Comparative Outcomes of Candida auris Bloodstream Infections: A Multicenter Retrospective Case-Control Study.

BACKGROUND: This study was performed to compare clinical characteristics and outcomes between patients with bloodstream infections (BSIs) caused by Candida auris and those with BSIs caused by other Candida spp. METHODS: A multicenter retrospective case-control study was performed at 3 hospitals in Brooklyn, New York, between 2016 and 2020. The analysis included patients ≥18 years of age who had a positive blood culture for any Candida spp. and were treated empirically with an echinocandin. The primary outcome was the 30-day mortality rate. Secondary outcomes were 14-day clinical failure, 90-day mortality rate, 60-day microbiologic recurrence, and in-hospital mortality rate. RESULTS: A total of 196 patients were included in the final analysis, including 83 patients with candidemia caused by C. auris. After inverse propensity adjustment, C. auris BSI was not associated with increased 30-day (adjusted odds ratio, 1.014 [95% confidence interval, .563-1.828]); P = .96) or 90-day (0.863 [.478-1.558]; P = .62) mortality rates. A higher risk for microbiologic recurrence within 60 days of completion of antifungal therapy was observed in patients with C. auris candidemia (adjusted odds ratio, 4.461 [95% confidence interval, 1.033-19.263]; P = .045). CONCLUSIONS: C. auris BSIs are not associated with a higher mortality risk than BSIs caused by other Candida spp. The rate of microbiologic recurrence was higher in the C. auris group.

Nephrotoxicity of Vancomycin in Combination With Beta-Lactam Agents: Ceftolozane-Tazobactam vs Piperacillin-Tazobactam.

BACKGROUND: Vancomycin (VAN)-associated acute kidney injury (AKI) is increased when VAN is combined with certain beta-lactams (BLs) such as piperacillin-tazobactam (TZP) but has not been evaluated with ceftolozane-tazobactam (C/T). Our aim was to investigate the AKI incidence of VAN in combination with C/T (VAN/C/T) compared with VAN in combination to TZP (VAN-TZP). METHODS: We conducted a multicenter, observational, comparative study across the United States. The primary analysis was a composite outcome of AKI and risk, injury, failure, loss, end stage renal disease; Acute Kidney Injury Network; or VAN-induced nephrotoxicity according to the consensus guidelines. Multivariable logistic regression analysis was conducted to adjust for confounding variables and stratified Kaplan-Meir analysis to assess the time to nephrotoxicity between the 2 groups. RESULTS: We included VAN/C/T (n = 90) and VAN-TZP (n = 284) at an enrollment ratio of 3:1. The primary outcome occurred in 12.2% vs 25.0% in the VAN-C/T and VAN-TZP groups, respectively (P = .011). After adjusting for confounding variables, VAN-TZP was associated with increased odds of AKI compared with VAN-C/T; with an adjusted odds ratio of 3.308 (95% confidence interval, 1.560-6.993). Results of the stratified Kaplan-Meir analysis with log-rank time-to-nephrotoxicity analysis indicate that time to AKI was significantly shorter among patients who received VAN-TZP (P = .004). Cox proportional hazards analysis demonstrated that TZP was consistent with the primary analysis (P = .001). CONCLUSIONS: Collectively, our results suggest that the AKI is not likely to be related to tazobactam but rather to piperacillin, which is a component in VAN-TZP but not in VAN-C/T.

Efficacy and Safety of Vancomycin Bayesian-Estimated Area Under the Curve Versus Trough-Based Dosing.

