Anti-Xa Directed Thromboprophylaxis in Critically Ill Patients with Coronavirus Disease 2019.

Objective: To compare Anti-Xa directed thromboprophylaxis using low molecular weight heparin (LMWH) (anti-Xa peak goal 0.2-0.5 IU/mL) to alternative anticoagulation strategies in critically ill COVID-19 patients. Methods: This was a retrospective, multicenter, single health-system study. Primary outcomes were thromboembolic events and clinically important bleeding events. Secondary outcomes included dosing comparisons between LMWH cohorts. Main Results: A total of 695 patients were included. No differences were found in the incidence of thrombotic events with any of the dosing strategies. The incidence of major bleeding was significantly higher in the standard dose thromboprophylaxis, intermediate dose subcutaneous heparin (SQH), and therapeutic anticoagulation cohorts. Forty-nine percent of patients within the anti-Xa directed group had their first anti-Xa peak at goal, while 43% were above goal. Patients who had levels above goal had dose modifications made, therefore anti-Xa directed LMWH resulted in significantly lower total daily doses compared to intermediate dose LMWH. Conclusions: Anti-Xa directed LMWH dosing provided comparable thromboprophylaxis with lower total daily doses of LMWH in critically ill COVID-19 patients. Further randomized controlled trials are needed to confirm our findings.

Ceftriaxone versus cefazolin for the treatment of methicillin-susceptible Staphylococcus aureus bacteraemia.

Few studies have evaluated the use of ceftriaxone (CRO) in the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) infections. The purpose of this study was to compare the safety and efficacy of CRO versus cefazolin (CZO) for patients with MSSA bacteraemia. This was a multicentre, single health-system, retrospective study. Adult inpatients were included if they had a primary episode of MSSA bacteraemia and received CRO or CZO as definitive therapy. The primary endpoint was clinical cure at 28 days or at discharge, whichever came first. Secondary endpoints included treatment failure at 90 days, time to treatment failure, re-admission due to recurrent MSSA bacteraemia, duration of bacteraemia, discontinuation of treatment due to adverse drug events, and Clostridioides difficile infection. A total of 248 patients were included, of which 87 (35.1%) received CRO and 161 (64.9%) received CZO. There was no difference in the primary outcome of clinical cure at 28 days or at discharge between the CRO and CZO groups [75 (86.2%) vs. 145 (90.1%); P = 0.359], even after adjusting for Charlson comorbidity index and Pitt bacteremia score (adjusted OR = 1.35, 95% CI 0.58-3.12; P = 0.49). There were no differences in time to clinical cure, treatment failure at 90 days or safety events between the two groups. In conclusion, our findings suggest no clinical difference between CRO and CZO for the definitive treatment of MSSA bacteraemia. Further prospective studies are needed to confirm these findings.

Evaluation of Early Administration of Insulin Glargine in the Acute Management of Diabetic Ketoacidosis.

BACKGROUND: Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution. OBJECTIVES: To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients. METHODS: This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed. RESULTS: Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76-37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8-36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04-7.92; p<0.0001). CONCLUSION: Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion.