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Cranis M, Elamin A, Hatch-Vallier B, Collins CD, Malani AN. Impact of infectious diseases consultation for hospitalized patients with Clostridioides difficile infection. Infect Control Hosp Epidemiol 2024:1-4. [PMID: 38356353 DOI: 10.1017/ice.2024.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality. This study described outcomes associated with mandatory infectious diseases (ID) consultation in hospitalized patients with CDI. ID consultation was associated with increased appropriate concomitant antibiotic use, however longer courses of concomitant antibiotics were administered.
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Affiliation(s)
- Mara Cranis
- Department of Infection Prevention and Control, Trinity Health, Ann Arbor, MI, USA
- Department of Infection Prevention and Control, Trinity Health, Livonia, MI, USA
| | - Azza Elamin
- Department of Internal Medicine, Infectious Diseases, Trinity Health, Ann Arbor, MI, USA
| | - Brianna Hatch-Vallier
- Department of Internal Medicine, Infectious Diseases, Trinity Health, Ann Arbor, MI, USA
| | - Curtis D Collins
- Department of Pharmacy Services, Trinity Health, Ann Arbor, MI, USA
| | - Anurag N Malani
- Department of Infection Prevention and Control, Trinity Health, Ann Arbor, MI, USA
- Department of Internal Medicine, Infectious Diseases, Trinity Health, Ann Arbor, MI, USA
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2
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Collins CD, Dumkow LE, Kufel WD, Nguyen CT, Wagner JL. ASHP/SIDP Joint Statement on the Pharmacist's Role in Antimicrobial Stewardship. Am J Health Syst Pharm 2023; 80:1577-1581. [PMID: 37879095 DOI: 10.1093/ajhp/zxad164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Affiliation(s)
| | | | | | | | - Jamie L Wagner
- University of Mississippi School of Pharmacy, Jackson, MS, USA
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Collins CD, Bookal RS, Malani AN, Leo HL, Shankar T, Scheidel C, West N. Antibiotic Use in Patients With β-Lactam Allergies and Pneumonia: Impact of an Antibiotic Side Chain-Based Cross-Reactivity Chart Combined With Enhanced Allergy Assessment. Open Forum Infect Dis 2022; 9:ofab544. [PMID: 34988249 PMCID: PMC8715852 DOI: 10.1093/ofid/ofab544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND β-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with β-lactam allergies are often treated with non-β-lactam alternative antibiotics. An institutional β-lactam side chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for patients with β-lactam allergies. METHODS This single-center, retrospective cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following implementation. The primary outcome was the incidence of β-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes. RESULTS A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significantly greater use of β-lactams in the intervention cohort (70.4% vs 89.3%; P < .001) and decreased use of alternative therapy (58.1% vs 36%; P < .001). There was no difference in overall allergic reactions between cohorts (2.4% vs 1.6%; P = .738) or in reactions caused by β-lactams (1.3% vs 0.9%; P = .703). Inpatient mortality increased (0% vs 6.4%; P < .001); however, no deaths were due to allergic reactions. Healthcare facility-onset Clostridioides difficile infections decreased between cohorts (1.2% vs 0.2%; P = .032). CONCLUSIONS Implementation of a β-lactam side chain-based cross-reactivity chart and enhanced allergy assessment was associated with increased use of β-lactams in patients with pneumonia without increasing allergic reactions.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Renee S Bookal
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Nina West
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Collins CD, West N, Shankar T, Leo HL, Bookal R. 65. Impact of an Antibiotic Side-Chain-Based Cross-Reactivity Chart on Antibiotic Use in Patients With β-lactam Allergies and Pneumonia. Open Forum Infect Dis 2021. [PMCID: PMC8644959 DOI: 10.1093/ofid/ofab466.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background β-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with β-lactam allergies are too often treated with alternative antibiotic therapy. An institutional β-lactam side-chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for β-lactam allergies patients. Methods This single center, retrospective, cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with documented β-lactam allergies with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following institutional implementation and adoption. The primary outcome was the incidence of β-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes across time periods. Results A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significant increase in the use of β-lactams for treatment of pneumonia (70.4% vs 89.3%; p < 0.001) and the use of any alternative therapy decreased between cohorts (58.1% vs. 36%; p < 0.001) (Figure 1). β-lactam use per patient significantly improved between cohorts in patients with mild, Type 1 IgE-mediated hypersensitivity reactions (HSRs) and in patients with unknown reactions. There was no difference in overall HSRs between cohorts (2.4% vs. 1.45; p = 0.628), or in patients who received β-lactam antibiotics (1.3% historical group vs 1.1% intervention group; p = 0.467). Median alternative antibiotic days of therapy (3 vs. 2; p = 0.027) and duration of therapy per patient (3 days vs. 2 days; p = 0.023) decreased between cohorts. There was a significant increase in mortality while healthcare facility-onset Clostridioides difficile infections decreased between cohorts. β-Lactam vs. Alternative Therapy Use per Patients by Calendar Quarter ![]()
Conclusion Implementation of a β-lactam side-chain-based cross-reactivity chart significantly increased the utilization of β-lactams in patients with pneumonia without increasing HSRs. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | - Nina West
- St. Joseph Mercy Health System, Ypsilanti, Michigan
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, Ann Arbor, Michigan
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, Ann Arbor, Michigan
| | - Renee Bookal
- St. Joseph Mercy Health System, Ypsilanti, Michigan
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Abstract
Objectives: This study assessed the impact transitions of care (TOC) pharmacists have on optimizing antimicrobial use for patients at high risk for mortality at hospital discharge. In addition, this study aimed to summarize and categorize the types of interventions made. Methods: This was a retrospective descriptive study that included adult patients 18 years of age or older who were at high risk for readmission and mortality. Participants were selected if they had a hospital discharge date between January 2017 and June 2018, but were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible. TOC pharmacists identified eligible participants and reviewed their discharge medication lists to optimize pharmacological therapy, contacting the discharging prescriber if therapy changes were identified. The therapy recommendations made by TOC pharmacists were documented in an internal database for further analysis. Results: A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to study objectives, 298 (14.4%) of the interventions made by TOC pharmacists involved antimicrobial recommendations, affecting 255 (23.2%) patients. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made. Sixty-six (25.9%) patients received multiple interventions and 240 (80.5%) recommendations were accepted by the provider. Conclusion: An opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge.
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Affiliation(s)
- Noah Leja
- University of Michigan Health Systems, MI, USA.,Saint Joseph Mercy Hospital, Ann Arbor, MI, USA
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Malani AN, LaVasseur B, Fair J, Domeier R, Vershum R, Fowler R, Collins CD. Administration of Monoclonal Antibody for COVID-19 in Patient Homes. JAMA Netw Open 2021; 4:e2129388. [PMID: 34648014 PMCID: PMC8517740 DOI: 10.1001/jamanetworkopen.2021.29388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/11/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anurag N. Malani
- Department of Medicine, Section of Infectious Diseases, St Joseph Mercy Hospital, Ann Arbor, Michigan
- Department of Infection Prevention and Control, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Beth LaVasseur
- Department of Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Jason Fair
- Huron Valley Ambulance, Ann Arbor, Michigan
| | - Robert Domeier
- Department of Emergency Medicine, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Rita Vershum
- Department of Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Robin Fowler
- Department of Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Curtis D. Collins
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, Michigan
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Andrawis M, Carmichael J, Collins CD, Dopp AL, Ellison LTCC, Mahan KC, Riddle S. Improving patient care and demonstrating value during a global pandemic: Recommendations from leaders of the Pharmacy Accountability Measures Work Group. Am J Health Syst Pharm 2021; 77:2003-2005. [PMID: 32835361 PMCID: PMC7499484 DOI: 10.1093/ajhp/zxaa291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Steve Riddle
- Clinical Surveillance & Compliance, Wolters Kluwer, Madison, WI
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Collins CD, West N, Sudekum DM, Hecht JP. Perspectives from the frontline: A pharmacy department's response to the COVID-19 pandemic. Am J Health Syst Pharm 2021; 77:1409-1416. [PMID: 34279579 PMCID: PMC7449257 DOI: 10.1093/ajhp/zxaa176] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose The global coronavirus 2019 (COVID-19) pandemic has created unprecedented strains on healthcare systems around the world. Challenges surrounding an overwhelming influx of patients with COVID-19 and changes in care dynamics prompt the need for care models and processes that optimize care in this medically complex patient population. The purpose of this report is to describe our institution’s strategy to deploy pharmacy resources and standardize pharmacy processes to optimize the management of patients with COVID-19. Methods This retrospective, descriptive report characterizes documented pharmacy interventions in the acute care of patients admitted for COVID-19 during the period April 1 to April 15, 2020. Patient monitoring, interprofessional communication, and intervention documentation by pharmacy staff was facilitated through the development of a COVID-19–specific care bundle integrated into the electronic medical record. Results A total of 1,572 pharmacist interventions were documented in 197 patients who received a total of 15,818 medication days of therapy during the study period. The average number of interventions per patient was 8. The most common interventions were regimen simplification (15.9%), timing and dosing adjustments (15.4%), and antimicrobial therapy and COVID-19 treatment adjustments (15.2%). Patients who were admitted to an intensive care unit care at any point during their hospital stay accounted for 66.7% of all interventions documented. Conclusion A pharmacy department’s response to the COVID-19 pandemic was optimized through standardized processes. Pharmacists intervened to address a wide scope of medication-related issues, likely contributing to improved management of COVID-19 patients. Results of our analysis demonstrate the vital role pharmacists play as members of multidisciplinary teams during times of crisis.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Nina West
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - David M Sudekum
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Jason P Hecht
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
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Collins CD, Scheidel C, Anam K, Polega S, Malani AN, Hayward A, Leo HL, Shankar T, Morrin C, Brockhaus K. Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With β-Lactam Allergies. Clin Infect Dis 2021; 72:1404-1412. [PMID: 32155264 DOI: 10.1093/cid/ciaa232] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar. METHODS An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. RESULTS A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. CONCLUSIONS Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Kishore Anam
- Michigan Data Analytics, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Shikha Polega
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA.,Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Alexandra Hayward
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Cheryl Morrin
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Kara Brockhaus
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Collins CD, Kollmeyer S, Scheidel C, Dietzel CJ, Leeman LR, Morrin C, Malani AN. Impact of a Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Program Activities. Open Forum Infect Dis 2021; 8:ofab056. [PMID: 33738318 PMCID: PMC7953666 DOI: 10.1093/ofid/ofab056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship program (ASP) surveillance at our hospital is supplemented by an internally developed surveillance database. In 2013, the database incorporated a validated, internally developed, prediction rule for patient mortality within 30 days of hospital admission. This study describes the impact of an expanded ASP review in patients at the highest risk for mortality. METHODS This retrospective, quasi-experimental study analyzed adults who received antimicrobials with the highest mortality risk score. Study periods were defined as 2011-Q3 2013 (historical group) and Q4 2013-2018 (intervention group). Primary and secondary outcomes were assessed for confounders and analyzed using both unadjusted and propensity score weighted analyses. Interrupted time-series analyses also analyzed key outcomes. RESULTS A total of 3282 and 5456 patients were included in the historical and intervention groups, respectively. There were significant reductions in median antimicrobial duration (5 vs 4 days; P < .001), antimicrobial days of therapy (8 vs 7; P < .001), antimicrobial cost ($96 vs $85; P = .003), length of stay (LOS) (6 vs 5 days; P < .001), intensive care unit (ICU) LOS (3 vs 2 days; P < .001), total hospital cost ($10 946 vs $9119; P < .001), healthcare facility-onset vancomycin-resistant Enterococcus (HO-VRE) incidence (1.3% vs 0.3%; P ≤ .001), and HO-VRE infections (0.6% vs 0.2%; P = .018) in the intervention cohort. CONCLUSIONS Reductions in antimicrobial use, hospital and ICU LOS, HO-VRE, HO-VRE infections, and costs were associated with incorporation of a novel mortality prediction rule to guide ASP surveillance and intervention.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Scott Kollmeyer
- Department of Pharmacy Services, Covenant Healthcare, Saginaw, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | | | - Lauren R Leeman
- Michigan Data Analytics; St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Cheryl Morrin
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Division of Infectious Diseases; St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Olmack K, Collins CD. 80. Pharmacoeconomic Analysis Comparing the Empiric Utilization of Cefepime Versus Piperacillin/tazobactam. Open Forum Infect Dis 2020. [PMCID: PMC7776469 DOI: 10.1093/ofid/ofaa439.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In the hospital setting, cefepime (CFP) and piperacillin/tazobactam (PTZ) are among the most commonly utilized antipseudomonal agents in the empiric treatment of nosocomial and healthcare-associated infections. Institutional preference of CFP or PTZ as the preferred antipseudomonal antibiotic varies. Recent literature suggests each may be associated with increased rates of harmful adverse effects including Clostridiodes difficile infection (CDI) and acute kidney injury (AKI). The objective of this study is to perform a pharmacoeconomic analysis comparing CFP versus PTZ for empiric antibiotic treatment in patients where Pseudomonas aeruginosa is a concern.
Methods
We performed a cost-utility analysis comparing CFP and PTZ for empiric utilization in the hospital setting by creating a decision analytic model from the hospital perspective. Model variables were populated utilizing published clinical and economic data including incidence of AKI and CDI, their associated costs and mortality, and the cost of antibiotic therapy. Secondary and univariate sensitivity analyses tested the impact of model uncertainties and the robustness of our model. A willingness to pay (WTP) threshold of $0 was utilized.
Results
Results of our base-case model predicted that the use of CFP dominated PTZ as empiric utilization was less expensive ($7690 vs. $9331) and associated with a higher quality-adjusted life-years (QALY) (0.9193 vs. 0.9191) compared to the use of PTZ. Several variables had the potential to impact base case results. PTZ became cost-effective at our WTP threshold if CFP nephrotoxicity rates increased to 17.3%, the PTZ nephrotoxicity decreased to 28.5%, or if the cost of nephrotoxicity was less than $17,457. No other model variables, including incidence of CDI, impacted base case results.
Sensitivity Analysis on Cefepime Clostridioides difficile Infection Incidence and Piperacillin/tazobactam Nephrotoxicity
Conclusion
Results of our model showed that CFP dominated PTZ for the empiric treatment of nosocomial infections. The model was sensitive to variation in CFP and PTZ nephrotoxicity rates.
Disclosures
All Authors: No reported disclosures
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Abstract
PURPOSE The global coronavirus disease 2019 (COVID-19) pandemic and the search for ways in which to provide the best available care have created unprecedented times in terms of rapidly evolving reports of available treatment options. The primary objective of our analysis was to categorize online, open-source guidance to determine how US institutions approached their recommendations for management of patients with COVID-19 in the early weeks of the pandemic. METHODS A search for open-source, online institutional guidelines for the treatment of COVID-19 was conducted using predefined criteria. The search was limited to the United States and conducted from April 12 through 14, 2020, and again on April 22, 2020. Searches were conducted at 2 points in time in order to identify changes in treatment recommendations due to evolving literature or institutional experience. Treatment recommendations, including guidance on antiviral therapy, corticosteroid and interleukin-6 inhibitor use, and nutritional supplementation were compared. RESULTS Of the 105 institutions that met initial screening criteria, 14 institutions (13.3%) had online COVID-19 guidance available. Supportive care and clinical trial enrollment were the primary recommendations in all evaluated guidance. Recommendations to consider antimicrobial and adjunctive therapy varied. Eighty-six percent of guidelines contained recommendations for use, or consideration of use, of hydroxychloroquine. Guidance from 2 institutions mentioned use of hydroxychloroquine and azithromycin in combination. Of the 13 institutions listing hydroxychloroquine dosing recommendations, 62% recommended maintenance dosing of 200 mg twice daily. Infectious diseases or other specialty consultation was required by 89% of institutions using interleukin-6 inhibitors for COVID-19 management. CONCLUSION Overall, the analysis revealed variability in treatment or supplemental pharmacologic therapy for the management of COVID-19.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Jean Huang
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Brian A Potoski
- Departments of Pharmacy and Therapeutics and Medicine, University of Pittsburgh, Pittsburgh, PA
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Craggs M, Gibson GR, Whalley P, Collins CD. Bioaccessibility of Difenoconazole in Rice Following Industry Standard Processing and Preparation Procedures. J Agric Food Chem 2020; 68:10167-10173. [PMID: 32786844 PMCID: PMC7499419 DOI: 10.1021/acs.jafc.0c02648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
For pesticide registration a post application assessment is made on the safety of any residue remaining in the edible portion of the treated crop. This assessment does not typically consider the bioaccessibility of pesticide residues. The effects of this on potential exposure to incurred difenoconazole residues passing through the human gastrointestinal tract were studied, including the impact of commodity processing. It has previously been demonstrated that solvent extraction methods have the potential to overestimate the bioaccessible fraction, so in vitro simulated gut systems may offer a better approach to determine residue bioaccessibility to refine the risk assessment process. The bioaccessibility of difenoconazole residues associated with processed rice samples was assessed using in vitro intestinal extraction and colonic fermentation methods. The mean bioaccessibility following intestinal digestion was 33.3% with a range from 13% to 70.6%. Quantification of the colonic bioaccessible fraction was not possible due to compound metabolism. Mechanical processing methods generally increased the residue bioaccessibility, while chemical methods resulted in a decrease. Both mechanical and chemical processing methods reduced the total difenoconazole residue level by ca. 50%.
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Affiliation(s)
- M Craggs
- Product Safety, Jealott's Hill International Research Centre, Syngenta International AG, Bracknell, Berkshire RG42 6EY, United Kingdom
| | - G R Gibson
- Food Microbial Sciences Unit, School of Food Biosciences, University of Reading, Reading RG6 6AP, United Kingdom
| | - P Whalley
- Product Safety, Jealott's Hill International Research Centre, Syngenta International AG, Bracknell, Berkshire RG42 6EY, United Kingdom
| | - C D Collins
- Department of Soil Science, School of Human & Environmental Sciences, University of Reading, Whiteknights, Reading RG6 6DW, United Kingdom
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Collins CD, Brockhaus K, Sim T, Suneja A, Malani AN. Analysis to determine cost-effectiveness of procalcitonin-guided antibiotic use in adult patients with suspected bacterial infection and sepsis. Am J Health Syst Pharm 2020; 76:1219-1225. [PMID: 31369118 DOI: 10.1093/ajhp/zxz129] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Results of a study incorporating real-world results into a predictive model to assess the cost-effectiveness of procalcitonin (PCT)-guided antibiotic use in intensive care unit patients with sepsis are reported. METHODS A single-center, retrospective cross-sectional study was conducted to determine whether reductions in antibiotic therapy duration and other care improvements resulting from PCT testing and use of an associated treatment pathway offset the costs of PCT testing. Selected base-case cost outcomes in adults with sepsis admitted to a medical intensive care unit (MICU) were assessed in preintervention and postintervention cohorts using a decision analytic model. Cost-minimization and cost-utility analyses were performed from the hospital perspective with a 1-year time horizon. Secondary and univariate sensitivity analyses tested a variety of clinically relevant scenarios and the robustness of the model. RESULTS Base-case modeling predicted that use of a PCT-guided treatment algorithm would results in hospital cost savings of $45 per patient and result in a gain of 0.0001 quality-adjusted life-year. After exclusion of patients in the postintervention cohort for PCT test ordering outside of institutional guidelines, the mean inpatient antibiotic therapy duration was significantly reduced in the postintervention group relative to the preintervention group (6.2 days versus 4.9 days, p = 0.04) after adjustment for patient sex and age, Charlson Comorbidity Index score, study period, vasopressor use, and ventilator use. Total annual hospital cost savings of $4,840 were predicted. CONCLUSION Real-world implementation of PCT-guided antibiotic use may have improved patients' quality of life while decreasing hospital costs in MICU patients with undifferentiated sepsis.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Kara Brockhaus
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Taeyong Sim
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Anupam Suneja
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, MI.,Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, MI
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15
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Collins CD, Scheidel C, Dietzel CJ, Leeman LR, Morrin CA, Malani AN. 1030. Analysis of a Novel Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Team Activities. Open Forum Infect Dis 2019. [PMCID: PMC6811276 DOI: 10.1093/ofid/ofz360.894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Antimicrobial stewardship team (AST) surveillance at our hospital is facilitated by an internally-developed database. In 2013, the database was expanded to incorporate a validated internally-developed prediction rule for patient mortality within 30 days of hospital admission. AST prospective audit and feedback expanded to include all antimicrobials prescribed in patients with the highest risk for mortality determined by risk score. This study describes the impact of an expanded AST review in patients at the highest risk for mortality. Methods This retrospective, observational study analyzed all adult patients with the highest mortality risk score who received antimicrobials not historically captured via AST review. Patients were identified through administrative and AST databases. Study periods were defined as 2011 – Q3 2013 (historical group) and Q4 2013 – 2018 (intervention group). Primary and secondary outcomes were assessed for confounders including demographic data and infection-related diagnoses. Outcomes were assessed using both unweighted and propensity score weighted versions of the t-test or Wilcoxon rank-sum test for continuous variables and the chi-squared test or Fisher’s Exact test for discrete variables. Results A total of 2,852 and 5,460 patients were included in the historical and intervention groups, respectively. After adjusting for demographic and clinical characteristics, there were significant reductions in median antimicrobial duration (5 vs. 4, P = 0.002), antimicrobial days of therapy (7 vs. 7, P = 0.001), length of stay (LOS) (6 vs. 5 days, P = 0.001), intensive care unit (ICU) LOS (3 vs. 2 days, P < 0.001), and total hospital cost ($11,017 vs. $9,134, P < 0.001) in the intervention cohort. There were no significant differences observed in 30-day mortality or 30-day readmissions. Secondary analyses showed significant decreases in fluroquinolone and intravenous vancomycin utilization between cohorts. Conclusion Reductions in antimicrobial use, inpatient and ICU length of stay, and total hospital costs were observed in a cohort of patients following incorporation of a novel mortality prediction rule to guide AST surveillance. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | - Cheryl A Morrin
- St. Joseph Mercy Health System, Ann Arbor, Ypsilanti, Michigan
| | - Anurag N Malani
- St. Joseph Mercy Health System, Ann Arbor, Ypsilanti, Michigan
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16
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Andrawis M, Ellison LTCC, Riddle S, Mahan KC, Collins CD, Brummond P, Carmichael J. Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group. Am J Health Syst Pharm 2019; 76:874-887. [PMID: 31361855 DOI: 10.1093/ajhp/zxz069] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Pharmacists are accountable for medication-related services provided to patients. As payment models transition from reimbursement for volume to reimbursement for value, pharmacy departments must demonstrate improvements in patient care outcomes and quality measure performance. The transition begins with an awareness of quality measures for which pharmacists and pharmacy personnel can demonstrate accountability across the continuum of care. The objective of the Pharmacy Accountability Measures (PAM) Work Group is to identify measures for which pharmacy departments can and should assume accountability. SUMMARY The National Quality Forum (NQF) Quality Positioning System (QPS) was queried for NQF-endorsed medication-related measures. Included measures were curated into a data set of 6 therapeutic categories: antithrombotic safety, cardiovascular control, glucose control, pain management, behavioral health, and antimicrobial stewardship. Subject matter expert (SME) panels assigned to each area analyzed each measure according to a predetermined ranking system developed by the PAM Work Group. Measures remaining after SME review were disseminated during a public comment period for review and ballot. Over 1,000 measures are captured in the NQF QPS; 656 of the measures were found to be endorsed and medication use related or impacted by medication management services. A single reviewer categorized 140 measures into therapeutic categories for SME review; the remaining measures were unrelated to those clinical domains. The SME groups identified 28 measures for inclusion. CONCLUSION An understanding of the endorsed quality measures available for public reporting programs provides an opportunity for pharmacists to demonstrate accountability for performance, thus improving quality and safety and demonstrating value of care provided.
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Affiliation(s)
| | | | - Steve Riddle
- Clinical Software Solutions, Pharmacy OneSource/Wolters Kluwer, Seattle, WA
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17
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Cagney DN, Thirion PG, Dunne MT, Fleming C, Fitzpatrick D, O'Shea CM, Finn MA, O'Sullivan S, Booth C, Collins CD, Buckney SJ, Shannon A, Armstrong JG. A Phase II Toxicity End Point Trial (ICORG 99-09) of Accelerated Dose-escalated Hypofractionated Radiation in Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2017; 30:30-38. [PMID: 29097074 DOI: 10.1016/j.clon.2017.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 09/18/2017] [Accepted: 09/21/2017] [Indexed: 12/25/2022]
Abstract
AIMS The objective of this phase II clinical trial was to prospectively evaluate the safety and efficacy of accelerated hypofractionated three-dimensional conformal radiation therapy (3DCRT) in localised non-resectable/non-operable non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Sixty patients with stage I-III NSCLC were enrolled in a prospective single-arm All Ireland Co-operative Oncology Research Group (ICORG 99-09) toxicity end point phase II trial. The protocol allocated patients between three radiation schedule dose levels (60, 66 or 72 Gy, in 20, 22 and 24 fractions, respectively, 3 Gy daily, five fractions per week) according to combined lung V25Gy (V25Gy ≤ 30%) with built-in early stopping toxicity rules. The primary end point was toxicity with evaluation of dose-limiting toxicity. The secondary objectives included radiological tumour response rate at 3 months after the completion of radiation therapy and the thoracic progression-free survival time. RESULTS Sixty patients were recruited from August 1999 to June 2009. Forty-nine patients were included in the primary per-protocol analysis. Eleven patients were not evaluable. In the first 30 evaluable patient cohort, severe oesophageal toxicity was reported in two patients (2/49; 4% experiencing grade 5 oesophageal late toxicity, related to the 97% oesophageal length). The trial was temporarily closed and was then reopened to validate an oesophageal dose volume constraint (DVC) of limiting the length of oesophagus fully encompassed by the 97% isodose to less than 1 cm (applied to 21 patients). The trial prospectively showed the safety of the oesophageal DVC, with no oesophageal toxicity above grade 3 thereafter. Thirty-nine per cent of patients had disease progression at 3-4 months after radiotherapy, 22% had stable disease, 20% had a complete response and 14% had a partial response. The median overall survival was 13.6 months (95% confidence interval 10.5-16.7) and overall survival at 1 and 3 years was 57% and 29%, respectively. CONCLUSION A strategy using accelerated hypofractionated 3DCRT is feasible and reasonably safe for patients with inoperable NSCLC. It is safe to deliver for centrally located tumours if DVCs are applied to the oesophagus, which is the primary dose-limiting toxicity. Further studies are required to assess the efficacy of hypofractionated regimens for centrally located tumours using an oesophageal DVC and monitoring for oesophageal toxicity.
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Affiliation(s)
- D N Cagney
- St Luke's Radiation Oncology Network, Dublin, Ireland.
| | - P G Thirion
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - M T Dunne
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - C Fleming
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - D Fitzpatrick
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - C M O'Shea
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - M A Finn
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - S O'Sullivan
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - C Booth
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - C D Collins
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - S J Buckney
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - A Shannon
- Cancer Trials Ireland (formerly ICORG), Dublin, Ireland
| | - J G Armstrong
- St Luke's Radiation Oncology Network, Dublin, Ireland; Cancer Trials Ireland (formerly ICORG), Dublin, Ireland
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18
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Richards PG, Dang KM, Kauffman CA, Stalker KL, Sudekum D, Kerr L, Brinker-Bodley M, Cheriyan B, West N, Collins CD, Polega S, Malani AN. Therapeutic drug monitoring and use of an adjusted body weight strategy for high-dose voriconazole therapy. J Antimicrob Chemother 2017; 72:1178-1183. [PMID: 28108679 DOI: 10.1093/jac/dkw550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/22/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives A high-dose 12 mg/kg/day (6 mg/kg twice daily) voriconazole regimen was recommended by the CDC to treat patients injected with contaminated methylprednisolone acetate that caused a multi-state fungal outbreak in 2012-13. Therapeutic drug monitoring results of this unique regimen are unknown, as is the most appropriate dosing weight for obese patients. We evaluated voriconazole trough measurements for this dosing scheme, as well as the use of adjusted body weight dosing for obese patients. Methods Voriconazole trough levels were analysed in obese (BMI ≥35 kg/m 2 ) and non-obese (BMI <35 kg/m 2 ) patients who were given initial therapy with 12 mg/kg/day. Results Of 138 patients, the first steady-state voriconazole troughs were supratherapeutic (>5 mg/L) in 65 (47%) patients, therapeutic (2-5 mg/L) in 57 (41%) patients and subtherapeutic (<2 mg/L) in 16 (12%) patients. Twenty-three patients had pre-steady-state dose decreases due to supratherapeutic levels, with subsequent first steady-state troughs in the therapeutic ( n = 17) and subtherapeutic ( n = 6) categories. Voriconazole doses >11 and >8 mg/kg/day produced mainly first steady-state supratherapeutic troughs in 44 obese and 94 non-obese patients, respectively. An initial 12 mg/kg/day was progressively lowered to a median maintenance dose of 8.5 mg/kg/day in the obese and 8.6 mg/kg/day in the non-obese. Conclusions A high-dose voriconazole regimen produced initial supratherapeutic troughs that required dose adjustment downward by nearly 30%. Adjusted body weight dosing in obese patients resulted in a similar maintenance dose to total body weight dosing in the non-obese, and appears to be a sensible dosing strategy for these patients.
