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Scott T Micek

Publications and source records attributed to Scott T Micek.

18 recordsLinked to original sources
PubMed2006

Increasing incidence of sterile-site infections due to non-multidrug-resistant, oxacillin-resistant Staphylococcus aureus among hospitalized patients.

The incidence of community-associated, healthcare-associated, and hospital-acquired sterile-site infections due to methicillin-resistant Staphylococcus aureus (MRSA) isolates and the susceptibility of the isolates to non- beta -lactam antibiotics were evaluated for 549 hospitalized patients during a 3-year period. The incidence of community-associated MRSA infection increased significantly. The annual percentage of MRSA isolates from cases of healthcare-associated and hospital-acquired infection that were susceptible to 3 or more non- beta -lactam antibiotics increased significantly.

Anti-Bacterial Agents↗
PubMed2006

Methicillin-resistant Staphylococcus aureus sterile-site infection: The importance of appropriate initial antimicrobial treatment.

OBJECTIVE: The first goal of this investigation was to determine the rate of appropriate initial antimicrobial administration to patients with methicillin-resistant Staphylococcus aureus (MRSA) sterile-site infections. Our second goal was to evaluate the influence of appropriate initial treatment of MRSA sterile-site infection on outcome. DESIGN: A retrospective, single-center, observational cohort study. SETTING: Barnes-Jewish Hospital, a 1200-bed urban teaching facility. PATIENTS: Adult patients requiring hospitalization identified to have an MRSA sterile-site infection. INTERVENTIONS: Retrospective data collection from automated hospital and pharmacy databases. MEASUREMENTS AND MAIN RESULTS: Five hundred forty-nine patients with S. aureus sterile site infections were identified during a 3-yr period (January 2002 through December 2004). One hundred twenty-seven (23.1%) died during hospitalization. Hospital mortality was statistically greater for patients receiving inappropriate initial antimicrobial treatment (n = 380) within 24 hrs of a positive culture than for those receiving appropriate initial treatment (n = 169) (26.1% vs. 16.6%; p = .015). Multiple logistic regression analysis identified inappropriate initial antimicrobial treatment (adjusted odds ratio [AOR], 1.92; 95% confidence interval [CI], 1.48-2.50; p = .0134), vasopressor administration (AOR, 5.49; 95% CI, 4.08-7.38; p < .001), and increasing age (1-yr increments) (AOR, 1.03; 95% CI, 1.02-1.04; p < .001) as independent determinants of hospital mortality. CONCLUSIONS: Inappropriate initial antimicrobial treatment of MRSA sterile-site infections is common and is associated with an increased risk of hospital mortality. Appropriate antimicrobial treatment of MRSA sterile-site infections may be maximized by increased use of initial empirical antimicrobial treatment regimens targeting MRSA in patients at risk for this infection until organism identification and susceptibility become known.

Adolescent↗
PubMed2006

Before-after study of a standardized hospital order set for the management of septic shock.

OBJECTIVE: To evaluate a standardized hospital order set for the management of septic shock in the emergency department. DESIGN: Before-after study design with prospective consecutive data collection. SETTING: Emergency department of a 1,200-bed academic medical center. PATIENTS: A total of 120 patients with septic shock. INTERVENTIONS: Implementation of a standardized hospital order set for the management of septic shock. MEASUREMENTS AND MAIN RESULTS: A total of 120 consecutive patients with septic shock were identified. Sixty patients (50.0%) were managed before the implementation of the standardized order set, constituting the before group, and 60 (50.0%) were evaluated after the implementation of the standardized order set, making up the after group. Demographic variables and severity of illness measured by the Acute Physiology and Chronic Health Evaluation II were similar for both groups. Patients in the after group received statistically more intravenous fluids while in the emergency department (2825 +/- 1624 mL vs. 3789 +/- 1730 mL, p = .002), were more likely to receive intravenous fluids of >20 mL/kg body weight before vasopressor administration (58.3% vs. 88.3%, p < .001), and were more likely to be treated with an appropriate initial antimicrobial regimen (71.7% vs. 86.7%, p = .043) compared with patients in the before group. Patients in the after group were less likely to require vasopressor administration at the time of transfer to the intensive care unit (100.0% vs. 71.7%, p < .001), had a shorter hospital length of stay (12.1 +/- 9.2 days vs. 8.9 +/- 7.2 days, p = .038), and a lower risk for 28-day mortality (48.3% vs. 30.0%, p = .040). CONCLUSIONS: Our study found that the implementation of a standardized order set for the management of septic shock in the emergency department was associated with statistically more rigorous fluid resuscitation of patients, greater administration of appropriate initial antibiotic treatment, and a lower 28-day mortality. These data suggest that the use of standardized order sets for the management of septic shock should be routinely employed.

