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In the last decade, there has been a dramatic increase in advance practice registered nurses (APRNs) in the acute care setting. In 2017, the Joint Commission issued antimicrobial stewardship (AMS) standards for the acute care setting. The role of the APRNs has not formally been recognized in the guidelines for implementing and operative AMS programs. Regardless, APRNs are increasingly performing essential roles in antibiotic stewardship, and the aim of this review is to describe areas APRNs can impact antibiotics stewardship. Articles that described AMS process were indexed from PubMed. APRNs have expertise in managing and coordinating care for across many clinical conditions and are able to improve the quality of care and improve AMS. The following core competencies are addressed in this article: Medical knowledge, Patient care.

Aim: We sought to correlate pharmacokinetic (PK)/pharmacodynamic (PD) predictions of antibacterial efficacy and clinical outcomes in patients with augmented renal clearance (ARC) and Pseudomonas aeruginosa bacteremia or pneumonia treated with extended infusion cefepime or piperacillin/tazobactam. Materials and Methods: Cefepime (2 g every 8 h) and piperacillin/tazobactam (4.5 g every 8 h) were administered over 4 h after a loading dose infused over 30 min, and minimum inhibitory concentration was determined by E-test. Published population PK evaluations in critically ill patients were used, and PD analyses were conducted using estimated patient-specific PK parameters and known minimum inhibitory concentration values for P. aeruginosa. Concentration–time profiles were generated every 6 min using first-dose drug exposure estimates including a loading infusion, and free concentration above the minimum inhibitory concentration (f T> MIC) was estimated. Clinical cure was defined as resolution of signs and symptoms attributable to P. aeruginosa infection without need for escalation of antimicrobial. Results: One hundred and two patients were included (36 cefepime and 66 piperacillin/tazobactam). The two groups of patients had similar age, serum creatinine, weight, and creatinine clearance. The majority of patients required intensive care unit care (63.9% vs. 63.6%) and most had pneumonia (61%). The f T>MIC (93.6 [69.9–100] vs. 57.2 [47.6–72.4], P Conclusions: Patients with ARC and P. aeruginosa pneumonia and/or bacteremia who received extended-infusion cefepime achieved higher f T>MIC and clinical cure than those receiving extended infusion piperacillin/tazobactam.

Context: Stress ulcer prophylaxis (SUP) has become the standard of care in the intensive care unit (ICU) but is often continued inappropriately at discharge. Aims: The primary aim was to evaluate the impact of granting clinical privileges to assess appropriate discontinuation of SUP in the ICU. Settings and Design: This study was a single-center, retrospective, observational study. Materials and Methods: Patients admitted to medical or surgical ICUs in January 2015 (pregroup) were compared to January 2016 (postgroup). Statistical Analysis Used: Continuous parametric data were analyzed with Student's t-test, continuous nonparametric data were analyzed with Mann–Whitney U-test, and dichotomous variables were analyzed with Fisher's exact method. Results: One hundred and sixty patients were included (80 per group). Over 50% of patients had documented home acid suppression therapy use (52.5% pregroup vs. 58.8% postgroup, P = 0.53) and approximately 30% had gastroesophageal reflux disease documented as a problem in their medical record (27.5% pregroup vs. 31.3% postgroup, P = 0.73). The rate of inappropriate continuation of acid suppression therapy was not different between groups (15.4% vs. 14.9%, P = 0.999). The major reason for appropriate continuation of acid suppressive therapy was the presence of a chronic condition that provided a reasonable indication for therapy (46.1% vs. 60.0%, P = 0.228). Conclusions: Overall we found no difference in continuation of SUP at ICU discharge, but this was confounded by a high rate of reported home acid suppression. Targets for education and improvement have been identified, especially the need for attention to documentation and medication reconciliation across the spectrum of patient care to allow for acid suppression therapy deprescribing. The following core competencies are addressed in this article: Patient care, Systems-based practice

The importance of hyperglycemia in the Intensive Care Unit (ICU) is well established. However, little is known regarding the clinical predictive value of acute hyperglycemic events. This report describes a graphical model that quantifies the correlation between momentum/stochastic indicators, acute hyperglycemia, and clinical events in chronic ICU patients. The model is based on previously described principles of graphical representations of biomedical parameter data. We hypothesize that acute hyperglycemic events are significantly associated with major clinical events and that the model described herein helps to better characterize and quantify this important relationship. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice. Republished with permission from: Stawicki SP, Schuster D, Liu JF, Kamal J, Erdal S, Gerlach AT, Whitmill ML, Lindsey DE, Thomas YM, Murphy C, Steinberg SM. Introducing the glucogram: Description of a novel technique to quantify clinical significance of acute hyperglycemic events. OPUS 12 Scientist. 2009;3:2-5.

