Impact of prospective verification of intravenous antibiotics in an ED.

BACKGROUND: Delay in appropriate antibiotic therapy is associated with an increase in mortality and prolonged length of stay. Automatic dispensing machines decrease the delivery time of intravenous (IV) antibiotics to patients in the emergency department (ED). However, when IV antibiotics are not reviewed by pharmacists before being administered, patients are at risk for receiving inappropriate antibiotic therapy. The objective of this study was to determine if a difference exists in the time to administration of appropriate antibiotic therapy before and after implementation of prospective verification of antibiotics in the ED. METHODS: This retrospective, institutional review board-approved preimplementation vs postimplementation study evaluated patients 18years or older who were started on IV antibiotics in the ED. Patients were excluded if pregnant, if the patient is a prisoner, if no cultures were drawn, or if the patient was transferred from an outside facility. Appropriate antibiotic therapy was based on empiric source-specific evidence-based guidelines, appropriate pharmacokinetic and pharmacodynamic properties, and microbiologic data. The primary end point was the time from ED arrival to administration of appropriate antibiotic therapy. RESULTS: Of the 1628 evaluated, 128 patients met the inclusion criteria (64 pre vs 64 post). Patients were aged 65.2±17.0years, with most of infections being pneumonia (44%) and urinary tract infections (18%) and most patients being noncritically ill. Time to appropriate antibiotic therapy was reduced in the postgroup vs pregroup (8.1±8.6 vs 15.2±22.8hours, respectively, P=.03). In addition, appropriate empiric antibiotics were initiated more frequently after the implementation (92% post vs 66% pre; P=.0001). There was no difference in mortality or length of stay between the 2 groups. CONCLUSION: Prompt administration of the appropriate antibiotics is imperative in patients with infections presenting to the ED. The impact of prospective verification of antibiotics by pharmacists led to significant improvement on both empiric selection of and time to appropriate antibiotic therapy.

Sarm1 is not necessary for activation of neuron-intrinsic growth programs yet required for the Schwann cell repair response and peripheral nerve regeneration.

Upon peripheral nervous system (PNS) injury, severed axons undergo rapid SARM1-dependent Wallerian degeneration (WD). In mammals, the role of SARM1 in PNS regeneration, however, is unknown. Here we demonstrate that Sarm1 is not required for axotomy induced activation of neuron-intrinsic growth programs and axonal growth into a nerve crush site. However, in the distal nerve, Sarm1 is necessary for the timely induction of the Schwann cell (SC) repair response, nerve inflammation, myelin clearance, and regeneration of sensory and motor axons. In Sarm1-/- mice, regenerated fibers exhibit reduced axon caliber, defective nerve conduction, and recovery of motor function is delayed. The growth hostile environment of Sarm1-/- distal nerve tissue was demonstrated by grafting of Sarm1-/- nerve into WT recipients. SC lineage tracing in injured WT and Sarm1-/- mice revealed morphological differences. In the Sarm1-/- distal nerve, the appearance of p75NTR+, c-Jun+ SCs is significantly delayed. Ex vivo, p75NTR and c-Jun upregulation in Sarm1-/- nerves can be rescued by pharmacological inhibition of ErbB kinase. Together, our studies show that Sarm1 is not necessary for the activation of neuron intrinsic growth programs but in the distal nerve is required for the orchestration of cellular programs that underlie rapid axon extension.

Combination exenatide-sitagliptin therapy used with glipizide in a patient with type 2 diabetes mellitus.

PURPOSE: The case of a patient with type 2 diabetes mellitus who received combination exenatide-sitagliptin with glipizide is reported. SUMMARY: A 55-year-old, 204-lb Caucasian woman arrived at a clinic with polydipsia. Her blood glucose concentration was 450 mg/dL and her glycosylated hemoglobin (HbA(1c)) value was 13.4%. She was diagnosed with type 2 diabetes mellitus and started on metformin hydrochloride 500 mg orally twice daily. Metformin was later discontinued due to elevated liver function test values. Sitagliptin 100 mg daily was substituted, and glipizide was later added and its dosage adjusted over the next several months. After six months, her HbA(1c) value had decreased to 9.3% and she had gained 14 lb. Exenatide was then added to her regimen, and the dosage was adjusted to 10 µg subcutaneously twice daily. Two months after the initiation of sitagliptin, glipizide, and exenatide, the patient had lost 10 lb, reported significant improvements in self-monitored blood glucose readings, and required a reduction in glipizide dosage despite no reported therapeutic lifestyle changes. Seven months after the initiation of exenatide, sitagliptin, and glipizide, her HbA(1c) value was 7.4%. Triple therapy resulted in a total HbA(1c) value reduction of 1.9%, a weight loss of 11 lb, and normalized liver function test values. The patient's high blood pressure was treated with losartan and remained at goal throughout the duration of this report. CONCLUSION: In a patient with type 2 diabetes mellitus, the addition of the incretin mimetic exenatide and the dipeptidyl peptidase-4 inhibitor sitagliptin to glipizide therapy appeared effective and safe.