Adult↗
PubMed2006

Methicillin-resistant Staphylococcus aureus: a new community-acquired pathogen?

PURPOSE OF REVIEW: The main goal of this review is to describe the emergence of methicillin-resistant Staphylococcus aureus (MRSA) as a community pathogen. RECENT FINDINGS: Community-acquired MRSA has emerged as an important infection in the community setting. It has primarily been associated with skin and soft-tissue infections, but can also cause severe pulmonary infections, including pneumonia and empyema. Community-acquired MRSA is typically more susceptible to a wider class of antibiotics than healthcare-associated MRSA. Community-acquired MRSA is also more virulent compared with healthcare-associated MRSA isolates. Community-acquired MRSA usually contains the gene encoding Panton-Valentive leukocidin, which is a toxin that creates lytic pores in the cell membranes of neutrophils and induces the release of neutrophil chemotactic factors that promote inflammation and tissue destruction. The optimal antibiotic treatment for Panton-Valentive leukocidin-positive community-acquired MRSA is unknown; however, antibiotics with activity against MRSA and the ability to inhibit toxin production may be optimal (linezolid or clindamycin for susceptible isolates). SUMMARY: Clinicians should be aware of the emergence of community-acquired MRSA as an important cause of serious infections arising in the community setting. Appropriate antibiotic therapy should be initiated as soon as infection with this pathogen is suspected.

Community-Acquired Infections↗
PubMed2006

Predictors of mortality for methicillin-resistant Staphylococcus aureus health-care-associated pneumonia: specific evaluation of vancomycin pharmacokinetic indices.

OBJECTIVE: The goal of this investigation was to determine whether vancomycin pharmacokinetic indexes (eg, serum trough concentrations or area under the concentration curve [AUC] values) were associated with mortality for patients with health-care-associated pneumonia (HCAP) attributed to methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: A retrospective, single-center, observational cohort study. SETTING: Barnes-Jewish Hospital, a 1,200-bed urban teaching facility. PATIENTS: Adult patients requiring hospitalization who were identified as having HCAP attributed to MRSA by BAL semi-quantitative cultures. INTERVENTIONS: Retrospective data collection from automated hospital, microbiology, and pharmacy databases. MEASUREMENTS AND MAIN RESULTS: One hundred two patients with MRSA HCAP were identified over a 6.5-year period. Thirty-two patients (31.4%) died during their hospitalization. The mean (+/- SD) vancomycin trough concentrations (13.6 +/- 5.9 vs 13.9 +/- 6.7 microg/mL, respectively; p = 0.866) and AUC values (351 +/- 143 vs 354 +/- 109 microg/h/mL, respectively; p = 0.941) did not differ between survivors and nonsurvivors. The stratification of the vancomycin trough concentrations and AUC values yielded no relationship with hospital mortality. CONCLUSIONS: We found no evidence that greater vancomycin trough concentrations or AUC values correlated with hospital outcome. Based on these results, aggressive dosing strategies for vancomycin (eg, trough concentrations of > 15 microg/mL) may not offer any advantage over traditional dose targets (range, 5 to 15 microg/mL).

