Antibiotics for Patients With a Planned Re-Laparotomy for Intra-Abdominal Infection

Background: Appropriate antimicrobial therapy for the management of intra-abdominal infection (IAI) continues to evolve based on available literature. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial provided evidence to support four days of antibiotic agents in IAI post-source control but excluded patients with a planned re-laparotomy. This study aimed to determine the short- and long-term recurrent infection risk in this population. Patients and Methods: This is a single-center, retrospective, observational study of adult patients admitted to a quaternary medical center between January 1, 2016, and August 1, 2022, with IAI requiring planned laparotomy. Patients were designated as receiving five or less days of antibiotic agents (short course) or more than five days (long course) after source control. The primary outcome was IAI recurrence within 30 days. Results: Of the 104 patients who met inclusion criteria, 78 were included in analysis. Average age was 57 ± 13.3 years, 56% were male, 94% Caucasian, with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 17 ± 7.09. All other baseline characteristics and clinical severity markers were similar between the two groups. Regarding the primary outcome of IAI recurrence, there was no difference when comparing those who received short course versus those who received long course therapy (41.2% vs. 44.4%; p = 0.781). No differences were found between groups with respect to secondary outcomes. Conclusions: In patients admitted with IAI managed with planned re-laparotomy those who received short course antimicrobial therapy were not found to have an increase in IAI recurrence compared to those with longer courses of therapy.

Evaluation of Antibiotic Duration after Surgical Debridement of Necrotizing Soft Tissue Infection

Background: Necrotizing soft tissue infection (NSTI) is known to be a medical emergency with high morbidity and mortality. Guidelines do not specify the optimal duration of antibiotic agents after completion of surgical debridements of NSTI, which has created variable practice. It was hypothesized that patients with NSTI who receive 48 hours or less of post-operative antibiotic agents after final debridement have similar rates of subsequent intervention or infection recurrence, suggesting that a shorter duration of antibiotic agents may treat NSTI adequately after final surgical debridement. Patients and Methods: This was a retrospective study including adults with NSTI identified through International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, Tenth Revision (ICD-10), and Current Procedural Terminology (CPT) codes admitted to one academic institution between January 1, 2010 and July 31, 2020. Demographics, surgical practices, antibiotic practices, and clinical outcomes including inpatient mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, total antibiotic days, necrotizing infection clinical composite end point (NICCE) success, and infection recurrence were compared based on the duration of antibiotic agents after final debridement. Results: Three hundred twenty-two patients with NSTI were included and baseline characteristics and clinical severity markers were well balanced between the two groups. In 71 patients (22%) who received less than 48 hours of antibiotic agents after final debridement there was no difference in recurrence (1.4% vs. 3.6%; p = 0.697), mortality (1.4% vs. 4.4%; p = 0.476), or ICU LOS (1 vs. 2 days; p = 0.300], but they did have a shorter hospital LOS (7 vs. 10 days; p = 0.011). Conclusions: Shorter duration of antibiotic therapy after final surgical debridement of NSTI may be appropriate in patients without another indication for antibiotic agents.

Asystole Following Concomitant Intravenous Administration of Neostigmine and Dexmedetomidine in a Patient With Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a condition characterized by acute dilation of the large bowel without evidence of mechanical obstruction that occurs in a variety of hospitalized patients with many predisposing factors. Management includes supportive care and limitation of offending medications with mainstays of treatment of neostigmine administration and colonic decompression. We report the case of a critically ill patient with ACPO who experienced bradycardia and a brief episode of asystole when receiving concomitant dexmedetomidine and neostigmine infusions but who later remained hemodynamically stable when receiving propofol and neostigmine infusions. The bradycardia and associated hemodynamic instability experienced while on dexmedetomidine and neostigmine infusions were rapidly corrected with atropine and cessation of offending agents. Because ACPO is encountered frequently and the use of dexmedetomidine as a sedative agent in the ICU is increasing, practitioners should be aware of the additive risk of bradycardia and potential for asystole with the combination of neostigmine and dexmedetomidine. Electronic drug interaction databases should be updated and drug information sources should include a drug-drug interaction between dexmedetomidine and neostigmine to reduce the likelihood of concomitant administration.

