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Artigo em Inglês | MEDLINE | ID: mdl-34097227


In major/life-threatening bleeding, administration of timely and appropriate reversal agents is imperative to reduce morbidity and mortality. Due to complexities associated with the use of reversal agents, a clinical pharmacist-driven anticoagulation reversal program (ARP) was developed. The goal of this program was to ensure appropriateness of reversal agents based on the clinical scenario, optimize selection and avoid unintended consequences. This study describes the impact of a pharmacist-driven anticoagulation program on patient outcomes and cost. A single center retrospective chart review of adult patients whom the ARP was consulted from October 2018 to January 2020 was performed. Patients were included in the efficacy analysis if they were > 18 years of age and presented with acute bleeding. Patients were excluded from the efficacy analysis if the recommended reversal agent was not administered, if a repeat head CT was not available for patients who presented with intracranial hemorrhage (ICH), or if the patient was not bleeding. All patients were included in the economic evaluation. The primary outcome was the percentage of patients who achieved effective hemostasis within 24 h of anticoagulation reversal. Secondary outcomes include incidence of thromboembolic events, in-hospital mortality, and cost avoidance. One hundred twenty-one patients were evaluated by the ARP with 92 patients included in the efficacy analysis. The primary sites of bleeding were ICH in 46% and gastrointestinal (GI) in 29%. Hemostasis was achieved in 84% of patients. Thrombotic events occurred in 7.4% of patients and in-hospital mortality was 26.4%. Total cost avoidance was $1,005,871.78. To our knowledge, this is the first study to evaluate the impact of a pharmacist-driven ARP on clinical and economic outcomes. Implementation of a pharmacist-driven ARP was associated with favorable outcomes and cost savings.

Crit Care Med ; 47(8): 1018-1025, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31107278


OBJECTIVES: Most septic patients are initially encountered in the emergency department where sepsis recognition is often delayed, in part due to the lack of effective biomarkers. This study evaluated the diagnostic accuracy of peripheral blood monocyte distribution width alone and in combination with WBC count for early sepsis detection in the emergency department. DESIGN: An Institutional Review Board approved, blinded, observational, prospective cohort study conducted between April 2017 and January 2018. SETTING: Subjects were enrolled from emergency departments at three U.S. academic centers. PATIENTS: Adult patients, 18-89 years, with complete blood count performed upon presentation to the emergency department, and who remained hospitalized for at least 12 hours. A total of 2,212 patients were screened, of whom 2,158 subjects were enrolled and categorized per Sepsis-2 criteria, such as controls (n = 1,088), systemic inflammatory response syndrome (n = 441), infection (n = 244), and sepsis (n = 385), and Sepsis-3 criteria, such as control (n = 1,529), infection (n = 386), and sepsis (n = 243). INTERVENTIONS: The primary outcome determined whether an monocyte distribution width of greater than 20.0 U, alone or in combination with WBC, improves early sepsis detection by Sepsis-2 criteria. Secondary endpoints determined monocyte distribution width performance for Sepsis-3 detection. MEASUREMENTS AND MAIN RESULTS: Monocyte distribution width greater than 20.0 U distinguished sepsis from all other conditions based on either Sepsis-2 criteria (area under the curve, 0.79; 95% CI, 0.76-0.82) or Sepsis-3 criteria (area under the curve, 0.73; 95% CI, 0.69-0.76). The negative predictive values for monocyte distribution width less than or equal to 20 U for Sepsis-2 and Sepsis-3 were 93% and 94%, respectively. Monocyte distribution width greater than 20.0 U combined with an abnormal WBC further improved Sepsis-2 detection (area under the curve, 0.85; 95% CI, 0.83-0.88) and as reflected by likelihood ratio and added value analyses. Normal WBC and monocyte distribution width inferred a six-fold lower sepsis probability. CONCLUSIONS: An monocyte distribution width value of greater than 20.0 U is effective for sepsis detection, based on either Sepsis-2 criteria or Sepsis-3 criteria, during the initial emergency department encounter. In tandem with WBC, monocyte distribution width is further predicted to enhance medical decision making during early sepsis management in the emergency department.

Serviço Hospitalar de Emergência , Monócitos/metabolismo , Sepse/metabolismo , Choque Séptico/metabolismo , Adulto , Idoso , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Humanos , Contagem de Linfócitos/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sepse/diagnóstico , Choque Séptico/diagnóstico , Adulto Jovem
Chest ; 152(3): 518-526, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28625579


