Empirical antimicrobial prescribing for pyelonephritis in patients discharged from 15 US Emergency Departments: an opportunity for improvement.

BACKGROUND: Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing. OBJECTIVES: To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics. METHODS: We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy. RESULTS: Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07-0.83). CONCLUSIONS: In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis.

Evaluation of blood glucose changes with regular versus rapid-acting insulin for hyperglycaemia management in the emergency department.

OBJECTIVES: As emergency department (ED) visits secondary to hyperglycaemia increase, goals should focus on optimising treatment to minimise the length of stay (LOS). Both regular and rapid-acting insulins can effectively treat hyperglycaemia, but have different pharmacokinetic profiles. The purpose of this study is to compare blood glucose (BG) reduction over time in patients receiving subcutaneous regular versus rapid-acting insulin in the ED. METHODS: This retrospective chart review from 1 January 2018 to 31 December 2020 included adult ED patients with a BG ≥200 mg/dl who received subcutaneous regular insulin or insulin aspart. The primary endpoint was a change in BG immediately before and ≥30 min after insulin administration over time. RESULTS: There were 279 patients included in the study (108 regular insulin and 171 insulin aspart). Change in BG over time was 41.5 mg/dl/h in the regular insulin group and 47 mg/dl/h in the insulin aspart group (P = 0.36). There was no difference in hypoglycaemic events, ED LOS, time from insulin administration to discharge and total change in BG during ED stay. Patients who received regular insulin required less additional insulin doses (8.3% vs. 18.1%, P = 0.02), received a greater volume of intravenous fluids (1629 ml vs. 1280 ml, P = 0.02) and higher weight-based dose for the first insulin dose (0.11 units/kg vs. 0.10 units/kg, P = 0.02). CONCLUSION: There was no significant difference in BG reduction between insulin types for hyperglycaemic patients treated in the ED. This suggests that regular insulin and rapid-acting insulin have similar efficacy in the treatment of hyperglycaemia in the ED.

High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018-2020.

BACKGROUND: Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs). METHODS: We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli. RESULTS: Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04-3.51, and OR 6.93, 95% CI: 4.95-9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance. CONCLUSION: FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments.

Appropriateness of antibiotic selection for pneumonia in the emergency department: pre- and post-order set changes.

OBJECTIVES: Emergency department (ED) providers face pressure to meet sepsis mandates such as prompt administration of antibiotic therapy, which can lead to the overuse of broad-spectrum antibiotics. In recent years, there has also been a push to adhere to institutional antibiotic stewardship goals including decreasing inappropriate antibiotic therapy and limiting duration of therapy. Previous literature has demonstrated that the incorporation of clinical decision support (CDS) tools in electronic medical records can aid in guiding appropriate antibiotic prescribing. Therefore, the objective of this study was to determine whether the implementation of a CDS tool could improve antibiotic selection for pneumonia management in the ED. METHODS: This was a retrospective single-centre observational study conducted in patients that presented to the ED with pneumonia. In November 2018, a CDS tool was incorporated into the ED sepsis order set to guide practitioners in selecting appropriate antibiotics for pneumonia. Antibiotic prescribing patterns were assessed pre-CDS (January-February 2018) and post-CDS (January-February 2019) implementation. Patients were included if they were 18 years of age or older, had an ED visit with ICD10 code reflective of pneumonia, and had at least one antibiotic ordered from the ED sepsis order set. The primary endpoint was the percentage of patients prescribed appropriate antibiotic therapy for pneumonia based on patient risk factors pre- and post-CDS implementation. KEY FINDINGS: There were 161 patients in the pre-CDS group and 119 patients in the post-CDS group included in the study. There was a significant improvement in the selection of appropriate antibiotics in the post-CDS group (31.9% versus 65.3%, P < 0.0001) with no significant differences in duration of antibiotics, intubation rates, vasopressor initiation, length of stay, mortality or 30-day readmission. CONCLUSION: The implementation of a CDS tool for empiric management of pneumonia in the ED significantly improved the selection of appropriate antibiotics.

Impact of clinical decision support on oritavancin prescribing in the emergency department.

