MRSA nasal swab PCR to de-escalate antibiotics in the emergency department.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) nasal swab polymerase chain reaction (PCR) assay has a 96.1-99.2% negative predictive value (NPV) in pneumonia and may be used for early de-escalation of MRSA-active antibiotic agents. Xu (2018), File (2010) [1,2]. OBJECTIVE: The objective of our study was to determine if a negative MRSA PCR nasal swab collected in the emergency department (ED) improves early MRSA-active antibiotic de-escalation. METHODS: A single center observational cohort study used ICD-10 codes to identify records for adults admitted to the ED with a hospital discharge diagnosis of pneumonia. The primary outcome was proportion of patients with early de-escalation on an MRSA-active agent (≤ 1 dose). Secondary outcomes included rate of acute kidney injury (AKI), positive MRSA cultures (blood culture, respiratory sputum, tracheal aspirate), hospital length of stay (LOS), in-hospital mortality, and 30-day readmission rates. RESULTS: A total of 341 patients were included in the study. Of the patients with an MRSA PCR swab, 35.2% of patients with a negative swab received >1 dose of MRSA-active agent compared to 52% of patients without an MRSA nasal swab (p < 0.01). There were no significant differences in secondary outcomes except readmission rate of 1.6% of patients that did not have an MRSA swab in the ED vs 6.6% of patients that received an MRSA swab in the ED. CONCLUSION AND RELEVANCE: MRSA PCR nasal swabs in the ED may serve as a useful tool for early MRSA-active antibiotic de-escalation when treating pneumonia.

Utilization of anti-factor Xa levels to guide reversal of oral factor Xa inhibitors in the emergency department.

PURPOSE: Oral factor Xa inhibitors (FXaIs) are increasingly utilized for outpatient anticoagulation therapy; however, laboratory monitoring is not routinely used to assess the safety and efficacy of these agents. We aimed to evaluate the role of chromogenic anti-factor Xa (anti-Xa) assays in the emergency department (ED) in the setting of patients with an acute bleed or requiring emergent procedures. METHODS: A retrospective review of anti-Xa levels obtained in the ED between June 1, 2019, and April 30, 2020, was completed. Data were collected to describe the clinical setting of anti-Xa level collection, oral FXaIs used before admission, administration of reversal agents, and patient disposition to further characterize the role of anti-Xa levels in the management of rivaroxaban and apixaban reversal. RESULTS: Thirty anti-Xa levels were included in the final analysis. The median time from sample collection to anti-Xa assay result was 45.9 minutes (interquartile range, 35.3-54.7 minutes). Eleven patients (37%) received anticoagulation reversal after their anti-Xa levels were determined. Anticoagulation reversal agents included either activated prothrombin complex concentrates (aPCCs) or prothrombin complex concentrates (PCCs). Anti-Xa levels were collected in 2 patients who had received PCCs before arrival at our ED. Of the patients with anti-Xa levels below 30 ng/mL, none received aPCCs or PCCs after their anti-Xa levels were determined. Anti-Xa assays were used to rule out the presence of FXaIs in 3 patients. CONCLUSION: This study illustrates the novel role of anti-Xa levels in managing patients with an emergent need for reversal in the ED. The assay may be used to rule out the presence of oral FXaIs and avoid unnecessary administrations of anticoagulation reversal agents.