Appropriate Indications For Use Research Articles

Appropriateness of proton pump inhibitor therapy in an ambulatory geriatrics clinic: A retrospective cross-sectional analysis.

Proton pump inhibitors are considered potentially inappropriate medications in the geriatric population. The use of proton pump inhibitors by older adults has increased over the past several decades; however, existing literature suggests that only one-third of patients prescribed these medications have a valid indication for use. The aim of this study was to assess the appropriateness of proton pump inhibitor therapy in a population of ambulatory geriatric patients and to determine the impact of an interdisciplinary clinic on their use. This was a retrospective, cross-sectional study of patients referred to an ambulatory geriatrics clinic between October 2017 and March 2021. Participants were eligible for inclusion if they were taking a proton pump inhibitor at the time of clinic admission. Appropriateness of proton pump inhibitor therapy was assessed based on indication and dosing regimen. In total, 280 participants were included. The mean age was 79.6 years (SD 7.7) and 60% were female. Overall, 94 of 280 (33.6%) participants had a documented valid indication for their proton pump inhibitor. The clinic team intervened to reduce the dose or discontinue 76 of 186 (40.8%) inappropriate proton pump inhibitors. Only one-third of proton pump inhibitors used by ambulatory geriatric patients have a documented appropriate indication for use. Given the medical complexity of this population and their vulnerability to adverse effects, the ambulatory geriatric population should be a priority target for proton pump inhibitor deprescribing initiatives.

Contemporary Features and Management of Endocarditis.

Infective endocarditis is a rare but devastating disease. Morbidity and mortality rates have failed to improve despite new technological advances. The disease has evolved over time with new significant populations at risk-most notably those with prosthetic valves or implantable cardiovascular devices. These devices pose new challenges for achieving a timely and accurate diagnosis of infection. While the modified Duke criteria is accepted as the gold standard for diagnosing native valve endocarditis, it has been shown to have significantly inferior sensitivity when it comes to identifying infections related to right-heart endocarditis, prosthetic valves, and indwelling cardiac devices. Additionally, prosthetic valves and cardiovascular implantable electronic devices can exhibit shadowing and artifact, rendering transthoracic echocardiography and transesophageal echocardiography results inconclusive or even normal. Having a keen awareness of the varying clinical presentations, as well as emerging valvular imaging modalities such as F-fluorodeoxyglucose cardiac positron-emission tomography plus computed tomography, promises to improve the evaluation and diagnosis of infective endocarditis. However, indications for appropriate use of these studies and guidance on modern clinical management are still needed.

992: QUALITY IMPROVEMENT PROJECT TO REMOVE UNNECESSARY CENTRAL VENOUS CATHETERS IN THE NON-ICU SETTING

Introduction: Indications for the use of central venous catheters (CL) outside the ICU are limited and prolonged use is associated with CL associated infections (CLABSI). This quality improvement study aimed to reduce the number of unnecessary CLs in the non-ICU setting. Methods: A prospective interventional study was performed between April 4 and July 3, 2022, at a large tertiary care center. Daily chart audits were conducted on all non-ICU adult patients who had a non-tunneled CL to include peripherally inserted central catheters (PICC). Discharged patients, CLs removed prior to audit, duplicate documentation, or inaccurately labeled tunneled lines as non-tunneled were excluded. Predetermined non-ICU indications for CL use were need for hemodialysis (HD), chemotherapy, total parenteral nutrition (TPN), long-term antibiotics (ABX), inotropes, and lack of IV access as a last resort. If the CL met indications, the chart was re-audited at one-week intervals to assess for ongoing need. Otherwise, the primary teams were advised to remove CLs. Descriptive statistics were used for analysis. Results: Of 1093 charts audited, 536 CLs were addressed (male: 60.1%; mean age: 60.7 ±14.5). Locations of insertion were the floors (48.5%), the ICUs (24.6%) and the OR (16.6%). PICC lines constituted 62.1% of all CLs. Indications for CL placement were ABX (24.4%), vasopressors (20.9%), TPN (16.9%), inotropes (16.0%) and HD (12.1%). CL use in 9.9% of patients did not meet indications and were removed after prompting. Of 553 CLs placed in the ICU, 23.9% made it to the floor; 18.9% of these did not meet indications. Our intervention rate decreased in time: 16.2% in the first two weeks vs 6.8% in the last week of the study period. There was no significant change in the number of CLABSIs in the study period (n=2) as compared to the three months prior (n=3) and a similar pre-COVID-19 time period (2019: n=2). All CLABSIs during the study period had appropriate indications for use. Conclusions: Approximately 10% of CLs outside the ICU did not have appropriate indications. A daily audit protocol on the floors reduced CL days. A significant proportion of CLs placed in the ICUs were inappropriately continued and should be removed when its use is no longer indicated. Continued education is essential to reduce inappropriate CL use.

Modern concepts of teeth whitening – a narrative review

Whitening has been known since Biblical times. Nowadays, in the developed world, patients are placing a stronger interest in the aesthetic appearance of their teeth. As a result, public demand for aesthetic dentistry, including tooth whitening, has recently increased. Aesthetics of the teeth is of great importance to many patients.
 The aim is to summarise and discuss the teeth whitening procedure, tools, materials, and methods, as well as its efficacy and safety. In addition, the paper aims to provide full and comprehensive information for dentists and their patients about the merits and perils of whitening.
 Methods. Relevant literature from Scopus published in English was selected using the following search criteria "tooth OR teeth AND whitening OR bleaching" by 2022. In total, there were found 3840 papers. Then, we applied the inclusion and exclusion criteria to the selected scientific papers to choose the relevant ones.
 Results. A comprehensive study of the available information related to means and products for teeth whitening was carried out. Whitening may be accomplished by the physical removal of the stain or a chemical reaction to lighten the tooth colour. The indications for appropriate use of tooth-whitening methods and products depend on the correct diagnosis of the discolouration. When used appropriately, tooth-whitening methods are safe and effective.
 Conclusions. Tooth whitening is a form of dental treatment and should be completed as part of a comprehensive treatment plan developed by a dentist after an oral examination.

Evaluation of proton pump inhibitor administration in hospitalized dogs in a tertiary referral hospital.

BackgroundAlthough proton pump inhibitors (PPIs) are commonly administered to hospitalized dogs, prescribing patterns and appropriateness of use require continued investigation.Hypothesis/ObjectiveDescribe prescription patterns and appropriateness of use associated with PPIs in hospitalized dogs at a single tertiary care facility. We hypothesized that the majority of prescriptions would not comply with current guidelines for the rational use of acid suppressants.AnimalsTwo hundred randomly selected hospitalized dogs.MethodsRetrospective evaluation of the medical records associated with a randomly selected sample of hospitalized dogs that received PPIs between January 2013 and December 2018.ResultsA total of 12 610 dogs were admitted for first‐time hospitalization between January 2013 and December 2018. Forty percent of these dogs (5062/12610) were prescribed a PPI PO or IV. Of the 200 randomly selected records, an adequate indication for use was identified in 27% of dogs (54/200). Of the dogs surviving to discharge, 54% (95/175) were discharged with a PPI and 51.6% (49/95) of those were prescribed an inadequate dose.Conclusions and ImportanceOur findings support other studies in which the majority of PPI prescriptions for hospitalized dogs at a tertiary care hospital lacked an appropriate indication. Furthermore, analysis of the prescribing patterns of dispensed PPIs identified a frequent occurrence of dosages considered inadequate, raising concern for ineffective treatment even with appropriate indications of use. With growing concern of adverse effects associated with PPI and other acid suppressant administration in human and veterinary medicine, rational use of these medications following consensus guidelines should be emphasized and treatment should be reserved for dogs with historical, physical examination, clinicopathologic, and imaging findings supportive of an appropriate indication for use.