Adult↗
PubMed2006

Optimizing antibiotic treatment for ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is the most common infectious complication in patients receiving mechanical ventilation and accounts for exorbitant use of resources in the intensive care unit. Antimicrobial management of VAP incorporates an initial broad-spectrum, empiric regimen to ensure appropriate coverage with deescalation of therapy after 48-72 hours based on culture results and sensitivities. When VAP clinically responds to treatment, antimicrobials should be discontinued after 7-8 days to reduce overall antibiotic consumption and the selection pressure on flora observed in the intensive care unit and thus minimize the development and spread of antimicrobial resistance.

Anti-Bacterial Agents↗
PubMed2005

Implementing a commercial rule base as a medication order safety net.

A commercial rule base (Cerner Multum) was used to identify medication orders exceeding recommended dosage limits at five hospitals within BJC HealthCare, an integrated health care system. During initial testing, clinical pharmacists determined that there was an excessive number of nuisance and clinically insignificant alerts, with an overall alert rate of 9.2%. A method for customizing the commercial rule base was implemented to increase rule specificity for problematic rules. The system was subsequently deployed at two facilities and achieved alert rates of less than 1%. Pharmacists screened these alerts and contacted ordering physicians in 21% of cases. Physicians made therapeutic changes in response to 38% of alerts presented to them. By applying simple techniques to customize rules, commercial rule bases can be used to rapidly deploy a safety net to screen drug orders for excessive dosages, while preserving the rule architecture for later implementations of more finely tuned clinical decision support.

Clinical Pharmacy Information Systems↗
PubMed2005

A retrospective Evaluation of fluconazole for the treatment of Candida glabrata fungemia.

BACKGROUND: Candida glabrata accounts for 21% of Candida bloodstream isolates in the United States and ranges from susceptible-dose-dependent to resistant to fluconazole. A fluconazole dose of 800 mg/d ( approximately 12 mg/kg per day) is predicted to produce peak plasma concentrations that surpass the susceptible-dose-dependent MIC breakpoint of 16 to 32 mug/mL. Accordingly, the Infectious Diseases Society of America treatment guidelines for candidiasis recommend fluconazole 12 mg/kg per day as an alternative option for treatment of C glabrata fungemia. OBJECTIVE: The main objective of this study was to evaluate fluconazole retrospectively as a treatment for C glabrata fungemia. METHODS: Data were collected through a database that stores patient information electronically and can be accessed and queried, and chart review at Barnes-Jewish Hospital (St. Louis, Missouri) from January 1999 to August 2002. Eligible patients who had at least 1 positive blood culture for C glabrata and received at least 1 dose of fluconazole were identified through the electronic query. Chart reviews of these patients followed. The primary outcomes were fungemia eradication and in-hospital mortality. RESULTS: Of the total 124 cases of C glabrata fungemia identified, 54 patient charts were evaluable. Chart review revealed that 65% (17/26) of patients receiving fluconazole as the sole antifungal therapy had successful bloodstream eradication of C glabrata, whereas approximately 54% (15/28) of patients who were changed from fluconazole to an amphotericin B formulation had successful bloodstream eradication. Although no association was found between fluconazole dose and fungemia eradication in the entire study population, higher doses of fluconazole (> or =400 mg/d) were more likely to achieve fungemia eradication than lower doses (< or =400 mg/d) in the subset of patients who received only fluconazole (P = 0.042). Mortality rates were approximately 24% (4/17) and 40% (6/15) in patients having successful bloodstream eradication with fluconazole alone and with fluconazole followed by amphotericin B, respectively, compared with 38% (3/8) in patients with persistent fungemia who received fluconazole alone. CONCLUSIONS: Fluconazole was a viable therapy for C glabrata fungemia, with bloodstream eradication in 65% of patients and mortality rates of 24% to 40% in this retrospective chart review.

Algorithms↗
PubMed2005

Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients.