BACKGROUND: Emergency department (ED) visits and hospitalizations from skin and soft tissue infections (SSTIs) have been on the rise and have led to an increased clinical and economic burden. Owing to their single-dose regimen, recently approved lipoglycopeptides such as oritavancin have the potential to shift the management of SSTIs from an inpatient to outpatient setting. Limited data exist regarding the use of these drugs in the ED setting. OBJECTIVES: The purpose of this study was to describe the impact that clinical decision support (CDS) incorporation into the computerized physician order entry (CPOE) system had on oritavancin use and to assess compliance with appropriate use guidelines in the ED. METHODS: This was a retrospective cohort study evaluating patients who received oritavancin from September 2016 to May 2018. The patients were assigned to the pre-CDS-implementation group if oritavancin was used between September 13, 2016, and June 28, 2017 and to the post-CDS-implementation group if oritavancin was used between August 28, 2017, and May 25, 2018. There was a 2-month transition period between the 2 study time periods. Patients were excluded if the administration occurred outside of the ED or during the transition period. The primary endpoints were oritavancin use and compliance with the appropriate use guidelines after the implementation. RESULTS: There were 169 oritavancin orders in total, of which 119 met the inclusion criteria. There was a marked decrease in use post-CDS implementation (9.2 orders/mo vs. 3 orders/mo). Among those who were prescribed oritavancin, compliance with the appropriate use guidelines increased; however, this did not reach statistical significance. CONCLUSION: The implementation of the appropriate use guidelines with CDS integration into the CPOE system decreased overall oritavancin use but did not have an impact on compliance with the appropriate use guidelines.

Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update.

PURPOSE: To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY: Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION: There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.

Sexually Transmitted Infection Review for the Acute Care Pharmacist.

PURPOSE: Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting. SUMMARY: In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs. CONCLUSION: In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

The impact of an emergency medicine clinical pharmacist on nursing satisfaction.

BACKGROUND: In the United States, emergency medicine clinical pharmacists have become more common over the last several decades. Despite being a vital component of the emergency department interdisciplinary team, there is very limited information published regarding the direct impact emergency medicine clinical pharmacists have on other emergency department-based professions. OBJECTIVE: To determine if the addition of an emergency medicine clinical pharmacist improves nursing satisfaction with pharmacy services. SETTING: The study was conducted at a 422-bed urban teaching hospital consisting of approximately 60 emergency medicine nurses. METHODS: This was a prospective study that evaluated nursing satisfaction prior to the initiation of an emergency medicine clinical pharmacist and one year after implementation. The survey consisted of 29 questions and was designed to assess three areas of pharmacy: general pharmacy, pharmacy information technology, and emergency medicine clinical pharmacy services. For the majority of questions, a 5-point Likert scale ranging from 1 representing strongly disagree to 5 representing strongly agree was utilized. Responses for the 5 point Likert scale were further tabulated into either positive or negative responses. All emergency department nurses employed during the study period (September 2015 and 2016) were eligible to participate anonymously. MAIN OUTCOME MEASURE: The main outcome assessed was the difference in satisfaction scores between study periods. RESULTS: A total of 52 surveys were returned over the course of the study (22 [36.7%] in the pre-intervention group versus 30 [50%] in the post-intervention group). All general pharmacy questions were improved at one year with timely resolution of pharmacy related issues, medication procurement, and satisfaction with pharmacy services achieving statistical significance. Pharmacy information technology questions were significantly improved with respect to satisfaction with the automated medication dispensing system inventory, prevention and resolution of medication stock outs, and ease of medication removal compared to baseline. The perceived impact of emergency medicine clinical pharmacy services in the pre-intervention group was validated after the one-year implementation period. CONCLUSION: An emergency medicine clinical pharmacist increases nursing satisfaction with central pharmacy and pharmacy technology services and was able to maintain the nurses' perceived expected role of the clinical pharmacist.

The Use of Continuous Ketamine for Analgesia and Sedation in Critically Ill Patients with Opioid Abuse: A Case Series.

Managing pain and agitation in patients with opioid abuse is becoming more common in intensive care units. Tolerance to commonly used agents is often observed, leading to inadequate pain control and increased agitation. Ketamine's unique mechanism of action and opioid-sparing effects make it an ideal agent for patients with suboptimal response to opioid therapy. This report describes our experience using continuous ketamine infusions for analgesia and sedation in four mechanically ventilated patients with histories of opioid abuse that had suboptimal response to standard therapy. Ketamine was successful in improving analgesia and sedation in three patients while reducing the need for other analgesics and sedatives with minimal adverse effects. Continuous ketamine infusions may be useful to facilitate mechanical ventilation in patients with histories of opioid abuse with minimal toxicity. More information is needed on the optimal dose and titration parameters.

