Managing a Rivaroxaban Bleed: Understanding the Difficulties in Acute Reversal of the New Oral Anticoagulants through a Case Report.

With the arrival of a new generation of oral anticoagulants significant burdens associated with warfarin's use on both the patient and the healthcare system have been alleviated. Nevertheless, a shortfall exists in regard to an agent or protocol for reversal of these new anticoagulants in the setting of an acute bleed. Our case of a patient presenting to the hospital with a vaginal bleed while on rivaroxaban highlights the difficulty in management without a clear protocol or agent for reversal of anticoagulation.

Vancomycin therapeutic guidelines: a summary of consensus recommendations from the infectious diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists.

Practice guidelines for therapeutic monitoring of vancomycin treatment for Staphylococcus aureus infection in adult patients were reviewed by an expert panel of the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. A literature review of existing evidence regarding vancomycin dosing and monitoring of serum concentrations, in addition to patient outcomes combined with expert opinion regarding the drug's pharmacokinetic, pharmacodynamic, and safety record, resulted in new recommendations for targeting and adjustment of vancomycin therapy.

Causes and consequences of critical bleeding and mechanisms of blood coagulation.

Pharmacists who practice in the critical care setting require a solid background on the causes and consequences of bleeding, as well as the mechanisms of hemostasis. This article provides an overview of these topics. Bleeding and outcomes as a result of surgery and trauma, from medical and pharmacologic causes, and in obstetrics and gynecology are discussed.

Effect of growth phase and pH on the in vitro activity of a new glycopeptide, oritavancin (LY333328), against Staphylococcus aureus and Enterococcus faecium.

Oritavancin (LY333328) is a novel glycopeptide with activity against Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium. We compared the effects of pH and growth phase on the activity of oritavancin and vancomycin against methicillin-resistant S. aureus and vancomycin-susceptible and -resistant E.

Influence of platelets and platelet microbicidal protein susceptibility on the fate of Staphylococcus aureus in an in vitro model of infective endocarditis.

Several lines of evidence indicate that platelets protect against endovascular infections such as infective endocarditis (IE). It is highly likely that a principal mechanism of this platelet host defense role is the release of platelet microbicidal proteins (PMPs) in response to agonists generated at sites of endovascular infection. We studied the ability of platelets to limit the colonization and proliferation of Staphylococcus aureus in an in vitro model of IE.

Pharmacodynamics of vancomycin and ampicillin alone and in combination with gentamicin once daily or thrice daily against Enterococcus faecalis in an in vitro infection model.

We compared the pharmacodynamic activities of vancomycin and ampicillin with or without gentamicin once daily or thrice daily in an in vitro infection model with fibrin-platelet clots (FPCs) infected with Enterococcus faecalis. Antibiotics were administered as a bolus to simulate human pharmacokinetics with regimens consisting of vancomycin 1 g q12h, ampicillin 2 g q6h and gentamicin 1.3 mg/kg q8h and 5 mg/kg qd.

In vitro activities of daptomycin, vancomycin, linezolid, and quinupristin-dalfopristin against Staphylococci and Enterococci, including vancomycin- intermediate and -resistant strains.

The in vitro activity of daptomycin was compared with those of vancomycin, linezolid, and quinupristin-dalfopristin against a variety (n = 203) of gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and S. epidermidis (MRSA and MRSE, respectively), vancomycin-resistant enterococci (VRE), and vancomycin-intermediate S. aureus (VISA).

Safety and feasibility of continuous infusion of remifentanil in the neurosurgical intensive care unit.

Objective: Remifentanil is a selective mu-opioid agonist with a context-sensitive half-time of 3 to 5 minutes, independent of dose or administration duration. Other desirable effects include decreased cerebral metabolism and intracranial pressure (ICP) with minimal cerebral perfusion pressure changes. We present six cases illustrating indications for the use of remifentanil in the neurosurgical intensive care unit.

Comparative in vitro activities and postantibiotic effects of the oxazolidinone compounds eperezolid (PNU-100592) and linezolid (PNU-100766) versus vancomycin against Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, and Enterococcus faecium.

