In this episode I’ll:

1. Discuss an article about early discontinuation of antibiotics in VAP.

2. Answer the drug information question “Does relative bradycardia predict drug fever?”

3. Share a resource to gain more minutes before 9am in your day.

If you have been wondering if my Critical Care Pharmacy Academy is right for you, now is the time to check it out. To ring in the new year I am offering a $1 trial where you can get full access to the Academy for a limited time. The Academy is entirely self-paced and is designed to help pharmacists like you develop new critical care skills and stay ahead of the vast critical care literature.

Each month, a new Masterclass is published. Topics include:

1. ICU rounds

2. Airway pharmacology

3. Patient assessment

4. Pharmacist response to emergencies 101

5. ECG recognition for pharmacists

Every week, I review the critical care literature and create a brief digest in video and audio formats of the most important articles. I include my opinion of where each article fits in clinical practice.

To learn more go to pharmacyjoe.com/trial.

Article

Ultra short course antibiotics for patients with suspected ventilator-associated pneumonia but minimal and stable ventilator settings

Lead author: Michael Klompas

Published online in Clinical Infectious Disease December 2016

Background

Empiric treatment for ventilator-associated pneumonia (VAP) is common. However, many patients who receive empiric treatment for VAP do not have pneumonia. When looking for candidates for early antibiotic discontinuation, it makes sense to focus on patients with minimal and stable ventilator settings. The authors of this study compared outcomes amongst patients with suspected VAP but minimal and stable ventilator settings treated with 1-3 versus >3 days of antibiotics.

Methods

The single center study examined 1290 consecutive adult patients started on antibiotics for possible VAP with daily minimum PEEPs ≤5cm H2O and FiO2s ≤40% for at least 3 days. The authors compared time to extubation alive versus ventilator death and time to hospital discharge alive versus hospital death using competing risks models amongst patients prescribed 1-3 days versus >3 days of antibiotics.

Results

259 patients were treated for 1-3 days and 1,031 patients were treated for >3 days. There were no significant differences between groups – either in demographics or outcome measures.

Conclusion

The authors concluded:

Very short antibiotic courses (1-3 days) were associated with outcomes similar to longer courses (>3 days) in patients with suspected VAP but minimal and stable ventilator settings. Assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation.

Discussion

Pneumonia is a clinical diagnosis without a single objective finding that can be used to support or refute empiric antibiotic therapy. Criteria such as fever may often be due to non-infectious causes. The antibiotics required to treat ventilator-associated pneumonia are often expensive and at risk of developing resistance. Therefore identifying patients who may have antibiotics quickly discontinued has the potential to prevent unnecessary adverse events, antibiotic resistance, and drug cost. The choice of using ventilator settings to guide early antibiotic discontinuation is excellent. It is hard to support a diagnosis of VAP if the PEEP is 5 cm and FIO2 is 40%. Given this study was retrospective and single-center, it will be helpful if another study confirms the results. Until then, I agree with the authors that assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation.

The choice of using ventilator settings to guide early antibiotic discontinuation is excellent. It is hard to support a diagnosis of VAP if the PEEP is 5 cm and FIO2 is 40%. Given this study was retrospective and single-center, it will be helpful if another study confirms the results. Until then, I agree with the authors that assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation.

Drug information question

Q: Does relative bradycardia predict drug fever?

A: Maybe.

I cannot locate sensitivity and specificity data for relative bradycardia predicting drug fever. It is considered a possible finding in drug fever, although it may be present in as few as 10% of patients with drug fever.

Relative bradycardia occurs when the heart rate does not increase to the extent that typically accompanies the temperature elevation.

To determine the presence of relative bradycardia, a temperature of at least 102°F is required, and sinoatrial disease or drugs that affect heart rate must not be present.

Take the last digit of the temperature in Fahrenheit, subtract 1, multiply by 10 then add 100. If the patient’s heart rate is less than this number, the patient has relative bradycardia.

For example, for a temperature of 102°F, the appropriate pulse response would be approximately 110 beats/minute. Any value less than this would be considered relative bradycardia.

Resource

In episode 154 I discussed how 1 minute before 9am equals 2 minutes after noon. The resource for this episode is the book The Miracle Morning by Hal Elrod. Hal has an inspirational life story. His book helped me set up a morning routine to start each day focused and energized. WARNING: You might become a “morning person” after reading this book! If you implement Hal’s strategies you will definitely gain more minutes before 9am in your personal and professional day.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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