BACKGROUND: Vancomycin guidelines by the Infectious Diseases Society of America and American Society of Health-System Pharmacists endorse Bayesian-software-assisted area under the curve (AUC24h) in their 2020 update. At this time, there are limited clinical data that support its use. OBJECTIVES: The purpose of this study is to evaluate the safety benefits and efficacy outcomes of using Bayesian-assisted AUC24h dosing compared to trough dosing. METHODS: Hospitalized patients from before February 1, 2020, (preimplementation of AUC24h dosing) and after August 1, 2020, (postimplementation) were reviewed. Patients with confirmed or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection of the lungs, heart, bones, prosthetic joint, or blood receiving vancomycin for at least 72 hours were included. The primary endpoint was the percentage of patients experiencing an acute kidney injury (AKI) in the trough-based group versus those experiencing AKI in the AUC24h group. The composite of all-cause mortality, 30-day readmission, or change in antibiotic therapy due to clinical worsening in patients with confirmed MRSA infections was included as a secondary endpoint. Data were analyzed with statistical testing methods as appropriate. RESULTS: There was a significant reduction in AKI between the AUC24h dosing and trough dosing groups (3% vs 12%; P < 0.01). The efficacy for MRSA infections was also similar between groups (11% vs 14%; P = 0.72). CONCLUSION AND RELEVANCE: Bayesian-assisted AUC24h dosing was associated with a significant reduction in incidence of AKI when compared to trough-based dosing. There was no difference in the composite efficacy endpoint for patients with confirmed MRSA infection, although the study was not powered for this analysis. These data may provide evidence for more institutions to adopt the Bayesian software to assist in dosing of vancomycin.

Expansion of a Pharmacist-Led Culture Follow-Up Program to Real-Time Notification of Multidrug-Resistant Microbiology Results in the Emergency Department.

Introduction: There are currently limited published data for a pharmacist-led multidrug-resistant (MDR) culture follow-up program through a collaborative drug therapy management (CDTM) agreement in the emergency department (ED). Objective: The objective of this study was to assess the impact of a pharmacist-led culture follow-up program for MDR microbiology results on ED revisit rate. Methods: A single-center quasi-experimental retrospective study was conducted comparing the outcomes before (December 2017 to March 2019) and after (April 2019 to July 2020) implementation of the ED MDR Culture program. Patients 18 years of age or older; with confirmed positive microbiology culture of extended-spectrum beta-lactamases (ESBL), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) at any site; and discharged from the ED were included. The primary outcome was to evaluate ED revisit within 30 days due to antimicrobial treatment failure, defined as lack of resolution or worsening of infection. A statistical analysis was performed for categorical data using Fisher's exact test, and for continuous data using unpaired t test or Mann-Whitney U Test, when applicable. Results: A total of 130 patients were included in the analysis. Patients in the post-implementation group (n = 70) had a significant reduction in ED revisits compared to the pre-implementation group (n = 60); 9 [12.9%] versus 17 [28.3%], respectively; P = .046. Conclusion: Implementation of an ED MDR culture program was associated with significantly less ED revisits within 30 days due to antimicrobial treatment failure, thus demonstrating the expanded role of ED pharmacists in antimicrobial stewardship in the outpatient setting.

Risk factors for mortality in COVID-19 patients in a community teaching hospital.

As of December 2020, there were over 450,000 confirmed coronavirus disease 2019 (COVID-19) cases in New York City (NYC) with approximately 25,000 deaths. Previous literature identified advanced age, higher severity of illness, elevated inflammatory biomarkers, acute organ dysfunction, comorbidities, and presentation from long-term care facility as risk factors for mortality in patients from Wuhan, China, and the United States. Additional studies conducted in NYC are warranted to confirm these findings. The objective of this study was to assess the risk factors for in-hospital mortality in patients with confirmed COVID-19 infections. This was a retrospective case-control study at The Brooklyn Hospital Center, a 464-bed community teaching hospital. Adult patients with a confirmed COVID-19 infection and who received at least 24 h of COVID-19 therapy were included. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for in-hospital mortality. Two-hundred and eighty four patients were included, of whom 95 (33.5%) were nonsurvivors and 189 (66.5%) patients were survivors. Multivariate analysis showed higher in-hospital mortality with advanced age (odds ratio [OR] 6.476; 95% confidence interval [CI], 1.827-22.953), presentation from long-term care facility (OR 4.259; 95% CI 1.481-12.250), elevated total bilirubin (OR 4.947; 95% CI 1.048-23.350), vasopressor initiation (OR 36.262; 95% CI 5.319-247.216), and development of renal failure (OR 36.261; 95% CI 2.667-493.046). Risk factors associated with mortality for patients with COVID-19 in a community teaching hospital included advanced age, vasopressor initiation, development of renal failure, elevated total bilirubin, and presentation from long-term care facility.

