Impact of Student Pharmacist State Anxiety on Vasopressor Calculation Accuracy in Advanced Cardiac Life Support Simulations.

OBJECTIVE: To assess the impact of student pharmacist state anxiety on vasopressor calculation accuracy in advanced cardiac life support (ACLS) simulations. METHODS: Third-year professional students participated in 2 ACLS-related simulation laboratory sessions. In week 1, students completed 3 calculations at their workstation with no stressors. Students were then randomized into teams for a bedside simulation where they independently completed 3 additional calculations either with or without stressors. Team assignments were maintained for week 2 where all participants completed a high-fidelity ACLS simulation that included a team vasopressor calculation. At both encounters, calculation accuracy was assessed as well as pre- and post-state anxiety using the Spielberger State-Trait Anxiety Inventory (STAI) survey tool. RESULTS: Students' (N = 145) trait anxiety aligned with normative data for similarly aged professional students. Post-simulation state anxiety in week 1 was found to be higher for those completing the activity with stressors than without (STAI score 44.7 vs 36.9) paired with lower bedside calculation accuracy, despite similar initial workstation calculation accuracy. In week 2, pre-simulation state anxiety score and calculation accuracy were not significantly different between the 2 groups. However, the state anxiety score significantly increased post-simulation for those exposed to stress in the previous week. CONCLUSION: Stress negatively impacted student pharmacist vasopressor calculation accuracy. However, the repeated exposure to a stressed simulation did not result in a significant difference in pre- or post-simulation state anxiety score or calculation accuracy when compared to a non-stressed control. Consideration should be made whether to include more "real-life" simulations in student pharmacist education.

Prevalence and Value of Board Certification Among Pharmacy Practice Faculty in the United States.

OBJECTIVE: To determine the prevalence of board certification among pharmacy practice faculty in the United States, motivators and barriers to certification, and association between board certification and professional achievements and accomplishments that may support career advancement. METHODS: In phase I, the prevalence of board-certified pharmacy practice faculty in the United States was determined by cross-referencing lists of faculty and board-certified pharmacists. In phase II, faculty were stratified by rank and invited to participate in a survey regarding professional characteristics, motivators and barriers to board certification, and professional achievements and accomplishments that may support career advancement for pharmacy practice faculty. RESULTS: The prevalence of board certification among the 3276 pharmacy practice faculty was 56%. The prevalence was the highest among assistant professors (61%). A total of 746 faculty completed the survey (33% response rate). Of those respondents, 73% reported being currently certified, 23% never certified, and 4% previously certified. Overall, to be recognized as an expert in the field was identified as the most commonly perceived reason faculty obtain board certification (44%). Currently and previously certified faculty ranked the desire to be recognized as an expert in the field as the most common reason they obtained board certification (61%). There was a positive correlation between board certification and certain professional accomplishments. CONCLUSION: The prevalence of board-certified pharmacy practice faculty has increased since 2011, but motivators and barriers for board certification remain similar. Board certification may support career advancement for pharmacy practice faculty.

Optimal energy provision early in ICU stay for critically ill patients receiving parenteral nutrition.

BACKGROUND: Literature on optimal energy provision via parenteral nutrition (PN) is limited and the evidence quality is low. The purpose of this study is to determine if there is a difference in outcomes in adult critically ill patients when receiving lower vs higher calorie provision via PN early in intensive care unit (ICU) stay. METHODS: Adult patients initiated on PN within the first 10 days of ICU stay from May 2014 to June 2021 were included in this retrospective study. The primary outcome was to determine the impact of lower (<20 kcal/kg/day) vs higher (>25 kcal/kg/day) calorie provision on all-cause, in-hospital mortality. Secondary outcomes were to determine the impact of calorie provision on hospital or ICU length of stay and incidence of complications. RESULTS: This study included 133 patients: a lower calorie provision group (n = 77) and a higher calorie provision group (n = 56). There was a significant difference in all-cause, in-hospital mortality between the lower and the higher calorie provision groups (36.36% and 17.86%, respectively; P = 0.02). However, upon a multivariate analysis of death at discharge, the specific calorie provision group did not affect the probability of death at hospital discharge. The secondary outcomes were not significantly different between groups. CONCLUSION: When comparing lower calorie provision with higher calorie provision in adult critically ill patients receiving PN early within their ICU stay, there were no differences in outcomes after controlling for significant confounders. Future larger prospective studies should further evaluate optimal caloric provision via PN in this population.