EAU-EANM Consensus Statements on the Role of Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography in Patients with Prostate Cancer and with Respect to [177Lu]Lu-PSMA Radioligand Therapy

BackgroundProstate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) is useful for selected clinical indications in patients with prostate cancer (PCa) but it may have broader clinical utility owing to the emergence of lutetium-177-PSMA-617 ([177Lu]Lu-PSMA) therapy. However, robust data regarding the impact of PSMA PET/CT on patient management and treatment are lacking, and in many areas, the role of next-generation imaging has not been defined. ObjectiveTo assess expert opinion on the use of PSMA-based imaging and therapy to develop interim guidance. Design, setting, and participantsA panel of 21 PCa experts from various disciplines received thematic topics and relevant literature. A questionnaire to assess proposed guidance statements regarding PSMA PET/CT and [177Lu]Lu-PSMA therapy was developed for completion remotely in a first e-Delphi round. A subsequent panel discussion was conducted during a 1-d meeting, which included a second Delphi round. Outcome measurements and statistical analysisPanellists voted anonymously on statements using a nine-point Likert scale from 1 = strongly disagree to 9 = strongly agree. Median scores were calculated and consensus was assessed using methods proposed by the Research and Development (RAND) corporation. Results and limitationsStatements were developed to cover the following topics: PSMA PET/CT utility, clinical use, and choice of tracer; patient selection; and management of patients receiving [177Lu]Lu-PSMA for metastatic PCa. Consensus was reached for 33/36 statements. In-group bias is a potential limitation, as some statements were rephrased during discussions at the 1-d meeting. ConclusionsAdoption of PSMA PET/CT as an imaging tool to guide [177Lu]Lu-PSMA therapy should be supported by indications for appropriate use. Patient summaryA panel of experts in prostate cancer reached a consensus for the majority of statements proposed regarding the role of prostate-specific membrane antigen (PSMA)-based imaging and therapy, particularly the use of PSMA-based imaging in patients suitable for [177Lu]Lu-PSMA therapy and the need to perform PSMA-based imaging before considering patients as candidates for this therapy.

Prevalence and appropriateness of indwelling urinary catheters in Japanese hospital wards: a multicenter point prevalence study

BackgroundIndwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals.MethodsThis prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review.ResultsWe assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients.ConclusionThis multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

Proximal Tibia Skeletal Traction: Technique and Indications

Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity orthopaedic injuries. Skeletal traction has proven to be an effective initial means of stabilization in patients with these injuries. Traction may be used for both temporary and definitive treatment in a variety of orthopaedic injuries. With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications. Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons to be proficient not only in their application but also understanding of the appropriate indications for use. Here we present a case example of a patient with a right femur fracture and discuss the technique and indications for placement of proximal tibia skeletal traction.

Technical Report: Durable efficacy of an endoscope-assisted syringo-panventriculoatrial shunt for concurrent hydrocephalus and syrinx

The management of syringomyelia in association with hydrocephalus can be a challenging pathology to treat with durable results. We present a durable treatment of a patient with symptomatic, idiopathic hydrocephalus, Chiari type I malformation, and syringomyelia with an endoscope-assisted placement of a single syringo-panventricular multiperforated shunt catheter via a transfrontal transaqueductal approach with simultaneous endoscopic third ventriculostomy (ETV). We discuss the technical details required for this single-shunt approach to a complex pathology, and indications for appropriate use of this novel approach in experienced hands. The patient rapidly improved radiographically and symptomatically, with a functioning shunt twelve years postoperatively. For surgeons well-versed in endoscopic techniques, this approach can be safe, durable, and obviate the need for an otherwise complex shunting system with multiple catheters, or a more traditional invasive craniovertebral decompression, in a patient with idiopathic hydrocephalus and a syrinx.

Novel Therapies in Acute Myeloid Leukemia.

To provide a comprehensive review of evidence-based data on the newly approved therapeutic agents in acute myeloid leukemia (AML) with regards to appropriate indications for use, efficacy, and safety. Published clinical trials and observational studies. Optimal treatment decisions for AML should be personalized based on individual patients' performance status, disease risk as determined by mutational profile, response status, and prior therapies received. While the treatment options have expanded, several questions remain regarding appropriate patient selection, long-term efficacy and safety of these agents, and sequencing of therapies among available options. Nurses need to be familiar with the peculiarities of the administration regimens of newer AML therapies, adopt formal monitoring strategies for side effects that are unique to these agents, and develop a framework to facilitate timeliness of follow-up and monitoring while on these therapies.

