RESUMO
The objective of this study was to evaluate the safety and efficacy of apixaban 5 mg twice daily vs 2.5 mg twice daily for nonvalvular atrial fibrillation or venous thromboembolism in patients with chronic kidney disease stage 4 and 5, including those on hemodialysis. Data were collected retrospectively on patients with advanced chronic kidney disease and nonvalvular atrial fibrillation and/or venous thromboembolism who received apixaban while hospitalized at our institution between January 2013 and August 2018. The 5 mg twice daily group included 22 patients, and the 2.5 mg twice daily group included 73 patients. There was no difference between groups in major bleeding events (9.1% vs. 12.3%, P = 1.00), any bleeding event (45.4% vs. 67.1%, P = 0.08), ischemic stroke (0% vs. 2.7%, P = 1.00), or venous thromboembolism (4.5% vs. 0%, P = 0.23). Subgroup analyses of patients with a serum creatinine >2.5 mg/dL or creatinine clearance <25 mL/min and patients on hemodialysis produced similar results. Until larger trials are conducted, clinicians should make patient-specific decisions about the optimal dose of apixaban in patients with severe renal impairment.
RESUMO
We retrospectively characterized scheduled, newly initiated, nocturnal neuroactive medication use, and related clinician documentation, in a cohort of consecutive adults admitted greater than or equal to 24 hours to seven different medical/surgical ICUs at two academic centers who had not received a scheduled nocturnal neuroactive medication prior to admission, over a 5-month period (April 1, 2017, to August 31, 2017). A total of 207 different newly initiated, scheduled nocturnal neuroactive medication orders were written (melatonin agonist 101 [48.8%], antipsychotic 80 [38.6%], antidepressant 17 [8.2%], benzodiazepine 9 [4.3%]) in 189 (9.7%) of the 1,955 patients. Among the 1,553 nights, the 189 patients spent in the ICU, a scheduled nocturnal neuroactive medication was administered on 1,103 (71%), an "as needed" nocturnal neuroactive medication was solely administered on 183 (11.8%), delirium occurred on 736 (47.4%), and nurses were twice as likely as physicians (28.8% vs 11.4%; p < 0.0001) to document a note about sleep quality. Among the 69.8% of patients discharged to the floor, and the 64.5% from the hospital, the scheduled nocturnal neuroactive medication was continued in 85.6% and 87.3%, respectively. Scheduled nocturnal neuroactive medication initiation is common, often continued beyond hospital discharge, and poorly documented.
RESUMO
BACKGROUND: Evidence supporting beta-lactam plus vancomycin synergy for methicillin-resistant Staphylococcus aureus (MRSA) continues to grow. Current in vivo evidence demonstrates that combination therapy is associated with shorter time to blood sterilization than vancomycin monotherapy. However, this combination has not been reported as salvage therapy for persistent MRSA bacteremia. CASE REPORT: We report a case of an 81-year-old male who was successfully treated with vancomycin plus nafcillin after failing vancomycin monotherapy, daptomycin monotherapy, and daptomycin plus gentamicin combination therapy. The patient originally presented with sepsis from a suspected urinary tract infection. Blood cultures drawn on days 1, 3, 5, 15, 19, 23, and 28 remained positive for MRSA despite multiple antimicrobial therapy changes. On day 29, therapy was changed to vancomycin plus nafcillin. Blood cultures drawn on day 32 remained negative. After 11 days, nafcillin was changed to piperacillin-tazobactam due to an infected decubitus ulcer. The combination was continued for 42 days after achieving blood sterility, 71 days after the patient originally presented. Evidence regarding salvage therapy for persistent bacteremia is sparse and is limited to case reports and case series. CONCLUSION: This case report supports that vancomycin plus an anti-staphylococcal beta-lactam combination should be further studied as salvage therapy for persistent MRSA bacteremia.