OBJECTIVE: The first goal of this investigation was to identify individuals with delirium defined by the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) among medical patients with respiratory failure. Our second goal was to compare clinical interventions including use of continuous sedation infusions, the number of ventilator-free days, ICU length of stay, hospital mortality, and use of physical restraints in mechanically ventilated patients with and without delirium. DESIGN: A prospective, single-center, observational cohort study. SETTING: The medical intensive care unit (19 beds) of an urban teaching hospital. PATIENTS: Adult, intubated, and mechanically ventilated patients. INTERVENTIONS: Daily evaluation with the CAM-ICU, outcomes assessment, and prospective data collection. MEASUREMENTS AND MAIN RESULTS: Among 93 patients evaluated using the CAM-ICU, 44 patients (47%) developed delirium (CAM-ICU+) for >/=1 day while in the intensive care unit. Twenty-two patients (24%) had no episodes of delirium recorded (CAM-ICU-), and 27 (29%) remained comatose until extubation or death. A statistically greater number of patients with delirium (CAM-ICU+) received continuous infusions of midazolam (59% vs. 32%, p < .05) or fentanyl (57% vs. 32%, p < .05) and physical soft-limb restraints (77% vs. 50%, p < .05) compared with patients without delirium (CAM-ICU-). CONCLUSIONS: The identification of delirium using the CAM-ICU was associated with greater use of continuous sedation infusions and physical restraints. Additional studies are required to determine how the use of these specific interventions influences the occurrence and the natural history of delirium among critically ill patients.

Adult↗
PubMed2005

Strategies to prevent antimicrobial resistance in the intensive care unit.

OBJECTIVE: To assemble the available clinical data for the prevention of antimicrobial resistance into practical recommendations for clinicians. DATA SOURCE: A Medline database and references from identified articles were employed to perform a literature search relating to the prevention of antimicrobial resistance. CONCLUSIONS: Antimicrobial resistance has emerged as an important determinant of mortality for patients in the intensive care unit. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents, resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. These strategies can be divided into nonpharmacologic infection control strategies (e.g., routine hand hygiene, implementation of infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotic treatment, narrowing of antimicrobial spectrum based on culture results). Increasing current efforts aimed at the prevention of antimicrobial resistance is especially important given the limited availability of new antimicrobial drug classes for the foreseeable future.

Algorithms↗
PubMed2005

Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment.

Pseudomonas aeruginosa bloodstream infection is a serious infection with significant patient mortality and health-care costs. Nevertheless, the relationship between initial appropriate antimicrobial treatment and clinical outcomes is not well established. This study was a retrospective cohort analysis employing automated patient medical records and the pharmacy database at Barnes-Jewish Hospital. Three hundred five patients with P. aeruginosa bloodstream infection were identified over a 6-year period (January 1997 through December 2002). Sixty-four (21.0%) patients died during hospitalization. Hospital mortality was statistically greater for patients receiving inappropriate initial antimicrobial treatment (n = 75) compared to appropriate initial treatment (n = 230) (30.7% versus 17.8%; P = 0.018). Multiple logistic regression analysis identified inappropriate initial antimicrobial treatment (adjusted odds ratio [AOR], 2.04; 95% confidence interval [CI], 1.42 to 2.92; P = 0.048), respiratory failure (AOR, 5.18; 95% CI, 3.30 to 8.13; P < 0.001), and circulatory shock (AOR, 4.00; 95% CI, 2.71 to 5.91; P < 0.001) as independent determinants of hospital mortality. Appropriate initial antimicrobial treatment was administered statistically more often among patients receiving empirical combination antimicrobial treatment for gram-negative bacteria compared to empirical monotherapy (79.4% versus 65.5%; P = 0.011). Inappropriate initial empirical antimicrobial treatment is associated with greater hospital mortality among patients with P. aeruginosa bloodstream infection. Inappropriate antimicrobial treatment of P. aeruginosa bloodstream infections may be minimized by increased use of combination antimicrobial treatment until susceptibility results become known.

