Evaluation of a pharmacist-led antimicrobial stewardship service in a pediatric emergency department.

Background To improve antimicrobial use, incorporation of a pharmacist in antimicrobial stewardship initiatives in the emergency department has been recommended. Recognizing the potential value, a pharmacist-led antimicrobial stewardship (AMS) service which included review and follow up of microbiology results for patients discharged from the pediatric emergency department (PED) with suspected infections was implemented at our local institution. Objective The objective of this study was to evaluate the impact of pharmacists delivering this service compared to usual care. Setting Pediatric emergency department at the IWK Health Centre in Halifax, Canada. Method This study was completed as a retrospective chart review of pediatric patients discharged from the PED 6 months before and after implementation of the pharmacist-led AMS service. Data was extracted from electronic medical records. Data were reported descriptively and compared using a two-sided chi-square test and ordinal logistic regression. Main outcome measures The primary outcome measure was rate of return visits to the PED within 96 h of initial presentation. Results This study included 1070 patient encounters pre-implementation and 1040 patient encounters post-implementation. The rate of return visits to the PED within 96 h was 12.0% (129/1070) pre-implementation vs. 10.0% (100/1049) post-implementation (p = 0.07). The rate of return visits or hospitalization at 30 days was 22.1% (237/1070) pre-implementation compared to 19.9% (207/1040) in the post-implementation phase (p = 0.21). Inappropriate antimicrobial therapy was identified more often in the pre-implementation phase (7.0%, 68/975) vs. the post-implementation phase (5.0%, 46/952), p = 0.047. Time to notification within the first day after discharge occurred more frequently in the post-implementation phase (53.3%, 80/150) as compared to the pre-implementation phase (40.3%, 52/129, p = 0.0298). Conclusion Although this pharmacist-led AMS service did not significantly affect the rate of return visits or hospitalization, it may have led to more judicious use of antimicrobial agents and faster time to notification.

An observational study of the relationship between Capacity for Care as an animal shelter management model and cat health, adoption and death in three animal shelters.

Animal shelters struggle to function at their 'right size' in terms of physical, staffing and outcome capacity, especially with seasonal fluctuations in cat intake. To address this, a Capacity for Care (C4C) management model was devised to balance health and welfare requirements of all animals while maintaining or improving goals for positive outcomes, such as adoption or transfer. In this observational study of three shelters, applying the C4C management system gave each organization an optimal average daily shelter cat population target (to be achieved through proactive length of stay management) and helped each shelter to increase the size of their feline housing units. Pre- and post-C4C implementation data were evaluated to determine impact on average monthly isolation ward populations and cat outcomes such as adoptions and shelter deaths (euthanasia/died). Improved outcomes including increased adoption probability, decreased shelter death probability and fewer cats requiring infectious disease isolation were seen after C4C institution. Results suggest that implementation of this management model could help other shelters achieve similar results.

Survey of animal shelter managers regarding shelter veterinary medical services.

Veterinary services are increasingly used in animal shelters, and shelter medicine is an emerging veterinary specialty. However, little is known about working relationships between animal shelters and veterinarians. The aims of this survey were to characterize working relationships that shelter personnel have and want with veterinarians, identify opinions that shelter managers have regarding the veterinarians they work with, and determine areas for relationship growth between veterinarians and shelter managers. An electronic survey was distributed to 1373 managers of North American animal shelters; 536 (39.0%) responded. Almost all shelters had some veterinary relationship, and most had regular relationships with veterinarians. The proportion of shelters that used local clinics (73.9%) was significantly higher than the proportion that retained on-site paid veterinarians (48.5%). The proportion of respondents who did not have but wanted a paid on-site veterinarian (42%) was significantly higher than the proportion of respondents who did not use local clinics but wanted to (7.9%). These data suggest shelter managers valued veterinary relationships, and wished to expand on-site veterinary services. Almost all shelters in this study provided some veterinary care, and all respondents identified at least one common infectious disease, which, for most, had a substantial negative impact on shelter successes. Respondents indicated that the most important roles and greatest expertise of veterinarians were related to surgery, diagnosis and treatment of individual animals. Education of both veterinarians and shelter managers may help ensure that shelters benefit from the full range of services veterinarians can provide, including expertise in disease prevention and animal behavior.

