A Comparison of Inhaled Epoprostenol in Patients With Acute Respiratory Distress Syndrome and COVID-19-Associated Acute Respiratory Distress Syndrome.

Introduction Acute respiratory distress syndrome (ARDS) and coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (CARDS) are both characterized by non-cardiogenic pulmonary edema and severe hypoxemia that leads to a high percentage of patients suffering in-hospital mortality. Mechanistically, inhaled epoprostenol (iEPO) has shown a role in the treatment of ARDS and CARDS but little data are available directly comparing the two disease processes. Due to the lack of evidence of iEPO in ARDS and CARDS, the authors sought to compare the pulmonary effects of iEPO for mechanically ventilated patients with CARDS against a case match control of those with ARDS. Methods A retrospective cohort of all patients receiving iEPO between January 1, 2020, and February 22, 2022, was reviewed. Patients with ARDS were case-matched in a 2:1 allocation ratio of CARDS to ARDS by the number of medical comorbidities and age +/- 5 years. Clinical data collected included patient demographics, laboratory values, ventilator settings, length of hospitalization, and 28-day mortality. Comparisons of the effectiveness of iEPO between ARDS and CARDS were conducted using the chi-squared statistic for categorical variables and the Mann-Whitney statistic for continuous variables. Results A total of 72 patients were included in the final analysis, with 24 having ARDS and 48 CARDS. The number of medical comorbidities was no different for patients with ARDS or CARDs (p = 0.18), though the frequency of patients diagnosed with coronary artery disease (p=0.007), congestive heart failure (p=0.003), chronic obstructive pulmonary disease (p=0.004), and pulmonary hypertension (p=0.004) did vary between the two groups. A moderate but non-significant difference in pre-iEPO partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio was noted between the groups (0.74 vs 0.65; p=0.33). Following iEPO treatment, patients with ARDS showed a greater PaO2/FiO2 ratio than those with CARDS (0.87 vs 0.70; p=0.02). CARDS patients who received iEPO had a longer length of stay as compared to those with ARDS (17.5 vs 12.5 days; p=0.01). However, no difference was noted in 28-day mortality between the two groups (14 vs 34; p=0.29). Conclusion In this small sample from a single community hospital, a statistically significant improvement in the PaO2/FiO2 ratio was noted for both those with ARDS and CARDS. However, those with CARDS who were given iEPO had a longer length of stay without a significant difference in mortality as compared to those with traditional ARDS.

Casirivimab/imdevimab treatment for outpatient COVID-19 during a SARS-CoV-2 B1.617.2 (Delta) surge at a community hospital.

CONTEXT: Vaccination status has been shown to be linked to patient-centered outcomes in those with COVID-19. However, minimal data have explored the relationship between vaccination status and representation rates after receiving monoclonal antibodies (MABs) the Delta strain of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) in a community setting. OBJECTIVES: The authors sought to determine if there was a difference in patient-centered outcomes between those who were vaccinated and unvaccinated after the administration of casirivimab/imdevimab for mild-to-moderate COVID-19 during the time when the Delta strain was most prevalent. METHODS: A convenience sample of consecutive adults given casirivimab/imdevimab at either an outpatient infusion center or within the emergency department (ED) were included in analysis. Patient demographics, authorized-use qualifiers from the emergency use authorization (EUA), baseline vital signs at the time of infusion, representation rates to a healthcare provider within the hospital's network, and any admissions to the hospital following infusion were all collected from the patient's electronic medical record. Vaccination status was confirmed in both the patient's electronic medical record and the Arizona State Immunization Information System (ASIIS). Analysis was conducted utilizing descriptive statistics, the Mann-Whitney U test for continuous data, and the chi-squared analysis for nominal data. RESULTS: In total, 743 patients were included in the study, with 585 being unvaccinated and 158 being vaccinated at the time of administration. Those in the vaccinated group were more likely to be older (60.0 vs. 55.0 years; p<0.001) and to have a history of diabetes (18.4% vs. 11.3%; p=0.02), hypertension (39.9% vs. 28.5%; p=0.006), immunosuppression (7.0% vs. 1.4%; p<0.001), and chronic kidney disease (7.0% vs. 3.4%; p=0.05). In the entire sample, 105 (14.1%) patients had an unexpected return visit to either the ED or urgent care at 28 days, with 17 (2.3%) requiring hospitalization. Patients who were vaccinated were more likely to represent for care after casirivimab/imdevimab infusion (20.3% vs. 12.5%; p=0.01), but no difference was noted in hospitalization rates between the two groups (18.8% vs. 15.1%; p=0.15). CONCLUSIONS: MAB therapy with casirivimab/imdevimab for the outpatient treatment of mild-to-moderate COVID-19 was associated with a low rate of hospitalization. However, those who were vaccinated were more likely to present for unexpected return care at either the ED or urgent care within 28 days of the initial infusion.

Real world utilization of Dalbavancin at a rural community emergency department.

INTRODUCTION: Acute bacterial skin and skin structure infections (ABSSI) are frequently encountered in the emergency department and compromise more than 700,000 hospital admissions annually. Dalbavancin is a single dose long acting semi-synthetic lipogylcopepitde antibiotic with coverage against gram-positive organisms including methicillin resistant Staphylococcus aureus. Recent data from large tertiary care centers have shown a decrease in hospital admissions and repeat emergency department visits for ABSSI's but little data is available for those who practice in a rural community setting. The primary objective of this study was to describe the use of dalbavancin at a single rural emergency department. METHODS: A retrospective cohort study of all adult patients who received dalbavancin between 2019 and 2021 while in the emergency department was completed. Abstracted data included patient demographics, infection location by body region, emergency department return visits, hospital admissions, and length of stay. Analysis was conducted using descriptive statistics, the Mann-Whitney test for continuous data, and the chi-squared analysis for nominal data. RESULTS: A total of 125 patients were included in the final analysis with 35.2% being female. The median age of those treated with dalbavancin was 54 years (42.0-64.0) and the most common infection site was the lower extremities. A total of 35 patients re-presented to the emergency department following treatment with dalbavancin within 30 days and 16 were admitted to the hospital. Of those who re-presented to the emergency department, the median age was 56 (40.0-66.0) and the median re-presentation was 9 days (3-17) after dalbavancin administration. A total of 16 patients (12.8%) were subsequently admitted to the hospital with a median length of stay of 5.5 days (3.0-8.0). 30-day readmission rates were 23.9% in those who had an abnormal WBC count at initial presentation, 26.1% for those with congestive heart failure, 20.3% for those with hypertension, and 26.0% in those who had diabetes mellitus. CONCLUSION: Following the administration of dalbavancin for ABSSI at a rural emergency department, few patients are subsequently admitted within the following 30 days. To further decrease this number and alleviate the burden on emergency departments and hospitals, local treatment algorithms should be developed to minimize the risk of representation and hospitalization following administration.

Real World Utilization of Bamlanivimab at a Rural Community Hospital.

Introduction Although there were several proposed treatments for patients that were hospitalized with COVID-19, outpatient treatments for those with mild to moderate illness were limited prior to the emergency use authorization (EUA) of virus-neutralizing monoclonal antibodies. To assess the efficacy of outpatient monoclonal therapy, the investigators assessed the seven, 14, and 28-day emergency department and hospitalization rates of adult patients given bamlanivimab for the treatment of COVID-19 at a community hospital. Methods A retrospective chart review was performed of all adult patients given bamlanivimab within the emergency department or an outpatient infusion center from December 2, 2020 through January 8, 2021 for the treatment of mild to moderate COVID-19. Patients were compared to a set of controls who would have qualified for bamlanivimab treatment prior to its authorization in reverse temporal order from November 30, 2020 through August 1, 2020. Abstracted data included patient demographics, allergic reactions, emergency department presentations, and hospitalizations at seven, 14, and 28 days post-infusion due to COVID-19 and any in-hospital mortality in those admitted with a COVID-19 complication.  Results A total of 136 patients received bamlanivimab during the study period with none having an allergic reaction during infusion. In those who received bamlanivimab, 84 (61.8%) patients included were aged 65 years or older. At 28 days, there was a statistically significant reduction in emergency department visits in those who received bamlanivimab (20 vs 36 patients; p = 0.03) but not at seven days (12 vs 20 patients; p = 0.18) or 14 days (17 vs 28 patients; p = 0.11). No statistically significant difference in emergency department returns was noted in those aged 65 years or older at seven (eight vs eight patients; p = 0.70), 14 (11 vs 10 patients; p = 0.83), or 28 days (13 vs 14 patients, p = 0.46). A total of six (4.4%) patients were hospitalized at 28 days following the bamlanivimab infusion with five (83.3%) being aged 65 or older. No statistical difference was noted for decreased hospitalizations at seven (four vs five patients; p = 0.79), 14 (five vs nine patients; p = 0.32), or 28 days (six vs nine patients; p = 0.49) post-infusion. No patients suffered from in-hospital mortality after infusion with bamlanivimab. Conclusion Outpatient infusion of bamlanivimab reduced the incidence of those with mild to moderate COVID-19 requiring subsequent care through the emergency department at 28 days but not hospitalizations within this time frame. No statistical difference was noted in either emergency department visits or hospitalizations in those aged 65 or greater who were treated as an outpatient with bamlanivimab for mild to moderate COVID-19.

