Ashley E. Woodruff

Daptomycin-Nonsusceptible Vancomycin-Intermediate Staphylococcus aureus Vertebral Osteomyelitis Cases Complicated by Bacteremia Treated with High-Dose Daptomycin and Trimethoprim-Sulfamethoxazole

ABSTRACT We report two cases of daptomycin (DAP)-nonsusceptible (DNS) vancomycin-intermediate Staphylococcus aureus (VISA) vertebral osteomyelitis cases complicated by bacteremia treated with high-dose daptomycin and trimethoprim-sulfamethoxazole. Both patients responded rapidly and favorably to this combination. The clinical isolates from the two patients were tested post hoc in an in vitro pharmacokinetic/pharmacodynamic (PK/PD) model to confirm the bactericidal activity and enhancement of daptomycin and trimethoprim-sulfamethoxazole. The combination of high-dose daptomycin and trimethoprim-sulfamethoxazole should be explored further for the treatment of DNS VISA strains.

Abdominal Migraine in Adults: A Review of Pharmacotherapeutic Options

OBJECTIVE: To report the case of a 32-year-old woman with abdominal migraine and present a literature review to evaluate abdominal migraine in adults, with particular regard to effective treatment. CASE SUMMARY: A 32-year-old African American female presented with recurrent, severe abdominal pain. The patient had several previous admissions with similar symptoms and an extensive gastrointestinal workup in which findings were normal. Attacks of abdominal pain occurred despite treatment with analgesics and antiemetics. She had a family history of migraine headaches. A diagnosis of abdominal migraine was presumed and prophylactic therapy with topiramate 50 mg twice daily relieved the symptoms. DISCUSSION: Most published cases of adult abdominal migraine describe females who had a long history of abdominal pain refractory to conventional therapies. The majority of patients had a strong family history of migraine and reported similar episodic abdominal pain. Patients responded to prophylactic migraine therapies, including calcium channel blockers, β-blockers, topiramate, and antihistamines; a few responded to abortive sumatriptan therapy. CONCLUSIONS: Abdominal migraine should be considered a possible source of incurable abdominal pain in adults when accompanied by a complete gastrointestinal workup with normal results. We recommend a trial of topiramate as prophylactic therapy if abdominal migraine is the likely source of the pain.

Efficacy and Safety of High-Dose Subcutaneous Unfractionated Heparin Prophylaxis for the Prevention of Venous Thromboembolism in Obese Hospitalized Patients.

Background Obese patients experience a higher risk of venous thromboembolism (VTE) than their nonobese counterparts, which may warrant a more aggressive approach to thromboprophylaxis in this population. Objective The purpose of this study was to compare rates of nosocomial VTE in obese patients treated with high-dose versus conventional-dose subcutaneous unfractionated heparin sodium (UFH) for thromboprophylaxis. Methods A retrospective, single-center, cohort study was conducted to evaluate obese, adult, hospitalized patients admitted between April 2011 and April 2014 who received heparin 5,000 or 7,500 units subcutaneously every 8 hours for thromboprophylaxis. The primary outcome assessed the rate of nosocomial VTE in obese patients treated with high-dose heparin (7,500 units subcutaneously q 8 h) versus conventional-dose heparin (5,000 units subcutaneously q 8 h). Additionally, a secondary outcome assessed safety by quantifying bleeding events. Results Nosocomial VTE occurred in 2/196 (1.02%) patients who received high-dose heparin thromboprophylaxis and in 5/2,182 (0.23%) patients who received conventional-dose heparin (p = .05). Bleeding occurred in 0/196 (0%) patients in the high-dose heparin group and in 2/2,182 (0.09%) patients in the conventional-dose heparin group (p = .67). All bleeding events were minor. Conclusions This study failed to demonstrate a statistically significant reduction in the rate of nosocomial VTE in obese patients who received high-dose heparin thromboprophylaxis. Despite receiving a higher heparin dose, no increased risk of bleeding was observed in the high-dose group. Further investigation is needed to identify the optimal heparin dose for thromboprophylaxis in obese patients.

Discharge Diuretic Dose and 30-Day Readmission Rate in Acute Decompensated Heart Failure:

Background: Loop diuretics play a crucial role in symptom management in patients with fluid overload. There is a paucity of data regarding optimal diuretic dose at hospital discharge for acute decompensated heart failure (ADHF) patients requiring loop diuretics. Objective: To compare all-cause 30-day readmission in ADHF patients on chronic loop diuretics who had an increase in loop diuretic dose at discharge (relative to their preadmission dose) with patients without a change or a decrease in loop diuretic dose at discharge. Methods: This was a multicenter, retrospective cohort study. Institutional review board approval was obtained. Patients admitted with a primary discharge diagnosis of heart failure, evidence of fluid overload, and reduced ejection fraction were included. Patients were divided into 2 groups based on total daily loop diuretic dose at discharge: those discharged on an increased dose and those discharged on a dose less than or equal to their preadmission dose. Results: A total of 131 patient admissions met inclusion criteria; 50 had an increase in loop diuretic dose at discharge, and 81 were discharged with no change or a decrease in diuretic dose. Patients in the increased dose group had an all-cause 30-day readmission rate of 20% compared with 38% of patients with no change or a decrease in diuretic dose (adjusted odds ratio = 0.320; 95% CI = 0.117-0.873). Conclusion: In patients admitted for ADHF with reduced ejection fraction and evidence of fluid overload, an increase in loop diuretic dose at discharge was associated with a reduced rate of 30-day hospital readmission.

Advanced Screencasting With Embedded Assessments in Pathophysiology and Therapeutics Course Modules

Objective. To implement and assess the effectiveness of a hybrid learning model using advanced screencasting with embedded assessments in pathophysiology and therapeutics modules. Design. Two pathophysiology and therapeutics course modules on viral hepatitis and the clinical pharmacokinetics of aminoglycosides were chosen for study. The preclass portion of the hybrid model involved student completion of interactive e-lectures that were created with the use of advanced screencasting and included embedded assessments. Students viewed the e-lectures and completed the assessment questions prior to in-class lecture. Assessment. Preimplementation and postimplementation test scores were compared and student survey data were analyzed. Test scores improved significantly and students’ perceptions of the learning method were favorable. Test scores improved most significantly on higher-level Bloom’s taxonomy questions. Conclusion. A hybrid model that used advanced screencasting with embedded assessments offered a novel method to afford students active-learning opportunities to progress to higher cognitive domains of learning.

Comparing Pharmacotherapy Instruction to the 2009 and 2016 ACCP Toolkit Recommendations

Objective. To compare pharmacotherapy instruction in Doctor of Pharmacy (PharmD) programs with the 2009 and 2016 American College of Clinical Pharmacy (ACCP) pharmacotherapy toolkits. Methods. A survey was sent to representatives at US schools and colleges with PharmD programs. The survey consisted of questions pertaining to pharmacotherapy credit-hours, contact time spent for each therapeutic subject area, and pedagogical methods used. Data were analyzed using descriptive statistics. Results. Representatives from 75 of 129 PharmD programs responded (response rate 58%). A median of 23 credit-hours were devoted to required pharmacotherapy. Infectious diseases and cardiology were taught with the most number of contact hours. Lecture was the most popular principal method of instruction delivery but the incorporation of case-based learning was also common. Conclusion. Devoted curricular time to pharmacotherapy is adequate to provide coverage of tier 1 and 2 topics from the ACCP toolkit. PharmD programs should continue to review their pharmacotherapy coursework to adjust topic coverage as needed to incorporate active learning strategies whenever possible.

Impact of a pharmacist-driven transition of care program for patients with acute coronary syndromes

Pharmacist‐driven transition of care (TOC) initiatives have been shown to reduce rates of medication errors and readmission rates in several patient populations, including heart failure. Existing literature evaluating pharmacist‐driven TOC initiatives targeting patients with acute coronary syndromes (ACSs) are limited.

