Outcomes of a pharmacist-driven vancomycin monitoring initiative in a community hospital.

WHAT IS KNOWN AND OBJECTIVE: Vancomycin, an antibiotic commonly used to treat MRSA infections, can be nephrotoxic. Administering vancomycin requires close monitoring of serum vancomycin levels and appropriate dosing based on patients' renal function, underlying infection type and serum concentration levels. This article discusses the results and implications of a pharmacist-driven vancomycin monitoring initiative, which was implemented at Mercy Catholic Medical Center's Philadelphia Campus (MPC) in July 2016. METHODS: MPC pharmacists were trained on how to give appropriate vancomycin dosing recommendations based on patients' vancomycin trough levels, renal function and underlying infection. This retrospective observational study consisted of patients who presented to MPC and were administered vancomycin over a 3-month period in 2015 for pre-implementation cohort and over a 3-month period in 2018 for post-implementation cohort. Patients with age ≥18 and receiving vancomycin for a minimum of 48 hours were included, whereas ESRD patients were excluded. Primary goal evaluated whether the incidence of AKI decreased with the pharmacist-driven initiative. Secondary goal assessed whether vancomycin level monitoring and achievement of goal serum levels improved with the initiative. RESULTS AND DISCUSSION: A total of 214 patients were included in the final data analysis, with 110 patients in the pre-implementation cohort and 104 patients in the post-implementation cohort. Although not statistically significant, a higher incidence of AKI was observed in the post-implementation cohort. However, compared to pre-implementation cohort, post-implementation group had higher percentage of patients with underlying comorbidities (such as CKD), higher number of cases of severe sepsis and septic shock, and greater number of patients with concomitant exposure to CT contrast and piperacillin-tazobactam-all of which were confounding factors that likely increased the AKI incidence in post-implementation cohort. With the initiative, there was a significant increase in the number of patients with appropriate vancomycin trough level monitoring (27.3% vs 55.8%, p value < 0.001) in the post-implementation cohort and a decrease in the number of patients with no trough level monitoring (30% vs. 7.6%, p value < 0.001). WHAT IS NEW AND CONCLUSION: Pharmacist-driven vancomycin monitoring significantly improved the monitoring compliance of vancomycin trough levels. In patients who developed AKI during their hospital course, pharmacist interventions improved the total percentage of patients attaining desired trough goals and helped reduce further renal insult from supratherapeutic vancomycin level. Incorporation of AUC-guided dosing and monitoring has the potential to further optimize vancomycin efficacy and safety.

Hyper-Eosinophilic Syndrome Masquerading as Myocardial Infarction, Stroke and Cancer.

Hyper-eosinophilic syndrome (HES) can be fatal if left untreated; and it is difficult to make a diagnosis early on due to the symptoms overlapping with many other conditions. For patients presenting with eosinophilia and end-organ damage, clinicians should have a high degree of suspicion for HES. Treatment with steroids can prevent further progression or can lead to complete resolution of the symptoms.

Bronchogenic Cyst Presenting as Acute Pericarditis.

Bronchogenic cysts are speculated to arise from abnormal budding of the foregut tissue during embryogenesis. Around 90% of mediastinal bronchogenic cysts are asymptomatic, and a small percentage of them present with chest pain and dyspnea. Pericardial effusion is one of the manifestations described; however, pericarditis has not been widely reported. We describe a case of a bronchogenic cyst in a 19-year-old female with an initial presentation of pericarditis due to mechanical impingement. There was an associated trace to small pericardial effusion. The bronchogenic cyst was planned to be excised; however, it could only be partially excised due to its adherence to the left atrium.

Atrial fibrillation induced by peripherally inserted central catheters.

Peripherally inserted central catheters (PICCs), a form of central venous catheter (CVC) inserted into the cephalic or basilic veins, are most commonly used for administration of long-term antibiotics or for total parenteral nutrition. PICCs are associated with fewer complications than traditional CVCs; however, they have been implicated in accidental malpositioning, leading to both atrial and ventricular arrhythmias. We present a case of atrial fibrillation possibly triggered by migration of the tip of the PICC deep into the right atrium. Retraction of the tip resulted in resolution of the arrhythmia.

Remote Patient Monitoring in IBD: Current State and Future Directions.

PURPOSE OF REVIEW: Mobile apps are now increasingly used in conjunction with telemedicine and wearable devices to support remote patient monitoring (RPM). The goal of this paper is to review the available evidence and assess the scope of RPM integration into standard practices for care and management of chronic disease in general and, more specifically, inflammatory bowel disease (IBD). RECENT FINDINGS: RPM has been associated with improvements in health outcomes and indicators across a broad range of chronic diseases. However, there is limited data on the effectiveness of RPM in IBD care. From the emerging literature and body of research, we found promising results about the feasibility of integrating RPM in IBD care and RPM's capacity to support IBD improvement in key process and outcome metrics. Concerns regarding privacy and provider acceptability have limited the mass integration of RPM to date. However, with the healthcare industry's move toward value-based population care and the advent of novel payment models for RPM reimbursement, the adoption of RPM into standard IBD care practices will likely increase as the technology continues to improve and become a mainstream tool for healthcare delivery in the near future.