2687. Extended Infusions of Piperacillin/Tazobactam vs. Cefepime for Empiric Treatment of Neutropenic Fever

Abstract Background In neutropenic patients, a fever may be the only indication of a severe underlying infection. According to the National Comprehensive Cancer Network (NCCN) guidelines, for high-risk patients, monotherapy with an anti-pseudomonal β-lactam agent should be initiated. NCCN states emerging data may support extended or continuous infusions of β-lactam therapies; however, preference is not given for cefepime or piperacillin/tazobactam. The objective of this study was to compare the outcomes of extended infusions of piperacillin/tazobactam vs. cefepime for the empiric treatment of neutropenic fever. Methods This retrospective, single-center cohort study included patients ≥18 years with an absolute neutrophil count (ANC) less than 500 cells/mm3, single oral temperature measurement ≥38.3°C or ≥38°C sustained over 1 hour period and admitted to a bone marrow transplant unit. Patients received extended infusion piperacillin/tazobactam or cefepime as initial antibiotic therapy for at least 48 hours between January 1, 2015 and September 1, 2018. The primary outcome was time to defervescence in hours. Secondary outcomes included time to defervescence and no acetaminophen use within 8 hours, defervescence by 72 hours, hospital length of stay, clinical failure, in-hospital mortality, and acute kidney injury. Results 73 patients were included in this study (36 received piperacillin/tazobactam and 37 received cefepime). The primary outcome of median time to defervescence was 31.8 hours in the piperacillin/tazobactam group and 25 hours in the cefepime group (P = 0.26). Secondary outcomes in the piperacillin/tazobactam group compared with cefepime, respectively included median time to defervescence and no acetaminophen use: 43 vs. 35 hours (P = 0.16), defervescence by 72 hours: 66.7% vs. 91.9% (P = 0.01), median hospital length of stay 28 vs. 22 days (P = 0.04), clinical failure 22.2% vs. 24.3% (P = 0.83), in-hospital mortality 8.3% vs. 2.8% (P = 0.36), rate of acute kidney injury: 50% vs. 24.3% (P = 0.02). Conclusion These findings suggest there is no difference in time to defervescence between extended infusions of piperacillin/tazobactam compared with extended infusions of cefepime for the empiric treatment of neutropenic fever. Disclosures All authors: No reported disclosures.

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Incidence of Acute Kidney Injury in Intermittent Versus Continuous Infusion of Polymyxin B in Hospitalized Patients

Annals of Pharmacotherapy ◽

10.1177/1060028019841898 ◽

2019 ◽

Vol 53 (9) ◽

pp. 886-893 ◽

Cited By ~ 3

Author(s):

Yarelis Alvarado Reyes ◽

Raquel Cruz ◽

Julia Gonzalez ◽

Yeiry Perez ◽

William R. Wolowich

Keyword(s):

Acute Kidney Injury ◽

Hospital Mortality ◽

Continuous Infusion ◽

Kidney Injury ◽

Polymyxin B ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Baseline Serum ◽

Increased Risk ◽

Dosing Strategies

Background: Studies evaluating the risk of developing acute kidney injury (AKI) with different dosing strategies of polymyxin B are limited. Objectives: To compare the incidence of AKI in patients treated with intermittent versus continuous polymyxin B therapy. Secondary objectives included time to onset of AKI, hospital length of stay (LOS), and all-cause hospital mortality. Variables associated with an increased risk of AKI were evaluated. Methods: A retrospective record review was conducted at a single center in Puerto Rico. Adult patients (≥18 years old) treated with polymyxin B (first course) for at least 48 hours from 2013-2015 were evaluated. Patients with a creatinine clearance <10 mL/min and/or on renal replacement were excluded. Results: A total of 69 patients were included: 42 in the continuous infusion and 27 in the intermittent dosing group. Incidence of AKI was not significantly different between the groups (intermittent 41% vs continuous 31%, P = 0.4). No difference was found in the onset of nephrotoxicity, hospital LOS, or all-cause hospital mortality. Variables associated with increased risk of AKI were baseline serum creatinine, age, and intensive care unit admission. Patients with a body mass index (BMI) >25 kg/m2 on polymyxin B via continuous infusion had a significantly higher cumulative incidence of AKI ( P = 0.016). Conclusion and Relevance: No difference in the risk of polymyxin B nephrotoxicity was found between intermittent and continuous infusion administration. Administration of polymyxin B via a continuous infusion may result in a higher risk of AKI in patients with a BMI >25 kg/m2.