Real world utilization of REGEN-COV2 at a community hospital.

INTRODUCTION: Monoclonal antibodies received an Emergency Use Authorization (EUA) from the U.S. Food & Drug Administration for the outpatient treatment of mild to moderate coronavirus disease 2019 (COVID-19). REGN-COV2, casirivimab and imdevimab, has been shown to decrease the viral load and healthcare visits of those with mild to moderate COVID-19 who are treated in the outpatient setting. OBJECTIVE: To determine 7- and 14-day emergency department (ED) and hospitalization rates of adult patients given REGN-COV2 for the outpatient treatment of COVID-19 at a community hospital. METHODS: A convenience sample of consecutive adult patients given REGN-COV2 from January 18, 2021 through March 31, 2021 for the outpatient treatment of mild to moderate COVID-19. Abstracted data included patient demographics, allergic reactions, ED presentations and hospitalizations at 7 and 14 days, and in-hospital mortality. RESULTS: A total of 68 patients with a medain age of 69 years (IQR 57-75.5) and 58.3% being female were given REGEN-COV2 during the study period. No allergic reactions were noted during infusion. Of those infused, 18% (12/68) were infused in the ED and had a median length of stay of 477 min. Following infusion, 10% (7/68) of patients re-presented to the ED and 2% (1/68) were hospitalized for COVID-19 at 14 days. In those aged 65 years or greater, 12% (5/42) of patients re-presented to the ED following infusion. Of those who re-presented to the emergency department, the median age was 72.5 years and the median time from infusion to re-presentation was 2.0 days. No patients suffered in-hospital mortality during the study period. CONCLUSION: There was a significant length of stay associated with REGN-COV2 infusion in the emergency department. Following REGN-COV2 infusion, few patients under the age of 65 re-presented to the emergency department at seven and 14 days. However, a large number of patients aged over 65 years re-presented to the ED following infusion.

Remdesivir for the Treatment of Severe COVID-19: A Community Hospital's Experience.

Context: Following the emergence of the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), researchers sought safe and effective treatment modalities. Remdesivir is currently being evaluated for clinical efficacy and safety in patients with COVID-19. Objective: To describe the clinical outcomes of COVID-19 patients following treatment with remdesivir at a community hospital. Methods: A retrospective review of medical records was conducted in August 2020 for all patients given remdesivir while hospitalized for severe COVID-19 between May 1 and August 19, 2020. A convenience sample of consecutive patients with treatment including remdesivir, antibiotics, convalescent plasma, dexamethasone, or a combination of multiple drugs was included in the analysis. Patients receiving remdesivir were administered a 5-day treatment course. Patients with a glomerular filtration rate of less than 30 mL/min, those with liver function tests 5 times the normal reference range, and those who were pregnant were excluded from treatment with remdesivir. Differences in between men and women were detected with χ2 and independent samples t tests. The degree to which presenting symptoms influenced patient outcomes was analyzed with a stepwise logistic regression. Results: Among the 76 patients who received remdesivir, the mean (95% confidence interval, CI) age was 63 years (59.8-66.2). Thirty-six (47.4%) were men and 40 (52.6%) were women. Forty-nine (64.5%) were White and 27 (35.5%) were nonWhite. The majority of patients (54; 71.1%) had at least 1 comorbid condition, with hypertension being the most common (43; 56.6%). The mean (95% CI) length of stay for patients who received remdesivir was 10.09 days (8.6-11.6) and the mean (95% CI) duration of oxygen therapy was 9.42 days (8.0-10.8). A total of 14 (18.4%) patients given remdesivir were admitted to the intensive care unit (ICU) with an mean (95% CI) length of stay of 9.29 days (5.6-13.0). Women administered remdesivir were more likely to be admitted to the ICU (11 [27.5%] vs 3 [8.3%]; P=.031). The mortality rate was 14 patients (18.4%), with no statistically significant difference observed between men (5; 13.9%) and women (9; 22.5%; P=.33). No significant difference was seen amongst sexes for duration of oxygen therapy (men, 8.0 days [6.2-9.8] vs women, 10.76 days [8.8-12.8]; P=.051) or length of stay (men, 8.61 days [6.7-10.5] vs women, 11.43 days [9.3-13.5]; P=.058). There was no statistically significant difference in pooled racial groups (White vs nonWhite) for in-hospital mortality, number admitted to the ICU, days spent in the ICU, duration of oxygen use, or length of stay. Conclusion: Remdesivir may show clinical efficacy for the treatment of severe COVID-19 in a community setting. Although this was a small-scale study with limited patients, it represents a point of reference for the use of remdesivir at other community hospitals.

