Faculty Bibliography

Objective/UNASSIGNED:The increased incidence of multidrug-resistant organisms is associated with increased morbidity, mortality, hospital length of stay, and cost. Estimates show that up to 50% of antimicrobial use is inappropriate. This initiative focuses on inappropriate use of antibiotics in respiratory syncytial virus (RSV) infections. This virus is the most common cause of bronchiolitis during childhood. Methods/UNASSIGNED:Baseline data from the 2011-2012 RSV season showed that 56.2% of our RSV-positive patients received antibiotics. To decrease inappropriate antibiotic use in RSV infections, we established an antimicrobial stewardship program (ASP). This process improvement initiative aimed to decrease exposure to antibiotics and days of antibiotic therapy per 1,000 patient days (DOT/1000PD) in hospitalized RSV-positive patients by 25%. Key drivers included building health-care knowledge, proactive interventions using prospective audit and feedback, emergency department engagement, and performance dashboards. Results/UNASSIGNED:= 0.017). This change represents a reduction of 164.6 DOT/1000PD from baseline after full ASP implementation. Conclusion/UNASSIGNED:Despite the lack of a unified hospitalist group in our institution, we were successful in reducing inappropriate antibiotic use by focusing on standardizing care among different private pediatricians in the community. A multifaceted strategy and well-designed quality improvement methodology led to a sustained reduction in antibiotic use.

PURPOSE/OBJECTIVE:To compare the effectiveness of continuous infusion of hydrocortisone versus intermittent boluses in the resolution of septic shock. METHODS:A retrospective chart review was performed to investigate the effects of low-dose hydrocortisone continuous infusion (200 mg per day) versus intermittent boluses (50 mg every six hours) in septic shock patients who did not respond to fluid resuscitation and vasopressors. The primary outcome was time to resolution of shock, defined by time from the initiation of hydrocortisone to time of vasopressor withdrawal when mean arterial pressure was greater than 65 mm Hg. Hospital length of stay, intensive care unit (ICU) length of stay, 28-day all-cause in-hospital mortality, and hyperglycemia were secondary outcomes. RESULTS:= 0.04). CONCLUSION/CONCLUSIONS:There was no significant difference in time to resolution of septic shock between continuous infusion (200 mg per day) and intermittent boluses (50 mg every six hours) of hydrocortisone. There were also no statistically significant differences in overall hospital length of stay, ICU length of stay, and 28-day all-cause in-hospital mortality. However, there was a significant difference in the incidence of hyperglycemia between the two groups, with patients in the bolus group experiencing more hyperglycemia than those in the continuous infusion group.

PURPOSE:The goal of this pharmacokinetic (PK) study was to evaluate whether a single 2-g prophylactic dose of cefazolin given (IV) bolus provides effective protective cefazolin levels for prophylaxis against methicillin-sensitive S. aureus (MSSA), the primary skin pathogen in bariatric surgery. MATERIALS AND METHODS:Thirty-seven patients having gastric bypass or sleeve gastrectomy received cefazolin 2-g preoperative prophylaxis. Serum, subcutaneous adipose tissue, and deep peri-gastric adipose tissue specimens were collected at incision and before skin closure. Cefazolin concentrations in serum and adipose tissue were determined by high-performance liquid chromatography. RESULTS:Penetration of cefazolin, a water soluble antibiotic, into adipose tissue was only 6-8 % of simultaneous serum levels. However, cefazolin tissue concentrations in all adipose tissue specimens, exceeded mean MIC for MSSA. CONCLUSIONS:not dose-dependent. Extremely high-dosed cefazolin, i.e., 3 or 4 g is excessive and unnecessary for bariatric surgery prophylaxis. A single cefazolin 2 g preoperative dose also eliminates the need for intraoperative redosing at 4 h.

OBJECTIVE:To assess the prevalence of delirium and coma in mechanically ventilated patients sedated with dexmedetomidine or propofol alone; to evaluate the hospital length of stay for both treatment groups; and to evaluate the level of sedation, adverse effects, and hospital outcomes. METHODS:Medical records were reviewed retrospectively for patients who were admitted to the medical or surgical intensive care units (ICUs) in a 591-bed teaching hospital and who received either dexmedetomidine or propofol alone for 24 hours or more for sedation. RESULTS:A total of 111 patients were included in the study, with 56 patients in the dexmedetomidine group and 55 patients in the propofol group. Results of the analysis showed that the propofol group had a higher prevalence of coma (43.6% versus 12.5%; P < 0.001). Dexmedetomidine patients had a longer median hospital length of stay of 23.5 days (interquartile range [IQR], 11.5-39.5 days) versus 15.0 days (IQR, 7.0-24.0 days; P = 0.01). The rates of delirium were similar in both groups, with 16% in dexmedetomidine-treated patients versus 20% in propofol-treated patients (P = 0.63). CONCLUSION/CONCLUSIONS:No difference in the prevalence of delirium was found when comparing the dexmedetomidine- and propofol-treated groups. Propofol was associated with more coma and oversedation; dexmedetomidine was associated with longer time to extubation, longer length of stay in the ICU, and longer hospital length of stay.

