Two Cases of Vancomycin-Induced Neutropenia.

(1) Background: The incidence of vancomycin-induced neutropenia in hospitalized patients is estimated to be around 2 to 8 percent Data surrounding vancomycin-induced neutropenia is limited as it is based on a small number of observational case reports. Additionally, it is difficult to provide generalized conclusions since patient characteristics and indications for treatment vary between reports. (2) Case Reports: We present two cases of vancomycin-induced neutropenia that occurred at our facility; a 50-year-old male who developed neutropenia after treatment with vancomycin for a gluteal abscess and a 51-year-old female who developed neutropenia after treatment with vancomycin for lumbar osteomyelitis. In both cases, neutropenia resolved within 2 days of discontinuation of vancomycin. (3) Conclusions: Vancomycin-induced neutropenia is thought to be a relatively uncommon adverse drug reaction. These two cases of neutropenia likely caused by prolonged exposure to vancomycin occurred at our facility within 3 months of each other. Additional studies are needed to better understand the true incidence of this adverse drug reaction and to identify risk factors that may predispose patients to vancomycin-induced neutropenia.

Comparison of Students' Self-Assessment and Simulated Patient Assessment in a Patient Counseling Evaluation and Perceived Importance of Communication Skills.

The primary objective of this study was to compare students' self-assessment ratings with simulated patient (SP) assessment ratings of communication skills in a patient counseling Objective Structured Clinical Exam (OSCE). The secondary objective was to evaluate student perceptions of the importance of communication skills in the practice of pharmacy as well as the impact of a virtual OSCE format. First-year pharmacy students completed an OSCE focused on self-care product counseling. The evaluation was graded using a rubric covering both verbal and non-verbal communication. Students who completed the course were provided a 15-question, post-evaluation survey with questions related to self-assessment of communication skills and perceptions of the importance of communication skills. Of the 138 students in the course, 68 completed the optional post-assessment survey (49% response rate). There were no statistically significant differences between the ratings by students and SPs for the four communication elements included in the self-assessment. Most of the students recognized the importance of communication skills, including developing rapport and trust. Recognition of the importance of communication skills to future practice as a pharmacist positively correlated with performance on the evaluation (r2 = 0.5409, p-value = 0.0007). Student self-assessment is an effective and cost-effective mode of feedback for practice experiences as an alternative to the use of SPs.

Transitioning Competency-Based Communication Assessments to the Online Platform: Examples and Student Outcomes.

In light of the COVID-19 pandemic, pharmacy education has shifted from in-person teaching and assessments to the virtual environment. Many education programs had previously adopted objective structured clinical examinations (OSCEs) to assess communication abilities in-person with standardized patients (SPs). However, comparative student outcome data between virtual and in-person methods as well as guidance on how to conduct communication-based OSCEs in the virtual environment is lacking. The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) describes its methods of conducting two types of communication-based OSCEs (patient counseling and gathering a medical history). Student performance data from the two virtual OSCEs in 2020 was compared to results from two 2019 in-person OSCEs using Mann Whitney U Tests. The 2020 cohort scored significantly higher than the 2019 cohort in all variables (i.e., using effective verbal and non-verbal communication, using patient friendly education, organizing the encounter, demonstrating empathy, establishing trust, professionalism) and in overall score. However, the effect size for these findings indicate the differences between performances are generally small and more likely due to changes in grading patterns due to the pandemic.

Septic Shock Caused by Rahnella aquatilis Bacteremia in an Immunocompetent Adult.

BACKGROUND Rahnella aquatilis is a facultatively anaerobic, gram-negative rod bacterium commonly found in freshwater. There are few cases of bacteremia caused by Rahnella aquatilis in the literature and even fewer cases reported of it causing sepsis in immunocompetent individuals. In this case report, we present a rare case of an immunocompetent individual who developed sepsis secondary to bacteremia caused by Rahnella aquatilis. CASE REPORT A 37-year-old immunocompetent man with cerebral palsy and chronic enterocutaneous fistulas, with an indwelling peripherally inserted central catheter (PICC) line for total parenteral nutrition (TPN), presented to the emergency department with complaints of increased enteric drainage from his fistula, rigors, and subjective fevers following a mechanical fall, which occurred approximately 1 week before. The day following admission, the patient developed septic shock and was transferred to the intensive care unit for vasopressor support. He was given intravenous cefepime and metronidazole for empiric therapy. Blood cultures grew Rahnella aquatilis, and antibiotic therapy was de-escalated to monotherapy with intravenous ceftriaxone. The patient's condition stabilized, his PICC line was replaced, and he was successfully discharged, and continued on outpatient antibiotic therapy with ceftriaxone. CONCLUSIONS This case report represents a novel presentation of septic shock secondary to bacteremia caused by a gram-negative rod bacterium, Rahnella aquatilis, in an immunocompetent host dependent on TPN via a PICC line. This case also demonstrates that Rahnella aquatilis can be susceptible to and treated successfully with intravenous ceftriaxone. Bacteremia caused by Rahnella aquatilis can cause a swift, aggressive decompensation and should be treated with antibiotics immediately.

Metastatic Klebsiella pneumoniae Invasive Liver Abscess Syndrome in Denver, Colorado.

BACKGROUND: Klebsiella pneumoniae has gained recognition for its association with invasive liver abscess syndrome (ILAS). ILAS is associated with a hypervirulent strain of K pneumoniae and can impact immunocompetent as well as immunocompromised patients. CASE REPORT: A 42-year-old Hispanic male with no significant past medical history was admitted with complaints of subjective fevers and worsening fatigue. The patient was found to have multiple septic pulmonary emboli, a prostate abscess, a seminal vesicle abscess, bilateral frontoparietal and left temporal infarcts thought to be due to septic emboli, pyelonephritis, endophthalmitis, and hepatic abscesses. Cultures grew K pneumoniae that was determined to be the hypervirulent strain associated with ILAS. The patient was treated for a total of 71 days, including ceftriaxone and multiple intravitreal injections with ceftazidime. CONCLUSION: Notably, this case report details a disease state new to Colorado. Pharmacists are able to assist in the care of ILAS with antibiotic selection, considering sites of infection and encouraging appropriate consultation of specialized care teams.

Knowledge, Perceptions, and Uptake of the Human Papillomavirus Vaccine in a Sample of US High School Adolescents.

OBJECTIVE: To assess high school students' knowledge and perceptions of human papillomavirus (HPV) and HPV vaccines and evaluate high school students' self-reported uptake of the HPV vaccine. METHODS: This was an observational, descriptive study using a 44-question survey. Participants were ninth grade students in a Colorado public school district. The survey was administered as part of a health education course. RESULTS: Ninety-two surveys were included in the analysis. Demographic characteristics included 64/92 (69.6%) male and 55/92 (59.8%) Hispanic/Latino students. There was no difference between males and females regarding self-reported vaccination status. Non-Hispanic students were 71.6% less likely to have received the HPV vaccine than Hispanic students (OR 0.284; 95% CI, 0.088-0.920; p = 0.036). The average score on the knowledge section was 42.7% with a standard deviation of 22.6%. When assessing students' perceptions, 71/92 (77.2%) disagreed or strongly disagreed that they felt at risk for getting an HPV infection. There was no significant difference between males and females regarding awareness of the HPV vaccine (p = 0.14). More than half of students (58.7%) did not know if they had received the HPV vaccine. CONCLUSION: HPV vaccine awareness was low and many students did not know if they had received the HPV vaccine. Ninth grade students did not have accurate knowledge of HPV and HPV vaccines and this study presents opportunities for increased education.

Development and implementation of a remotely precepted, interprofessional advanced pharmacy practice experience in rural Guatemala.

BACKGROUND AND PURPOSE: It is well-established that interprofessional experiences in the international setting provide students with additional skills in cultural humility and adapting to specific patient circumstances. Though these experiences are integral to the development of students, they are difficult to establish due to a lack of in-country preceptorship. This manuscript describes the development and implementation of an interprofessional advanced pharmacy practice experience (APPE) and outlines the interventions students have made to advance patient care, build trust, and improve the education of patients and providers in rural Guatemala. EDUCATIONAL ACTIVITY AND SETTING: The APPE in rural Guatemala was developed to include pharmacy distribution activities, education (patient, technician, provider, community), and clinical pharmacy services in an interprofessional environment. Pharmacy faculty served remotely as the primary preceptors using FaceTime, WhatsApp, and email. FINDINGS: A total of 12 APPE pharmacy students have completed the six-week Guatemala rotation since implementation. Students reported that they spent the majority of their time (60% to 70%) seeing patients and training the technician. The remaining time was split between assisting United States and Guatemalan providers during clinic visits and conducting home visits with community nurses. Students made 1191 patient care recommendations, of which 969 were accepted (81.4%). Students completed 17 patient education and quality improvement projects. SUMMARY: This APPE in Guatemala meets the needs of underserved populations, establishes effectiveness of distance precepting by pharmacy faculty, and provides international, interprofessional opportunities for fourth year pharmacy students.

