Background: Cellulitis is a common cause of hospitalization imposing significant burden on healthcare systems. Treatment disposition is dependent on extent and severity of infection with a range of possibilities from ambulatory to inpatient management. Limited evidence is available, aside from expert opinion, to guide the use of long-acting lipoglycopeptides (LaLGPs) to reduce hospitalizations. Objective: Identify patient-specific risk factors associated with short-stay hospitalizations (<72 hours) for cellulitis to guide development of an emergency department (ED) LaLGP decision algorithm. Methods: Adult patients with cellulitis treated with antibiotic monotherapy were screened. Three cohorts were identified based on length of hospitalization (ED discharge, <72 hours, ≥72 hours). The primary outcome was to identify risk factors associated with short-stay hospitalization. Patients were excluded if they required surgical intervention in the operating room, received polymicrobial therapy, required intensive care unit admission, received cellulitis treatment in the past 30 days, or were treated for multiple infections. Results: A total of 161 patients were analyzed (ED discharge, n = 75; Short-stay, n = 46; and Long-stay, n = 40). Need for incision and drainage (odds ratio [OR] 1.8; 95% confidence interval [CI]: 0.76-2.36), advancing age (OR 1.02; 95% CI 1.00-1.05), or presenting with fever (OR 32.7; 95% CI 5.89-616.5) were associated with short-stay hospitalization compared to ED discharge. Diabetes (OR 3.02, 95% CI 1.31-7.11), presence of purulence (OR 3.86, 95% 1.09-13.79), and history of methicillin-resistant Staphylococcus aureus (MRSA) (OR 4.31, 95% CI 1.08-17.96) were independently associated with long-stay hospitalizations. Conclusion and Relevance: Fever was the only factor independently associated with short-stay hospitalization, compared to patients discharged directly from the ED. Diabetes, purulence, and history of MRSA were associated with longer hospitalizations. Inclusion of these factors in a decision algorithm may help guide use of LaLGPs for cellulitis in the ED, potentially reducing cellulitis hospitalization rates.

Background: Although the SCCM PADIS guidelines suggest fentanyl or hydromorphone infusions for analgesia during mechanical ventilation (MV), few studies compare patient-centered outcomes. Objective: This study evaluated therapeutic outcomes and adverse effects of fentanyl and hydromorphone in MV intensive care unit patients. Methods: This single-center, retrospective cohort study evaluated adult MV patients who were intubated for 1 to 14 days and received either hydromorphone or fentanyl infusion for analgesia, while targeting light sedation. The primary endpoint was 28-day MV-free survival. Select secondary endpoints included cumulative and hourly opioid doses during MV, duration of MV, and time within goal pain and sedation score ranges during MV. Multivariate regression analysis was performed for patients intubated more than 72 hours. Results: A total of 238 patients were included; 144 received fentanyl and 94 received hydromorphone. Baseline characteristics were similar between groups with a median age of 66 years, weight 78 kg, and 33% female. Median 28-day MV-free survival was 22 and 21 days for the fentanyl and hydromorphone groups, respectively ( P = 0.36). Patients given fentanyl received higher cumulative opioid doses, expressed in fentanyl equivalents, during MV compared to hydromorphone-treated patients, 4241 (interquartile range [IQR] 1817-8146) mcg and 2448 (IQR 1012-4926) mcg ( P < 0.001), respectively, and higher hourly average doses, 55 (IQR 39-75) mcg/h and 37 (IQR 29-51) mcg/h ( P < 0.001), respectively. Conclusion and Relevance: There was no difference in 28-day MV-free survival with fentanyl- and hydromorphone-based analgesia, but hydromorphone was associated with lower cumulative and hourly opioid requirements.

Cytomegalovirus (CMV)-specific cell-mediated immunity is important for control of CMV after transplant. Assays exist to measure this, but their place in therapy is unclear, particularly in CMV high-risk recipients, without pretransplant exposure. The objective of this study was to evaluate predictive potential of a positive assay to determine freedom from DNAemia and describe subsequent 3-month CMV outcomes. Adult CMV high-risk kidney and/or pancreas transplant recipients were included if a CMV inSIGHT T Cell Immunity Panel (TCIP, Eurofins Viracor) was ordered and resulted between 1 August, 2019 and 30 July, 2022. Seventy-six patients were included in our study; 49 tested during prophylaxis and 27 during treatment. Most TCIP assays obtained in the prophylaxis cohort were negative (n = 46, 93.9%). Rate of post-TCIP CMV infection was 10.2%. In those tested during treatment, 33.3% were positive and rate of post-TCIP CMV recurrence was 22.2%. The positive predictive value of the assay to successfully predict immunity was 66.7% during both prophylaxis and treatment. There were 4 cases of TCIP predictive failure with progressive CMV replication. At time of replication, 2 patients had concomitant clinical confounders thought to influence immune control of viral replication. All patients had intensification of immunosuppression prior to recurrent replication, but after TCIP was collected. The data obtained from the TCIP are not static, immune control of CMV in latency can change and must be evaluated in clinical context. Timing of TCIP after transplant is significant, and patient-specific factors remain important to assess the likelihood of CMV in each unique patient-specific scenario. A CMV stewardship program can aid in application and interpretation of results.

As patients transition between health care settings, they are at an increased risk of adverse events and medication errors as a result of medication changes and miscommunication. Pharmacists have traditionally provided transitions of care (TOC) services, including patient education, in a face-to-face manner with the goal of reducing medication errors and enhancing patient safety and understanding. However, changes in care delivery models, a burdened health care workforce, and diminishing resources necessitate innovative approaches for the provision of patient education within TOC. Pharmacists should consider novel approaches to expand scope, reduce barriers, and creatively use existing resources to optimize patient education in TOC.

Carbapenem-resistant (Car-R) Pseudomonas aeruginosa is an urgent threat. These isolates may remain susceptible to traditional noncarbapenem antipseudomonal β-lactams, but it is unclear if carbapenem resistance impacts the effectiveness of these agents. The purpose of this study was to compare clinical outcomes in Car-R and cephalosporin-susceptible (Ceph-S) P. aeruginosa pneumonia treated with cefepime versus other susceptible agents. This retrospective cohort study evaluated patients diagnosed with hospital-acquired or ventilator-associated pneumonia who had a respiratory isolate of Car-R Ceph-S P. aeruginosa. Patients were excluded if they had polymicrobial respiratory cultures, other concomitant infections, empyema, death within 3 days of index culture, or received less than 3 days of susceptible therapy. Patients treated with cefepime were compared to other susceptible therapies. The primary endpoint was 30-day in-hospital mortality. Eighty-seven patients were included: cefepime, n = 61; other susceptible therapies, n = 26. There were no differences in 30-day in-hospital mortality between cefepime and other susceptible therapies (19.6% vs. 19.2%, p value = 0.719). In addition, there were no differences between clinical cure rates (cefepime 65.6% vs. other therapies 72 %, p value = 0.47). In multivariate logistic regression, treatment with cefepime (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.11-2.52) was not independently associated with 30-day in-hospital mortality. For the treatment of Car-R Ceph-S P. aeruginosa pneumonia, cefepime showed similar rates of 30-day in-hospital mortality and clinical outcomes when compared to other susceptible therapies. Cefepime may be utilized to conserve novel β-lactam and β-lactamase inhibitors.