Intra-abdominal hematomas and identifiable risk factors in patients receiving subcutaneous enoxaparin.

BACKGROUND: Low molecular weight heparin has proven to be safe and effective but is not without potential risks such as spontaneous bleeding in the abdominal cavity. There is limited evidence evaluating the true incidence of this potential risk and the available literature is primarily via case reports. CASE SUMMARY: The purpose of this study was to identify the incidence and risk factors associated with enoxaparin use (prophylaxis or treatment) abdominal hematomas in a 350-bed community hospital during an 8-month time period. A total of 44 patients were identified as clinically significant bleeds receiving enoxaparin treatment or prophylactic therapy. Ultimately, 25 patients were excluded from the analysis due to an external cause of the abdominal hematoma or a temporal mismatch in enoxaparin administration and hematoma formation. After exclusion, there were a total of 19 patients that were assessed for the risk factors such as age, gender, renal function, and weight. After evaluation of risks, over half of the patients developing a clinically significant bleed were considered elderly (>65 years of age) and impaired renal function with a creatinine clearance of 60ml/min or less. CONCLUSION: Patients at risk for an enoxaparin associated hematoma include female patients with a CrCl <60ml/min and/or BMI >30 kg/m2 receiving enoxaparin treatment dosing.

Incidence of Clostridium difficile infections in patients receiving antimicrobial and acid-suppression therapy.

STUDY OBJECTIVES: To determine the incidence of Clostridium difficile infection (CDI) at one community hospital by identifying patients with stool samples positive for C. difficile toxin A or B, and to compare the incidence with a 2008 national estimate; and to determine which patient characteristics and concomitant antimicrobial and acid-suppression drugs are risk factors for the development of CDI. DESIGN: Retrospective, single-center, medical record review. SETTING: 350-bed community hospital. PATIENTS: A total of 11,010 admissions between January 1, 2009, and December 31, 2009; 115 of these patients had stool samples positive for C. difficile toxin A or B. MEASUREMENTS AND MAIN RESULTS: All C. difficile toxin A and B enzyme immunoassay tests were performed by a central laboratory. The incidence of CDI was 10.4 cases/1000 patient admissions, which was significantly lower than the overall incidence reported in a 2008 national survey of 13.1 CDI cases/1000 patient admissions (p=0.021). Demographic and clinical data of the patients with CDI were collected by using electronic medical records. Patients were more likely to be elderly and female, and to have developed CDI during hospitalization. Of the 115 patients, 95 (82.6%) received acid-suppression therapy and 91 (79.1%) received antimicrobials. Of the patients receiving acid-suppression therapy, 72 (75.8%) received a proton pump inhibitor during their hospitalization, and 49 (51.6%) received both a proton pump inhibitor and an antibiotic. The most frequently used antibiotics in this population were fluoroquinolones, cephalosporins, and carbapenems, with a significantly larger proportion of patients who received carbapenems developing CDI compared with the other classes of antibiotics (p≤0.05 for both comparisons). Patients receiving antimicrobial and acid-suppression therapy were more likely to develop CDI than those who did not receive these drugs. CONCLUSION: The incidence of CDI in 2009 at one community hospital was significantly lower than a 2008 national estimate. Antimicrobial and acid-suppression therapies--in particular, combinations of fluoroquinolones, cephalosporins, carbapenems, and proton pump inhibitors--were found to be risk factors for the development of CDIs in hospitalized patients.

Multicenter treatment and outcome evaluation of aspiration syndromes in critically ill patients.

BACKGROUND: Aspiration syndromes (pneumonia and pneumonitis) have significantly different processes. An evaluation of treatment and outcomes for these different syndromes has not been reported previously. OBJECTIVE: To characterize and assess antimicrobial prescribing patterns for aspiration syndromes in intensive care unit (ICU) patients and describe outcomes of those patients. METHODS: A retrospective, observational evaluation was conducted using a convenience sample of patients at 27 hospitals in North America; these patients were admitted to an adult ICU with a diagnosis of suspected/confirmed aspiration or had a suspected/confirmed aspiration while in the ICU. Hospital demographic, diagnosis, treatment, and clinical outcome data were collected. RESULTS: Over a 12 month period, 187 patients were observed. Aspiration syndromes included suspected aspiration (31%; n = 58), aspiration pneumonitis (12%; n = 23), aspiration pneumonia (55%; n = 103), and diagnosis not available (1.6%; n = 3). Antimicrobial management for the aspiration syndromes was as follows: suspected aspiration: 59% single agent, 38% multiple agents, and 3% no therapy; aspiration pneumonitis: 48% single agent, 39% multiple agents, and 13% no therapy; aspiration pneumonia: 48% single agent, 52% multiple agents, and 0% no therapy. Antimicrobial therapy was prescribed in patients with suspected (97%) and confirmed (100%) aspiration. Antibiotic therapy duration was significantly longer for aspiration pneumonia (9.1 +/- 7.5 days) than for aspiration pneumonitis (5.2 +/- 3.6 days; p = 0.013). Length of ICU stay was similar across patient groups. CONCLUSIONS: Antimicrobial agents are frequently prescribed to treat aspiration syndromes despite the lack of demonstrated efficacy for aspiration pneumonitis. Outcomes between aspiration syndromes were similar with the exception of duration of antibiotic treatment.