Comparison of emergency department to hospital antibiograms: Influence of patient risk factors on susceptibility.

OBJECTIVES: Traditional antibiograms use local resistance patterns and susceptibility data to guide empiric antimicrobial therapy selection. However, antibiograms are rarely unit-specific and do not account for patient-specific risk factors. METHODS: This retrospective, single-center descriptive study used culture and susceptibility data from January 1 to December 31, 2016 to develop an Emergency Department (ED)-specific antibiogram and compare the antimicrobial susceptibilities of the most commonly identified organisms to the hospital antibiogram. All ED isolates were further stratified by the following risk factors that may influence antimicrobial susceptibility: age, disposition from ED, previous antimicrobial use and/or hospitalization within 30 days, and presenting location (i.e. healthcare facility residence versus community). RESULTS: A total of 2158 isolates from the ED were included: Escherichia coli (n = 1244), Klebsiella pneumoniae (n = 232), Proteus mirabilis (n = 131), Pseudomonas aeruginosa (n = 103), Staphylococcus aureus (n = 303), and Enterococcus faecalis (n = 145). There were no statistically significant differences between the ED and hospital antibiogram (n = 5739) with the exception of Escherichia coli. The hospital antibiogram overestimated Escherichia coli resistance rates for cefazolin (20% vs 15.6%, p = 0.049), ceftriaxone (9.6% vs 6.4%, p < 0.033), and ciprofloxacin (23.7% vs 15.4%, p < 0.006). There were significantly more risk factors present in patients admitted versus discharged from the ED (p < 0.001). Healthcare facility residence had the greatest influence on susceptibility, especially Escherichia coli (81.8% vs 34.9%, p < 0.001) and Proteus mirabilis (75.3% vs 33%, p < 0.001) ciprofloxacin susceptibility. CONCLUSIONS: There were no statistically significant differences between the ED and hospital antibiogram with the exception of Escherichia coli. However, development of an ED-specific antibiogram can aid physicians in prescribing appropriate empiric therapy when risk factors are included.

Understanding and managing the possible adverse effects associated with bevacizumab.

PURPOSE: The adverse events associated with bevacizumab therapy are characterized, and the underlying pathophysiology, risk factors, frequency, and management of these events are described. SUMMARY: The adverse events associated with bevacizumab include hypertension, proteinuria, thromboembolism, impaired wound healing, bleeding, perforation, reversible leukoencephalopathy syndrome, skin rash, and infusion-related hypersensitivity reactions. Patients should be monitored for these events throughout the course of bevacizumab therapy. Hypertension is by far the most common adverse event associated with bevacizumab. Blood pressure should be routinely monitored, and hypertension should be medically managed with antihypertensive drugs as deemed appropriate during bevacizumab therapy. Patients should be monitored for proteinuria every three to four weeks, and bevacizumab should be discontinued with persistent proteinuria of >2+. Thromboembolic events, impaired wound healing, bowel and nasal septum perforation, and bleeding share similar pathophysiology. Thromboembolic events should be managed in accordance with guidelines established by the American College of Chest Physicians, and bevacizumab should be discontinued for new life-threatening venous or arterial thromboembolism. To minimize the risk of bleeding or impaired wound healing, bevacizumab should be started at least four weeks after surgery or discontinued for at least six to eight weeks before elective surgery. The management of other adverse events is more anecdotal, with relatively few reports of their occurrence with bevacizumab. CONCLUSION: Many of the potential serious complications of bevacizumab can be averted by close monitoring of patient-specific variables, which should be measured at baseline and then at predetermined intervals throughout the course of therapy to maximize patient safety.