Betthauser, Kevin D.

Abstract Background Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) remain significant causes of morbidity and mortality among patients admitted to a medical facility. Consensus guidelines for the treatment of HAP/VAP recommend patients with certain risk factors be empirically treated with an anti-methicillin resistant Staphylococcus aureus (MRSA) and anti-pseudomonal antibiotic. The most commonly utilized anti-pseudomonal agents at BJC hospitals include cefepime, followed by piperacillin/tazobactam and meropenem. The purpose of this study is to determine if there is a difference in clinical outcomes between cefepime and the other most commonly used anti-pseudomonal antibiotics, piperacillin/tazobactam or meropenem, at these institutions for the treatment of HAP/VAP. Methods This retrospective, multicenter cohort study included adult patients with HAP/VAP who received cefepime, meropenem, or piperacillin/tazobactam. Major exclusion criteria included patients that received antibiotics within 48 hours of hospital admission or less than 48 hours of empiric antibiotics. The primary outcome was in-hospital mortality. Secondary outcomes included change in initial antibiotic, mechanical ventilation-free days, ICU length of stay, hospital length of stay, hospital readmission, and new C. difficile infection. Results Of 1,117 included patients, 1,008 patients received cefepime and 109 received meropenem or piperacillin/tazobactam. Incidence of in-hospital mortality was not observed to be significantly different among empiric Gram-negative regimens (cefepime group 19.4% vs. meropenem or piperacillin/tazobactam 22%, p=0.521. Change in initial antibiotic, ICU length of stay, and hospital length of stay were observed to be significantly higher in the cefepime group. Conclusion We observed no difference in in-hospital mortality between cefepime and piperacillin/tazobactam or meropenem. However, there was a significantly higher incidence of change in initial antibiotic, ICU length of stay, and hospital length of stay observed in the cefepime group, though additional research is needed to corroborate these observations. Disclosures Kevin Betthauser, PharmD, La Jolla Pharmaceutical Company: Advisor/Consultant|La Jolla Pharmaceutical Company: Grant/Research Support Paul Juang, Pharm.D., Merck & Co: Grant/Research Support

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock.