Analysis of heparin-induced thrombocytopenia diagnostic and management strategies in individuals with inconclusive antibody optical densities.

Heparin-induced thrombocytopenia (HIT) is an uncommon but serious complication of exposure to heparin. Antibody optical densities (ODs) used to diagnose HIT exceeding 2 are highly suggestive of disease, whereas ODs less than 0.5 often 'rule out' HIT. Variation in the clinical care of patients with inconclusive ODs between 0.5 and 2 is likely. This single-centre, retrospective analysis evaluates the diagnosis, management and outcomes of those with antibody ODs between 0.5 and 2. We queried our institution's Healthcare Enterprise Repository for Ontological Narration (HERON) database to identify individuals with antibody ODs between 0.5 and 2. Chart review was completed to calculate 4T scores, corroborate diagnosis codes with documented information in our electronic health record (EHR) and evaluate the diagnosis, management and outcomes of these individuals. These data were evaluated using descriptive and univariate statistics. Among individuals evaluated for HIT between November 2007 and July 2020, we identified 302 individuals with ODs between 0.5 and 2. Serotonin release assays (SRAs) were assessed in 55% (165/302) and were positive in 12% (20/165). In those with available data, 96% with low 4T scores had negative SRAs and 4% had positive SRAs. As 4T scores and antibody ODs proportionally increased, SRA positivity also increased. Clinical management varied widely; however, 4T scoring remains a valuable assessment in this cohort. In those with HIT antibody ODs between 0.5 and 2, true positives were uncommon, and their clinical management varied widely. Fortunately, 4T scoring is a useful prognostic tool that improves the diagnosis and management among those with inconclusive HIT.

Impact of a community-based diabetes self-management program on key metabolic parameters / Impacto sobre los parámetros metabólicos clave de un programa de auto-manejo de la diabetes en farmacia comunitaria

Objective: Characterize the impact of a pharmacist-led diabetes self-management program on three key metabolic parameters: glycosylated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and mean arterial blood pressure (MAP) among employee health program participants. Methods: A self-insured company in the Kansas City metropolitan area began offering a pharmacist-led diabetes self-management program to eligible company employees and their dependents in 2008. A retrospective pre-post analysis was conducted to determine if the program affected key metabolic parameters in participants by determining mean change after one year of participation. Results: Among 183 program participants, 65 participants met inclusion criteria. All three key metabolic parameters were significantly reduced from baseline to one year of program participation: HbA1c decreased from 8.1% to 7.3% (p=0.007); LDL-C decreased from 108.3 mg/dL to 96.4 mg/dL (p=0.009); and MAP decreased from 96.1 to 92.3 mm Hg (p=0.005). Conclusions: The pharmacist-led diabetes selfmanagement program demonstrated significant reductions in HbA1c, LDL-C, and MAP from baseline to one year of program participation. Improvements were statistically significant and clinically relevant for each parameter. Previous studies indicate these reductions may cause reduced overall healthcare costs (AU)

Objetivo: Caracterizar el impacto de un programa farmacéutico de auto-manejo de la diabetes entre os empelados participantes en un programa de salud sobre tres parámetros metabólicos claves: hemoglobina glicosilada (HbA1c), colesterol de baja densidad (LDLC), and media de presión arterial (MAP). Métodos: Una empresa auto-asegurada del área metropolitana de Kansas City comenzó a ofrecer un programa farmacéutico de automanejo de la diabetes a trabajadores elegibles y sus familiares en 2008. Se realizó un análisis retrospectivo pre-post para determinar si el programa afectó a los parámetros metabólicos clave de los participantes determinando el cambio medio tras un años de participación. Resultados: De los 183 participantes del programa, 65 cumplieron los criterios de inclusión. Los tres parámetros metabólicos clave se redujeron significativamente desde el inicio hasta un año de participación en el programa: HbA1c disminuyó de 8,1% a 7,3% (p=0,007); LDL-C disminuyó de 108,3 mg/dL a 96,4 mg/dL (p=0,009); y MAP disminuyó de 96,1 a 92,3 mm Hg (p=0,005). Concusiones: El programa farmacéutico de auto-manejo de la diabetes demostró reducciones significativas en HbA1c, LDL-C, y MAP entre su inicio y un año de participación. Las mejoras fueron estadísticamente significativas y clínicamente relevantes para todos los parámetros. Estudios previos indican que estas reducciones pueden producir ahorro de costes sanitarios generales (AU)

Impact of a community-based diabetes self-management program on key metabolic parameters.

OBJECTIVE: Characterize the impact of a pharmacist-led diabetes self-management program on three key metabolic parameters: glycosylated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and mean arterial blood pressure (MAP) among employee health program participants. METHODS: A self-insured company in the Kansas City metropolitan area began offering a pharmacist-led diabetes self-management program to eligible company employees and their dependents in 2008. A retrospective pre-post analysis was conducted to determine if the program affected key metabolic parameters in participants by determining mean change after one year of participation. RESULTS: Among 183 program participants, 65 participants met inclusion criteria. All three key metabolic parameters were significantly reduced from baseline to one year of program participation: HbA1c decreased from 8.1 % to 7.3% (p=0.007); LDL-C decreased from 108.3 mg/dL to 96.4 mg/dL (p=0.009); and MAP decreased from 96.1 to 92.3 mm Hg (p=0.005). CONCLUSIONS: The pharmacist-led diabetes self-management program demonstrated significant reductions in HbA1c, LDL-C, and MAP from baseline to one year of program participation. Improvements were statistically significant and clinically relevant for each parameter. Previous studies indicate these reductions may cause reduced overall healthcare costs.

Study of nonparticipation in an employee diabetes program.

OBJECTIVES: To determine factors that affect nonparticipation in an employee diabetes program and factors that may increase participation in future employee health programs. METHODS: Participants in this cross-sectional study were adults with type 1 or type 2 diabetes, 18 to 80 years of age, who were covered by employer insurance but chose not to participate in an employer-sponsored diabetes program. Potential factors affecting program participation were assessed through a face-to-face or mailed survey. RESULTS: Of 204 employees or their dependents eligible for the diabetes program, 75 (37%) chose not to participate. Among the nonparticipants, 46 (61%) were eligible for this study. A total of 22 surveys were collected for a 48% response rate. The majority of those individuals surveyed (91%) were aware of the diabetes program and had been notified by mail (42%) or phone (29%). Of those surveyed, 33% did not believe that program incentives had been sufficiently explained to them. Work schedule was not found to be a determinant of participation. More than one-half (52%) of responders identified satisfaction with their current diabetes management as the most notable reason for nonparticipation in the employee diabetes program. CONCLUSION: This study demonstrated that the primary reason for program nonparticipation was patient satisfaction with current physician management of their diabetes. In the future, companies offering health programs should emphasize that the program is being offered to supplement and complement current disease state management, not to replace it.

Community pharmacy-based medication therapy management services: financial impact for patients / Servicios de gestión de la medicación en farmacia comunitaria: impacto financiero para los pacientes

Objective: To determine the direct financial impact for patients resulting from Medication Therapy Management (MTM) interventions made by community pharmacists. Secondary objectives include evaluating the patient and physician acceptance rates of the community pharmacists’ recommended MTM interventions. Methods: This was a retrospective observational study conducted at 20 Price Chopper and Hen House grocery store chain pharmacies in the Kansas City metro area from January 1, 2010 to December 31, 2010. Study patients were Medicare Part D beneficiaries eligible for MTM services. The primary outcome was the change in patient out-ofpocket prescription medication expense as a result of MTM services. Results: Of 128 patients included in this study, 68% experienced no out-of-pocket financial impact on their medication expenses as a result of MTM services. A total of 27% of the patients realized a cost-savings (USD440.50 per year, (SD=289.69)) while another 5% of patients saw a cost increase in out-of-pocket expense (USD255.66 per year, (SD=324.48)). The net financial impact for all 128 patients who participated in MTM services was an average savings of USD102.83 per patient per year (SD=269.18, p<0.0001). Pharmacists attempted a total of 732 recommendations; 391 (53%) were accepted by both the patient and their prescriber. A total of 341 (47%) recommendations were not accepted because of patient refusal (290, 85%) or prescriber refusal (51, 15%). Conclusions: Patient participation in MTM services reduces patient out-of-pocket medication expense. However, this savings is driven by only 32% of subjects who are experiencing a financial impact on out-of-pocket medication expense. Additionally, the majority of the pharmacists’ recommended interventions (53%) were accepted by patients and prescribers (AU)

Objetivo: Determinar el impacto financiero directo para los pacientes resultando de las intervenciones de Gestión de la Medicación (MTM) hechas por farmacéuticos comunitarios. Los objetivos secundarios incluían evaluar las tasas de aceptación por pacientes y médicos de las recomendaciones de MTM de los farmacéuticos. Métodos: Fue un estudio observacional retrospectivo realizado en 20 tiendas de la cadena de farmacias Price Chopper and Hen House de la zona metropolitana de Kansas City desde 1 de enero 2010 a 31 de diciembre 2010. Los pacientes en estudio eran beneficiarios de Medicare Part D elegibles para servicios de MTM. El resultado primario fue los cambios en gastos sufragados por los pacientes de la medicación prescrita como resultado de los servicios de MTM. Resultados: De los 128 pacientes incluidos en el estudio, el 68% no experimentó impacto en sus gastos en medicación como resultado de los servicios de MTM. Un 27% de los pacientes consiguió un ahorro (USD440,50 por año, (SD=289,69)) mientras que otro 5% de pacientes vio incrementado su gasto en medicación (USD255,66 por año, (SD=324,48)). El impacto financiero neto para los 128 pacientes que participaron en el estudio fue un ahorro medio de USD102,83 por paciente y año (SD=269,18; p<0,0001). Los farmacéuticos intentaron un total de 732 recomendaciones; 391 (53%) fueron aceptadas tanto por pacientes como por prescriptor. Un total de 341 (47%) recomendaciones no fueron aceptadas, por negativa del paciente (290; 85%) o por negativa del prescriptor (51; 15%). Conclusiones: La participación de los pacientes en servicios de MTM reduce el gasto en medicamentos del paciente. Sin embargo, este ahorro se materializa sólo en un 32% de pacientes que sufren impacto financiero. Asimismo, la mayoría (53%) de las intervenciones recomendadas por el farmacéutico fueron aceptadas por pacientes y prescriptores (AU)

Community pharmacy-based medication therapy management services: financial impact for patients.

OBJECTIVE: To determine the direct financial impact for patients resulting from Medication Therapy Management (MTM) interventions made by community pharmacists. Secondary objectives include evaluating the patient and physician acceptance rates of the community pharmacists' recommended MTM interventions. METHODS: This was a retrospective observational study conducted at 20 Price Chopper and Hen House grocery store chain pharmacies in the Kansas City metro area from January 1, 2010 to December 31, 2010. Study patients were Medicare Part D beneficiaries eligible for MTM services. The primary outcome was the change in patient out-of-pocket prescription medication expense as a result of MTM services. RESULTS: Of 128 patients included in this study, 68% experienced no out-of-pocket financial impact on their medication expenses as a result of MTM services. A total of 27% of the patients realized a cost-savings (USD440.50 per year, (SD=289.69)) while another 5% of patients saw a cost increase in out-of-pocket expense (USD255.66 per year, (SD=324.48)). The net financial impact for all 128 patients who participated in MTM services was an average savings of USD102.83 per patient per year (SD=269.18, p<0.0001). Pharmacists attempted a total of 732 recommendations; 391 (53%) were accepted by both the patient and their prescriber. A total of 341 (47%) recommendations were not accepted because of patient refusal (290, 85%) or prescriber refusal (51, 15%). CONCLUSIONS: Patient participation in MTM services reduces patient out-of-pocket medication expense. However, this savings is driven by only 32% of subjects who are experiencing a financial impact on out-of-pocket medication expense. Additionally, the majority of the pharmacists' recommended interventions (53%) were accepted by patients and prescribers.

Preoperative Statin use is not Associated with a Reduced Risk of Atrial Fibrillation After Cardiac Surgery.

Introduction: Postoperative atrial fibrillation (POAF) is prevalent after cardiac surgery and associated with significant morbidity and costs. Statins are commonly used in this population and may be a preventative strategy for PAOF. We wished to examine the effect of preoperative statin use on the risk of POAF after cardiac surgery. Methods: A retrospective, observational study was conducted using data from 489 adult patients who underwent cardiac surgery at a single institution. Univariate analyses and unconditional logistic regression were used to determine the impact of preoperative statin use on the probability of developing POAF, while controlling for the baseline risk of POAF and the use of amiodarone prophylaxis (AMP). A baseline risk index was calculated for each patient using a previously validated model. Patients with chronic atrial fibrillation or missing data were excluded. Results: Mean patient age was 63 (SD=13) years, 73% were male, 68% underwent isolated coronary artery bypass grafting, 16% underwent isolated valve surgery, with 13% underwent combined CABG and valve surgeries, and 3% underwent other forms of cardiac surgery. POAF occurred in 27% of patients receiving statins and 24% of those not receiving statins (p=0.3792). After controlling for baseline risk of POAF and the use of AMP, we found that preoperative statins were not associated with reductions in POAF (OR=1.19, 95%CI=0.782-1.822, p=0.4118). Conclusions: Multiple factors impact the development of POAF after cardiac surgery including patient demographics, comorbidities, surgical type, and concomitant medications. In this study, after adjustment for these factors the preoperative use of statins did not significantly influence the development of POAF.

Impact of bisphosphonates on the risk of atrial fibrillation.

Osteoporosis is a major public health problem resulting in significant morbidity, mortality, and utilization of healthcare resources. Bisphosphonates are the most widely prescribed drugs for increasing bone mass and preventing osteoporosis-related fractures. Although these drugs have proven efficacy and are generally considered safe, a clinical trial of once-yearly zoledronic acid reported an unexpected increase in the risk of cardiac arrhythmias, primarily due to serious atrial fibrillation (AF). Subsequently, a post hoc analysis of another clinical trial reported a nonsignificant trend toward an increased risk of serious AF. Based on these concerns, the US FDA issued a cautionary advisory and is conducting an ongoing safety review. A major limitation of the clinical trials was the fact that none were designed or powered to evaluate arrhythmia endpoints. In search of more definitive answers, several observational studies using both population-based cohort and case-control designs have attempted to verify this association. However, only two studies, one cohort and one case-control study, have found a positive association, while six additional studies have reported negative findings. While most of the observational studies attempted to control for confounders, the chosen variables have varied considerably, and other key potential confounders such as smoking were not controlled for in any of the studies. Because the occurrence of AF events in the studies was relatively low, four meta-analyses have been conducted to increase sample size by using pooled data from multiple studies. Again, results have been inconsistent, with two of the analyses reporting a significant increase in serious AF and two finding no association. Additionally, no direct evidence has identified any underlying mechanism to explain an increased arrhythmia risk with bisphosphonate therapy. However, several possible mechanisms have been proposed, including an activated inflammatory state, altered electrolytes impacting cardiac conduction, and long-term atrial structural changes. Due to the widespread use of bisphosphonates in a population for whom the baseline risk of AF also increases with advancing age, further prospective assessment of this possible association is clearly warranted. If an association does exist between bisphosphonates and an increased risk for AF, several additional questions will need to be answered including impact of baseline risk, the time course for increased risk, relationship to drug dose, and whether or not this represents a drug-class adverse effect. Until definitive evidence is available, clinicians will continue to have to make clinical judgments based on the available and often inconsistent evidence to date. To provide further perspective on this possible association, we performed a systematic search of the PubMed database from 1966 to 30 June 2010, drug regulatory websites, and drug manufacturer websites. In this review we summarize the findings from clinical trials, observational studies, and meta-analyses evaluating the risk of AF following bisphosphonate exposure, and discuss possible mechanisms that could explain an increased risk.

Drug-induced arrhythmias.

The objective of this review is to characterize the mechanisms, risk factors, and offending pharmacotherapeutic agents that may cause drug-induced arrhythmias in critically ill patients. PubMed, other databases, and citation review were used to identify relevant published literature. The authors independently selected studies based on relevance to the topic. Numerous drugs have the potential to cause drug-induced arrhythmias. Drugs commonly administered to critically ill patients are capable of precipitating arrhythmias and include antiarrhythmics, antianginals, antiemetics, gastrointestinal stimulants, antibacterials, narcotics, antipsychotics, inotropes, digoxin, anesthetic agents, bronchodilators, and drugs that cause electrolyte imbalances and bradyarrhythmias. Drug-induced arrhythmias are insidious but prevalent. Critically ill patients frequently experience drug-induced arrhythmias; however, enhanced appreciation for this adverse event has the potential to improve prevention, treatment, patient safety, and outcomes in this patient population.

Potential use of statins to prevent atrial fibrillation after coronary artery bypass surgery.

OBJECTIVE: To review the published literature evaluating the effectiveness of statin therapy for preventing postoperative atrial fibrillation (POAF) after coronary artery bypass graft (CABG) surgery. DATA SOURCES: A MEDLINE search was performed (1950-October 2007) using the search terms statins, HMG-CoA reductase inhibitors, coronary artery bypass graft, cardiac surgery, and atrial fibrillation. STUDY SELECTION AND DATA EXTRACTION: All articles published in English describing or evaluating the use of statins in humans to prevent atrial fibrillation (AF) were included. Additional pertinent articles were identified from reference lists. DATA SYNTHESIS: POAF is a common complication following CABG surgery that is associated with significant morbidity. Current preventive strategies include the use of beta-blockers and antiarrhythmic drugs such as amiodarone and sotalol. Accumulating evidence suggests that statins may also reduce the risk of POAF. Numerous studies in nonsurgical cardiovascular patients have found reduced rates of AF with statins. In patients who have undergone CABG, several observational studies have also documented benefit. One randomized controlled trial reported a significant reduction in the risk of POAF and reduced length of hospital stay in patients given preoperative atorvastatin beginning 7 days before surgery. Ongoing research suggests that statins may reduce the risk of AF through pleiotropic effects independent of cholesterol lowering such as reductions in inflammation, oxidative damage, neurohormonal activation, and thrombosis. CONCLUSIONS: While the current evidence evaluating the use of statins to prevent POAF is encouraging, definitive conclusions cannot be drawn. However, because statins are widely used in cardiac patients for other indications and are not associated with the risks inherent to antiarrhythmic drugs, their value as an adjunct to current preventive strategies for POAF deserves further study. Additional research is needed to examine the effectiveness of statins in risk-stratified patients undergoing CABG surgery and the impact on patient outcomes and attributed costs.

Risk-stratified evaluation of amiodarone to prevent atrial fibrillation after cardiac surgery.

BACKGROUND: Amiodarone prophylaxis (AMP) reduces the prevalence of postoperative atrial fibrillation (POAF) after cardiac surgery. We investigated the impact of AMP on the frequency and duration of POAF, the intensive care unit and hospital length of stay, and its cost-effectiveness in a risk-stratified cohort. METHODS: A retrospective, observational analysis of 509 patients who underwent cardiac surgery in 2003 was performed. Data sources included The Society of Thoracic Surgeons national database; medical and medication administration records; and the activity-based cost data from our institution. Risk stratification for POAF was determined using a validated risk index. Cost-effectiveness was determined from the hospital's perspective. RESULTS: The mean patient age was 63 years, 27% were female, 80% underwent coronary artery bypass grafting, and 29% underwent valve surgery. When a risk-stratified evaluation was made, 50% of patients were at an elevated risk for having POAF develop. When compared with nonprophylaxed patients, those receiving AMP (59%) experienced less POAF (31% vs 22%; p = 0.027) and shorter durations of POAF (4.7 vs 2.7 days; p = 0.025). In the elevated-risk group, AMP clinically (but not significantly) reduced length of stay in the intensive care unit (101 vs 68 hours; p > 0.05) and post-procedural hospital length of stay (9.7 vs. 7.9 days, p > 0.05). In the elevated-risk group, AMP was robustly cost-effective in reducing POAF. CONCLUSIONS: Amiodarone prophylaxis reduced the prevalence and duration of POAF. Baseline risk for POAF was a major determinant of the overall cost-effectiveness of AMP. The greatest cost savings with AMP was seen in patients at an elevated risk for POAF. These findings suggest the need for risk stratification when prescribing AMP.

Osmol gap as a surrogate marker for serum propylene glycol concentrations in patients receiving lorazepam for sedation.

STUDY OBJECTIVES: To correlate serum propylene glycol concentration with osmol gap, serum lactate concentration, and amount of propylene glycol administered to mechanically ventilated patients receiving continuous infusions of lorazepam (80% propylene glycol by weight), and to characterize the prevalence of hyperosmolality and range of serum propylene glycol concentrations in this patient population. DESIGN: Prospective, controlled, observational study. SETTING: Adult surgical and cardiothoracic intensive care units (ICUs) of a 1200-bed, urban, tertiary care, teaching hospital. PATIENTS: Sixty-four consecutively enrolled intensive care patients requiring mechanical ventilation and pharmacologic sedation. INTERVENTION: Thirteen patients received continuous infusions of high-dose lorazepam (> or = 6 mg/hr) for a minimum of 36 hours, and 26 received continuous infusions of low-dose lorazepam (2-5.99 mg/hr) for 36 hours. Twenty-five control patients received sedatives that did not contain propylene glycol. MEASUREMENTS AND MAIN RESULTS: Serum propylene glycol and lactate concentrations, osmolality, and basic metabolic profiles were obtained 72-108 hours after ICU admission. Clinical data, drug administration, and severity of illness scores were recorded. Osmol gap and the amount of propylene glycol administered before serum sampling predicted propylene glycol concentrations (r(2)=0.692, p<0.05). Osmol gap alone also predicted serum propylene glycol concentrations (r(2)=0.532, p<0.05). Serum lactate concentrations did not correlate with serum propylene glycol concentrations. Unlike the low-dose and control patients, eight (62%) of 13 high-dose patients had osmol gaps above 10. All 13 high-dose patients had serum propylene glycol concentrations previously associated with toxicity. CONCLUSION: Osmol gap can be used as a surrogate marker for serum propylene glycol concentration. In critically ill patients receiving lorazepam for sedation, an osmol gap above 10 was associated with concentrations previously reported to cause toxicity.

Nationwide antibiogram analysis using NCCLS M39-A guidelines.

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

Eplerenone: a selective aldosterone receptor antagonist for patients with heart failure.

OBJECTIVE: To evaluate the pharmacology, pharmacokinetics, safety, and clinical use of eplerenone in heart failure (HF). DATA SOURCES: English-language MEDLINE searches were performed from 1966 to May 2004. Key words included eplerenone, aldosterone receptor antagonist, heart failure, myocardial infarction, left-ventricular dysfunction, and cost-effectiveness. Additional references were identified from bibliographies of selected articles. STUDY SELECTION AND DATA EXTRACTION: Human trials evaluating the efficacy, safety, and cost-effectiveness of aldosterone receptor antagonists in HF were evaluated. DATA SYNTHESIS: Eplerenone is the first selective aldosterone receptor antagonist. The drug is indicated to improve the survival of stable patients with left-ventricular systolic dysfunction (ejection fraction <40%) and clinical evidence of HF following acute myocardial infarction. Efficacy and safety in this population have been demonstrated in a large, randomized clinical trial. Eplerenone is associated with severe and sometimes life-threatening hyperkalemia. Patients with reduced renal function and diabetes, as well as those on other drugs that increase potassium levels, are at highest risk. Eplerenone is metabolized by the cytochrome P450 system and may interact with drugs that interfere with this system. A major advantage of eplerenone over the nonselective aldosterone receptor antagonist spironolactone is lack of binding to progesterone and androgen receptors, which is associated with drug-induced gynecomastia, breast pain, and impotence. CONCLUSIONS: The addition of eplerenone to traditional HF therapy has been shown to reduce morbidity and mortality in patients who develop left-ventricular dysfunction after acute myocardial infarction. Eplerenone's selectivity reduces sex hormone-related adverse effects. Despite these benefits, the overall cost-effectiveness has yet to be determined.

Enterobacter cloacae ventriculitis successfully treated with cefepime and gentamicin: case report and review of the literature.

A 55-year-old woman was found unresponsive and subsequently was diagnosed with a subarachnoid hemorrhage secondary to a right posterior communicating artery aneurysm. The development of hydrocephalus and decreased mental status necessitated placement of an intraventricular catheter; 18 days later she was diagnosed with Enterobacter cloacae ventriculitis. After treatment was begun with intravenous cefepime 2 g every 8 hours and intraventricular gentamicin 5 mg every 24 hours, the catheter was replaced. Cerebrospinal fluid (CSF) and plasma cefepime concentrations and a CSF trough gentamicin concentration were obtained. Intraventricular gentamicin was administered for 6 days and cefepime for 21 days; both clinical and microbiologic resolution of the ventriculitis occurred. The literature reports limited clinical experience with cefepime for the treatment of central nervous system infections in humans. This case report provides clinical evidence to support administration of intravenous cefepime in critically ill adult patients with Enterobacter ventriculitis. Because CSF is easily obtained from patients with intraventricular catheters, strong consideration should be given to monitoring CSF cefepime concentrations in concert with the minimum inhibitory concentration of the offending pathogen to help assure the efficacy of this approach to therapy.