Association between prothrombin time and bleeding in hospitalized patients receiving rivaroxaban

Purpose. Results of an investigation of the pharmacodynamic effect of rivaroxaban anticoagulation, as measured by prothrombin time (PT), on bleeding risk and other outcomes in hospitalized patients are reported. Methods. In a single‐center retrospective cohort study, adult inpatients who had a PT measured within 24 hours after rivaroxaban administration during a designated 23‐month period were identified. Patients who experienced in‐hospital bleeding events were compared with those who did not. A multivariable logistic regression model was used to quantify the association between PT and bleeding events while adjusting for albumin levels and use of nonsteroidal antiinflammatory drugs and/or antiplatelet agents. Thromboembolic events were assessed as a secondary outcome. Results. A total of 199 patients met the criteria for inclusion in the analysis; 41 experienced a bleeding event. Among patients with a PT of ≥30 seconds versus a PT of <30 seconds, the overall rate of bleeding events was significantly higher (38.7% versus 17.3%, p = 0.0067). Results of multivariable regression modeling showed that a PT of ≥30 seconds correlated with an approximately 3‐fold higher bleeding risk (odds ratio, 3.25; 95% confidence interval, 1.09–9.66). Hypoalbuminemia was also a positive predictor of bleeding risk. There was no significant between‐group difference in thromboembolic events. Conclusion. In hospitalized patients receiving rivaroxaban who had coagulation tests performed, a PT of ≥30 seconds was associated with a higher risk of bleeding. Hypoalbuminemia was also associated with bleeding in this population.

Azithromycin-Induced, Biopsy-Proven Acute Interstitial Nephritis in an Adult Successfully Treated with Low-Dose Corticosteroids

Acute interstitial nephritis (AIN) is a form of acute kidney injury (AKI) characterized by a rapid deterioration of renal function, inflammatory infiltration of interstitial tissues, and renal edema. Drug‐induced AIN is the most common etiology of AIN, but AIN can also have infectious, autoimmune, or idiopathic causes. β‐Lactam antibacterials, nonsteroidal antiinflammatory drugs, and proton pump inhibitors are recognized as leading causes of AIN; however, many other drugs have been identified as causes. We describe the case of a 59‐year‐old white male who developed AIN that required hemodialysis following azithromycin treatment. He presented to the hospital with complaints of nausea, vomiting, malaise, and fever over the past 3 days, along with no urine output in the preceding 24 hours. Two weeks earlier, he had completed a 5‐day course of azithromycin 500 mg on day 1 followed by 250 mg/day on days 2–5 (total dose 1.5 g) for an upper respiratory tract infection. On admission, the patients serum creatinine (Scr) concentration was 7.4 mg/dl (baseline = 1.3 mg/dl). He reported a similar episode of kidney failure 2 years earlier after taking azithromycin; however, at that time it was believed the AKI was likely due to benazepril use in the setting of acute infection, and a kidney biopsy was not performed. His Scr concentration peaked at 11.4 mg/dl, and three sessions of hemodialysis were required. A kidney biopsy was performed that revealed AIN. Low‐dose prednisone 0.3 mg/kg (30 mg)/day, tapered over the next 3 months, was administered, and his renal function improved to near baseline prior to discharge; 6 months later, his Scr concentration was 1.4 mg/dl. Despite lower than recommended dosing, this patient responded well to prednisone and did not experience long‐term sequelae from renal injury. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a definite relationship (score of 10) between azithromycin exposure and the manifestation of AIN. To our knowledge, this is the first report of azithromycin‐induced acute interstitial nephritis with near‐complete resolution of renal injury in an adult. This case report illustrates the importance of rapid recognition of drug‐induced renal injuries and discontinuation of the offending agent. Select use of corticosteroids may improve both time to and extent of renal function recovery.