Lindsay Saum

Impact of Evidence-Based Guidelines on Outcomes of Hospitalized Patients With Clostridium difficile Infection.

Objectives Clostridium difficile infection (CDI) is the most common healthcare-associated infection in the United States. Clinical practice guidelines for the treatment of CDI were updated in 2010 by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. An institutional guideline for the classification and management of CDI in accordance with the 2010 Society for Healthcare Epidemiology of America/Infectious Diseases Society of America guideline was developed and provided to attending physicians and medical residents in multiple formats. Methods We sought to determine the impact of an evidence-based guideline for the treatment of CDI at a community teaching hospital. A retrospective chart review was conducted to identify length of stay (LOS), readmission rates, direct cost, mortality, and physician adherence to guidelines in patients with International Classification of Diseases, Ninth Edition codes and laboratory confirmation of CDI between February 1, 2013 and January 31, 2014. Endpoints included LOS after diagnosis of CDI, 30-day readmission rates, direct cost after diagnosis of CDI, and mortality. Results A total of 351 patient encounters were included in the study. Although not statistically significant, it was found that guideline-based therapy (n = 131) was associated with a lower median LOS (6 days vs 8 days; P = 0.06). Thirty-day hospital readmission (25.2% vs 29.5%; P = 0.39) and median cost after diagnosis of CDI (

I.V. ascorbic acid for treatment of apparent rasburicase-induced methemoglobinemia in a patient with acute kidney injury and assumed glucose-6-phosphate dehydrogenase deficiency

7238.48 vs

Benzodiazepine Initiation and Dose Escalation: A Risk Factor for Inpatient Falls

8794.81; P = 0.10) also were lower but not statistically significant. Patients with mild-to-moderate infection were found to have a significantly lower median LOS (5 days vs 7 days; P = 0.03) and median cost after diagnosis (

Ceftriaxone Potentiates Warfarin Activity Greater Than Other Antibiotics in the Treatment of Urinary Tract Infections

5257.85 vs

Venous Thromboembolism Prophylaxis Compliance Before and After Electronic Health Record Implementation

7680.56; P = 0.03) when treated with guideline-based therapy. Overall physician adherence to guidelines was low, at 38%. Conclusions Treatment with guideline-based therapy for CDI was associated with a trend toward a significantly lower LOS and cost. Barriers to physician adherence to guidelines still exist, despite education and guideline availability. Electronic health record–based order sets or clinical decision tools may improve recognition of and adherence to guidelines.

Assessing the Accuracy and Quality of Medication History Collection: Effect of Implementation of Electronic Health Record [abstract]

PURPOSE A case of apparent rasburicase-induced methemoglobinemia and acute kidney injury treated with i.v. ascorbic acid because of suspected glucose-6-phosphate dehydrogenase (G6PD) deficiency is reported. SUMMARY A 46-year-old African-American man with a recent diagnosis of multiple myeloma and renal insufficiency was admitted to the hospital with a cough, hemoptysis, and fatigue. His medical history included hypertrophic cardiomyopathy, ventricular tachycardia, attention deficit/hyperactivity disorder, and pleural effusion. No treatments for multiple myeloma were started before hospital admission. Levofloxacin 750 mg orally daily for possible pneumonia, lenalidomide 10 mg orally daily, and dexamethasone 20 mg orally weekly were administered. Plasmapheresis was also initiated. Laboratory test results revealed sustained hyperuricemia, which was believed to be due in part to tumor lysis, and a single dose of rasburicase 6 mg i.v. was administered. Subsequently, the patient experienced a decrease in oxygen saturation. Methemoglobinemia was suspected, and the patients methemoglobin fraction was found to be 14.5%. The patient developed worsening shortness of breath and a drop in hemoglobin concentration, consistent with methemoglobinemia and hemolysis. Ascorbic acid 5 g i.v. every 6 hours was initiated for a total of six doses. Because the patient was assumed to have G6PD deficiency, which was later confirmed, methylene blue was avoided. Within 24 hours, the patients oxygen saturation values and symptoms improved. CONCLUSION A patient with apparent rasburicase-induced methemoglobinemia and acute kidney injury was treated with i.v. ascorbic acid (5 g every six hours for six doses) because of the possibility, later proved, that he had G6PD deficiency. The methemoglobinemia resolved without worsening of renal function.

Hypertension Management: Making Sense of Guidelines and Therapy Options for the Elderly

Background: Benzodiazepines (BZDs) place patients at a significant risk of falling. The current literature does not address if this risk is increased during initiation or dose escalations of BZDs. Objective: To determine if initiation or dose escalations of BZD regimens are associated with an increased risk of falls in hospitalized patients compared with patients maintained on their home dose or who had their dose decreased from baseline. Methods: This retrospective case-control study evaluated hospitalized patients aged 45 years or older who received a BZD. Patients who did not fall were collected in a 3:1 ratio to patients who fell. Comparisons were made between BZD regimens prior to admission and those 48 hours prior to the index date. The date of fall served as the index date for patients who fell, and the median time-to-fall served as the index date for all other patients. Results: A total of 132 patients were included in the study (33 falls and 99 without a fall). No significant differences were noted in demographics, baseline mobility, or past medical history. Patients who fell had a significantly longer median length of stay (15 vs 10 days; P = 0.025). Additionally, patients who fell were more likely to have had their BZD regimen initiated or dose escalated compared with patients who did not fall (63.6% vs 41.4%; P = 0.043). Conclusions: The risk of falling while on a BZD is increased on initiation and dose escalations. Hospitals should ensure judicious use of BZDs in inpatients to reduce the risk of falls.

