Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting

Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST

Penicillin Allergy Skin Testing in the Inpatient Setting

The consequences of a documented penicillin allergy in the medical record are especially troublesome in acutely ill, hospitalized patients. A penicillin allergy label may lead to alternative or second line therapies resulting in adverse drug events, negative clinical outcomes and increased costs. Reconciling penicillin allergies is a necessity to facilitate early, optimal therapy and is a shared responsibility among the healthcare team. Penicillin skin testing (PST) has been utilized successfully in hospitalized patients to de-label erroneous penicillin allergies and optimize antibiotic therapy. This targeted review aims to discuss the practical development and implementation of PST in the inpatient setting. This includes a needs assessment checklist with common considerations allowing for customization to one’s institution based on available personnel, time, and technological resources

Multicenter, observational cohort study evaluating third-generation cephalosporin therapy for bloodstream infections secondary to enterobacter, serratia, and citrobacter species

Objectives: There is debate on whether the use of third-generation cephalosporins (3GC) increases the risk of clinical failure in bloodstream infections (BSIs) caused by chromosomally-mediated AmpC-producing Enterobacterales (CAE). This study evaluates the impact of definitive 3GC therapy versus other antibiotics on clinical outcomes in BSIs due to Enterobacter, Serratia, or Citrobacter species. Methods: This multicenter, retrospective cohort study evaluated adult hospitalized patients with BSIs secondary to Enterobacter, Serratia, or Citrobacter species from 1 January 2006 to 1 September 2014. Definitive 3GC therapy was compared to definitive therapy with other non-3GC antibiotics. Multivariable Cox proportional hazards regression evaluated the impact of definitive 3GC on overall treatment failure (OTF) as a composite of in-hospital mortality, 30-day hospital readmission, or 90-day reinfection. Results: A total of 381 patients from 18 institutions in the southeastern United States were enrolled. Common sources of BSIs were the urinary tract and central venous catheters (78 (20.5%) patients each). Definitive 3GC therapy was utilized in 65 (17.1%) patients. OTF occurred in 22/65 patients (33.9%) in the definitive 3GC group vs. 94/316 (29.8%) in the non-3GC group (p = 0.51). Individual components of OTF were comparable between groups. Risk of OTF was comparable with definitive 3GC therapy vs. definitive non-3GC therapy (aHR 0.93, 95% CI 0.51–1.72) in multivariable Cox proportional hazards regression analysis. Conclusions: These outcomes suggest definitive 3GC therapy does not significantly alter the risk of poor clinical outcomes in the treatment of BSIs secondary to Enterobacter, Serratia, or Citrobacter species compared to other antimicrobial agents

Intravenous ibuprofen: the first injectable product for the treatment of pain and fever

This paper reviews the current data on the use of the first approved intravenous ibuprofen product for the management of post-operative pain and fever in the United States. The management of acute and post-operative pain and fever with nonsteroidal anti-inflammatory agents (NSAIDs) is well documented. A search in Medline and International Pharmaceutical Abstracts of articles until the end of November 2009 and references of all citations were conducted. Available manufacturer data on file were also analyzed for this report. Several randomized controlled studies have demonstrated the opioid-sparing and analgesic effects of 400 and 800 mg doses of intravenous ibuprofen in a series of post-operative patient populations. Two recent studies have also noted the improvement in fever curves in critically ill and burn patients. These data, along with pharmacokinetic and pharmacologic properties, are explored in this review, which addresses the clinical utility of a parenteral NSAID in a hospitalized patient for post-operative pain management and fever reduction. Further data on intravenous ibuprofen are needed to define long-term utilization, management of acute pain, and use in special populations

Real-world, multicentre evaluation of the incidence and risk factors for non-susceptible Stenotrophomonas maltophilia isolates

Background: Stenotrophomonas maltophilia is a cause of infection most commonly in the opportunistic host. Trimethoprim-sulfamethoxazole and levofloxacin are considered first-line treatment agents. With reports of increasing resistance to these first-line agents, it is important to determine risk factors associated with a non-susceptible isolate. Methods: This was a real-world, multicentre, retrospective case-control study from five centres in the southeast United States evaluating S. maltophilia. The primary outcome was risk factors associated with non-susceptibility of S. maltophilia isolates to ≥1 antimicrobial agents. Secondary outcomes include incidence of S. maltophilia non-susceptibility, all-cause mortality, and 30-day readmission rates. Results: There were 325 patients included in the study. For the primary outcome, the only factor associated with non-susceptibility per univariate analysis was isolation from urine culture (13.3% vs. 5.4%; P = 0.014), whereas the presence of mechanical ventilation (37.7% vs. 21.5%) and intensive care unit admission (35.3% vs. 18.4%) were associated with susceptibility (P \u3c 0.001). For the secondary outcomes, non-susceptibility was present in 49% of isolates with 43 of 325 (13.2%), 53 of 324 (16.4%), and 105 of 172 (61%) to TMP-SMX, levofloxacin, and ceftazidime, respectively. Resistance to chloramphenicol and tigecycline was observed among 5/26 and 11/16 of tested isolates, respectively. Sixty-six patients (20%) experienced all-cause, inpatient mortality (18% susceptible vs. 23% non-susceptible; P = 0.280) and 44 patients (17%) were readmitted within 30 days of discharge (16% susceptible vs. 18% non-susceptible; P = 0.673). Conclusion: S. maltophilia non-susceptibility had a prevalence of ∼50% to at least one first-line or commonly used agent. More research is needed to delineate risk factors for non-susceptible isolates

