Improving Antibiotic De-Escalation in Suspected Ventilator-Associated Pneumonia: An Observational Study With a Pharmacist-Driven Intervention.

BACKGROUND: Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care. MATERIALS AND METHODS: We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients. MAIN RESULTS: A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase. CONCLUSIONS: Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.

Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery: a double-blind, placebo-controlled, randomized trial.

OBJECTIVE: To determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Brigham and Women's Hospital, an 800-bed tertiary care teaching hospital in Boston, Massachusetts. PARTICIPANTS: A total of 251 adult patients undergoing elective thoracic surgery requiring tube thoracostomy between April 2008 and April 2011. INTERVENTIONS: Patients received preoperative antibacterial prophylaxis with cefazolin sodium (or other drug if the patient was allergic to cefazolin). Postoperatively, patients were randomly assigned (at a 1:1 ratio) using a computer-generated randomization sequence to receive extended antibacterial prophylaxis (n = 125) or placebo (n = 126) for 48 hours or until all thoracostomy tubes were removed, whichever came first. MAIN OUTCOME MEASURES: The combined occurrence of surgical site infection, empyema, pneumonia, and Clostridium difficile colitis by postoperative day 28. RESULTS: A total of 245 patients were included in the modified intention-to-treat analysis (121 in the intervention group and 124 in the placebo group). Thirteen patients (10.7%) in the intervention group and 8 patients (6.5%) in the placebo group had a primary end point (risk difference, -4.3% [95% CI, -11.3% to 2.7%]; P = .26). Six patients (5.0%) in the intervention group and 5 patients (4.0%) in the placebo group developed surgical site infections (risk difference, -0.93% [95% CI, -6.1% to 4.3%]; P = .77). Seven patients (5.8%) in the intervention group and 3 patients (2.4%) in the placebo group developed pneumonia (risk difference, -3.4% [95% CI, -8.3% to 1.6%]; P = .21). One patient in the intervention group developed empyema. No patients experienced C difficile colitis. CONCLUSIONS: Extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery requiring tube thoracostomy did not reduce the number of infectious complications compared with preoperative prophylaxis only. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00818766.

Use of postoperative creatinine to predict sustained kidney injury in patients undergoing mesothelioma surgery.

BACKGROUND AND OBJECTIVES: AKI leads to increased morbidity and mortality and progression to chronic kidney injury is a frequent consequence of AKI. Surgical treatment of mesothelioma is associated with increased risk for kidney injury. However, sustained kidney injury may limit therapeutic options for treating residual cancer. This study hypothesized that patients with significant serum creatinine (sCr) elevation within 48 hours of surgery would be at risk for sustained kidney injury. The goal was to determine the best acute sCr measure predictive of sustained kidney injury defined as a 50% increase in sCr from baseline measured 2-4 weeks after surgery. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a prospective, observational cohort of surgical patients with mesothelioma, receiver operator characteristic curves were generated for the 24- and 48-hour absolute difference and relative sCr change over baseline in the derivation cohort (n=279). The prediction was tested in a validation cohort (n=207). The ability of various other AKI definitions to predict sustained kidney injury was evaluated. RESULTS: Sustained kidney injury occurred in 9.8% of patients in the derivation cohort. A ≥59% increase in sCr 48 hours after surgery was most predictive of sustained kidney injury (c statistic=0.78). Among other AKI definitions, a sCr increase of 0.3 mg/dl in 24 hours or 0.5 mg/dl increase in 48 hours (Waikar and Bonventre criteria) also reliably predicted sustained kidney injury. CONCLUSIONS: Development of clinically significant sustained kidney injury can be predicted by acute postoperative sCr elevation in patients treated for mesothelioma.