A recent study suggested mortality benefits using vitamin C, hydrocortisone, and thiamine combination therapy (triple therapy) in addition to standard care in patients with severe sepsis and septic shock. In order to further evaluate the effects of triple therapy in real-world clinical practice, we conducted a retrospective observational cohort study at an academic tertiary care hospital. A total of 94 patients (47 in triple therapy group and 47 in standard care group) were included in the analysis. Baseline characteristics in both groups were well-matched. No significant difference in the primary outcome, hospital mortality, was seen between triple therapy and standard care groups (40.4% vs. 40.4%; p = 1.000). In addition, there were no significant differences in secondary outcomes, including intensive care unit (ICU) mortality, requirement for renal replacement therapy for acute kidney injury, ICU length of stay, hospital length of stay, and time to vasopressor independence. When compared to standard care, triple therapy did not improve hospital or ICU mortality in patients with septic shock. A randomized controlled trial evaluating the effects of triple therapy is necessary prior to implementing vitamin C, hydrocortisone, and thiamine combination therapy as a standard of care in patients with septic shock.

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Objectives: The objectives of this study were to evaluate the safety and efficacy of insulin dosing of less than 10 units versus 10 units in patients receiving hyperkalemia treatment. Design: Retrospective single-center study. Setting: Emergency department at a large academic medical center in the United States. Patients: Seven hundred adults treated for hyperkalemia with IV regular insulin between April 1, 2013, and September 27, 2018. Interventions: Patients that received less than 10 units of insulin were compared to those that received 10 units of insulin. Measurements and Main Results: Patients treated with less than 10 units had significantly lower frequency of hypoglycemia (11.2% vs 17.6%; p = 0.008). Reduction in serum potassium was significantly more modest in size in patients treated with less than 10 units (mean reduction 0.94 ± 0.71 mMol/L) compared with patients treated with 10 units (mean reduction 1.11 ± 0.8 mMol/L; p = 0.008). There were no statistically significant differences between groups in time to hypoglycemia, nadir serum glucose, severe hypoglycemia (<40 mg/dL), dextrose requirements, use of concurrent agents for hyperkalemia, need for repeat insulin dosing, length of stay, or mortality. Conclusions: Patients treated for hyperkalemia with insulin doses less than 10 units had reduced frequency of hypoglycemia; however, potassium reduction post treatment was more modest in these patients. These findings suggest providers choosing to administer 10 units IV insulin should ensure patients have adequate monitoring for hypoglycemia.

Antimicrobial resistance is a growing threat to public health and an increasingly common problem for acute care physicians to confront. Several novel antibiotics have been approved in the past decade to combat these infections; however, physicians may be unfamiliar with how to appropriately utilize them. The purpose of this review is to evaluate novel antibiotics active against resistant gram-negative bacteria and highlight clinical information regarding their use in the acute care setting. This review focuses on novel antibiotics useful in the treatment of infections caused by resistant gram-negative organisms that may be seen in the acute care setting. These novel antibiotics include ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilistatin/relebactam, cefiderocol, plazomicin, eravacycline, and omadacycline. Acute care physicians should be familiar with these novel antibiotics so they can utilize them appropriately.