Student Pharmacist-Led Basic Life Support Training for High School Students Improves Knowledge and Skill Achievement.

Introduction: The performance of bystander cardiopulmonary resuscitation (CPR) improves survival among cardiac arrest victims. Near-peer teaching of Basic Life Support (BLS) may be an effective way to deliver resuscitation education. This article aims to assess the effectiveness of a student pharmacist-led American Heart Association (AHA) BLS course on high school students' knowledge and skill achievement. Methods: Student pharmacists were trained as AHA instructors and delivered BLS certification courses to high school students. Participants completed pre- and post-assessments adapted from the course learning objectives. Skills performance was evaluated using the AHA's standardized forms. Participants completed questions regarding their perceptions of the pharmacist's role in BLS and confidence in pursuing a career in healthcare. Results: There were 321 participants with the majority in 11th or 12th grade (86.6%) and attending public school (99.1%). After completing the training, the mean percentage of correct assessment responses increased from 41.2% to 89% (p <0.0001). All participants correctly performed BLS skills. Most participants strongly agreed or agreed that the course changed their perspective of the pharmacist's role during BLS (74.8%) and increased their confidence in their decision to pursue future careers in healthcare (61.7%). Conclusion: Student pharmacist-led BLS training, using near-peer delivery, improves high school students' knowledge and skill achievement. This strategy promotes high school students' positive perceptions regarding pharmacists and their role in BLS, as well as their confidence in pursuing careers in healthcare.

Metabolic Complications Occur More Frequently in Older Patients Receiving Parenteral Nutrition.

BACKGROUND: The European Society for Clinical Nutrition and Metabolism Guidelines for Parenteral Nutrition in Geriatric Patients state metabolic complications are more frequent in elderly patients. However, literature provides limited information about metabolic complications in older patients receiving parenteral nutrition (PN). Consequently, the purpose of this study was to compare the development of metabolic complications in older vs younger patients receiving PN. METHODS: Patients receiving PN from May 1, 2014, to February 7, 2017, at Cooper University Hospital were included. Metabolic complications assessed included acid-base disturbances, hepatic complications, hypercapnia, hyperchloremia, hyperglycemia, hypernatremia, hypertriglyceridemia, hypochloremia, hypoglycemia, hypokalemia, hypophosphatemia, and refeeding syndrome. RESULTS: 595 patients were included (older group [≥65 years]: n = 245, median age: 76 years; younger group [<65 years]: n = 350, median age: 53 years]. Certain characteristics were similar between groups (female, 51%; mean body mass index of 28; critically ill, 34%; central PN, 97%; median duration of PN, 7 days; mean energy provision PN, 25.4 kcal/kg/d; mean dextrose infusion rate, 2.31 mg/kg/min). Overall, metabolic complications developed in 58% of patients and occurred more frequently in older vs younger patients (65.7% vs 53.4%; P = .003). Multivariate logistic analysis demonstrated increased odds of metabolic complications in the older group (odds ratio, 1.55; 95% CI, 1.014-2.375). CONCLUSIONS: Older hospitalized patients are more likely to develop a metabolic complication during their PN course than younger patients. This study heightens awareness that patients of advanced age are subject to metabolic complications; practitioners should anticipate and resolve complications in a timely manner.

Advanced cardiac life support certification for student pharmacists improves simulated patient survival.

BACKGROUND AND PURPOSE: Basic life support (BLS) and advanced cardiac life support (ACLS) skills performance, as well as simulated patient survival, were compared for student pharmacist teams with and without at least one member with American Heart Association (AHA) ACLS certification. EDUCATIONAL ACTIVITY AND SETTING: Doctor of pharmacy students in their third professional year completed a high-fidelity mannequin simulation. Within the previous year, 30 of 184 students (16%) completed ACLS certification. Rapid response teams (n = 31) of five to six members were formed through random student assignment. Two AHA instructors recorded and assessed performance using a checklist adapted from the AHA's standardized forms for BLS and ACLS assessment. Teams with and without ACLS certified members were compared for skills performance and simulated patient survival (i.e. correct performance of all BLS and ACLS skills). FINDINGS: Teams with ACLS certified members (n = 21) were superior to teams without certified members (n = 10) for correct performance of all observed BLS and ACLS skills, including pulse assessment and medication selection for cardiovascular support. For teams who had ACLS certified members, simulated patient survival was 86% higher. The study groups did not differ in their ability to calculate a correct vasopressor infusion rate if warranted. SUMMARY: BLS and ACLS skills performance were improved by AHA ACLS certification. Additionally, simulated patient survival was improved for teams with students who had at least one ACLS certified member.

