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118


Allergic Reactions in Hospitalized Patients With a Self-Reported Penicillin Allergy Who Receive a Cephalosporin or Meropenem

Crotty, Danielle Joset; Chen, Xian Jie Cindy; Scipione, Marco R; Dubrovskaya, Yanina; Louie, Eddie; Ladapo, Joseph A; Papadopoulos, John
BACKGROUND: Cefepime and meropenem are used frequently in hospitalized patients for broad-spectrum empiric coverage, however, practitioners are often reluctant to prescribe these antibiotics for patients with a self-reported nonsevere, nontype I allergic reaction to penicillin. METHODS: Retrospective review of electronic medical records of adults with a self-reported allergy to penicillin who received at least 1 dose of cefepime, ceftriaxone, cefoxitin, cephalexin, or meropenem to assess incidence and type of allergic reactions. RESULTS: Of 175 patients included, 10 (6%) patients experienced an allergic reaction. The incidence for individual study drugs were cefepime 6% (6 of 96), meropenem 5% (3 of 56), cefoxitin 8% (1 of 13), ceftriaxone 0% (0 of 69), and cephalexin 0% (0 of 8). The majority of patients experienced a rash with or without pruritus and fever. Patients with a concomitant "sulfa" allergy (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.4-21, P = .02) or >/=3 other drug allergies (OR 6.4, 95% CI 1.3-32, P = .025) were more likely to have an allergic reaction. CONCLUSIONS: In one of the largest retrospective reviews of hospitalized patients who received full dose therapy with cefepime, ceftriaxone, and meropenem, the incidence of allergic reactions was low and reactions were mild. Cefepime, ceftriaxone, and meropenem can be considered for use in patients with a self-reported nontype I penicillin allergy.
PMID: 26038245
ISSN: 1531-1937
CID: 2412232

Safety of the Peripheral Administration of Vasopressor Agents

Lewis, Tyler; Merchan, Cristian; Altshuler, Diana; Papadopoulos, John
Vasopressors are an integral component of the management of septic shock and are traditionally given via a central venous catheter (CVC) due to the risk of tissue injury and necrosis if extravasated. However, the need for a CVC for the management of septic shock has been questioned, and the risk of extravasation and incidence of severe injury when vasopressors are given via a peripheral venous line (PVL) remains poorly defined. We performed a retrospective chart review of 202 patients who received vasopressors through a PVL. The objective was to describe the vasopressors administered peripherally, PVL size and location, the incidence of extravasation events, and the management of extravasation events. The primary vasopressors used were norepinephrine and phenylephrine. The most common PVL sites used were the forearm and antecubital fossa. The incidence of extravasation was 4%. All of the events were managed conservatively; none required an antidote or surgical management. Vasopressors were restarted at another peripheral site in 88% of the events. The incidence of extravasation was similar to prior studies. The use of a PVL for administration of vasopressors can be considered in patients with a contraindication to a CVC.
PMID: 28073314
ISSN: 1525-1489
CID: 2979072

Nephrotoxicity associated with intravenous (IV) polymyxin B (PMB) once versus twice daily dosing

Ahmed, Nabeela; Scipione, Marco R; Papadopoulos, John; Eiras, Daniel; Dubrovskaya, Yanina
ORIGINAL:0014897
ISSN: 2328-8957
CID: 4722512

Dexmedetomidine: A novel approach to treating refractory adrenergic crisis in familial dysautonomia [Meeting Abstract]

Dillon, R C; Spalink, C; Norcliffe-Kaufmann, L; Palma, J A; Altshuler, D; Papadopoulos, J; Kaufmann, H
Background: Stress-induced adrenergic hypertensive crises are a cardinal feature of familial dysautonomia (FD). Classically, this is treated with clonidine and benzodiazepines, which cause excessive sedation and can lead to respiratory arrest. Dexmedetomidine is a recently introduced compound, 8 times more specific for central alpha-2 adrenergic receptors than clonidine, resulting in less sedation. Advantages over clonidine are also that dexmedetomidine can be administered intravenously (IV), and its half-life is shorter (12 vs. 2 h), which allows an easy titration.
Method(s): Retrospective chart review of IV dexmedetomidine use to treat refractory hypertensive crisis in patients with FD.
Result(s): IV dexmedetomidine was used 15 times in 9 patients (mean age: 26 years; 44 % men) with acute adrenergic crisis. Crisis triggers included respiratory infection (n = 8), emotional stress (n = 3), surgery (n = 1), bacteremia (n = 1), gastroenteritis (n = 1) and bleeding gastric ulcer (n = 1). Before treatment, all patients had signs of adrenergic activation including skin flushing, nausea/retching, vomiting, diaphoresis, and agitation. Blood pressure (BP) was 1616/1026 mmHg and heart rate (HR) was 1134 bpm. IV dexmedetomidine was administered at an average rate of 0.510.13 mcg/kg/h. One hour post-infusion, BP decreased to 1165/586 mmHg (p<0.0001) and HR to 975 bpm (p = 0.002). Drowsiness occurred in one patient, although he was easily arousable. There were no episodes of rebound hypertension or respiratory depression. In one case, rapid titration at a high dose resulted in paradoxical hypertension, which subsided immediately upon dexmedetomidine discontinuation.
Conclusion(s): IV dexmedetomidine is an effective, well-tolerated approach for managing adrenergic crises in patients with FD. In contrast to other commonly used medications, dexmedetomidine does not induce excessive sedation or respiratory depression. In a small percentage of patients, rapid IV dosing may result in paradoxical hypertension due to its direct action on peripheral postsynaptic alpha2-adrenergic receptors
EMBASE:612840929
ISSN: 0959-9851
CID: 3789352

