Navaneeth Narayanan

Acute exacerbations of chronic obstructive pulmonary disease: diagnosis, management, and prevention in critically ill patients.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is a substantial source of disability in the United States. Moderate‐to‐severe acute exacerbations of COPD (AECOPD) can progress to respiratory failure, necessitating ventilator assistance in patients in the intensive care unit (ICU). Patients in the ICU with AECOPD requiring ventilator support have higher morbidity and mortality rates as well as costs compared with hospitalized patients not in the ICU. The mainstay of management for patients with AECOPD in the ICU includes ventilator support (noninvasive or invasive), rapid‐acting inhaled bronchodilators, systemic corticosteroids, and antibiotics. However, evidence supporting these interventions for the treatment of AECOPD in critically ill patients admitted to the ICU is scant. Corticosteroids have gained widespread acceptance in the management of patients with AECOPD necessitating ventilator assistance, despite their lack of evaluation in clinical trials as well as controversies surrounding optimal dosage regimens and duration of treatment. Recent studies evaluating the safety and efficacy of corticosteroids have found that higher doses are associated with increased adverse effects, which therefore support lower dosing strategies, particularly for patients admitted to the ICU for COPD exacerbations. This review highlights recent findings from the current body of evidence on nonpharmacologic and pharmacologic treatment and prevention of AECOPD in critically ill patients. In addition, the administration of bronchodilators using novel delivery devices in the ventilated patient and the conflicting evidence surrounding antibiotic use in AECOPD in the critically ill is explored. Further clinical trials, however, are warranted to clarify the optimal pharmacotherapy management for AECOPD, particularly in critically ill patients admitted to the ICU.

Results of a Hepatitis C Virus Screening Program of the 1945–1965 Birth Cohort in a Large Emergency Department in New Jersey

Abstract Background Persons born between 1945 and 1965 account for an estimated 81% of those infected with hepatitis C virus (HCV) in the United States. However, up to 60% remain undiagnosed. Prior studies have reported HCV screening results from large urban emergency departments. Methods This is a retrospective cohort study of patients in the 1945–1965 birth cohort tested for HCV in a large emergency department (ED) in New Jersey from June 1, 2016, through December 31, 2016. The purpose was to report HCV antibody and viral load results of this testing program located in a small urban/suburban area and to analyze specific characteristics associated with positive results, such as race/ethnicity and insurance status. Descriptive statistics were performed, and, using a multivariate logistic regression model, adjusted odds ratios and 95% confidence intervals were calculated. Results A total of 3046 patients were screened: 55.8% were white, and 17.9% were black; 52.1% had private insurance, 33.4% Medicare, 3.9% Medicaid. One hundred ninety-two were antibody positive (6.3%). Of 167 with HCV viral load testing results, 43% had a positive viral load. On multivariate analysis, black race and Medicaid were independently associated with a positive HCV viral load. Conclusions HCV antibody seropositivity was above 6% and twice as high as the Centers for Disease Control and Prevention estimated prevalence in this birth cohort. These results indicate that EDs outside of large urban cities are also important sites for routine HCV screening. Other findings of interest include 43% with chronic HCV infection and the persistent association between black race and positive HCV viral load even when adjusted for insurance status.

Disaster Preparedness: Biological Threats and Treatment Options

Biological disasters can be natural, accidental, or intentional. Biological threats have made a lasting impact on civilization. This review focuses on agents of clinical significance, bioterrorism, and national security, specifically Category A agents (anthrax, botulism, plague, tularemia, and smallpox), as well as briefly discusses other naturally emerging infections of public health significance, Ebola virus (also a Category A agent) and Zika virus. The role of pharmacists in disaster preparedness and disaster response is multifaceted and important. Their expertise includes clinical knowledge, which can aid in drug information consultation, patient‐specific treatment decision making, and development of local treatment plans. To fulfill this role, pharmacists must have a comprehensive understanding of medical countermeasures for these significant biological threats across all health care settings. New and reemerging infectious disease threats will continue to challenge the world. Pharmacists will be at the forefront of preparedness and response, sharing knowledge and clinical expertise with responders, official decision makers, and the general public.

