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.

Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review.

PURPOSE: The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. METHODS: We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. RESULTS: The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. CONCLUSION: The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

MRSA nasal swab PCR to de-escalate antibiotics in the emergency department.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) nasal swab polymerase chain reaction (PCR) assay has a 96.1-99.2% negative predictive value (NPV) in pneumonia and may be used for early de-escalation of MRSA-active antibiotic agents. Xu (2018), File (2010) [1,2]. OBJECTIVE: The objective of our study was to determine if a negative MRSA PCR nasal swab collected in the emergency department (ED) improves early MRSA-active antibiotic de-escalation. METHODS: A single center observational cohort study used ICD-10 codes to identify records for adults admitted to the ED with a hospital discharge diagnosis of pneumonia. The primary outcome was proportion of patients with early de-escalation on an MRSA-active agent (≤ 1 dose). Secondary outcomes included rate of acute kidney injury (AKI), positive MRSA cultures (blood culture, respiratory sputum, tracheal aspirate), hospital length of stay (LOS), in-hospital mortality, and 30-day readmission rates. RESULTS: A total of 341 patients were included in the study. Of the patients with an MRSA PCR swab, 35.2% of patients with a negative swab received >1 dose of MRSA-active agent compared to 52% of patients without an MRSA nasal swab (p < 0.01). There were no significant differences in secondary outcomes except readmission rate of 1.6% of patients that did not have an MRSA swab in the ED vs 6.6% of patients that received an MRSA swab in the ED. CONCLUSION AND RELEVANCE: MRSA PCR nasal swabs in the ED may serve as a useful tool for early MRSA-active antibiotic de-escalation when treating pneumonia.

Intravenous Antibiotic Susceptibility for Urinary Tract Infection Prior to Emergency Department Discharge.

BACKGROUND: Urinary tract infection (UTI) is a common infectious disease managed in the emergency department (ED). Patients may be initially treated with an intravenous (IV) antibiotic and subsequently discharged with an oral antibiotic regimen. OBJECTIVE: The purpose of this study was to determine whether the current Infectious Diseases Society of America guideline recommendation for an initial dose of long-acting IV antibiotic for treatment of UTI when the prevalence of fluoroquinolone resistance exceeds 10% improves the likelihood of providing in vitro susceptibility to the isolated uropathogen. METHODS: This was a retrospective study of patients in ED presenting between May 2009 and August 2018 who received treatment for UTI. The primary outcome was susceptibility of uropathogen to the IV antibiotic administered. Secondary outcomes included susceptibility to the oral antibiotic regimen prescribed at discharge, repeat health care visit within 30 days related to UTI follow-up, adverse events (AEs) associated with antibiotic use, and identification of risk factors associated with pathogen resistance. RESULTS: A total of 255 patients were included for analysis. Of these patients, 230 (90.2%) had pathogens susceptible to the administered IV antibiotic. The oral regimen susceptibility was 81.6% with 29 patients returning for UTI follow-up and 4 patients reporting AEs related to antibiotic use. Men and long-term care facility residents were more likely to have resistant uropathogens. CONCLUSION: Administration of a long-acting IV antibiotic for treatment of UTI prior to ED discharge is recommended when the fluoroquinolone resistance rate exceeds 10% to improve in vitro susceptibility coverage.

Guideline adherence for the management of emergency department patients with febrile neutropenia and no infection source: Is there room for improvement?

INTRODUCTION: Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department. METHODS: A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality. RESULTS: Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died. CONCLUSION: Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.

Normal Saline Solution and Lactated Ringer's Solution Have a Similar Effect on Quality of Recovery: A Randomized Controlled Trial.

