Evaluation of Antibiotic Utilization in an Emergency Department After Implementation of an Antimicrobial Stewardship Pharmacist Culture Review Service.

Background: Antimicrobial stewardship programs (ASP) have been widely implemented in hospitals to improve antimicrobial use and prevent resistance. However, the role of ASP in the emergency department (ED) setting is not well defined. Objective: The objective of this study is to evaluate the impact of an ASP pharmacist culture review service in an ED. Methods: This was a retrospective, quasi-experimental study of all patients discharged from the ED with a positive culture. Patients discharged from the ED from February 1, 2015 to October 31, 2015 were managed by ED providers (pre-ASP), and those discharged from February 1, 2016 to October 31, 2016 were managed by a pharmacist-driven ASP (post-ASP implementation). The primary outcome was median time to change of antibiotic(s) in patients with inadequate antimicrobial therapy based on culture results. Secondary outcomes included time to culture evaluation, appropriateness of antimicrobials, and 30-day readmissions. Results: A total of 790 patients were included in the analysis (398 in pre-ASP group vs 392 in post-ASP implementation group). Median time to modification of inadequate antibiotic therapy decreased from 6.79 days in the pre-ASP group to 1.99 days in the post-ASP implementation group (P < .0001). Median time to culture review decreased in the post-ASP implementation group from 9.83 to 0.32 days (P < .0001). Appropriateness of culture-guided therapy increased in the post-ASP implementation group from 85.7 to 91.8% (P = .047). The rate of combined ED revisits and hospital readmissions was similar between groups (P = .367). Conclusion: ASP pharmacist evaluation of positive cultures in the ED was associated with a significant decrease in the time to appropriate therapy in patients discharged with inadequate therapy and higher rates of appropriate antimicrobial therapy.

Management of Extended-Spectrum Beta-Lactamase Urinary Tract Infections: Diagnostic and Treatment Considerations for the Older Adult.

OBJECTIVE: To review the treatment options for extended-spectrum beta-lactamase (ESBL) urinary tract infections (UTIs) in the long-term care facility setting.
DATA SOURCES: A PubMed search from January 1, 1990, through December 31, 2018, using terms "extended spectrum beta lactamase" and "urinary tract infection" was performed. Current guidelines, drug databases, and manufacturer package inserts were also used.
STUDY SELECTION: All English-language articles during the above time frame appearing in these searches were reviewed for relevance to this paper. In addition, their bibliographies were reviewed to identify any articles not originally identified.
DATA SYNTHESIS: ESBL UTIs are a growing concern in the long-term care facility as these pathogens are becoming more prevalent. Patients residing in long-term care facilities have fewer treatment modalities because of medication administration and care issues. This review highlights the data on different antibiotics and their efficacy toward ESBLs in the setting of UTI.
CONCLUSIONS: Despite the challenges and limitations, there are still options for clinicians to provide optimal care, including antibiotics with different routes of administration, as well as different administration techniques. Clinicians can be successful with treating ESBL UTIs in older adults.

Variability in Glycemic Control with Temperature Transitions during Therapeutic Hypothermia.

PURPOSE: Patients treated with therapeutic hypothermia (TH) and continuous insulin may be at increased risk of hyperglycemia or hypoglycemia, particularly during temperature transitions. This study aimed to evaluate frequency of glucose excursions during each phase of TH and to characterize glycemic control patterns in relation to survival. METHODS: Patients admitted to a tertiary care hospital for circulatory arrest and treated with both therapeutic hypothermia and protocol-based continuous insulin between January 2010 and June 2013 were included. Glucose measures, insulin, and temperatures were collected through 24 hours after rewarming. RESULTS: 24 of 26 patients experienced glycemic excursions. Hyperglycemic excursions were more frequent during initiation versus remaining phases (36.3%, 4.3%, 2.5%, and 4.0%, p = 0.002). Hypoglycemia occurred most often during rewarming (0%, 7.7%, 23.1%, and 3.8%, p = 0.02). Patients who experienced hypoglycemia had higher insulin doses prior to rewarming (16.2 versus 2.1 units/hr, p = 0.03). Glucose variation was highest during hypothermia and trended higher in nonsurvivors compared to survivors (13.38 versus 9.16, p = 0.09). Frequency of excursions was also higher in nonsurvivors (32.3% versus 19.8%, p = 0.045). CONCLUSIONS: Glycemic excursions are common and occur more often in nonsurvivors. Excursions differ by phase but risk of hypoglycemia is increased during rewarming.

Impact of Insulin Detemir Administration Time on Hypoglycemia Rates in Hospitalized Patients.

STUDY OBJECTIVE: To determine if insulin detemir administration time affects the frequency of hypoglycemia (blood glucose level <70 mg/dl) in hospitalized patients. DESIGN: Retrospective cohort study. PATIENTS: A total of 357 adults (aged 18-89 yrs) who received insulin detemir for at least 48 hours while hospitalized between January 1, 2014, and December 31, 2015, were included. Patients were categorized into one of three groups according to insulin detemir administration time: detemir given once/day between 7 a.m. and 10 a.m. (AM group [71 patients]), detemir given once/day between 6 p.m. and 10 p.m. (PM group [158 patients]), and detemir given twice/day (BID group [128 patients]). SETTING: Community hospital. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the percentage of patient days with any occurrence of hypoglycemia. The key secondary outcomes included the percentages of patients who experienced any hypoglycemic event, severe hypoglycemia, hypoglycemia requiring treatment, and refractory hypoglycemia; time of hypoglycemia; and percentage of patients experiencing one or more episodes of hyperglycemia. The AM group had a lower proportion of days with hypoglycemia compared with the PM group (7.9% vs 11.9%, p=0.008). There was a nonsignificant trend toward a lower proportion of days with hypoglycemia in the BID group compared with the PM group (9.1% vs 11.9%, p=0.0302). No significant differences in percentage of patient days with hyperglycemia and rates of severe hypoglycemia, hypoglycemia requiring treatment, or refractory hypoglycemia were noted among the three groups. CONCLUSION: Administration of detemir in the morning may reduce the occurrence of hypoglycemia in hospitalized patients. Institutions that include detemir on their formularies may consider evaluating the incidence of hypoglycemia and modifying administration schedules as part of their medication safety program.