BACKGROUND: Sepsis most often presents to the ED, and delayed detection is harmful. WBC count is often used to detect sepsis, but changes in WBC count size also correspond to sepsis. We sought to determine if volume increases of circulating immune cells add value to the WBC count for early sepsis detection in the ED. METHODS: A blinded, prospective cohort study was conducted in two different ED populations within a large academic hospital. RESULTS: Neutrophil and monocyte volume parameters were measured in conjunction with routine CBC testing on a UniCel DxH 800 analyzer at the time of ED admission and were evaluated for the detection of sepsis. There were 1,320 subjects in the ED consecutively enrolled and categorized as control subjects (n = 879) and those with systemic inflammatory response syndrome (SIRS) (n = 203), infection (n = 140), or sepsis (n = 98). Compared with other parameters, monocyte distribution width (MDW) best discriminated sepsis from all other conditions (area under the curve [AUC], 0.79; 95% CI, 0.73-0.84; sensitivity, 0.77; specificity, 0.73; MDW threshold, 20.50), sepsis from SIRS (AUC, 0.74; 95% CI, 0.67-0.84), and severe sepsis from noninfected patients in the ED (AUC, 0.88; 95% CI, 0.75-0.99; negative predictive value, 99%). The added value of MDW to WBC count was statistically significant (AUC, 0.89 for MDW + WBC vs 0.81 for WBC alone; P < .01); a decision curve analysis also showed improved performance compared with WBC count alone. CONCLUSIONS: The incorporation of MDW with WBC count is shown in this prospective cohort study to improve detection of sepsis compared with WBC count alone at the time of admission in the ED. TRIAL REGISTRY:; No.: NCT02232750; URL:

Serviço Hospitalar de Emergência , Monócitos , Sepse/sangue , Sepse/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Tamanho Celular , Estudos de Coortes , Diagnóstico Precoce , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC
Ann Pharmacother ; 51(7): 577-583, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28622739


BACKGROUND: Stress ulcer prophylaxis (SUP) is inappropriately prescribed in more than 30% of non-intensive care unit (ICU) patients, leading to unnecessary adverse events as well as increases in economic burden. OBJECTIVE: There was an increasing trend in the prophylactic use of acid suppressive therapy (AST) in non-critically ill patients at our institution, which prompted this initiative aimed at reducing the inappropriate use of AST in non-ICU patients. METHODS: This was a retrospective interventional study that consisted of formulation of a guideline, education to the hospitalist service, and intervention by clinical pharmacists. All adult non-ICU patients admitted to the hospitalist service who were newly initiated on AST were considered for inclusion. The primary outcome was a comparison of the proportion of inpatient days with inappropriate AST. Secondary outcomes included a comparison of patients discharged on inappropriate AST and drug acquisition costs, successful pharmacy interventions, hospitalist interventions, incidence of Clostridium difficile infection (CDI) or gastrointestinal (GI) bleeding, and drug costs averted through pharmacy intervention. RESULTS: There were 61 patients in the historical group and 81 patients in the interventional group. This intervention resulted in a 31% absolute reduction in inappropriate patient days of AST and a 24% absolute reduction in patients discharged on inappropriate AST. There were 23 successful interventions. There were no cases of CDI and 1 GI bleed. This intervention resulted in an 87% reduction in drug acquisition costs per patient. CONCLUSIONS: A collaboration between clinical pharmacists and a hospitalist service can significantly reduce the inappropriate use of AST in non-ICU patients.

Antiulcerosos/uso terapêutico , Hemorragia Gastrointestinal/epidemiologia , Úlcera Péptica/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Infecções por Clostridium/epidemiologia , Custos de Medicamentos , Feminino , Hospitalização , Humanos , Prescrição Inadequada/efeitos adversos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Farmacêuticos/organização & administração , Estudos Retrospectivos , Estresse Psicológico/complicações
J Antimicrob Chemother ; 66(9): 2112-8, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21697178


BACKGROUND: The MIC corresponding to daptomycin susceptibility for vancomycin-resistant enterococci (VRE) is ≤ 4 mg/L. Based on the concentration-dependent killing properties of daptomycin, there may be concern about achieving adequate concentrations when the MIC approaches the upper end of the susceptible range (3-4 mg/L). Higher doses of daptomycin may be needed to treat VRE isolates with higher MICs. METHODS: We conducted a single-centre retrospective chart review of adult cases with VRE bacteraemia who received daptomycin as initial therapy. The primary outcome was time to microbiological cure (TMC) between standard doses (≤ 6 mg/kg) and high doses (> 6 mg/kg) of daptomycin and whether TMC differed based on MICs. The secondary outcome evaluated the daptomycin MIC distribution and assessed whether recent exposure to vancomycin was associated with higher daptomycin MICs. RESULTS: Forty-six cases were included in the primary analysis and 60.9% of patients were neutropenic. The two dose groups differed in the baseline characteristics of age, body mass index, blood culture source and catheter removal. Median TMC was 2 days for both dose groups. There was no significant difference in TMC between MIC subgroups of ≤ 2 mg/L versus >2 and ≤ 4 mg/L. For the secondary analysis 227 VRE isolates were evaluated and 62% had daptomycin MICs of 3-4 mg/L. Each daptomycin MIC group had a similar incidence of prior vancomycin exposure. CONCLUSIONS: Based on this retrospective review we did not observe a difference in TMC based on daptomycin dose and MIC; however, there were various limitations to this study, and the study was not powered to detect a difference in TMC. Also, prior vancomycin exposure did not appear to influence daptomycin MICs. The frequency of daptomycin MICs of 3-4 mg/L reported in this study is higher than those reported in the literature.

Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Daptomicina/administração & dosagem , Daptomicina/uso terapêutico , Enterococcus/efeitos dos fármacos , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Resistência a Vancomicina , Idoso , Bacteriemia/microbiologia , Relação Dose-Resposta a Droga , Enterococcus faecalis/efeitos dos fármacos , Feminino , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Neutropenia/complicações , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento , Vancomicina/uso terapêutico