Impact of the Time to Initiation of Parenteral Nutrition on Patient Outcomes in Critically Ill Adults.

BACKGROUND: The optimal time to initiate parenteral nutrition (PN) in critically ill adults in whom enteral nutrition is not feasible is controversial. OBJECTIVE: The objectives were to compare in-hospital mortality and hospital length of stay in patients initiated on PN within 7 days or after 7 days of poor nutrient intake. METHODS: This single-center, retrospective study included critically ill adult patients who received at least 2 consecutive days of PN during hospitalization from May 2014 to July 2016. RESULTS: The median duration of PN (interquartile range) was 8 (5-13) days. In total, 110 patients received PN within 7 days of poor nutrient intake while 49 patients received PN after 7 days of poor nutrient intake. There was no statistically significant difference in in-hospital mortality between groups (29.09% vs 18.37%, P = .1535). Patients initiated within 7 days had a significantly shorter median hospital length of stay than patients initiated after 7 days (20 days vs 27 days, P = .0013). There were 69 patients who were classified as obese. Obese patients initiated within 7 days had a significantly shorter median hospital length of stay than obese patients initiated after 7 days (17 days vs 33 days, P = .0007). CONCLUSIONS: Time to initiation of PN did not impact in-hospital mortality. However, there was an association between early initiation of PN and a shorter hospital length of stay that was most pronounced among obese patients.

Student-Led Cardiopulmonary Resuscitation Education to Lay Providers Results in Successful Knowledge Acquisition and Skill Performance.

AIMS: To assess outcomes associated with student-led lay-responder cardiopulmonary resuscitation (CPR) education to community members. METHODS: Healthcare students (87% pharmacy) were trained as American Heart Association (AHA)-certified CPR instructors and delivered CPR certification programs for the community through the AHA's Heartsaver® CPR Automated External Defibrillator (AED) certification course from August 2016 to January 2017. Knowledge acquisition was evaluated using 5 pre/ post-course questions adapted from the AHA Basic Life Support (BLS) certification course to be consistent with the AHA Heartsaver® CPR AED course learning objectives. Skill performance was evaluated using the AHA's standardized form for adult, child, and infant CPR assessment. RESULTS: The majority of community member participants (n=105) were female (71%), African American (71%), 45-64 years of age (46%), employed (71%), college educated (50%), and had previous CPR training (63%). Participants demonstrated 100% success rate in correctly performing CPR skills. The mean percentage of correct responses increased from 36% for the pre-course questions to 85% for the post-course questions (p<0.001). CONCLUSION: Healthcare students successfully provided CPR education to community members who then correctly demonstrated adult, child, and infant CPR skills. Data suggest that student-led CPR training has a positive impact on knowledge acquisition in community members.

Impact of Implementation of the American Society for Parenteral and Enteral Nutrition Model for Parenteral Nutrition Order Writing and Review on Competency, Attitudes, and Perceptions.

BACKGROUND: The American Society for Parenteral and Enteral Nutrition (ASPEN) parenteral nutrition (PN) safety consensus recommendations advise a comprehensive education program and competency assessment for all healthcare professionals involved in the care of patients receiving PN. The ASPEN-model papers provide guidance for designing PN competencies for prescribers, pharmacists, and pharmacy technicians. The purpose of this research was to evaluate the impact of a comprehensive educational program that aligns with the ASPEN model on PN competency, attitudes, and perceptions in a multidisciplinary healthcare professional audience. METHODS: Dietitians, pharmacists, and physicians attended a 3-hour ASPEN model-based educational program focused on PN order writing and review. Matched preeducation and posteducation competency assessments were completed by attendees. Attitudes and perceptions were also assessed before and after the educational program using 5-point Likert scales. RESULTS: Ninety-seven subjects were included in the analysis. The majority of attendees were dietitians (53.6%), followed by pharmacists (45.4%). Overall, multidisciplinary competency assessment scores improved by an average of 12.6% (preassessment average of 62.7%, postassessment average of 75.3%, P < 0.0001). Nine out of 10 statements regarding PN attitudes and perceptions significantly improved on the 5-point Likert scales (P < 0.05). CONCLUSION: A comprehensive PN educational program in alignment with the ASPEN model positively impacted multidisciplinary healthcare professional PN competency, attitudes, and perceptions. To optimize patient safety, local organizations and institutions should implement formalized training as outlined by the ASPEN model for healthcare professionals involved in the care of patients receiving PN.

