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painting of cellulitis on a microscopic level

Researchers evaluate antibiotic effectiveness for cellulitis

Although most cases of cellulitis are uncomplicated and can be resolved in the community setting, the number of patients hospitalized for cellulitis has increased in recent years. The length and route of antimicrobials needed to resolve the infection are unclear, with approximately 20% of patients with cellulitis prescribed repeat courses of antimicrobials when it is likely that many of the patients have slowly resolving symptoms and additional treatment is unnecessary. Researchers from the University of Bristol and the Bristol Royal Infirmary (UK) used data from a randomized clinical trial of clindamycin as adjunctive therapy in cellulitis to illustrate the evolution of local parameters (pain, swelling, local erythema, and warmth) and the resolution of biomarkers over time.

Data from 247 individuals with mild to moderate unilateral lower limb cellulitis were used to examine antibiotic response dynamics. Results of the study, published in the October 2023 issue of Open Forum Infectious Diseases, indicated a local improvement in swelling, warmth, erythema, and pain by day 5 compared with baseline, though some individuals still had evidence of local inflammation at 10 days. Most biomarkers demonstrated a return to normal by day 3, although the initial fall in albumin only returned to baseline by day 10.

The authors suggest that clinicians can use these data to reassure themselves and their patients that ongoing local symptoms and signs after completion of antibiotic treatment do not indicate treatment failure or warrant extension of the initial antibiotic treatment or a change in antibiotic class or mode of administration. ■

White Graphic of blood pressure cuff and heart on green background

Does orthostatic or standing hypotension change the effectiveness of intensive BP treatment?

Concerns remain about the benefits of intensive BP treatment for adult patients with orthostatic hypotension or standing hypotension. In a recent study in JAMA, published online on October 17, 2023, a multinational group of researchers sought to determine the effect of a lower BP treatment goal or active therapy versus a standard BP treatment goal or placebo on CVD or all-cause mortality in patients with orthostatic or standing hypotension.

The study involved an individual data meta-analysis of more than 29,000 participants in nine hypertension trials based on a systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022. The researchers found that more intensive BP treatment lowered risk of CVD or all-cause mortality regardless of whether participants had orthostatic hypotension. Effects did not differ by the presence or absence of standing hypotension.

The authors indicate asymptomatic orthostatic hypotension or standing hypotension among adults with hypertension should not be a deterrent to more intensive hypertension treatment. ■

Middle aged man of Asian decent sits on the side of the bed in a lushly decorated bedroom while clutching his chest.

Is rosuvastatin or atorvastatin more effective in adults with CVD?

Reduction of LDL cholesterol levels is commonly recommended for patients with coronary artery disease to lower the risk of atherosclerotic cardiovascular events.

A recent study, published in the BMJ on October 18, 2023, compared the long-term efficacy and safety of the two most common statins used in this patient population, rosuvastatin and atorvastatin. The randomized, open label, multicenter trial was conducted in 12 hospitals in South Korea from September 2016 to November 2019.

More than 4,400 adults with coronary artery disease were assigned to receive either rosuvastatin (n = 2,204) or atorvastatin (n = 2,196) using 2×2 factorial randomization. Mean daily dose of study drugs was 17.1 mg in the rosuvastatin group and 36.0 mg in the atorvastatin group at 3 years.

The primary outcome (a 3-year composite of all-cause death, myocardial infarction, stroke, or any coronary revascularization) occurred in 189 patients in the rosuvastatin group and 178 patients in the atorvastatin group and the mean LDL cholesterol level during treatment was 1.8 mmol/L in the rosuvastatin group and 1.9 mmol/L in the atorvastatin group.

More patients in the rosuvastatin group developed new onset diabetes and underwent cataract surgery than in the atorvastatin group. Other safety endpoints did not differ between the two groups.

The authors note that because only Asian patients were included in this trial, the results may not be applicable to all populations.

In addition, the 3-year study may have been relatively too short to discover longer term effects of the two statin types. They suggest that these findings should be interpreted with caution and that further dedicated investigation with longer follow-up is warranted. ■

A drip chamber from an IV over a deep green background

Do cefepime and piperacillin-tazobactam increase the risk of acute kidney disease or neurological dysfunction?

Patients hospitalized with acute infections are often given cefepime and piperacillin-tazobactam to treat the infection. However, it has been suggested that piperacillin-tazobactam may cause acute kidney injury and that cefepime may cause neurological dysfunction. Researchers in the Vanderbilt Center for Learning Healthcare and the Pragmatic Critical Care Research Group conducted a randomized clinical trial (ACORN) to determine whether the choice between cefepime and piperacillin-tazobactam affects the risks of acute kidney injury or neurological dysfunction.

More than 2,500 adult patients for whom a clinician had initiated antipseudomonal antibiotics within 12 hours of presentation to the hospital were randomized in a 1:1 ratio to receive either cefepime (as an I.V. push over 5 minutes) or piperacillin-tazobactam (as an initial bolus and extended infusions over 4 hours for subsequent doses). The primary outcome of the study was the highest stage of acute kidney injury or death by day 14, measured on a five-level scale ranging from no acute kidney injury to death.

The study, published on October 14, 2023, in JAMA, showed that the highest stage of acute kidney injury or death was not significantly different between patients in the cefepime group and those in the piperacillin-tazobactam group, and the incidence of major adverse kidney events at day 14 did not differ between patients in the two groups. However, patients in the cefepime group experienced fewer days alive and free of delirium and coma within 14 days than those in the piperacillin-tazobactam group. ■



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