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Hochstetler LJ, Olney WJ, Bishop JM, Warriner ZD, VanHoose JD, Mynatt RP, Ali D, Schadler A, Parli SE. Antibiotics for Patients With a Planned Re-Laparotomy for Intra-Abdominal Infection. Surg Infect (Larchmt) 2024; 25:192-198. [PMID: 38407831 PMCID: PMC11001956 DOI: 10.1089/sur.2023.255] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Background: Appropriate antimicrobial therapy for the management of intra-abdominal infection (IAI) continues to evolve based on available literature. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial provided evidence to support four days of antibiotic agents in IAI post-source control but excluded patients with a planned re-laparotomy. This study aimed to determine the short- and long-term recurrent infection risk in this population. Patients and Methods: This is a single-center, retrospective, observational study of adult patients admitted to a quaternary medical center between January 1, 2016, and August 1, 2022, with IAI requiring planned laparotomy. Patients were designated as receiving five or less days of antibiotic agents (short course) or more than five days (long course) after source control. The primary outcome was IAI recurrence within 30 days. Results: Of the 104 patients who met inclusion criteria, 78 were included in analysis. Average age was 57 ± 13.3 years, 56% were male, 94% Caucasian, with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 17 ± 7.09. All other baseline characteristics and clinical severity markers were similar between the two groups. Regarding the primary outcome of IAI recurrence, there was no difference when comparing those who received short course versus those who received long course therapy (41.2% vs. 44.4%; p = 0.781). No differences were found between groups with respect to secondary outcomes. Conclusions: In patients admitted with IAI managed with planned re-laparotomy those who received short course antimicrobial therapy were not found to have an increase in IAI recurrence compared to those with longer courses of therapy.
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Affiliation(s)
- Lauren J. Hochstetler
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - William J. Olney
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Jacqueline M. Bishop
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | | | - Jeremy D. VanHoose
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Ryan P. Mynatt
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Dina Ali
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Aric Schadler
- Kentucky Children's Hospital, Lexington, Kentucky, USA
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Sara E. Parli
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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Kenneally AM, Warriner Z, VanHoose JD, Ali D, McCleary EJ, Davenport DL, Parli SE. Evaluation of Antibiotic Duration after Surgical Debridement of Necrotizing Soft Tissue Infection. Surg Infect (Larchmt) 2022; 23:357-363. [PMID: 35262418 DOI: 10.1089/sur.2021.256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/13/2022] Open
Abstract
Background: Necrotizing soft tissue infection (NSTI) is known to be a medical emergency with high morbidity and mortality. Guidelines do not specify the optimal duration of antibiotic agents after completion of surgical debridements of NSTI, which has created variable practice. It was hypothesized that patients with NSTI who receive 48 hours or less of post-operative antibiotic agents after final debridement have similar rates of subsequent intervention or infection recurrence, suggesting that a shorter duration of antibiotic agents may treat NSTI adequately after final surgical debridement. Patients and Methods: This was a retrospective study including adults with NSTI identified through International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, Tenth Revision (ICD-10), and Current Procedural Terminology (CPT) codes admitted to one academic institution between January 1, 2010 and July 31, 2020. Demographics, surgical practices, antibiotic practices, and clinical outcomes including inpatient mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, total antibiotic days, necrotizing infection clinical composite end point (NICCE) success, and infection recurrence were compared based on the duration of antibiotic agents after final debridement. Results: Three hundred twenty-two patients with NSTI were included and baseline characteristics and clinical severity markers were well balanced between the two groups. In 71 patients (22%) who received less than 48 hours of antibiotic agents after final debridement there was no difference in recurrence (1.4% vs. 3.6%; p = 0.697), mortality (1.4% vs. 4.4%; p = 0.476), or ICU LOS (1 vs. 2 days; p = 0.300], but they did have a shorter hospital LOS (7 vs. 10 days; p = 0.011). Conclusions: Shorter duration of antibiotic therapy after final surgical debridement of NSTI may be appropriate in patients without another indication for antibiotic agents.
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Affiliation(s)
- Allison M Kenneally
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Zachary Warriner
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Jeremy D VanHoose
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Dina Ali
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Emily J McCleary
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Dan L Davenport
- Division of Healthcare Outcomes and Optimal Patient Services, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Sara E Parli
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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3
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Gregory ER, Burgess DR, Cotner SE, VanHoose JD, Flannery AH, Gardner B, Autry EB, Forster DW, Burgess DS, Wallace KL. Pharmacist Survey: Pharmacist Perception of Vancomycin Area Under the Curve Therapeutic Drug Monitoring. J Pharm Pract 2019; 34:272-278. [PMID: 31422738 DOI: 10.1177/0897190019867494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/26/2022]
Abstract
BACKGROUND Evidence suggests the standard vancomycin trough goal of 15 to 20 mg/L for serious Staphylococcus aureus infections is associated with acute kidney injury, whereas appropriate monitoring of 24-hour area under the curve (AUC) may decrease nephrotoxicity. As a result, institutions have transitioned to AUC monitoring, the predictive pharmacokinetic/pharmacodynamic parameter of vancomycin to improve safety outcomes. However, this method may require increased pharmacist time and effort. Pharmacist perception of the practice change is largely unknown and warrants investigation. METHODS An electronic survey was disseminated via e-mail to pharmacists 5 months post-AUC implementation. Items of interest were focused on pharmacist perception, including quantity of patients monitored using AUC, justification of the practice change, differences in efficacy and safety, and changes in monitoring time requirements. RESULTS The pharmacist survey was distributed to 196 pharmacists and 84 responded (43% response rate). Eighty-one pharmacists had monitored patients using AUC methods. Sixty-nine percent of these respondents perceived the change to result in increased or slightly increased patient safety, 27% described no difference, and 4% stated safety was decreased or slightly decreased. Forty-two percent perceived the transition to result in increased or slightly increased efficacy, while 48% noted no difference and 10% responded that efficacy was decreased or slightly decreased. Pharmacists stated the creation of an institutional calculator decreased the time required to calculate AUC. CONCLUSION After the change to AUC monitoring, pharmacists perceived improvements in safety outcomes while efficacy was at least similar if not increased.