Performance and retention of basic life support skills improve with a peer-led training program.

BACKGROUND AND PURPOSE: Pharmacy students' performance and retention of Basic Life Support (BLS) skills were evaluated 120 days after completion of a peer-led BLS training program. EDUCATIONAL ACTIVITY AND SETTING: This was a single-center, parallel group, observational study. Doctor of pharmacy (PharmD) students in their third professional year completed a peer-led BLS training program (n = 148) and participated in a high-fidelity mannequin simulation activity 120 days later. Students were randomly assigned to rapid response teams (n = 24) of five to six members and the American Heart Association's standardized form for BLS assessment was used to assess BLS skills performance. The performance of skills was compared to that of students two years prior to the implementation of the peer-led BLS program. FINDINGS AND DISCUSSION: Students who received peer-led BLS training demonstrated retention of BLS skills 120 days after the BLS training program. The teams also displayed significant improvement of the skills evaluated when compared to student teams prior to implementation of the peer-led training (n = 22). Improvement was demonstrated for assessment of responsiveness (96% vs. 41%, p < 0.001), assessment for breathing (100% vs. 32%, p < 0.001), assessment for pulse (96% vs. 36%, p < 0.001), and administration of appropriate ventilation (100% vs. 32%, p < 0.001). Numerical superiority was exhibited for high-quality cardiopulmonary resuscitation (CPR) initiation by teams who received peer-led training (100% vs. 86%, p = 0.101). SUMMARY: Students who received peer-led BLS training demonstrated significant improvement in BLS skills performance and retention 120 days after the training program. Data suggests that peer-led BLS training can improve student BLS skills performance and retention.

Cardiotoxic effects of chemotherapy: A review of both cytotoxic and molecular targeted oncology therapies and their effect on the cardiovascular system.

Cardiotoxic effects of chemotherapy and targeted drugs are ubiquitous and challenging in the field of oncology therapeutics. The broad spectrum of toxicities ranging from ischemic, hypertensive, cardiomyopathic, and arrhythmic complications can present as a significant challenge for clinicians treating cancer patients. If early diagnosis and intervention of cardiotoxic complications is missed, this can lead to delay or abrogation of planned treatment, which can potentially culminate to significant morbidity due to not only the cardiotoxic complications but also the progression of cancer. Hence, full knowledge of cardiovascular complications of chemotherapeutic agents, essential diagnostics tests to order, and appropriate management is paramount to oncologist, oncology pharmacists, and scientific clinical investigators. The aforementioned is particularly true in the current oncology era of plenteous early clinical trials studying several pathway/molecular-targeting agents with an increased cardiotoxic potential and the rapid expedited approval of those drugs by the FDA. Herein, we present a review discussing cardiotoxic effects of drugs and guidelines for management of the toxicities to assist the medical field in general managing patients with cancer.

Intravenous Vancomycin Associated With the Development of Nephrotoxicity in Patients With Class III Obesity.

