Todd Miano

Nosocomial Pneumonia Risk and Stress Ulcer Prophylaxis: A Comparison of Pantoprazole vs Ranitidine in Cardiothoracic Surgery Patients

BACKGROUNDnStress ulcer prophylaxis (SUP) using ranitidine, a histamine H2 receptor antagonist, has been associated with an increased risk of ventilator-associated pneumonia. The proton pump inhibitor (PPI) pantoprazole is also commonly used for SUP. PPI use has been linked to an increased risk of community-acquired pneumonia. The objective of this study was to determine whether SUP with pantoprazole increases pneumonia risk compared with ranitidine in critically ill patients.nnnMETHODSnThe cardiothoracic surgery database at our institution was used to identify retrospectively all patients who had received SUP with pantoprazole or ranitidine, without crossover between agents. From January 1, 2004, to March 31, 2007, 887 patients were identified, with 53 patients excluded (pantoprazole, 30 patients; ranitidine, 23 patients). Our analysis compared the incidence of nosocomial pneumonia in 377 patients who received pantoprazole with 457 patients who received ranitidine.nnnRESULTSnNosocomial pneumonia developed in 35 of the 377 patients (9.3%) who received pantoprazole, compared with 7 of the 457 patients (1.5%) who received ranitidine (odds ratio [OR], 6.6; 95% confidence interval [CI], 2.9 to 14.9). Twenty-three covariates were used to estimate the probability of receiving pantoprazole as measured by propensity score (C-index, 0.77). Using this score, pantoprazole and ranitidine patients were stratified according to their probability of receiving pantoprazole. After propensity adjusted, multivariable logistic regression, pantoprazole treatment was found to be an independent risk factor for nosocomial pneumonia (OR, 2.7; 95% CI, 1.1 to 6.7; p = 0.034).nnnCONCLUSIONnThe use of pantoprazole for SUP was associated with a higher risk of nosocomial pneumonia compared with ranitidine. This relationship warrants further study in a randomized controlled trial.

Fatal Mycobacterium abscessus endocarditis misidentified as Corynebacterium spp.

Abstract The microbiological similarities of rapidly growing mycobacteria and corynebacteria impose potential for misidentification in the laboratory. This report describes a fatal case of infectious endocarditis caused by Mycobacterium abscessus, initially identified and treated as Corynebacterium spp. Acid-fast staining should be performed routinely when multiple blood cultures grow Corynebacterium spp.

Effect of an antibiotic algorithm on the adequacy of empiric antibiotic therapy given by a medical emergency team.

INTRODUCTIONnDelayed administration of effective antimicrobial therapy increases mortality in patients with septic shock. Empiric antibiotic selection in this setting can be inaccurate. The objective of this study was to determine whether an antibiotic algorithm (AA) tailored to institutional resistance patterns improves the adequacy of antimicrobial therapy.nnnMETHODSnA retrospective review of our rapid response system database was performed. Patients with possible sepsis with positive microbiological culture results were enrolled. Pathogens identified by culture were used to determine adequacy of antibiotic selection before and after implementation of an AA.nnnRESULTSnA total of 234 patients with septic shock were reviewed (before AA, n = 36; after AA, n = 198). Seventy-two patients had positive cultures and were enrolled (before AA, n = 13; after AA, n = 59). Significantly more patients received adequate coverage after AA implementation (54% vs 86%, P = .02). Before AA, inadequate Gram-negative coverage was the most common reason for failure. Reasons for failure in the after-AA group were nonadherence to the algorithm (n = 5) and multidrug-resistant pathogens (n = 3). The algorithm failed in patients with vancomycin-resistant enterococci (n = 3), multidrug-resistant Klebsiella pneumoniae (n = 1), and Candida albicans (n = 1).nnnCONCLUSIONSnThe use of an AA significantly improves the adequacy of empiric antimicrobial therapy.

A retrospective analysis of the effect of patient-specific factors on voriconazole concentrations in oncology patients

Objective. To identify patient-specific factors significantly associated with voriconazole exposure. Design, setting, and participants. Retrospective, single center at an academic medical center. Consecutive, adult oncology inpatients who received voriconazole by mouth and had at least one voriconazole level over a 14-month period. Voriconazole was ordered for 292 patients during the study period, a level was obtained in 41 patients. Nine patients were excluded; the study population was comprised of 32 patients. Methods and results. Univariate and multivariable regression analyses were utilized to predict the patient-specific factors significantly associated with level. A total of 36 levels meeting inclusion/exclusion criteria were performed in 32 patients. Sixty percent of levels (22/36) were between 1 and 5.5u2009µg/mL. Data were available to calculate a Child Pugh score for 66% (21/32) of patients. Using multivariable linear regression, three covariates were found to be statistically significant: age, international normalized ratio (INR), and alkaline phosphatase (ALP). Three outliers were notable in the ALP category, when removing the three individuals from the model, only an increasing INR remains significantly associated with increasing voriconazole level (pu2009=u20090.0093). No correlation was found with trough level and Child Pugh score. Conclusions. Sixty percent of voriconazole trough levels were between 1 and 5.5u2009µg/mL (range 0.1–7.4u2009µg/mL), only increasing INR was significantly associated with rising voriconazole level. Increasing Child Pugh score was not associated with increasing level. More investigation is warranted into the usefulness of the Child Pugh score for guidance of dose modifications in non-cirrhotic patients with acute hepatic injury.

601: PROPENSITY MATCHED ANALYSIS COMPARING HYPOTENSION BETWEEN ETOMIDATE AND KETAMINE IN SEPTIC PATIENTS

Learning Objectives: Etomidate is commonly used for intubation with minimal hemodynamic effects, however its suppression of cortisol production may have a significant impact on a patient’s ability to maintain hemodynamic stability. Ketamine is also frequently used and has minimal effects on hemodynamics but no proven influence on the adrenal axis. Methods: A retrospective cohort study was performed to compare the incidence of clinical hypotension between ketamine and etomidate in critically ill septic patients. Clinical hypotension was defined as: mean arterial pressure (MAP) decrease > 40% and MAP <70 mmHg, MAP <60 mmHg, systolic blood pressure (SBP) 15 min, initiation of vasopressors, or increase to > 30% of the initial vasopressor dose. In addition, patients were evaluated for length of hospital and ICU stay, and mortality. Statistical analyses included unmatched and matched cohorts using a propensity score analysis. Multivariable logistic regression was used to evaluate the incidence of clinical hypotension 24 hr post intubation and vasopressor requirements. Results: A total of 260 patients were included for analysis (129 etomidate and 131 ketamine) with 138 patients matched 1:1 based on propensity score. Prior to propensity matching, clinical hypotension 24 hr post intubation was 75.2% in the etomidate group compared to 69.5% in the ketamine group (p=0.302) and there was no statistical difference in new post intubation shock (37.2%; 48.5%, p=0.067). After matching no statistical difference was found in clinical hypotension within 24 hr (40.6%; 40.6%, p=0.99). A random-effects logistic regression model was applied and there was a 38% reduction in clinical hypotension with ketamine (OR=0.62; 95% CI 0.3–1.29, p=0.2). There was also no statistical difference in ICU or hospital length of stay or mortality. Conclusions: Administration of etomidate for intubation did not increase the incidence of clinical hypotension 24 hr post intubation when compared to ketamine in septic patients. Large, prospective trials are warranted to confirm these results.

777: Incidence of Infection in Emergent vs. Non-Emergent Extracorporeal Membrane Oxygenation (ECMO)

Introduction: ECMO cannulation typically occurs in the operating room (OR), however emergent situations may warrant cannulation outside of the OR, where sterility and aseptic technique may be compromised. Although no consensus guideline recommendations exist for antibiotic prophylaxis, patients typi