The Role of an Antimicrobial Stewardship Team in the Use of Rapid Diagnostic Testing in Acute Care: An Official Position Statement of the Society of Infectious Diseases Pharmacists

Rapid diagnostic technologies can assist Antimicrobial Stewardship Programs (ASPs) in achieving the goals of reducing unnecessary antimicrobial exposure and optimizing patient care. The Society of Infectious Diseases Pharmacists supports all members of the ASP team as essential components of optimal use of these technologies for management of antibiotic prescribing and cost-reduction strategies. Infect Control Hosp Epidemiol 2018;39:473-475.

Collaboration between an antimicrobial stewardship team and the microbiology laboratory can shorten time to directed antibiotic therapy for methicillin-susceptible staphylococcal bacteremia and to discontinuation of antibiotics for coagulase-negative staphylococcal contaminants

BACKGROUND Rapid identification of Gram-positive cocci in clusters (GPCC) in positive blood cultures (pBC) may limit exposure to unnecessary or inappropriate antibiotics. METHODS Inpatients with pBC showing GPCC between October 2013 and December 2017 were included. In the baseline period (BL), final ID and susceptibility results were reported in the electronic medical record (EMR) within 48 h of telephoned Gram stain report. The laboratory introduced rapid phenotypic identification and direct susceptibility testing (INT1), later replaced by PCR (INT2). In the last Intervention (INT3), Antimicrobial Stewardship Response Team (ASRT) contacted providers with PCR results and recommendations. RESULTS Time to directed therapy (TDT) for MSSA and coagulase-negative Staphylococci (CoNS) decreased from BL to INT3 (48.5-17.9 h, 50.3-16.4 h, respectively). Time to ID from BL to INT3 for MSSA and CoNS also decreased (23.2-1.9 h, 44.7-2.8, respectively). CONCLUSIONS TDT can be improved by modification of reporting methods with utilization of an ASRT.

Does a Negative Rapid Diagnostic Test for Detection of Candida Bloodstream Infection Lead to Less Antifungal Use

Abstract Background Candida species are the fourth leading cause of nosocomial bloodstream infections in the United States, however incidence is low and most patients who receive empiric treatment do not actually have candidemia. Unfortunately, detection, identification and susceptibility testing using standard instrumented blood culture systems and routine microbiological techniques takes 4–10 days. Astute clinicians may empirically treat patients with antifungal therapy (AFT) prior to having any results, often leading to unnecessary coverage for candida infection for up to 10 days. The T2 Candida Panel is an FDA-approved assay that rapidly detects the presence of 5 Candida species directly from whole blood in 3–5 hours. We determined whether AFT decisions were altered based on negative (neg) results of a T2 assay. Methods We performed a retrospective chart review of the first 50 patients at our institution from March 1, 2016 to March 1, 2017 with a neg T2 Candida assay result (data collection is ongoing). If a patient had multiple valid T2 assays, only the first result was used for analysis. The patients’ medical records were reviewed for use and duration of empiric AFT, results of blood cultures, treatment modification, underlying illness, risk factors for candida infection, length of stay, and 14-day mortality from the time of the T2 assay. Results Twenty-four patients were never started on AFT. Of the 26 who received AFT, it was stopped in 15 (57%) following T2 results (median time to stop empiric AFT = 2 days (1–16)). The reasons for continuing AFT in the cases of neg T2 assays included hematologic malignancy patients who were on long-term prophylaxis with antifungals (6 patients), empiric use in a case of severe sepsis (1 patient), and positive culture results despite neg T2 assay in 4 patients: 1 patient with C. lusitaniae in blood culture, 1 patient with C. parapsilosis from positive culture of medical device, 1 patient with neg T2 but positive blood cultures from 2 days prior for C. albicans (was on antifungal therapy at time of test), 1 patient with C. guilliermondii in blood culture. Conclusion We conclude that a neg T2 Candida assay affects empirical use of AFT in certain patient populations and may be useful in controlling the overuse of antifungal agents. Disclosures All authors: No reported disclosures.