Outcomes of Vancomycin plus a ß-Lactam versus Vancomycin Only for Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia.

The objective of this retrospective study was to compare the rates of treatment failure, which was a composite of clinical and microbiologic failure, of patients receiving vancomycin and a ß-lactam to those receiving vancomycin only for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Patients 16 to 89 years of age with MRSA bacteremia admitted to a university-affiliated hospital from 1 January 2014 to 31 December 2016 were screened for study inclusion. Patients were eligible if they received >48 h of vancomycin and a ß-lactam (combination group) or vancomycin only (standard group) within 48 h after bacteremia onset. A total of 182 patients were screened: 47 were included in the standard group, and 63 were in the combination group. The combination group had a higher baseline body mass index (29.2 ± 8.0 kg/m2 versus 25.8 ± 7.1 kg/m2, P = 0.022), acute physiologic assessment and chronic health evaluation-II (APACHE-II) score (median [interquartile range], 21 [15 to 26] versus 16 [10 to 22], P = 0.003), and incidence of septic shock (31.8% versus 14.9%, P = 0.047). Using multivariate analysis, combination therapy was the only variable that decreased treatment failures (odds ratio [95% confidence interval], 0.337 [0.142 to 0.997]), while vancomycin MIC > 1 mg/liter and male gender increased treatment failures (4.018 [1.297 to 12.444] and 2.971 [1.040 to 8.488], respectively). The 30-day mortality rates (15.0% versus 14.9%, P = 1.000) and the incidence of adverse drug events (19.1% versus 23.4%, P = 0.816) were not statistically different between the combination and standard groups. Combination therapy of vancomycin with a ß-lactam led to significantly fewer treatment failures than vancomycin monotherapy for MRSA bacteremia.

Quantifying pupillary asymmetry through objective binocular pupillometry in the normal and mild traumatic brain injury (mTBI) populations.

INTRODUCTION: Little is known about human inter-ocular pupillary asymmetry (IOPA). Thus, the purpose of the present investigation was to assess objectively static and dynamic IOPA in normals and in individuals with mild traumatic brain injury (mTBI). METHODS: The pupillary light reflex (PLR) was assessed in an adult population of normals and in those with mTBI using the Neuroptics DP-2000 binocular pupillometer. Four stimulus conditions were used to optimize the assessment. Two aspects of the pupil were assessed: baseline diameter prior to light stimulation and the dynamic amplitude of constriction following light stimulation. RESULTS: There was no statistical difference in either the static or dynamic IOPA between the two groups. Thus, the data were combined for a better global parameter estimate. The mean average static IOPA was 0.26 mm (SD = ± 0.20 mm) or 4.17% (± 3.29%). The mean average dynamic IOPA was dependent on the light stimulus condition, with the average across all four test conditions being 0.11 mm (± 0.10 mm) or 1.84% (± 1.70%). DISCUSSION: The inter-ocular pupillary effects of mTBI appear to be symmetrical rather than asymmetrical in nature. The findings provide clinicians and researchers a useful quantitative guideline to assess normal vs abnormal static and dynamic inter-ocular pupillary asymmetry (IOPA) in these two populations.

Comparison of pupillary dynamics to light in the mild traumatic brain injury (mTBI) and normal populations.

