Effectiveness of empiric carbapenem versus non-carbapenem therapy for extended-spectrum ß-lactamase producing Enterobacterales infections in non-intensive care unit patients: a real-world investigation in a hospital with high-prevalence of extended-spectrum ß-lactamase producing Enterobacterales.

Objective: To investigate whether empiric carbapenem therapy, compared to empiric non-carbapenem therapy, was associated with improved clinical outcomes among hospitalized, non-intensive care unit (ICU) patients with extended-spectrum ß-lactamase (ESBL)-producing Enterobacterales infections. Methods: We performed a retrospective cohort study of adult, non-ICU patients admitted with ESBL-producing Enterobacterales infections. Primary outcome was time to clinical stability from the first empiric antibiotic dose. Secondary outcomes were early clinical response and 30-day all-cause hospital readmission. We used multivariate regression methods to examine time to clinical stability. Results: Of the 142 patients, 59 (42%) received empiric carbapenems and 83 (58%) received empiric non-carbapenems, most commonly ceftriaxone (49/83, 59%). Median age was 59 years. The most common infection source was urinary (71%). The carbapenem group had a higher proportion of patients who received antibiotics within 6 months of admission (55% vs 28%, P < .01) and history of ESBL (57% vs 17%, P < .01). There were no significant differences in hours until clinical stability between the carbapenem and non-carbapenem groups (22 (IQR: 0, 85) vs 19 (IQR: 0, 69), P = .54). Early clinical response (88% vs 90%, P = .79) and 30-day all-cause hospital readmission (17% vs 8%, P = .13) were similar between groups. Conclusion: Among hospitalized non-ICU patients with ESBL-producing Enterobacterales infection, we found no difference in time to clinical stability after the first empiric antibiotic dose between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-producing Enterobacterales infection.

Utilization and Impact of Pharmacist-led, Urinary Culture Follow-Up After Discharge from the Emergency Department.

INTRODUCTION: Urinary tract infections (UTI) are a common reason for an emergency department (ED) visit. The majority of these patients are discharged directly home without a hospital admission. After discharge, emergency physicians have traditionally managed the care of the patient if a change is warranted (as a result of urine culture results). However, in recent years clinical pharmacists in the ED have largely incorporated this task into their standard practice. In our study, we aimed to 1) describe our unique process in having a pharmacist-led, urinary culture follow-up, and 2) compare it to our previous, more traditional process. METHODS: In our retrospective study, we evaluated the impact of a pharmacist-led, urinary culture follow-up program after discharge from the ED. We included patients prior to and after the implementation of our new protocol to compare the differences. The primary outcome was time to intervention after urine culture result was released. Secondary outcomes included rate of documentation of intervention, appropriate interventions made, and repeat ED visits within 30 days. RESULTS: We included a total of 265 unique urine cultures from 264 patients in the study: 129 cultures were from the period prior to implementation of the protocol, and 136 were from the post-implementation period. There were no significant differences between pre- and post-implementation groups for the primary outcome. Appropriate therapeutic intervention based on positive urine culture results was 16.3% in the pre-implementation group vs 14.7% in the post-implementation group (P=0.72). Secondary outcomes of time to intervention, documentation rates, and readmissions were similar between both groups. CONCLUSION: Implementation of a pharmacist-led, urinary culture follow-up program after discharge from the ED led to similar outcomes as a physician-run program. An ED pharmacist can successfully run a urinary culture follow-up program in an ED without physician involvement.

Clinical Implications of Combinatorial Pharmacogenomic Tests Based on Cytochrome P450 Variant Selection.

Despite the potential to improve patient outcomes, the application of pharmacogenomics (PGx) is yet to be routine. A growing number of PGx implementers are leaning toward using combinatorial PGx (CPGx) tests (i.e., multigene tests) that are reusable over patients' lifetimes. However, selecting a single best available CPGx test is challenging owing to many patient- and population-specific factors, including variant frequency differences across ethnic groups. The primary objective of this study was to evaluate the detection rate of currently available CPGx tests based on the cytochrome P450 (CYP) gene variants they target. The detection rate was defined as the percentage of a given population with an "altered metabolizer" genotype predicted phenotype, where a CPGx test targeted both gene variants a prospective diplotypes. A potential genotype predicted phenotype was considered an altered metabolizer when it resulted in medication therapy modification based on Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. Targeted variant CPGx tests found in the Genetic Testing Registry (GTR), gene selection information, and diplotype frequency data from the Pharmacogenomics Knowledge Base (PharmGKB) were used to determine the detection rate of each CPGx test. Our results indicated that the detection rate of CPGx tests covering CYP2C19, CYP2C9, CYP2D6, and CYP2B6 show significant variation across ethnic groups. Specifically, the Sub-Saharan Africans have 63.9% and 77.9% average detection rates for CYP2B6 and CYP2C19 assays analyzed, respectively. In addition, East Asians (EAs) have an average detection rate of 55.1% for CYP2C9 assays. Therefore, the patient's ethnic background should be carefully considered in selecting CPGx tests.

Development of a Bamlanivimab Infusion Process in the Emergency Department for Outpatient COVID-19 Patients.

The coronavirus disease 2019 (COVID-19) pandemic has prompted the creation of new therapies to help fight against the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Bamlanivimab is a SARS-CoV-2 monoclonal antibody that is administered as an intravenous infusion to ambulatory patients with mild or moderate COVID-19, but a concern that arose was deciding the optimal location for patients to receive the medication. This report describes the development and implementation of a bamlanivimab infusion center in the emergency department of three hospitals in Orange County, California, shortly after bamlanivimab received emergency use authorization. As a result, a total of 601 patients received bamlanivimab in one of these three emergency departments between December 2020 to April 2021. The emergency department was shown to be an optimal setting for administration of bamlanivimab due to its convenience, accessibility, and capabilities for monitoring patients.