Current practice of hypoglycemia management in the ED.

PURPOSE: To characterize hypoglycemia management and identify characteristics associated with refractory (need for additional treatment following initial management) and recurrent (adequate initial treatment followed by blood glucose [BG] ≤50 mg/dL) hypoglycemia. METHODS: Retrospective review of adult emergency department (ED) patients who presented to a large academic medical center with hypoglycemia (BG ≤ 50 mg/dL) between January 2011 and July 2015. Data collection focused on BG measurements and treatment practices. Data are reported using descriptive statistics, Wilcoxon rank sum, and χ2 analysis as appropriate. RESULTS: Two hundred forty-four patients were included (mean age, 59 ± 18.7 years; weight, 85 ± 24.3 kg). Patients arriving via prehospital care (n = 124) were assessed faster in the ED (median, 25 minutes; interquartile range [IQR], 10-40 minutes) compared with ambulatory arrival (median, 43 minutes; IQR, 17-95 minutes; P = .0018). There were 174 patients with a BG ≤ 50 mg/dL in the ED. Of those, 108 (62.1%) were treated with intravascular bolus dextrose/intramuscular glucagon and 21 patients (12%) did not receive any treatment or food. The overall median time to treatment after identification of hypoglycemia was 12 minutes (IQR, 6-27.8 minutes); treatment was administered faster after bedside point-of-care testing assessment compared with when serum samples resulted (11 [IQR, 6-23.5] minutes vs 25 [IQR, 10.75-42.5] minutes, respectively; P = .015). The overall time to repeat BG was obtained 22 (IQR, 8-44) minutes after bolus treatment, but this interval increased with subsequent measurements. Refractory or recurrent hypoglycemia occurred in 30.3% of patients. Mean initial BG was lower in the subset of patients who developed refractory hypoglycemia compared with those who did not (35.1 ± 9.8 vs 37.6 ± 10.2 mg/dL, P = .079), although not statistically significant. Patients with recurrent hypoglycemia were also less likely to receive dextrose containing intravenous fluids compared with those without recurrent hypoglycemia (P = .028). Infection was the only associated characteristic with refractory or recurrent hypoglycemia (P = .021). CONCLUSIONS: Overall, 12% of patients did not receive treatment for hypoglycemia in the ED with a BG ≤ 50 mg/dL. Time to treatment after identification was faster when identified by care testing vs serum sample result. Time to repeat BG in the ED was relatively quick, but did increase over time. About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia.

Interdependence and contributions of sun exposure and vitamin D to MRI measures in multiple sclerosis.

PURPOSE: To assess the relationships of sun exposure history, supplementation and environmental factors to vitamin D levels in multiple sclerosis (MS) patients and to evaluate the associations between sun exposure and MRI measures. METHODS: This study included 264 MS patients (mean age 46.9±10 years, disease duration 14.6±10 years; 67.8% relapsing-remitting, 28% secondary progressive and 4.2% primary progressive MS) and 69 healthy controls. Subjects underwent neurological and 3 T MRI examinations, provided blood samples and answered questions to a structured questionnaire. Information on race, skin and eye colour, supplement use, body mass index (BMI) and sun exposure was obtained by questionnaire. The vitamin D metabolites (25-hydroxy vitamin D3, 1, 25-dihydroxy vitamin D3 and 24, 25-dihydroxy vitamin D3) were measured using mass spectrometry. RESULTS: Multivitamin supplementation (partial correlation r(p)=0.29, p<0.001), BMI (r(p)=-0.24, p=0.001), summer sun exposure (r(p)=0.22, p=0.002) and darker eye colour (r(p)=-0.18, p=0.015) had the strongest associations with vitamin D metabolite levels in the MS group. Increased summer sun exposure was associated with increased grey matter volume (GMV, r(p)=0.16, p=0.019) and whole brain volume (WBV, r(p)=0.20, p=0.004) after correcting for Extended Disability Status Scale in the MS group. Inclusion of 25-hydroxy vitamin D3 levels did not substantially affect the positive associations of sun exposure with WBV (r(p)=0.18, p=0.003) and GMV (r(p)=0.14, p=0.026) in the MS group. CONCLUSIONS: Sun exposure may have direct effects on MRI measures of neurodegeneration in MS, independently of vitamin D.