BACKGROUND: A consensus statement recommends initial intravenous (IV) vancomycin dosing of 15-20 mg/kg every 8- 24 hours, with an optional 25- to 30-mg/kg loading dose. Although some studies have shown an association between weight and the development of vancomycin-associated nephrotoxicity, results have been inconsistent. OBJECTIVE: To evaluate the correlation between incidence of nephrotoxicity associated with weight-based IV vancomycin dosing strategies in nonobese and obese patients. METHODS: This retrospective cohort study evaluated hospitalized adult patients admitted who received IV vancomycin. Patients were stratified into nonobese (body mass index [BMI] <25 kg/m2), obesity class I and II (BMI 30-39.9kg/m2), and obesity class III (BMI≥40 kg/m2) groups; patients who were overweight but not obese were excluded. Incidence of nephrotoxicity and serum vancomycin trough concentrations were evaluated. RESULTS: Of a total of 62 documented cases of nephrotoxicity (15.1%), 13 (8.7%), 23 (14.3%), and 26 (26.3%) cases were observed in nonobese, obesity class I and II, and obesity class III groups, respectively ( P=0.002). Longer durations of therapy ( P<0.0001), higher initial maintenance doses in both total milligrams/day ( P=0.0137) and milligrams/kilogram ( P=0.0307), and any trough level >20 mg/L ( P<0.0001) were identified as predictors of development of nephrotoxicity. Concomitant administration of piperacillin/tazobactam, diuretics, and IV contrast were associated with development of nephrotoxicity ( P<0.005, all). Patients with class III obesity were 3-times as likely to develop nephrotoxicity when compared with nonobese patients (odds ratio [OR]=2.99; CI=1.12-7.94) and obesity class I and II patients (OR=3.14; CI=1.27-7.75). CONCLUSIONS: Obesity and other factors are associated with a higher risk of vancomycin-associated nephrotoxicity.

Do Patients With a Baseline Clinical Condition Warranting the Cautious Use of Parenteral Nutrition Develop Subsequent Metabolic Complications?

BACKGROUND: The American Society for Parenteral and Enteral Nutrition Adult Nutrition Support Core Curriculum describes clinical conditions that warrant cautious use of parenteral nutrition (CCWCPN). The Core Curriculum authors acknowledge there is no evidence for specific criteria suggested for the clinical conditions. Consequently, the purpose of this study was to determine the impact of a baseline CCWCPN on the development of subsequent metabolic complications in patients receiving parenteral nutrition (PN). METHODS: Adult patients initiated on PN from May 2014 to July 2015 at Cooper University Hospital were included in this retrospective study. The impact of a CCWCPN on the development of the following was determined: acid-base disturbances, hepatobiliary complications, hypercapnia, hyperchloremia, hyperglycemia, hypernatremia, hypertriglyceridemia, hypochloremia, hypoglycemia, hypokalemia, hypophosphatemia, and refeeding syndrome. RESULTS: Three hundred forty-one patients were included (mean age, 61.7 years; mean duration of PN, 8.5 days; central PN, 97%). Metabolic complications occurred more frequently in patients with a baseline CCWCPN than without these conditions (77% vs 53%, P = .001). Subgroup analyses for the development of metabolic complications in patients with or without each individual baseline CCWCPN yielded the following statistically significant results: hypernatremia (93% vs 57%, P = .007) and hyperchloremia (86% vs 57%, P = .033). CONCLUSIONS: Hospitalized adult patients with a baseline CCWCPN were more likely to develop a metabolic complication when receiving PN. Baseline hypernatremia and hyperchloremia were associated with the development of metabolic complications. Baseline CCWCPN should be recognized upon initiation of PN; practitioners should closely monitor patients to minimize subsequent metabolic complications.

Evaluation of safety and effectiveness of standardized antifactor Xa-based unfractionated heparin protocols in obese versus non-obese patients.

Recent data have suggested that standard unfractionated heparin (UFH) protocols may over-anticoagulate obese patients. The goal of this retrospective study was to observe differences in anticoagulation parameters and safety outcomes for standardized antifactor Xa UFH protocols in obese and non-obese populations. Obese patients (N = 148) were identified over a 20-month period and matched to 148 non-obese patients based on age, gender, and admission date. Patients were included if they were on one of three approved UFH protocols [high (target antifactor Xa 0.3-0.7 IU/mL), moderate (0.3-0.5 IU/mL), or low (0.1-0.2 IU/mL) dose] for ≥24 consecutive hours and had ≥1 antifactor Xa level drawn during the infusion. Groups were compared for doses at first and second consecutive therapeutic antifactor Xa level, major bleeding, and in-hospital mortality. Obese patients required a significantly lower mean weight-based infusion rate to attain first therapeutic antifactor Xa level compared to non-obese patients in both the high dose (19.45 vs. 15.29 units/kg/h, p < 0.001) and the moderate dose populations (15.0 vs. 12.94 units/kg/h, p = 0.003). Similarly, patients in both the high and moderate dose populations had significant differences in mean infusion rates to attain second consecutive therapeutic antifactor Xa levels. There was no difference between infusion rates for the primary outcomes in the low dose population. There was no difference between groups in major bleeding or mortality outcomes. Similar to data using UFH protocols based on activated partial thromboplastin time, obese patients require lower weight-based UFH doses to attain therapeutic anticoagulation. Institutions using or changing to antifactor Xa based protocols may need to modify protocols for obese patients.

Extended-Duration Venous Thromboembolism Prophylaxis in Hospitalized Acutely Ill Medical Patients: A Review of the Evidence.

Objective: To evaluate the risks and benefits of extended-duration thromboprophylaxis (EDT) beyond hospitalization in acutely ill medical patients. Data Sources: PubMed was searched from inception (1946) through February 2015 for the search terms venous thrombosis/prevention and control, venous thromboembolism/prevention and control, anticoagulants, and aspirin. Study Selection and Data Extraction: Relevant clinical trials evaluating pharmacologic strategies for EDT were screened for inclusion. Bibliographies of articles were extensively reviewed for additional sources. Data Synthesis: Three studies, and one additional subgroup analysis, were identified for inclusion. Enoxaparin and rivaroxaban demonstrated a significant reduction in venous thromboembolism (VTE) with EDT, but the benefit with enoxaparin was limited to the highest risk groups and women. The improved efficacy in both studies was accompanied by a ~2.5-fold increase in risk of major hemorrhage. Apixaban was unable to demonstrate a reduction of VTE and was also associated with a significant increase in bleeding. Conclusions: EDT should not be routinely provided to all medically ill patients. It may be considered in patients at the highest risk for VTE, but careful consideration must be used due to the increased risk of bleeding.

Assessment of bleeding events associated with short-duration therapeutic enoxaparin use in the morbidly obese.

BACKGROUND: Enoxaparin dosing for patients with morbid obesity is uncertain, and therefore, an elevated incidence of bleeding may exist in this group. OBJECTIVE: To determine if increased bleeding events occur in patients with morbid obesity (body mass index ≥ 40 kg/m(2)) compared with lower-weight patients with treatment doses of enoxaparin. METHODS: Patients at a single, academic medical center receiving enoxaparin for at least 24 hours from July to December 2009 were retrospectively evaluated. Patients with morbid obesity were randomly selected among the total cohort and were matched with lower-weight controls (1:2 ratio) based on the presence of renal dysfunction (serum creatinine >1.4 mg/dL). Bleeding events, defined on the basis of laboratory changes, administration of blood products, or clinical data, occurring up to 24 hours after enoxaparin administration were evaluated. Independent risk factors for bleeding were assessed via multivariate analysis. RESULTS: The maximum single dose administered throughout the study was 150 mg, and the largest patient enrolled weighed 175 kg. Final enoxaparin doses in morbidly obese (0.98 mg/kg) patients were lower compared with that in controls (1.04 mg/kg, P < .01). The proportion of patients with bleeding events was 29% in the morbidly obese and 23.5% in the control group (P = .30). Enoxaparin doses <0.9 mg/kg (adjusted odds ratio [AOR] = 2.35; 95% CI = 1.01-5.47; P = .04), durations of therapy beyond 48 hours (AOR = 2.42; 95% CI = 1.35-4.33; P < .01), and female gender (AOR = 2.05; 95% CI = 1.12-3.73; P = .02) were associated with bleeding, whereas warfarin use (AOR = 0.46; 95% CI = 0.26-0.81; P < .01) was associated with fewer bleeding events. CONCLUSIONS: Results suggest that dosing enoxaparin in morbidly obese patients (up to 175 kg in weight) with doses capped at 150 mg was not associated with increased bleeding incidence.

Prolonged infusion antibiotics for suspected gram-negative infections in the ICU: a before-after study.

BACKGROUND: ß-Lactam antibiotics demonstrate time-dependent killing. Prolonged infusion of these agents is commonly performed to optimize the time the unbound concentration of an antibiotic remains greater than the minimum inhibitory concentration and decrease costs, despite limited evidence suggesting improved clinical results. OBJECTIVE: To determine whether prolonged infusion of ß-lactam antibiotics improves outcomes in critically ill patients with suspected gram-negative infection. METHODS: We conducted a single-center, before-after, comparative effectiveness trial between January 2010 and January 2011 in the intensive care units at Barnes-Jewish Hospital, an urban teaching hospital affiliated with the Washington University School of Medicine in St. Louis, MO. Outcomes were compared between patients who received standardized dosing of meropenem, piperacillin-tazobactam, or cefepime as an intermittent infusion over 30 minutes (January 1, 2010, to June 30, 2010) and patients who received prolonged infusion over 3 hours (August 1, 2010, to January 31, 2011). RESULTS: A total of 503 patients (intermittent infusion, n = 242; prolonged infusion, n = 261) treated for gram-negative infection were included in the clinically evaluable population. Approximately 50% of patients in each group received cefepime and 20% received piperacillin-tazobactam. More patients in the intermittent infusion group received meropenem (35.5% vs 24.5%; p = 0.007). Baseline characteristics were similar between groups, with the exception of a greater occurrence of chronic obstructive pulmonary disease (COPD) in the intermittent infusion group. Treatment success rates in the clinically evaluable group were 56.6% for intermittent infusion and 51.0% for prolonged infusion (p = 0.204), and in the microbiologically evaluable population, 55.2% for intermittent infusion and 49.5% for prolonged infusion (p = 0.486). Fourteen-day, 30-day, and inhospital mortality rates in the clinically evaluable population for the intermittent and prolonged infusion groups were 13.2% versus 18.0% (p = 0.141), 23.6% versus 25.7% (p = 0.582), and 19.4% versus 23.0% (p = 0.329). CONCLUSIONS: Routine use of prolonged infusion of time-dependent antibiotics for the empiric treatment of gram-negative bacterial infections offers no advantage over intermittent infusion antibiotic therapy with regard to treatment success, mortality, or hospital length of stay. These results were confirmed after controlling for potential confounders in a multivariate analysis.

Role of new drugs for management of atrial fibrillation.

OBJECTIVE: To evaluate the role of newer agents in the management of atrial fibrillation (AF). DATA SOURCES: EMBASE and MEDLINE were searched (up to June 2012) combining medication names with atrial fibrillation, humans, clinical trials, and pharmacoeconomic. References of the articles identified and www.clinicaltrials.gov were also reviewed. STUDY SELECTION AND DATA EXTRACTION: Studies were limited to the English language with clinical or pharmacoeconomic end points followed by the consensus of 3 authors. DATA SYNTHESIS: Formulated to reduce some of the adverse effects associated with amiodarone by removing the iodine component, dronedarone has improved clinical outcomes over placebo when used in paroxysmal or persistent AF; however, it is less efficacious than amiodarone. Worse outcomes with dronedarone have been seen in patients with heart failure or permanent AF. It has not been compared to antiarrhythmic agents other than amiodarone, and pharmacoeconomic evaluations are lacking. Dabigatran 150 mg is superior to warfarin in preventing stroke or systemic embolism and has been associated with lower rates of vascular-associated mortality. Although the rates of major bleeding were not significantly different between the 2 agents, gastrointestinal bleeding and myocardial infarction occurred more frequently with dabigatran. Dabigatran appears to have the most pharmacoeconomic benefit over warfarin in patients with a higher risk of stroke. Rivaroxaban is noninferior to warfarin for the prevention of stroke and systemic embolism, with no difference in the rates of major bleeding. Cost-effectiveness studies have not been performed with this agent at this time. In patients with AF who were not suitable candidates for warfarin, apixaban is superior to aspirin in preventing stroke or systemic embolism without increasing the risk for major bleeding. Additionally, apixaban is superior to warfarin in preventing stroke or systemic embolism, results in fewer bleeding events, and is associated with lower mortality. Apixaban is not cost-effective against aspirin when used for a short duration but gains superiority with prolonged use or in patients with higher risks of stroke. Additionally, apixaban appears to offer a pharmacoeconomic advantage over warfarin at no to minimal cost. Each new anticoagulant lacks a reversal agent and an assay to detect the presence of the anticoagulant, as well as long-term data when used in the clinical setting. CONCLUSIONS: Use of dronedarone should be limited to patients with paroxysmal or persistent AF and should not be used in patients with heart failure or with permanent AF. Newer antithrombotic agents appear to be promising alternatives for the prevention of stroke in patients with AF; however, more data are needed to understand their role.