STUDY OBJECTIVE: The purpose of this study is to test the hypothesis that balanced crystalloids improve quality of recovery more than normal saline solution (0.9% sodium chloride) in stable emergency department (ED) patients. Secondary outcomes measured differences in health care use. METHODS: A single-site, participant- and evaluator-blinded, 2-arm parallel allocation (1:1), comparative effectiveness, randomized controlled trial allocated adults receiving intravenous fluids in the ED before discharge to receive 2 L of lactated Ringer's solution or normal saline solution. The primary outcome was symptom scores measured by the validated Quality of Recovery-40 instrument (scores 40 to 200) 24 hours after enrollment. Secondary outcomes included subsequent health care use and medication compliance. RESULTS: Participants (N=157) were enrolled and follow-up was analyzed for 94 (follow-up rate of 60%) with intention-to-treat methodology. There was no difference in postenrollment Quality of Recovery-40 scores between normal saline solution and lactated Ringer's solution groups (mean difference 2.4; 95% confidence interval [CI] -6.8 to 11.6). Although preenrollment scores were higher in the lactated Ringer's solution group (mean difference 10.5; 95% CI 1.9 to 19.0), adjusting for presurvey imbalances did not change the primary outcome (adjusted difference -3.9; 95% CI -12.9 to 5.2). There were no differences in return to ED (mean difference 7.5%; 95% CI -8.7% to 23.8%), prescriptions filled (mean difference 22.2%; 95% CI -3.3% to 47.6%), or seeking care from another provider (mean difference -2.0%; 95% CI -19.9% to 15.9%) at 7 days. CONCLUSION: Normal saline solution and lactated Ringer's solution were associated with similar 24-hour recovery scores and 7-day health care use in stable ED patients. These results supplement those of recent trials by informing fluid choice for stable ED patients.

Validation of a Clinical Decision Rule to Identify Risk Factors Associated With Multidrug-Resistant Urinary Pathogens in the Emergency Department.

BACKGROUND: Antimicrobial resistance remains a significant obstacle for clinicians when treating patients presenting to the emergency department (ED) with urinary tract infections. OBJECTIVE: The goal of the proposed study was to validate a previously developed clinical decision rule identifying risk factors for multidrug-resistant (MDR) urinary pathogens. METHODS: We conducted a validation study of a previously published clinical decision rule to identify patients with MDR urinary pathogens using a cohort from an urban academic center ED with annual census over 80 000. Using our previously identified clinical risk factors, we determined the sensitivity, specificity, positive likelihood ratio (+LR), and negative LR (-LR) to estimate measures of precision of our clinical decision rule in the validation cohort. RESULTS: Factors associated with MDR urinary pathogen included sex, recent hospitalization, nursing home residency, and catheter placement. Using our previously defined threshold of greater than 1 risk factor, the adjusted model in the validation cohort identified that only nursing home residency was associated with positive MDR pathogen (adjusted odds ratio = 4.13; 95% CI = 1.95-8.77). The clinical decision rule in the validation cohort yielded a sensitivity of 56.4%, specificity of 66.3%, +LR of 1.7, and -LR of 0.7. Conclusion and Relevance: Our clinical decision rule to identify patients at risk for MDR urinary pathogens was unable to be validated in the setting of different antimicrobial resistance patterns. Future studies should evaluate an improved clinical decision rule identifying risk factors associated with MDR pathogens that performs well in varying patient populations.

Safety and effectiveness of Factor Eight Inhibitor Bypassing Activity for direct oral anticoagulant-related hemorrhage reversal.

BACKGROUND: The incidence of patients who present with life-threatening bleeding complications has been increasing as the use of direct oral anticoagulation (DOAC) has increased. Therefore, effective reversal agents are urgently needed. Current guidelines recommend the use of prothrombin complex concentrates (PCCs) and activated PCCs (aPCC) for reversal of DOAC anticoagulant activity in the setting of traumatic and non-traumatic intracranial hemorrhage (ICH). However, little data is available. OBJECTIVE: Herein, we investigated the safety and effectiveness of Factor Eight Inhibitor Bypassing Activity [FEIBA (an aPCC)] in a population of patients who required emergent reversal of DOAC for hemorrhage or urgent surgical interventions. METHODS: This is a case series study. Medical records from patients who required emergent reversal of DOAC for life threatening hemorrhage or urgent surgical interventions were collected from February 1, 2014, to April 1, 2017 and reviewed. Data, including demographics as well as safety, outcomes, and dosing of FEIBA for reversal of DOAC effects were collected and descriptive statistics were obtained. RESULTS: Forty-two patients who received FEIBA were included in the study. The rates of thrombotic events (10%), hemorrhage progression (10%), and observed mortality (29%) were similar to rates previously published in the limited literature evaluating aPCC use in this population. CONCLUSION: This case series suggests that FEIBA administration is relatively safe and effective to reverse DOACs in the setting of hemorrhage or need for urgent surgical procedures. Until target-specific reversal agents are available, future studies are warranted to evaluate the effectiveness of aPCC administration for DOAC-associated hemorrhagic complications.

