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Background: Central line-associated bloodstream infection (CLABSI) is a complication of central venous access devices used for parenteral nutrition (PN). PN overfeeding is associated with increased adverse effects; however, whether risk for CLABSI is influenced by PN dosing is uncertain. Objective: The purpose of the study was to assess differences in CLABSI risk associated with recommended total energy dosing in hospitalized adult patients receiving PN. Methods: A case-control study was conducted in a single United States Veterans Health Administration health system to assess the potential CLABSI risk factor of weight-based PN kilocalorie dosing. Hospitalized adult patients who developed CLABSI while receiving PN were identified and compared to a control group of patients who did not develop CLABSI. The exposures evaluated were overfeeding, defined as greater than 30 kcal/kg/day, and underfeeding, defined as less than 20 kcal/kg/day. Results: Twenty-nine cases of CLABSI were identified and compared with 274 controls. Odds of CLABSI were significantly higher in patients receiving greater than 30 kcal/kg/day (OR, 3.63; 95% CI, 1.55-8.48; P < .01). No significant difference in odds was found for patients receiving less than 20 kcal/kg/day (OR, .74; 95% CI, 0.21-2.57; P = .63). Conclusion: Increased risk for CLABSI in hospitalized adult patients receiving PN was found to be associated with overfeeding, but not underfeeding. These results may aid clinicians in the management of patients requiring PN and in the generation of hypothesis for future investigations.

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Introduction Septic shock is defined as a dysregulated host response to infection characterized by hemodynamic instability. Concern for the increased risk of acute kidney injury (AKI) with piperacillin-tazobactam in combination with vancomycin may prompt more use of alternative broad-spectrum antipseudomonal beta-lactam antibiotics, such as cefepime. This study assessed whether cefepime was associated with improved outcomes compared to piperacillin-tazobactam in patients with septic shock. Methods This retrospective cohort study included veterans treated for septic shock between September 1, 2008, and August 31, 2018. This study compared cefepime and piperacillin-tazobactam as initial antibiotic management for septic shock. Outcomes included AKI, Clostridioides difficile infection (CDI), hospital length of stay, intensive care unit mortality, and mortality within 30 days of hospitalization. Results In total, 240 patients were included in this study (120 in each cohort). The proportion of AKI was 60.0% in the piperacillin-tazobactam cohort compared to 58.3% in the cefepime cohort (p = 0.90). Mortality was significantly higher in the cefepime cohort. There were no significant differences in CDI or hospital length of stay. Conclusion The results of this study do not suggest that the use of the antipseudomonal beta-lactam antibiotic used in the initial management of septic shock is associated with differences in the AKI or CDI. The higher mortality observed with cefepime may warrant further investigation.

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BACKGROUND: Drug product shortages, including injectable opioids, are common and have the potential to adversely affect patient care. OBJECTIVE: To evaluate the impact of an injectable opioid shortage for hospitalized adult patients in the acute postoperative setting. METHODS: A single-center, retrospective cohort study of noncritically ill hospitalized, postoperative patients requiring opioids for acute pain management was conducted. Patient cohorts were compared preshortage and postshortage for proportion of total intravenous (IV) opioids used, proportions of specific pain medications used, subjective pain scores, 30-day mortality, respiratory depression, need for opioid reversal, hospital length of stay, and opioid equivalent doses. RESULTS: A total of 275 patients were included, 130 patients in the preshortage cohort and 145 in the postshortage cohort. The proportion of total IV opioid doses was lower in the postshortage cohort versus the preshortage cohort (16.6% vs 20.5%; P < 0.01). Specific medications used were significantly different between the cohorts. The proportion of severe pain scores was lower in the postshortage cohort versus the preshortage cohort (55.6% vs 58.5%; P = 0.04). No significant differences were seen in the overall proportion of nonopioid analgesic use, 30-day mortality, respiratory depression, need for emergent opioid reversal, hospital length of stay, or opioid equivalent doses between cohorts. CONCLUSION AND RELEVANCE: In hospitalized, postoperative adults, an injectable opioid shortage was associated with significant decreases in IV opioid use and severe pain scores but no significant differences in nonopioid analgesic use, safety outcomes, or opioid equivalent doses. These results may assist clinicians in developing strategies for injectable opioid shortages and generating hypotheses for future studies.

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Background: The use of an intravenous insulin infusion protocol (IIP) is recommended for management of hyperglycemia in the intensive care unit (ICU); however, limited evidence of comparison has been made with subcutaneous (SC) insulin regimens. Objective: This study aims to evaluate the safety and effectiveness of an IIP compared with SC insulin regimens in an ICU patient sample since the implementation of an IIP using a computerized clinical-decision support tool. Methods: This investigation was a retrospective cohort study of patients who were treated for hyperglycemia while admitted to any of the ICUs at a Veterans Affairs Medical Center. Patients who were treated with either an IIP or a scheduled SC insulin regimen between May 1, 2015, and May 25, 2016, were included for evaluation. Results: Blood glucose (BG) was within the normoglycemia range (70-180 mg/dL) for 63.0% of the measurements in patients treated with an IIP (n = 171) compared with 45.7% in those treated with SC insulin regimens (n = 121; P < 0.01). Overall, patients managed with an IIP had a lower proportion of hypoglycemic BG measurements (1.2% vs 2.1%, P < 0.01), a lower proportion of hyperglycemic BG measurements (35.8% vs 52.2%, P < 0.01), and a lower mean BG (172.4 vs 194.3 mg/dL, P < 0.01). Conclusion and Relevance: The results of this study suggest that an IIP in a sample of adult ICU patients was associated with better BG control and lower occurrence of hypoglycemia compared with SC insulin regimens.

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