Sleep quality during an overnight on-call program

PURPOSE

Many institutions deploy pharmacy residents to expand clinical pharmacy services, often in the form of overnight, in-house on-call programs. There is little published evidence regarding pharmacy resident sleep and sleepiness after a night of overnight, in-house on-call activity. A prospective observational cohort study was conducted to determine the relationship between overnight, in-house on-call programs and pharmacy resident sleep and sleep quality.

METHODS

The cohort study included both postgraduate year 1 and postgraduate year 2 pharmacy residents. Each resident participated in 10 to 15 overnight on-call shifts. Sleep and sleep quality were assessed using devices worn on residents' wrists on the nights prior to, during, and after on-call shifts. Resident sleepiness was assessed via the Epworth Sleepiness Scale (ESS) during specified baseline and postcall periods. Univariate and multivariate analysis were used to assess the relationship between measurements of sleep, sleep quality, and sleepiness.

RESULTS

We enrolled a total of 23 residents in the study and recorded data on 269 on-call shifts. Frequently (42.6% of shifts) residents had no time to sleep during overnight on-call shifts. Among those who did have sleep time, the mean sleep time during an overnight, in-house on-call shift was 1.22 (SD, 1.56) hours. Additionally, ESS scores indicated a 2.4-fold increase in sleepiness on the morning after vs the morning before on-call shifts.

CONCLUSION

Residents often did not sleep while on call. Sleep periods overnight were short and of poor quality. Predictably, residents reported increased sleepiness after an overnight on-call shift. Residents received an average of approximately 10 clinical consultation calls per overnight shift.

Minimizing opioid use after acute major trauma

PURPOSE

Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported.

METHODS

In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before (n = 489) and after (n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition.

RESULTS

Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p < 0.001); after stratification of MME data by baseline opioid use, this finding held true only for patients with no opioid prescription at admission. Although utilization of gabapentinoids, skeletal muscle relaxants, and clonidine increased during the postintervention period, inpatient opioid use did not differ significantly in the 2 cohorts. Utilization of both nonsteroidal antiinflammatory drugs and acetaminophen was lower in the postintervention cohort versus the preintervention cohort.

CONCLUSION

Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.

Procalcitonin: Usefulness in Acute Care Surgery and Trauma

BACKGROUND

Procalcitonin (PCT) is a serum biomarker currently suggested by the Surviving Sepsis Campaign to aid in determination of the appropriate duration of therapy in sepsis patients. We review the use of procalcitonin in patients after trauma or acute care surgery.

METHOD

A MEDLINE search via PubMed was performed using the combination of "procalcitonin" and "humans" and "injuries, trauma," "wounds and injuries," or "wounds." Studies of burn patients, children, other biomarkers, and non-acute care surgery were excluded.

RESULTS

Procalcitonin may be useful in identifying infection in trauma and post-operative acute care surgery. However, heterogenity exists among patients, and surgery and trauma alone elevate PCT even in the absence of infection.

CONCLUSIONS

Although trends in PCT concentrations may offer insight, no standard approach can be recommended currently.

Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

PubMed/MEDLINE (1966-November 2014) was searched to identify relevant published studies on the overall frequency, types, and examples of medication errors during medical emergencies involving cardiopulmonary resuscitation and related situations, and the breakdown by type of error. The overall frequency of medication errors during medical emergencies, specifically situations related to resuscitation, is highly variable. Medication errors during such emergencies, particularly cardiopulmonary resuscitation and surrounding events, are not well characterized in the literature but may be more frequent than previously thought. Depending on whether research methods included database mining, simulation, or prospective observation of clinical practice, reported occurrence of medication errors during cardiopulmonary resuscitation and surrounding events has ranged from less than 1% to 50%. Because of the chaos of the resuscitation environment, errors in prescribing, dosing, preparing, labeling, and administering drugs are prone to occur. System-based strategies, such as infusion pump policies and code cart management, as well as personal strategies exist to minimize medication errors during emergency situations.