Helicopter "Drip and Ship" Flights Do Not Alter the Pharmacological Integrity of rtPA.

INTRODUCTION: Rural and critical access hospitals rely on the "drip and ship" practice using helicopter emergency medical services (HEMS). But those helicopter flights are an unusual environment with physical factors such as vibration and accelerations that could potentially affect the stability, and pharmacological properties of IV rtPA, an issue that has not been previously addressed. MATERIALS AND METHODS: This was a prospective cohort study of consecutive acute ischemic stroke patients receiving IV rtPA through a Comprehensive Stroke Center from November 2015 to February 2017 to measure the effects of HEMS on the integrity and activity of rtPA by collecting residual medication left in the vial. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. NCT02752256 RESULTS: A total of 33 patients and rtPA samples were included; 18 patients who presented directly to the Comprehensive Stroke Center emergency department and 15 patients who received rtPA during air ambulance transfer. The median rtPA antigen concentration in the residual medication vial was 3.04 mg/mL (IQR: 1.24-3.87) in the HEMS group and 1.91 mg/mL (IQR: 1.33-2.60) in the controls (P = .168). There were no significant differences in rtPA activity or specific activity between the HEMS and control groups and there was no association between total HEMS flight time on overall rtPA specific activity. CONCLUSIONS: In summary, this study provides supportive evidence of the lack of a detrimental effect of the HEMS physical environment on the integrity of rtPA, therefore endorsing current drip and ship practices without infusion adjustments.

Interhospital Transfer Delays Anticoagulation Reversal in Warfarin-Associated Intracranial Hemorrhage.

INTRODUCTION: Intracranial hemorrhage (ICH) is a complication of warfarin-associated anticoagulation resulting in significant morbidity and mortality. The purpose of this study was to assess whether interhospital transfer delays the administration of 4-factor prothrombin complex concentrate to patients with warfarin-associated ICH. MATERIALS AND METHODS: This was a retrospective cohort study of all patients presenting to a 60,000 visit academic ED between August 2013 and July 2017 requiring emergent anticoagulation reversal for warfarin-associated ICH. Patients were divided into 2 cohorts: (1) transfer patients who arrived at the academic center after receiving care in a local community hospital and (2) control patients who presented directly to the academic center ED. The primary outcome was time to administration of 4-factor prothrombin complex concentrate. Secondary outcomes included hematoma expansion, guideline-adherent vitamin K administration (10mg IV), intensive care unit and hospital length of stay, disposition at discharge, and in-hospital mortality. RESULTS: This study included 203 patients (177 transfer patients, 26 control). The median time to arrival in transfer patients was 186 minutes (IQR 145-242). The median time to administration of guideline-adherent therapy in transfer patients was 296 minutes, compared to 119 minutes in patients who were not transferred (median difference= -176, 95% confidence interval -143 to -208, P ≤ .001). Delay in anticoagulation reversal did not result in hematoma expansion, intensive care unit and hospital length of stay, discharge disposition, or in-hospital mortality. CONCLUSIONS: Patients requiring interhospital transfer experienced significant delays in guideline-adherent anticoagulation reversal for warfarin-associated ICH, but this delay was not associated with worse outcomes.

Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock: A Retrospective Cohort Study.

OBJECTIVE: To test the hypothesis that interhospital transfer causes significant delays in the administration of appropriate antibiotics and compliance with the completion of Surviving Sepsis Bundle elements. DESIGN: Single-center retrospective cohort study. SETTING: A comprehensive 60,000-visit emergency department at a 711-bed Midwestern academic medical center. PATIENTS: Patients with severe sepsis and septic shock treated between 2009 and 2014 were identified by International Classification of Diseases,9th Revision, Clinical Modification, codes, then divided into two cohorts: 1) transfer patients who arrived at the tertiary academic center after receiving care in a local community hospital and 2) control patients who presented directly to the tertiary academic center emergency department. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: One hundred ninety-three patients were included. Transfer patients were more likely to require surgery in the hospital (p < 0.001) and require ICU care (p = 0.001) but had similar illness severity based on (Acute Physiology and Chronic Health Evaluation II, 17.7 vs 17.5; p = 0.662). Antibiotic administration at 1 and 3 hours was comparable between the two cohorts, but initial antibiotic appropriateness was lower in transfer patients (34% vs 79%; p < 0.001). Transfer patients were less likely to have fluid resuscitation started by 3 hours (54% vs 89%; p < 0.001), but they were not less likely to receive an adequate fluid bolus (30 mL/kg) by the time of hospital admission (p = 0.056). There were no differences in ICU length of stay or mortality. CONCLUSIONS: Interhospital transfer significantly delays administration of appropriate initial antibiotics and resuscitation therapy. Future studies are needed to identify strategies of providing regional sepsis care prior to transfer to tertiary centers and to continue care pathways during the interhospital transfer process.