Proper indwelling catheter use to prevent CAUTIs

Proper indwelling catheter use to prevent CAUTIs

Lower-Extremity Skeletal Traction Following Orthopaedic Trauma: Indications, Techniques, and Evidence.

» Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity injuries.» Immobilization of fractures in the pelvis, acetabulum, and proximal part of the femur can be difficult with traditional splinting techniques. Skeletal traction has proved to be an effective alternative means of immobilization in such cases.» Traction may be utilized for both temporary and definitive treatment of a variety of orthopaedic injuries.» With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications.» Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons not only to be proficient in their application but also to understand the appropriate indications for use.

Clinical Utilization of the FilmArray Meningitis/Encephalitis (ME) Multiplex Polymerase Chain Reaction (PCR) Assay.

Objective: To assess the clinical utilization and performance of the FilmArray® Meningitis/Encephalitis (ME) multiplex polymerase chain reaction (PCR) panel in a hospital setting.Background: Rapid diagnosis and treatment of central nervous system (CNS) infections are critical to reduce morbidity and mortality. The ME panel is a Food and Drug Administration (FDA) approved rapid multiplex PCR assay that targets 14 bacteria, viruses, and fungi. Previous studies show an overall agreement of 93–99% between the ME panel and conventional diagnostic testing. However, few studies have evaluated the clinical implementation of the ME assay, which is available for routine use at our institution.Methods: We performed a single center retrospective chart review of inpatients who underwent ME panel testing from August 2016 to May 2017. Clinical, radiologic, and laboratory data were reviewed to determine the clinical significance of results. Indication for lumbar puncture (LP), time to results of the ME panel, and duration of antimicrobial therapy were evaluated.Results: Seven hundred and five inpatients underwent ME testing, of whom 480 (68.1%) had clinical suspicion for CNS infection with 416 (59.0%) receiving empiric antimicrobial treatment for CNS infection. The median time-to-result of the ME panel was 1.5 h (IQR, 1.4–1.7). Overall agreement between the ME panel results and clinico-laboratory assessment was 98.2%. Forty-five patients tested positive by ME, of which 12 (26.6%) were determined likely to be clinically insignificant.Conclusions: Routine availability of the ME panel led to overutilization of diagnostic test ordering, as demonstrated by the fact that over one-third of ME panel tests performed were ordered for patients with little or no suspicion for CNS infection. The median time from LP to ME panel result was 1.5 h (IQR, 1.4–1.7). The ME panel's rapid turn-around time contributed to the overuse of the test. Approximately one-quarter of positive ME results were deemed clinically insignificant, though the impact of these positive results requires additional evaluation. Twenty-four and forty-eight hours after the ME panel resulted, 68 and 25% of patients started on empiric therapy remained on antibiotics, respectively. The median time from diagnosis to discontinuation and/or narrowing of antibiotic coverage was 25.6 h (IQR, 3.6–42.5). Further consideration of the appropriate indications for use of the ME panel in clinical settings is required.

118 Knee Immobilizer Use in the Emergency Department

Assess the prescription of knee immobilizers by emergency department providers. Assess if educational interventions describing appropriate prescription of knee immobilizers changes the prescription patterns of emergency department providers. Knee pain is one of the most common presenting complaints to emergency departments in the United States. Patients are frequently prescribed knee immobilizers despite not meeting adequate criteria (evidence of ligamentous instability, presence of a tibial plateau fracture, patellar fracture, patellar dislocation, acute traumatic joint effusion). Inappropriate use of knee immobilizers pose a risk of muscle atrophy, joint stiffness, increased risk of DVT, and prolonged patient recovery. Many providers are likely unaware of the risks posed by immobilizers and the appropriate indications for use. A retrospective chart review was performed at four different urban academic hospitals in NYC using each institution’s respective electronic medical record system. Each system queried adult and pediatric patient visits in the emergency department in which a knee immobilizer was prescribed and the patient was discharged. Exclusion criteria included patients admitted to the hospital. Chart review was performed from January 1, 2011- December 31, 2012. The intervention arm included lectures describing appropriate indications for knee immobilizer. The lectures were both in person and an online video format given to providers at each academic institution during March-June 2016. There is ongoing chart review from July 1, 2016- June 30, 2017. Chart review from 2011 to 2012 is summarized in Table 1.Tabled 1Table 1. Chart review data from 2011-2012InstitutionKnee Immobilizers PrescribedCorrectly PrescribedInappropriately PrescribedA437210227B1579067C10555535520D856442414 Open table in a new tab Data collection is ongoing; however, there is preliminary data from July 1, 2016 to Dec 31, 2016, summarized in Table 2.Table 2Chart review data from July 1, 2016 to December 31, 2016.InstitutionKnee Immobilizers PrescribedCorrectly PrescribedInappropriately PrescribedA775918B613922C775522D917615 Open table in a new tab Knee immobilizer use in the ED was not indicated in almost 50% of the patients who received them. Data collection is still ongoing for part 2 of the study, but shows a trend toward a decreasing percentage of inappropriately prescribed knee immobilizers.

