Faculty Bibliography

To evaluate the safety of direct oral anticoagulants (DOACs) versus low-molecular weight heparin (LMWH) in patients with central nervous system (CNS) malignancies and secondary metastases. All adult patients with CNS malignancies and secondary metastases who were treated with a DOAC or LMWH for any indication from 2018 to 2022 were included. The primary outcome was the incidence of any intracranial hemorrhage (ICH) after anticoagulation initiation. Secondary outcomes included non-ICH bleeding events and thromboembolic events. Tolerability was assessed by any changes in anticoagulant therapy during study period. 153 patients were included; 48 patients received enoxaparin and 105 received DOACs, of which apixaban was used most commonly. The population was predominantly White (74%) and male (59%) with a median age of 65. Data was censored for immortal time bias for outcomes evaluated beyond 3 months. ICH occurred in 7.7% of the population, more frequently in the enoxaparin group (DOACs 4, 4% vs. enoxaparin 7, 16%, p = 0.037). Non-ICH bleeds were predominantly minor and more common in the DOAC group (DOACs 13, 13% vs. enoxaparin 1, 2%, p = 0.037). Thromboembolic events were not different between groups (DOACs 9. 9% vs, enoxaparin 2, 4%, p = 0.503). Anticoagulant switches occurred more in the enoxaparin group (DOACs 12, 12.4% vs. enoxaparin, 37.8%, p < 0.001), primarily due to patient or provider preference. Our data supports DOACs to be preferred over LMWH for the treatment of VTE or for stroke prevention with AF to prevent ICH in patients with brain tumors or metastases.

BACKGROUND:infection (CDI) in patients requiring concomitant systemic antibiotics. OBJECTIVES/OBJECTIVE:To evaluate prescribing practices of vancomycin for CDI in patients that required concurrent systemic antibiotics and to determine whether a prolonged duration of vancomycin (>14 days), compared to a standard duration (10-14 days), decreased CDI recurrence. METHODS:(VRE). RESULTS:= .083) were not significantly different between groups. Discontinuation of vancomycin prior to completion of antibiotics was an independent predictor of 8-week recurrence on multivariable logistic regression (OR, 4.8; 95% CI, 1.3-18.1). CONCLUSIONS:Oral vancomycin prescribing relative to the systemic antibiotic end date may affect CDI recurrence to a greater extent than total vancomycin duration alone. Further studies are needed to confirm these findings.

OBJECTIVE/UNASSIGNED:To evaluate whether an antimicrobial stewardship bundle (ASB) can safely empower frontline providers in the treatment of gram-negative bloodstream infections (GN-BSI). INTERVENTION AND METHOD/UNASSIGNED:From March 2021 to February 2022, we implemented an ASB intervention for GN-BSI in the electronic medical record (EMR) to guide clinicians at the point of care to optimize their own antibiotic decision-making. We conducted a before-and-after quasi-experimental pre-bundle (preBG) and post-bundle (postBG) study evaluating a composite of in-hospital mortality, infection-related readmission, GN-BSI recurrence, and bundle-related outcomes. SETTING/UNASSIGNED:New York University Langone Health (NYULH), Tisch/Kimmel (T/K) and Brooklyn (BK) campuses, in New York City, New York. PATIENTS/UNASSIGNED:Out of 1097 patients screened, the study included 225 adults aged ≥18 years (101 preBG vs 124 postBG) admitted with at least one positive blood culture with a monomicrobial gram-negative organism. RESULTS/UNASSIGNED:= 0.043. CONCLUSIONS/UNASSIGNED:GN-BSI bundle worked as a nudge-based strategy to guide providers in VAN DC and increased de-escalation to aminopenicillin-based antibiotics without negatively impacting patient outcomes.