A clinical decision rule identifies risk factors associated with antimicrobial-resistant urinary pathogens in the emergency department: a retrospective validation study.

BACKGROUND: Identifying patients at high risk for multidrug-resistant urinary tract infections (UTIs) is important for guiding empirical antimicrobial therapy. Clinical risk factors associated with antimicrobial-resistant urinary pathogens and the derivation of a simple clinical decision rule could help define health care-associated UTI. OBJECTIVE: To derive a simple clinical decision rule to identify clinical risk factors associated with antimicrobial-resistant urinary pathogens. METHODS: This was a retrospective case-control study of all emergency department (ED) patients from July 1, 2011, to July 1, 2012, who presented to the ED with UTI and a positive urine culture. Candidate risk factors were collected retrospectively from medical record review. We compared differences in patient characteristics stratified by the presence of an antimicrobial-resistant urinary pathogen. RESULTS: A total of 360 patients with UTI had a positive, noncontaminated urine culture during the study period. About 6.7% of patients (n = 24) had a multidrug-resistant (MDR) urinary infection. Logistic regression modeling identified 3 clinical factors associated with the identification of a MDR pathogen: male sex, chronic hemodialysis, and nursing home residence. A scoring system was created to identify patients with MDR pathogens. Test characteristics were calculated using bootstrapping for internal validation, with a sensitivity of 74.7% (95% CI = 55.1%-91.3%) and specificity of 85.1% (95% CI = 77.8%-86.2%), positive likelihood ratio of 4.3, and a negative likelihood ratio of 0.3. CONCLUSIONS: Clinical factors can be used to identify UTI patients at high risk of MDR urinary pathogens.

Rapid Sequence Intubation, is it Time to Find an Alternative Induction Agent? A Narrative Review.

OBJECTIVE: To review the efficacy, safety, and place in therapy of fentanyl as an induction agent for rapid sequence intubation (RSI) in critically ill patients. DATA SOURCES: A comprehensive search of PubMed, EMBASE, and clinical trial registries (1964-June 2021) was performed utilizing the keywords fentanyl, rapid sequence intubation, intubation, induction, anesthesia, hemodynamics, operating room (OR), and emergency. STUDY SELECTION AND DATA EXTRACTION: Only primary literature evaluating fentanyl in combination with a sedative or as the sole induction agent was included in the final analysis. Primary literature included peer-reviewed publications and results posted on ClinicalTrials.gov actively recruiting participants. DATA SYNTHESIS: Fentanyl has been used for decades as an adjunct, and sole induction agent in the OR. Questions surrounding the use of fentanyl as a sole induction agent include optimal dosing and safety in critically ill patients as evaluation in non-OR settings remain limited. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Commonly used induction agents (eg, etomidate and ketamine) are associated with adverse events that may increase risk of morbidity and mortality. Fentanyl, a high-potency opioid could serve as an alternative induction agent for RSI due to its neutral hemodynamic response and fast onset of action. This paper compiles and describes existing data on the use of fentanyl as an induction agent for RSI. CONCLUSION: Fentanyl in combination with sedatives provides optimal intubating conditions with minimal impact on hemodynamic parameters. Future studies should focus on safety and impact of awareness during paralysis before fentanyl can be considered as a sole induction agent.

A Review of the Metabolism and Potential Drug-drug Interactions With Addictive Drugs.