PURPOSE: To determine if mTBI adversely affects the pupillary light reflex (PLR). METHODS: The PLR was evaluated in mTBI and compared to normal individuals under a range of test conditions. Nine pupil parameters (maximum, minimum and final pupil diameter, latency, amplitude and peak and average constriction and dilation velocities) and six stimulus conditions (dim pulse, dim step, bright pulse, bright step, bright red step and bright blue step) were assessed in 32 adults with mTBI (21-60 years of age) and compared to 40 normal (22-56 years of age). The Neuroptics, infrared, DP-2000 binocular pupillometer was used (30 Hz sampling rate; 0.05 mm resolution) with binocular stimulation and recording. RESULTS: Different test conditions allowed for discrimination of different parameters. For any of the given six test conditions, five-to-eight of the nine pupillary parameters were statistically different (p < 0.05) between the two diagnostic groups. The most promising parameters for diagnostic differentiation were constriction latency, all pupillary diameters, average constriction velocity and peak dilation velocity. CONCLUSIONS: MTBI adversely affects the PLR. This suggests an impairment of the autonomic nervous system. The findings suggest the potential for quantitative pupillary dynamics to serve as an objective mTBI biomarker.

Do formulation differences between the reference listed drug and generic piperacillin-tazobactam impact reconstitution?

Pharmaceutical differences between the reference listed drug (RLD) and generic formulations of piperacillin-tazobactam may impact the reconstitution process for intravenous administration. This study evaluated the RLD against three generic formulations and measured their reconstitution times using a standardized process. The mean (standard deviation [SD]) reconstitution time for one generic formulation was 5.57 (1.49) min, which was 35% to 42% longer (P < 0.002) than that for the RLD and two other formulations. Observable microscopic differences in powder particle morphology may explain these findings.

Photosensitivity in mild traumatic brain injury (mTBI): a retrospective analysis.

PRIMARY OBJECTIVE: To determine whether photosensitivity (PS) changes over time and, if so, what factors may be related to the change; furthermore, to determine whether tint density changes over time, all in mild traumatic brain injury (mTBI). DESIGN AND METHODS: A retrospective analysis of 62 patient records (aged 18-40 years) with mTBI and PS was conducted. All charts were obtained from the SUNY/College of Optometry clinics from 2004-2011. RESULTS: Fifty per cent demonstrated reduced PS over time, with most occurring after year 1 post-injury (40%). Promotion of PS reduction appears to be associated with the lack of spectacle tint usage (p = 0.01) and the use of contact lenses (p = 0.03). Inhibition of PS reduction appears to be associated with tinted lenses (p = 0.06), hyperacusis (p = 0.03), dry eye (p = 0.04), migraines (p = 0.03) and loss of consciousness at the time of injury (p = 0.05). Concerning tint density changes over time, 71% (p = 0.002) maintained the same degree over time, while 27% (p = 0.002) reduced and 2% waxed and waned. CONCLUSION: Neural adaptation to PS appears to be a long-term process. Tint usage may act to inhibit this adaptive process, while the use of contact lenses may act to promote it. These findings may provide guidance in the clinical management of photosensitivity in the mTBI population.

Eravacycline, the first four years: health outcomes and tolerability data for 19 hospitals in 5 U.S. regions from 2018 to 2022.

IMPORTANCE: The rise of multidrug-resistant (MDR) pathogens, especially MDR Gram-negatives, poses a significant challenge to clinicians and public health. These resilient bacteria have rendered many traditional antibiotics ineffective, underscoring the urgency for innovative therapeutic solutions. Eravacycline, a broad-spectrum fluorocycline tetracycline antibiotic approved by the FDA in 2018, emerges as a promising candidate, exhibiting potential against a diverse array of MDR bacteria, including Gram-negative, Gram-positive, anaerobic strains, and Mycobacterium. However, comprehensive data on its real-world application remain scarce. This retrospective cohort study, one of the largest of its kind, delves into the utilization of eravacycline across various infectious conditions in the USA during its initial 4 years post-FDA approval. Through assessing clinical, microbiological, and tolerability outcomes, the research offers pivotal insights into eravacycline's efficacy in addressing the pressing global challenge of MDR bacterial infections.

Prevalence and Distribution of Refractive Errors Among Members of the U.S. Armed Forces and the U.S. Coast Guard, 2019.