Antibiotic Lock Therapy: Review of Technique and Logistical Challenges

Antibiotic lock therapy (ALT) for the prevention and treatment of catheter-related bloodstream infections is a simple strategy in theory, yet its real-world application may be delayed or avoided due to technical questions and/or logistical challenges. This review focuses on these latter aspects of ALT, including preparation information for a variety of antibiotic lock solutions (ie, aminoglycosides, beta-lactams, fluoroquinolones, folate antagonists, glycopeptides, glycylcyclines, lipopeptides, oxazolidinones, polymyxins, and tetracyclines) and common clinical issues surrounding ALT administration. Detailed data regarding concentrations, additives, stability/compatibility, and dwell times are summarized. Logistical challenges such as lock preparation procedures, use of additives (eg, heparin, citrate, or ethylenediaminetetraacetic acid), timing of initiation and therapy duration, optimal dwell time and catheter accessibility, and risks of ALT are also described. Development of local protocols is recommended in order to avoid these potential barriers and encourage utilization of ALT where appropriate

Direct Measurement of Performance: A New Era in Antimicrobial Stewardship

Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST

Impact of Outpatient vs Inpatient ABSSSI Treatment on Outcomes: A Retrospective Observational Analysis of Medical Charts Across US Emergency Departments

Background The objective of this study was to characterize treatment of patients with acute bacterial skin and skin structure infections (ABSSSIs) and describe the association between hospital admission and emergency department (ED) visits or readmissions within 30 days after initial episode of care (IEC). Methods This was a retrospective, observational, cohort study of adults with ABSSSI who presented to an ED between July 1, 2012, and June 30, 2013. Patient, health care facility, and treatment characteristics, including unplanned ED visits or readmissions, were obtained through manual chart review and abstraction. Adjusted logistic regression analysis examined likelihood of all-cause unplanned ED visits or readmissions between admitted and nonadmitted patients. Results Records from 1527 ED visits for ABSSSI from 40 centers were reviewed (admitted, n = 578 [38%]; nonadmitted, n = 949 [62%]). Admitted patients were typically older (mean age, 52.2 years vs 43.0 years), more likely to be morbidly obese (body mass index \u3e 40 kg/m2; 17.3% vs 9.1%), and had more comorbidities (Charlson Comorbidity Index ≥ 4; 24.4% vs 6.8%) compared with those not admitted. In the primary analysis, adjusted logistic regression, controlling for comorbidities and severity of illness, demonstrated that there was a similar likelihood of all-cause unplanned ED visits or readmissions between admitted and nonadmitted patients (odds ratio, 1.03; 95% confidence interval, 0.74–1.43; P = .87). Conclusions ABSSSI treatment pathways leveraging outpatient treatment vs hospital admission support similar likelihood of unplanned 30-day ED visits or readmissions, an important clinical outcome and quality metric at US hospitals. Further research regarding the decision criteria around hospital admission to avoid potentially unnecessary hospitalizations is warranted

Differences in hospital glycemic control and insulin requirements in patients recovering from critical illness and those without prior critical illness

INTRODUCTION: Hospital patients recovering from critical illness on general floors often receive insulin therapy based on protocols designed for patients admitted directly to general floors. The objective of this study is to compare glycemic control and insulin dosing in patients recovering from critical illness and those without prior critical illness. METHODS: Medical record review of blood glucose measurements and insulin dosing in 25 patients under general ward care while transitioning from the intensive care unit (transition group) and 25 patients admitted directly to the floor (direct floor group). RESULTS: Average blood glucose did not differ significantly between groups (transition group 9.49 mmol/L, direct floor group 9.6 mmol/L; P = 0.83). Significant differences in insulin requirements were observed between groups with average daily doses of 55.9 units in patients transitioning from the intensive care unit (ICU) versus 25.6 units in the direct floor group (P = 0.004). CONCLUSIONS: Patients recovering from critical illness required significantly larger doses of insulin than those patients admitted directly to the floor. Managing insulin therapy in patients transitioning from the ICU may require greater insulin doses

Clinical Outcomes of Antimicrobial Lock Solutions Used in a Treatment Modality: A Retrospective Case Series Analysis

BACKGROUND: Antimicrobial lock therapy (ALT) may be considered as adjunctive therapy in the treatment of catheter-related bloodstream infections (CRBSI) when catheter removal is not a favorable option. OBJECTIVE: To evaluate the outcomes associated with ALT as adjunctive treatment of CRBSI. METHODS: This was a 24-month retrospective case series analysis evaluating patients treated for more than 24 hours with ALT. The primary outcome was blood culture sterilization for 30 days posttherapy. The impact of ALT duration and time to initiation on central venous catheter (CVC) salvage were evaluated. Logistic regression modeled the association between ALT and sterilization rates, with a prespecified level of significance (α) of 0.1. RESULTS: Twenty-six cases were included in data analysis. Patients included ranged from 5 months to 82 years of age; 77% of patients were receiving total parenteral nutrition or chemotherapy. The majority of patients received vancomycin, daptomycin, or gentamicin combined with heparin in a lock solution. Blood culture sterilization was achieved in 69.2% of cases, and sterilization plus CVC retention was achieved in 11 cases (42.3%). Longer durations of ALT (≥9 days) were significantly correlated with blood culture sterilization (odds ratio = 1.367, P = 0.077). CONCLUSION: ALT used as an adjunct to systemic therapy for adequate duration in CRBSI can achieve CVC sterilization and retainment without subsequent infectious complications