The association between empiric antimicrobial therapy and the risk of clinical failure in critically ill patients with aspiration pneumonia.

WHAT IS KNOWN AND OBJECT: Aspiration pneumonia is a clinically important infectious process that can result in increased morbidity and mortality. Empiric antimicrobial therapy with activity against anaerobes has been a standard practice based on previous studies, which isolated anaerobes from respiratory cultures. Recent studies have failed to identify anaerobes as causative pathogens, however, these studies did not assess patient outcomes based on the presence or absence of anaerobic coverage. METHODS: This retrospective cohort study evaluated patients at least 18 years of age requiring mechanical ventilation diagnosed with aspiration pneumonia between 1 October 2020 and 31 July 2021. The primary outcome was the incidence of clinical failure. Secondary outcomes included the time to clinical failure, the incidence of Clostridioides difficile infections and development of multidrug-resistant infections, as well as time on mechanical ventilation and intensive care unit length of stay. RESULTS: A total of 141 patients were included with 83 patients initially receiving anaerobic coverage and 58 patients treated without anaerobic coverage. There was no difference in the incidence of clinical failure between cohorts (18.1% vs. 22.4%; p = 0.41). There was a statistically significant difference in anaerobic escalations with more escalations in the cohort without anaerobic coverage (0% vs. 20.7%; p < 0.0001). Patients initially treated with drugs with anaerobic activity had a higher incidence of multidrug resistant infections on current admission (7.2% vs. 0%; p = 0.04) and a longer length of intensive care unit stay. WHAT IS NEW AND CONCLUSION: In critically ill adults with aspiration pneumonia, our study found no difference in clinical failure based on the presence or absence of empiric anaerobic coverage adding to evolving literature suggesting that anaerobic coverage is not routinely warranted in this patient population. Interpretation of the results needs to consider, however, that the retrospective design led to the inclusion of sicker patients in the anaerobic cohort. The frequency of empiric anaerobic coverage demonstrates the need for a prospective randomized control trial to confirm these findings.

Breakthrough venous thromboembolic events in five patients with COVID-19 on direct oral anticoagulants.

WHAT IS KNOWN AND OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with increased risk of venous thromboembolism (VTE). Guidance for VTE prophylaxis continues to evolve, including addressing direct oral anticoagulants (DOACs) continued upon hospitalization. CASE SUMMARIES: We present 5 patients hospitalized for COVID-19 while on DOACs. Four patients had atrial fibrillation and had a previous VTE. Four patients developed acute VTE and one developed stroke-like symptoms. Monitoring D-dimer assisted with the detection of VTE. Three patients died, and two were discharged alive. WHAT IS NEW AND CONCLUSION: Therapeutic failure with DOACs appears to be commonplace in COVID-19. Further research is needed to determine whether there is an underlying cause to this association.

Engaging student pharmacists to improve Hospital Consumer Assessment of Health Care Providers and Systems scores.

INTRODUCTION: Student pharmacists have historically served in shadowing roles for their experiential training at our institution. However, engaging students through active learning assignments has the potential to benefit both the student and the institution. The purpose of this project was to evaluate the impact of student pharmacists on Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) scores, a direct reflection of patient satisfaction within the hospital. METHODS: In a four-month quality-improvement pilot project, student pharmacists were given active learning assignments directed at helping patients understand the purpose and side effects of their medications. Patients with hospital-initiated medications were provided with medication cards via student pharmacist-run counseling programs. The primary outcome was top response ("always") in medication-related HCAHPS scores. Secondary outcomes included scores on individual questions, number of medication education encounters, number of interventions, cost savings, and student feedback. RESULTS: There were 482 medication education encounters. The top response for all medication-related HCAHPS scores improved by 14% (49% to 63%). Top response regarding medication indication increased 23% (63% to 86%). There were 552 interventions accepted, projecting a savings of $135,658. The top score on student evaluations of the practice site increased 20% (69% to 89%). CONCLUSIONS: Student pharmacists can have a meaningful impact on medication-related HCAHPS scores. Additionally, student pharmacists benefit from active learning opportunities by providing and improving patient care leading to a more meaningful experience.

Failure of ceftolozane-tazobactam salvage therapy in complicated pneumonia with lung abscess.

Treatment of Pseudomonas aeruginosa remains challenging, despite the availability ceftolozane-tazobactam. We report a treatment failure with ceftolozane-tazobactam salvage therapy for pneumonia complicated by lung abscess. Drug resistance, dose selection, and source control are possible contributing factors. Ceftolozane-tazobactam susceptibility testing should precede therapy and consideration should be given to dosing selection.

Implementation of Global Strategies to Prevent Hospital-Onset Clostridium difficile Infection: Targeting Proton Pump Inhibitors and Probiotics.

BACKGROUND: Proton pump inhibitors (PPIs) have been identified as a significant risk factor for the development of Clostridium difficile infection (CDI). Probiotics given concurrently with antibiotics have been shown to have a moderate impact on preventing CDI. OBJECTIVE: To evaluate the effectiveness of hospital-wide interventions designed to reduce PPI use and increase probiotics and whether these interventions were associated with a change in the incidence of hospital onset (HO)-CDI. METHODS: This retrospective cohort study compared 2 fiscal years: July 2013 to June 2014 (FY14) and July 2014 to June 2015 (FY15). In July of FY15, global educational initiatives were launched targeting PPIs. Additionally, a HO-CDI prevention bundle was added to antibiotic-containing order sets targeting probiotics. Overall PPI use, probiotic use, and incidence of HO-CDI were recorded and compared for each cohort. Charts were also reviewed for patients who developed HO-CDI for the presence and appropriateness of a PPI and presence of probiotics. RESULTS: The interventions resulted in a decrease in PPI use by 14% or 96 doses/1000 patient days (TPD; P = 0.0002) and a reduction in IV PPI use by 31% or 71 doses/TPD ( P = 0.0008). Probiotic use increased by 130% or 126 doses/TPD ( P = 0.0006). The incidence of HO-CDI decreased by 20% or 0.1 cases/TPD ( P = 0.04). CONCLUSIONS: A collaborative, multifaceted educational initiative directed at highlighting the risks associated with PPI use was effective in reducing PPI prescribing. The implementation of a probiotic bundle added to antibiotic order sets was effective in increasing probiotic use. These interventions were associated with a decrease in incidence of HO-CDI.

Risk and Severity of Hospital-Acquired Clostridium difficile Infection in Patients Taking Proton Pump Inhibitors.

STUDY OBJECTIVE: To compare the rates and severity of hospital-acquired Clostridium difficile infection (CDI) among patients taking proton pump inhibitors (PPIs) versus those not taking PPIs. DESIGN: Retrospective, single-center, cohort study. SETTING: Tertiary community hospital with a teaching service. PATIENTS: A total of 41,663 patients with CDI who were hospitalized between January 2013 and May 2014; of those, 17,471 patients (41.9%) had received at least one dose of a PPI (PPI group), and 24,192 patients (58.1%) had no PPI exposure (control group). MEASUREMENTS AND MAIN RESULTS: A total of 348 patients had CDI during the study period, with 269 cases present on admission. Hospital-acquired CDI was defined as CDI diagnosis occurring on or after the third calendar day of admission. After excluding those patients with CDI on admission, 65 (0.38%) of 17,302 patients later developed CDI in the hospital in the PPI group compared with only 14 (0.058%) of 24,092 patients in the control group. Of these patients, 36 patients (0.21%) in the PPI group met the definition of severe CDI compared with 8 (0.03%) in the control group. This demonstrated an unadjusted relative risk (RR) of 6.46 (95% confidence interval [CI] 3.63-11.51, p<0.0001) of developing hospital-acquired CDI and an unadjusted RR of 6.27 (95% CI 2.91-13.48, p<0.0001) of developing severe CDI while taking a PPI. When evaluating only patients who developed severe-complicated CDI, there were 22 cases in the PPI group and 2 cases in the control group, demonstrating an unadjusted RR of 15.3 (95% CI 3.6-65.13, p=0.0002) of developing severe-complicated CDI. Confounding variables were similar between groups. CONCLUSION: PPI use was associated with an increase in both the rate and severity of hospital-acquired CDI.

Evaluation of extended interval dosing aminoglycosides in the morbidly obese population.

Aminoglycoside dosing has been studied in the obese population, typically recommending an adjusted weight utilizing a 40% dosing weight correction factor (IBW + 0.4 × (TBW-IBW)). These studies included limited numbers of morbidly obese patients and were not done in the era of extended interval aminoglycoside dosing. Here, we report a retrospective evaluation of morbidly obese patients receiving gentamicin or tobramycin at our hospital. The objective of this study was to evaluate the accuracy of the commonly recommended adjusted weight for weight-based dosing. There were 31 morbidly obese patients who received gentamicin or tobramycin 5-7 mg/kg every 24 hours using a 40% dosing weight correction factor. Our institution utilizes 16-hour postdose concentrations to monitor extended interval aminoglycosides. Twenty-two of the 31 patients (71%) achieved an appropriate serum drug concentration. Four patients (13%) were found to be supratherapeutic and 5 patients (16%) subtherapeutic. The only variable that correlated with supratherapeutic levels was older age (P = 0.0378). Our study helps to validate the current dosing weight correction factor (40%) in the morbidly obese population. We recommend caution when dosing aminoglycosides in morbidly obese patients who are of older age.