The relative clinical efficacy of 4-factor prothrombin complex concentrate (4F-PCC) in oral anticoagulant-associated intracranial hemorrhage is unknown, especially for factor Xa-inhibiting anticoagulants. We report short-term outcomes of patients with oral anticoagulant-associated intracranial hemorrhage on vitamin K antagonists and factor Xa inhibitors who were treated with 4F-PCC. This multicenter, observational study involved patients presenting to the emergency department in nine hospitals in an integrated health care delivery system in Texas between July 2013 and December 2015. Forty-two patients diagnosed with oral anticoagulant-associated intracranial hemorrhage-24 taking a vitamin K antagonist and 14 taking a factor Xa inhibitor-were treated with 4F-PCC as part of usual care. Study patients had similar baseline demographics, with the exception of suspected etiology of hemorrhage. Outcomes of the vitamin K antagonist group were similar to those of the factor Xa inhibitor group, with no significant differences in overall in-hospital mortality (32.1% vs 14.2%, respectively), length of stay, or rates of hemorrhagic expansion, thromboembolism, or discharge to home. In conclusion, this small sample of patients with oral factor Xa inhibitor and vitamin K antagonist-associated intracranial hemorrhage treated with 4F-PCC had similar mortality and neurological outcomes, with no venous thromboembolic events.
BackgroundAcute bacterial skin and skin structure infections (ABSSSIs) are a frequent cause of emergency department (ED) visits. Providers in the ED have many decisions to make during the initial treatment of ABSSSI. There are limited data on the patient factors that influence these provider decisions.MethodsAn anonymous survey was administered to providers at 6 EDs across the United States. The survey presented patient cases with ABSSSIs ≥75 cm2 and escalating clinical scenarios including relapse, controlled diabetes, and sepsis. For each case, participants were queried on their decision for admission vs discharge and antibiotic therapy (intravenous, oral, or both) and to rank the factors that influenced their antibiotic decision.ResultsThe survey was completed by 130 providers. For simple ABSSSI, the majority of providers chose an oral antibiotic and discharged patients home. The presence of recurrence or controlled diabetes resulted in more variation in responses. Thirty-four (40%) and 51 (60%) providers chose intravenous followed by oral antibiotics and discharged the recurrence and diabetes cases, respectively. Presentation with sepsis resulted in initiation with intravenous antibiotics (122, 95.3%) and admission (125, 96.1%) in most responses.ConclusionsVariability in responses to certain patient scenarios suggests opportunities for education of providers in the ED and the development of an ABSSSI clinical pathway to help guide treatment.
BackgroundLimited research has assessed patient preferences for treatment disposition and antibiotic therapy of acute bacterial skin and skin structure infection (ABSSSI) in the emergency department (ED). Understanding patient preference for the treatment of ABSSSI may influence treatment selection and improve satisfaction.MethodsA survey was conducted across 6 US hospital EDs. Patients with ABSSSI completed a baseline survey assessing preferences for antibiotic therapy (intravenous versus oral) and treatment location. A follow-up survey was conducted within 30–40 days after ED discharge to reassess preferences and determine satisfaction with care.ResultsA total of 94 patients completed both baseline and follow-up surveys. Sixty (63.8%) participants had a history of ABSSSI, and 69 (73.4%) were admitted to the hospital. Treatment at home was the most common preference reported on baseline and follow-up surveys. Patients with higher education were 82.2% less likely to prefer treatment in the hospital. Single dose intravenous therapy was the most commonly preferred antibiotic regimen on baseline and follow-up surveys (39.8 and 19.1%, respectively). Median satisfaction scores for care in the ED, hospital, home, and with overall antibiotic therapy were all 8 out of a maximum of 10.ConclusionsIn these patients, the most common preference was for outpatient care and single dose intravenous antibiotics. Patient characteristics including higher education, younger age, and current employment were associated with these preferences. Opportunities exist for improving ABSSSI care and satisfaction rates by engaging patients and offering multiple treatment choices.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3751-0) contains supplementary material, which is available to authorized users.