A clonal outbreak of acute fatal hemorrhagic pneumonia in intensively housed (shelter) dogs caused by Streptococcus equi subsp. zooepidemicus.

An outbreak of acute, fatal, hemorrhagic pneumonia was observed in more than 1,000 mixed breed dogs in a single animal shelter. The Department of Anatomic Pathology at the University of California at Davis School of Veterinary Medicine performed necropsies on dogs that were found moribund in acute respiratory distress or found dead with evidence of nasal bleeding. All dogs had hemothorax and an acute, fibrinosuppurative pneumonia. Large numbers of gram-positive cocci were observed within the lungs of all dogs and within septic thromboemboli of remote organs in about 50% of cases. Bacterial cultures from the dogs and their environment revealed widespread beta-hemolytic Streptococus equi subspecies zooepidemicus (Lancefield Group C). Extensive diagnostic testing failed to reveal the consistent presence of copathogens in individual cases. The clinical, epidemiologic, molecular biologic, and pathologic data indicate that a single clone of S. zooepidemicus was the cause of an acutely fatal respiratory infection in these dogs.

Fatal Streptococcus canis infections in intensively housed shelter cats.

Three independent, fatal outbreaks of Streptococcus canis infection occurred in a 2-year period in shelter cats. The outbreaks occurred in Northern California (Yolo County), Southern California (Kern County), and North Carolina (Guilford County). An estimation of the affected population is >150 cats among 3 affected shelters, with a mortality rate of up to 30%. Among 20 cats submitted for necropsy there were 2 distinct pathologic presentations. The first (shelters 1 and 2) was skin ulceration and chronic respiratory infection that progressed, in some cats, to necrotizing sinusitis and meningitis. The second (shelter 3) was rapid progression from necrotizing fasciitis with skin ulceration to toxic shock-like syndrome, sepsis, and death. S canis was the sole pathogen identified in most cases. Whether hypervirulent S canis strains exist is unknown; there is little understanding of how these bacteria cause invasive disease in cats.

Emergency department patients' opinions of screening for intimate partner violence among women.

BACKGROUND: Universal screening for intimate partner violence (IPV) in the emergency department (ED) has been advocated by many medical institutions. Policies implemented for IPV screening have met with numerous obstacles. One such obstacle is the perception by emergency personnel that patients might be offended by such screening if they presented to the ED for problems unrelated to trauma. OBJECTIVES: To assess opinions of adult ED patients regarding a policy of universal IPV screening for women presenting to the ED. METHODS: This study was conducted in EDs in Halifax, Nova Scotia, and St John's, Newfoundland. Patients were questioned as to whether it was appropriate for all women to be asked if they had experienced violent or threatening behaviour from someone close to them. Patients in significant pain or in extremis were not approached. RESULTS: The data consist of a convenience sample of 514 adult ED patients, aged 16-95 years. Two (0.4%) were excluded from the analysis. Of 512 analysed, 442 (86.0%) answered "yes" to the question, 53 (10.3%) answered "no", 17 (3.3%) had no opinion. There were no significant differences between the proportion of "yes" and "no" answers in the male and female groups. CONCLUSION: Universal screening for IPV of adult female patients presenting to the ED was supported by most patients. Patient objections should not be seen as a reason to withhold questioning on this issue.

Pathologic, immunohistochemical, and electron microscopic findings in naturally occurring virulent systemic feline calicivirus infection in cats.

Infection with feline calicivirus (FCV) is a common cause of upper respiratory and oral disease in cats. FCV infection is rarely fatal, however, virulent, systemic strains of FCV (VS-FCV) that cause alopecia, cutaneous ulcers, subcutaneous edema, and high mortality in affected cats have recently been described. Seven cats with natural VS-FCV infection all had subcutaneous edema and ulceration of the oral cavity, with variable ulceration of the pinnae, pawpads, nares, and skin. Other lesions that were present in some affected cats included bronchointerstitial pneumonia, and pancreatic, hepatic, and splenic necrosis. Viral antigen was present within endothelial and epithelial cells in affected tissues as determined by immunohistochemical staining with a monoclonal antibody to FCV. Mature intranuclear and intracytoplasmic virions in necrotic epithelial cells were identified by transmission electron microscopy. VS-FCV infection causes epithelial cell cytolysis and systemic vascular compromise in susceptible cats, leading to cutaneous ulceration, severe edema, and high mortality.