Pharmacist and physician insight of vancomycin therapeutic drug-monitoring changes.

The updated vancomycin guideline for treatment of serious methicillin-resistant Staphylococcus aureus infections prompted institutions to convert from trough to area-under-the-curve monitoring. The physician perception of the transition, coupled with that of pharmacists, was measured by pre- and postimplementation surveys. Both groups believed safety would be increased without efficacy changes.

Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care During a Pandemic.

Introduction: Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19 infection. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of labs that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infection. Methods: An anonymous 10-question survey was distributed to 125 physicians (Infectious Disease, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results: Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3 - 10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusions: Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

A Retrospective, Pilot Study of De Novo Antidepressant Medication Initiation in Intensive Care Unit Patients and Post-ICU Depression.

Post-ICU Syndromes (PICS) remain a devastating problem for intensive care unit (ICU) survivors. It is currently unknown if de novo initiation of an antidepressant medication during ICU stay decreases the prevalence of post-ICU depression. We performed a retrospective, pilot study evaluating patients who had not previously been on an antidepressant medication and who were started on an antidepressant while in the trauma surgical, cardiothoracic, or medical intensive care unit (ICU). The PHQ-2 depression scale was used to ascertain the presence of depression after ICU discharge and compared this to historical controls. Of 2,988 patients admitted to the ICU, 69 patients had de novo initiation of an antidepressant medication and 27 patients were alive and available for study inclusion. We found the prevalence of depression in these patients to be 26%, which is not statistically different than the prevalence of post-ICU depression in historical controls [95% CI (27.6%, 51.6%)]. De novo initiation of an antidepressant medication did not substantially decrease the prevalence of post-ICU depression in this retrospective, pilot study.

Analysis of Outcomes Using Low-Dose and Early Administration of Recombinant Activated Factor VII in Cardiac Surgery.

BACKGROUND: Although not currently approved for postoperative cardiac surgical bleeding, recombinant activated factor VII (rFVIIa) has been used for this purpose. This study sought to analyze outcomes in patients who had cardiac surgical bleeding and received low-dose and early administration of rFVIIa versus outcomes in patients who had cardiac surgical bleeding and did not receive rFVIIa. METHODS: Fifty-one patients receiving rFVIIa were matched, using The Society of Thoracic Surgeons morbidity and mortality scores, with 51 patients who underwent cardiac surgical procedures and met criteria for surgical bleeding. Primary outcomes were ventilator hours and intensive care unit length of stay. Secondary outcomes included 30-day mortality, acute kidney injury, postoperative hospital length of stay, thromboembolic events, postoperative pneumonia, and sternal wound infections. Reoperations for bleeding were analyzed for each group to assess for achievement of hemostasis. RESULTS: The median total dose of rFVIIa was 12 mcg/kg. rFVIIa was given as the first and only treatment for bleeding in 7 of 51 (13%) patients, whereas 13 of 51 patients receiving rFVIIa (25%) also received up to 1 unit of any blood product. Patients who received rFVIIa had increased duration of mechanical ventilation (p = 0.002) and increased length of stay in the intensive care unit (p = 0.02). There were no differences in hospital length of stay, 30-day mortality, acute kidney injury, postoperative pneumonia, sternal wound infections, postoperative thromboembolic events, or rate of reoperations for bleeding. CONCLUSIONS: Low-dose and early administration of rFVIIa (median total dose 12 mcg/kg) for cardiac surgical bleeding shows potential in achieving hemostasis without increased risk of thromboembolism or acute kidney injury.