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In Nonagenarians, Acute Kidney Injury Predicts In-Hospital Mortality, while Heart Failure Predicts Hospital Length of Stay

PLoS ONE ◽

10.1371/journal.pone.0077929 ◽

2013 ◽

Vol 8 (11) ◽

pp. e77929 ◽

Cited By ~ 8

Author(s):

Chia-Ter Chao ◽

Yu-Feng Lin ◽

Hung-Bin Tsai ◽

Nin-Chieh Hsu ◽

Chia-Lin Tseng ◽

...

Keyword(s):

Heart Failure ◽

Acute Kidney Injury ◽

Length Of Stay ◽

Hospital Mortality ◽

Kidney Injury ◽

Hospital Length ◽

Hospital Length Of Stay

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696. Optimal Duration of Prophylactic Antibiotics in Patients with Cirrhosis and Upper Gastrointestinal Bleeding

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.893 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S449-S449

Author(s):

Kristin C Davis ◽

Lindsay Reulbach ◽

John Schrank ◽

Alex Ewing ◽

Emily Johnson

Keyword(s):

Hospital Mortality ◽

Antibiotic Prophylaxis ◽

Primary Outcome ◽

Hospital Length ◽

Prophylactic Antibiotics ◽

Hospital Length Of Stay ◽

Variceal Hemorrhage ◽

Bacterial Peritonitis ◽

Clostridioides Difficile ◽

Secondary Outcomes

Abstract Background Spontaneous bacterial peritonitis (SBP) is a serious complication of variceal hemorrhage. Guidelines recommend a maximum of seven days of antibiotics after variceal hemorrhage to prevent SBP and reduce rates of rebleeding and mortality. However, studies supporting these guidelines used varied durations of therapy including those with less than seven days. The objective of this study was to determine if less than seven days of antibiotic prophylaxis was noninferior to seven or more days in patients with cirrhosis and variceal hemorrhage. Methods This was a single-center, retrospective cohort conducted from August 2019 to August 2020 including adult patients who received treatment for variceal hemorrhage and antibiotics for prevention of SBP during hospitalization. Patients were excluded if they were diagnosed with non-variceal hemorrhage, received treatment with antibiotics within 72 hours prior to the variceal hemorrhage, or expired or transitioned to end of life care within 48 hours of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes included SBP within the first 30 days after variceal hemorrhage, 30-day mortality, 30-day readmission rate, incidence of rebleeding at seven and 30 days, incidence of Clostridioides difficile infection, and intensive care unit and hospital length of stay. Results 64 patients were included with 45 patients in the less than seven days group and 19 patients in the seven or more days of antibiotic prophylaxis group. In each group, patients were primarily male with a median age of approximately 60 years. There was no difference in the primary outcome of in-hospital mortality between the less than seven days group as compared to the seven or more days group (22.2% vs 0%, p=1). No difference was identified between the less than seven days group as compared to the seven or more days group for any of the secondary outcomes. Conclusion This study identified no difference in patient-centered outcomes when comparing less than seven days of prophylactic antibiotics to seven or more days in patients with variceal hemorrhage. Less than seven days of prophylactic antibiotics may be a reasonable duration for prevention of SBP. Disclosures All Authors: No reported disclosures

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Severe Acute Kidney Injury in Critically Ill Patients with COVID-19 Admitted to ICU: Incidence, Risk Factors, and Outcomes

Journal of Clinical Medicine ◽

10.3390/jcm10061217 ◽

2021 ◽

Vol 10 (6) ◽

pp. 1217

Author(s):

Muriel Ghosn ◽

Nizar Attallah ◽

Mohamed Badr ◽

Khaled Abdallah ◽

Bruno De Oliveira ◽

...

Keyword(s):

Risk Factors ◽

Acute Kidney Injury ◽

Respiratory Failure ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Kidney Injury ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Incidence Risk

