BackgroundAcute kidney injury (AKI) remains a treatment-limiting toxicity of colistin. Recently developed clinical practice guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) group have harmonized definitions of AKI, but have not been widely applied to patients receiving colistin.MethodsWe retrospectively defined AKI by KDIGO definitions among adult patients receiving intravenous colistin for ≥ 3 days. Risk factors for AKI within 48 hours and 7 days of initiating colistin were determined by multivariable logistic regression.ResultsAmong 249 patients treated with colistin, rates of AKI were 12% and 29% at 48 hours and 7 days, respectively. At 48 hours, patients in the intensive care unit were at increased risk for AKI. Within 7 days, colistin daily doses >5mg/kg, chronic liver disease, and concomitant vancomycin were independent predictors. Seven percent of patients required renal replacement therapy at a median of 5 days (range: 3–7) following colistin initiation.ConclusionSafe use of colistin is promoted by early detection of AKI with KDIGO criteria, avoiding nephrotoxins, and limiting duration of therapy.
Antimicrobial overuse and multidrug‐resistant pathogens are growing problems throughout the United States, yet most counties in the United States lack access to infectious diseases (ID) expertise. Developing an effective antimicrobial stewardship program (ASP) is challenging for many health care institutions, especially rural, community, and critical access hospitals with limited access to specialty care. Pharmacists are instrumental for the success of ASPs and pharmacy expertise is a requirement to meet federal ASP standards. Antimicrobial stewardship guidelines suggest telehealth consultation as an acceptable alternative to in‐person availability of an ID physician‐pharmacist team and encourage facilities to consider creative solutions for optimizing antimicrobial use. As a result, an understanding of successful telemedicine and tele‐ASP (TASP) models as a sustainable option is crucial. Data on existing TASP models, the role of clinical pharmacy services in TASPs, and future directions are herein described. Existing data on TASP are organized into three main categories of fully remote, integrated, or collaborative TASP models. TASPs may be led by remote ID physicians and/or ID‐trained clinical pharmacists within an affiliated health system or from an unaffiliated private practice, health system, or private telehealth entity. The on‐site stewardship pharmacist champion has a vital role in the success of many of the TASP models described by building trusting relationships with prescribers and key stakeholders, facilitating uptake of interventions and acceptance of the TASP, and ensuring timely therapy changes for patients. Future targets for TASP research should include TASP efforts in critical access hospitals and nonacute settings, the specific role of technology and clinical decision support software tools in TASP to improve and enhance pharmacist impact, and further descriptions of TASP models that improve patient‐centered outcomes.
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