Faculty Bibliography

As New York became the epicenter of the COVID-19 pandemic early on, clinicians were challenged to provide optimal medical and pharmaceutical care, despite the paucity of supporting literature and guidance. We sought to describe prescribing patterns and outcomes of physician response to the urgent need to treat COVID-19 patients before initiation of randomized clinical trials.

BACKGROUND:Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. METHODS:In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. RESULTS:A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. DISCUSSION/CONCLUSIONS:Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

In 2012, the Centers for Disease Control and Prevention issued a recommendation for hepatitis C screening of adults born between 1945-1965. Our institution incorporated birthcohort screening into its pre-admission testing program for elective orthopedic procedures on February 3, 2015. The goal of this study was to report the results and costs of pre-admission birth-cohort hepatitis C screening at our institution from February 3, 2015, to January 27, 2017. A total of 11,659 elective inpatient procedures were scheduled during this time and 97.8% of eligible patients were screened. Nine patients with active infection were identified, and four were successfully treated. Costs were calculated using time-driven activity-based costing. The total screening cost per successfully treated patient was $36,930.02. Since patients were not routinely screened at our institution before this intervention, our 97.8% screening capture rate demonstrates that pre-admission testing for elective procedures is a novel, yet effective and underutilized way, to engage "baby boomers" in screening.

BACKGROUND:Although dalbavancin's (DBV's) long half-life and one-time dosing strategy confer ideal administration in the ambulatory setting, the optimal role of DBV in the management of acute bacterial skin and skin structure infections (ABSSSIs) remains to be elucidated. OBJECTIVES/OBJECTIVE:The primary objective of this study was to compare treatment outcomes of ABSSSI between patients who received DBV in the emergency department (ED) as part of standard care versus patients who received DBV as part of a telehealth program. METHODS:This was a retrospective cohort study evaluating patients who received DBV at 3 urban EDs. The primary end point was the incidence of ABSSSI recurrence. Secondary outcomes included need for hospital admission and ED length of stay (LOS; in hours). RESULTS:A total of 65 ABSSSI treatment courses were included; 42 were included in the telehealth criteria (TC) cohort and 23 in the initial criteria (IC) cohort. There were 14% (6/42) infection recurrences in the TC cohort and 22% (5/23) in the IC cohort, with median time to recurrence being 4 and 14 days, respectively. Median ED LOS was significantly shorter in the TC (5 vs 25 hours, P < 0.05). Numerically fewer individuals in the TC cohort required inpatient admission (0 vs n = 2, 9%). Conclusion and Relevance: Our results suggest that patients may be safely administered DBV in an ED setting, with telehealth follow-up. Providing structured patient selection criteria is an effective method of assisting ED providers in selecting appropriate DBV candidates to limit potential recurrences and readmissions.

Background. Oral treatment strategies for Enterobacteriaceae bacteremia (EB) are controversial, with both beta-lactams (BL) and fluoroquinolones (FQ) used in clinical practice. FQ may be preferred for their high bioavailability, but other oral antibiotics are needed due to concerns of resistance and adverse effects. As an effort to facilitate antibiotic stewardship, BL should be explored as an additional oral option for EB treatment. Methods. This retrospective study compared clinical characteristics and outcomes in patients with EB treated with BL vs. FQ as definitive oral therapy between January 2013 and July 2017. Adult patients diagnosed with their first incidence of EB and transitioned from IV antibiotics to either study antibiotic class were included. Primary and secondary outcomes assessed recurrence, collateral damage, readmission, and all-cause mortality. Results. A total of 173 patients were included (BL n = 59, FQ n = 114). Median age was 70 years, Pitt bacteremia score was 2 (range 0-7), and Charlson Comorbidity Index was 5 (0-12); all were comparable between groups. Urinary source of infection was most common (57%). The majority of oral BL courses used cefpodoxime (63%). More patients in FQ vs. BL had a prior transplant (9% vs. 0%, P = 0.05), presence of abscess (11% vs. 0%, P = 0.01), and Infectious Diseases consultation (63% vs. 34%, P = 0.0001). Onset of EB in an intensive care unit was more common in BL vs. FQ (24% vs. 10%, P = 0.01). Median duration of IV and oral therapy was 5 vs. 4 days, P = 0.22 and 11 vs. 12 days, P = 0.17 in BL and FQ, respectively. Recurrence within 90 days was 7% in BL and 4% in FQ, P = 0.49 (adjusted OR 1.44, 95% CI 0.31-6.66; P = 0.64). Multivariate analysis identified liver cirrhosis (OR 16.89, 95% CI 1.06-268.32; P = 0.05) as an independent predictor of recurrence within 90 days. All secondary outcomes were similar between BL vs. FQ: superinfection within 90 days (10% vs. 9%, P = 0.76), C. difficile infection within 90 days (3% vs. 1%, P = 0.27), 30-day readmission (15% vs. 20%, P = 0.43), all-cause 30-day mortality (0% vs. 3%, P = 0.55). Conclusion. In our cohort of patients with EB, clinical outcomes were similar between those treated with oral BL compared with FQ. Oral BL may be considered for definitive treatment of EB, although further investigation in larger studies is needed

