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Taylor J, Curtis SD, St Onge E, Egelund EF, Venugopalan V, Whalen K. Implementation of standard setting for high-stakes objective structured clinical examinations. Curr Pharm Teach Learn 2024; 16:465-468. [PMID: 38582641 DOI: 10.1016/j.cptl.2024.03.008] [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] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/03/2024] [Accepted: 03/16/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND AND PURPOSE To describe one institution's approach to transformation of high-stakes objective structure clinical examinations (OSCEs) from norm-referenced to criterion-referenced standards setting and to evaluate the impact of these changes on OSCE performance and pass rates. EDUCATIONAL ACTIVITY AND SETTING The OSCE writing team at the college selected a modified Angoff method appropriate for high-stakes assessments to replace the two standard deviation method previously used. Each member of the OSCE writing team independently reviewed the analytical checklist and calculated a passing score for active stations on OSCEs. Then the group met to determine a final pass score for each station. The team also determined critical cut points for each station, when indicated. After administration of the OSCEs, scores, pass rates, and need for remediation were compared to the previous norm-referenced method. Descriptive statistics were used to summarize the data. FINDINGS OSCE scores remained relatively unchanged when switched to a criterion-referenced method, but the number of remediators increased up to 2.6 fold. In the first year, the average score increased from 86.8% to 91.7% while the remediation rate increased from 2.8% to 7.4%. In the third year, the average increased from 90.9% to 92% while the remediation rate increased from 6% to 15.6%. Likewise, the fourth-year average increased from 84.9% to 87.5% while the remediation rate increased from 4.4% to 9%. SUMMARY Transition to a modified Angoff method did not impact average OSCE score but did increase the number of remediations.
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Affiliation(s)
- James Taylor
- University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, United States of America.
| | - Stacey D Curtis
- University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, United States of America.
| | - Erin St Onge
- University of Florida College of Pharmacy, 6550 Sanger Rd, Orlando, FL 32827, United States of America.
| | - Eric F Egelund
- University of Florida College of Pharmacy, 580 W 8th ST, Jacksonville, FL 32209, United States of America.
| | - Veena Venugopalan
- University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, United States of America.
| | - Karen Whalen
- University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, United States of America.
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Venugopalan V, Satheesh G, Jain V, Hemnaath R, Sakthi. Re: New method of arch bar fixation. Br J Oral Maxillofac Surg 2024; 62:387. [PMID: 38565490 DOI: 10.1016/j.bjoms.2023.12.023] [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] [Received: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 04/04/2024]
Affiliation(s)
- V Venugopalan
- Oral and maxillofacial surgery, Adiparashakthi Dental College and Hospital, India.
| | - G Satheesh
- Oral and maxillofacial surgery, Adiparashakthi Dental College and Hospital, India.
| | - Vijaykumar Jain
- Oral and maxillofacial surgery, Adiparashakthi Dental College and Hospital, India.
| | - R Hemnaath
- Oral and maxillofacial surgery, Adiparashakthi Dental College and Hospital, India.
| | - Sakthi
- Oral and maxillofacial surgery, Adiparashakthi Dental College and Hospital, India.
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Harrison I, DeSear K, Santevecchi BA, Venugopalan V, Cherabuddi K, Iovine N, Radhakrishnan N. Brincidofovir for disease progression due to suspected tecovirimat resistance in association with advanced HIV. Int J STD AIDS 2024:9564624241238813. [PMID: 38502040 DOI: 10.1177/09564624241238813] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
A man with advanced HIV presented with verrucous plaques 2-3 months after initial mpox infection. He received two courses of tecovirimat without resolution of initial mpox lesions and development of new lesions raising concern for resistance. He was treated with two doses of brincidofovir and demonstrated improvement 6 months later.
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Affiliation(s)
- Iris Harrison
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Kathryn DeSear
- Department of Pharmacy, University of Florida Health, Gainesville, FL, USA
| | - Barbara A Santevecchi
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases & Global Medicine, University of Florida Health, Gainesville, FL, USA
| | - Nicole Iovine
- Division of Infectious Diseases & Global Medicine, University of Florida Health, Gainesville, FL, USA
| | - Nila Radhakrishnan
- Department of Medicine, University of Florida Health, Gainesville, FL, USA
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Zheng L, Alshaer MH, Peloquin C, Venugopalan V, Alnuaimat HM, Converse M. Cefepime pharmacokinetics in adult extracorporeal membrane oxygenation patients. Pulm Pharmacol Ther 2024; 84:102271. [PMID: 38008397 DOI: 10.1016/j.pupt.2023.102271] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/25/2023] [Accepted: 11/21/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND The impact of extracorporeal membrane oxygenation (ECMO) on the pharmacokinetics/dynamics (PK/PD) of beta-lactam antibiotics have not been well studied in general, but cefepime specifically has the least amount of data. We aimed to investigate whether ECMO alters the PK of cefepime in adult intensive care unit (ICU) patients. METHODS This single-center, retrospective case-control study evaluated cefepime therapeutic drug monitoring (TDM) results from ECMO patients that were matched 1:1 with TDM results in non-ECMO patients for drug regimen and renal function. The primary outcome was the difference in PK/PD of cefepime in ECMO compared with non-ECMO ICU patients. Secondary outcomes included hospital length of stay, treatment failure, superinfection, bacterial resistance, and survival to discharge. RESULTS Eighty-two patients were included with 44 matched cefepime concentrations in each group. ECMO patients had higher free maximum concentrations (fCmax) (p = 0.003), lower free minimum concentration (fCmin)/1x minimum inhibitory concentration (MIC) ratios (p = 0.040), and lower attainment of free Cmin/4x MIC (p = 0.010). There were no differences between the groups for free Cmin, time above 1xMIC or 4x MIC, and pharmacokinetic parameters (ke, half-life, and Vd). Of those who survived to discharge, hospital length of stay was longer in the ECMO group (p < 0.001). Patients on ECMO were more likely to experience treatment failure (p = 0.036). The incidence of bacterial resistance, superinfection, or survival were similar among the groups. CONCLUSION These data suggest that more aggressive empiric dosing may be warranted in patients on ECMO. Therapeutic drug monitoring and future prospective studies would provide more evidence to guide decision making regarding dose adjustments.
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Affiliation(s)
- Lily Zheng
- Department of Pharmacy Services, University of Florida Health Jacksonville North, 15255 Max Leggett Pkwy, Jacksonville, FL, USA.
| | - Mohammad H Alshaer
- Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Medical Science Bldg Rm P4 05, 1600 SW Archer Rd., Gainesville, FL, USA
| | - Charles Peloquin
- Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Medical Science Bldg Rm P4 05, 1600 SW Archer Rd., Gainesville, FL, USA
| | - Veena Venugopalan
- Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Medical Science Bldg Rm P4 05, 1600 SW Archer Rd., Gainesville, FL, USA
| | - Hassan M Alnuaimat
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, 1505 SW Archer Road, Gainesville, FL, USA
| | - Maureen Converse
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, USA
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Maranchick NF, Trillo-Alvarez C, Kariyawasam V, Venugopalan V, Kwara A, Rand K, Peloquin CA, Alshaer MH. A Randomized Clinical Trial of Bayesian-Guided Beta-Lactam Infusion Strategy and Associated Bacterial Resistance and Clinical Outcomes in Patients With Severe Pneumonia. Ther Drug Monit 2024; 46:95-101. [PMID: 38018847 PMCID: PMC10769161 DOI: 10.1097/ftd.0000000000001144] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Antimicrobial resistance is a growing health concern worldwide. The objective of this study was to evaluate the effect of beta-lactam infusion on the emergence of bacterial resistance in patients with severe pneumonia in the intensive care unit. METHODS Adult intensive care patients receiving cefepime, meropenem, or piperacillin-tazobactam for severe pneumonia caused by Gram-negative bacteria were randomized to receive beta-lactams as an intermittent (30 minutes) or continuous (24 hours) infusion. Respiratory samples for culture and susceptibility testing, with minimum inhibitory concentrations (MIC), were collected once a week for up to 4 weeks. Beta-lactam plasma concentrations were measured and therapeutic drug monitoring was performed using Bayesian software as the standard of care. RESULTS The study was terminated early owing to slow enrollment. Thirty-five patients were enrolled in this study. Cefepime (n = 22) was the most commonly prescribed drug at randomization, followed by piperacillin (n = 8) and meropenem (n = 5). Nineteen patients were randomized into the continuous infusion arm and 16 into the intermittent infusion arm. Pseudomonas aeruginosa was the most common respiratory isolate (n = 19). Eighteen patients were included in the final analyses. No differences in bacterial resistance were observed between arms ( P = 0.67). No significant differences in superinfection ( P = 1), microbiological cure ( P = 0.85), clinical cure at day 7 ( P = 0.1), clinical cure at end of therapy ( P = 0.56), mortality ( P = 1), intensive care unit length of stay ( P = 0.37), or hospital length of stay ( P = 0.83) were observed. Achieving 100% ƒT > MIC ( P = 0.04) and ƒT > 4 × MIC ( P = 0.02) increased likelihood of clinical cure at day 7 of therapy. CONCLUSIONS No differences in the emergence of bacterial resistance or clinical outcomes were observed between intermittent and continuous infusions. Pharmacokinetic/pharmacodynamic target attainment may be associated with a clinical cure on day 7.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Cesar Trillo-Alvarez
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, Florida
| | - Vidhu Kariyawasam
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida; and
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, Florida
| | - Awewura Kwara
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida; and
| | - Kenneth Rand
- College of Medicine, University of Florida, Gainesville, Florida
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
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Venugopalan V, Maranchick N, Hanai D, Hernandez YJ, Joseph Y, Gore A, Desear K, Peloquin C, Neely M, Felton T, Shoulders B, Alshaer M. Association of piperacillin and vancomycin exposure on acute kidney injury during combination therapy. JAC Antimicrob Resist 2024; 6:dlad157. [PMID: 38259903 PMCID: PMC10801827 DOI: 10.1093/jacamr/dlad157] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Objectives Acute kidney injury (AKI) is a well-documented adverse effect observed with piperacillin/tazobactam in combination with vancomycin. The pharmacokinetics of these antibiotics when given in combination have not been previously evaluated. The purpose of this study was to compare the exposure of vancomycin + piperacillin/tazobactam in patients with and without AKI. Methods Ninety adult patients, who received at least 72 h of vancomycin + piperacillin/tazobactam combination therapy and had available serum concentrations of vancomycin and piperacillin were included in the study. Nephrotoxicity was defined as a 1.5-fold increase in serum creatinine within 7 days from baseline. Median daily AUCs were calculated in those with nephrotoxicity (vancomycin + piperacillin/tazobactam 'N') versus those without nephrotoxicity (vancomycin + piperacillin/tazobactam 'WN') during the first 7 days of combination therapy. Results The overall incidence of AKI in those receiving vancomycin + piperacillin/tazobactam was 20% (18/90). The median daily vancomycin AUCs did not differ between the vancomycin + piperacillin/tazobactam 'WN' and vancomycin + piperacillin/tazobactam 'N' groups. Although not statistically significant, the median daily vancomycin AUCs in the vancomycin + piperacillin/tazobactam 'N' group were numerically greater on Day 5 and trended downwards thereafter. For the piperacillin group, the median daily AUCs did not vary between groups, except on Day 7 where the vancomycin + piperacillin/tazobactam 'WN' group had statistically greater median piperacillin AUC than the vancomycin + piperacillin/tazobactam 'N' group (P = 0.046). Conclusions Utilizing serum creatinine-defined AKI, our study did not find any significant differences in vancomycin and piperacillin/tazobactam exposure between the groups with and without nephrotoxicity. These data indicate that vancomycin + piperacillin/tazobactam should not be avoided due to the risk of overexposure; instead, clinicians should continue to use these therapies cautiously.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Nicole Maranchick
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Devorah Hanai
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Yaima Jimenez Hernandez
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Yuliya Joseph
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Amanda Gore
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Kathryn Desear
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
| | - Charles Peloquin
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Michael Neely
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Timothy Felton
- Division of Immunology, Immunity to Infection and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Bethany Shoulders
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Mohammad Alshaer
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
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Allen JM, Cavanaugh TM, Hathorn T, Awunti M, Whitner C, Venugopalan V, Ozimek M, Butler LM, Buring SM. Exploring Trends in Social Vulnerability for Pharmacy Students at a Large Public University. Am J Pharm Educ 2023; 87:100551. [PMID: 37336326 DOI: 10.1016/j.ajpe.2023.100551] [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] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE This study aimed to describe trends in social vulnerability (SV) among pharmacy students at a large public college of pharmacy, and to describe differences in SV by race and ethnicity using the Centers for Disease Control and Prevention Social Vulnerability Index (SVI). METHODS The SVI was determined for each student admitted between Fall 2017 and Fall 2022 using the submitted permanent address for each student in a deidentified fashion. International students and students not from the 50 US states were excluded from the analysis. RESULTS During the study period, 1427 pharmacy students met the study inclusion criteria and were included in the final analysis. Students from historically minoritized populations accounted for 53.4% (n = 763/1427) of students. The median SVI score for all students was 0.4091 (interquartile range [IQR]: 0.2091-0.6395), which is consistent with low/moderate SV risk. When considering SVI by race, students from historically minoritized populations had a higher median SVI (0.4807 [IQR: 0.2791-0.7071] vs 0.3562 [IQR: 0.1561-0.5523]), and were more likely to come from moderate/high SV regions compared with White students (odds ratio 2.00 [95% confidence interval: 1.609-2.486]). CONCLUSION Among pharmacy students at a large public university, a substantial proportion of students had moderate/high SV risk, particularly those from historically minoritized backgrounds. Colleges and schools of pharmacy need to consider the unique needs of students from high SV backgrounds and provide intentional equity-based mitigation strategies to maximize the potential for student success for all.
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Affiliation(s)
- John M Allen
- University of Florida College of Pharmacy, Orlando, FL, USA.
| | | | - Tyisha Hathorn
- University of Florida College of Pharmacy, Gainesville, FL, USA
| | | | - Chardae Whitner
- University of Florida College of Pharmacy, Jacksonville, FL, USA
| | | | - Milena Ozimek
- University of Florida College of Pharmacy, Orlando, FL, USA
| | | | - Shauna M Buring
- University of Florida College of Pharmacy, Gainesville, FL, USA
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Lodl EF, Alshaer MH, Adams CB, Richards A, Peloquin C, Venugopalan V. Utilization of cefepime therapeutic drug monitoring in febrile neutropenia patients with hematologic malignancies. J Oncol Pharm Pract 2023:10781552231213883. [PMID: 37981806 DOI: 10.1177/10781552231213883] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Cefepime is a fourth-generation cephalosporin and is a workhorse for the empiric treatment of febrile neutropenia (FN). Beta-lactam therapeutic drug monitoring (TDM) has emerged as a dose optimization strategy in patient populations with altered kinetics. Prior literature has demonstrated that patients with FN exhibit augmented renal clearance which may lead to subtherapeutic drug concentrations with standard dosing regimens. The aim of this study was to evaluate pharmacokinetic/pharmacodynamic (PK/PD) target attainment and clinical outcomes in patients with hematologic malignancies and FN who were treated empirically with cefepime. METHODS This was a prospective, single-center study of adults with hematologic malignancies and FN admitted to the inpatient unit. The primary outcome was PK/PD target attainment (defined as 100% free time greater than minimum inhibitory concentration (100% fT > MIC)). Secondary clinical outcomes were time to defervescence, time to ANC recovery, in-hospital mortality, and cefepime failure. RESULTS There were 55 patients in our study. Forty-three (78%) patients achieved the primary outcome of PK/PD target attainment. The mean time to defervescence was similar between those that achieved PK/PD target attainment and those that did not (95% CI -0.75 to 1.25, p = 0.62). CONCLUSIONS This study showed that standard cefepime dosing in patients with hematologic malignancies and FN does not result in achievement of 100% fT > MIC in all patients. Patients in the group that did not achieve PK/PD target attainment were younger with increased creatinine clearance, indicating that cefepime TDM may be especially beneficial in these patients.
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Affiliation(s)
- Emma F Lodl
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chang J, Liu J, Alshaer MH, Venugopalan V, Maranchick N, Peloquin CA, Rhodes NJ, Scheetz MH. Making the case for precision dosing: visualizing the variability of cefepime exposures in critically ill adults. J Antimicrob Chemother 2023; 78:2170-2174. [PMID: 37449472 PMCID: PMC10686690 DOI: 10.1093/jac/dkad211] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE To investigate and describe the variability in cefepime exposures among 'real-world', critically ill patients by using population pharmacokinetic modelling and simulations, and with translation of these findings to visualizations. METHODS A cohort of adult medical ICU patients who received cefepime with therapeutic drug monitoring was studied. Two compartment models were developed to estimate cefepime clearance (Model 1) and simulate cefepime exposures among 1000 patients, each with identical creatinine clearance of 60 mL/min and receiving a regimen of cefepime 1 gram IV over 30 minutes, every 8 hours (Model 2). Variability in the relationship between cefepime clearance and creatinine clearance (CrCL) was visualized, and a random, representative sample of 10 simulated patients was utilized to illustrate variability in cefepime exposures. RESULTS A total of 75 adult medical ICU patients (52% female) and 98 serum cefepime samples were included in the study. Population parameter estimates for cefepime displayed a wide range of variation in Model 1 (CV: 45% to 95%), with low bias at the individual level at 0.226 mg/L but high bias in the population model 10.6 mg/L. Model 2 displayed similar fits, demonstrating that correcting for individual patient creatinine clearance slightly improves the bias of the population model (bias = 4.31 mg/L). Among 10 simulated patients that a clinician would deem similar from a dosing perspective (i.e. equivalent creatinine clearance), maximum concentrations after three simulated doses varied more than 8-fold from 41.2 to 339 mg/L at the 5th and 95th percentiles, and clearance profiles were highly different. CONCLUSION Creatinine clearance estimates alone are inadequate for predicting cefepime exposures. Wide variations in cefepime exposure exist among ICU patients, even for those with similar kidney function estimates. Current population adjustment schemes based solely on creatinine clearance will result in unintended high and low exposures leading to safety and efficacy concerns, respectively.
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Affiliation(s)
- Jack Chang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, 555 31st St., Downers Grove, IL 60515, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Jiajun Liu
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, United States Food and Drug Administration, Silver Spring, MD, USA
- Work was carried out while employed at Midwestern University College of Pharmacy, Downers Grove, IL, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, 555 31st St., Downers Grove, IL 60515, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, 555 31st St., Downers Grove, IL 60515, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
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Garg M, Venugopalan V, Vouri SM, Diaby V, Iovine NM, Park H. Oral fluoroquinolones and risk of aortic aneurysm or dissection: A nationwide population-based propensity score-matched cohort study. Pharmacotherapy 2023; 43:883-893. [PMID: 37381584 DOI: 10.1002/phar.2841] [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] [Received: 01/10/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 06/30/2023]
Abstract
STUDY OBJECTIVE To investigate risk of aortic aneurysm or dissection in patients using oral fluoroquinolones compared to those using macrolides in real-world clinical practice among a large US general population. DESIGN Retrospective cohort study design. DATA SOURCE MarketScan commercial and Medicare supplemental databases. PATIENTS Adults patients with at least one prescription fill for fluoroquinolone or macrolide antibiotics. INTERVENTION Fluoroquinolone or macrolide antibiotics. MEASUREMENTS AND MAIN RESULTS The primary outcome was estimated incidence of aortic aneurysm or dissection associated with the use of fluoroquinolones compared with macrolides during a 60-day follow-up period in a 1:1 propensity score-matched cohort. We identified 3,174,620 patients (1,587,310 in each group) after 1:1 propensity score matching. Crude incidence of aortic aneurysm or dissection was 1.9 cases per 1000 person-years among fluoroquinolone users and 1.2 cases per 1000 person-years among macrolide users. In multivariable Cox regression, compared with macrolides, the use of fluoroquinolones was associated with an increased risk of aortic aneurysm or dissection (aHR: 1.34; 95% CI: 1.17-1.54). The association was primarily driven by a high incidence of aortic aneurysm cases (95.8%). Results of sensitivity (e.g., fluoroquinolone exposure ranging from 7 to 14 days (aHR: 1.47; 95% CI: 1.26-1.71)) and subgroup analyses (e.g., ciprofloxacin (aHR: 1.26; 95% CI: 1.07-1.49) and levofloxacin (aHR: 1.44; 95% CI: 1.19-1.52)) remained consistent with main findings. CONCLUSIONS Fluoroquinolone use was associated with a 34% increased risk of aortic aneurysm or dissection compared with macrolide use among a general US population.
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Affiliation(s)
- Mahek Garg
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Nicole M Iovine
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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11
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Branton AC, Vu CH, Venugopalan V, Santevecchi BA, Cherabuddi K, Ramphal R, Manohar T, Desear KE. Re-evaluation of cefepime or piperacillin/tazobactam to decrease use of carbapenems in ESBL-producing Enterobacterales urinary tract infections (REDUCE-UTI). JAC Antimicrob Resist 2023; 5:dlad021. [PMID: 36936190 PMCID: PMC10020980 DOI: 10.1093/jacamr/dlad021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/14/2023] [Indexed: 03/18/2023] Open
Abstract
Objectives To re-examine the use of non-carbapenems (NCBPs), specifically piperacillin/tazobactam and cefepime, for ESBL-producing Enterobacterales (ESBL-E) urinary tract infections (UTIs). Patients Retrospective cohort study of adults hospitalized between January 2016 and June 2020 with pyuria on urinalysis, a urine culture positive for ESBL-E treated with a study antibiotic (meropenem, ertapenem, cefepime or piperacillin/tazobactam) and did not meet criteria for study exclusion. Methods To compare carbapenems (CBPs) with cefepime or piperacillin/tazobactam for the treatment of ESBL-E UTI. The primary outcome was clinical cure, defined as complete resolution of signs and symptoms of infection. Secondary outcomes included in-hospital mortality, recurrence within 30 days and resistance emergence within 30 days. Results One-hundred and thirty-three patients were included, based on definitive therapy received; 69 (51.9%) received CBP and 64 (48.1%) received NCBP therapy. Of the total patient population, 17 (12.8%) were admitted to the ICU, 84 (63.1%) had a complicated UTI and 64 (48.1%) had pyelonephritis. There was no difference in clinical cure between the CBP and NCBP groups (95.7% versus 96.9%, P = 0.999). Additionally, no differences in secondary outcomes were observed. Conclusions When compared with CBPs, cefepime and piperacillin/tazobactam resulted in similar clinical cure, in-hospital mortality, recurrence and resistance emergence in the treatment of ESBL-E UTI.