BACKGROUND/UNASSIGNED: METHODS/UNASSIGNED:infections. The primary composite endpoint included escalation to intensive care unit, infection- or treatment-related readmission, mortality, and infection recurrence. Outcomes were compared between groups who received carbapenem (CG) versus carbapenem-sparing agents (CSG) as targeted gram-negative therapy. RESULTS/UNASSIGNED:= .001), while treatment with carbapenem-sparing therapy was not. CONCLUSIONS/UNASSIGNED:Our study did not find improved clinical outcomes with targeted carbapenem therapy for TZP-NS/CRO-S infections. Carbapenem-sparing agents may be considered to spare carbapenems in noncritically ill patients similar to those included in our cohort.

BACKGROUND/UNASSIGNED:Delirium is a common complication of critical illness, with a prevalence of 25% among pediatric intensive care unit (ICU) patients. Pharmacological treatment options for ICU delirium are limited to off-label use of antipsychotics, but their benefit remains uncertain. OBJECTIVE/UNASSIGNED:The purpose of this study was to evaluate quetiapine effectiveness for the treatment of delirium in critically ill pediatric patients and to describe the safety profile of quetiapine. METHODS/UNASSIGNED:A single-center, retrospective review of patients aged ≤ 18 years who screened positive for delirium via the Cornell Assessment of Pediatric Delirium (CAPD ≥ 9) and received ≥ 48 hours of quetiapine therapy was conducted. The relationship between quetiapine and deliriogenic medication doses was evaluated. RESULTS/UNASSIGNED:This study included 37 patients who received quetiapine for the treatment of delirium. The change in sedation requirements before quetiapine initiation to 48 hours after the highest quetiapine dose demonstrated a downward trend; 68% of patients had a decrease in opioid requirements and 43% of patients had a decrease in benzodiazepine requirements. The median CAPD score at baseline was 17 and the median CAPD score at 48 hours after the highest dose was 16. Three patients experienced QTc prolongation (defined as a QTc ≥ 500), although none developed dysrhythmias. CONCLUSION AND RELEVANCE/UNASSIGNED:Quetiapine did not have a statistically significant impact on deliriogenic medication doses. There were minimal changes in QTc and dysrhythmias were not identified. Therefore, quetiapine can be safe to use in our pediatric patients but further studies are needed to find an effective dose.

Ultrasound enhancing agents (UEAs) are medications that enable clear visualization of ultrasound images. While large studies have demonstrated the safety of these agents, case reports of life-threatening reactions temporally associated with their use have been published and reported to the Food and Drug Administration. Current literature describes the most serious adverse reactions due to UEAs to be allergic in nature; however, embolic phenomena may play a role as well. Here, we report a case of unexplained cardiac arrest following the administration of sulfur hexafluoride (Lumason^®) in an adult inpatient undergoing echocardiography where resuscitative efforts were ultimately unsuccessful, and review possible mechanisms of cardiac arrest based on prior published literature.