During calendar year 2019, the estimated prevalence of myopia, hyperopia, and astigmatism were 17.5%, 2.1%, and 11.2% in the active component of the U.S. Armed Forces and 10.1%, 1.2%, and 6.1% of the U.S. Coast Guard, respectively. The prevalence of spectacle correction in the active component of the U.S. Armed Forces was 24.0%, which included single-vision distance (92.0%), multifocal (eg, bifocal, 6.0%), and single-vision reading (2.0%) spectacles. In comparison, the prevalence of spectacle correction was 14.6% in the U.S. Coast Guard. Additionally, among all U.S. Armed Forces service members who received spectacle correction for distance vision in 2019, service members of the reserve component, military academy cadets, and the National Guard were significantly more myopic (near-sightedness) than the active component or Coast Guard (p<.001). Within the active component, the Air Force was the most myopic and the Marine Corps followed it closely. These 2 military branches were not significantly different from each other (p=.46) but both were significantly more myopic than the Navy or the Army (p<.001). The Navy was more myopic than the Army (p=.01). The U.S. Coast Guard was significantly less myopic than any other military branch (p=.03).

A Case Report of Sudden Sensorineural Hearing Loss (SSNHL) After Administration of the COVID-19 Vaccine.

Since the issuance of the emergency use authorization (EUA) of 3 coronavirus disease 2019 (COVID-19) vaccines, there have been over 180 million individuals fully vaccinated in the United States (US). With the increasing administration of COVID-19 vaccinations, there have been over 550,000 adverse events reported in the Vaccine Adverse Event Reporting System (VAERS) with approximately 230,000 experienced after receipt of the Pfizer-BioNTech COVID-19 Vaccine as of September 23rd 2021. Audio-vestibular symptoms (including Sudden Sensorineural Hearing Loss (SSNHL)) secondary to immunizations has previously been evaluated. However, this report describes the first case of bilateral sudden sensorineural hearing loss potentially due to the Pfizer-BioNTech COVID-19 vaccine. We further review the available literature regarding the treatment of Sudden Sensorineural Hearing Loss, and the association of SSNHL with previous immunizations and COVID-19 infection. Lastly, we hypothesize the underlying potential mechanisms between SSNHL and the Pfizer-BioNTech COVID-19 vaccine.

Evaluation of Individualized Cefepime Dosing Strategy Using Population Pharmacokinetics.

The use of population pharmacokinetics (PK) to optimize cefepime dosing could be an effective strategy, given the increasing prevalence of resistant gram-negative organisms. The objective of this study is to retrospectively compare dosing using a PK approach (intervention) vs traditional dosing (control) for cefepime in patients with hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). Adult hospitalized patients with HAP or VAP receiving cefepime for ≥72 hours were screened first from August 2018 to January 2019 to be included in the intervention group, then screened during the preintervention period from August 2017 to July 2018 for the control group. Clinical improvement on day 7 of cefepime therapy was achieved in 72% of the patients in the intervention group and 70% of the patients in the control group (P = .8110). However, the clinical cure rate in the intervention group was higher than that of the control group (50% vs 36.5%; P = .0034). Cefepime dosing using population PK appears to be a novel, effective, and safe dosing strategy for patients with HAP or VAP.

Clinical Outcomes of Eravacycline in Patients Treated Predominately for Carbapenem-Resistant Acinetobacter baumannii.

Forty-six patients were treated with eravacycline (ERV) for Acinetobacter baumannii infections, where 69.5% of isolates were carbapenem resistant (CRAB). Infections were primarily pulmonary (58.3%), and most patients received combination therapy (84.4%). The median (IQR) ERV duration was 6.9 days (5.1 to 11.1). Thirty-day mortality was 23.9% in the cohort and 21.9% in CRAB patients. One patient experienced an ERV-possible adverse event. IMPORTANCE Acinetobacter baumannii, particularly when carbapenem resistant (CRAB), is one of the most challenging pathogens in the health care setting. This is complicated by the fact that there is no consensus guideline regarding management of A. baumannii infections. However, the recent Infectious Diseases Society of America guidelines for treatment of resistant Gram-negative infections provided expert recommendations for CRAB management. The panel suggest using minocycline among tetracycline derivatives rather than eravacycline (ERV) until sufficient clinical data are available. Therefore, we present the largest multicenter real-world cohort in patients treated with ERV for A. baumannii, where the majority of isolates were CRAB (69.5%). Our analysis demonstrate that patients treated with ERV-based regimens achieved a 30-day mortality of 23.9% and had a low incidence of ERV-possible adverse events (2.1%). This study is important as it fills the gap in the literature regarding the use of a novel tetracycline (i.e., ERV) in the treatment of this challenging health care infection.

