A Resident-Preceptor Collaboration to Encourage Wellness and Reduce Burnout Amongst Pharmacy Residents

Pharmacy residents are especially vulnerable to burnout given the professional and personal stressors associated with postgraduate training. Residency programs need to prioritize burnout reduction strategies to support resident health and well-being. This commentary describes a resident-preceptor collaborative approach to encourage wellness and reduce burnout within a large residency program at an academic medical center. Strategies that have been utilized include (1) fostering collaboration among residents and preceptors; (2) assessing resident interests and needs to ensure alignment; (3) leveraging available institutional and community resources; and (4) integrating initiatives within the existing residency program structure. This commentary aims to provide suggestions that can be implemented to address resident burnout for other residency programs, regardless of resource availability.

Clinical Outcomes With Definitive Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia With Retained Daptomycin and Ceftaroline Combination Therapy vs De-escalation to Monotherapy With Vancomycin, Daptomycin, or Ceftaroline

Background

Lower mortality has been observed with combination therapy compared to monotherapy for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; however, there is a lack of evidence for continued combination therapy over de-escalation to monotherapy following bacteremia clearance.

Methods

This was a single-center, retrospective study evaluating patients with MRSA bacteremia hospitalized from November 1, 2011, through July 31, 2019. Patients who received three to ten days of combination therapy followed by de-escalation to monotherapy were directly compared to patients retained on combination therapy. The primary composite outcome included inpatient infection-related mortality, 60-day readmission, and 60-day bacteremia recurrence.

Results

A total of 286 patients with MRSA bacteremia were identified, with 146 patients omitted based on exclusion criteria. The study population included 66 in the combination therapy group and 74 in the monotherapy group. Study population was 51% female (n = 71) and 78% white (n = 109) with median age of 46 years (IQR 34.5-61). No significant difference was observed in the primary composite outcome (21% combination therapy group vs 24% monotherapy group; P =.66), with retained observations after controlling for confounders. Within this outcome, there was no significant difference in 60-day readmission (20% combination therapy group vs 18% monotherapy group; P =.75), bacteremia recurrence (3% combination therapy group vs 7% monotherapy group; P =.45), or inpatient infection-related mortality (2% combination therapy group vs 5% monotherapy group; P = 1.00).

Conclusions

No difference was found in the composite outcome of 60-day bacteremia recurrence, readmission, or inpatient infection-related mortality for patients with MRSA bacteremia retained on combination therapy versus those de-escalated to monotherapy.

Clinical Outcomes of Daptomycin Versus Anti-Staphylococcal Beta-Lactams in Definitive Treatment of Methicillin-susceptible Staphylococcus aureus Bloodstream Infections

OBJECTIVES

Staphylococcus aureus (S. aureus) is the leading cause of bacteraemia and infective endocarditis worldwide. The preferred management of patients with methicillin-susceptible S. aureus (MSSA) bacteraemia includes definitive therapy with intravenous anti-staphylococcal beta-lactam (ASBL) antibiotics. Daptomycin (DAP) has been targeted as a viable substitute for beta-lactam allergic or intolerant patients.

METHODS

This single-center retrospective cohort study assessed clinical outcomes of DAP compared with ASBL antibiotics [nafcillin (NAF) or cefazolin (CFZ)] for the treatment of MSSA bacteraemia in patients hospitalised from 01 November 2011 to 31 October 2018. The primary outcome was a composite of the following: clinical failure, MSSA recurrence and MSSA persistence or inpatient infection-related mortality. Secondary outcomes included duration of MSSA bacteraemia, infection-related length of stay, infection-related 90-day readmission, 30-day all-cause mortality, and adverse events necessitating a change in therapy.

RESULTS

Of 89 patients with MSSA bacteraemia who were included: 29 received DAP, 30 received NAF and 30 received CFZ. There was no difference in the composite primary outcome in patients treated with DAP compared with ASBL (10% vs. 5%, P = 0.39). The DAP cohort had a longer hospital length of stay compared with the ASBL group (20 days vs. 11.5 days, P = 0.0007). No differences were detected between other secondary outcomes.

CONCLUSION

This study suggests that DAP may serve as a comparable alternative to ASBLs for treatment of MSSA bacteraemia, as no differences in clinical outcomes were identified. Larger studies are needed to confirm these findings.

Clinical outcomes following treatment of Enterobacter species pneumonia with piperacillin/tazobactam compared to cefepime or ertapenem

BACKGROUND

Enterobacter spp. are a common cause of nosocomial pneumonia and treatment can be complicated by AmpC resistance. Carbapenems are the treatment of choice; however, alternatives are needed. Cefepime has been shown to be non-inferior to carbapenems. There are limited data to support the use of piperacillin/tazobactam. The objective of this study was to determine if piperacillin/tazobactam is non-inferior to cefepime or ertapenem for Enterobacter pneumonia treatment.

OBJECTIVES

To compare the rate of clinical cure in patients with Enterobacter pneumonia receiving definitive treatment with piperacillin/tazobactam, cefepime, or ertapenem. Secondary outcomes included hospital mortality, infection-related length of stay, duration of mechanical ventilation, recurrent pneumonia, and resistance.

METHODS

Retrospective, single-center study.

RESULTS

Of 114 patients included, 59 received definitive treatment with piperacillin/tazobactam and 55 received cefepime or ertapenem. There was no difference in the proportion of patients who achieved clinical cure in the piperacillin/tazobactam group compared to the cefepime or ertapenem group (76.3% vs. 87.3%, P = 0.13). Treatment group was not associated with clinical cure when controlling for confounders in multivariable logistic regression (adjusted odds ratio [OR] 0.59, 95% confidence interval [CI] 0.15-2.37). The rate of recurrent pneumonia was 11.4% in the piperacillin/tazobactam group and 6.7% in the cefepime or ertapenem group (P = 0.48). Other secondary outcomes did not differ between the groups.

CONCLUSIONS

In this retrospective study of patients with Enterobacter pneumonia, clinical cure with piperacillin/tazobactam was comparable to that with cefepime or ertapenem; however, a prospective trial with a larger population is needed to determine if definitive treatment with piperacillin/tazobactam is non-inferior to definitive treatment with cefepime or ertapenem.

Clinical Outcomes with Penicillin Versus Alternative β-Lactams in the Treatment of Penicillin-Susceptible Staphylococcus aureus Bacteremia

OBJECTIVES

To identify the impact of penicillin versus alternative β-lactams on clinical outcomes in patients with penicillin-susceptible Staphylococcus aureus (PSSA) bacteremia.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENTS

Adult patients with PSSA bacteremia treated with a β-lactam as definitive therapy.

MEASUREMENTS

The primary outcome was a composite end point of 30-day clinical failure (change in PSSA therapy due to persistent or worsening signs and symptoms, PSSA bacteremia recurrence or persistence, and/or infection-related mortality) in patients treated with penicillin versus alternative β-lactams. Secondary outcomes included infection-related and hospital length of stay (LOS), 90-day recurrence, 90-day infection-related readmission, 30-day all-cause mortality, adverse drug events (ADEs), and 30-day change in PSSA therapy due to ADEs. A subgroup analysis comparing penicillin, nafcillin, and cefazolin was also conducted.

MAIN RESULTS

For the 122 patients who were included, the most common definitive therapies were nafcillin (37%), cefazolin (29%), and penicillin (21%). No difference was found in 30-day clinical failure (4% vs 11%, p=0.46), infection-related LOS (12 days vs 11 days, p=0.39), hospital LOS (12.5 days vs 12 days, p=0.69), 90-day recurrence (p=1.00), 90-day infection-related readmission (p=1.00), or 30-day all-cause mortality (p=0.45) between penicillin and other β-lactams. The prevalence of ADEs was different among penicillin, nafcillin, and cefazolin (p=0.049), with nafcillin requiring more changes in therapy (p=0.005).

CONCLUSIONS

Definitive therapy with penicillin had similar efficacy compared with alternative β-lactams for the treatment of PSSA bacteremia. However, nafcillin was associated with more ADEs requiring a change in therapy.