Antibiotic stewardship in the emergency department setting: Focus on oral antibiotic selection for adults with skin and soft tissue infections.

PURPOSE: An advisory panel of experts was convened by the ASHP Foundation as a part of its Medication-Use Evaluation Resources initiative to provide commentary on an approach to antibiotic stewardship in the treatment of skin and soft tissue infections (SSTIs), with a focus on oral antibiotics in the emergency department (ED) setting for patients who will be treated as outpatients. Considerations include a need to update existing guidelines to reflect new antibiotics and susceptibility patterns, patient-specific criteria impacting antibiotic selection, and logistics unique to the ED setting. SUMMARY: While national guidelines serve as the gold standard on which to base SSTI treatment decisions, our advisory panel stressed that institutional guidelines must be regularly updated and grounded in local antimicrobial resistance patterns, patient-specific factors, and logistical considerations. Convening a team of experts locally to establish institution-specific guidelines as part of a comprehensive antibiotic stewardship program can ensure patients receive the most appropriate oral therapy for the outpatient treatment of SSTIs in patients visiting the ED. CONCLUSION: SSTI treatment considerations for antibiotic selection in the ED supported by current, evidence-based guidelines, including guidance on optimal oral antibiotic selection for patients discharged for outpatient treatment, are a useful tool to improve the quality and efficiency of care, enhance patient-centric outcomes and satisfaction, decrease healthcare costs, and reduce overuse of antibiotics.

Two Times Versus Four Times Daily Cephalexin Dosing for the Treatment of Uncomplicated Urinary Tract Infections in Females.

Background: The current treatment guidelines of the Infectious Diseases Society of America recommend ß-lactam antibiotics as alternative rather than first-line agents for the treatment of uncomplicated urinary tract infection (uUTI). Cephalexin is a commonly prescribed first-generation cephalosporin with excellent bioavailability and urinary penetration; however, little data exist to support optimal dosing for uUTI. Methods: This retrospective multicenter cohort study included adult female patients who received 5 to 7 days of cephalexin for symptomatic uUTI with a cefazolin-susceptible urine culture. The primary objective was to compare uUTI treatment failure (eg, continued or recurrent symptoms within 30 days) between patients treated with cephalexin 500 mg twice daily (BID group) and 500 mg 4 times daily (QID group) in the outpatient setting. Secondary outcomes included time to treatment failure, reported adverse events within 7 days of treatment, and occurrence of Clostridioides difficile within 30 days of treatment. Results: A total of 261 patients were included (BID, n = 173; QID, n = 88). Baseline characteristics were similar between the groups. Escherichia coli was the most commonly isolated pathogen (85.4%). There was no difference in treatment failure observed between the groups (BID 12.7% vs QID 17%, P = .343), including failure while undergoing therapy (BID 2.3% vs QID 5.7%, P = .438) or recurrence within 30 days (BID 10.4% vs QID 11.3%, P = .438). No differences in reported adverse events (BID 4.6% vs QID 5.6%, P = .103) were observed between groups. Conclusions: Twice-daily cephalexin is as effective as 4-times-daily dosing for uUTI. A twice-daily dosing strategy may improve patient adherence.

Feasibility evaluation to expand a collaborative practice agreement and discontinue antibiotics after an emergency department or urgent care visit.

PURPOSE: The impact of pharmacist-led culture follow-up programs for positive cultures is well established. The benefits and feasibility of evaluating negative cultures and deprescribing unnecessary antibiotics after emergency department (ED) and urgent care (UC) visits are unknown; therefore, this evaluation characterized the burden of negative urine cultures and chlamydia tests and estimated how many potential antibiotic days could be saved with deprescribing. METHODS: This retrospective, descriptive study evaluated patients discharged from an ED or UC location with a pharmacist-led culture follow-up program. The primary objective was to characterize the proportion of patients with a negative urine culture or chlamydia test where an opportunity would exist to deprescribe antibiotics at follow-up. Secondary endpoints included estimating the number of potential antibiotic days that could be saved, postvisit healthcare utilization, and documented adverse drug reactions (ADRs). RESULTS: For a 1-month period, pharmacists reviewed 398 cultures, of which 208 (52%) were urine cultures or chlamydia tests with negative results. Fifty patients (24%) with negative results had been prescribed empiric antibiotics. The median duration of antibiotic treatment was 7 days (interquartile range [IQR], 5-7 days), while the median time to culture finalization was 2 days (IQR, 1-2 days). There was an opportunity to save a median of 5 antibiotic days per patient. Thirty-two patients (15.3%) followed up with their primary care physician within 7 days; of these patients, 1 (0.05%) had their antibiotic prescription discontinued by the primary care physician. There were no documented ADRs. CONCLUSION: Expansion of pharmacist-led culture follow-up programs to deprescribe antibiotics for patients with negative cultures has the potential to save significant antibiotic exposure.