Background: Critically ill patients with COVID-19 are prone to develop severe acute kidney injury (AKI), defined as KDIGO (Kidney Disease Improving Global Outcomes) stages 2 or 3. However, data are limited in these patients. We aimed to report the incidence, risk factors, and prognostic impact of severe AKI in critically ill patients with COVID-19 admitted to the intensive care unit (ICU) for acute respiratory failure. Methods: A retrospective monocenter study including adult patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection admitted to the ICU for acute respiratory failure. The primary outcome was to identify the incidence and risk factors associated with severe AKI (KDIGO stages 2 or 3). Results: Overall, 110 COVID-19 patients were admitted. Among them, 77 (70%) required invasive mechanical ventilation (IMV), 66 (60%) received vasopressor support, and 9 (8.2%) needed extracorporeal membrane oxygenation (ECMO). Severe AKI occurred in 50 patients (45.4%). In multivariable logistic regression analysis, severe AKI was independently associated with age (odds ratio (OR) = 1.08 (95% CI (confidence interval): 1.03–1.14), p = 0.003), IMV (OR = 33.44 (95% CI: 2.20–507.77), p = 0.011), creatinine level on admission (OR = 1.04 (95% CI: 1.008–1.065), p = 0.012), and ECMO (OR = 11.42 (95% CI: 1.95–66.70), p = 0.007). Inflammatory (interleukin-6, C-reactive protein, and ferritin) or thrombotic (D-dimer and fibrinogen) markers were not associated with severe AKI after adjustment for potential confounders. Severe AKI was independently associated with hospital mortality (OR = 29.73 (95% CI: 4.10–215.77), p = 0.001) and longer hospital length of stay (subhazard ratio = 0.26 (95% CI: 0.14–0.51), p < 0.001). At the time of hospital discharge, 74.1% of patients with severe AKI who were discharged alive from the hospital recovered normal or baseline renal function. Conclusion: Severe AKI was common in critically ill patients with COVID-19 and was not associated with inflammatory or thrombotic markers. Severe AKI was an independent risk factor of hospital mortality and hospital length of stay, and it should be rapidly recognized during SARS-CoV-2 infection.

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Risk of Polymyxin B-induced Acute Kidney Injury in Non-adjusted Dose Versus Adjusted Dose based on Renal Function: a retrospective cohort study

10.1101/2020.11.23.20237479 ◽

2020 ◽

Author(s):

Guanhao Zheng ◽

Shenghui Zhou ◽

Ning Du ◽

Jiaqi Cai ◽

Hao Bai ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Primary Outcome ◽

Kidney Injury ◽

Polymyxin B ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Dosage Group ◽

Microbiological Cure ◽

Adjusted Dose

AbstractBackgroundThis study aimed to observe the difference in risk of polymyxin B-induced acute kidney injury with or without dose adjustment by patients’ renal function.MethodA retrospective cohort analysis was carried out for patients who were treated with polymyxin B in Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from November 2018 to October 2019. Patients were divided into adjusted dosage group and non-adjusted dosage group depended on dosage adjustment with renal function or not. A comparison of acute kidney injury incidence between the two groups was the primary outcome of this research. The secondary outcome included hospital length of stay, microbiological cure, clinical cure, and 30-day mortality.ResultA total of 115 patients met the requirements of this study and were included in the analysis. Thirty-five patients were included in the non-adjusted dosage group and 80 in the adjusted dosage group. Patients from both groups had similar characteristics. The total daily dose of polymyxin B in the Non-adjusted dosage group was significantly higher than the adjusted dosage group (1.98 mg/kg/d vs 1.59 mg/kg/d, P=0.001). For the primary outcome of this research, no significant difference in the incidence of acute kidney injury was observed in these two groups (47.5% vs 37.14%, P=0.304), as well as the secondary outcomes, including hospital length of stay, microbiological cure, clinical cure, 30-day mortality.ConclusionDosing adjustment renally could not lower the risk of polymyxin B-induced acute kidney injury significantly. A non-adjusted dosing strategy of polymyxin B is recommended when patients suffered from various levels of renal impairment.

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Diarrhoea: interventions, consequences and epidemiology in the intensive care unit (DICE-ICU): a protocol for a prospective multicentre cohort study

BMJ Open ◽

10.1136/bmjopen-2018-028237 ◽

2019 ◽

Vol 9 (6) ◽

pp. e028237 ◽

Cited By ~ 3

Author(s):

Joanna C Dionne ◽

Kristen Sullivan ◽

Lawrence Mbuagbaw ◽

Alyson Takaoka ◽

Erick Huaileigh Duan ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Cohort Study ◽

Intensive Care ◽

Hospital Mortality ◽

Critically Ill ◽

Primary Outcome ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Secondary Outcomes

IntroductionDiarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence ofClostridium difficile-associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay.Methods and analysisThis international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System.Ethics and disseminationThe protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research.Lay summaryDiarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.

