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Background: Four-factor prothrombin complex concentrate (4F-PCC) is indicated for vitamin K antagonist (VKA) reversal but is associated with thrombotic events (TE). In 2018, the institution revised 4F-PCC dosing for VKA reversal from INR and weight-based dosing to a fixed-dose of 1500 units. Objective: The purpose of this study was to compare hemostatic efficacy and TE rate of fixed-dose 4PCC to weight-based dosing. Methods: This was a retrospective, single-center, quasi-experimental study of adult patients who received 4F-PCC for VKA reversal from January 2014 through May 2016 (INR and weight-based dosing) or April through October 2018 (fixed-dosing). The primary endpoint was hemostatic efficacy, defined by achieving an INR of ≤1.4, or an INR of ≤1.7 with evidence of hemostasis. The key secondary endpoint was TE within 14 days of 4F-PCC administration. Data were analyzed using descriptive statistics, chi-squared for nominal data and Mann-Whitney U for ordinal and continuous data. Results: The study included 163 patients who received weight-based dosing and 45 who received fixed-dose 4F-PCC. Hemostatic efficacy was 76.9% of patients in the weight-based group and 77.4% of patients in the fixed-dose group (P =.229). TE occurred in 13.5% of the weight-based vs 6.7% of the fixed-dose group (P =.181). Conclusion: This study found no difference in hemostatic efficacy with fixed-dose 4F-PCC for VKA reversal compared to INR and weight-based dosing. The occurrence of TE was reduced by 50% with the 4F-PCC fixed-dose strategy; however, this difference was not statistically significant. Further randomized studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Burn patients have numerous risk factors for multidrug-resistant organisms (MDROs) and altered pharmacokinetics, which both independently increase the risk of treatment failure. Data on appropriate antimicrobial dosing are limited in this population and therapeutic drug monitoring (TDM) for beta-lactams is impractical at most facilities. Technology is available that can detect genetic markers of resistance, but they are not all encompassing, and often require specialized facilities that can detect less common genetic markers. Newer antimicrobials can help combat MDROs, but additional resistance patterns may evolve during treatment. Considering drug shortages and antimicrobial formularies, clinicians must remain vigilant when treating infections. This case report describes the development of resistance to ceftazidime-avibactam in a burn patient. The patient was a 54-year-old burn victim with a 58% total body surface area (TBSA) thermal burn who underwent multiple courses of antibiotics for various Pseudomonal infections. The initial Pseudomonal wound infection was sensitive to cefepime, aminoglycosides, and meropenem. A subsequent resistant pseudomonal pneumonia was treated with ceftazidime-avibactam 2.5 g every 6 hours due to the elevated MIC to cefepime (16 mcg/mL) and meropenem (>8 mcg/mL). Although the patient improved over 7 days, the patient again spiked fevers and had increased white blood counts (WBC). Repeat blood cultures demonstrated a multidrug-resistant (MDR) Pseudomonas with a minimum inhibitory concentration (MIC) to ceftazidime-avibactam of 16 mcg/mL, which is above the Clinical and Laboratory Standards Institute (CLSI) breakpoint of 8 mcg/mL. At first, resistance was thought to have occurred due to inadequate dosing, but genetic work demonstrated multiple genes encoding beta-lactamases. [ABSTRACT FROM AUTHOR]

Toxic epidermal necrolysis (TEN) is a severe cutaneous reaction that can be life-threatening. In the United States, there are no established guidelines for the treatment of TEN. Supportive care including fluids and supportive therapies are the current recommendations. Research surrounding TEN involves mostly case studies or small, uncontrolled studies. Recent literature describes the use of tumor necrosis factor blockers in the treatment of TEN with positive results. These case reports describe decreased time to reepithelization, hospital length of stay, and minimal side effects. Conversely, we present three fatalities after the administration of etanercept. [ABSTRACT FROM AUTHOR]

Introduction: Reducing infection in burn patients can have a major impact on clinical outcomes. The purpose of this study is to evaluate the rate of bacteremia pre/post the implementation of a line change and nasal decolonization protocol. Methods: This quasi-experimental study assessed adult patients admitted to a single center ABA verified burn center from August 2019 - August 2020 (pre-intervention group) versus September 2020 - September 2021 (post-intervention group). Patients must have received at least 1 round of intranasal decolonization treatment (mupirocin intranasal twice a day for 5 days and repeated every 30 days during hospital stay) during the post-protocol period. A line change policy was also implemented post protocol period for central and peripheral lines. Patients were excluded if they had a total loss of nasal alae, injury deemed nonsurvivable, or transitioned to comfort care within 72 hours of admission. Results: A total of 558 burn patients were included, 324 patients in the pre-group and 234 post-group. There was no significant difference in comorbidities between the two groups. The majority of patients were admitted for an integumentary burn (87.6%) with the most common cause being flame (49.8%) or hot water contact (19.0%). Compliance with the decolonization protocol was appropriate for 87.6% of patients post-intervention. During the pre-intervention period, there were 18 (7.7%) positive blood cultures versus only 9 (3.8%) in the post-group (p=0.426). Gram-positive infections occurred in 44.4% of the pre-group and only 11.1% in the post-group (p=0.087). The rate of Gram-negative infections was similar between the pre and post-groups at 44.4% and 55.6%, p = 0.695. MRSA bacteremia was 44.4% of total Gram-positive bacteremia, with pre and post-intervention 4 (50%) vs. 0 (0%), p = 0.1. The median time of line placement to bacteremia pre-intervention was 7(5-12) days vs. post-intervention 11(6-14) days (p = 0.220). Hospital mortality between both periods was 9(3.8%) vs. 5(2.1%), p = 0.786. No significant difference was found in hospital LOS, ICU LOS, or discharge disposition. Conclusions: Overall, this study showed a 50% decreased rate of MRSA bacteremia with the implementation of an intranasal decolonization protocol and a delay in Gram-negative bacteremia post implementation of a line change policy, potentially leading to a decrease in morbidity and hospital bloodstream infection-related costs. Applicability of Research to Practice: Reducing infection rates can have a major impact on burn patient outcomes and lead to significant cost savings. [ABSTRACT FROM AUTHOR]