Use of Integrated Clinical Decision Support Tools to Manage Parenteral Nutrition Ordering: Experience From an Academic Medical Center.

Parenteral nutrition (PN) is a complex therapy with numerous opportunities for error during the prescribing, preparation, and administration processes. Advances in technology, such as computerized provider order entry (CPOE), electronic health records (EHRs), and clinical decision support (CDS) have helped decrease the risks associated with PN therapy. These technologies can be utilized to guide prescribing, provide automated safety checks, and increase overall safety and accuracy in PN ordering, compounding, and administration. In recent years, increased awareness of the risks associated with PN therapy, in particular issues with ordering and transcription, have magnified the need for improved support of PN ordering within currently available systems. Additionally, drug shortages continue to impact key components of PN admixtures, further increasing the risks associated with this complex therapy. These concerns and risks present an opportunity for the development of new functionality, as well as improvements in and innovative utilization of available technology within systems supporting the PN use process. This discussion will highlight the risks associated with PN, examine the role of drug shortages on the safety of this therapy, describe the application of available technology to manage shortages, and report the experience of using commercially available CDS tools at one academic medical center. It will also include a discussion of the transition from paper orders to CPOE/EHR-based orders for PN and the transition from one commercially available electronic system to another at this particular institution.

Incidence of Acute Kidney Injury in Critically Ill Patients Receiving Vancomycin with Concomitant Piperacillin-Tazobactam, Cefepime, or Meropenem.

Critically ill patients are frequently treated with empirical antibiotic therapy, including vancomycin and ß-lactams. Recent evidence suggests an increased risk of acute kidney injury (AKI) in patients who received a combination of vancomycin and piperacillin-tazobactam (VPT) compared with patients who received vancomycin alone or vancomycin in combination with cefepime (VC) or meropenem (VM), but most studies were conducted predominately in the non-critically ill population. A retrospective cohort study that included 2,492 patients was conducted in the intensive care units of a large university hospital with the primary outcome being the development of any AKI. The rates of any AKI, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, were 39.3% for VPT patients, 24.2% for VC patients, and 23.5% for VM patients (P < 0.0001 for both comparisons). Similarly, the incidences of stage 2 and stage 3 AKI were also significantly higher for VPT patients than for the patients in the other groups. The rates of stage 2 and stage 3 AKI, respectively, were 15% and 6.6% for VPT patients, 5.8% and 1.8% for VC patients, and 6.6% and 1.3% for VM patients (P < 0.0001 for both comparisons). In multivariate analysis, the use of vancomycin in combination with piperacillin-tazobactam was found to be an independent predictor of AKI (odds ratio [OR], 2.161; 95% confidence interval [CI], 1.620 to 2.883). In conclusion, critically ill patients receiving the combination of VPT had the highest incidence of AKI compared to critically ill patients receiving either VC or VM.

Minocycline for the Treatment of Multidrug and Extensively Drug-Resistant A. baumannii: A Review.

Acinetobacter baumannii can cause life-threatening nosocomial infections associated with high rates of morbidity and mortality. In recent years, the increasing number of infections due to extensively drug-resistant Acinetobacter with limited treatment options has resulted in a need for additional therapeutic agents, and a renaissance of older, neglected antimicrobials. This has led to an increased interest in the use of minocycline to treat these infections. Minocycline has been shown to overcome many resistance mechanisms affecting other tetracyclines in A. baumannii, including tigecycline. Additionally, it has favorable pharmacokinetic and pharmacodynamic properties, as well as excellent in vitro activity against drug-resistant A. baumannii. Available data support therapeutic success with minocycline, while ease of dosing with no need for renal or hepatic dose adjustments and improved safety have made it an appealing therapy. This review will focus on the mechanisms of action and resistance to tetracyclines in A. baumannii, the in vitro activity, pharmacokinetic and pharmacodynamic properties of minocycline against A. baumannii, and finally the clinical experience with minocycline for the treatment of invasive infections due to this pathogen.