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Affiliation(s)
| | - Catherine H Vu
- Department of Pharmacy, University Medical Center New Orleans, New Orleans, LA, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Barbara A Santevecchi
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Reuben Ramphal
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Tanvi Manohar
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kathryn E Desear
- Corresponding author. E-mail: ; @IDPharmD_Kate, @acbranton, @kartc, @Veena_PharmD, @cvu_idpharmd
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12
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Alosaimy S, Lagnf AM, Hobbs ALV, Mubarez M, Kufel WD, Morrisette T, Polisetty RS, Li D, Veve MP, Simon SP, Truong J, Finch N, Venugopalan V, Rico M, Amaya L, Yost C, Cubillos A, Chandler E, Patch M, Smith IMK, Biagi M, Wrin J, Moore WJ, Molina KC, Rebold N, Holger D, Kunz Coyne AJ, Jorgensen SCJ, Witucki P, Tran NN, Davis SL, Sakoulas G, Rybak MJ. Nephrotoxicity of Vancomycin in Combination With Beta-Lactam Agents: Ceftolozane-Tazobactam vs Piperacillin-Tazobactam. Clin Infect Dis 2023; 76:e1444-e1455. [PMID: 35982631 DOI: 10.1093/cid/ciac670] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/27/2022] [Accepted: 08/16/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vancomycin (VAN)-associated acute kidney injury (AKI) is increased when VAN is combined with certain beta-lactams (BLs) such as piperacillin-tazobactam (TZP) but has not been evaluated with ceftolozane-tazobactam (C/T). Our aim was to investigate the AKI incidence of VAN in combination with C/T (VAN/C/T) compared with VAN in combination to TZP (VAN-TZP). METHODS We conducted a multicenter, observational, comparative study across the United States. The primary analysis was a composite outcome of AKI and risk, injury, failure, loss, end stage renal disease; Acute Kidney Injury Network; or VAN-induced nephrotoxicity according to the consensus guidelines. Multivariable logistic regression analysis was conducted to adjust for confounding variables and stratified Kaplan-Meir analysis to assess the time to nephrotoxicity between the 2 groups. RESULTS We included VAN/C/T (n = 90) and VAN-TZP (n = 284) at an enrollment ratio of 3:1. The primary outcome occurred in 12.2% vs 25.0% in the VAN-C/T and VAN-TZP groups, respectively (P = .011). After adjusting for confounding variables, VAN-TZP was associated with increased odds of AKI compared with VAN-C/T; with an adjusted odds ratio of 3.308 (95% confidence interval, 1.560-6.993). Results of the stratified Kaplan-Meir analysis with log-rank time-to-nephrotoxicity analysis indicate that time to AKI was significantly shorter among patients who received VAN-TZP (P = .004). Cox proportional hazards analysis demonstrated that TZP was consistent with the primary analysis (P = .001). CONCLUSIONS Collectively, our results suggest that the AKI is not likely to be related to tazobactam but rather to piperacillin, which is a component in VAN-TZP but not in VAN-C/T.
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Affiliation(s)
- Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Athena L V Hobbs
- Department of Pharmacy, Baptist Memorial Hospital-Memphis, Memphis, Tennessee, USA
| | - Musa Mubarez
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee, USA
| | - Wesley D Kufel
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York, USA.,Department of Pharmacy, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Taylor Morrisette
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA.,Department of Pharmacy Services, Medical University of South Carolina Shawn Jenkins Children's Hospital, Charleston, South Carolina, USA
| | - Radhika S Polisetty
- Department of Pharmacy Practice, Midwestern University College of Pharmacy Downers Grove Campus, Downers Grove, Illinois, USA.,Department of Pharmacy, Northwestern Medicine Central Dupage Hospital, Winfield, Illinois, USA
| | - David Li
- Department of Pharmacy, Northwestern Medicine Central Dupage Hospital, Winfield, Illinois, USA
| | - Michael P Veve
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee, USA.,Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sam P Simon
- Maimonides Medical Center, Brooklyn, New York, USA
| | - James Truong
- Department of Pharmacy, Brooklyn Hospital, Brooklyn, New York, USA
| | - Natalie Finch
- Department of Pharmacy Services, Harris Health System, Bellaire, Texas, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy & Translational Research, University of Florida, Gainesville, Florida, USA
| | - Matthew Rico
- Department of Pharmacy, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Lee Amaya
- Department of Pharmacy, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Christine Yost
- Department of Pharmacy, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Ashley Cubillos
- Department of Pharmacy, Lee Memorial Health System, Fort Myers, Florida, USA
| | - Elisabeth Chandler
- Department of Pharmacy, Lee Memorial Health System, Fort Myers, Florida, USA
| | - Megan Patch
- Department of Pharmacy, Lee Memorial Health System, Fort Myers, Florida, USA
| | | | - Mark Biagi
- Department of Pharmacy, Swedish American Hospital, Rockford, Illinois, USA
| | - Justin Wrin
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - W Justin Moore
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Kyle C Molina
- Department of Pharmacy-Infectious Disease, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Nicholas Rebold
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Dana Holger
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Ashlan J Kunz Coyne
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Sarah C J Jorgensen
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Paige Witucki
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Nikki N Tran
- Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA.,Department of Pharmacy, Ohio State University Waxner Medical Center, Columbus, Ohio, USA
| | - Susan L Davis
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
| | - George Sakoulas
- Division of Host-Microbe Systems and Therapeutics, University of California San Diego School of Medicine, San Diego, California, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Detroit Receiving Hospital, Detroit, Michigan, USA.,Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
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13
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Venugopalan V, Casaus D, Kainz L, Slaton CN, Hurst N, Bruzzone M, Hu C, Sword G, Cherabuddi K, Iovine N, Liu J, Scheetz MH, Rhodes N, Maranchick N, Peloquin CA, Klinker K, Alshaer MH. Use of therapeutic drug monitoring to characterize cefepime-related neurotoxicity. Pharmacotherapy 2023; 43:6-14. [PMID: 36401796 DOI: 10.1002/phar.2744] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVES Data evaluating cefepime thresholds associated with neurotoxicity remain limited. The objectives of this study were to evaluate the incidence of cefepime-related neurotoxicity (CRN) in patients with plasma cefepime concentrations, assess the relationship between cefepime exposure and CRN, investigate clinical factors associated with CRN, and describe electroencephalogram (EEG) abnormalities in CRN. DESIGN This was a retrospective study of adult inpatients admitted between 2016 and 2018 who received cefepime therapeutic drug monitoring (TDM). Potential CRN cases were identified utilizing a standard definition. The primary outcomes of the study were to determine the incidence of CRN and evaluate the relationship between cefepime trough concentrations, the average daily AUC, and neurotoxicity. Bayesian posteriors were generated for each patient using a cefepime pharmacokinetic (PK) model, and the mean daily area under the concentration-time curve (AUC) was calculated. Multiple regression was performed to assess the association between CRN, cefepime PK, and clinical predictors of neurotoxicity. MAIN RESULTS Four hundred eighty-one patients with 503 hospital encounters received cefepime TDM and were included in the analysis. The incidence of CRN was 4.4% (22/503). Patients with CRN had a higher incidence of renal dysfunction, hypertension, and diabetes mellitus compared to patients without CRN (non-NT). The mean cefepime trough concentration was significantly greater in the CRN patients than in the non-NT group (61.8 ± 33.7 vs. 30 ± 27.7 mg/L, respectively, p = 0.0002). Cefepime trough concentration and renal dysfunction were independently associated with increased risk of CRN in the adjusted multiple regression model. Moderate generalized slowing of the background rhythm was the most common EEG pattern associated with CRN. Delaying cefepime TDM greater than 72 h after the initiation of cefepime was associated with a 3-fold increased risk of CRN. CONCLUSION Cefepime should be used cautiously in hospitalized patients with renal dysfunction due to the risk of neurotoxicity. Dose optimization utilizing TDM early in cefepime treatment may minimize adverse effects and improve patient safety.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Danielle Casaus
- Department of Pharmacy, University of Florida Health-Shands Hospital, Gainesville, Florida, USA
| | - Leonie Kainz
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Cara N Slaton
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Natalie Hurst
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Calvin Hu
- Division of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Gabriel Sword
- Division of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Nicole Iovine
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jiajun Liu
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA.,Northwestern Memorial Hospital, Chicago, Illinois, USA.,Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Marc H Scheetz
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA.,Northwestern Memorial Hospital, Chicago, Illinois, USA.,Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Nathaniel Rhodes
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA.,Northwestern Memorial Hospital, Chicago, Illinois, USA.,Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Kenneth Klinker
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
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14
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Venugopalan V, Hamza M, Santevecchi B, DeSear K, Cherabuddi K, Peloquin CA, Al-Shaer MH. Implementation of a β-lactam therapeutic drug monitoring program: Experience from a large academic medical center. Am J Health Syst Pharm 2022; 79:1586-1591. [PMID: 35704702 DOI: 10.1093/ajhp/zxac171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the implementation and operationalization of a β-lactam (BL) therapeutic drug monitoring(TDM) program at a large academic center. SUMMARY BLs are the most used class of antibiotics. Suboptimal antibiotic exposure is a significant concern in hospitalized patients, particularly in those with altered pharmacokinetics. BL-TDM provides clinicians the opportunity to optimize drug concentrations to ensure maximal therapeutic efficacy while minimizing toxicity. However, BL-TDM has not been widely adopted due to the lack of access to assays. The University of Florida Shands Hospital developed a BL-TDM program in 2015. This is a consultative service primarily run by pharmacists and is conducted in all patient care areas. An analysis was performed on the first BL-TDM encounter for 1,438 patients. BL-TDM was most frequently performed for cefepime (61%, n = 882), piperacillin (15%, n = 218), and meropenem (11%, n = 151). BL-TDM was performed a median of 3 days (interquartile range, 1-5 days) from BL initiation. Among patients with available minimum inhibitory concentration (MIC) values and trough concentrations, the pharmacokinetic/pharmacodynamic (PK/PD) target of 100% fT>MIC was attained in 308 patients (88%). BL-TDM resulted in a dosage adjustment in 25% (n = 361) of patients. CONCLUSION Implementation of a BL-TDM program requires the concerted efforts of physicians, pharmacists, nursing staff, phlebotomists, and personnel in the analytical laboratory. Standard antibiotic dosing failed to achieve optimal PK/PD targets in all patients; utilizing BL-TDM, dose adjustments were made in 1 of every 4 patients.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Malva Hamza
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Barbara Santevecchi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kathryn DeSear
- University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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15
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Koro M, Borgert S, Abbott A, Venugopalan V. Evaluation of Susceptibility Patterns in Uropathogens and Empiric Antibiotic Therapy in the Emergency Department. Hosp Pharm 2021; 56:745-750. [PMID: 34732933 DOI: 10.1177/0018578720957965] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Urinary Tract Infections (UTIs) are the most common bacterial infections encountered in the Emergency Department (ED). Objectives of this study are to describe the urological pathogens associated with UTIs in the ED, report antibiotic susceptibilities, and assess empiric antibiotic treatment. Methods: A retrospective chart review of 154 patients with positive urine cultures from January to June 2016 were reviewed for inclusion in the study. Patients were excluded if less than 18 years of age, hospitalized, discharged from the ED without antibiotics or diagnosed with pyelonephritis. Patient demographics, uropathogens isolated, in-vitro susceptibility to commonly prescribed oral antibiotics (nitrofurantoin, ciprofloxacin, and sulfamethoxazole/trimethoprim), and antibiotics selected for treatment were recorded. Results: One hundred patients were included in the final analysis. Of the 106 bacterial isolates, Escherichia coli, Klebsiella pneumoniae, and Group B Streptococcus accounted for 62.5%, 8%, and 8% of pathogens, respectively. Overall susceptibilities were 88.1%, 87.9%, 85.4%, and 70.6% for nitrofurantoin, cefazolin, ciprofloxacin, and sulfamethoxazole/trimethoprim, respectively. Escherichia coli was most susceptible to nitrofurantoin at 96.9% followed by cefazolin at 94%. Ciprofloxacin was the most prescribed antibiotic followed by cephalexin, nitrofurantoin and sulfamethoxazole/trimethoprim. Conclusions: Based on bacterial susceptibility patterns, nitrofurantoin and cephalexin are reasonable first line agents in the empiric treatment of urinary tract infections identified in the emergency department. The most frequently prescribed antibiotic was ciprofloxacin, highlighting the importance of implementing antimicrobial stewardship initiatives and designing specific tools and educational programs for the emergency department targeted at minimizing fluoroquinolone use.
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Affiliation(s)
- Mira Koro
- UF Health Shands Hospital, Gainesville, FL, USA
| | - Samuel Borgert
- UF Health Shands Hospital, Gainesville, FL, USA.,Melinta Therapeutics, Morristown, NJ, USA
| | | | - Veena Venugopalan
- UF Health Shands Hospital, Gainesville, FL, USA.,University of Florida, Gainesville, FL, USA
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16
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Alosaimy S, Lagnf AM, Morrisette T, Scipione MR, Zhao JJ, Jorgensen SCJ, Mynatt R, Carlson TJ, Jo J, Garey KW, Allen D, DeRonde K, Vega AD, Abbo LM, Venugopalan V, Athans V, Saw S, Claeys KC, Miller M, Molina KC, Veve M, Kufel WD, Amaya L, Yost C, Ortwine J, Davis SL, Rybak MJ. Real-world, Multicenter Experience With Meropenem-Vaborbactam for Gram-Negative Bacterial Infections Including Carbapenem-Resistant Enterobacterales and Pseudomonas aeruginosa. Open Forum Infect Dis 2021; 8:ofab371. [PMID: 34430671 PMCID: PMC8378588 DOI: 10.1093/ofid/ofab371] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 03/31/2021] [Accepted: 07/12/2021] [Indexed: 12/28/2022] Open
Abstract
Background We aimed to describe the clinical characteristics and outcomes of patients treated with meropenem-vaborbactam (MEV) for a variety of gram-negative infections (GNIs), primarily including carbapenem-resistant Enterobacterales (CRE). Methods This is a real-world, multicenter, retrospective cohort within the United States between 2017 and 2020. Adult patients who received MEV for ≥72 hours were eligible for inclusion. The primary outcome was 30-day mortality. Classification and regression tree analysis (CART) was used to identify the time breakpoint (BP) that delineated the risk of negative clinical outcomes (NCOs) and was examined by multivariable logistic regression analysis (MLR). Results Overall, 126 patients were evaluated from 13 medical centers in 10 states. The most common infection sources were respiratory tract (38.1%) and intra-abdominal (19.0%) origin, while the most common isolated pathogens were CRE (78.6%). Thirty-day mortality and recurrence occurred in 18.3% and 11.9%, respectively. Adverse events occurred in 4 patients: nephrotoxicity (n = 2), hepatoxicity (n = 1), and rash (n = 1). CART-BP between early and delayed treatment was 48 hours (P = .04). MEV initiation within 48 hours was independently associated with reduced NCO following analysis by MLR (adusted odds ratio, 0.277; 95% CI, 0.081–0.941). Conclusions Our results support current evidence establishing positive clinical and safety outcomes of MEV in GNIs, including CRE. We suggest that delaying appropriate therapy for CRE significantly increases the risk of NCOs.
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Affiliation(s)
- Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Taylor Morrisette
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Marco R Scipione
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
| | - Jing J Zhao
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
| | - Sarah C J Jorgensen
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ryan Mynatt
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,University of Kentucky, Lexington, Kentucky, USA
| | - Travis J Carlson
- College of Pharmacy, University of Houston, Houston, Texas, USA.,Fred Wilson School of Pharmacy, High Point University, High Point, North Carolina, USA
| | - Jinhee Jo
- College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Kevin W Garey
- College of Pharmacy, University of Houston, Houston, Texas, USA
| | - David Allen
- Department of Pharmacy, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | | | - Ana D Vega
- Jackson Health System, Miami, Florida, USA
| | | | - Veena Venugopalan
- College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Saw
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mathew Miller
- University of Colorado Hospital, Aurora, Colorado, USA
| | - Kyle C Molina
- University of Colorado Hospital, Aurora, Colorado, USA
| | - Michael Veve
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,College of Pharmacy, University of Tennessee, Knoxville, Tennessee, USA.,University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Wesley D Kufel
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York, USA.,State University of New York Update Medical University, Syracuse, New York, USA
| | - Lee Amaya
- Beaumont Hospital, Royal Oak, Michigan, USA.,Miami Cancer Institute, Miami, Florida, USA
| | | | - Jessica Ortwine
- Parkland Health and Health hospital system, Dallas, Texas, USA
| | - Susan L Davis
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA.,Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
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17
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Shabana FS, Sudhakar R, Ravishankar P, Venugopalan V, Satheesh B, Devi R. LOW-GRADE PAPILLARY ADENOCARCINOMA: A RARE ENTITY. Oral Surg Oral Med Oral Pathol Oral Radiol 2021. [DOI: 10.1016/j.oooo.2021.03.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Al-Shaer MH, Rubido E, Cherabuddi K, Venugopalan V, Klinker K, Peloquin C. Early therapeutic monitoring of β-lactams and associated therapy outcomes in critically ill patients. J Antimicrob Chemother 2021; 75:3644-3651. [PMID: 32910809 DOI: 10.1093/jac/dkaa359] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/17/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In the ICU, early and appropriate antimicrobial therapy is important to lower infection-related mortality. OBJECTIVES Assess whether achieving early β-lactam free concentration above the MIC 100% of the time (fT>MIC) is associated with positive outcomes in the ICU. METHODS This retrospective study was conducted in ICU patients admitted to UF Health Shands Hospital between 2016 and 2018. Adult patients who received β-lactam therapy and had drug concentration measured were included. Data collected included demographics, β-lactam regimens and concentrations, sources of infection, cultures and susceptibilities, mortality, length of stay, resistance acquisition for 30 days and clinical outcome at end of therapy. Multiple regression and time-to-event (TTE) analyses were performed. RESULTS Two-hundred and six patients were included. Clinical cure occurred in 71%, microbial eradication occurred in 58% and new resistance to the β-lactam received developed in 8% of patients. Hospital and 30 day mortalities were 17% and 14%, respectively. fT>MIC and fT>4×MIC were associated with clinical cure (P = 0.0303), microbial eradication (P = 0.0476) and suppression of resistance (P = 0.0043). Delay in measuring β-lactam concentration was associated with clinical failure (P = 0.0072), longer ICU stay (P < 0.0001) and higher mortality (P = 0.0387). In the TTE analysis, patients with 100% fT>MIC had a significantly shorter ICU stay (P = 0.0297). Patients who had clinical cure and microbial eradication had drug concentrations measured earlier (P = 0.0025 and 0.0254, respectively). CONCLUSIONS This study highlights the importance of early measurement of β-lactam concentration and confirms the association between fT>MIC and clinical cure, microbial eradication and emergence of resistance.
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Affiliation(s)
- Mohammad H Al-Shaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Eric Rubido
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kenneth Klinker
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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19
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Venugopalan V, Crawford R, Ho K, Garg M, Park H, Premraj S, Klinker K, Cherabuddi K, DeSear K. Resource Over-Utilization in Hospitalized Patients With Uncomplicated Skin and Soft Tissue Infections. J Pharm Pract 2021; 35:675-679. [PMID: 33752488 DOI: 10.1177/08971900211000216] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inpatient management of SSTIs utilizes considerable healthcare resources. The CREST+SEWS score categorizes patients with SSTIs into 4 severity classes. Hospitalizations can be avoided in Class I as they are treated as outpatients with oral antibiotics, whereas Class IV require hospitalization for intravenous antibiotics. OBJECTIVE The purpose of this study was to perform a budget impact analysis on CREST+SEWS Class 1 patients, to compare the medical costs of current treatment, in the inpatient setting with intravenous antibiotics, with a proposed alternative of using oral antibiotics in the outpatient setting. Further, resource utilization in Class I was evaluated. METHODS This was a retrospective study of adult patients hospitalized in 2015 for SSTIs who received >24 hours of antimicrobials. The CREST+SEWS scoring system was used to stratify patients into Class I to IV. Pharmacy and medical costs and resources associated with inpatient management of Class I SSTIs were derived from the itemized discharge records. RESULTS Of the 252 patients who met the inclusion criteria, 61 (24%) were classified as Class I. The total cost of treating Class I SSTI patients in the inpatient setting was $281,816 (cost per patient: $4,619) in 2015 USD. In the hypothetical situation of treatment with oral antibiotics in the outpatient setting, the cost savings were estimated to be $4,398 per patient. Fifty-three percent of patients had blood cultures, and on average, each patient received 2 radiographic tests. CONCLUSIONS Identifying outpatient candidates, and avoiding tests with low diagnostic can reduce the economic burden of SSTIs.
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Affiliation(s)
- Veena Venugopalan
- University of Florida Health Shands Hospital, Fl, USA.,15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Robert Crawford
- 8674Novant Health, Forsyth Medical Center Winston-Salem, NC, USA
| | - Kennedy Ho
- 15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Mahek Garg
- 15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Haesuk Park
- 15505University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Sasha Premraj
- 138492Ascension Sacred Heart Hospital Pensacola, FL, USA
| | | | - Kartikeya Cherabuddi
- University of Florida Health Shands Hospital, Fl, USA.,University of Florida, College of Medicine, FL, USA
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20
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Allen JM, Egelund EF, Santevecchi BA, Venugopalan V, Whalen K, Patel PN. Impact of supplemental individual verbal defense on confidence, engagement, and performance in a team-based learning therapeutics course. Curr Pharm Teach Learn 2021; 13:152-158. [PMID: 33454072 DOI: 10.1016/j.cptl.2020.09.010] [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] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/09/2020] [Accepted: 09/21/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND PURPOSE Team-based learning (TBL) has been successfully applied to multiple healthcare education disciplines. A primary tenet of TBL is the development of solutions leveraging the collective knowledge of a team rather than the individual competency of any one student. In an effort to enhance individual student accountability, an individual verbal defense (IVD) format was implemented in a multi-campus TBL-based pharmacotherapeutics course. The study sought to investigate the use of TBL-IVD embedded within a traditional TBL format on student engagement, teaching style preferences, and exam performance compared to a TBL-only format. EDUCATIONAL ACTIVITY AND SETTING In this cross-sectional study, second-year pharmacy students enrolled in a pharmacotherapeutics course during fall 2019 completed an 11-item survey. The survey was designed to assess TBL-IVD on student engagement and teaching style preference. Free-response qualitative feedback was solicited to assess positive-negative themes related to the activity. Aggregate exam performance for community-acquired pneumonia (CAP) related content was compared to historical exam data to assess the impact on student performance. FINDINGS The majority of students (72%, n = 54) preferred the TBL-IVD compared to a TBL-only format. Students reported higher engagement with TBL-IVD (84%, n = 63). Correct exam responses for CAP related content were higher in the TBL-IVD group (67% vs. 55%, P < .001). Positive themes included an increased opportunity to defend recommendations verbally and increased interaction with an on-campus faculty member. SUMMARY The study demonstrates the addition of IVD can enhance student perceptions, confidence, and performance within a large, multi-campus, TBL-based pharmacotherapeutics course.
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Affiliation(s)
- John M Allen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 6550 Sanger Road, Suite 420G, Orlando, FL 32827, United States; Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL 32827, United States.
| | - Eric F Egelund
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 580 W. 8th Street, Jacksonville, FL 32209, United States.
| | - Barbara A Santevecchi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, United States.
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, United States.
| | - Karen Whalen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, United States.
| | - Priti N Patel
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, United States.
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21
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Boulos JM, DeSear K, Shoulders B, Venugopalan V, Voils SA, Vu C, Logan M, Santevecchi BA. 143. Modification of Linezolid Restriction Criteria Reduces ICU Gram-positive Antibiotic Consumption. Open Forum Infect Dis 2020. [PMCID: PMC7778099 DOI: 10.1093/ofid/ofaa439.453] [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
Antibiotic time out (ATO) policies have been proposed by the Centers for Disease Control and Prevention to limit unnecessary use of antibiotics. Critically ill patients are often treated empirically with MRSA-active agents for a prolonged duration. The objective of this study was to assess the impact of an ATO policy by targeting empiric gram-positive coverage.
Methods
Before this intervention, linezolid required pre-approval by the antimicrobial stewardship program or infectious diseases (ID) consult service before dispensing, and no automatic ATO policy was in place for any agent. In 2018, restriction of linezolid was modified to allow 72 hours of empiric use in the intensive care unit (ICU). This retrospective, single-center, pre- post-intervention study looked at eight ICUs at our institution from two equal periods. Adults (age ≥ 18 years) were included who received an IV gram-positive antibiotic (IVGP-AB), specifically linezolid or vancomycin, used for empiric therapy and were admitted to the ICU. The primary outcome was antimicrobial consumption of IVGP-AB defined as days of therapy (DOT) per patient. Secondary outcomes included in-hospital length of stay (LOS), ICU LOS, in-hospital mortality, 30-day readmission, and incidence of acute kidney injury (AKI).
Figure 1. Flowchart of patient inclusion into the study
Results
2718 patients met criteria for inclusion in the study. 1091 patients were included in the pre-intervention group and 1627 patients were included in the post-intervention group. Baseline characteristics between the two groups were similar, with ID consults being higher in the pre-intervention group. Total mean DOT of IVGP-AB in pre- and- post-intervention groups was 4.97 days vs. 4.36 days, p< 0.01. Secondary outcomes of in-hospital LOS, ICU LOS, and in-hospital mortality did not vary significantly between groups. Thirty-day readmission was lower in the post-intervention group (12.9% vs. 3.9%, p< 0.01). AKI did not differ significantly between groups, however the need for renal replacement therapy was higher in the pre-intervention group (1.2% vs. 0.2%, p< 0.01).
Conclusion
This study assessed the impact of an ATO policy allowing 72 hours of empiric linezolid in the ICU. We found a statistically significant reduction in days of therapy of IVGP-AB without increases in LOS, mortality, readmission, and AKI.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- John M Boulos
- University of Florida Health Shands Hospital, Durham, North Carolina
| | - Kathryn DeSear
- University of Florida Health Shands Hospital, Durham, North Carolina
| | | | | | - Stacy A Voils
- University of Florida College of Pharmacy, Gainesville, Florida
| | - Catherine Vu
- University of Florida Health Shands Hospital, Durham, North Carolina
| | - Megan Logan
- University of Florida Health Shands Hospital, Durham, North Carolina
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22
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Alosaimy S, Lagnf AM, Jorgensen S, Carlson TJ, Jo J, Garey KW, Allen D, Abbo LM, Abbo LM, DeRonde K, Vega A, Venugopalan V, Saw S, Athans V, Claeys KC, Kufel W, Miller M, Veve M, Yost C, Amaya L, Ortwine J, Morrisette T, Davis SL, Davis SL, Rybak MJ. 1575. Predictors of Negative Clinical Outcomes among Patients treated with Meropenem-Vaborbactam for Serious Gram-Negative Bacterial Infections: Impact of Delayed Appropriate Antibiotic Selection. Open Forum Infect Dis 2020. [PMCID: PMC7778041 DOI: 10.1093/ofid/ofaa439.1755] [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: 11/14/2022] Open
Abstract
Abstract
Background
Numerous number of studies have found a positive correlation between delayed appropriate antibiotic therapy and negative clinical outcomes (NCO) in Gram-negative bacterial infections (GNBI). The combination of meropenem with vaborbactam (MVB) received Food and Drug Administration approval for the treatment of complicated urinary tract infections and acute pyelonephritis caused by susceptible organisms in August 2017. We sought to determine the impact of delayed appropriate therapy with MVB on NCO among patients with GNBI.
Methods
Multi-center, retrospective cohort study from October 2017 to March 2020. We included adult patients treated with MVB for >72 hours. We excluded patients who received alternative appropriate antibiotics for GNB prior to MVB and patients with unknown dates for index culture. NCO were defined as 30-day mortality and/or microbiological recurrence. All outcomes were measured from MVB start date. Classification and regression tree analysis (CART) was used to identify the time breakpoint (BP) that delineates the risk of NCO. Multivariable logistic regression analysis (MLR) was used to examine the independent association between the CART-derived-BP and NCO. Variables were retained in the model if P< 0.2 and removed in a backward stepwise approach.
Results
A total of 86 patients were included from 13 institutions in the United States: median(IQR) age 55 (37-67) years, 67% male, and 48% Caucasian. Median(IQR) APACHE II and Charlson Comorbidity index scores were 18(11-26) and 4(2-6), respectively. Common sources of infection were respiratory (37%) and intra-abdominal (21%). The most common pathogens were carbapenem-resistant Enterobacterales (83%). CART-derived BP between early and delayed treatment was 48 hours, where NCO was increased (36% vs.7%; P=0.04). Delayed MVB initiation was independently associated with NCO in the MLR (aOR=7.4, P=0.02).
Results of Regression Analysis of Variables Associated With Negative Clinical Outcomes and Delayed Appropriate Therapy with Meropenem-vaborbactam
Conclusion
Our results suggest that delaying appropriate antibiotic therapy with MVB for >48 hours significantly increases the risk of NCO in patients with GNBI. Clinicians must ensure timely administration of MVB to assure best outcomes in patients with GNBI.
Disclosures
Kevin W. Garey, PharMD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator) Michael J. Rybak, PharmD, MPH, PhD, Paratek (Grant/Research Support)
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Affiliation(s)
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory; Wayne State University, Detroit, Michigan
| | | | | | - Jinhee Jo
- University of Houston, Houston, Texas
| | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX
| | | | - Lilian M Abbo
- University of Miami Miller School of Medicine & Jackson Health System, Miami, Florida
| | - Lilian M Abbo
- University of Miami Miller School of Medicine & Jackson Health System, Miami, Florida
| | | | - Ana Vega
- Jackson Memorial Hospital, Miami, FL
| | | | - Steven Saw
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Michael Veve
- University of Tennessee Medical Center, Knoxville, TN
| | | | | | | | | | - Susan L Davis
- Wayne State University / Henry Ford Hospital, Detroit, Michigan
| | - Susan L Davis
- Wayne State University / Henry Ford Hospital, Detroit, Michigan
| | - Michael J Rybak
- Wayne State University / Detroit Medical Center, Detroit, Michigan
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23
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Vu CH, Venugopalan V, Santevecchi BA, Voils SA, Cherabuddi K, DeSear K. 1576. Re-Evaluation of cefepime or piperacillin-tazobactam to Decrease Use of Carbapenems in ESBL-Producing Enterobacterales BloodStream Infections (REDUCE-BSI). Open Forum Infect Dis 2020. [PMCID: PMC7777247 DOI: 10.1093/ofid/ofaa439.1756] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background The ideal therapy for treatment of bloodstream infections (BSI) due to ESBL-producing organisms is widely debated. Although prior studies have demonstrated efficacy of non-carbapenems (CBPNs) for ESBL infections, results from the MERINO study group found increased mortality associated with piperacillin/tazobactam (PT) when compared with meropenem for treatment of ESBL BSI. The goal of this study was to investigate patient outcomes associated with the use of CBPN-sparing therapies (PT and cefepime (CEF)) for ESBL BSI. The primary outcome was in-hospital mortality between non-CBPN (PT and CEF) and CBPN groups. Secondary outcomes included clinical cure, microbiologic cure, infection recurrence, and development of resistance. Methods This was a retrospective observational study of patients admitted to the hospital from May 2016 - May 2019 with a positive blood culture for an ESBL-producing organism. Patients receiving meropenem, ertapenem, PT, or CEF were included. Patients were excluded if < 18 years old, receiving antibiotics for < 24 hours, treated for a polymicrobial BSI, or receiving concomitant antibiotic therapy for another gram-negative (non-ESBL) infection. Results One hundred and fourteen patients were analyzed; 74 (65%) patients received CBPN therapy compared with 40 (35%) patients that received a non-CBPN (CEF N=30, PT N=10). There were no statistically significant differences in baseline characteristics between groups. The overall in-hospital mortality rate was 6% (N=7). Eight percent of patients (N=6) in the CBPN arm died compared to 3% (N=1) of patients in the non-CBPN arm, P = 0.42. No difference in mortality was detected between groups when evaluating subgroups with Pitt bacteremia score ≥4 (N=25), requiring ICU admission (N=50), non-genitourinary source (N=50), or by causative organism (N=76 E. coli; N=38 Klebsiella spp.). There was no difference between groups for secondary outcomes. Conclusion CEF and PT are reasonable options for the treatment of ESBL BSI and did not result in increased mortality or decreased clinical efficacy when compared to CBPNs in this cohort. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Stacy A Voils
- University of Florida College of Pharmacy, Gainesville, Florida
| | | | - Kathryn DeSear
- University of Florida Health Shands Hospital, Gainesville, Florida
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24
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Venugopalan V, Satheesh G, Balatandayoudham A, Duraimurugan S, Balaji TS. A Comparative Randomized Prospective Clinical Study on Modified Erich Arch Bar with Conventional Erich Arch Bar for Maxillomandibular Fixation. Ann Maxillofac Surg 2020; 10:287-291. [PMID: 33708569 PMCID: PMC7943981 DOI: 10.4103/ams.ams_20_20] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 06/04/2020] [Accepted: 08/20/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Erich arch bar used for maxillomandibular fixation (MMF) since decades has several disadvantages such as risks of injury, additional operating room time, and gingival trauma. To overcome these downsides, modified Erich arch bar was introduced; however, there is not much available literature, indicating the efficacy of modified Erich arch bar over that of conventional arch bar wire. Therefore, the present study focuses on comparing efficiency of modified arch bar with conventional arch bar. Materials and Methods This comparative randomized study was conducted on 32 patients that required MMF and were divided into Group A patients who received intermaxillary fixation (IMF) with modified Erich arch bars and Group B patients with conventional Erich arch bars. The parameters recorded were average surgical time required, wire prick injuries, IMF stability, occlusal stability, screw loosening, oral hygiene status, and vitality response of the teeth. The variables were statistically analyzed using Student's t-test and Wilcoxon signed-rank test. Results The wire prick injury, intraoperative time noted in Group A was significantly reduced in comparison to Group B (P < 0.0001). Debris indices were significantly good in Group A in comparison to Group B (P < 0.0001). Nonvitality response of tooth was significantly more in Group B than in Group A patients (P < 0.05). Discussion The efficiency of modified Erich arch bar group was superior to the conventional arch bar with very limited restrictions.
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Affiliation(s)
- V Venugopalan
- Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry, India
| | - G Satheesh
- Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry, India
| | - A Balatandayoudham
- Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry, India
| | - S Duraimurugan
- Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry, India
| | - T S Balaji
- Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry, India
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25
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Alosaimy S, Jorgensen SCJ, Lagnf AM, Melvin S, Mynatt RP, Carlson TJ, Garey KW, Allen D, Venugopalan V, Veve M, Athans V, Saw S, Yost CN, Davis SL, Rybak MJ. Real-world Multicenter Analysis of Clinical Outcomes and Safety of Meropenem-Vaborbactam in Patients Treated for Serious Gram-Negative Bacterial Infections. Open Forum Infect Dis 2020; 7:ofaa051. [PMID: 32161775 PMCID: PMC7060146 DOI: 10.1093/ofid/ofaa051] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/10/2020] [Indexed: 02/05/2023] Open
Abstract
Fourty patients were treated with meropenem-vaborbactam (MEV) for serious Gram-negative bacterial (GNB) infections. Carbapenem-resistant Enterobacteriaceae (CRE) comprised 80.0% of all GNB infections. Clinical success occurred in 70.0% of patients. Mortality and recurrence at 30 days were 7.5% and 12.5%, respectively. One patient experienced a probable rash due to MEV.
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Affiliation(s)
- Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Sarah C J Jorgensen
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Sarah Melvin
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Ryan P Mynatt
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
| | | | - Kevin W Garey
- College of Pharmacy, University of Houston, Houston, Texas, USA
| | - David Allen
- Department of Pharmacy, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Veena Venugopalan
- College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Michael Veve
- College of Pharmacy, University of Tennessee, Knoxville, Tennessee, USA.,University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Saw
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Susan L Davis
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA.,Division of Infectious Diseases, Department of Medicine, School of Medicine, Wayne State University, Detroit, Michigan, USA
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26
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Bias TE, Vincent WR, Trustman N, Berkowitz LB, Venugopalan V. Impact of an antimicrobial stewardship initiative on time to administration of empirical antibiotic therapy in hospitalized patients with bacteremia. Am J Health Syst Pharm 2019; 74:511-519. [PMID: 28336761 DOI: 10.2146/ajhp160096] [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: 12/21/2022] Open
Abstract
PURPOSE The impact of an antimicrobial stewardship initiative on time to first antibiotic dose and clinical outcomes in bacteremic patients was evaluated. METHODS A single-center, retrospective study was conducted for adult inpatients who received antibiotics before and after implementation of a rapid administration of antimicrobials by an infectious diseases specialist (RAIDS) protocol. Patients admitted to an inpatient service from June to October 2011 (pre-RAIDS protocol) and from December 2011 to February 2012 (post-RAIDS protocol) were eligible for inclusion if (1) they were age 18 years or older, (2) their infection occurred two or more days after hospital admission, and (3) they had a blood culture growing an organism other than common skin contaminants (i.e., coagulase-negative staphylococci, Bacillus species). The primary outcome was the time to the first antibiotic dose (TFAD), defined as the time that elapsed from a positive blood culture result to administration of the first empirical antimicrobial dose. RESULTS A total of 111 bacteremic patients were included in the analysis. Implementation of the RAIDS protocol led to significantly faster antibiotic order entry, verification, and administration of empirical antibiotics in patients with bacteremia. The median TFAD was approximately 8 hours faster in the post-RAIDS group than in the pre-RAIDS group (9:09 hr:min versus 1:23 hr:min, p < 0.001). Patients in the post-RAIDS group had a significant reduction in infection-related mortality (p = 0.047), though all-cause 30-day mortality was similar. CONCLUSION Early notification of an infectious diseases pharmacist about positive blood cultures using the RAIDS protocol led to increased appropriateness of empirical drug selection and a dramatic reduction in the administration of antibiotics and was associated with decreased infection-related mortality.
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Affiliation(s)
- Tiffany E Bias
- Department of Pharmacy, Hahnemann University Hospital, Philadelphia, PA.
| | | | | | | | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL
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27
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Klinker K, Nys C, Venugopalan V, Cherabuddi K. 2425. Clinical and Microbiologic Outcomes Among Patients With Monomicrobial Stenotrophomonas maltophilia Infections. Open Forum Infect Dis 2018. [PMCID: PMC6253602 DOI: 10.1093/ofid/ofy210.2078] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Stenotrophomonas maltophilia is an opportunistic pathogen observed in nosocomial infections. Due to biofilm production and intrinsic resistance to numerous antimicrobials, organism eradication is difficult and morbidity and mortality remain high. Unfortunately, study outcomes are often confounded by co-infecting organisms. Therefore, clinical and microbiologic outcome data for monomicrobial infections is warranted. Methods Single-center, retrospective chart review of adult patients receiving treatment for S. maltophilia between January 2012 and October 2016. Polymicrobial infections and cystic fibrosis patients were excluded. Primary endpoint was clinical cure (CC) at end of therapy. Secondary endpoints included microbiological eradication (ME), 28-day mortality, and resistance selection. An exploratory analysis was performed in patients receiving trimethoprim-sulfamethoxazole (TMP/SMX) or levofloxacin (LVX). Results Seventy-six patients were included in the analysis. The population was 60 years of age, predominantly female (62%) with median APACHE score of 16. Infection onset occurred 6 days after admission with 71% located in the ICU. Approximately 2/third of ICU patients were intubated. Primary site of infection was the lung (92%). Treatment strategies included TMP/SMX (45 patients) or LVX (31 patients). Overall, CC, ME, and 28-day mortality was observed in 79%, 82%, and 14%, respectively. Adverse events were uncommon with three patients receiving TMP/SMX requiring alternate therapy. Comparative analysis revealed similar baseline characteristics except higher APACHE scores (18 vs. 14; P = 0.03) and frequency of mechanical ventilation in the TMP/SMX group (64% vs. 30%; P = 0.007). CC was similar between TMP/SMX and LVX (82% vs. 74%, respectively (P = 0.4)). ME was observed in 84% and 77%, respectively (P = 0.5). Resistance selection to primary treatment was observed in 29% (2/7) and 86% (6/7), respectively (P = 0.1). Conclusion Use of TMP/SMX or LVX for S. maltophilia infections resulted in high CC rates. No differences in primary or secondary outcomes were observed; however, a trend toward resistance selection with LVX was identified. Larger studies assessing outcomes and resistance selection are warranted to further delineate treatment. Disclosures K. Klinker, Melinta Therapeutics: Consultant, Speaker honorarium. Nabriva Therapeutics: Scientific Advisor, Consulting fee.
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Affiliation(s)
- Kenneth Klinker
- UF Health Shands Hospital, University of Florida College of Pharmacy, Gainesville, Florida
| | - Cara Nys
- University of Florida College of Pharmacy, Gainesville, Florida
| | - Veena Venugopalan
- UF Health Shands Hospital, University of Florida College of Pharmacy, Gainesville, Florida
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Venugopalan V, Manigaba K, Borgert SJ, Cope J, Peloquin CA, Klinker KP. Training a Drug to Do New Tricks: Insights on Stability of Meropenem Administered as a Continuous Infusion. Microbiol Insights 2018; 11:1178636118804549. [PMID: 30349291 PMCID: PMC6194917 DOI: 10.1177/1178636118804549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 08/09/2018] [Accepted: 09/07/2018] [Indexed: 11/17/2022] Open
Abstract
Background The antibiotic armamentarium used to combat multi-drug resistant organisms (MDROs) include carbapenems. Continuous infusion (CI) dosing is frequently employed to maximize beta-lactam efficacy; however, use of meropenem CI has been limited due to concerns with product instability. Objective The primary objective of this study was to quantify meropenem serum concentrations to reflect drug stability when administered as CI over 8- or 12-h exchanges. In addition, a stability experiment was performed to further establish meropenem integrity over 12 h. The secondary objectives were to assess the ability of meropenem to achieve target pharmacokinetic/pharmacodynamic (PK/PD) exposures relative to the minimum inhibitory concentration (MIC) of the pathogen, and to determine clinical cure. Methods This was a retrospective, observational study on use of CI meropenem (infused either over 8- or 12- h) at a 1% concentration. The stability experiment was conducted on 1% meropenem at room temperature. Results In 22 patients, a median meropenem daily dose of 6 g/day (range 2-6 g/day) resulted in a median serum concentration of 17.8 mg/L (interquartile range, 9.3-27.8 mg/L). In 95% of cases, meropenem delivered as CI resulted in free drug concentrations at or above the MIC of the pathogen for the entire dosing interval. Clinical cure was achieved in 80% of patients included in this review. The stability experiment revealed negligible drug degradation at the end of the 12-h dosing interval. Conclusions The data from this study provides compelling evidence for the use of meropenem as CI utilizing either a 12- or 8-h exchange process.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kayihura Manigaba
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Samuel J Borgert
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Jessica Cope
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kenneth P Klinker
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
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McKamey L, Venugopalan V, Cherabuddi K, Borgert S, Voils S, Shah K, Klinker KP. Assessing antimicrobial stewardship initiatives: Clinical evaluation of cefepime or piperacillin/tazobactam in patients with bloodstream infections secondary to AmpC-producing organisms. Int J Antimicrob Agents 2018; 52:719-723. [PMID: 30125680 DOI: 10.1016/j.ijantimicag.2018.08.007] [Citation(s) in RCA: 9] [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] [Received: 02/26/2018] [Revised: 05/30/2018] [Accepted: 08/12/2018] [Indexed: 12/19/2022]
Abstract
Management of micro-organisms harbouring AmpC β-lactamases remains challenging. Carbapenems are often considered first-line agents. Due to growing concern regarding carbapenem-resistant Enterobacteriaceae, integrating non-carbapenem treatment strategies is being explored for these pathogens. The primary objective of this study was to evaluate clinical outcomes in patients with bacteraemia secondary to AmpC-producing organisms treated with cefepime or piperacillin/tazobactam (TZP). A retrospective study of adult patients receiving cefepime or TZP for the treatment of AmpC -producing organisms with positive cefoxitin screen (i.e. Citrobacter, Enterobacter or Serratia spp. along with cefoxitin resistance) isolated from blood cultures was conducted. The primary endpoint was clinical cure at end of therapy (EOT). Secondary endpoints included microbiological eradication, frequency of susceptibility changes following treatment, and 7- and 30-day all-cause mortality. Clinical cure at EOT was 87.1%, with 93.2% of patients achieving microbiological eradication. The 7- and 30-day mortality rates were 3.8% and 10.6%, respectively. Organism susceptibility was exceptionally high, with minimum inhibitory concentrations (MICs) of ≤2 μg/mL in 90% of patients treated with cefepime (n = 108). Selection for resistance to third-generation cephalosporins or primary antimicrobial therapy was infrequent at 6.1% (8/132). In conclusion, use of cefepime or TZP for management of AmpC bloodstream infections was associated with clinical and microbiological cure with infrequent selection for resistance.
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Affiliation(s)
- Lacie McKamey
- Clinical Pharmacy Specialist-Infectious Diseases, Novant Health, Charlotte, NC, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, University of Florida College of Medicine, Gainesville, FL, USA
| | - Samuel Borgert
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
| | - Stacy Voils
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, USA
| | - Kairav Shah
- Division of Infectious Diseases, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kenneth P Klinker
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, FL 32610, USA.
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Su CP, Hidayat L, Rahman S, Venugopalan V. Use of an Anti-Infective Medication Review Process at Hospital Discharge to Identify Medication Errors and Optimize Therapy. J Pharm Pract 2018. [PMID: 29534629 DOI: 10.1177/0897190018761411] [Citation(s) in RCA: 3] [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: 11/17/2022]
Abstract
BACKGROUND Medication reconciliation is a major patient safety concern, and the impact of a structured process to evaluate anti-infective agents at hospital discharge warrants further review. OBJECTIVE The aim of this study was to (1) describe a structured, multidisciplinary approach to review anti-infectives at discharge and (2) measure the impact of a stewardship-initiated antimicrobial review process in identifying and preventing anti-infective-related medication errors (MEs) at discharge. METHODS A prospective study to evaluate adult patients discharged on anti-infectives was conducted from October 2013 to May 2014. The antimicrobial stewardship program (ASP) classified interventions on anti-infective regimens into predefined ME categories. RESULTS Forty-five patients who were discharged on 59 anti-infective prescriptions were included in the study. The most common indications for anti-infective regimens at discharge were pneumonia (22%, n = 10), bacteremia (18%, n = 8), and skin and soft tissue infections (16%, n = 7). An ME was identified in 42% (n = 19/45) of anti-infective regimens. Seventy percentage of ASP team recommendations were accepted which resulted in an avoidance of MEs in 68% (n = 13/19) of patients with an ME prior to discharge. CONCLUSION This study describes the outcomes of a stewardship-initiated review process in preventing MEs at discharge. Developing a systematic process for a multidisciplinary ASP team to review all anti-infectives can be a valuable tool in preventing MEs at hospital discharge.
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Affiliation(s)
- Christy P Su
- Department of Pharmacy, Memorial Hermann Greater Heights Hospital, Houston, TX, USA
| | - Levita Hidayat
- Global Health Science, The Medicines Company, Parsipanny, NJ, USA
| | - Shafiqur Rahman
- Division of Infectious Diseases, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
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Klinker K, Venugopalan V, Carnley A, Voils S, Cope J, Cherabuddi K. Impact of an Extended Infusion Β-lactam Strategy on Outcomes in Critically Ill Patients with Pseudomonas Infections. Open Forum Infect Dis 2017. [PMCID: PMC5632209 DOI: 10.1093/ofid/ofx163.689] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pseudomonas aeruginosa (PSA) is frequently associated with nosocomial infections resulting in significant morbidity and mortality. High MICs in MDR strains highlights the need to maximize antibiotic exposure with the goal of improving patient outcomes. For β-lactams, optimal efficacy is achieved when free drug concentrations are above the MIC for ~ 40–60% of the dosing interval. Unfortunately, due to significant pharmacokinetic variability in the critically ill, achieving this target with standard intermittent infusions (II) is challenging, resulting in preference for extended (EI) or continuous infusion strategies. Additional data in patients with PSA infections are needed to understand the association between infusion strategy and clinical outcome. Methods A single-center, retrospective chart review. Adult patients with positive respiratory or blood cultures for PSA treated with cefepime or piperacillin/tazobactam managed in an ICU from January 2012 to May 2016 were included. Primary endpoint was clinical cure (CC) at end of therapy (EOT) between patients receiving EI or II. Secondary endpoints included microbiologic eradication (ME), 28-day mortality, length of ICU and hospital stay, and effect of baseline kidney function on clinical cure. Results Eighty-three patients were included in the analysis. Patient characteristics were well matched except for a higher frequency of malignancy in the EI arm (P = 0.02). CC was achieved in an overwhelming majority of EI patients compared with II (89.2% vs. 69.6%, P = 0.031). Further, patients with normal renal function (CrCL ≥ 60; P = 0.02) or APACHE II ≥ 17 (P = 0.04) receiving II experienced higher failure rates. In multivariate analysis, use of II associated with 4-fold higher incidence of clinical failure (OR 4.5 [1.3–16.3]). For other secondary endpoints, ME was observed in 73% of EI vs. 65% of II (P = 0.44) and 28-day mortality was observed in 13% of patients in both arms (P = 0.94). No significant differences were observed with other secondary variables. Conclusion Use of an EI strategy in critically ill patients with PSA infections improves CC. Further, EI benefitted those patients with normal to augmented renal clearance suggesting that improved exposure may play a role in clinical outcomes. Disclosures K. Klinker, The Medicines Company: Scientific Advisor, Consulting fee.
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Affiliation(s)
- Kenneth Klinker
- University of Florida, College of Pharmacy, Gainesville, Florida
| | - Veena Venugopalan
- UF Health Shands Hospital; University of Florida College of Pharmacy, Gainesville, Florida
| | - Andrea Carnley
- University of Florida, College of Pharmacy, Gainesville, Florida
| | - Stacy Voils
- University of Florida, College of Pharmacy, Gainesville, Florida
| | - Jessica Cope
- University of Florida Shands Hospital, Gainesville, Florida
| | - Kartikeya Cherabuddi
- Infectious Disease and Global Medicine, University of Florida, Gainesville, Florida
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Venugopalan V, Nogid B, Le TN, Rahman SM, Bias TE. Double carbapenem therapy (DCT) for bacteremia due to carbapenem-resistant Klebsiella pneumoniae (CRKP): from test tube to clinical practice. Infect Dis (Lond) 2017; 49:867-870. [PMID: 28695756 DOI: 10.1080/23744235.2017.1350880] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Veena Venugopalan
- a Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmac , Gainesville , FL , USA
| | - Boris Nogid
- b Department of Medical Affairs , Medical Science Liason, Theravance Biopharma, Inc. , South San Francisco , CA , USA
| | - Thy N Le
- c Department of Clinical Pharmacotherapy , Infectious Diseases, The Brooklyn Hospital Center , Brooklyn , NY , USA
| | - Shafiqur M Rahman
- d Division of Infectious Diseases , The Brooklyn Hospital Center , Brooklyn , NY , USA
| | - Tiffany E Bias
- e Department of Pharmacy , Hahnemann University Hospital , Philadelphia , PA , USA
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Bowden J, Venugopalan V, Cherabuddi K, Klinker K. Implementation of a Β-Lactam Therapeutic Drug Monitoring Program. Open Forum Infect Dis 2017. [DOI: 10.1093/ofid/ofx163.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hashem NG, Hidayat L, Berkowitz L, Venugopalan V. Management of skin and soft-tissue infections at a community teaching hospital using a severity-of-illness tool. J Antimicrob Chemother 2016; 71:3268-3275. [PMID: 27494908 DOI: 10.1093/jac/dkw263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/28/2016] [Accepted: 06/01/2016] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Skin and soft-tissue infections (SSTIs) encompass a diverse range of infections of varying severity. The Clinical Resource Efficiency Support Team (CREST) scoring system stratifies patients into four classes (I = least severe to IV = most severe) based on the Standardized Early Warning Score (SEWS). The objective of this study was to apply CREST to hospitalized patients with SSTIs in order to quantify disease severity and evaluate appropriateness of antibiotic management. METHODS This was a retrospective, hypothesis-generating, single-centre evaluation of hospitalized patients with SSTIs admitted in 2011. Based on CREST classification, the empirical antimicrobial choices were categorized as appropriate, over-treatment or under-treatment. RESULTS A total of 369 patients were screened and 200 met the inclusion criteria. The majority of patients were classified as either CREST class I (n = 68) or class II (n = 102). Over-treatment was more common in the less severe classes (88% and 32% in class I and class II, respectively; P < 0.05). Sixty-three percent of class I (n = 43) were over-treated due to both the use of intravenous antibiotics when oral therapy was sufficient and use of unnecessarily broad-spectrum antibiotics. In contrast, 25% (n = 26) of class II were over-treated due to use of unnecessarily broad-spectrum antibiotics. Overall clinical failure rates remained low with only 1%, 4% and 17% of patients unable to achieve initial response in class II, class III and class IV. CONCLUSIONS Retrospective application of CREST identified opportunities to improve the management of SSTIs. CREST can be of great value in discriminating less-severe SSTIs, which can be treated on an outpatient basis.
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Affiliation(s)
| | - Levita Hidayat
- Pharmacy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA.,Touro College of Pharmacy, New York, NY, USA
| | - Leonard Berkowitz
- Internal Medicine Department - Infectious Diseases Subdivision. The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Veena Venugopalan
- Pharmacy Department, The Brooklyn Hospital Center, Brooklyn, NY, USA
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Abstract
PURPOSE Exposure of pharmacy students to postgraduate training prior to clinical practice is currently endorsed by national professional organizations. To meet this goal, colleges and schools of pharmacy are developing residency preparation programs. In this descriptive report, we review published studies of curricular activities and structured programs from academic institutions across the United States aimed at preparing students for residency training and promoting postgraduate education. Additionally, we discuss our experience developing a residency preparation program at Touro College of Pharmacy (TCOP). SUMMARY A literature search yielded 15 residency preparation programs. While the format, content, and length of programs varied, there were common components such as curriculum vitae critique, mock interviews, and focused sessions on the residency application process. At TCOP, a 5-themed residency preparation workshop series was implemented during the third and fourth academic year. The workshops were modeled after existing programs and included several of the core components. One feature unique to the TCOP program was the addition of multiple mock interviews. CONCLUSION The growing focus on residency training has led to increased competition among applicants. To better prepare students for this rigorous application and interview process, development of structured residency preparation programs, similar to TCOP's, should be encouraged.
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Affiliation(s)
- Levita Hidayat
- 1 Global Health Science, The Medicines Company, Parsippany, NJ, USA
| | - Charnicia E Huggins
- 2 Department of Pharmacy Practice, Touro College of Pharmacy, New York, NY, USA.,3 Bronx-Lebanon Hospital Center, Bronx, NY, USA
| | - Veena Venugopalan
- 4 Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Evangelina Berrios-Colon
- 5 Department of Social, Behavioral and Administrative Sciences, Touro College of Pharmacy, New York, NY, USA
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Venugopalan V, Trustman N, Manning N, Hashem N, Berkowitz L, Hidayat L. Administration of a survey to evaluate the attitudes of house staff physicians towards antimicrobial resistance and the antimicrobial stewardship programme at a community teaching hospital. J Glob Antimicrob Resist 2016; 4:21-27. [PMID: 27436388 DOI: 10.1016/j.jgar.2016.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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] [Received: 10/15/2015] [Revised: 01/14/2016] [Accepted: 01/18/2016] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians' perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn Hospital Center (TBHC) and (ii) measure physicians' beliefs and attitudes to the current system of prior authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents significantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P=0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics, only 26% (34/129) agreed that they themselves were contributing to the current problem (P=0.0003). Fifty-seven percent of respondents agreed that individual patient care is improved by having an antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical residents were more likely (33% vs. 13%; P=0.02) to feel that the antibiotic approval programme forced them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the survey, there was no difference in score when stratified by specialty or years of postgraduate training. Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP is valuable for patient care.
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Affiliation(s)
- Veena Venugopalan
- Scripps La Jolla, 9888 Genesee Avenue, La Jolla, CA 92037, USA; The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
| | - Nathan Trustman
- Long Island University, 1 University Plaza, Brooklyn, NY 11201, USA
| | - Nyla Manning
- The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA; SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Nehal Hashem
- The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA; Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
| | - Leonard Berkowitz
- The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
| | - Levita Hidayat
- Touro College of Pharmacy, 230 West 125th Street, New York, NY 10027, USA; The Medicines Company, 8 Sylvan Way, Parsippany, NJ 07054, USA.