BackgroundReducing hospital admission and improving transitions of care can lessen the burden of ABSSSIs in EDs and hospitals. Limited research to date has assessed the patient’s preference for ABSSSI treatment. Understanding patient preferences may provide insights that encourage optimal treatment plans and improve satisfaction with their care.MethodsA patient survey was conducted across 5 hospital EDs in the US. After providing informed consent, patients with ABSSSI completed a baseline survey assessing their ABSSSI history and preferences for antibiotic (ABX) therapy [intravenous (IV) vs. oral] and treatment location. Patient characteristics and ensuing treatment details were collected from the medical record after the ED or hospitalization was completed. Descriptive statistics were used for analyses.ResultsSeventy-one patients were enrolled and completed the baseline survey. The mean ± SD age was 50 ± 17 years, 22 (31%) had diabetes, and 47 (66.2%) had a previous ABSSSI. The median (25th-75th quartile) lesion size was 190 (53-613) cm2; 51 (71.8%) presented with cellulitis, an abscess, or both. Fifty-four (76.1%) were admitted to the hospital with a median (25th-75thquartile) length of stay of 4.5 (2-9) days. In the ED, vancomycin (39.4%) and β-lactams (36.6%) were the most common ABX; IV was prescribed in 58/63 (92.1%) patients. Once admitted, 37 (68.5%) and 34 (63%) patients received vancomycin and β-lactams, respectively. When surveyed, 26 (36.6%) patients preferred to receive ABX at home, while 22 (31.0%) chose hospital stay for one or more nights. The most common ABX preference was a single IV dose to complete treatment, selected by 29 (40.8%) patients. The most important ABX factors were efficacy and their doctor’s opinion, then convenience and route of administration; least important were treatment location, adverse events, and cost.ConclusionIn these patients presenting to the ED with ABSSSI, the majority were admitted to the hospital and received IV ABX. Patient preferences for treatment location varied, but many valued therapies that could prevent admission. These data suggest opportunities for improving ABSSSI care by engaging the patient and offering treatment alternatives they may not be aware of.Disclosures K. R. Keyloun, Allergan: Employee, Salary. D. P. Nicolau, Allergan: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. J. L. Kuti, Allergan: Grant Investigator, Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium
Objective: To report on a patient who required increased dosages of warfarin to achieve therapeutic anticoagulation while taking dicloxacillin. Case Summary: A 60-year-old woman was hospitalized for an infected lymphocele and cellulitis. Based on microbiology results, dicloxacillin 500 mg by mouth 4 times daily was initiated to complete 14 days of treatment. Concurrently, a deep vein thrombosis was diagnosed by computed tomography angiography. Enoxaparin 100 mg subcutaneously twice daily and warfarin 5 mg by mouth daily were initiated with an international normalized ratio (INR) goal of 2–3. The patient had a history of a supratherapeutic INR while on warfarin 5 mg daily. Throughout the 20-day hospitalization, her warfarin dose was steadily increased in an attempt to achieve a therapeutic INR. Required doses ranged from 7.5 to 15 mg daily. Two days after discontinuation of dicloxacillin and with administration of a 15-mg warfarin boost, the INR was therapeutic at 2.3. Enoxaparin was discontinued and the patient was discharged on warfarin 7.5 mg daily. Upon clinic follow-up 5 days after discharge, the INR was supratherapeutic at 3.3 and the warfarin dose was decreased. The patient was then lost to follow-up. Discussion: This interaction between warfarin and dicloxacillin has been described in the literature; however, the mechanism responsible remains unknown. In all cases reported, increased warfarin requirements appeared after several days of dicloxacillin therapy and slowly disappeared after dicloxacillin discontinuation. This case differs from previously reported cases because it demonstrates warfarin resistance associated with dicloxacillin and a subsequent new initiation of warfarin therapy. The Naranjo probability scale and the Horn Drug Interaction Probability Scale both rate this interaction as probable. Conclusions: Patients taking dicloxacillin who are initiated on warfarin may require a longer duration of concurrent low-molecular-weight heparin therapy, as well as higher doses of warfarin, and may take longer to achieve a therapeutic INR.
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