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Affiliation(s)
| | | | - Carol A Kauffman
- Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kay Lyn Stalker
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - David Sudekum
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Lisa Kerr
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | | | - Beena Cheriyan
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Nina West
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Curtis D Collins
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Shikha Polega
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Hospital, Ann Arbor, MI, USA.,Department of Infection Prevention and Control, St Joseph Mercy Hospital, Ann Arbor, MI, USA
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20
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Brumley PE, Malani AN, Kabara JJ, Pisani J, Collins CD. Effect of an antimicrobial stewardship bundle for patients with Clostridium difficile infection. J Antimicrob Chemother 2015; 71:836-40. [PMID: 26661392 DOI: 10.1093/jac/dkv404] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/29/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The study objective was to determine whether there was an improvement in compliance with recommended Clostridium difficile infection (CDI) treatment after introduction of an institutional CDI bundle with daily antimicrobial stewardship assessment. PATIENTS AND METHODS This was a single-centre, quasi-experimental study evaluating compliance with an antimicrobial stewardship team-implemented care bundle in patients with CDI compared with historical controls. The primary outcome, compliance with overall bundle elements, was achieved when the following measures were accomplished: (i) appropriate CDI antimicrobial therapy based on the institutional treatment algorithm; (ii) discontinuation of acid-suppressant therapy in the absence of a pre-specified indication; and (iii) discontinuation of unnecessary antimicrobials. Secondary objectives were to evaluate the extent to which antimicrobial stewardship involvement affected treatment compliance and to assess trends in CDI clinical outcomes, such as mortality and readmission. RESULTS One-hundred-and-sixty-nine patients were evaluated; 83 after implementation of the care bundle (bundle group) and 89 prior to bundle implementation (historical control group). Compliance with overall bundle endpoints was significantly higher in the bundle group versus the control group (81% versus 45%, P < 0.001). Individual bundle components that were significantly improved in the bundle group were discontinuation of non-essential acid suppressants (90% versus 18%, P < 0.001) and administration of appropriate CDI therapy (82% versus 64%, P < 0.009). No significant differences were observed in overall or CDI-related mortality or readmissions, durations of therapy or reduction of non-essential concomitant antimicrobials. CONCLUSIONS Introduction of an antimicrobial stewardship bundle for CDI significantly improved adherence to institutional treatment recommendations and overall management of patients with CDI.
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Affiliation(s)
- Paul E Brumley
- Department of Pharmacy Services, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA Department of Infection Prevention and Control, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, Michigan, USA
| | - Jared J Kabara
- Quality Institute, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA
| | - Jennifer Pisani
- University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI, USA
| | - Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI, USA
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21
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Collins CD, Miller DE, Kenney RM, Mynatt RP, Tiberg MD, Cole K, Sutton JD, Pogue JM. The State of Antimicrobial Stewardship in Michigan: Results of a Statewide Survey on Antimicrobial Stewardship Efforts in Acute Care Hospitals. Hosp Pharm 2015; 50:180-4. [PMID: 26405304 DOI: 10.1310/hpj5003-180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Curtis D Collins
- Clinical Pharmacy Specialist, Infectious Diseases, St. Joseph Mercy Health System , Ann Arbor, Michigan
| | - Dianne E Miller
- Chief Operations Officer, Michigan Pharmacists Association , Lansing Michigan
| | - Rachel M Kenney
- Pharmacy Specialist, Antimicrobial Stewardship, Henry Ford Hospital , Detroit, Michigan
| | - Ryan P Mynatt
- Clinical Pharmacist Specialist, Infectious Diseases, Detroit Receiving Hospital, Detroit Medical Center , Detroit, Michigan
| | - Michael D Tiberg
- Clinical Pharmacy Specialist in Infectious Diseases, Department of Pharmacy and Infectious Diseases, Munson Medical Center , Traverse City, Michigan
| | - Kelli Cole
- Antimicrobial Stewardship Pharmacist, The University of Toledo, Main and Health Science Campuses , Toledo, Ohio
| | - Jesse D Sutton
- Infectious Diseases Pharmacist, Baptist Health Louisville Pharmacy Department , Louisville, Kentucky
| | - Jason M Pogue
- Clinical Pharmacist, Infectious Diseases, Sinai-Grace Hospital, Detroit Medical Center , Detroit, Michigan ; Clinical Assistant Professor of Medicine, Wayne State University School of Medicine , Detroit, Michigan
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22
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Collins CD, Schwemm AK. Linezolid Versus Vancomycin in the Empiric Treatment of Nosocomial Pneumonia: A Cost-Utility Analysis Incorporating Results from the ZEPHyR Trial. Value Health 2015; 18:614-621. [PMID: 26297089 DOI: 10.1016/j.jval.2015.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 04/07/2015] [Accepted: 04/24/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To examine the cost-effectiveness of vancomycin versus linezolid in the empiric treatment of nosocomial pneumonias incorporating results from a recent prospective, double-blind, multicenter, controlled trial in adults with suspected methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia. METHODS A decision-analytic model examining the cost-effectiveness of linezolid versus vancomycin for the empiric treatment of nosocomial pneumonia was created. Publicly available cost, efficacy, and utility data populated relevant model variables. A probabilistic sensitivity analysis varied parameters in 10,000 Monte-Carlo simulations, and univariate sensitivity analyses assessed the impact of model uncertainties and the robustness of our conclusions. RESULTS Results indicated that the cost per quality-adjusted life-year (QALY) increased 6% ($22,594 vs. $23,860) by using linezolid versus vancomycin for nosocomial pneumonia. The incremental cost per QALY gained by using linezolid over vancomycin was $6,089, and the incremental cost per life saved was $68,615 with the use of linezolid. Vancomycin dominated linezolid in the subset of patients with documented MRSA. The incremental cost per QALY gained using linezolid if no mortality benefit exists between agents or a 60-day time horizon was analyzed was $19,608,688 and $443,662, respectively. CONCLUSIONS Linezolid may be a cost-effective alternative to vancomycin in the empiric treatment of patients with suspected MRSA nosocomial pneumonia; however, results of our model were highly variable on a number of important variables and assumptions including mortality differences and time frame analyzed.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, MI, USA.
| | - Ann K Schwemm
- Department of Pharmacy Services, University of Washington Medical Center, Harborview Medical Center Seattle, Seattle, WA, USA
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23
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Bickel RJ, Collins CD, Lucarotti RL, Stevenson JG, Pawlicki K, Baumann TJ, Pratt DM. Moving the Pharmacy Practice Model Initiative forward within a state affiliate. Am J Health Syst Pharm 2015; 71:1679-85. [PMID: 25225452 DOI: 10.2146/ajhp140056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Efforts to advance the ASHP Pharmacy Practice Model Initiative (PPMI) in the Michigan Society of Health-System Pharmacists (MSHP) are described. SUMMARY After the Pharmacy Practice Model Summit in November 2010, the board of directors of MSHP began to strategize ways to help health-system pharmacists in Michigan achieve the vision and concepts envisioned by the PPMI. The ultimate goal was to develop a process for acting on recommendations developed by the PPMI to advance the practice of health-system pharmacy in Michigan. A task force was formed and reviewed the 147 national recommendations from the ASHP Pharmacy Practice Model Summit and grouped them into related areas of focus. Six focus areas were identified: acute care, ambulatory care, education and training, organizational affairs and leadership, pharmacy technicians, and technology and information systems. A PPMI Michigan conference was arranged in which focus groups would assess these six areas. Each focus group was limited to six or seven participants, with a member of the task force serving as the facilitator for the group. Individual focus groups then formulated recommendations MSHP could develop into actionable strategies to address the key issues identified during the morning session. A total of 56 recommendations were submitted by the focus groups for consideration by all conference participants. Over 80% of the recommendations were deemed to be high impact/high feasibility. CONCLUSION A process for acting on recommendations of the ASHP PPMI to advance the practice of health-system pharmacy within the state of Michigan was developed.
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Affiliation(s)
- Ryan J Bickel
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI
| | - Curtis D Collins
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI
| | - Richard L Lucarotti
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI
| | - James G Stevenson
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI
| | - Kathleen Pawlicki
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI
| | - Terry J Baumann
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI
| | - Denise M Pratt
- Ryan J. Bickel, Pharm.D., BCPS, is Pharmacy Manager, Borgess Pipp Hospital, Plainwell, MI. Curtis D. Collins, Pharm.D., M.S., FASHP, is Clinical Pharmacy Specialist, St. Joseph Mercy Health System, Ann Arbor, MI. Richard L. Lucarotti, Pharm.D., is Professor and Director of Experiential Education, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI. James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer, University of Michigan Health System, Ann Arbor, and Professor and Associate Dean for Clinical Sciences, University of Michigan College of Pharmacy, Ann Arbor. Kathleen Pawlicki, M.S., FASHP, is Administrative Director, Professional Services, and Director of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI. Terry J. Baumann, Pharm.D., BCPS, DAAPM, is Clinical Manager, Pharmacy Department, Munson Medical Center, Traverse City, MI. Denise M. Pratt, Pharm.D., is Critical Care Clinical Pharmacist, Sparrow Hospital, Lansing, MI.
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McComb MN, Collins CD. Comparative cost-effectiveness of alternative empiric antimicrobial treatment options for suspected enterococcal bacteremia. Pharmacotherapy 2014; 34:537-44. [PMID: 24390863 DOI: 10.1002/phar.1393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Enterococcus species are the fourth leading cause of bacteremia. Resistance rates are rising and delays in appropriate initial antimicrobial therapy have been associated with increased mortality. Empiric treatment of patients with suspected enterococcal bacteremia varies and significant cost differences exist between alternatives. The objective of this study was to determine the cost-effectiveness of various empiric treatments for patients with suspected enterococcal bacteremia. METHODS A decision-analytic model was constructed from the hospital perspective to assess the cost-effectiveness of alternative empiric treatment options for enterococcal bacteremia, including antimicrobials active against vancomycin-resistant enterococcus (VRE). The model was populated from available literature sources and included resistance patterns, associated mortality with early versus delayed effective treatment, and the cost of treatment. Univariate sensitivity analyses tested the robustness of the model to determine the degree to which model uncertainties influenced outcomes. We also undertook a probabilistic sensitivity analysis varying parameters in 10,000 Monte Carlo simulations. MAIN RESULTS The incremental cost-effectiveness ratio was $791 and $749/quality-adjusted-life-year utilizing empiric daptomycin and linezolid, respectively. The model also predicted an incremental cost/life saved of $11,703 by utilizing empiric daptomycin and $11,084 with linezolid utilization. Ampicillin was dominated (i.e., less effective and associated with increased costs) by both VRE-active agents and vancomycin. A probabilistic Monte Carlo sensitivity analysis showed that an agent with VRE activity had a 100% chance of being cost-effective at traditionally used willingness-to-pay thresholds. The decision-analytic model was sensitive to variations in E. faecium mortality and short-term postdischarge survival rates. CONCLUSION Results of our model showed that empiric utilization of an antimicrobial with activity against VRE may be a cost-effective option for the treatment of suspected enterococcal bacteremia when compared with vancomycin or β-lactam therapy.
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Affiliation(s)
- Meghan N McComb
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan
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Collins CD, Mosquera-Vazquez M, Gomez-Eyles JL, Mayer P, Gouliarmou V, Blum F. Is there sufficient 'sink' in current bioaccessibility determinations of organic pollutants in soils? Environ Pollut 2013; 181:128-132. [PMID: 23850629 DOI: 10.1016/j.envpol.2013.05.053] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/29/2013] [Accepted: 05/31/2013] [Indexed: 06/02/2023]
Abstract
Bioaccessibility tests can be used to improve contaminated land risk assessments. For organic pollutants a 'sink' is required within these tests to better mimic their desorption under the physiological conditions prevailing in the intestinal tract, where a steep diffusion gradient for the removal of organic pollutants from the soil matrix would exist. This is currently ignored in most PBET systems. By combining the CEPBET bioaccessibility test with an infinite sink, the removal of PAH from spiked solutions was monitored. Less than 10% of spiked PAH remained in the stomach media after 1 h, 10% by 4 h in the small intestine compartment and c.15% after 16 h in the colon. The addition of the infinite sink increased bioaccessibility estimates for field soils by a factor of 1.2-2.8, confirming its importance for robust PBET tests. TOC or BC were not the only factors controlling desorption of the PAH from the soils.
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Affiliation(s)
- C D Collins
- Soil Research Centre, University of Reading, Reading RG6 6DW, UK.
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Huang AM, Newton D, Kunapuli A, Gandhi TN, Washer LL, Isip J, Collins CD, Nagel JL. Impact of Rapid Organism Identification via Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Combined With Antimicrobial Stewardship Team Intervention in Adult Patients With Bacteremia and Candidemia. Clin Infect Dis 2013; 57:1237-45. [DOI: 10.1093/cid/cit498] [Citation(s) in RCA: 400] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Stranges PM, Hutton DW, Collins CD. Cost-effectiveness analysis evaluating fidaxomicin versus oral vancomycin for the treatment of Clostridium difficile infection in the United States. Value Health 2013; 16:297-304. [PMID: 23538181 DOI: 10.1016/j.jval.2012.11.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 11/08/2012] [Accepted: 11/24/2012] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Fidaxomicin is a novel treatment for Clostridium difficile infections (CDIs). This new treatment, however, is associated with a higher acquisition cost compared with alternatives. The objective of this study was to evaluate the cost-effectiveness of fidaxomicin or oral vancomycin for the treatment of CDIs. METHODS We performed a cost-utility analysis comparing fidaxomicin with oral vancomycin for the treatment of CDIs in the United States by creating a decision analytic model from the third-party payer perspective. RESULTS The incremental cost-effectiveness ratio with fidaxomicin compared with oral vancomycin was $67,576/quality-adjusted life-year. A probabilistic Monte Carlo sensitivity analysis showed that fidaxomicin had an 80.2% chance of being cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. Fidaxomicin remained cost-effective under all fluctuations of both fidaxomicin and oral vancomycin costs. The decision analytic model was sensitive to variations in clinical cure and recurrence rates. Secondary analyses revealed that fidaxomicin was cost-effective in patients receiving concominant antimicrobials, in patients with mild to moderate CDIs, and when compared with oral metronidazole in patients with mild to moderate disease. Fidaxomicin was dominated by oral vancomycin if CDI was caused by the NAP1/Bl/027 Clostridium difficile strain and was dominant in institutions that did not compound oral vancomycin. CONCLUSION Results of our model showed that fidaxomicin may be a more cost-effective option for the treatment of CDIs when compared with oral vancomycin under most scenarios tested.
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Affiliation(s)
- Paul M Stranges
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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Antworth A, Collins CD, Kunapuli A, Klein K, Carver P, Gandhi T, Washer L, Nagel JL. Impact of an antimicrobial stewardship program comprehensive care bundle on management of candidemia. Pharmacotherapy 2013; 33:137-43. [PMID: 23355283 DOI: 10.1002/phar.1186] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE To analyze the impact of a comprehensive care bundle directed by an antimicrobial stewardship team (AST) on the management of candidemia. DESIGN Single-center, quasi-experimental study. SETTING A 930-bed academic hospital. PATIENTS Seventy-eight patients with candidemia were evaluated; 41 patients received the candidemia care bundle (AST group), and 37 did not (historical control group). MEASUREMENTS AND MAIN RESULTS A candidemia care bundle was developed by an interdisciplinary AST, incorporating key elements from the Infectious Diseases Society of America's Clinical Practice Guidelines for the Management of Candidemia. The AST made prospective recommendations in accordance with the care bundle. Bundle elements were utilization of appropriate antifungal agents with appropriate duration of use, removal of intravenous catheters, repeat blood cultures, monitoring of time until clearance of candidemia, and performance of ophthalmologic examinations. Compliance with all candidemia care bundle elements was significantly higher in the AST group versus the control group (78.0% vs 40.5%, p=0.0016). Implementation of the care bundle significantly improved rates of ophthalmologic examination (97.6% vs 75.7%, p=0.0108), selection of appropriate antifungal therapy (100% vs 86.5%, p=0.0488), and compliance with an appropriate duration of therapy (97.6% vs 67.7%, p=0.0012). In addition, the AST group had fewer excess total days of therapy beyond the recommended duration than the control group (5 vs 83 total antifungal days). Length of hospitalization (20 vs 21 days, p=0.9184), time until clearance of candidemia (3 vs 3 days p=0.610), rate of persistent candidemia (22% vs 40.5%, p=0.126), and rate of recurrent candidemia (4.9% vs 5.4%, p=0.916) were similar in the AST group versus the control group. CONCLUSION A comprehensive candidemia care bundle directed by our institution's AST improved the management of patients with candidemia. We encourage further exploration into the use of care bundles by ASTs as part of their multifaceted approach to promoting appropriate antimicrobial utilization and optimizing the management of patients with infectious diseases.
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Affiliation(s)
- Allen Antworth
- Department of Pharmacy, University of Michigan Hospital and Health Systems, Ann Arbor, MI 48109, USA
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Tilston EL, Gibson GR, Collins CD. Colon extended physiologically based extraction test (CE-PBET) increases bioaccessibility of soil-bound PAH. Environ Sci Technol 2011; 45:5301-5308. [PMID: 21568264 DOI: 10.1021/es2004705] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Assessment of the risk to human health posed by contaminated land may be seriously overestimated if reliant on total pollutant concentration. In vitro extraction tests, such as the physiologically based extraction test (PBET), imitate the physicochemical conditions of the human gastro-intestinal tract and offer a more practicable alternative for routine testing purposes. However, even though passage through the colon accounts for approximately 80% of the transit time through the human digestive tract and the typical contents of the colon in vivo are a carbohydrate-rich aqueous medium with the potential to promote desorption of organic pollutants, PBET comprises stomach and small intestine compartments only. Through addition of an eight-hour colon compartment to PBET and use of a carbohydrate-rich fed-state medium we demonstrated that colon-extended PBET (CE-PBET) increased assessments of soil-bound PAH bioaccessibility by up to 50% in laboratory soils and a factor of 4 in field soils. We attribute this increased bioaccessibility to a combination of the additional extraction time and the presence of carbohydrates in the colon compartment, both of which favor PAH desorption from soil. We propose that future assessments of the bioaccessibility of organic pollutants in soils using physiologically based extraction tests should have a colon compartment as in CE-PBET.
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Affiliation(s)
- E L Tilston
- Soil Research Centre, University of Reading, Reading, RG6 6DW, UK
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Collins CD, Cookinham S, Smith J. Management of oropharyngeal candidiasis with localized oral miconazole therapy: efficacy, safety, and patient acceptability. Patient Prefer Adherence 2011; 5:369-74. [PMID: 21845036 PMCID: PMC3150165 DOI: 10.2147/ppa.s14047] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Indexed: 11/23/2022] Open
Abstract
Oropharyngeal candidiasis is a very common localized infection of the mucus membranes of the oropharynx that is most commonly caused by the patient's own commensal Candida albicans. It is the most common opportunistic infection affecting patients with the human immunodeficiency virus (HIV) and is also quite common in patients with hematological malignancies. Effective treatment options are of high importance given the worldwide incidence of these disease states and the potential for development of oropharyngeal candidiasis in these patients. Various systemic and topical treatment options for patients with oropharyngeal candidiasis have existed for many years. Miconazole buccal tablets have recently been approved by the US Food and Drug Administration for the treatment of oropharyngeal candidiasis. Clinical trials have demonstrated noninferiority in the treatment of oropharyngeal candidiasis when compared with clotrimazole troches in patients with HIV and against miconazole gel in patients with head and neck cancer. Miconazole buccal tablets exhibit few drug interactions because of low systemic absorption and are generally well tolerated with a safety profile similar to comparators. The once-daily dosing schedule may improve patient adherence compared with topical alternatives; however, the cost of therapy may be a barrier for some patients and should be considered by prescribers compared with alternative treatments.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services
- Correspondence: Curtis D Collins, UHB2D301/0008, Department of Pharmacy Services University of Michigan Health System 1500 E. Med Ctr Dr, Ann Arbor, MI 48109, USA, Tel +1 734 936 8210, Fax +1 734 936 7027, Email
| | - Sarah Cookinham
- Department of Medicine, Division of Infectious Disease, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jeannina Smith
- Department of Medicine, Division of Infectious Disease, University of Michigan Health System, Ann Arbor, MI, USA
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Abstract
This paper summarises the current status of PET/CT in relation to breast cancer.
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Affiliation(s)
- C Hegarty
- St. Vincent's University Hospital, Dublin 4, Ireland
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Abstract
The challenges in managing patients with infection in the intensive care unit are increased in an era where there are dwindling antimicrobial choices for multidrug-resistant pathogens. Clinicians in the intensive care unit must balance between choosing appropriate antimicrobial treatment for patients with suspected infection and utilizing antimicrobials in a judicious fashion. Improving antimicrobial utilization is a critical component to reducing antimicrobial resistance. Although providing effective antimicrobial therapy and improving antimicrobial utilization may seem to be competing goals, there are effective strategies to accomplish both. Antimicrobial stewardship programs provide an organized way to implement these strategies and can enhance the intensive care unit physician's success in improving patient outcomes and combating antimicrobial resistance in the intensive care unit.
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Affiliation(s)
- Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.
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Collins CD, Boylen CW. Ecological Consequences of Long-Term Exposure of Anabaena variabilis (Cyanophyceae) to Shifts in Environmental Factors. Appl Environ Microbiol 2010; 44:141-8. [PMID: 16346050 PMCID: PMC241981 DOI: 10.1128/aem.44.1.141-148.1982] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cultures of Anabaena variabilis were exposed to different light intensities, and the time course of photoadaptation was measured by photosynthetic rate and changes in pigmentation. A shift down in intensity of 284 muEin . m . sec caused a temporary decrease in the photosynthetic response followed by gradual adaptation to the new conditions. Final chlorophyll a and carotenoid concentrations were reached after 1 day, although other physiological indicators showed that adaptation required 4 days. The parameter I(k) was shown to be the best indicator of photoadaptation. A shift up in light intensity of the same magnitude also required 4 days for complete photoadaptation by the culture, although chlorophyll and carotenoid concentrations stabilized within 1 day. A shift down in light intensity of 392 muEin . m . sec resulted in a temporary attempt to adapt followed by collapse of the population. This demonstrates an apparent threshold in the magnitude of the shift in light intensity which will permit successful adaptation. Simultaneous changes in light intensity and temperature also adversely affected culture populations. Our observations present a possible cause for the decline or prevention of an algal bloom under a fluctuating light regime and suggest that it may be possible to predict this decline as a result of synoptic weather patterns or hydrodynamic influences.
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Affiliation(s)
- C D Collins
- Center for Ecological Modeling and Biology Department, Rensselaer Polytechnic Institute, Troy, New York 12181
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Nemerovski CW, Mackler ER, DePestel DD, Collins CD, Welch KS, Stevenson JG. Drug costs and utilization after implementation of a posaconazole prophylaxis protocol in adults with acute myelogenous leukemia. Am J Health Syst Pharm 2010; 67:295-9. [PMID: 20133535 DOI: 10.2146/ajhp090101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Drug costs and utilization after implementation of a posaconazole prophylaxis protocol in adults with acute myelogenous leukemia (AML) were studied. METHODS Adult patients who initiated induction or reinduction chemotherapy for the treatment of AML between December 1, 2006, and March 31, 2008, at a tertiary care hospital were included in this retrospective cohort study. Patients were divided into two groups: preprotocol (treated before June 1, 2007) and postprotocol (treated on or after June 1, 2007). Medical charts, including pharmacy and laboratory data, were reviewed for all patients. Outcomes measured included antifungal and antibacterial drug costs and utilization and total pharmacy costs. RESULTS A total of 66 patients were evaluated (33 in each group). Baseline characteristics, except patient age, were similar between groups. Each group incurred similar costs and utilized resources for similar periods of time as evidenced by similar lengths of stay, duration of neutropenia, and mortality. Antibacterial costs, total pharmacy costs, and other utilization outcomes were also similar between the two groups. Alterations to antifungal management strategy occurred more often in the postprotocol group (33% versus 58%, p = 0.048). CONCLUSION Implementation of a posaconazole protocol did not significantly alter antifungal or antibacterial drug costs or utilization or total pharmacy costs. Prophylactic posaconazole was frequently changed to alternative antifungal therapy due to an adverse drug event, perceived lack of efficacy, avoidance of a drug interaction, or inability to tolerate oral intake.
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Affiliation(s)
- Carrie W Nemerovski
- University of Michigan Hospitals and Health Centers (UMHHC), Ann Arbor, MI, USA.
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Cinti SK, Barnosky AR, Gay SE, Goold SD, Lozon MM, Kim K, Rodgers PE, Baum NM, Cadwallender BA, Collins CD, Wright CM, Winfield RA. Bacterial pneumonias during an influenza pandemic: how will we allocate antibiotics? Biosecur Bioterror 2010; 7:311-6. [PMID: 19821750 DOI: 10.1089/bsp.2009.0019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.
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Affiliation(s)
- Sandro K Cinti
- Infectious Diseases, University of Michigan Hospitals/VA Ann Arbor Health Systems, Ann Arbor, Michigan 48105, USA.
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Miller JT, Collins CD, Stuckey LJ, Luan FL, Englesbe MJ, Magee JC, Park JM. Clinical and economic outcomes of rabbit antithymocyte globulin induction in adults who received kidney transplants from living unrelated donors and received cyclosporine-based immunosuppression. Pharmacotherapy 2009; 29:1166-74. [PMID: 19792990 DOI: 10.1592/phco.29.10.1166] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the efficacy, safety, and costs of rabbit antithymocyte globulin (TMG) induction in patients who received kidney transplants from living unrelated donors. DESIGN Retrospective cohort study. SETTING Large academic medical center. PATIENTS Eighty-seven patients who received kidney transplants from living unrelated donors: 40 of the recipients underwent transplantation between January 1, 2003, and December 31, 2004, and did not receive TMG induction (no induction group); 47 underwent transplantation between January 1, 2005, and June 30, 2006, and received TMG induction (induction group). All patients received cyclosporine-based immunosuppression. MEASUREMENTS AND MAIN RESULTS Biopsy-proven acute rejection, posttransplantation complications, and inpatient hospital costs for the first 12 months after transplantation were compared between groups using standard univariate statistical analyses. Induction significantly decreased the occurrence of biopsy-proven acute rejection versus no induction (2% vs 48%, p<0.001). Fifty percent of rejection episodes in the no induction group required hospitalization, and 46% of rejection episodes required TMG treatment. Slightly elevated initial costs associated with TMG induction were offset by lower costs related to rejection treatment. Total inpatient costs for the 12 months after transplantation were comparable between the groups (no induction $66,038 vs induction $74,183, p>0.05). For the no induction versus induction groups, no significant differences in cytomegalovirus disease (5% vs 6%), malignancy (3% vs 2%), graft failures (5% vs 6%), mortality (5% vs 4%), and serum creatinine concentrations (mean +/- SD 1.4 +/- 0.3 vs 1.5 +/- 0.3 mg/dl) were observed at 12 months (p>0.05 for all comparisons). CONCLUSION Five-day TMG induction effectively reduced the 1-year acute rejection rate without significantly increasing total inpatient costs or posttransplantation complications among recipients of kidney transplants from living unrelated donors.
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Affiliation(s)
- James T Miller
- Department of Pharmacy Services, Sinai-Grace Hospital, Detroit, MI 48109-5008, USA
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Chun ED, Rodgers PE, Vitale CA, Collins CD, Malani PN. Antimicrobial use among patients receiving palliative care consultation. Am J Hosp Palliat Care 2009; 27:261-5. [PMID: 19959846 DOI: 10.1177/1049909109352336] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We sought to characterize antimicrobial use among patients receiving palliative care consultation. METHODS Retrospective review of patients seen by the Palliative Care Service at the University of Michigan Health System from January 2008 to May 2008. RESULTS Of 131 patients seen in consultation, 70 received antimicrobials. We identified 92 infections among these 70 patients; therapy for 54 (58.7%) was empiric. Empiric therapy was most commonly prescribed for respiratory infection and urinary tract infection. Piperacillin/tazobactam (P/T) was the most frequently used agent, with 26 patients receiving P/T (37.1%); 22 of 26 received this agent empirically (84.6%, P = .005). Vancomycin was prescribed to 23 patients (32.9%). Sixteen patients (22.9%) died in hospital; another 31 were enrolled in hospice care. CONCLUSIONS Our results suggest significant use of empiric, broad-spectrum antimicrobial therapy among hospitalized patients near the end of life. We advocate for careful assessment of potential benefits and treatment burdens of antimicrobial therapy, especially when palliation is the goal.
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Affiliation(s)
- Erin Diviney Chun
- Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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Collins CD, Desmet BD, Depestel DD. Institutional Experience with Daptomycin Treatment in Patients with Gram-Positive Infections. Hosp Pharm 2009. [DOI: 10.1310/hpj4409-766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose Daptomycin was originally approved for the treatment of complicated skin and skin-structure infections caused by gram-positive bacteria, and recently, its indications were expanded to include bacteremia and right-sided infective endocarditis caused by Staphylococcus aureus. This retrospective chart review examines outcomes and costs for individuals treated with daptomycin at a tertiary care medical center. Methods During an 11-month period, records of patients treated with daptomycin at the institution were reviewed. Cases for which complete cost data were available were included in the analysis. Outcomes were assigned to 4 categories: cured, improved, failed, or unevaluable. Hospital stay details were recorded, and antibiotic and total hospital treatment costs were calculated. Results Thirty-five patients representing 37 cases were included in the review. Of those cases, 89% (33 of 37) involved documented infections with gram-positive bacteria, 22% involved confirmed methicillin-resistant S. aureus infections, and 32% involved confirmed vancomycin-resistant enterococcus infections. Most cases (27 of 37; 73%) involved infections with multiple bacterial isolates for which previous therapy had failed. Of all clinically evaluable cases, 54% were classified as cured and 42% as improved after daptomycin therapy. Median and mean ± standard deviation (SD) total cost of hospitalization were $46,730 and $111,604 ± $137,138, respectively. Overall median duration of therapy for all 37 cases was 14 days (range, 1 to 143; mean ± SD duration, 25.5 ± 32 days). Conclusion Daptomycin cured or improved most evaluable gram-positive infections. The results of this study suggest that daptomycin may be considered a therapeutic option for treatment of drug-resistant gram-positive infections.