Prevalence and Appropriateness of Urinary Catheters in Japanese Intensive Care Units: Results From a Multicenter Point Prevalence Study.

Catheter-associated urinary tract infection is a common and costly problem throughout the world. As limited data from Asia exist regarding the prevalence and appropriateness of urinary catheters in critically ill patients, we sought to assess both prevalence and appropriateness of urinary catheters in Japan. Using independent observers, we evaluated the prevalence and clinical necessity of indwelling urinary catheters in 7 Japanese intensive care units. Data were collected on 1289 catheter-days and 1706 patient days in the 7 participating intensive care units between August 2015 and May 2016. Urinary catheter prevalence was 76% (range, 49%-94%). The observers deemed that only 54% of the catheters met an appropriate indication for use (range, 40%-74%). The most common appropriate indications for urinary catheter use were (1) the need for accurate input and output monitoring in critically ill patients; (2) perioperative use; and (3) prolonged immobilization. The use of monitoring accurate input and output in critically ill patients, however, may be overused as bedside nurses used this indication in 27% more patients than the objective observer deemed necessary. Urinary catheters were frequently used in the 7 participating Japanese intensive care units and almost half did not meet an appropriate indication for use. Overusing catheters for monitoring accurate input and output was especially notable. Multimodal interventions may be needed to limit inappropriate urinary catheter use.

Evaluation of XSTAT® and QuickClot® Combat Gauze® in a Swine Model of Lethal Junctional Hemorrhage in Coagulopathic Swine.

Hemorrhage is associated with most potentially survivable deaths on the battlefield. Effective and field-tested products are lacking to treat junctional and noncompressible injuries. XSTAT® is a newly developed, U.S. Food and Drug Administration-approved product designed to treat junctional hemorrhage. The Committee on Tactical Combat Casualty Care has recently approved the product for use as part of its treatment guidelines, but data are lacking to assess its efficacy in different wounding patterns and physiologic states. Dilutional coagulopathy was induced in 19 large (70-90kg), healthy, male swine by replacing 60% of each animal's estimated blood volume with room temperature Hextend ®. After dissection, isolation, and lidocaine incubation, uncontrolled hemorrhage was initiated by transection of both axillary artery and vein. Free bleeding was allowed to proceed for 30 seconds until intervention with either XSTAT or QuickClot® Combat Gauze® (CG) followed by standard backing. Primary outcomes were survival, hemostasis, and blood loss. XSTAT-treated animals achieved hemostasis in less time and remained hemostatic longer than those treated with CG. Less blood was lost during the first 10 minutes after injury in the XSTAT group than the CG group. However, no differences in survival were observed between XSTAT-treated and CG-treated groups. All animals died before the end of the observation period except one in the XSTAT-treated group. XSTAT performed better than CG in this model of junctional hemorrhage in coagulopathic animals. Continued testing and evaluation of XSTAT should be performed to optimize application and determine appropriate indications for use.

