Impact of an Antipsychotic Discontinuation Bundle During Transitions of Care in Critically Ill Patients.

INTRODUCTION:: Delirium affects a large proportion of patients admitted to the intensive care unit (ICU) and is associated with increased morbidity and mortality. Antipsychotics have become frequently used agents for the treatment of delirium; however, they are often continued at transitions of care. This has potential negative short- and long-term health consequences that are preventable. We investigated the antipsychotic tapering bundle's impact on the rate of antipsychotic continuation at transitions from the medical intensive care unit (MICU). METHODS:: This was a preretrospective and postretrospective chart review that included adult patients in the MICU initiated on antipsychotic therapy for ICU delirium. A bundled multidisciplinary education program and antipsychotic discontinuation algorithm were implemented in the MICU to provide recommendations for safe and effective use of antipsychotics for ICU delirium and minimize continuation of therapy at transitions of care. Rates of antipsychotic continuation at transition from the MICU were compared between the preintervention and postintervention groups with the χ2 test. RESULTS:: A total of 140 patients in the prebundle group and 141 patients in the postbundle group were enrolled. Overall, baseline characteristics were similar. After implementation of the discontinuation bundle, antipsychotic continuation at MICU discharge decreased (27.9% in the prebundle group vs 17.7% in the postbundle group; P < .05). In the multivariate analysis, patients were less likely to be continued on antipsychotic therapy at MICU discharge after implementation of the bundle (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.26-0.86). There were also lower rates of overall antipsychotic continuation at hospital discharge (OR: 0.4; 95% CI: 0.18-0.89). CONCLUSION:: This is the first study to demonstrate a reduction in antipsychotic continuation at transition from the MICU after implementation of an antipsychotic discontinuation bundle in ICU patients. We believe this bundle allows for safer transitions of care from the MICU and decreases unnecessary antipsychotic therapy.

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now?

OBJECTIVE: To synthesize the literature and provide guidance to practitioners regarding double therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI). DATA SOURCES: PubMed and MEDLINE (January 2000 to February 2018) were searched using the following terms: atrial fibrillation, myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, anticoagulation, dual-antiplatelet therapy, clopidogrel, aspirin, ticagrelor, prasugrel, and triple therapy. STUDY SELECTION AND DATA EXTRACTION: The results included randomized and nonrandomized clinical trials and meta-analyses. Each study was reported based on study design, population, intervention, comparator, and key cardiovascular (CV) and bleeding outcomes. DATA SYNTHESIS: A total of 15 studies were included in the review. The majority of studies evaluating DT and TT utilized clopidogrel and warfarin as components of the regimen, although there are emerging data with newer agents. Evidence purporting DT regimens to be equally effective in preventing CV events and improved safety profiles compared with TT regimens included populations with relatively low risk for recurrent CV events, and many of these studies were observational in nature. Overall, current evidence as well as American and European guidelines support the use of TT in patients with AF who require PCI for the least possible amount of time, depending on patient-specific factors involving bleeding and thrombosis. CONCLUSIONS: In the majority of patients with AF who require PCI, TT should be used for the shortest period of time possible. DT regimens may be used in patients requiring PCI who have low risk for thrombosis and/or high bleeding risk.

Hepatitis C Virus Screening: A Review of the OraQuick Hepatitis C Virus Rapid Antibody Test.

Objective: To provide a review on the use, percent positive agreement (PPA), percent negative agreement (PNA), and implementation of using the OraQuick HCV Rapid Antibody Test for hepatitis C virus (HCV) screening in community pharmacies in an effort to increase overall HCV screening in target populations. Data Sources: PubMed and Sagepub were searched for the following keywords: hepatitis C virus, rapid diagnostic tests, rapid assay, and rapid HCV assay. Dates searched were from January 2000 to October 2013. Study Selection: All studies including the use of the OraQuick HCV Rapid Antibody Test were included. Data Synthesis: Sensitivity and specificity of this device are compared with several standard laboratory tests for detecting HCV antibodies. In comparing these values with the clinical "standards," PPA and PNA are more applicable terms to describe whether the OraQuick device is an effective tool for initial screening by pharmacists. The OraQuick HCV Rapid Antibody Test demonstrates high accuracy in providing accurate HCV infection status. Conclusion: The OraQuick HCV Rapid Antibody Test is a unique tool pharmacists can use in an effort to enhance the screening capabilities for HCV infection. Pharmacists often have the most contact with those patients at high risk for having contracted HCV in the past. With a relatively high PPA and high NPA, a high confidence in the accuracy of the device can be placed on initial test results. Patients should then be triaged to proper follow-up care depending on initial results.

Treatment options for extended-spectrum beta-lactamase (ESBL) and AmpC-producing bacteria.

INTRODUCTION: Extended spectrum ß-lactamases (ESBL) and AmpC ß-lactamases are increasing causes of resistance in many Gram-negative pathogens of common infections. This has led to a growing utilization of broad spectrum antibiotics, most predominately the carbapenem agents. As the prevalence of ESBL and AmpC-producing isolates and carbapenem resistance has increased, interest in effective alternatives for the management of these infections has also developed. AREAS COVERED: This article summarizes clinical literature evaluating the utility of carbapenem-sparing regimens for the treatment of ESBL and AmpC-producing Enterobacteriaceae, mainly ß-lactam-ß-lactamase inhibitor combinations and cefepime (FEP). EXPERT OPINION: Based on available data, the use of piperacillin-tazobactam (PTZ) and FEP in the treatment of ESBL-producing Enterobacteriaceae cannot be widely recommended. However, certain infections and patient characteristics may support for effective use of these alternative agents. In the treatment of infections caused by AmpC-producing Enterobacteriaceae, FEP has been shown to be a clinically useful carbapenem-sparing alternative. Carbapenems and FEP share many structurally similar characteristics in regards to susceptibility to AmpC ß-lactamases, which further create confidence in the use FEP in these situations. Patient and infection specific characteristics should be used to employ FEP optimally.