Extended infusion (EI) administration of β-lactams can improve target attainment in critically ill patients with altered pharmacokinetics/pharmacodynamics. To optimize meropenem dosing in patients with severe sepsis/septic shock, our Antimicrobial Stewardship Program implemented a EI meropenem (EIM) protocol in an 18-bed Medical Intensive Care Unit in March 2014. In this retrospective study, we compared intensive care unit (ICU) mortality and clinical response in patients who received meropenem for ≥72 hours administered per EIM protocol of 1 g over 3 hours every 8 hours versus intermittent infusion (IIM) protocol of 500 mg over 30 minutes every 6 hours. Age, weight, comorbidities, severity of illness, and vasopressor use were comparable between groups (EIM protocol n = 52, IIM protocol n = 96). The IIM protocol group had higher rates of renal dose adjustment at meropenem initiation. Among 56 identified gram-negative (GN) pathogens, 94% had meropenem minimal inhibitory concentration ≤0.25 mg/L. The ICU mortality was lower (19 vs 37%; P = .032) and clinical response was higher (83% vs 46%; P < .01) in the EIM protocol versus IIM protocol group. Total vasopressor days were shorter (2 vs 3 days; P = .038), and white blood cell normalization rate was higher (87% vs 51%; P < .01) in the EIM protocol versus IIM protocol group. There was no difference in days of mechanical ventilation, duration of therapy, and ICU stay. The IIM protocol was also identified as an independent risk factor associated with ICU mortality (hazard ratio: 3.653, 95% confidence interval: 1.689-7.981; P = .001) after adjusting for Sequential Organ Failure Assessment score. In this cohort of patients with severe sepsis/septic shock and highly susceptible GN pathogens, there was improved mortality and clinical response in the EIM protocol group.

Purpose: Leveraging pharmacy personnel resources for the purpose of antimicrobial stewardship program (ASP) operations presents a challenging task. We describe our experience integrating all pharmacists into an ASP, and evaluate the impact on ASP interventions, antimicrobial utilization, rate of selected hospital-onset infections and readmission. Summary: During a study period (January 1 to December 31, 2015), a total of 14 552 ASP-related pharmacy interventions were performed (ASP clinical pharmacotherapy specialists [CPS] n = 4025; non-ASP CPS n = 4888; hospital pharmacists n = 5639). Sixty percent of interventions by ASP CPS were initiated utilizing the dedicated ASP phone, and 40% through prospective audit and feedback. Non-ASP CPS performed interventions during bedside rounds (dose adjustment 23%, initiate new or alternative anti-infective 21%, discontinue antibiotic(s) 12%, therapeutic drug monitoring 11%, de-escalation 4%), whereas hospital pharmacists participated at the point of verification (dose adjustment 75%, restricted antibiotic verification 15%, and reporting major drug-drug interactions 4%). The acceptance rate of interventions by providers and clinicians was >90% for all groups. Annual aggregate antimicrobial use decreased by 6.4 days of therapy/1000 patient-days (DOT/1000 PD; P = 1.0). Ceftriaxone use increased by 8.4 DOT/1000 PD (P = .029) without a significant compensatory increase in the use of antipseudomonal agents. Sustained low rates of hospital-onset Clostridium difficile (CDI) and carbapenem-resistant Enterobacteriaceae (CRE) infections were observed in 2015 compared with the prior year (1.1 and 1.2 cases/1000 PD, 0.2 and 0.1 cases/1000 PD, respectively). Thirty-day readmission rate decreased by 0.6% (P = .019). Conclusions: Integration of all pharmacists into ASP activities based on the level of patient care and responsibilities is an effective strategy to expand clinical services provided by ASP.