Longitudinal well-being measurements in doctor of pharmacy students following a college-specific intervention.

BACKGROUND AND PURPOSE: Supporting clinician mental health and well-being must start in the learning environment, especially as health profession students have been shown to have higher rates of mental illness than their peers pursuing other careers. This project aimed to support positive mental health in pharmacy students through small changes that faculty implemented both inside and outside of the classroom. EDUCATIONAL ACTIVITY AND SETTING: In partnership with the Counseling and Mental Health Center, faculty received training, resources, and (in some cases) classroom observation and feedback on how to incorporate small changes that support student well-being. Assessments were performed each semester beginning in spring 2018 and ending in spring 2020. These included the Mental Health Continuum - Short Form (measuring positive mental health and well-being), the Theories of Intelligence Scale - Self Form for Adults (measuring growth mindset), the Sense of Belonging Scale (measuring five domains of social connectedness), and the Brief Resilience Scale (measuring resilience). Participating faculty were surveyed regarding how frequently selected activities were incorporated into their practice and how comfortable they felt supporting student mental health. FINDINGS: Positive trends were seen throughout the project on the scales assessing growth mindset and sense of belonging. SUMMARY: Supporting positive mental health in pharmacy students in the learning environment is important for both students and the quality and safety of the health care system. Future efforts should expand on this work by refining the measurements used, identifying more interventions, and evaluating the impact these efforts have as students become pharmacists.

A possible association between statin use and improved Clostridioides difficile infection mortality in veterans.

Clostridioides difficile infection (CDI) is the most common cause of nosocomial diarrhea and places a significant burden on patients and the health care system. Statins could lead to improvements in CDI clinical response due their pleiotropic effects, including immunomodulatory and lipid-lowering effects; however, few studies have assessed this association. The primary objective of this study was to compare CDI health outcomes in statin users and non-users in a national cohort of patients. This was a retrospective cohort study of all adult CDI patients receiving care from the Veterans Health Administration from 2002 to 2014. Patients were divided into two groups based on statin exposure 90 days prior to and during their first CDI encounter. CDI health outcomes, including mortality and CDI recurrence, were compared using a propensity-score matched cohort of statin users and non-users and multivariable logistic regression. A total of 26,149 patients met study inclusion criteria, of which 173 statins-users and 173 non-users were propensity score matched. Thirty-day mortality was significantly lower among statins users with CDI (12.7%) compared to non-users (20.2%) (aOR 0.34; 95% CI 0.16-0.72). Sixty-day CDI recurrence was non-significantly lower among statin-users (9.0%) compared to non-users (16.6%) (aOR 0.68; 95% CI 0.29-1.59). In this nationally-representative study of veterans with CDI, statin use was associated with lower 30-day mortality compared to non-use. Statin use was not associated with 60-day CDI recurrence.

Epidemiology of Methicillin-Resistant Staphylococcus aureus Diabetic Foot Infections in a Large Academic Hospital: Implications for Antimicrobial Stewardship.

INTRODUCTION: Diabetic foot infections (DFIs) are the leading cause of non-traumatic lower extremity amputations in the United States. Antimicrobials active against methicillin-resistant Staphylococcus aureus (MRSA) are recommended in patients with associated risk factors; however, limited data exist to support these recommendations. Due to the changing epidemiology of MRSA, and the consequences of unnecessary antibiotic therapy, guidance regarding the necessity of empirical MRSA coverage in DFIs is needed. We sought to 1) describe the prevalence of MRSA DFIs at our institution and compare to the proportion of patients who receive MRSA antibiotic coverage and 2) identify risk factors for MRSA DFI. METHODS: This was a retrospective cohort study of all adult, culture-positive DFI patients managed at University Hospital, San Antonio, TX between January 1, 2010 and September 1, 2014. Patient eligibility included a principal ICD-9-CM discharge diagnosis code for foot infection and a secondary diagnosis of diabetes. The primary outcome was MRSA identified in the wound culture. Independent variables assessed included patient demographics, comorbidities, prior hospitalization, DFI therapies, prior antibiotics, prior MRSA infection, and laboratory values. Multivariable logistic regression was used to identify risk factors for MRSA DFI. RESULTS: Overall, 318 patients met inclusion criteria. Patients were predominantly Hispanic (79%) and male (69%). Common comorbidities included hypertension (76%), dyslipidemia (52%), and obesity (49%). S. aureus was present in 46% of culture-positive DFIs (MRSA, 15%). A total of 273 patients (86%) received MRSA antibiotic coverage, resulting in 71% unnecessary use. Male gender (OR 3.09, 95% CI 1.37-7.99) and bone involvement (OR 1.93, 1.00-3.78) were found to be independent risk factors for MRSA DFI. CONCLUSIONS: Although MRSA was the causative pathogen in a small number of DFI, antibiotic coverage targeted against MRSA was unnecessarily high.

Monotherapy with minocycline or trimethoprim/sulfamethoxazole for treatment of Stenotrophomonas maltophilia infections.

OBJECTIVES: Stenotrophomonas maltophilia is a Gram-negative bacillus intermittently isolated from hospitalized patients. Trimethoprim/sulfamethoxazole is considered the treatment of choice for S. maltophilia infections, though limited by toxicities. Minocycline is utilized at our institution for S. maltophilia infections due to its improved tolerability and in vitro susceptibility rates. Our objective was to evaluate the effectiveness of minocycline monotherapy compared with trimethoprim/sulfamethoxazole monotherapy for treatment of S. maltophilia infections. METHODS: Patients were identified via microbiology laboratory data and those with at least one positive culture for S. maltophilia were cross-referenced with pharmacy data to detect patients who received trimethoprim/sulfamethoxazole or minocycline. Patients initially receiving combination therapy were excluded. Our primary outcome was treatment failure, defined as receipt of alternative antibiotics with in vitro activity against S. maltophilia, isolation of S. maltophilia on repeat culture or death within 30 days of treatment. RESULTS: Forty-five patients were evaluated. Overall mortality rate was 9% and equal between groups; 41% of patients (9/22) who received trimethoprim/sulfamethoxazole and 30% (7/23) of patients who received minocycline experienced treatment failure (P = 0.67). Patients who received minocycline were more likely to have had a recent acute kidney injury (AKI) (43.5% versus 9%; P = 0.017) or chronic lung disease (52% versus 9%; P = 0.003). Logistic regression showed consistent results of non-inferiority of the primary outcome when controlling for rates of underlying lung pathology and recent AKI (P = 0.728). CONCLUSIONS: Treatment failure did not differ between patients receiving trimethoprim/sulfamethoxazole or minocycline monotherapy for treatment of S. maltophilia infections.

Synthetic cannabinoid hyperemesis resulting in rhabdomyolysis and acute renal failure.

Synthetic cannabinoid usage has increased in the past decade. Concurrently, emergency management of associated adverse effects due to synthetic cannabinoid usage has also risen. Reported toxicities include psychosis, seizures, cardiotoxicity, acute kidney injury, and death. While cannabis was first described as a cause of acute hyperemesis in 2004, a more recent case series also describes the association between cannabinoid hyperemesis and risk of acute renal failure. Synthetic cannabinoids have also been reported to cause acute hyperemesis and acute renal failure; however, the risk of rhabdomyolysis-induced renal failure has yet to be elucidated. In this article, we report the first known case of synthetic cannabinoid hyperemesis leading to rhabdomyolysis and acute renal failure.

Retrospective cohort study evaluating the incidence of diabetic foot infections among hospitalized adults with diabetes in the United States from 1996-2010.

BACKGROUND: The prevalence of diabetes has increased over the last 2 decades; however, the national incidence of diabetic foot infections (DFIs) in the United States is unknown. We sought to determine national trends in DFIs among hospitalized adults in the United States over 15 years. METHODS: This was a retrospective cohort study of the U.S. National Hospital Discharge Survey from 1996-2010. Adult patients with a principal diagnosis of foot infection and a secondary diagnosis of diabetes were identified using ICD-9-CM codes. Incidence was defined as DFI discharges per 100 diabetes discharges. Independent risk factors for DFI among diabetics were identified using multivariable logistic regression. RESULTS: These data represent 1,059,552 DFI discharges over the study period. The incidence of DFI decreased from 1996 (2.3 DFIs/100 diabetes discharges) to 2010 (1.1 DFI/100 diabetes discharges). The proportion of patients experiencing lower-extremity amputation declined from 33.2% in 1996 to 17.1% in 2010. Peripheral vascular disease (odds ratio [OR], 2.89; 95% confidence interval [CI], 2.87-2.91), peripheral neuropathy (OR, 2.62; 95% CI, 2.60-2.64), and male sex (OR, 1.67; 95% CI, 1.66-1.68) were the leading risk factors for DFI. CONCLUSION: The incidence of DFI among hospitalized adults in the United States declined by more than half from 1996-2010.

Staphylococcus lugdunensis bacteremia and endocarditis treated with cefazolin and rifampin.

PURPOSE: This case report describes the treatment of a rare infection caused by Staphylococcus lugdunensis with cefazolin and rifampin. SUMMARY: A 48-year-old man with significant comorbidities was admitted to our institution with complaints of malaise, shortness of breath, and vague persistent pain. He was diagnosed with S. lugdunensis infective endocarditis and was treated with cefazolin continuous infusion for 10 days without resolution of bacteremia. As surgical intervention was deemed inappropriate, rifampin was added to the treatment regimen for its antibiofilm activity. After rifampin initiation, resolution of bacteremia was rapidly achieved. Subsequent blood cultures remained negative, and the patient was discharged home in stable condition to complete six weeks of i.v. cefazolin and rifampin therapy. The patient continued treatment, as documented by the infusion center, weekly for five weeks. The patient was rehospitalized during his sixth week of treatment due to impending respiratory failure, whereupon he was intubated and admitted to the intensive care unit. The patient's cardiac status gradually worsened over the following days, and he ultimately died. Blood cultures from days 1 and 2 of hospitalization revealed no bacterial growth at five days. CONCLUSION: Cefazolin and rifampin therapy in a hospitalized patient with bacteremia and aortic valve endocarditis caused by S. lugdunensis resulted in rapid eradication of the bacteremia. After more than five weeks of cefazolin-rifampin treatment, the patient was rehospitalized with worsening cardiac function and died. Blood cultures during the second admission were negative.

Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis.

BACKGROUND: The use of intravenous bicarbonate in diabetic ketoacidosis (DKA) may be considered for patients with a pH less than 6.9 according to the American Diabetes Association. The impact of this therapy on resolution of acidosis in patients with DKA is unclear. OBJECTIVE: To determine whether the use of intravenous bicarbonate therapy was associated with improved outcomes in patients with severe DKA who were seen in the emergency department. METHODS: This review was conducted from 2007 to 2011 in the emergency department of a tertiary teaching hospital. Adults diagnosed with DKA with an initial pH less than 7.0 were included. Patients were stratified into 2 groups based on receipt of intravenous bicarbonate. The primary study outcome was time to resolution of acidosis, defined as return to pH greater than 7.2. Secondary outcomes included length of stay; continuous infusion insulin use; and intravenous fluid, po tas si um, and insulin requirements within the first 24 hours of hospital admission, beginning upon admittance to the emergency department. We also conducted a subgroup analysis of patients with an initial pH less than 6.9. RESULTS: There was no significant difference in time to resolution of acidosis (8 hours vs 8 hours; p = 0.7) or time to hospital discharge (68 hours vs 61 hours; p = 0.3) between patients who received intravenous bicarbonate (n = 44) compared with those who did not (n = 42). The median dose of intravenous bicarbonate was 100 mEq (100-150) for patients who received intravenous bicarbonate. Insulin and fluid requirements in the first 24 hours were significantly higher in patients who received intravenous bicarbonate compared with those who did not (100 units vs 86 units; p = 0.04 and 7.6 L vs 7.2 L; p = 0.01, respectively). There was no significant difference in hours of continuous insulin infusion (27 hours vs 26 hours; p = 0.09) or potassium requirements in the first 24 hours of hospital stay (135 mEq vs 120 mEq; p = 0.84). CONCLUSIONS: Intravenous bicarbonate therapy did not decrease time to resolution of acidosis or time to hospital discharge for patients with DKA with an initial pH less than 7.0.