Abstract 12577: The Efficacy and Safety of Third Generation P2Y12 Inhibitors in Women versus Men: A Sex-Specific Meta-Analysis

Introduction: Sex-specific differences in the response to antiplatelet therapies have been described. Whether women and men derive comparable efficacy and safety from intensification of antiplatelet therapy with 3rd generation P2Y12 inhibitors is uncertain. Methods: A sex-specific meta-analysis was conducted of phase III or IV randomized trials that examined the efficacy and safety of 3 rd generation P2Y12 inhibitors in patients with CAD, including prasugrel, ticagrelor, and cangrelor. Five trials were included that enrolled a total of 19,536 women and 52,043 men based on published data. MACE was defined as the primary endpoint for each trial (components included CV death and MI for all trials). The safety endpoint was defined as non-CABG major bleeding for each trial. Data used for analyses were obtained from published reports. Results: Administration of a 3 rd generation P2Y12 inhibitor significantly reduced the risk of MACE by 14% in women (HR 0.86, 95% CI 0.77-0.95) and by 17% in men (HR 0.83, 95% CI 0.79-0.88) with no heterogeneity in the magnitude of effect (P interaction =0.66; Figure). The 3 rd generation P2Y12 inhibitors increased the risk of non-CABG major bleeding by 38% in women (HR 1.38, 95% CI 1.05-1.81) and by 50% in men (HR 1.50, 95% CI 1.09-2.07), again without heterogeneity (P interaction = 0.88). Conclusions: In randomized trials, the efficacy and safety of the 3 rd generation P2Y12 inhibitors were comparable between men and women. Since women remain undertreated with guideline-recommended therapies, these data support the administration of 3 rd generation P2Y12 inhibitors in women with appropriate indications for use.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study.

The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice. Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient. The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11). This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

Vancomycin Use in Patients Discharged From the Emergency Department: A Retrospective Observational Cohort Study

BackgroundInfections due to methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant morbidity and mortality and are typically treated with intravenous vancomycin. Given vancomycin's time-dependent mechanism of action, it is unlikely that vancomycin administration in the emergency department (ED) prior to disposition home could be beneficial. Study ObjectivesTo characterize the indications, dosing, and appropriateness of vancomycin use in patients discharged from the ED. MethodsThis is a single-center retrospective observational cohort study of patients who received vancomycin in an urban, academic, tertiary care ED. The subjects were consecutive adult patients administered intravenous vancomycin in the ED and then discharged home over an 18-month period. Outcomes were measured 1) to characterize patients receiving vancomycin prior to discharge home from the ED; and 2) to identify patients that did not meet indications for appropriate use based on the 2011 Infectious Diseases Society of America guidelines for treating MRSA infections. ResultsThere were 526 patients that received vancomycin in the ED prior to discharge during the study period. In this cohort, 368 (70%) patients were diagnosed with skin and soft tissue infections. A MRSA risk factor was present in 396 (75%) patients. Prior to discharge, one dose of vancomycin was administered to 357 (68%) patients. Underdosing of vancomycin occurred in 239 (73%) patients. ConclusionsVancomycin was given frequently to patients discharged home from the ED, most commonly for conditions where vancomycin was not indicated, such as skin and soft tissue infections. The majority of these patients received a vancomycin dosing strategy that is not only unlikely to lead to clinical improvement, but also has the potential to contribute adversely to the development of antibiotic resistance. Further investigation is needed into the impact of vancomycin use, the emergence of vancomycin resistance, and the role of ED-based antibiotic stewardship.

Treatment, Management and Prevention of Catheter-associated Urinary Tract Infection

Catheter-associated urinary tract infection (CAUTI) is the most commonly occurring nosocomial infection worldwide, accounting for approximately 40% of all hospital acquired infections. A lot of hospitalized patients undergo insertion of a urinary catheter at some time during their hospital days, and the use of indwelling urinary catheters appears to be increasing. And 80% of urinary tract infection is related to urinary catheterization. Unfortunately, many physicians don' t know about appropriate indications for use of indwelling urethral catheters as well as accurate criteria of CAUTI. Therefore, these could result in a potential source of CAUTI, leading to unnecessary use of antibiotics for treatment of asympk)matic bacteriuria, inducing of resistant organisms. Most CAUTI are derived from the patient's own colonic flora and the catheter predisposes to UTI in several ways. The most important risk factor for the development of CAUTI is the duration of catheterization. The clinician should be aware of two priorities： the catheter system should remain closed and the duration of catheterization should be minimal. While the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter-associated bacteriuria is not recommended, except for some special cases.