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562. Tocilizumab for the Treatment of Severe COVID-19: A Retrospective, Multi-Center, Case-Matched Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.756 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S346-S346

Author(s):

Sarah Norman ◽

Sara Jones ◽

David Reeves ◽

Christian Cheatham

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Hospital Mortality ◽

Primary Outcome ◽

Fungal Infections ◽

Hospital Length ◽

Hospitalized Patients ◽

Hospital Length Of Stay ◽

Matched Design ◽

Median Hospital

Abstract Background At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients. Methods This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections. Results The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin > 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer > 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients. Conclusion These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results. Disclosures Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)

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Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.02060221 ◽

2021 ◽

pp. CJN.02060221

Author(s):

Yvelynne Kelly ◽

Kavita Mistry ◽

Salman Ahmed ◽

Shimon Shaykevich ◽

Sonali Desai ◽

...

Keyword(s):

Acute Kidney Injury ◽

Length Of Stay ◽

Kidney Injury ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Controlled Study ◽

Control Group ◽

Inpatient Mortality ◽

Icu Length Of Stay ◽

Kidney Replacement Therapy

Background: Acute kidney injury (AKI) requiring kidney replacement therapy (KRT) is associated with high mortality and utilization. We evaluated the use of an AKI-Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes including mortality, hospital and ICU length of stay. Methods: We conducted a 12-month controlled study in the ICUs of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4-6-week blocks. The primary outcome was risk of inpatient mortality. Pre-specified secondary outcomes included 30-day mortality, 60-day mortality and hospital and ICU length of stay. Generalized estimating equations were used to estimate the impact of the AKI-SCAMP on mortality and length of stay. Results: There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% vs 47% control). AKI-SCAMP use was associated with significantly reduced ICU length of stay (mean 8 (95% CI 8-9) vs 12 (95% CI 10-13) days; p = <0.0001) and hospital length of stay (mean 25 (95% CI 22-29) vs 30 (95% CI 27-34) days; p = 0.02). Patients in the AKI-SCAMP group less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% vs 7%, p=0.003). Conclusions: Use of the AKI-SCAMP tool for AKI-KRT was not significantly associated with inpatient mortality but was associated with reduced ICU and hospital length of stay and use of KRT in cases of physician-perceived treatment futility.

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2669. Evaluation of Post-Operative Acute Kidney Injury with Piperacillin–Tazobactam Combined with Vancomycin for Lung Transplant Prophylaxis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.2347 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S936-S936

Author(s):

Natasha N Pettit ◽

Cynthia T Nguyen ◽

Lisa Potter ◽

Jennifer Pisano

Keyword(s):

Acute Kidney Injury ◽

Antibiotic Prophylaxis ◽

Lung Transplant ◽

Statistical Significance ◽

Prophylactic Antibiotic ◽

Kidney Injury ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Transplant Patients ◽

The Difference

Abstract Background Several studies have identified that the addition of vancomycin (VAN) to piperacillin–tazobactam (PT) is associated with a higher incidence of nephrotoxicity when compared with other antibiotic regimens. Beginning in June 2017, our lung transplant antibiotic prophylaxis regimen was modified from PT monotherapy to VAN and PT. Methods All adult lung transplant patients between January 1, 2015 and November 10, 2018 were included. Patients were excluded if acute kidney injury (AKI) was present prior to transplant. Rates of AKI within 7 days of transplant were compared between those who received prophylaxis with PT and VAN vs. those receiving alternative regimens (AR). Patients receiving less than 1 dose of vancomycin or less than 3 doses PT (less than 24hours) were deemed to be in the alternative regimen group. AKI was defined as either an increase in serum creatinine (SCr) by ≥0.3 mg/dL within 48 hours or increase in SCr to ≥1.5 times baseline (within 7 days post-transplant). Secondary outcomes included duration of initial prophylactic antibiotic regimens, hospital length of stay (LOS), and all-cause inpatient mortality. Results Eighty-six patients were included, 44 (51%) patients received PT/VAN. Baseline characteristics and results shown in Table 1. Of those receiving PT/VAN for prophylaxis, 24 (54%) developed AKI within 7 days of transplant while 15 (36%) of 42 patients receiving AR developed AKI (P = 0.08). Conclusion A larger proportion of patients that received PT/VAN for transplant antibiotic prophylaxis experienced AKI within 7 days. Although the difference did not reach statistical significance, a 19% higher incidence of AKI warrants need for further investigation. Disclosures All authors: No reported disclosures.

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