The activities of the oxazolidinone antibacterial agents eperezolid (PNU-100592) and linezolid (PNU-100766) were compared with that of vancomycin against clinical isolates of methicillin-susceptible and -resistant Staphylococcus aureus (n = 200), coagulase-negative staphylococci (n = 100), and vancomycin-susceptible and -resistant Enterococcus faecalis and Enterococcus faecium (n = 50). Eperezolid and linezolid demonstrated good in vitro inhibitory activity, regardless of methicillin susceptibility for staphylococci (MIC at which 90% of the isolates are inhibited [MIC90] range, 1 to 4 microg/ml) or vancomycin susceptibility for enterococci (MIC90 range, 1 to 4 microg/ml). In time-kill studies, eperezolid and linezolid were bacteriostatic in action.

In vitro activities of an investigational quinolone, glycylcycline, glycopeptide, streptogramin, and oxazolidinone tested alone and in combinations against vancomycin-resistant Enterococcus faecium.

We evaluated the in vitro activities of clinafloxacin, CL331,002, LY333328, quinupristin dalfopristin, and eperezolid (formerly known as U-100,592) against four strains of enterococci. All regimens tested resulted in the growth inhibition of each isolate. Against the three clinafloxacin-susceptible strains, clinafloxacin tested alone was the most active treatment, decreasing the bacterial inoculum by more than 3 log10 CFU/ml after 24 h in time-kill curve studies.

Pharmacodynamics of vancomycin alone and in combination with gentamicin at various dosing intervals against methicillin-resistant Staphylococcus aureus-infected fibrin-platelet clots in an in vitro infection model.

We compared the pharmacodynamic activities of vancomycin with or without gentamicin in an in vitro infection model with methicilin-resistant Staphylococcus aureus-infected fibrin-platelet clots. Infected fibrin-platelet clots (FPCs) were prepared with human cryoprecipitate, human platelets, thrombin, and the organism (approximately 10[9] CFU of MRSA-494/g) and were suspended with monofilament line in an infection model capable of simulating human pharmacokinetics. Antibiotics were bolused to simulate vancomycin regimens of 2 g every 24 h (q24h), 1 g q12h, 500 mg q6h, and continuous infusion (steady-state concentration of 20 microg/ml) and gentamicin regimens of 1.

Pharmacodynamic evaluation of a new glycopeptide, LY333328, and in vitro activity against Staphylococcus aureus and Enterococcus faecium.

The objectives of the present study were to compare the in vitro activity of LY333328 (LY) to that of vancomycin (V) alone and in combination with gentamicin (G) and rifampin (R) against methicillin-resistant Staphylococcus aureus (MRSA) and V-resistant Enterococcus faecium (VREF), by using the killing curve methods. In addition, the effect of the inoculum size and protein on LY's activity was evaluated by using MICs and killing curves. MICs, MBCs, and killing curves were determined with supplemented Mueller-Hinton broth (B), B with albumin (4 g/dl) (A), and B with 50% pooled human serum (S).

Physical effects of heroin and cocaine: considerations for a wound care service.

Use of illicit substance is a major health care problem in the United States. Two commonly used illicit substances are heroin and cocaine. Both drugs can have multiple effects on the body, including the development of wounds.

Bactericidal activities of cefprozil, penicillin, cefaclor, cefixime, and loracarbef against penicillin-susceptible and -resistant Streptococcus pneumoniae in an in vitro pharmacodynamic infection model.

We examined the bactericidal activities of penicillin, cefprozil, cefixime, cefaclor, and loracarbef against three clinical isolates of Streptococcus pneumoniae which were susceptible, moderately susceptible, and resistant to penicillin. An in vitro two-compartment glass infection model was used to simulate human pharmacokinetics in the presence of bacteria. Also, changes in organism susceptibility and development of resistant subpopulations were evaluated.

Comparison of methodologies for synergism testing of drug combinations against resistant strains of Pseudomonas aeruginosa.

The purpose of this study was to determine if synergism was maintained for various combinations of beta-lactams with an aminoglycoside against four clinical strains and one laboratory strain of Pseudomonas aeruginosa which were resistant, according to the MICs, to the beta-lactams and/or aminoglycoside. The results from both the checkerboard and killing curve methodologies were compared. The laboratory strain (ATCC 27853) was manipulated in vitro by serial passage onto agar containing increasing concentrations of each antibiotic to select for resistance.

Pharmacodynamics of ceftazidime administered as continuous infusion or intermittent bolus alone and in combination with single daily-dose amikacin against Pseudomonas aeruginosa in an in vitro infection model.

