Clinical Effects of Perioperative Selective Decontamination of the Digestive Tract (SDD) in Cardiac Surgery: A Propensity Score Matched Cohort Analysis.

OBJECTIVES: To determine the clinical effects of perioperative endotoxin reduction in the gut lumen in patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN: Retrospective cohort analysis with propensity score matching according to treatment group. SETTING: Tertiary center for cardiopulmonary diseases and intensive care medicine. PARTICIPANTS: Included were patients who underwent cardiac surgery with cardiopulmonary bypass between 2008 and 2017. Excluded were readmitted patients. INTERVENTIONS: Endotoxin reduction in the gut lumen by ingestion of oral tobramycin 80 mg and polymyxin B 100 mg 4 times daily (TP) as part of selective digestive tract decontamination, which contains amphotericin B 500 mg as well. MEASUREMENTS AND MAIN RESULTS: A total of 6,394 patients were included, of whom 2,044 patients were in the intervention group. A total of 835 patients received both pre- and postoperative TP (Pre+/Post+), and 1,165 patients received TP only postoperatively (Pre-/Post+). The control group, not treated with TP at any moment, consisted of 4,350 patients (Pre-/Post-). After matching, 652 Pre+/Post+ patients were compared with an equal number of controls (Pre-/Post-). Pre+/Post+ group did not do better for any clinical outcome. A total of 682 Pre+/Post+ patients matched with an equal number of Pre-/Post+ patients. The latter group had a 0.3 points higher mean Sequential Organ Failure Assessment score and in the regression analysis a significantly higher intensive care unit mortality but not hospital mortality. A significant reduction in length of stay and length of mechanical ventilation for the Pre+/Post+ group was shown compared with Pre-/Post+, but these differences can be explained by unbalanced differences in the severity of illness. CONCLUSION: Cardiosurgical patients who receive tobramycin and polymyxin orally preoperatively to reduce the gut endotoxin level do not expose convincing and relevant beneficial effects on clinical outcomes in this retrospective propensity score matching cohort study.

A mandatory indication-registration tool in hospital electronic medical records enabling systematic evaluation and benchmarking of the quality of antimicrobial use: a feasibility study.

OBJECTIVES: Evaluation of the extent and appropriateness of antimicrobial use is a cornerstone of antibiotic stewardship programs, but it is time-consuming. Documentation of the indication at the moment of prescription might be more time-efficient. We investigated the real-life feasibility of mandatory documentation of the indication for all hospital antibiotic prescriptions for quality evaluation purposes. METHODS: A mandatory prescription-indication format was implemented in the Electronic Medical Record (EMR) of three hospitals using EPIC or ChipSoft HIX software. We evaluated the retrieved data of all antibiotics (J01) prescribed as empiric therapy in adult patients with respiratory tract infections (RTI) or urinary tract infections (UTI), from January through December 2017 in Hospital A, June through October 2019 in Hospital B and May 2019 through June 2020 in Hospital C. Endpoints were the accuracy of the data, defined as agreement between selected indication for the prescription and the documented indication in the EMR, as assessed by manually screening a representative sample of eligible patient records in the EMR of the three hospitals, and appropriateness of the prescriptions, defined as the prescriptions being in accordance with the national guidelines. RESULTS: The datasets of hospitals A, B and C contained 9588, 338 and 5816 empiric antibiotic prescriptions indicated for RTI or UTI, respectively. The selected indication was in accordance with the documented indication in 96.7% (error rate: 10/300), 78.2% (error rate: 53/243), and 86.9% (error rate: 39/298), respectively. A considerable variation in guideline adherence was seen between the hospitals for severe community acquired pneumonia (adherence rate ranged from 35.4 to 53.0%), complicated UTI (40.0-67.1%) and cystitis (5.6-45.3%). CONCLUSIONS: After local validation of the datasets to verify and optimize accuracy of the data, mandatory documentation of the indication for antibiotics enables a reliable and time-efficient method for systematic registration of the extent and appropriateness of empiric antimicrobial use, which might enable benchmarking both in-hospital and between hospitals.

Pharmacotherapy within a learning healthcare system: rationale for the Dutch Santeon Farmadatabase.

OBJECTIVES: The increasing number of available, often expensive, medicines asks for continuous assessment of rational prescribing. We aimed to develop a simple and robust data infrastructure in order to monitor hospital medicine utilisation in real time. METHODS: Within a collaboration (Santeon) of large teaching hospitals in the Netherlands, we set up a process for extraction, transformation, anonymisation and load of individual medicine prescription data and major clinical outcomes from different hospital information systems into a central database. Quarterly reports were constructed to monitor and validate the quality of the uploaded data. RESULTS: A central database has been developed that includes data from all patients from 2010 onwards and is refreshed on a weekly basis by an automated process. Beginning in 2017, the database holds data from almost 800 000 patients with prescriptions. All hospitals provide at least 18 mandatory data items per patient. Provided data include, among others, individual prescriptions, diagnosis data, and hospitalisation and survival data. The database is currently used to benchmark the level of biosimilar prescribing and to assess the impact of novel systemic treatments on survival rates in metastatic cancers. CONCLUSION: We showed that it is feasible for a group of hospitals to construct their own database that can serve as a tool to benchmark the positioning of medicines and to start with monitoring their impact on clinical outcomes.

[Recurrent neutropenia due to adulterated cocaine]. / Herhaalde neutropenie door versneden cocaïne.

BACKGROUND: Since 2009, a warning has been issued about cocaine that has been adulterated with levamisole, mainly in the USA and Canada. Agranulocytosis occurs as an idiosyncratic reaction in 3-10% of patients exposed to levamisole. CASE DESCRIPTION: A 36-year-old man was referred to our hospital because of an episode of high fever and infections on his hands, mouth and ears. Laboratory testing showed neutropenia. The infections were treated successfully with antibiotics. The neutropenia disappeared, but returned with recurrence of the infections. Upon presentation at the emergency care unit, the patient had signs of intoxication. This patient's urine contained metabolites of cocaine (benzoylecgonine and ecgonine methyl ester), whereupon additional testing showed levamisole to be present in serum. The patient discontinued cocaine use. Following treatment of the infections, the neutropenia fully resolved and did not recur. CONCLUSION: This patient had acquired agranulocytosis, due to the use of cocaine adulterated with levamisole.

Evaluation of the concurrent use of potassium-influencing drugs as risk factors for the development of hyperkalemia.

BACKGROUND: Hyperkalemia is a potentially dangerous electrolyte abnormality with a reported incidence of 1-10 % in hospitals. Patients are especially at risk of developing this complication if they use a combination of potassium supplements and potassium sparing diuretics or renin-angiotensin-aldosterone-system (RAAS) inhibitors. Previous studies on the occurrence of hyperkalemia in patients who use multiple potassium influencing drugs simultaneously were either small in sample size or did not investigate the full range of drugs involved. OBJECTIVE: To assess the prevalence of hyperkalemia and to identify risk factors for its development in hospitalised patients using potassium supplements, potassium-sparing diuretics and/or RAAS-inhibitors concurrently. SETTING: The study was conducted at the Onze Lieve Vrouwe Hospital in Amsterdam, The Netherlands from January 2009 to May 2010. METHOD: A retrospective, nested case-control study included hospitalised patients who used a combination of potassium-influencing drugs. Cases were patients with serum potassium ≥ 5.5 mmol/l, controls were patients with normal serum potassium levels. Cases and controls were included in a ratio of 1:2. The following known risk factors associated with hyperkalemia were recorded and statistically analyzed: diabetes mellitus, congestive heart failure, decreased renal function, advanced age, gender and use of heparin, digoxin, non-steroidal anti-inflammatory drugs, beta-blockers, calcineurin antagonists and trimethoprim. MAIN OUTCOME MEASURE: Identify risk factors for the development of hyperkalemia as a result of the concurrent use of potassium supplements, RAAS inhibitors and/or potassium-sparing diuretics. RESULTS: Of 774 patients included in this study, 52 patients developed hyperkalemia; a prevalence of 6.7 %. The only risk factor found to be significantly associated with hyperkalemia was lowered renal function, expressed as estimated glomerular filtration rate (eGFR) <50 ml/min (adjusted OR 5.08; 95 % CI 2.46-10.48). None of the other tested risk factors was identified as significant. CONCLUSION: This study showed that decreased renal function (eGFR <50 ml/min) was associated with a fivefold increased risk for hyperkalemia in patients using potassium-influencing drugs. While previous studies showed that hyperkalemia substantially increases below a threshold of eGFR <30 or 40 ml/min, we observed a lower threshold of eGFR <50 ml/min. It is therefore recommended that physicians should be particularly alert while monitoring the use of potassium-influencing drugs in patients with decreased renal function.