Extended-Interval Gentamicin Dosing for Pulmonic Tularemia.

Francisella tularensis is a Gram-negative coccobacillus that is rarely encountered in clinical practice. Patients can present with cutaneous, pulmonary, cardiac, mucous membrane, or gastrointestinal involvement. A clinician should have a heightened suspicion in endemic areas or when outbreaks appear. Diagnosis is achieved through serological testing or polymerase chain reaction assays. Although historically the treatment of choice was streptomycin, gentamicin is now preferred due to its availability and relatively safer side effect profile with extended-interval dosing. Limited published evidence exists on the effectiveness of extended-interval gentamicin for tularemia. This case series describes four patients with pulmonic tularemia successfully treated with extended-interval dosing of gentamicin without treatment failure or relapse.

Emerging Fungal Infections in the Era of Antibiotic Stewardship.

Pneumonia is one of the most common causes of infection seen worldwide and still remains one of the most common causes of mortality despite significant advancements in medicine. With the increase in immunosuppression and antimicrobial usage, emerging infectious agents have been isolated in patients with pneumonia. The authors present a case in which Nonomuraea solani, Candida glabrata, and Candida dubliniensis were isolated from a bronchoalveolar lavage from an immunosuppressed patient with pneumonia.

Streptococcus gordonii: A Rare Cause of Infective Endocarditis.

Infective endocarditis is a rare but life-threatening disease seen across the globe. Organisms from the oral cavity still represent a large proportion of pathogens seen in endocarditis and can be from either daily dental routines or invasive procedures. With the recent changes to antibiotic prophylaxis for infective endocarditis prior to dental procedures, the physician must have a heightened degree of suspicion when presented with a patient with undifferenced sepsis following dental procedures. The authors present a case of infective endocarditis caused by Streptococcus gordonii after the drainage of a dental abscess.

Impact of a Pharmacist-driven Methicillin-resistant Staphylococcus aureus Polymerase Chain Reaction Nasal Swab Protocol on the De-escalation of Empiric Vancomycin in Patients with Pneumonia in a Rural Healthcare Setting.

Introduction Pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA) carries a high rate of morbidity and mortality. Many clinicians empirically treat those at risk of developing MRSA pneumonia with vancomycin. Several studies have identified a high negative predictive value of the MRSA polymerase chain reaction (PCR) nasal swab test in lower respiratory tract infections, suggesting it can be used to guide the de-escalation of empiric anti-MRSA therapy. Objective To evaluate the impact of a pharmacist-driven MRSA PCR nasal swab protocol on the de-escalation of empiric vancomycin in patients with pneumonia in a rural healthcare setting. Secondarily, to assess the rate of hospital length of stay, the rate of vancomycin-associated acute kidney injury, and in-hospital mortality after pharmacist-driven de-escalation of empiric vancomycin in patients with pneumonia.  Methods A retrospective, single-center, pre-post cohort study was conducted in patients after the implementation of a pharmacist-driven protocol allowing pharmacists to obtain nasal swabs and PCR testing for MRSA in those on empiric vancomycin therapy for suspected MRSA pneumonia. Based on negative test results, pharmacists recommended a de-escalation of empiric vancomycin to the physician. Patients were included if they were adults at least 18 years of age, had a physician diagnosis of suspected or confirmed pneumonia, and initiated on at least one dose of intravenous vancomycin within 48 hours of admission. Results A total of 79 patients were identified for inclusion in the pre-protocol group (n=32) or post-protocol group (n= 47). The mean duration of vancomycin therapy in the pre-protocol group was 3.1 days as compared to 1.7 days in the post-protocol group for a 1.4 days reduction (p=0.044). There was no significant impact on the number of vancomycin cases de-escalated within 24 hours (p=0.14) but there was a significant reduction at 48 hours (p=0.01). Protocol implementation was associated with a reduction in the average length of hospitalization (8 versus 5.20 days, p=0.006). Neither group had a vancomycin-associated acute kidney injury or in-hospital mortality. Conclusion Among patients with suspected MRSA pneumonia, a pharmacist-driven MRSA PCR nasal swab protocol resulted in a significant reduction of empiric vancomycin duration of therapy without an adverse impact on clinical outcomes in a rural healthcare setting.