We compared the pharmacodynamics and killing activity of ceftazidime, administered by continuous infusion and intermittent bolus, against Pseudomonas aeruginosa ATCC 27853 and ceftazidime-resistant P. aeruginosa 27853CR with and without a single daily dose of amikacin in an in vitro infection model over a 48-h period. Resistance to ceftazidime was selected for by serial passage of P.

Pharmacodynamics of levofloxacin, ofloxacin, and ciprofloxacin, alone and in combination with rifampin, against methicillin-susceptible and -resistant Staphylococcus aureus in an in vitro infection model.

The pharmacodynamic properties of levofloxacin (an optically active isomer of ofloxacin), ofloxacin, and ciprofloxacin, alone and in combination with rifampin, were evaluated over 24 to 48 h against clinical isolates of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA 1199 and MRSA 494, respectively) in an in vitro infection model. The incidence of the emergence of resistance among the test strains was also determined. The fluoroquinolones were administered to simulate dosage regimens of 200 mg, 400 mg given intravenously (i.

Small-bowel obstruction secondary to activated charcoal and adhesions.

Gastrointestinal obstruction is a rare complication of multiple-dose administration of activated charcoal. Previous reports deal only with obstruction after ingestion of drugs that impair gastrointestinal motility. This patient developed a small-bowel obstruction associated with the administration of multiple doses of activated charcoal (350 g, total) for treatment of theophylline toxicity.

Infection control for health care workers caring for critically injured patients: a national survey.

Prevention of transmission of bloodborne pathogens to health care workers (HCWs) involved in resuscitation of critically injured patients presents special challenges. As a step toward creation of a standard, a telephone survey of the infection control practices in this setting of the 100 busiest EDs in the United States (US) was performed. Departmental staff who were knowledgeable about ED infection prevention protocols were questioned about general policy, barrier protection measures, sharps management, and educational programs directed to HCWs.

Controversial issues in clinical management of the simple wound.

The primary goals of the practitioner managing a simple wound are to encourage primary healing and avoid infection. We conclude from this analysis that the four basic aspects of wound management we have reviewed, the timing of wound repair, the preparation of the wound, local anesthetic management, and antimicrobial therapy, will continue to be fertile topics for investigation and debate.

Comparative effect of protein binding on the killing activities of teicoplanin and vancomycin.

The effect of protein binding on the activity of teicoplanin against Staphylococcus aureus was evaluated. Bactericidal rates of teicoplanin in cation-supplemented Mueller-Hinton broth (SMHB) and in a 1:1 mixture of pooled human serum and cation-supplemented Mueller-Hinton broth (PHS-SMHB) were compared with those of vancomycin. Eight concentrations of each drug ranging from 15 to 150 micrograms/ml were studied in two series which correspond to the concentrations in serum achieved with low- (6 mg/kg of body weight once daily) and high-dose (30 mg/kg once daily) teicoplanin.

Severe oral phenytoin overdose does not cause cardiovascular morbidity.

Study Objective: To evaluate the potential for cardiovascular toxicity from severe oral phenytoin overdose.

Study Population: Fifty-seven patients admitted during a two-year period to an inner-city hospital for severe oral phenytoin overdose, which is defined as a peak level of 40 micrograms/mL or more.

Methods: Case records were reviewed retrospectively for symptoms and signs of phenytoin toxicity, especially circulatory effects.

Therapeutic efficacy of timentin and augmentin versus silvadene in burn wound infections.

Successful closure of thermal injuries, by either skin graft or delayed wound closure, largely depends on the ability to control the number of bacteria in the wound. The purpose of this study was to investigate the efficacy of two new antimicrobial agents, ticarcillin and clavulanate (Timentin) and amoxicillin and clavulanate (Augmentin), in the infected thermal injury. The therapeutic results were compared with the model treated with the standard topical silver sulfadiazine (Silvadene).

A new approach to catastrophic injury: spinal cord injury patients.

Catastrophic injuries and illnesses create great financial strains on patients who require lifetime care. Families, health care providers and insurers recognise that individual patient care needs require a closer look at the prudent allocation of health care benefit dollars. Blue Cross Blue Shield of Michigan has initiated an approach to this problem called 'case management'.