Impact of Opioid Administration in the Intensive Care Unit and Subsequent Use in Opioid-Naïve Patients.

BACKGROUND: Opioids are a mainstay of therapy for patients in the intensive care unit (ICU) as part of the analgesia-first approach to sedation. Despite knowledge of acute consequences of opioid based analgosedation, less is known about the potential long-term consequences, including the effect of opioid administration in the ICU on subsequent opioid use in opioid-naïve patients. OBJECTIVE: To evaluate the relationship between ICU opioid administration to opioid-naïve patients and subsequent opioid use following discharge. METHODS: A query of the electronic medical record was performed to identify opioid-naïve adult patients admitted directly to an ICU. Patients who received continuous intravenous infusion of fentanyl, hydromorphone, or morphine were screened for inclusion into the analysis. RESULTS: Of the 342 patients included for analysis, 164 (47.1%) received an opioid at hospital discharge. In total, 17 of the 342 patients (5.0%) became long-term users, noted to be more common in patients who received an opioid prescription at discharge (8.7% vs 1.6%; P = 0.006). Neither total ICU morphine milligram equivalent (MME) nor average daily ICU MME administration were found to correlate with daily MME prescription quantity at discharge (R2 = 0.008 and R2 = 0.03, respectively). Following control for potentially confounding variables, total ICU MME administration remained an insignificant predictor of subsequent receipt of an opioid prescription at discharge and long-term opioid use. CONCLUSION AND RELEVANCE: This study failed to find a significant relationship between ICU opioid use in opioid-naïve patients and subsequent opioid use. These findings highlight the need to focus on transitions points between the ICU and discharge as potential opportunities to reduce inappropriate opioid continuation.

Impact of a stewardship-focused culture follow-up initiative on the treatment of pharyngitis in the emergency department and urgent care settings.

A culture follow-up program with an emphasis on symptom assessment may limit antibiotic exposure in patients with Group A Streptococcus on throat culture. A quasi-experimental study of such patients was conducted in our Emergency Department and Urgent Care centers. During the prestewardship initiative phase (March 2011-June 2012), the standard of care for culture follow-up did not include symptom assessment prior to prescribing antibiotics. During the stewardship initiative phase (March 2015-June 2016), culture follow-up was completed with a focus on symptom assessment and antibiotic avoidance. Two-hundred eighty patients were included. Antibiotic prescribing at follow-up decreased from 97.0% to 71.3% (P < 0.001); overall appropriateness of therapy at follow-up, including symptom assessment, increased from 6.0% to 81.5% (P < 0.001). There was no difference in 72-h revisit between the pre- and poststewardship initiative groups (P = 0.121). This study demonstrated improved antimicrobial prescribing with initiation of a stewardship-focused culture follow-up program in the Emergency Department and Urgent Care centers.

Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Decreased door-to-needle (DTN) time with tissue plasminogen activator (tPA) for acute ischemic stroke is associated with improved patient outcomes. Emergency medicine pharmacists (EMPs) can expedite the administration of tPA by assessing patients for contraindications, preparing, and administering tPA. The purpose of this study was to determine the impact of EMPs on DTN times and clinical outcomes in patients with acute ischemic stroke who receive tPA in the emergency department. METHODS: A retrospective, single-center, cohort study of patients who received tPA between August 1, 2012, and August 30, 2014, was conducted to compare DTN times with or without EMP involvement in stroke care. Secondary outcomes included changes in neurological status as measured by the National Institutes of Health Stroke Scale (NIHSS), length of hospital stay, discharge disposition, symptomatic intracranial hemorrhage, and in-hospital all-cause mortality. RESULTS: A total of 100 patients were included. The EMPs were involved in the care of 49 patients. The EMP involvement was associated with a significant improvement in DTN time (median 46 [interquartile range IQR: 34.5-67] vs 58 [IQR: 45-79] minutes; P = .019) and with receiving tPA within 45 minutes of arrival (49% vs 25%, odds ratio [OR]: 2.81 [95% confidence interval [CI]: 1.21-6.52]). National Institutes of Health Stroke Scale scores were significantly improved at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR: 0-4] vs 2 [IQR: 1-9.25]; P = .047). CONCLUSIONS: The EMP involvement in initial stroke care was associated with a significant improvement in DTN time.

Impact of rapid diagnostic testing for chlamydia and gonorrhea on appropriate antimicrobial utilization in the emergency department.

Prolonged turnaround time of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) test results may delay time to notification and treatment of test-positive patients and result in unnecessary antimicrobial use in test-negative patients. This quasi-experimental study evaluated the impact of NG/CT rapid diagnostic testing (RDT) in an urban emergency department (ED) on treatment appropriateness, time to notification, and cost. Patients tested in December 2013-January 2014 (traditional group, n=200) were compared with those in December 2014-January 2015 (RDT group, n=200). There was a significant increase in treatment appropriateness in the RDT group, 72.5% versus 60% (P=0.008) and time to results notification was significantly faster (median 17.4 versus 51.5hours, P=0.010). Availability of test result prior to discharge was associated with increased treatment appropriateness (odds ratio, 22.65 [95% confidence interval, 2.86-179.68]). The RDT would save approximately $37,000 annually. These results support the use of NG/CT RDT to expand antimicrobial stewardship efforts within the ED.

Comparison of bacteria isolated from emergency department patients versus hospitalized patients.

PURPOSE: The frequencies and corresponding susceptibilities of bacteria isolated from patients in the emergency department (ED) were compared with those from hospitalized patients. METHODS: A microbiology laboratory report of all positive bacterial cultures obtained in the ED, regardless of the source (e.g., blood, urine, sputum), was obtained. In the case of duplicate cultures, only the first isolate cultured from a single patient was included. Colonization-site cultures (e.g., nasal swabs) and culture reports identified by the laboratory as contaminant organisms were excluded from the evaluation. Antimicrobial susceptibility results were then compiled into a standardized ED-specific antibiogram. Antimicrobial susceptibilities for each pathogen in the ED antibiogram were compared with those in the hospitalwide antibiogram. If there was a difference of ≥5% between the susceptibility of a single antimicrobial agent, chi-square tests were conducted, and unadjusted odds ratios were calculated. Pathogens with fewer than 30 isolates were excluded from the susceptibility comparison. RESULTS: A total of 3140 cultures were evaluated (1417 from the ED, 1723 from the hospital). The frequencies of pathogens isolated in the ED and hospitalwide were similar, with the exception of Escherichia coli, which were more commonly isolated in ED patients, and Enterococcus species and Pseudomonas aeruginosa, which were more common in hospitalized patients. Significant differences in susceptibility profiles were identified for Staphylococcus aureus, coagulase-negative Staphylococcus, Enterococcus faecalis, E. coli, Klebsiella pneumoniae, and P. aeruginosa. CONCLUSION: Significant differences in the frequencies of bacteria isolated and corresponding susceptibilities were found in cultures obtained in ED patients compared with those obtained in hospitalized patients.

Aspirin resistance: disparities and clinical implications.