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Affiliation(s)
- Curtis D. Collins
- Infectious Diseases, University of Michigan Health System, Ann Arbor, Michigan
| | | | - Daryl D. Depestel
- University of Michigan College of Pharmacy, Infectious Diseases, University of Michigan Health System, Ann Arbor, Michigan
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Abstract
An understanding of the primary pathways of plant uptake of organic pollutants is important to enable the risks from crops grown on contaminated soils to be assessed. A series of experiments were undertaken to quantify the importance of the pathways of contamination and the subsequent transport within the plant using white clover plants grown in solution culture. Root uptake was primarily an absorption process, but a component of the contamination was a result of the transpiration flux to the shoot for higher solubility compounds. The root contamination can be easily predicted using a simple relationship with K(OW), although if a composition model was used based on lipid content, a significant under prediction of the contamination was observed. Shoot uptake was driven by the transpiration stream flux which was related to the solubility of the individual PAH rather than the K(OW). However, the experiment was over a short duration, 6 days, and models based on K(OW) may be better for crops grown in the field where the vegetation will approach equilibrium and transpiration cannot easily be measured. A significant fraction of the shoot contamination resulted from aerial deposition derived from volatilized PAH. This pathway was more significant for compounds approaching log K(OA) > 9 and log K(AW) < -3. The shoot uptake pathways need further investigation to enable them to be modeled separately. There was no evidence of significant systemic transport of the PAH, so transfer outside the transpiration stream is likely to be limited.
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Affiliation(s)
- Yanzheng Gao
- College of Resource and Environmental Sciences, Nanjing Agricultural University, Nanjing 210095, PR China
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Collins CD, Ellis JJ, Kaul DR. Comparative cost-effectiveness of posaconazole versus fluconazole or itraconazole prophylaxis in patients with prolonged neutropenia. Am J Health Syst Pharm 2009; 65:2237-43. [PMID: 19020192 DOI: 10.2146/ajhp070588] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE A cost-effectiveness analysis was performed to investigate the financial impact of using posaconazole versus fluconazole or itraconazole prophylaxis in patients with prolonged neutropenia. METHODS A decision-analytic model was developed from a hospital perspective based on the use of posaconazole versus fluconazole or itraconazole prophylaxis in patients with prolonged neutropenia (i.e., longer than 7-10 days). Data reported in a multicenter study, medication-cost information, and reports of costs to treat invasive fungal infections were used to accurately populate the model. Sensitivity analyses enhanced the robustness of the model through variation of all probabilities and costs. RESULTS In the base case, patients initiated on posaconazole displayed a 45% reduction in overall cost as compared with patients initiated on fluconazole or itraconazole ($3051 versus $5529, respectively). Sensitivity analyses determined that univariate changes in all model variables, including medication cost, duration of therapy, and cost of treating invasive fungal infections, did not impact overall results. A Monte Carlo simulation analysis found that use of posaconazole remains the best overall prophylactic strategy when taking into consideration the potential variance in all model assumptions. Posaconazole dominated the use of fluconazole or itraconazole because of previously demonstrated lower incidence of breakthrough fungal infections and lower overall treatment cost. CONCLUSION The decision model indicated that use of posaconazole as prophylaxis in patients with prolonged neutropenia should result in lower overall treatment costs relative to the cost of fluconazole or itraconazole.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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Aherne NJ, Fitzpatrick DA, Gibbons D, Collins CD, Armstrong JG. Recurrent malignant pilomatrixoma invading the cranial cavity: Improved local control with adjuvant radiation. J Med Imaging Radiat Oncol 2009; 53:139-41. [DOI: 10.1111/j.1754-9485.2009.02049.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sjöström AE, Collins CD, Smith SR, Shaw G. Degradation and plant uptake of nonylphenol (NP) and nonylphenol-12-ethoxylate (NP12EO) in four contrasting agricultural soils. Environ Pollut 2008; 156:1284-1289. [PMID: 18433956 DOI: 10.1016/j.envpol.2008.03.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 03/20/2008] [Accepted: 03/20/2008] [Indexed: 05/26/2023]
Abstract
Nonylphenol polyethoxylates (NPEOs) are surfactants found ubiquitously in the environment due to widespread industrial and domestic use. Biodegradation of NPEOs produces nonylphenol (NP), an endocrine disruptor. Sewage sludge application introduces NPEOs and NP into soils, potentially leading to accumulation in soils and crops. We examined degradation of NP and nonylphenol-12-ethoxylate (NP12EO) in four soils. NP12EO degraded rapidly (initial half time 0.3-5 days). Concentrations became undetectable within 70-90 days, with a small increase in NP concentrations after 30 days. NP initially degraded quickly (mean half time 11.5 days), but in three soils a recalcitrant fraction of 26-35% remained: the non-degrading fraction may consist of branched isomers, resistant to biodegradation. Uptake of NP by bean plants was also examined. Mean bioconcentration factors for shoots and seeds were 0.71 and 0.58, respectively. Removal of NP from the soil by plant uptake was negligible (0.01-0.02% of initial NP). Root concentrations were substantially higher than shoot and seed concentrations.
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Affiliation(s)
- A E Sjöström
- Department of Environment, Food and Rural Affairs, London, UK
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Shehab N, DePestel DD, Mackler ER, Collins CD, Welch K, Erba HP. Institutional Experience with Voriconazole Compared with Liposomal Amphotericin B as Empiric Therapy for Febrile Neutropenia. Pharmacotherapy 2007; 27:970-9. [PMID: 17594202 DOI: 10.1592/phco.27.7.970] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To assess the effectiveness, safety, and cost of empiric treatment of febrile neutropenia before and after implementing an algorithm in which voriconazole was substituted for liposomal amphotericin B (L-AmB). DESIGN Retrospective cohort analysis. SETTING An 850-bed tertiary care hospital, which is also a referral site for patients with acute leukemia. PATIENTS Fifty-five adult patients who started empiric antifungal therapy for febrile neutropenia between January 1, 2002, and December 31, 2003, encompassing 58 treatment episodes (defined as a hospitalization during which empiric antifungal therapy was administered). MEASUREMENTS AND MAIN RESULTS Medical charts, including patients' pharmacy and laboratory data, were reviewed. Twenty-six and 32 episodes of L-AmB and voriconazole use, respectively, were identified. No significant differences between the L-AmB and voriconazole groups were noted at baseline. Rates of fever resolution (54% vs 59%, p=0.791) and breakthrough invasive fungal infections (11% vs 12%, p>0.999) were similar for the L-AmB and voriconazole episodes. Premature drug discontinuation due to the prescriber's perceived lack of efficacy occurred most frequently in the voriconazole group (25% vs 8%, p=0.160). Survival was significantly higher in the voriconazole than in the L-AmB group (100% vs 77%, p=0.006). Adverse effects that were significantly more common in the L-AmB group than in the voriconazole group were elevated serum creatinine levels (27% vs 3%, p=0.017) and electrolyte disturbances (19% vs 0%, p=0.014). Adverse effects reported more frequently in the voriconazole group than in the L-AmB group were visual disturbances (9% vs 0%, p=0.245) and elevated hepatic enzyme levels (9% vs 8%, p>0.999). Mean drug expenditures/episode for initial empiric antifungal therapy were lower for voriconazole than for L-AmB ($1593 vs $4144, or $153 vs $380/day). CONCLUSION Our institution's algorithm incorporating voriconazole into the empiric management of febrile neutropenia was associated with effectiveness outcomes comparable to those observed with L-AmB as well as a lower frequency of adverse effects and overall expenditures for antifungal drugs.
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Affiliation(s)
- Nadine Shehab
- Department of Clinical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Collins CD, Eschenauer GA, Salo SL, Newton DW. To test or not to test: a cost minimization analysis of susceptibility testing for patients with documented Candida glabrata fungemias. J Clin Microbiol 2007; 45:1884-8. [PMID: 17409208 PMCID: PMC1933067 DOI: 10.1128/jcm.00192-07] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This cost minimization analysis investigated the financial impact of the treatment of fungemias due to Candida glabrata from a hospital perspective using three competing alternatives: (i) performing in-house susceptibility testing on all C. glabrata isolates and changing patients to less expensive fluconazole therapy for isolates that test susceptible; (ii) susceptibility testing at outside laboratories with delayed deescalation to fluconazole if isolates test susceptible; and (iii) no routine susceptibility testing with full echinocandin treatment course. Sensitivity analyses and Monte Carlo simulation enhanced the robustness of the model through variation of all assumptions and costs. In the base case, the use of in-house testing displayed a cost advantage over the options of send-out testing and no susceptibility testing ($2,226 versus $2,410 versus $3,136, respectively). Sensitivity analyses determined that the cost of echinocandin therapy and the turnaround time for send-out testing had the potential to impact the base case model. The decision model indicated that in-house susceptibility testing of C. glabrata isolates should result in lower overall treatment costs in patients with documented C. glabrata fungemias.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, University of Michigan Health System, UHB2D301 University Hospital, Ann Arbor, MI 48109-0008, USA.
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Moran DE, Smith MJ, O'Sullivan MJ, Bannon H, Crotty TB, Collins CD, Skehan SJ, O'Higgins N, McDermott EW, Evoy D, Hill ADK. Sentinel lymph node biopsy in elderly irish patients with malignant melanoma. Ir Med J 2007; 100:422-4. [PMID: 17566474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In patients with malignant melanoma, Breslow depth increases with age. However, studies suggest that the frequency of sentinel lymph node metastases in malignant melanoma decreases with age. We investigated whether this applied to the cohort of patients undergoing sentinel lymph node biopsy (SLNB) in our institution. In a prospectively accrued database we identified 149 patients undergoing SLNB from 1997 to 2005. Tumour thickness as measured by Breslow depth was assessed in stratified age groups. We assessed the relationship between SLNB positivity and age using the Chi-square for trend. We directly examined the relationship between SLNB positivity in patients aged less than 65 and aged 65 years of age and over. Disease-free and overall survival in patients aged less than 65 and aged 65 years of age and over were also assessed. Comparing the age groups, there was no significant difference identified in Breslow depth (<65 years, median Breslow > or = 1.2 mm (range 0.2-9.7); > or =65 years, median Breslow > or = 1.4 mm (range 0.12-8.5); p > or = 0.06, Mann-Whitney U). Chi-square for trend identified no significant relationship between SLNB positivity and age. We found n=120 patients <65 had SLNB, of which 26 (21.7%) were positive. In patients =65, n=29 had SLNB of which 3 (10.3%) were positive. These differences were not statistically significant (Fisher's exact test, p > or = 0.2). There was no difference in disease-free or overall survival between patients aged <65 or > or =65 who had SLNB (median follow-up 37.5 months (range 5-70); disease-free survival, p > 0.08; overall survival, p > or = 0.3, Logrank test). We did not find that elderly patients with malignant melanoma had a demonstrable difference in tumour thickness when compared to younger patients. In those patients who underwent SLNB there was no significant difference in node positivity between the age groups. Disease-free and overall survival were not significantly different between the age groups. Further study and longer follow-up will help establish the relationship between age and SLNB positivity.