Adult↗
PubMed2005

Pleuropulmonary complications of Panton-Valentine leukocidin-positive community-acquired methicillin-resistant Staphylococcus aureus: importance of treatment with antimicrobials inhibiting exotoxin production.

Four patients with pleuropulmonary complications attributed to community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) positive for Panton-Valentine leukocidin (PVL) are described. These patients presented to Barnes-Jewish Hospital with severe necrotizing pneumonia, empyema, ARDS-complicating pneumonia, and ventilator-associated pneumonia-complicating acute pancreatitis, respectively. The first three patients had influenza-like illnesses preceding their PVL-positive CAMRSA infections. In all four cases, PVL-positive CAMRSA was isolated from respiratory secretions, and from blood cultures in three of the individuals. Antimicrobial therapy was inappropriate initially in all four patients. Three patients failed to respond to subsequent treatment with vancomycin, including two patients with persistent bacteremia despite at least 48 h of treatment with vancomycin. These patients were subsequently treated with antimicrobials inhibiting exotoxin production (linezolid or clindamycin) with good clinical results. Clinicians should be aware of PVL-positive CAMRSA due to the rapid and severe progression of pleuropulmonary complications associated with this infection. Additionally, specific antimicrobial therapy directed against CAMRSA differs from the traditional antimicrobial agents prescribed for community-acquired pneumonia. Antimicrobial agents that specifically inhibit exotoxin production appear to be the preferred treatment agents.

Adult↗
PubMed2005

Predictors of hospital mortality for patients with severe sepsis treated with Drotrecogin alfa (activated).

STUDY OBJECTIVE: To identify predictors of hospital mortality among patients with severe sepsis who were treated with drotrecogin alfa (activated). DESIGN: Prospective observational cohort study. SETTING: A 1400-bed academic medical center. PATIENTS: One hundred two patients treated with drotrecogin alfa (activated) for severe sepsis. MEASUREMENTS AND MAIN RESULTS: To identify potential risk factors for hospital mortality, the main outcome evaluated, all patients who received drotrecogin alfa (activated) were segregated according to hospital survival. The following characteristics were recorded: age, sex, weight, surgical or nonsurgical, Acute Physiology and Chronic Health Evaluation (APACHE) II score, number of acquired organ-system derangements, mechanical ventilation, use of vasopressors or dobutamine, patient location 24 hours before receiving drotrecogin alfa (activated), source of infection, microbiologically positive culture, and other process-of-care variables. Of the 102 patients, 43 (42.2%) died during their hospitalization. Potential predictors of hospital mortality identified by univariate analysis included greater APACHE II scores, administration of vasopressin or dobutamine, number of acquired organ-system derangements, time to treatment with drotrecogin alfa (activated), intravenous fluid administered before receiving vasopressors or drotrecogin alfa (activated), number of red blood cell transfusions, and administration of inappropriate initial antimicrobial treatment. Multivariate analysis revealed that vasopressin administration (odds ratio [OR] 3.72, 95% confidence interval [CI] 1.95-7.10), number of acquired organ-system derangements (OR 2.30, 95% CI 1.59-3.31), and administration of inappropriate initial antimicrobial treatment (OR 15.5, 95% CI 6.78-35.6) were independently associated with hospital mortality. CONCLUSION: Number of acquired organ-system derangements, vasopressin administration, and treatment with an inappropriate initial antimicrobial regimen are independently associated with an increased risk of hospital mortality among patients treated with drotrecogin alfa (activated) for severe sepsis. These findings suggest that other specific medical interventions may increase survival in this patient population.

Gastrointestinal Diseases↗
PubMed2004

A randomized controlled trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia.