Pharmacokinetics and Pharmacodynamics of High-Dose Piperacillin-Tazobactam in Obese Patients.

BACKGROUND AND OBJECTIVE: Standard piperacillin-tazobactam (P-T) dosing may be suboptimal in obesity, but high-dose regimens have not been studied. We prospectively evaluated the pharmacokinetics and pharmacodynamics of standard- and high-dose P-T in obese adult inpatients. METHODS: Those receiving standard-dose P-T with BMI ≥ 30 kg/m2 weighing 105-139 kg or ≥ 140 kg were given up to 6.75 g or 9 g every 6 h, respectively. Patients were monitored closely for safety. Elimination phase blood samples were drawn for 28 patients on standard and high doses to calculate the pharmacokinetic values using a one-compartment model. The likelihood of pharmacodynamic target attainment (100% fT > 16/4 mg/L) on various P-T regimens was calculated using each patient's own pharmacokinetic values. RESULTS: Piperacillin and tazobactam half-lives ranged from 0.5-10.6 to 0.9-15.0 h, while volumes of distribution ranged from 13.6-54.8 to 11.5-60.1 L, respectively. Predicted dose requirements for target attainment ranged from 2.25 g every 6 h in hemodialysis patients to a 27 g/24-h continuous infusion in a patient with a short P-T half-life. An amount of 4.5 g every 6 h would have met the target for only 1/12 (8%) patients with creatinine clearance ≥ 80 mL/min and 13/28 (46%) for all enrolled patients. One patient (3%) experienced an adverse event deemed probably related to high-dose P-T. CONCLUSION: Some patients required high P-T doses for target attainment, but dosing requirements were highly variable. Doses up to 6.75 g or 9 g every 6 h may be tolerable; however, studies are needed to see if high dosing, prolonged infusions, or real-time therapeutic drug monitoring improves outcomes in obese patients. CLINICAL TRIAL REGISTRATION (CLINICALTRIALS.GOV): NCT01923363.

Early Experience With Eravacycline for Complicated Infections.

Eravacycline (ERV) was used in 35 patients for various infections. The most common pathogen was Klebsiella pneumoniae, and 30-day survival was 74%. Absence of 30-day recurrence and resolution of signs and symptoms of infection were 91% and 57%, respectively. ERV was well-tolerated, with adverse events leading to drug discontinuation in one patient.

A Multicenter Evaluation of Vancomycin-Associated Acute Kidney Injury in Hospitalized Patients with Acute Bacterial Skin and Skin Structure Infections.

BACKGROUND: We sought to determine the real-world incidence of and risk factors for vancomycin-associated acute kidney injury (V-AKI) in hospitalized adults with acute bacterial skin and skin structure infections (ABSSSI). METHODS: Retrospective, observational, cohort study at ten U.S. medical centers between 2015 and 2019. Hospitalized patients treated with vancomycin (≥ 72 h) for ABSSSI and ≥ one baseline AKI risk factor were eligible. Patients with end-stage kidney disease, on renal replacement therapy or AKI at baseline, were excluded. The primary outcome was V-AKI by the vancomycin guidelines criteria. RESULTS: In total, 415 patients were included. V-AKI occurred in 39 (9.4%) patients. Independent risk factors for V-AKI were: chronic alcohol abuse (aOR 4.710, 95% CI 1.929-11.499), no medical insurance (aOR 3.451, 95% CI 1.310-9.090), ICU residence (aOR 4.398, 95% CI 1.676-11.541), Gram-negative coverage (aOR 2.926, 95% CI 1.158-7.392) and vancomycin duration (aOR 1.143, 95% CI 1.037-1.260). Based on infection severity and comorbidities, 34.7% of patients were candidates for oral antibiotics at baseline and 39.3% had non-purulent cellulitis which could have been more appropriately treated with a beta-lactam. Patients with V-AKI had significantly longer hospital lengths of stay (9 vs. 6 days, p = 0.001), higher 30-day readmission rates (30.8 vs. 9.0%, p < 0.001) and increased all-cause 30-day mortality (5.1 vs. 0.3%, p = 0.024) CONCLUSIONS: V-AKI occurred in approximately one in ten ABSSSI patients and may be largely prevented by preferential use of oral antibiotics whenever possible, using beta-lactams for non-purulent cellulitis and limiting durations of vancomycin therapy.