Abstract Aspirin is one of the most widely prescribed drugs for the prevention of thrombosis in patients with vascular disease. Yet, aspirin is unable to prevent thrombosis in all patients. The term "aspirin resistance" has been used to broadly define the failure of aspirin to prevent a thrombotic event. Whether this is directly related to aspirin itself through biochemical aspirin resistance or treatment failure, or if it is because of aspirin's inability to overcome the thrombogenic aspects of the disease process itself, has not been elucidated. This can have dramatic clinical implications for a variety of vascular disease subsets and is cause for concern, considering the high prevalence of aspirin use for both primary and secondary prevention. Disparities exist in the rates of aspirin resistance among certain patient populations, such as women, patients with diabetes mellitus, and those with heart failure, and across clinical conditions, such as cardiovascular and cerebrovascular disease. Clinical trial data from studies observing resistance have revealed that regardless of study size, dose of aspirin, control for drug interactions and adherence, or assay used to measure platelet function, aspirin resistance is associated with an increased risk for adverse events. Although the evidence is mounting, there has yet to be a consensus on the appropriate clinical response to aspirin resistance.

Association of pharmacist presence on compliance with advanced cardiac life support guidelines during in-hospital cardiac arrest.

BACKGROUND: The pharmacist has many potential roles as part of the resuscitation team during cardiopulmonary arrest. Limited published research has evaluated the practice of advanced cardiac life support (ACLS) during in-hospital arrest. Recent reviews indicate that an audit of in-hospital resuscitation practices should be performed to guide future resuscitation training programs for hospital personnel. OBJECTIVE: To assess compliance with ACLS guidelines during in-hospital cardiopulmonary arrest in a community teaching hospital and evaluate the association of compliance with the presence of a pharmacist on the resuscitation team. METHODS: A retrospective analysis of the records of 74 consecutive in-hospital arrests occurring between January 1, 2003, and June 30, 2004, was conducted to evaluate compliance with American Heart Association ACLS guidelines. RESULTS: A total of 74 arrests were evaluated. Noncompliance was noted in 58.1% of all documented arrests; of the 650 treatment interventions identified, 10.6% were noncompliant with ACLS guidelines. The reasons cited for noncompliance included an incorrect medication dosage (20.3%), prolonged period of time between sequential interventions (26.1%), omission of an indicated treatment (17.4%), deviation from recommended treatment guidelines (26.1%), and incorrect energy for defibrillation (10.1%). A pharmacist was present at 36.5% of documented arrests. Compliance with ACLS treatment guidelines was more likely during resuscitations in which a pharmacist was present (59.3% vs 31.9%; p = 0.03). CONCLUSIONS: Noncompliance with resuscitation guidelines was common during in-hospital resuscitation. The presence of a pharmacist on the resuscitation team was associated with improved compliance with treatment guidelines. Despite institutional requirements for pharmacist participation during resuscitation efforts, participation rates remain low. Further evaluation of the role of the pharmacist on the resuscitation team and the impact of the pharmacist on resuscitation practices should be considered.

Depressive disorder associated with mycophenolate mofetil.

Immunosuppressive pharmacologic agents are associated with a diverse array of adverse drug reactions. One of these agents, mycophenolate mofetil, is indicated for prevention of allogeneic organ transplant rejection and has recently been evaluated for treatment of autoimmune disease states, including myasthenia gravis. Although the prescribing information for mycophenolate mofetil reports depression as an adverse event, no descriptions of the onset or manifestation of this idiosyncratic reaction have been published. This case report describes a 64-year-old woman with myasthenia gravis who received mycophenolate mofetil and developed a severe depressive disorder requiring hospitalization 4 days after the start of therapy. The drug was discontinued, and she was treated with sertraline, quetiapine, and clonazepam. Within 2 days after mycophenolate mofetil discontinuation, the patient's depressive symptoms had markedly improved. Eight days later, mycophenolate mofetil was reintroduced under direct observation. After day 2 of this rechallenge, the patient reported a substantial increase in her depressive symptoms. Treatment was discontinued again, with improvement in the patient's symptoms within 2 days. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship between the patient's development of depression and mycophenolate mofetil therapy. Future evaluations of mycophenolate mofetil should include an assessment of psychological adverse effects. In addition, postmarketing surveillance should be encouraged to further delineate the association between depression and mycophenolate mofetil therapy.