PURPOSE: Trauma dogma dictates that the physiologic response to injury is blunted by beta-blockers and other cardiac medications. We sought to determine how the pre-injury cardiac medication profile influences admission physiology and post-injury outcomes. MATERIALS AND METHODS: Trauma patients older than 45 evaluated at our center were retrospectively studied. Pre-injury medication profiles were evaluated for angiotensin-converting enzyme inhibitors / angiotensin receptor blockers (ACE-I/ARB), beta-blockers, calcium channel blockers, amiodarone, or a combination of the above mentioned agents. Multivariable logistic regression or linear regression analyses were used to identify relationships between pre-injury medications, vital signs on presentation, post-injury complications, length of hospital stay, and mortality. RESULTS: Records of 645 patients were reviewed (mean age 62.9 years, Injury Severity Score >10, 23%). Our analysis demonstrated no effect on systolic and diastolic blood pressures from beta-blocker, ACE-I/ARB, calcium channel blocker, and amiodarone use. The triple therapy (combined beta-blocker, calcium channel blocker, and ACE-I/ARB) patient group had significantly lower heart rate than the no cardiac medication group. No other groups were statistically different for heart rate, systolic, and diastolic blood pressure. CONCLUSIONS: Pre-injury use of cardiac medication lowered heart rate in the triple-agent group (beta-blocker, calcium channel blocker, and ACEi/ARB) when compared the no cardiac medication group. While most combinations of cardiac medications do not blunt the hyperdynamic response in trauma cases, patients on combined beta-blocker, calcium channel blocker, and ACE-I/ARB therapy had higher mortality and more in-hospital complications despite only mild attenuation of the hyperdynamic response. Language: en

Background: Obesity is endemic in the United States and obese patients are at increased risk of thromboembolism but little data are available for dosing unfractionated heparin (UFH). We evaluated the relationship between obesity and UFH efficacy during critical illness by examining UFH infusions in non-obese, obese, and morbidly obese critically ill patients. Materials and Methods: Retrospective review of UFH infusions in non-obese, obese, and morbidly obese critically ill patients. Heparin was initiated without a bolus at 16 units/kg/h or 12 units/kg/h in obese and morbidly obese patients. Demographics, UFH dosage/therapy duration, laboratory values, and bleeding events were reviewed for patients receiving UFH for >24 h. Steady state (SS) was defined as the dosage that resulted in three consecutive activated partial thromboplastin times (aPTT) within target range. Results: Sixty-two patients were analyzed including 21 non-obese (mean body mass index (BMI) 24.2 ± 2.3); 21 obese (BMI 34.1 ± 3.1); and 20 morbidly obese (mean BMI 55.3 ± 13.7). Patients had otherwise similar demographics. Although 92% had at least one therapeutic aPTT, only 55% of patients reached SS. Six patients developed minor bleeding, but no major hemorrhagic complications. The dosing of heparin based on actual body weight (units/kg/h) and time to first therapeutic aPTT was similar between groups, but dose was statistically higher at steady state in the non-obese (16.3 ± 5.3 non-obese, 11.6 ± 5.5 obese and 11.1 ± 1.2 obese, P = 0.01) with similar times to steady state. Conclusions: Dosing of UFH in morbidly obese and obese critically ill patients based on actual body weight and a reduced initial dose was associated with similar time to first therapeutic aPTT and steady state.

Background : Aminoglycosides are commonly used antibiotics in the intensive care unit (ICU), but are associated with nephrotoxicity. This study evaluated the development of aminoglycoside-associated nephrotoxicity (AAN) in a single surgical intensive care unit. Materials and Methods : Adult patients in our surgical ICU who received more than two doses of aminoglycosides were retrospectively reviewed for demographics, serum creatinine, receipt of nephrotoxins [angiotensin converting enzyme (ACE) inhibitors, angiotensin-II receptor blockers, diuretics, non-steroidal anti-inflammatory drugs, cyclosporine, tacrolimus, vasopressors, vancomycin and intravenous iodinated contrast] and the need for dialysis. AAN was defined as an increase in serum creatinine >0.5 mg/dL on at least 2 consecutive days. Univariate and multiple regression analyses were performed. Results : Sixty-one patients (43 males) receiving aminoglycoside were evaluated. Mean age, weight, initial serum creatinine, and duration of aminoglycoside therapy were 58.7 (±15) years, 83.3 (±24.4) kg, 0.9 (±0.5) mg/dL, and 4 (±2.3) days, respectively. Thirty-one (51%) aminoglycoside recipients also received additional nephrotoxins. Seven aminoglycoside recipients (11.5%) developed AAN, four of whom required dialysis and all had received additional nephrotoxins. Only concurrent use of vasopressors (P = 0.041) and vancomycin (P = 0.002) were statistically associated with AAN. Receipt of vasopressors or vancomycin were independent predictors of acute kidney insufficiency (AKI) with odds ratios of 19.9 (95% CI: 1.6-245, P = 0.019) and 49.8 (95% CI: 4.1-602, P = 0.002), respectively. Four patients (6.6%) required dialysis. Conclusions : In critically ill surgical patients receiving aminoglycosides, AAN occurred in 11.5% of the patients. Concurrent use of aminoglycosides with other nephrotoxins increased the risk of AAN.