Influence of refractive error on pupillary dynamics in the normal and mild traumatic brain injury (mTBI) populations.

PURPOSE: There have been several studies investigating static, baseline pupil diameter in visually-normal individuals across refractive error. However, none have assessed the dynamic pupillary light reflex (PLR). In the present study, both static and dynamic pupillary parameters of the PLR were assessed in both the visually-normal (VN) and the mild traumatic brain injury (mTBI) populations and compared as a function of refractive error. METHODS: The VN population comprised 40 adults (22-56 years of age), while the mTBI population comprised 32 adults (21-60 years of age) over a range of refractive errors (-9.00D to +1.25D). Seven pupillary parameters (baseline static diameter, latency, amplitude, and peak and average constriction and dilation velocities) were assessed and compared under four white-light stimulus conditions (dim pulse, dim step, bright pulse, and bright step). The Neuroptics, infrared, DP-2000 binocular pupillometer (30Hz sampling rate; 0.05mm resolution) was used in the monocular (right eye) stimulation mode. RESULTS: For the majority of pupillary parameters and stimulus conditions, a Gaussian distribution best fit the data, with the apex centered in the low myopic range (-2.3 to -4.9D). Responsivity was reduced to either side of the apex. CONCLUSIONS: Over a range of dynamic and static pupillary parameters, the PLR was influenced by refractive error in both populations. In cases of high refractive error, the PLR parameters may need to be compensated for this factor for proper categorization and diagnosis.

Individualized Pharmacokinetic Dosing of Vancomycin Reduces Time to Therapeutic Trough Concentrations in Critically Ill Patients.

Dosing vancomycin in critically ill patients often results in subtherapeutic and supratherapeutic trough concentrations. In this retrospective study, we compared the time to goal trough attainment and incidence of acute kidney injury in intensive care unit (ICU) patients whose vancomycin was dosed by a pharmacy pharmacokinetic (PK) dosing and monitoring service to the standard of care. Three-hundred fifty adult ICU patients at a Level 1 trauma, teaching hospital who received vancomycin for >24 hours from February 1, 2016, to November 30, 2016, were screened. Patients were included in the PK group if consecutive serum concentrations were used to calculate individualized PK and determine a dosing regimen. Patients who were dosed using troughs only were then matched 1-to-1 to the PK group by date of vancomycin initiation and included in the traditional group. Fifty patients were included in each group. Baseline characteristics were similar, except the PK group had more patients under the care of the neuromedical ICU service (42% vs 18%; P = .02) and fewer patients with a corrected creatinine clearance <30 mL/min/1.73 m2 (22% vs 46%; P = .02). Attainment of goal trough concentrations for the PK and traditional groups were 84.4% and 29.4% by 48 hours (P = .0001), 88.4% and 60.7% by 72 hours (P = .009), and 92.9% and 77.8% by 96 hours (P = .1), respectively. Incidence of acute kidney injury between the PK and traditional groups was not statistically significant (8.3% vs 14%; P = .5). Utilization of individualized pharmacokinetic dosing of vancomycin in critically ill patients resulted in faster goal trough attainment without an increase in nephrotoxicity.