis 0.5 1.8 1.4 26 Completed HDV, discharged home. 9 18 MRSA bacteremia, osteomyelitis, bursitis 0.7 1.5 1.2 0 Switched to Conclusions: Although Nftx occurred in 29% of HDV pts, discontinuation of HDV therapy is not always required and SCr may improve on continued therapy with careful monitoring. R Weinstein, MD1, R Xamplas, PharmD2, R Glowacki, PharmD3, Bala Hota, MD4, C Teng, MS (Clinical Pharmacy)5, D Schwartz, MD6, G Itokazu, PharmD, K Rezai, MD2, K Rodvold, PharmD3, P Antonopoulos, PharmD2 and C. B. Teng, None., (1)Rush Medical College, (2)Stroger Hospital of Cook County, (3)University of Illinois at Chicago, College of Pharmacy, (4)John H. Stroger, Jr. Cook County Hospital, Chicago, IL, (5)University of Illinois at Chicago, College of Pharmacy, Singapore, Singapore, (6)Tel-Aviv Sourasky Med. Ctr.
Cook County Hospital
Chicago, Illinois, United States
- Division of Infectious Diseases