BACKGROUND:The use of opioids to achieve adequate pain relief following surgery is a common clinical practice. Opioids, however, are associated with serious adverse effects, such as respiratory depression, excessive sedation, and prolonged ileus, as well as increased mortality. The administration of intravenous (IV) acetaminophen to control postoperative pain has been effective in reducing opioid consumption in various surgical populations, but no studies have been conducted in bariatric surgery patients. This investigation was performed to determine whether IV acetaminophen reduces opioid requirements after bariatric surgery. METHODS:IV acetaminophen was added to the Winthrop-University Hospital formulary in September 2012. We conducted a retrospective chart-review analysis of bariatric surgery patients who received at least four doses of IV acetaminophen (1 g every six hours) plus opioids from October 2012 to March 2013 (after IV acetaminophen was added to the hospital formulary), compared with bariatric surgery patients who received only opioids for postoperative pain control from January 2012 to June 2012 (before IV acetaminophen was added to the hospital formulary). The study's primary endpoint was the difference between the two groups in opioid consumption, expressed in oral morphine equivalents (OMEs). Secondary endpoints included the reduction in the baseline pain score; the total amount of each opioid used; and the average hospital length of stay (LOS). RESULTS:A total of 96 patients were identified for potential enrollment from January 2012 to March 2013. Eight patients, however, did not qualify for participation because they had received only one dose of IV acetaminophen. The remaining 88 patients comprised two study groups: IV acetaminophen plus opiates (n = 44) and IV opiates alone (n = 44). Paradoxically, the patients in the acetaminophen/opiates group required significantly more opiates (in OMEs) compared with the group that received opiates alone (median, 93.5 mg versus 63.0 mg, respectively; P = 0.017). There were no significant differences between the two treatment groups in terms of the median change from baseline in pain scores (-4 versus -4; P = 0.162) or the median hospital LOS (two days versus two days; P = 0.704). CONCLUSION/CONCLUSIONS:IV acetaminophen did not reduce opioid use for postoperative pain management in bariatric surgery patients.

We present a case of a 36-year-old female who came into the emergency department with right-side abdominal pain. She went to the operating room for a diagnostic laparoscopy and appendectomy. She received intravenous (IV) acetaminophen every six hours both preoperatively and postoperatively for pain control. The patient's aspartate aminotransferase and alanine aminotransferase levels were elevated and peaked at 4,833 and 6,600 IU/L, respectively, from baselines of 14 and 15, respectively, while she was receiving 16 doses of IV acetaminophen. The patient was transferred to a regional liver transplant center for evaluation for a transplant. She was treated with IV N-acetylcysteine and discharged with a normal liver-function test without a transplant. This case report supports the possibility of hepatotoxicity associated with IV acetaminophen.

BACKGROUND:Multiple sclerosis is a debilitating autoimmune disorder that causes disability in young adults. OBJECTIVE:To review the efficacy and safety of IFN-beta1b in the management of relapsing-remitting and secondary progressive multiple scleroses and clinical isolated syndrome. METHODS:A MEDLINE (1966-May 2007) search of clinical trials using the terms 'multiple sclerosis' and 'interferon' was performed. Manual bibliographic search was conducted. English-language articles were evaluated. RESULTS:IFN-beta1b is more efficacious than placebo and at least as efficacious as IFN-beta1a or glatiramer for the management of relapsing-remitting multiple sclerosis. IFN-beta1b also delayed the time to diagnosis of definite multiple sclerosis and reduced brain lesion burden in patients with clinical isolated syndrome. More long-term, large scale clinical data are warranted to ascertain its relative efficacy compared to other treatments. CONCLUSION/CONCLUSIONS:IFN-beta1b is an effective treatment for multiple sclerosis. Common side effects are lymphopenia, injection site reactions, asthenia, flu-like symptoms and headache.