A practical guide to real-world implementation of pre-emptive therapy for Cytomegalovirus disease prevention in high-risk seronegative liver transplant recipients with seropositive donors.

The Comparison of Antiviral Preventative Strategies In Liver Transplant (CAPSIL) study showed pre-emptive therapy (PET) to be superior to antiviral prophylaxis for Cytomegalovirus (CMV) disease prevention in high-risk CMV seronegative liver transplant recipients (LTRs) with seropositive donors (D+R-). Despite the statistical superiority of PET over prophylaxis in research settings, PET is perceived as a logistically more complex strategy that requires careful coordination of weekly CMV PCR testing, prompt initiation of CMV antivirals upon viremia detection, and timely cessation of antivirals following viremia resolution. Transplant centers may be hesitant to use PET for CMV disease prevention in D+R- LTRs out of concern that PET coordination is not feasible in clinical practice. We recently described our experience using PET in CMV D+R- LTRs in a real-world setting, and found it to be as effective for CMV disease prevention as PET performed as part of a clinical trial. Here, we describe a systematic approach for PET implementation in real-world settings and provide practical tools to address anticipated challenges. This framework can support transplant programs in overcoming logistical barriers to PET and incorporating an evidence-based and cost-effective CMV prevention strategy into routine care for high-risk CMV D+R- LTRs.

Therapeutic Myths in Solid Organ Transplantation Infectious Diseases.

Infection management in solid organ transplantation poses unique challenges, with a diverse array of potential pathogens and associated antimicrobial therapies. With limited high-quality randomized clinical trials to direct optimal care, therapeutic "myths" may propagate and contribute to suboptimal or excessive antimicrobial use. We discuss 6 therapeutic myths with particular relevance to solid organ transplantation and provide recommendations for infectious diseases clinicians involved in the care of this high-risk population.

Prescriber Compliance with a New Computerized Insulin Guideline for Noncritically Ill Adults.

BACKGROUND: In March 2008, the University of California, Davis Medical Center (UCDMC), implemented a guideline for the inpatient management of diabetes in noncritically ill adults. In accordance with national guidelines, all patients with type 2 diabetes are prescribed basal, nutritional, and correctional insulin. The guideline was added to the electronic medical record as a standardized physician order set in April 2008 and provider training on the insulin guideline occurred in May 2008. OBJECTIVE: To evaluate provider compliance with a new electronic standardized insulin order set in a hospital setting. METHODS: All patients with insulin orders admitted to the general internal medicine service between June 1, 2008, and November 1, 2008, were evaluated in this single-center retrospective chart review at UCDMC in Sacramento. Patients older than 18 years with a history of type 2 diabetes were included in the analysis. Insulin orders were categorized as preferred (followed the guideline) or nonpreferred regimens (did not follow all components of the guideline). RESULTS: A total of 265 patients were identified during the study period. The preferred regimen was ordered in 82 (30.9%) of the evaluated patient admissions. Of the 183 (69.1%) nonpreferred regimens, more than half (54.6%) contained correctional insulin alone; 84.2% of patient admissions prescribed nonpreferred regimens lacked nutritional insulin. Average admission blood glucose readings were higher in the preferred versus nonpreferred regimen group (224.4 vs 164.8 mg/dL, p < 0.001). CONCLUSIONS: The preferred regimen was not prescribed for the majority of patients admitted with a history of type 2 diabetes, despite computerized decision support. Nutritional insulin was the most common missing component in the nonpreferred regimens. Baseline clinical factors, educational modalities, and guideline content may have influenced prescribing patterns.

Relationships between vancomycin minimum inhibitory concentration, dosing strategies, and outcomes in methicillin-resistant Staphylococcus aureus bacteremia.

Retrospective study aimed to examine outcomes of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in relationship to vancomycin minimum inhibitory concentration (VAN MIC) and serum trough concentrations among subjects who had ≥1 blood culture positive for MRSA between April 2008 and August 2009. Treatment failure occurred in 7/24 (29%) subjects with VAN MIC = 2 mg/L versus 20/94 (21%) subjects with VAN MIC ≤1.5 mg/L (adjusted OR 1.11, 95% confidence interval [CI] 0.24-5.14). Among subjects who had documented VAN serum trough concentrations, treatment failure occurred in 5/26 (19%) subjects with concentrations <15 mg/L versus 18/68 (27%) subjects with concentrations ≥15 mg/L (adjusted OR 0.91, 95% CI 0.21-3.84). In conclusion, treatment outcomes were similar regardless of VAN MIC, although there was a non-statistically significant trend towards decreased clinical efficacy among patients with VAN MIC = 2 mg/L. Optimization of VAN pharmacokinetic indices did not appear to correlate with clinical responses.