INTRODUCTION: Thiamine (TH) is a co-factor for pyruvate dehydrogenase, an enzyme necessary for pyruvate entry into the Krebs cycle, and without this enzyme, pyruvate would be converted to lactate. Elevated lactate, which is often used as a marker of perfusion, is proportionally associated with increased mortality in septic shock. The few publications on TH in septic shock are inconclusive. This study aims to ascertain if there is benefit to adding TH to standard of care (SOC) in the management of septic shock.
METHOD(S): IRB-approved, multicenter, retrospective review from 2016 to 2021. Adult patients admitted to the ICU for septic shock and receiving >= 400 mg a day of IV TH (in divided doses) were included. Patients < 18, pregnant, admitted for SARS-COV-2, or whom received < 400 mg of TH daily were excluded. Two matched cohorts were evaluated, SOC plus TH versus SOC alone. The primary endpoint is time to shock reversal, defined as off vasopressors for at least 12 hrs and alive. Secondary endpoints include time to lactate clearance (< 2 mmol/L), lactate trends at 6, 12, 24, 48 hrs, and end of therapy, hospital and ICU lengths of stay, new end organ dysfunction, and in-hospital mortality.
RESULT(S): Data from 50 patients were analyzed: 25 in the SOC plus TH and 25 in the SOC arm. The TH arm had greater number of vasopressors (2 vs. 1, p=.019), and greater utilization of stress-dose steroids (72% vs. 8%, p<.001), however there was no difference in cumulative vasopressor dose in norepinephrine equivalents at baseline (BL) (30.1 vs. 25.8 mcg/min, p=.248). There was no difference in SOFA score at ICU admission (10 vs. 8.5, p=.106) or lactate level at ICU admission (5.9 vs. 3.9 mmol/L, p=.055). There was a longer time to shock reversal from vasopressor initiation time in the TH arm (93 vs. 37.1 hrs, p=.023). Lactate clearance was slower in the TH arm (44.75 vs. 15.8 hrs, p=.027), and there was increased in-hospital mortality in the TH arm (13 vs. 5, p=.018).
CONCLUSION(S): Compared to SOC alone, TH treated patients had longer times to shock reversal. However, this outcome may have been confounded by differences at BL with regard to number of vasopressors, and stress-dose steroid utilization, which indicate these patients were sicker at BL. Larger, prospective studies are required to confirm these findings

INTRODUCTION: Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Salvage therapy may include IVIG, fecal microbiota transplant (FMT) or colectomy. There is limited data regarding the effectiveness of IVIG for CDI (43-65%) or optimal dosing strategies.
METHOD(S): This is a retrospective review of critically ill patients who received IVIG (Gamunex-C) for severe or fulminant CDI at NYU Langone Health. The primary outcome was response to therapy, defined as hospital survival and complete resolution of CDI symptoms by the last day of CDI treatment without need for surgery or FMT.
RESULT(S): Fifteen patients received IVIG for severe (n=6) or fulminant (n=9) CDI, with the BI/NAP1/027 strain isolated in 27% of cases. Patients were primarily female (66%) with a median age of 62 years and had a SOFA score of 7 (IQR 4,8) at the time of IVIG administration. Twelve patients were immunosuppressed (e.g., transplant, malignancy) and nine had chronic kidney disease. There were five patients with recurrent CDI for the index infection, defined as CDI in the previous 8 weeks. Active anti-CDI therapies prior to IVIG administration included enteral vancomycin (93%), IV metronidazole (80%), rectal vancomycin (27%), fidaxomicin (7%), tigecycline (7%) and cholestyramine (7%). Median time to IVIG administration from the date of CDI positivity was 41 hours (21,75). The median total dose of IVIG administered per patient was 1.2 g/kg given over 2 days (1.5,3). Response to treatment was observed in 11 patients (73%); 4 required either colectomy (n=3) or FMT (n=1). Among the 5 patients with recurrent disease who received IVIG, response was observed in 4 cases (80%). Adverse events related to IVIG were not reported, and there were no cases of CDI recurrence within 6 months of CDI therapy completion. One in-hospital mortality was observed, which was unrelated to CDI.
CONCLUSION(S): For severe or fulminant CDI, IVIG pharmacotherapy was associated with a favorable treatment response in 73% of patients, possibly averting the need for care escalation to colectomy or FMT. Various dosing strategies were utilized, limiting assessment of a doseresponse relationship. Further data and a comparison to a cohort of critically ill patients who did not receive IVIG is needed to delineate place in therapy

OBJECTIVE:concentration after KCl administration) and assess the incidence of hyperkalemia. METHODS:This single-center, retrospective study evaluated infants and children who received parenteral KCl supplementation of 0.5 or 1 mEq/kg between January 2017 and December 2019. RESULTS:compared with those who had a concentration drawn after this time frame (0.8 vs 0.6 mEq/L; p < 0.01). CONCLUSIONS:of 0.8 and 0.5 mEq/L, respectively, in non-cardiac pediatric patients, with low observed incidence of hyperkalemia.