Implementation of a Pharmacist-Directed Antimicrobial Stewardship Protocol Utilizing Rapid Diagnostic Testing.

Background: Rapid identification of gram-positive bacteria and resistance determinants from blood cultures can reduce the time to optimal antibiotic therapy. Objective: This study evaluates the use of technology to rapidly identify gram-positive bacteria in combination with a pharmacist-directed antimicrobial stewardship protocol in a tertiary-care facility. Methods: Rapid diagnostic testing was performed on gram-positive blood cultures. Pharmacists were instructed to notify prescribers of results and recommend appropriate antimicrobial therapy based on targeted treatment chart. The primary outcomes were mean time to optimal antibiotic therapy, mean time antibiotics were avoided before traditional culture results, and percent of patients with time to optimal antibiotic therapy reached in less than or equal to 2 hours. Results: Inclusion criteria were met for 297 patients. Mean time to identify bacteria was 26.8 hours with nucleic acid assay versus 75.3 hours with traditional culture (difference = 48.5 hours, p < .0001). The rapid identification of gram-positive bacteria combined with accepted pharmacist intervention improved time to optimal antibiotic therapy (8.4 vs 15.4 hours, p = .0095). When contaminants were identified, antibiotics were avoided for 39.5 hours before traditional culture with pharmacist intervention versus 37.2 hours (p > .05). Antibiotic change occurred in less than or equal to 2 hours in more patients in the pharmacist intervention group (28% vs 10.5%, p = .0002). Conclusions: Rapid identification combined with pharmacist intervention significantly improved time to optimal antibiotic therapy and significantly increased the number of patients receiving optimal antibiotic therapy in less than or equal to 2 hours over rapid identification alone. A pharmacist-directed protocol combined with rapid identification enhanced antimicrobial stewardship.

Improving denials management at the enterprise level.

Providers have just one last chance to prepare for implementation of ICD-0. These three components are key to a successful transition: Strong leadership, proactive processes and technology, diligence with denials.

Successful mobilization with AMD3100 and filgrastim with engraftment of autologous peripheral blood stem cells in a heavily pretreated pediatric patient with recurrent Burkitt lymphoma.

The authors report a case of a 13-year-old female with recurrent Burkitt lymphoma who was heavily pretreated with chemotherapy. During chemotherapy for relapse, she developed serious aspergillus infection of the palate and sinuses. Despite 10 microg/kg of filgrastim for 5 days, peripheral blood CD34(+) cells remained

Playing with curricular milestones in the educational sandbox: Q-sort results from an internal medicine educational collaborative.

PURPOSE: In competency-based medical education, the focus of assessment is on learner demonstration of predefined outcomes or competencies. One strategy being used in internal medicine (IM) is applying curricular milestones to assessment and reporting milestones to competence determination. The authors report a practical method for identifying sets of curricular milestones for assessment of a landmark, or a point where a resident can be entrusted with increased responsibility. METHOD: Thirteen IM residency programs joined in an educational collaborative to apply curricular milestones to training. The authors developed a game using Q-sort methodology to identify high-priority milestones for the landmark "Ready for indirect supervision in essential ambulatory care" (EsAMB). During May to December 2010, the programs'ambulatory faculty participated in the Q-sort game to prioritize 22 milestones for EsAMB. The authors analyzed the data to identify the top 8 milestones. RESULTS: In total, 149 faculty units (1-4 faculty each) participated. There was strong agreement on the top eight milestones; six had more than 92% agreement across programs, and five had 75% agreement across all faculty units. During the Q-sort game, faculty engaged in dynamic discussion about milestones and expressed interest in applying the game to other milestones and educational settings. CONCLUSIONS: The Q-sort game enabled diverse programs to prioritize curricular milestones with interprogram and interparticipant consistency. A Q-sort exercise is an engaging and playful way to address milestones in medical education and may provide a practical first step toward using milestones in the real-world educational setting.

A conceptual selenium management model.

We describe herein a conceptual selenium (Se) management model, directed toward coal mining in western Canada, but which can be applied to other coal mines and, with appropriate modification, to other industrial sources of Se to aquatic and terrestrial environments. This conceptual model provides a transparent means to integrate and synthesize existing information that can be used to provide an adaptive approach for managing ecological exposures and associated risk. It is particularly useful for visualizing and subsequently developing management interventions for Se control and risk reduction. The model provides a structured process by which critical information needs can be identified and addressed. It effectively provides the foundation for making management decisions related to Se discharges to aquatic and terrestrial environments by showing interrelationships of the various media and receptors as well as primary sources, release mechanisms, secondary sources, and exposure pathways.

Use of surface charges from DFT calculations to predict intestinal absorption.

A model for prediction of percent intestinal absorption (%Abs) of neutral molecules was developed based upon surface charges of the molecule calculated by density functional theory (DFT). The surface charges are decomposed into sigma moments which are correlated to a partition coefficient representing transfer of the molecule between water and the epithelial membrane. The model was built and tested using a data set of 241 drugs. It achieved an RMS deviation of 13% on a training set of 38 compounds as well as on a test set of 107 drugs for which the experimental data were classified as high quality. Property maps of the molecule, depicting which atoms contribute to or hinder absorption, are produced to aid drug design.

Does the use of antibiotics in food animals pose a risk to human health? A critical review of published data.

The use of antibiotics in food animals selects for bacteria resistant to antibiotics used in humans, and these might spread via the food to humans and cause human infection, hence the banning of growth-promoters. The actual danger seems small, and there might be disadvantages to human and to animal health. The low dosages used for growth promotion are an unquantified hazard. Although some antibiotics are used both in animals and humans, most of the resistance problem in humans has arisen from human use. Resistance can be selected in food animals, and resistant bacteria can contaminate animal-derived food, but adequate cooking destroys them. How often they colonize the human gut, and transfer resistance genes is not known. In zoonotic salmonellosis, resistance may arise in animals or humans, but human cross-infection is common. The case of campylobacter infection is less clear. The normal human faecal flora can contain resistant enterococci, but indistinguishable strains in animals and man are uncommon, possibly because most animal enterococci do not establish themselves in the human intestine. There is no correlation between the carriage of resistant enterococci of possible animal origin and human infection with resistant strains. Commensal Escherichia coli also exhibits host-animal preferences. Anti-Gram-positive growth promoters would be expected to have little effect on most Gram-negative organisms. Even if resistant pathogens do reach man, the clinical consequences of resistance may be small. The application of the 'precautionary principle' is a non-scientific approach that assumes that risk assessments will be carried out.