RESUMO
OBJECTIVE: Blood cultures (BCx) are important for selecting appropriate antibiotic treatment. Ordering BCx for conditions with a low probability of bacteremia has limited utility, thus improved guidance for ordering BCx is needed. Inpatient studies have implemented BCx algorithms, but no studies examine the intervention in an Emergency Department (ED) setting. METHODS: We performed a quasi-experimental pre and postintervention study from January 12, 2020, to October 31, 2023, at a single academic adult ED and implemented a BCx algorithm. The primary outcome was the blood culture event rates (BCE per 100 ED admissions) pre and postintervention. Secondary outcomes included adverse event rates (30-day ED and hospital readmission and antibiotic days of therapy). Seven ED physicians and APP reviewed BCx for appropriateness, with monthly feedback provided to ED leadership and physicians. RESULTS: After the BCx algorithm implementation, the BCE rate decreased from 12.17 BCE/100 ED admissions to 10.50 BCE/100 ED admissions. Of the 3,478 reviewed BCE, we adjudicated 2,153 BCE (62%) as appropriate, 653 (19%) as inappropriate, and 672 (19%) as uncertain. Adverse safety events were not statistically different pre and postintervention. CONCLUSIONS: Implementation of an ED BCx algorithm demonstrated a reduction in BCE, without increased adverse safety events. Future studies should compare outcomes of BCx algorithm implementation in a community hospital ED without intensive chart review.
RESUMO
BACKGROUND: Mobile calcified emboli are a rare cause of large vessel occlusion and acute ischemic stroke and pose unique challenges to standard mechanical thrombectomy techniques. Intracranial stenting has been reported as a rescue maneuver in cases of failed mechanical thrombectomy owing to dissection or calcified atherosclerotic plaques, but its use for calcified emboli is not well described. CASE DESCRIPTION: We present 2 cases of acute ischemic stroke caused by mobile calcified emboli. Standard mechanical thrombectomy techniques using aspiration catheters and stent-retrievers failed to remove these emboli, so intracranial stenting was successfully performed in each case, albeit after overcoming unique challenges associated with the stenting of calcified emboli. We also review the literature on intracranial stenting as a salvage therapy for failed mechanical thrombectomy. CONCLUSIONS: Mobile calcified emboli are rare causes of acute ischemic stroke. Intracranial stenting can be used to successfully treat calcified emboli when mechanical thrombectomy has failed.
