ABSTRACT
PURPOSE: Results of a study to evaluate the impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) surveillance screening protocol are reported. METHODS: A retrospective single-center, quasi-experimental, pre-post cohort study was conducted to assess medication-use and clinical outcomes before and after implementation of a protocol allowing pharmacists to order nasal swabs and polymerase chain reaction (PCR) testing for MRSA in selected patients receiving vancomycin for pneumonia or acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Negative assay results were used to guide de-escalation of vancomycin therapy. The primary outcome was vancomycin days of therapy (DOT). Secondary outcomes included hospital length of stay, the rate of vancomycin-associated acute kidney injury, and in-hospital mortality. RESULTS: A total of 300 patients were identified for inclusion in the preprotocol group (n = 150) or postprotocol group (n = 150) through medical records review. Compared with patients in the preprotocol group, those in the postprotocol group had a median 2.1-day reduction in vancomycin DOT (2.1 days versus 4.2 days, p < 0.0001). Protocol implementation was also associated with a decrease in the median number of vancomycin serum levels obtained per patient but did not have a significant impact on other secondary outcomes. CONCLUSION: Among patients with suspected or confirmed pneumonia or an AECOPD, the expansion of pharmacists' traditional scope of practice to include a surveillance protocol using a MRSA PCR nares assay to guide vancomycin de-escalation resulted in a reduction in vancomycin utilization without compromising clinical outcomes.
Subject(s)
Anti-Bacterial Agents/adverse effects , Anti-Bacterial Agents/therapeutic use , Methicillin-Resistant Staphylococcus aureus , Pharmacists , Staphylococcal Infections/drug therapy , Staphylococcal Infections/microbiology , Vancomycin/adverse effects , Vancomycin/therapeutic use , Aged , Aged, 80 and over , Clinical Protocols , Cohort Studies , Female , Hospital Mortality , Humans , Length of Stay , Male , Middle Aged , Nasal Cavity/microbiology , Pharmacy Service, Hospital , Polymerase Chain Reaction , Pulmonary Disease, Chronic Obstructive/complications , Retrospective Studies , Staphylococcal Infections/mortality , Vancomycin ResistanceSubject(s)
Anticoagulants/adverse effects , Factor IX/therapeutic use , Factor VII/therapeutic use , Factor X/therapeutic use , Hemorrhage/chemically induced , Hemorrhage/drug therapy , Prothrombin/therapeutic use , Anticoagulants/therapeutic use , Arterial Occlusive Diseases/drug therapy , Arterial Occlusive Diseases/prevention & control , Blood Coagulation Factors/therapeutic use , Critical Illness/therapy , Dose-Response Relationship, Drug , Drug Combinations , Emergency Service, Hospital , Emergency Treatment/methods , Humans , Infusions, Intravenous , Risk Assessment , Thrombolytic Therapy/adverse effects , Thrombolytic Therapy/methods , Treatment Outcome , Venous Thrombosis/drug therapy , Venous Thrombosis/prevention & controlABSTRACT
The 'cement in cement' technique for revision hip arthroplasty has become popular in recent years, particularly in relation to polished taper stems. Since 2006 a short Exeter stem with 44 mm offset has been available specifically for this purpose. We report a fracture of such a stem in the absence of trauma 5 years after the revision procedure. The patient had a BMI of 27.8 and the proximal cement mantle gave good support to the stem. The fracture initiated and propagated from the introducer hole on the shoulder of the prosthesis. Macroscopically there was no defect in this area. This may be an unusual case of fatigue failure.
