Rech, Megan A.

Abstract Skin and soft tissues infections (SSTIs) are common conditions, affecting millions worldwide. SSTIs range from uncomplicated cellulitis to necrotizing fasciitis and can be divided into non-purulent and purulent forms. Non-purulent SSTI is most commonly associated with beta-haemolytic streptococci, while purulent SSTI is typically associated with Staphylococcus aureus . Cellulitis most commonly presents with acute warmth, pain, tenderness to palpation, erythema, and oedema. Skin abscess typically presents with a fluctuant tender area with erythema. Laboratory testing is of limited use in most patients. Point-of-care ultrasound is useful for distinguishing cellulitis from abscess if the diagnosis is unclear. Management of SSTI includes antibiotics such as penicillin VK, dicloxacillin, or a cephalosporin, while treatment for skin abscess includes incision and drainage, with antibiotics recommended in select patients. Patients should elevate the affected extremity when possible, and non-steroidal anti-inflammatory drugs may reduce pain and inflammation. The effectiveness of decolonization for patients with recurrent cellulitis or skin abscess is controversial. While most patients with cellulitis or skin abscess are appropriate for discharge with follow-up, patients with sepsis and those with challenges adhering to therapy, immunosuppression, or failed outpatient therapy should be referred to the emergency department. Novel antibiotics such as tedizolid, delafloxacin, omadacycline, and ceftaroline may be considered in select cases.

ABSTRACT Clinical pharmacists are increasingly recognized as vital contributors to acute stroke care, yet their role remains inconsistently defined and underutilized across health care systems. This consensus statement explores the expanding presence of clinical pharmacists within interdisciplinary stroke teams, particularly in the management of both acute ischemic stroke ( AIS ) and hemorrhagic stroke. This consensus statement panel was composed of clinical pharmacists, emergency medicine physicians, and a vascular neurologist. The Grading of Recommendations, Assessment, Development, and Evaluation ( GRADE ) approach was used to assess the level of certainty and strength of recommendations. We focused on two questions regarding the clinical pharmacist's role in caring for adult patients presenting to the emergency department ( ED ) with AIS or hemorrhagic stroke. Despite the very low level of evidence, a consensus was reached for the following recommendations: (1) clinical pharmacist involvement in AIS care for adult patients presenting to the ED and (2) clinical pharmacist involvement in hemorrhagic stroke care for adult patients presenting to the ED . Based on the available literature, we believe optimizing the clinical pharmacist role is a critical factor in improving time‐sensitive treatment and equity in care delivery.

ABSTRACT Inpatient, acute care clinical pharmacists have contributed to many notable improvements in patient outcomes. Several studies have shown a reduction in mortality and other clinical markers when pharmacists are integrated within the care team. Economic analyses of inpatient clinical pharmacy services (CPS) generally demonstrate cost savings related to specific medication classes, prevention of adverse drug events, decreased length of stay, and decreased rehospitalization. Studies also show high satisfaction from other health care professionals, noting improvements in medication‐related patient safety. Finally, studies conducted in tertiary care hospital settings report high levels of patient satisfaction with CPS. As such, the ECHO framework, based on economic, clinical, and humanistic outcomes, is used herein to organize the summary of literature associated with CPS. Given the growing body of evidence, numerous health professional and government organizations recognize the role of pharmacists as an integral part of the inpatient team. Yet implementation of CPS has not been fully realized by hospitals and health systems. This paper briefly describes inpatient CPS, highlights many benefits of and endorsements for clinical pharmacist participation on interdisciplinary teams, and provides high‐level recommendations for health system administrators and the profession of pharmacy to further encourage broader integration of CPS into patient care teams. Effectively positioning inpatient clinical pharmacists as indispensable team members will require intentional work and strategic planning with a focus on high‐impact value, visibility, and leadership.