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Affiliation(s)
- D E Moran
- Department of Surgery, Saint Vincent's University Hospital, Elm Park, Dublin
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Collins CD, Stuntebeck ER, DePestel DD, Stevenson JG. Pharmacoeconomic Analysis of Liposomal Amphotericin B versus Voriconazole for Empirical Treatment of Febrile Neutropenia. Clin Drug Investig 2007; 27:233-41. [PMID: 17358095 DOI: 10.2165/00044011-200727040-00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Liposomal amphotericin B (LAmB) has demonstrated similar efficacy to conventional amphotericin B for antifungal treatment in patients with febrile neutropenia; however, it is not without toxicities and is associated with a high acquisition cost. Despite this high cost, LAmB has been shown to have a pharmacoeconomic advantage over less expensive agents. Voriconazole is a potential alternative for empirical antifungal treatment of febrile neutropenia. The objective of this study was to assess the economic outcomes of voriconazole versus LAmB in patients with fever and neutropenia. METHODS A decision analytical model was developed from a hospital perspective based on a 2-year (2002-2003) review of outcomes and prescribing practices in febrile neutropenic patients at a tertiary care medical centre. Literature reports and expert opinion were used to further populate the model. Sensitivity analyses and Monte Carlo simulation enhanced the robustness of the model through variation of all probabilities and costs that populated the model. RESULTS Sixty-three cases were evaluated in the retrospective review. Thirty-two were initially given voriconazole and 31 were given LAmB. Patient demographic data were similar in each group. In the base case, patients initially given voriconazole displayed a 27% reduction in overall treatment cost over patients initially given LAmB (14,950 vs 20,591 $US). Sensitivity analysis determined that the cost advantage in the voriconazole arm was maintained over a wide range of costs and probabilities. Variance in the cost of nephrotoxicity and medication cost did not significantly alter results. Monte Carlo simulation determined the voriconazole arm to be the optimal path in 65% of cases. CONCLUSION The decision model indicated that use of voriconazole as the preferred antifungal agent in adult haematology patients with febrile neutropenia should result in lower overall treatment costs relative to LAmB.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI 48109-0008, USA.
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Collins CD, Purohit S, Podolsky RH, Zhao HS, Schatz D, Eckenrode SE, Yang P, Hopkins D, Muir A, Hoffman M, McIndoe RA, Rewers M, She JX. The application of genomic and proteomic technologies in predictive, preventive and personalized medicine. Vascul Pharmacol 2006; 45:258-67. [PMID: 17030152 DOI: 10.1016/j.vph.2006.08.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2006] [Revised: 08/05/2006] [Accepted: 08/05/2006] [Indexed: 11/17/2022]
Abstract
The long asymptomatic period before the onset of chronic diseases offers good opportunities for disease prevention. Indeed, many chronic diseases may be preventable by avoiding those factors that trigger the disease process (primary prevention) or by use of therapy that modulates the disease process before the onset of clinical symptoms (secondary prevention). Accurate prediction is vital for disease prevention so that therapy can be given to those individuals who are most likely to develop the disease. The utility of predictive markers is dependent on three parameters, which must be carefully assessed: sensitivity, specificity and positive predictive value. Specificity is important if a biomarker is to be used to identify individuals either for counseling or for preventive therapy. However, a reciprocal relationship exists between sensitivity and specificity. Thus, successful biomarkers will be highly specific without sacrificing sensitivity. Unfortunately, biomarkers with ideal specificity and sensitivity are difficult to find for many diseases. One potential solution is to use the combinatorial power of a large number of biomarkers, each of which alone may not offer satisfactory specificity and sensitivity. Recent technological advances in genetics, genomics, proteomics, and bioinformatics offer a great opportunity for biomarker discovery. The newly identified biomarkers have the potential to bring increased accuracy in disease diagnosis and classification, as well as therapeutic monitoring. In this review, we will use type 1 diabetes (T1D) as an example, when appropriate, to discuss pertinent issues related to high throughput biomarker discovery.
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Affiliation(s)
- C D Collins
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, 1120 15th Street, CA4124, Augusta, GA 30912-2400, United States
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Eschenauer GA, Fedewa K, Collins CD, Alaniz C. Compliance with Institutional Guidelines on the Use of Vancomycin in a Medical Intensive Care Unit. Hosp Pharm 2006. [DOI: 10.1310/hpj4108-749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose The University of Michigan implemented guidelines and restrictions for the use of vancomycin in 1995, based on recommendations from the Centers for Disease Control and Prevention. This study evaluated vancomycin use in the University of Michigan's Medical Intensive Care Unit (MICU), and assessed compliance with these institutional guidelines. Methods The primary objective of the study was to assess compliance with institutional guidelines. All patients admitted to the MICU who received vancomycin during the period of October 2002 through January 2003 were included in the study. Patients were identified retrospectively and patient medical records were accessed to gather pertinent information. Approval of the Institutional Review Board was obtained. Results Fifty-one patients received a total of 71 courses of vancomycin therapy (55 empiric, 16 definitive). Fifty-five (77.5%) of the 71 total courses of vancomycin therapy met institutional criteria. All courses of definitive therapy met specific criteria. Thirty-nine (71%) of the 55 courses of empiric therapy met criteria. Of the courses of empiric therapy which did not fulfill criteria, 12 were from patients exhibiting signs of sepsis and received vancomycin for more than 72 hours, and nine involved immunocompromised patients. Conclusions The implementation of guidelines and restrictions is essential to limiting and preventing resistance, but are only effective if designed with the specific hospital's patient population in mind. The results of this study suggest that immunocompromised patients may require a different approach than what is allowed by existing criteria.
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Affiliation(s)
- Gregory A. Eschenauer
- Infectious Diseases Specialty Resident, University of Michigan Health System, Adjunct Faculty, University of Michigan College of Pharmacy, Ann Arbor, MI
| | | | - Curtis D. Collins
- Clinical Pharmacist, University of Michigan Health System, University of Michigan College of Pharmacy, Ann Arbor, MI
| | - Cesar Alaniz
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, MI
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Borschel DM, Chenoweth CE, Kaufman SR, Hyde KV, VanDerElzen KA, Raghunathan TE, Collins CD, Saint S. Are antiseptic-coated central venous catheters effective in a real-world setting? Am J Infect Control 2006; 34:388-93. [PMID: 16877109 DOI: 10.1016/j.ajic.2005.08.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Revised: 08/11/2005] [Accepted: 08/11/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Catheter-related bloodstream infections are common, costly, and morbid. Randomized controlled trials indicate that antiseptic-coated central venous catheters reduce infection rates. OBJECTIVE To assess the clinical and economic effectiveness of antiseptic-coated catheters for critically ill patients in a real-world setting. METHODS Central venous catheters coated with chlorhexidine/silver-sulfadiazene were introduced in all patients requiring central venous access in adult intensive care units at the University of Michigan Health System, a large, tertiary care teaching hospital. A pretest-posttest cohort design measured the primary outcome of catheter-related bloodstream infection rate, comparing the 2 years prior to the intervention with the 2 years following the intervention. We also evaluated cost-effectiveness and changes in vancomycin use. RESULTS The intervention was associated with a 4% per month relative reduction in the incidence of catheter-related bloodstream infection, after controlling for the effects of time. Overall, a 35% relative risk reduction (P < .0003) in the catheter-related bloodstream infection rate occurred in the posttest phase. The use of antiseptic-coated catheters reduced costs more than $100,000 annually. Vancomycin use was less in units in which antiseptic catheters were used compared with wards in which these catheters were not used. CONCLUSION Antiseptic-coated catheters appear to be clinically effective and economically efficient in a real-world setting.
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Affiliation(s)
- Debaroti M Borschel
- Department of Internal Medicine, University of Michigan, Ann Arbor, 48109-0376, USA.
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Horan G, McArdle O, Martin J, Collins CD, Faul C. Pelvic radiotherapy in patients with hydronephrosis in stage IIIB cancer of the cervix: Renal effects and the optimal timing for urinary diversion? Gynecol Oncol 2006; 101:441-4. [PMID: 16337996 DOI: 10.1016/j.ygyno.2005.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Revised: 10/16/2005] [Accepted: 11/03/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Many patients with Stage IIIB cervix cancer (Ca) and hydronephrosis will require ureteral stenting. The timing is important as delays or prolonged overall treatment times adversely affect outcome. Our aim was to measure the effect of pelvic radiotherapy (R/T) on renal function and identify a subset of patients at high risk of acute urinary obstruction during R/T. PATIENTS AND METHODS From 1/1/2000 to 1/1/2002, all patients with Stage IIIB cervix Ca and hydronephrosis were analysed retrospectively. To quantify the impact of pelvic R/T, all eligible patients from 1/7/2002-1/7/2004 had prospectively recorded baseline biochemistry, creatinine clearance and renal ultrasounds; these were repeated weekly to detect any change in renal function or degree of hydronephrosis. RESULTS 13 eligible patients were analysed retrospectively, 5 with unilateral hydronephrosis with 40% requiring urinary diversion (UD). 8 had bilateral hydronephrosis, with 75% requiring UD; 50% before R/T and 35% during R/T. Average creatinine clearance (CrCl) was 74 mL/min (1.24 mL/s) in unilateral hydronephrosis , bilateral = 52 mL/min (0.87 mL/s), in those stented during R/T it was < 40 mL/min (0.67 mL/s). The resulting break in R/T was 6 and 19 days. In the prospective study, 5 patients were eligible and 4 consented. 75% had unilateral hydronephrosis and did not require UD with an average CrCl = 71 mL/min (1.19 mL/s). 1 patient with bilateral hydronephrosis had a CrCl of < 20 mL/min (0.33 mL/s) with bilateral stents placed before R/T. CONCLUSIONS Patients with bilateral hydronephrosis and a low CrCl < 50 mL/min (0.84 mL/s) should be considered for elective UD prior to R/T. Pelvic R/T did not induce any deterioration in renal function or degree of hydronephrosis.
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Affiliation(s)
- G Horan
- Oncology Centre, Box 193, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2QQ, UK.
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