Geriatric and Student Perceptions following Student-led Educational Sessions

Background: The cephalosporin class has been associated with an increased risk of bleeding among elderly patients receiving warfarin. Urinary tract infections (UTI) are the most prevalent infection in elderly patients. Objective: To determine the extent of interaction between antibiotics used in the treatment of UTI, particularly specific cephalosporins and warfarin. Methods: A retrospective chart review was conducted on chronic warfarin patients with a diagnosis of UTI treated with ceftriaxone, a first-generation cephalosporin, penicillin, or ciprofloxacin. The primary outcome was the comparison of the extent of international normalized ratio (INR) change from baseline between each antibiotic group. Results: The ceftriaxone group was found to have a statistically significant higher peak INR value compared to all other studied antibiotics (ceftriaxone: 3.56, first-generation cephalosporins: 2.66, penicillins: 2.98, ciprofloxacin: 2.3; P = .004), a statistically significant greater extent of change in INR value (+1.19, +0.66, +0.8, +0.275; P = .006), and a statistically significant greater percentage change in INR value when compared to ciprofloxacin (54.4% vs 12.7%; P = .037). Conclusion: Ceftriaxone interacts with warfarin to increase a patient’s INR value more than other commonly administered antibiotics for UTI treatment. Other antibiotics should be preferred for UTI treatment in patients on warfarin.

Pharmacy resident-led student mentoring program: A focus on developing mentoring skills

Background Adherence to American College of Chest Physicians (CHEST) and National Comprehensive Cancer Network (NCCN) guidelines for venous thromboembolism (VTE) prophylaxis helps avoid thromboembolic complications during hospitalization. Electronic health records (EHR) have the potential to make an impact on guideline adherence, but data are lacking. Objectives To determine compliance with VTE prophylaxis guidelines in internal medicine and oncology populations and to determine whether EHR implementation had any effect on the rate and appropriateness of prophylaxis practices. Methods A retrospective chart review was conducted on medical and oncology patients admitted to the hospital for a 2-month period pre-EHR and post-EHR implementation. Risk assessment tools were available pre and post, however they were not mandatory. The rate of VTE prophylaxis was compared between the 2 time periods, with appropriateness assessed in a subgroup of participants without prophylaxis. Results A total of 2,423 patients on the oncology and internal medicine floors were identified during the pre-EHR (n = 1,171) and post-EHR (n = 1,252) time periods. Patients in the post-EHR group were less likely to be prescribed prophylaxis as compared to those in the pre-EHR group (43% vs 50%; P = .001). In the patients audited for proper prophylaxis use (n = 750), significantly more patients in the post-EHR group had risk factors (84% vs 53%; P <.001) and contraindications (23% vs 8%; P = .001) than in the pre-EHR group. Noncompliance to prophylaxis in patients who were candidates (positive risk factors without contraindications) occurred more often in the post-EHR group (51% vs 39%; P <.001). Conclusion Implementation of an EHR was associated with an increase in the documentation of risk factors and contraindications; however, there was a significant decrease in VTE prophylaxis utilization after EHR implementation.

Original Article Venous Thromboembolism Prophylaxis Compliance Before and After Electronic Health Record Implementation

ed from electronic medical record. RESULTS: Alcohol exposure was found in 21.9% of the sample, and 75.3% of the newborns required pharmacologic treatment for NAS. In univariate analyses, PAE trended towards a greater need for pharmacologic treatment of NAS (81.3% vs. 73.7%), longer duration of hospital stay (19.5 15.7 vs. 16.3 9.8 days), and higher cumulative methadone dose received by the newborn (14.2 16.2 vs. 9.9 6.8 mg); however, none of these differences were statistically significant (p>0.05). In multivariate analysis, PAE was not an independent predictor; however, lack of breastfeeding was associated with longer hospital stay (b=7.6, p=0.008) and greater cumulative methadone dose received by the newborn (b=6.7, p=0.03). In addition, the use of buprenorphine rather than methadone predicted later initiation of NAS treatment, while coexposure with amphetamines predicted earlier initiation (p<0.01). CONCLUSION: PAE was not associated with NAS outcomes possibly due to moderate levels of alcohol consumption in this cohort and stronger effects of other maternal factors. The effect of amphetamines on earlier initiation of NAS treatment requires examination in future studies. e294 PHARMACOTHERAPY Volume 33, Number 10, 2013