People who use drugs (PWUD) are at increased risk for drug-related harms such as overdose. Additionally, they are also at increased risk of secondary harms from bacterial and other infections such as hepatitis B, hepatitis C, and Human Immunodeficiency Virus. These secondary harms, along with other medical conditions, typically require treatment with prescription medications. When considering treatment options, drug-drug interactions (DDIs) must be considered, unfortunately these interactions are often overlooked with addictive drugs. Although DDIs in PWUD have been reviewed for certain drug classes and specific drugs of abuse, no comprehensive list could be found. The objective of this article is to compile a list of potential DDIs between prescription drugs and addictive drugs to create a list allowing prescribers to make more informed decisions when prescribing a medication to PWUD.

Utilization of anti-factor Xa levels to guide reversal of oral factor Xa inhibitors in the emergency department.

PURPOSE: Oral factor Xa inhibitors (FXaIs) are increasingly utilized for outpatient anticoagulation therapy; however, laboratory monitoring is not routinely used to assess the safety and efficacy of these agents. We aimed to evaluate the role of chromogenic anti-factor Xa (anti-Xa) assays in the emergency department (ED) in the setting of patients with an acute bleed or requiring emergent procedures. METHODS: A retrospective review of anti-Xa levels obtained in the ED between June 1, 2019, and April 30, 2020, was completed. Data were collected to describe the clinical setting of anti-Xa level collection, oral FXaIs used before admission, administration of reversal agents, and patient disposition to further characterize the role of anti-Xa levels in the management of rivaroxaban and apixaban reversal. RESULTS: Thirty anti-Xa levels were included in the final analysis. The median time from sample collection to anti-Xa assay result was 45.9 minutes (interquartile range, 35.3-54.7 minutes). Eleven patients (37%) received anticoagulation reversal after their anti-Xa levels were determined. Anticoagulation reversal agents included either activated prothrombin complex concentrates (aPCCs) or prothrombin complex concentrates (PCCs). Anti-Xa levels were collected in 2 patients who had received PCCs before arrival at our ED. Of the patients with anti-Xa levels below 30 ng/mL, none received aPCCs or PCCs after their anti-Xa levels were determined. Anti-Xa assays were used to rule out the presence of FXaIs in 3 patients. CONCLUSION: This study illustrates the novel role of anti-Xa levels in managing patients with an emergent need for reversal in the ED. The assay may be used to rule out the presence of oral FXaIs and avoid unnecessary administrations of anticoagulation reversal agents.

Pharmacist authors of emergency medicine organization work products pertaining to pharmacotherapy.

PURPOSE: Despite the expertise that emergency medicine (EM) pharmacists bring to multidisciplinary teams in the emergency department (ED) setting, they are not commonly present on writing groups for guidelines, policies, or task forces pertaining to EM pharmacotherapy. The purpose of this article is to quantify EM pharmacist involvement on author bylines of guidelines, position statements, and other official documents that specifically encompass EM pharmacotherapy. METHODS: Official work products released between January 1, 2010, and May 1, 2021, were collected from the American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and American Academy of Emergency Medicine (AAEM) and the table of contents of the following journals: Annals of Emergency Medicine, Academic Emergency Medicine, and Journal of Emergency Medicine. A modified Delphi approach was used to gain consensus amongst the authors on which work products to include in the initial review and which works pertained to pharmacotherapy. The primary endpoint was the percentage of pharmacists listed as authors on EM work products pertaining to pharmacotherapy. RESULTS: Overall, 76 EM work products were identified. Forty-seven work products with a total of 248 authors contained at least 1 recommendation pertaining to pharmacotherapy. Of these 47 EM work products, 23 (49%) were from AAEM, 16 (34%) were from Annals of Emergency Medicine (published on behalf of ACEP), 5 (11%) were from Journal of Emergency Medicine (published on behalf of AAEM), and 3 (6%) were from SAEM. The median number of authors per work product was 4. There were 5 pharmacists listed on work products (2% of the total of 248 authors). Additionally, there were 9 nonpharmacist/nonphysician authors (4% of the total). CONCLUSION: Pharmacist inclusion on author lists of recently published EM work products pertaining to pharmacotherapy is extremely low. Given their unique knowledge pertaining to EM pharmacotherapy, an effort should be made to increase inclusion of pharmacists as authors of EM work products with recommendations that pertain to pharmacotherapy.

Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices.

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.

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.