OBJECTIVE: To evaluate an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia (VAP). DESIGN: Prospective, randomized, controlled clinical trial. SETTING: A medical ICU from a university-affiliated urban teaching hospital. PATIENTS: Between April 2002 and July 2003, 290 patients completed the clinical trial. INTERVENTIONS: Patients were assigned to have the duration of antibiotic treatment for VAP determined by an antibiotic discontinuation policy (discontinuation group) or their treating physician teams (conventional group). RESULTS: Severity of illness using APACHE (acute physiology and chronic health evaluation) II score (22.8 +/- 9.0 vs 23.2 +/- 9.4, p = 0.683) [mean +/- SD] and the clinical pulmonary infection score (7.1 +/- 0.9 vs 7.2 +/- 0.9, p = 0.222) were similar for both patient groups. The duration of antibiotic treatment for VAP was statistically shorter among patients in the discontinuation group compared to patients in the conventional antibiotic management group (6.0 +/- 4.9 days vs 8.0 +/- 5.6 days, p = 0.001). The occurrence of a secondary episode of VAP was not statistically different between these two groups (17.3% vs 19.3%, p = 0.667). Hospital mortality (32.0% vs 37.1%, p = 0.357) and ICU length of stay (6.8 +/- 6.1 days vs 7.0 +/- 7.3 days, p = 0.798) were also statistically similar. CONCLUSIONS: The application of an antibiotic discontinuation policy for clinically suspected VAP was associated with a decrease in the overall duration of antibiotic treatment. These findings suggest that shorter courses of empiric antibiotic therapy for patients treated for clinically suspected VAP can be safely achieved.

Adult↗
PubMed2004

Enterococcus faecalis resistant to linezolid: case series and review of the literature.

Reports of linezolid resistance among Enterococcus faecalis have been relatively rare. We describe three patients with linezolid-resistant strains of E. faecalis, discovered after the patients had received long courses (> 30 days) of linezolid therapy. All strains contained the G2576U mutation in 23S rRNA. A literature review revealed one other case in the United States and three cases in Europe; all involved patients who had received long courses of therapy. It appears that recent or extended linezolid therapy may be a risk factor for development of resistant E. faecalis. In patients who have recently been treated with linezolid and have an identified new systemic enterococcal isolate, linezolid sensitivity should be verified as soon as possible to guide therapy. This strategy also should be considered for patients with a breakthrough enterococcal isolate during linezolid therapy.

Acetamides↗
PubMed2003

Management of severe sepsis: integration of multiple pharmacologic interventions.

Severe sepsis is an infection-induced process that often promotes organ dysfunction and death in up to 50% of afflicted patients. Clinical advances that improve patient survival include early goal-directed volume resuscitation, broad-spectrum empiric antimicrobial therapy with deescalation strategies, therapy with drotrecogin alfa (activated), glucocorticoid replacement in patients with adrenal insufficiency, and tight control of blood glucose levels. The challenge for critical care practitioners is to integrate the many pharmacologic and supportive interventions required for optimal care of these patients.

Animals↗
PubMed2003

Enterobacter cloacae ventriculitis successfully treated with cefepime and gentamicin: case report and review of the literature.

A 55-year-old woman was found unresponsive and subsequently was diagnosed with a subarachnoid hemorrhage secondary to a right posterior communicating artery aneurysm. The development of hydrocephalus and decreased mental status necessitated placement of an intraventricular catheter; 18 days later she was diagnosed with Enterobacter cloacae ventriculitis. After treatment was begun with intravenous cefepime 2 g every 8 hours and intraventricular gentamicin 5 mg every 24 hours, the catheter was replaced. Cerebrospinal fluid (CSF) and plasma cefepime concentrations and a CSF trough gentamicin concentration were obtained. Intraventricular gentamicin was administered for 6 days and cefepime for 21 days; both clinical and microbiologic resolution of the ventriculitis occurred. The literature reports limited clinical experience with cefepime for the treatment of central nervous system infections in humans. This case report provides clinical evidence to support administration of intravenous cefepime in critically ill adult patients with Enterobacter ventriculitis. Because CSF is easily obtained from patients with intraventricular catheters, strong consideration should be given to monitoring CSF cefepime concentrations in concert with the minimum inhibitory concentration of the offending pathogen to help assure the efficacy of this approach to therapy.

Cefepime↗