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Qatato M, Venugopalan V, Amoah A, Szumska J, Dinter J, Biebermann H, Brix K. Visualising trafficking of trace amine-associated receptors (TAAR) in polarised thyroid epithelial cells. Exp Clin Endocrinol Diabetes 2015. [DOI: 10.1055/s-0035-1547741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hidayat LK, Venugopalan V. Urinary Tract Infections. Prim Care 2015. [DOI: 10.1891/9780826171481.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Venugopalan V, Hidayat LK. Infections. Prim Care 2015. [DOI: 10.1891/9780826171481.0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Szumska J, Qatato M, Venugopalan V, Rehders M, Völker U, Homuth G, Biebermann H, Brix K. Expression and localization of trace amine-associated receptors in thyroid epithelial cells treated with cathepsin B and K inhibitors. Exp Clin Endocrinol Diabetes 2014. [DOI: 10.1055/s-0034-1372164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Qatato M, Amoah A, Szumska J, Venugopalan V, Babusyte A, Dinter J, Krautwurst D, Biebermann H, Brix K. TAAR expression in thyroid epithelial cell lines as to establish an in vitro-model for signalling analysis. Exp Clin Endocrinol Diabetes 2014. [DOI: 10.1055/s-0034-1372100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ma H, Venugopalan V. Time-resolved digital holographic microscopy of laser-induced forward transfer process. Appl Phys B 2014; 114:361-366. [PMID: 24748724 PMCID: PMC3990434 DOI: 10.1007/s00340-013-5524-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
We develop a method for time-resolved digital holographic microscopy to obtain time-resolved 3-D deformation measurements of laser induced forward transfer (LIFT) processes. We demonstrate nanometer axial resolution and nanosecond temporal resolution of our method which is suitable for measuring dynamic morphological changes in LIFT target materials. Such measurements provide insight into the early dynamics of the LIFT process and a means to examine the effect of laser and material parameters on LIFT process dynamics.
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Affiliation(s)
- H Ma
- Department of Chemical Engineering and Materials Science, University of California, 916 Engineering Tower, Irvine, CA 92697-2575, USA ; Laser Microbeam and Medical Program, Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA 92697-1475, USA
| | - V Venugopalan
- Department of Chemical Engineering and Materials Science, University of California, 916 Engineering Tower, Irvine, CA 92697-2575, USA ; Laser Microbeam and Medical Program, Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA 92697-1475, USA ; Department of Biomedical Engineering, University of California, Irvine, CA 92697-2715, USA
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Abstract
Background: Human immunodeficiency virus (HIV) providers are treating more comorbid conditions with additional pharmacologic agents, resulting in patients with HIV being disproportionately at risk for clinically significant drug–drug interactions (CSDDIs). There is a potential to overlook these interactions and ultimately place patients at risk for drug toxicity, resistance, and virologic failure. Objective: To assess the burden of CSDDIs among patients receiving antiretroviral therapy (ART) within 24 hours of admission and to evaluate the effect of a clinical pharmacist operating through an antiretroviral stewardship (ARVSP) program in identifying and correcting potential drug interactions. Methods: Adult HIV-positive patients receiving ART who were admitted to The Brooklyn Hospital Center from November 2010 through January 2012 were included in the analysis. Drug interactions were categorized according to time frame (ie, within 24 hours of admission vs after 24 hours of admission) and type (ie, contraindicated combinations, dosage modifications, and frequency alterations). The Liverpool HIV drug reference, Micromedex drug database, and the Department of Health and Human Services Guidelines were used as comprehensive tools for identification of antiretroviral drug errors. Results: Eighty-four CSDDIs were identified from 252 admissions among 158 patients receiving ART during the study period. Of the identified CSDDIs, 61 (73%) occurred within 24 hours of admission and 23 (27%) later in the hospital course. Forty-eight drug interactions (57%) represented contraindicated drug combinations. Protease inhibitor–based regimens were associated with the highest percentage of CSDDIs (98%). Of all CSDDIs, the most common interacting drug class was acid-suppressive therapy (63%). Clinical pharmacists identified and intervened in 80% of the CSDDIs that occurred on patient admission with all interventions accepted. Conclusions: CSDDIs are common among patients receiving ART at the time of admission and throughout the hospital course. Interventions including medication review by clinical pharmacists are critical in the prevention of CSDDIs on admission.
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Affiliation(s)
| | | | | | - Agnes Cha
- The Brooklyn Hospital Center, Brooklyn, NY, USA
- Long Island University, Brooklyn, NY, USA
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Bias TE, Davanos E, Rahman SM, Venugopalan V. Impact of Gastric Acidity on the Acquisition of Cholera Post Gastric Bypass. Bariatr Surg Pract Patient Care 2013. [DOI: 10.1089/bari.2013.9977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tiffany E. Bias
- Department of Pharmacy, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Evangelia Davanos
- Department of Clinical Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, New York
| | - Shafiqur M. Rahman
- Division of Infectious Diseases, The Brooklyn Hospital Center, Brooklyn, New York
| | - Veena Venugopalan
- Department of Clinical Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, New York
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Arita Y, Antkowiak M, Venugopalan V, Gunn-Moore FJ, Dholakia K. Dynamics of primary and secondary microbubbles created by laser-induced breakdown of an optically trapped nanoparticle. Phys Rev E Stat Nonlin Soft Matter Phys 2012; 85:016319. [PMID: 22400669 PMCID: PMC3509749 DOI: 10.1103/physreve.85.016319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Indexed: 05/30/2023]
Abstract
Laser-induced breakdown of an optically trapped nanoparticle is a unique system for studying cavitation dynamics. It offers additional degrees of freedom, namely the nanoparticle material, its size, and the relative position between the laser focus and the center of the optically trapped nanoparticle. We quantify the spatial and temporal dynamics of the cavitation and secondary bubbles created in this system and use hydrodynamic modeling to quantify the observed dynamic shear stress of the expanding bubble. In the final stage of bubble collapse, we visualize the formation of multiple submicrometer secondary bubbles around the toroidal bubble on the substrate. We show that the pattern of the secondary bubbles typically has its circular symmetry broken along an axis whose unique angle rotates over time. This is a result of vorticity along the jet towards the boundary upon bubble collapse near solid boundaries.
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Affiliation(s)
- Y. Arita
- SUPA, School of Physics and Astronomy, University of St Andrews, St Andrews, Fife, KY16 9SS, United Kingdom
| | - M. Antkowiak
- SUPA, School of Physics and Astronomy, University of St Andrews, St Andrews, Fife, KY16 9SS, United Kingdom
- SULSA, School of Biology, Medical and Biological Sciences Building, North Haugh, University of St Andrews, St Andrews, Fife, KY16 9TF, United Kingdom
| | - V. Venugopalan
- Department of Chemical Engineering and Materials Science, University of California, Irvine, California 92697-2575, USA
- Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, California 92612-3010, USA
| | - F. J. Gunn-Moore
- SULSA, School of Biology, Medical and Biological Sciences Building, North Haugh, University of St Andrews, St Andrews, Fife, KY16 9TF, United Kingdom
| | - K. Dholakia
- SUPA, School of Physics and Astronomy, University of St Andrews, St Andrews, Fife, KY16 9SS, United Kingdom
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Abstract
Depending on intended use of a probiotic (drug vs. dietary supplement), regulatory requirements differ greatly. For dietary supplements, premarketing demonstration of safety and efficacy and approval by the Food and Drug Administration are not required; only premarket notification is required. Saccharomyces boulardii is a probiotic regulated as a dietary supplement intended for use by the general healthy population, not as a drug to prevent, treat, or mitigate disease. However, since recent increases in incidence and severity of Clostridium difficile infection, probiotics have been used to treat recurrent and/or refractory disease in hospitalized patients. Saccharomyces fungemia secondary to use of the probiotic has been described for patients who are critically ill, are receiving nutrition enterally, or have a central venous catheter. Before use of a probiotic is considered for hospitalized patients, careful assessment of risk versus benefit must be made. To ensure patient safety, probiotics should be properly handled during administration.
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Affiliation(s)
- Veena Venugopalan
- University of Southern California, Los Angeles, California 90033, USA
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Venugopalan V, Thornton AC, Steinke DT, Rapp RP, Romanelli F, Feola DJ. Trimethoprim-sulfamethoxazole exposure alters ex vivo function of B lymphocytes isolated from human immunodeficiency virus-infected patients receiving Zidovudine. Pharmacotherapy 2009; 29:373-82. [PMID: 19323617 DOI: 10.1592/phco.29.4.373] [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: 01/23/2023]
Abstract
STUDY OBJECTIVE To determine if exposure to trimethoprim-sulfamethoxazole (TMP-SMX) causes a defect in peripheral B-cell function among patients with the human immunodeficiency virus (HIV) who are receiving zidovudine antiretroviral therapy. DESIGN Prospective, single-center, single-group, case-crossover design with a 4-week exposure period. SETTING University-affiliated infectious diseases outpatient clinic. PATIENTS Fourteen HIV-infected adult men receiving zidovudine, who had CD4(+) cell counts above 350 cells/mm(3) and undetectable viral loads. INTERVENTION Patients were administered a 28-day course of TMP 160 mg-SMX 800 mg/day (one double-strength tablet/day). Peripheral blood mononuclear cells (PBMCs) were obtained and isolated before and after exposure to TMP-SMX. Cells were cultured ex vivo with three mitogens of differing immunologic properties: pokeweed mitogen ([PWM] T-cell-dependent B-cell mitogen), Staphylococcus aureus Cowan ([SAC] T-cell-independent B-cell mitogen), and phytohemagglutinin A ([PHA] T-cell mitogen). Functionality of the B and T lymphocytes was then assessed. MEASUREMENTS AND MAIN RESULTS Proliferative capacity, cytokine secretion, and antibody production were measured and compared before and after TMP-SMX exposure. Reduced proliferative capacities of both PBMC and B cells stimulated with mitogens were observed at the 3-day culture time point in response to PWM, PHA, and SAC (p=0.029, 0.028, and 0.026, respectively). Proliferative capacity at day 7 of culture was not significantly different for any condition examined. Cytokine production was not altered by combination drug exposure after 10 days of culture when cells were stimulated with either PWM or PHA. Although antibody responses to PWM and PHA were similar, total immunoglobulin G concentration was lower in cells stimulated with SAC in samples obtained after TMP-SMX regimen completion compared with those obtained before exposure (p=0.005). CONCLUSION Although these data were affected by limitations in power and study design, they suggest that peripheral B-lymphocyte function is altered as a result of TMP-SMX exposure in HIV-infected patients concurrently receiving zidovudine. Further study of this effect is warranted.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacy Practice, University of Kentucky Chandler Medical Center, Lexington, Kentucky, USA
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Abstract
We demonstrate a method using a spatial light modulator (SLM) to generate arbitrary 2-D spatial configurations of laser induced cavitation bubbles. The SLM acts as a phase hologram that controls the light distribution in the focal plane of a microscope objective. We generate cavitation bubbles over an area of 380 x 380 microm(2) with a 20x microscope objective through absorption of the pulsed laser light in a liquid ink solution. We demonstrate the ability to accurately position up to 34 micrometer sized bubbles using laser energies of 56 microJ.
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Affiliation(s)
- P. A. Quinto-Su
- Nanyang Technological University, School of Physical and Mathematical Sciences, Department of Physics and Applied Physics, 21 Nayang Link, Singapore
| | - V. Venugopalan
- Department of Chemical Engineering & Materials Science and Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, Irvine, CA 92697-2575
| | - C. D. Ohl
- Nanyang Technological University, School of Physical and Mathematical Sciences, Department of Physics and Applied Physics, 21 Nayang Link, Singapore
- Corresponding author:
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Venugopalan V, Martin CA. Selecting anti-infective agents for the treatment of bone infections: new anti-infective agents and chronic suppressive therapy. Orthopedics 2007; 30:832-4. [PMID: 17990408 DOI: 10.3928/01477447-20071001-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Veena Venugopalan
- University of Kentucky HealthCare, 800 Rose St, Rm H110, Lexington, KY 40536-0293, USA
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