ABSTRACT Background Intracranial and extracranial hemorrhages are significant causes of morbidity and mortality. Emergency medicine pharmacists (EMPs) can play a crucial role in anticoagulation reversal by identifying patients on anticoagulation, selecting the optimal anticoagulation reversal agent, and ensuring adequate dosing and prompt administration. The goal of this systematic review and meta‐analysis was to determine the impact EMPs have on time to anticoagulation reversal and patient outcomes in anticoagulation‐associated hemorrhages. Methods A medical librarian performed a literature search in EBSCO CINAHL, Ovid Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection from inception to January 2025 for all types of oral anticoagulants and for life‐threatening bleeding that required emergent reversal. Newcastle‐Ottawa was used to assess the risk of bias, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the level of certainty of the evidence. Random effects models estimating mean differences and 95% confidence intervals are reported. Results There were 2445 titles and abstracts screened, with 44 undergoing full‐text evaluation. Six observational studies including 219 patients who received an anticoagulation reversal agent with the presence of an EMP and 198 patients who received a reversal agent without an EMP were included. Time from emergency department (ED) presentation to anticoagulation reversal agent administration (75.60 min, 95% confidence interval [CI]: −101.7 to −49.5) and time from medication order to administration were faster with an EMP (−18.7 min, 95% CI: −23.5 to −14.0). There was no difference in short‐term mortality. The included studies had a high risk of bias and were deemed very low quality of evidence. Conclusion EMP involvement in patient care during anticoagulation reversal of acute hemorrhages improved time to anticoagulation reversal agent administration. Larger scale, higher‐quality studies are necessary to assess the value of EMPs in improving patient‐centered outcomes.

Abstract Introduction: Current guidelines state the effectiveness of desmopressin to reduce hematoma expansion in antiplatelet-related intracerebral hemorrhage (ICH) is uncertain. This study sought to determine if desmopressin decreased hematoma expansion in ICH patients on antiplatelet agents. Methods: We conducted a multi-center, retrospective propensity-matched cohort study at 11 US emergency departments (ED) that participate in EMPHARM-NET. Adult patients ≥18 years with a primary diagnosis of spontaneous ICH on antiplatelets prior to admission from January 1, 2017 through May 1, 2021 were included. The primary endpoint was good or excellent hemostatic efficacy within the first 24 hours following ICH between patients that did and did not receive desmopressin. Brain imaging was reviewed using 3D-Slicer by blinded expert physicians. Results: Overall, 1408 patients were evaluated for inclusion. A total of 324 patients were included, of which 13.8% (n=45) received desmopressin and 86.1% (n=279) did not. After propensity matching, 35 patients receive desmopressin compared to 140 controls. Baseline hematoma volume (27.6 mL vs. 2.1 mL) and was significantly higher in the desmopressin group. The primary endpoint of good or excellent hemostatic efficacy was similar between groups (74.3% desmopressin group vs. 85% control group, -10.7% [-28.1% to 6.7%]). There was no difference in secondary outcomes. Conclusion: In this multicenter cohort, patients receiving desmopressin had higher baseline intraparenchymal hematoma volume, and did not appear to result in improved hemostatic efficacy relative to the control group. These results suggest against routine administration of desmopressin for antiplatelet-related ICH, though future study in a randomized trial design is necessary.

Abstract Background Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing. Objectives To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics. Methods We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy. Results Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07–0.83). Conclusions In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis.

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers.

AbstractCoagulopathy is common in critically ill patients and may result in complications such as bleeding or thromboembolic events. Viscoelastic testing (VET), including both thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), offers a benefit over conventional coagulation tests in that it provides a qualitative and quantitative assessment of the degree of coagulopathy, including the ability to measure fibrinolysis. This review is a “how‐to” primer for critical care pharmacists to interpret and utilize VET in practice across a spectrum of coagulopathies, including trauma and traumatic brain injury, neurologic injury and emergencies, cardiothoracic surgery, liver disease, and medication‐induced coagulopathy.