Implementation of an antibiotic rotation protocol in our SICU resulted in overall improvement in the antibiotic susceptibility profile of gram-negative microorganisms relative to our medical intensive care unit, where such a protocol was not used.
Background Six years after initiating a monthly antibiotic cycling protocol in the surgical intensive care unit (SICU), we retrospectively reviewed antibiogram-derived sensitivities of predominant gram-negative pathogens before and after antibiotic cycling. We also examined susceptibility patterns in the medical intensive care unit (MICU) where antibiotic cycling is not practiced. Materials and methods Antibiotic cycling protocol was implemented in the SICU starting in 2003, with monthly rotation of piperacillin/tazobactam, imipenem/cilastin, and ceftazidime. SICU antibiogram data from positive clinical cultures for years 2000 and 2002 were included in the pre-cycling period, and those from 2004 to 2009 in the cycling period. Results Profiles of SICU pseudomonal isolates before (n=116) and after (n=205) implementing antibiotic cycling showed statistically significant improvements in susceptibility to ceftazidime (66% vs. 81%; p = 0.003) and piperacillin/tazobactam (75% vs. 85%; p = 0.021), while susceptibility to imipenem remained unaltered (70% in each case; p = 0.989). Susceptibility of E. coli isolates to piperacillin/tazobactam improved significantly (46% vs. 83%; p<0.0005), trend analysis showing this improvement to persist over the study period (p = 0.025). Similar findings were not observed in the MICU. Review of 2009 antibiotic prescription practices showed monthly heterogeneity in the SICU and a two-fold higher overall use of piperacillin/tazobactam in the MICU (p<0.0001). Conclusions Six years into antibiotic cycling, we found either steady or improved susceptibilities of clinically relevant gram-negative organisms in the SICU. How much of this effect is from cycling vs. mixing is unknown, but the antibiotic heterogeneity provided by this practice justifies its ongoing use.
Implementation of a closed-loop order-processing system resulted in a significant decrease in order-to-administration times for i.v. antimicrobial therapy.
Background The purpose of this study was to determine if mechanically-ventilated trauma patients with a positive urine drug screen (UDS) for cocaine and/or amphetamines have different opioid analgesic and sedative requirements compared to similar patients with a negative drug screen for these stimulants. Methods This retrospective, single-center cohort study at a tertiary care, academic medical center and level 1 trauma center in the United States, included patients admitted to an adult intensive care unit (ICU) with a diagnosis of trauma between 2009 and 2013, aged 16 years and older with a UDS documented within 24 hours of admission, and mechanically ventilated for greater than 24 hours. The primary endpoint was the daily dose of opioid received during mechanical ventilation, expressed as morphine equivalents, for patients presenting with a positive UDS for cocaine and/or amphetamines as compared to patients with a negative UDS for these stimulants. Secondary endpoints included the daily benzodiazepine dose and median infusion rates of propofol and dexmedetomidine received during mechanical ventilation, duration of mechanical ventilation, ICU and hospital length of stay and in-hospital mortality. Analgesic and sedative goals were similar for the duration of the study period and both intermittent and continuous infusions of opioids and sedatives were administered to achieve these targets, though a standardized approach was not employed. A multivariate logistic regression analysis and a propensity-adjusted model evaluated patient characteristics predictive of a higher median opioid requirement. Results One-hundred and fifty patients were included in the final analysis. In univariate analysis, opioid and sedative requirements were similar for patients presenting with a positive UDS for cocaine and/or amphetamines as compared to patients with a negative UDS for these stimulants. In the multivariate regression analysis, increasing age and Abbreviated Injury Scale – head and neck were associated with decreased daily opioid requirements, (OR 0.95, 95% CI 0.93–0.97) and (OR 0.71, 95% CI 0.65–0.77), respectively, while pre-injury stimulant use was not predictive of opioid requirements (OR 0.88, 95% CI 0.40–1.90). In a propensity-score adjusted model, pre-injury stimulant was similarly not predictive of opioid requirements during mechanical ventilation (OR 0.97, 95% CI 0.44–2.11). Conclusions For trauma patients presenting with acute, pre-injury use of cocaine and/or amphetamines, analgesic and sedative requirements are variable and may not be greater than those patients presenting with a stimulant-negative UDS to achieve desirable pain control and depth of sedation, though this observation should be interpreted cautiously in light of the wide confidence interval observed in the propensity-score adjusted model. Although unexpected, these findings indicate that empirically increasing analgesic and sedative doses based on positive UDS results for these stimulants may not be necessary.
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