Safety and Effectiveness of Intravenous Pentamidine for Prophylaxis of Pneumocystis jirovecii Pneumonia in Pediatric Hematology/Oncology Patients

Solodokin, Loriel J; Klejmont, Liana M; Scipione, Marco R; Dubrovskaya, Yanina; Lighter-Fisher, Jennifer; Papadopoulos, John
BACKGROUND: Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection that can lead to significant morbidity and mortality in immunocompromised pediatric hematology/oncology patients. Trimethoprim/sulfamethoxazole is the gold standard for prophylaxis. Intravenous (IV) pentamidine is the preferred second-line agent for PCP prophylaxis at our institution and is used first-line under certain circumstances. The purpose of this study is to evaluate the effectiveness and safety of IV pentamidine for PCP prophylaxis in pediatric hematology/oncology patients. MATERIALS AND METHODS: A retrospective analysis of pediatric hematology/oncology patients (N=121) who received >/=1 dose of IV pentamidine between January 2009 and July 2014 was conducted. Electronic health records were reviewed to determine baseline characteristics, rate of breakthrough PCP infection, characteristics of IV pentamidine use, and adverse events. The follow-up period was 6 months after the last reported IV pentamidine dose or the last recorded clinic visit/hospital admission. RESULTS: No patients developed PCP during the entirety of their IV pentamidine course or during the follow-up period. Nineteen patients (16%) experienced adverse events and 5 of the 19 patients required discontinuation of IV pentamidine. CONCLUSIONS: IV pentamidine is a safe, tolerable, and effective agent for PCP prophylaxis in pediatric hematology/oncology patients and may be considered a reasonable therapeutic alternative when trimethoprim/sulfamethoxazole cannot be used for PCP prophylaxis.
PMID: 27164533
ISSN: 1536-3678
CID: 2107602

Initial Therapy for Mild to Moderate Clostridium difficile Infection Exploring the Role of Oral Metronidazole Versus Vancomycin in 168 Hospitalized Patientsl

Siegfried, Justin; Dubrovskaya, Yanina; Flagiello, Thomas; Scipione, Marco R.; Phillips, Michael; Papadopoulos, John; Chen, Donald; Safdar, Amar
Background: Oral vancomycin is being increasingly used for treatment of Clostridium difficile infection (CDI), although the feasibility for such approach and avoidance of currently recommended oral metronidazole for mild to moderate (mm)-CDI remain uncertain. We sought to assess treatment response in hospitalized patients with mm-CDI at our university medical center.
ISI:000378861200007
ISSN: 1056-9103
CID: 3853712

Catheter-Directed Low-Dose Alteplase In The Management Of Pulmonary Embolism (pe) Resulting In Fatal Intracranial Hemorrhage (ich): A Case Report [Meeting Abstract]

Mendelson, JS; Lewis, T; Papadopoulos, J; Schwartz, DR
ISI:000390749603330
ISSN: 1535-4970
CID: 2414702

Phenibut Overdose in Combination with Fasoracetam: Emerging Drugs of Abuse

Merchan, Cristian; Morgan, Ryan; Papadopoulos, John; Fridman, David
The widespread availability of non-traditional dietary supplements and pharmacologically active substances via the Internet continues to introduce mechanisms for inadvertent toxidromes not commonly seen. Consumers are virtually unrestricted in their ability to acquire products purporting augmentation of normal physiology for the purposes of enhancement, recreation, and/or potential abuse. The safety profiles at standard or toxic doses remain largely unknown for many agents that can be purchased electronically. We report a case of mixed toxicity related to phenibut and fosaracetam, both of which are readily available for consumer purchase from online retailers. Written and verbal consent was obtained for this case presentation
ORIGINAL:0012267
ISSN: n/a
CID: 2713332

EVALUATING ANTI-XA AND APTT MONITORING OF HEPARIN IN PATIENTS WITH AN IMPELLA DEVICE [Meeting Abstract]

Musallam, Nadine; Altshuler, Diana; Ahuja, Tania; Aberle, Caitlin; Papadopoulos, John
ISI:000388910200178
ISSN: 0090-3493
CID: 5333312

Evaluation of Treatment Courses When Vancomycin Is Given Every 8 Hours in Adult Patients

Brumer, Erica; Dubrovskaya, Yanina; Scipione, Marco R; Aberle, Caitlin; Rahimian, Joseph; Papadopoulos, John
BACKGROUND: Several nomograms include recommendations to give intravenous (IV) vancomycin at 8-hour dosing intervals (Q8H). However, there is a lack of detailed data regarding this dosing recommendation. METHODS: A retrospective chart review of 100 patients who received 107 treatment courses of vancomycin Q8H for at least 5 days was performed. Distribution of vancomycin trough levels and rate of nephrotoxicity were evaluated. RESULTS: Median patient age was 38 years (interquartile range [IQR] 27-50 years), median weight was 67 kg (IQR 55-79 kg), and median creatinine clearance was 124 mL/min (IQR 101-147 mL/min). Median duration of Q8H dosing was 9 days (IQR 7-12 days). Within the initial 96 hours, only 7% (7 of 104) of maximum trough concentrations were >20 mg/L (median dose 15 mg/kg [IQR 15-18 mg/kg]). After 96 hours of Q8H dosing, 34% (30 of 89) of maximum troughs were >20 mg/L (median dose 17 mg/kg [IQR 15-20 mg/kg]), P = .0005. The rate of nephrotoxicity was 4%. CONCLUSION: We observed an increase in the percentage of trough levels >20 mg/L later during treatment courses of vancomycin IV Q8H with a relatively small corresponding increase in vancomycin dose. Close monitoring of trough levels (eg, every 3 days) with prolonged courses of vancomycin IV Q8H is warranted.
PMID: 25112304
ISSN: 1531-1937
CID: 1847672