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Affiliation(s)
- Eric R Gregory
- Department of Pharmacy Services, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Donna R Burgess
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Sarah E Cotner
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | - Alexander H Flannery
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Brian Gardner
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Elizabeth B Autry
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Derek W Forster
- Division of Infectious Diseases, Department of Internal Medicine, 12252University of Kentucky College of Medicine, Lexington, KY, USA
| | - David S Burgess
- Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Katie L Wallace
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
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4
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Gregory ER, Burgess DR, Cotner SE, VanHoose JD, Flannery AH, Gardner B, Autry EB, Forster DW, Burgess DS, Wallace KL. Vancomycin Area Under the Curve Dosing and Monitoring at an Academic Medical Center: Transition Strategies and Lessons Learned. J Pharm Pract 2019; 33:774-778. [PMID: 30852937 DOI: 10.1177/0897190019834369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 11/16/2022]
Abstract
Due to the inconsistent correlation of vancomycin trough concentrations with 24-hour area under the curve (AUC) and a desire to reduce rates of vancomycin-associated acute kidney injury, an institutional guideline was implemented by the Antimicrobial Stewardship Team in September 2017 to monitor vancomycin using AUC. Three stages were utilized to organize the process: preparation, implementation, and evaluation. The preparation stage was used to present literature to key stakeholders, and pharmacy meetings focused on the development of a dosing and monitoring guideline. Along with institution-wide education, the implementation stage included information technology development and support. The evaluation stage was comprised of quality improvement and clinical research. Future plans include dissemination of the results and analyses. Numerous lessons were learned due to barriers experienced during the process, but the transition was successful.
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Affiliation(s)
- Eric R Gregory
- Department of Pharmacy Services, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Donna R Burgess
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Sarah E Cotner
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | - Alexander H Flannery
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Brian Gardner
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Elizabeth B Autry
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Derek W Forster
- Division of Infectious Diseases, Department of Internal Medicine, 4530University of Kentucky College of Medicine, Lexington, KY, USA
| | - David S Burgess
- Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Katie L Wallace
- Department of Pharmacy Services, UK HealthCare, Lexington, KY, USA.,Department of Pharmacy Practice and Science, 4530University of Kentucky College of Pharmacy, Lexington, KY, USA
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5
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Oyler D, Bernard AC, VanHoose JD, Parli SE, Ellis CS, Li D, Procter LD, Chang PK. Minimizing opioid use after acute major trauma. Am J Health Syst Pharm 2018; 75:105-110. [PMID: 29371190 DOI: 10.2146/ajhp161021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 01/21/2023] Open
Abstract
PURPOSE Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported. METHODS In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before (n = 489) and after (n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition. RESULTS Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p < 0.001); after stratification of MME data by baseline opioid use, this finding held true only for patients with no opioid prescription at admission. Although utilization of gabapentinoids, skeletal muscle relaxants, and clonidine increased during the postintervention period, inpatient opioid use did not differ significantly in the 2 cohorts. Utilization of both nonsteroidal antiinflammatory drugs and acetaminophen was lower in the postintervention cohort versus the preintervention cohort. CONCLUSION Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.
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Affiliation(s)
- Douglas Oyler
- University of Kentucky HealthCare, Lexington, KY .,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, KY
| | - Andrew C Bernard
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Kentucky HealthCare, Lexington, KY
| | - Jeremy D VanHoose
- University of Kentucky HealthCare, Lexington, KY.,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, KY
| | - Sara E Parli
- University of Kentucky HealthCare, Lexington, KY.,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, KY
| | - C Scott Ellis
- University of Kentucky College of Pharmacy, Lexington, KY
| | - David Li
- University of Kentucky College of Pharmacy, Lexington, KY
| | - Levi D Procter
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Kentucky HealthCare, Lexington, KY
| | - Phillip K Chang
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Kentucky HealthCare, Lexington, KY
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VanHoose JD, Moody EB, Arrazola L. An unusual perfusion pattern of hepatic metastases. Clin Nucl Med 1997; 22:420-1. [PMID: 9193826 DOI: 10.1097/00003072-199706000-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- J D VanHoose
- Department of Diagnostic Radiology, University of Kentucky College of Medicine, Lexington, USA
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