Establishing the Therapeutic Index of Fluid Resuscitation in the Septic Patient: A Narrative Review and Meta-Analysis.

This comprehensive review comparatively evaluates the safety and benefits of parenteral fluids used in resuscitation with a focus on sepsis. It also provides a random-effects meta-analysis of studies comparing restrictive resuscitation and usual care in sepsis with the primary outcome of mortality. In the septic patient, fluid therapy remains a complex interplay between fluid compartments in the body, the integrity of the endothelial barrier, and the inflammatory tone of the patient. Recent data have emerged describing the pharmacokinetics of fluid resuscitation that can be affected by the factors just listed, as well as mean arterial pressure, rate of infusion, volume of fluid infusate, nature of the fluid, and drug interactions. Fluid overload in sepsis has been associated with vasodilation, kidney injury, and increased mortality. Restrictive resuscitation after the initial septic insult is an emerging practice. Our search strategy of Medline databases revealed six randomized studies with 706 patients that examined restrictive resuscitation in sepsis. Results of this meta-analysis demonstrated no differences in mortality with restrictive resuscitation compared with usual care (30.6% vs 37.8%; risk ratio 0.83, 95% confidence interval 0.66-1.05, respectively) but was limited by the small number of studies and larger quantities of pre-randomization fluids. Another approach to address fluid overload is active (diuresis) de-resuscitation strategies that may shorten the need for mechanical ventilation and intensive care unit length of stay. Data suggest that colloids may confer mortality benefit over saline in the most severely ill septic patients. Compared with isotonic saline, balanced resuscitation fluids are associated with a lower incidence of acute kidney injury and mortality. The benefits of balanced resuscitation fluids are most evident when higher volumes of fluids are used for sepsis. Clinicians should consider these pharmacotherapeutic factors when selecting a fluid, its quantity, and rate of infusion.

Pseudomonas Mendocina Bacteremia: A Case Study and Review of Literature.

BACKGROUND Pseudomonas mendocina is a Gram-negative, aerobic, rod-shaped bacterium belonging to the family Pseudomonadaceae. In nature, P. mendocina has been isolated from water and soil samples. The species rarely causes disease in humans though severe infections resulting in hospitalization and intensive care have been documented. This case is perhaps the second reported case in the United States of a P. mendocina related infection. In this case report, we analyze the clinical and laboratory features of P. mendocina infection in a severely immunocompromised acquired immunodeficiency syndrome (AIDS) patient and review the available literature. CASE REPORT A 64-year-old white male with past medical history significant for human immunodeficiency virus (HIV)/AIDS (CD4 count on admission <10 cells/mm³) diagnosed in 1988 and on antiretroviral therapy since 1992, was admitted to our facility for acute management of a suspected invasive mold infection. On hospital day 20 the patient developed a fever of 39.9°C, had an elevated lactate of 2.6 mmol/L and absolute neutrophil count greater than 1000 cells/mm³. On hospital day 22, both blood culture sets were positive for Pseudomonas mendocina. Antibiotic therapy was de-escalated to ceftazidime and after a total treatment course of 10 days the was successfully discharged. CONCLUSIONS There have been 14 reported cases of P. mendocina in the world. Four cases presented with meningitis and 5 with endocarditis. Beyond typical anti-pseudomonal agents, 2 of the reported cases show susceptibility of P. mendocina antibiotics such as sulfamethoxazole/trimethoprim and ceftriaxone. All documented case reports of P. mendocina infection resulted in successful treatment with antibiotics and survival of the patient.

Management of severe asymptomatic hypertension in the hospitalized patient.

Hypertension is common in the hospital setting. While the epidemiology, management, and outcomes of chronic hypertension are well defined, data and clinical guidance on the management of severe blood pressure elevations in the hospitalized patient are lacking. This article aims to review the literature related to the risks and benefits of managing severe asymptomatic hypertension in the hospitalized patient, summarize the concerns regarding managing severe asymptomatic hypertension with as-needed antihypertensive medication, and suggest alternative management strategies.