Evaluation of Critical Care Pharmacist Evening Services at an Academic Medical Center

Purpose: Critical care pharmacists are considered essential members of the healthcare team; however, justification and recruitment of new positions, especially in the evening or weekend shifts, remains a significant challenge. The purpose of this study was to investigate the number of interventions, type of interventions, and associated cost savings with the addition of 1 board certified critical care clinical pharmacist to evening shift. Methods: This was a prospective collection and characterization of 1 evening shift critical care pharmacist's clinical interventions over a 12-week period. Interventions were collected and categorized daily from 13:00 to 22:00 Monday through Friday. After collection was complete, cost savings estimates were calculated using pharmacy wholesaler acquisition cost. Results: Interventions were collected on 52 of 60 weekdays. A total of 510 interventions were collected with an average of 9.8 interventions accepted per day. The most common interventions included transitions of care, medication dose adjustment, and antibiotic de-escalation and the highest proportion of interventions occurred in the medical intensive care unit. An estimated associated cost avoidance of $66 537.80 was calculated for an average of $1279.57 saved per day. Additionally, 22 (4.1%) of interventions were considered high yield interventions upon independent review by 2 pharmacists. Conclusion: The addition of 1 board-certified critical care pharmacist to evening shift resulted in multiple interventions across several categories and a significant cost avoidance when calculated using conservative measures.

Time to blood, respiratory and urine culture positivity in the intensive care unit: Implications for de-escalation

Objectives

Concern for late detection of bacterial pathogens is a barrier to early de-escalation efforts. The purpose of this study was to assess blood, respiratory and urine culture results at 72 h to test the hypothesis that early negative culture results have a clinically meaningful negative predictive value.

Methods

We retrospectively reviewed all patients admitted to the medical intensive care unit between March 2012 and July 2018 with blood cultures obtained. Blood, respiratory and urine culture results were assessed for time to positivity, defined as the time between culture collection and preliminary species identification. The primary outcome was the negative predictive value of negative blood culture results at 72 h. Secondary outcomes included sensitivity, specificity, positive predictive value and negative predictive value of blood, respiratory and urine culture results.

Results

The analysis included 1567 blood, 514 respiratory and 1059 urine cultures. Of the blood, respiratory and urine cultures ultimately positive, 90.3%, 76.2% and 90.4% were positive at 72 h. The negative predictive value of negative 72-h blood, respiratory and urine cultures were 0.99, 0.82 and 0.97, respectively. Antibiotic de-escalation had good specificity, positive predictive value and negative predictive value for finalized negative cultures.

Conclusion

Negative blood and urine culture results at 72 h had a high negative predictive value. These findings have important ramifications for antimicrobial stewardship efforts and support protocolized re-evaluation of empiric antibiotic therapy at 72 h. Caution should be used in patients with clinically suspected pneumonia, since negative respiratory culture results at 72 h were weakly predictive of finalized negative cultures.

Hydrocortisone Continuous Infusion Versus Bolus Dose on Glycemic Control in Critically Ill Subjects

BACKGROUND

Corticosteroid therapy in patients with septic shock can improve hemodynamics but can also cause hyperglycemia. Continuous infusion (CI) hydrocortisone has limited evidence that it may reduce hyperglycemia relative to bolus dose (BD) therapy, but CI can be cumbersome and requires attention to intravenous access and drug incompatibilities.

OBJECTIVE

To compare the effects of CI hydrocortisone with BD on glycemic control.

METHODS

A matched, retrospective cohort study of blood glucose, insulin requirements, and glycemic variability was performed between patients with shock receiving CI and BD hydrocortisone. Patients were matched based on history of type 2 diabetes and intensive care unit (ICU) admission.

RESULTS

Baseline blood glucose was similar between groups, with higher baseline hourly insulin requirements in the CI group (CI: 12 [12.8] units, BD: 6.7 [7] units, P = .0012). For the first 72 hours of treatment, there was no difference in mean blood glucose with higher average hourly insulin requirements in the CI group (CI 7.8 [7.7] units, BD: 5.5 [6.9] units, P < .0001). There was no difference in glycemic variability between groups.

CONCLUSIONS

CI hydrocortisone therapy for septic shock does not appear to have a favorable impact on mean blood glucose or influence glycemic variability relative to BD therapy.

Minocycline repurposing in critical illness: focus on stroke

Stroke is a devastating disease associated with high morbidity and mortality. Despite the approved indication of systemic thrombolytic therapy in the United States for the acute management of ischemic stroke, its use is limited given a strict eligibility criteria and a risk for hemorrhagic transformation as a feared adverse effect. Many agents have been studied without success for neuroprotection in patients with stroke to reduce vascular injury and improve long-term functional outcomes. Minocycline is a tetracycline antibiotic that shows promise for its neuroprotective effects in multiple animal models and three human trials. It affects multiple pathways to reduce apoptosis, neuroinflammation, infarct size, and vascular injury. The aim of this review is to discuss current evidence for minocycline from pre-clinical and early clinical trials and its potential role in neuroprotection in patients with acute ischemic stroke.

Examination of the Relationship Between Antimicrobials and Thrombocytosis

Objective:

To evaluate whether there is a relationship between antimicrobial therapy and the development of thrombocytosis.

Data Sources:

Literature was accessed through EMBASE (1977-June 2012) and MEDLINE (1977-June 2012) using the terms thrombocytosis and antimicrobial. In addition, reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

All English-language publications identified were evaluated. For case reports, the Naranjo probability scale was used to calculate the likelihood of the drug causing the reaction.

Data Synthesis:

Thrombocytosis occurring during antimicrobial therapy is well documented, with several case reports and clinical trial observations. However, a direct causal relationship is not yet supported by the available literature. Platelets are welt known to be an acute phase reactant, with an elevated count occurring after acute conditions such as blood loss, inflammation, or infection. Thrombocytosis during antimicrobial therapy may be the result of an infectious process and not an adverse drug event.

Conclusions:

Based on the current available literature, a definitive link cannot be established between antimicrobial therapy and occurrence of thrombocytosis.