Purpose Urinary alkalinization with intravenous sodium bicarbonate is standard during high-dose methotrexate administration. Due to a national intravenous sodium bicarbonate shortage, a urinary alkalinization protocol involving hyperhydration with intravenous fluids, oral bicarbonate, and intravenous or oral acetazolamide was utilized from 10 April to 30 May 2017 (“shortage protocol”). This study compared outcomes between protocols. Methods A single-center, retrospective chart review was conducted for adults who received methotrexate ≥500 mg/m2 on ≥ two occasions, at least once during each protocol, between 19 February and 19 July 2017. Results Eighteen patients (50% male), median age 65 years, received 76 total high-dose methotrexate cycles. Shortage protocol was used in 37 cycles (48.7%). Mean time to methotrexate clearance did not differ between groups (p = ns). Mean time to urinary alkalinization and duration of hospitalization were not statistically different (p = 0.49 and 0.23, respectively). Average total bicarbonate administered per 24 hours was higher in standard protocol (p < 0.05), but hydration rates were similar (p = 0.73). Creatinine clearance and urine output on days 1 and 2 post-high-dose methotrexate did not significantly differ (creatinine clearance day 1, p = 0.27; creatinine clearance day 2, p = 0.55; urine output day 1, p = 0.62; urine output day 2, p = 0.60). Interruptions in alkalinization were significantly higher during shortage (0.41 ± 0.75 instances of urine pH < 7 during standard vs. 1.3 ± 1.7 under shortage, p < 0.05).

Objective To characterize the rate of guideline‐concordant initiation of oral anticoagulation (OAC) among elderly Veterans with atrial fibrillation (AF) and high stroke risk. Data Sources/Study Setting Veterans Health Administration (VHA) Corporate Data Warehouse (CDW) linked with Medicare claims 2011‐2015. Study Design We identified 6619 elderly, high stroke‐risk patients with a new episode of AF initially diagnosed in the VHA during fiscal years 2012‐2015. We used logistic regression to estimate marginal effects of associations between patient characteristics and OAC initiation within 90 days of the first AF episode. Data Extraction Methods We identified OACs using generic drug names. We calculated comorbidities and risk scores using diagnosis codes from 1 year of baseline data. Principal Findings Overall, 66.5% of Medicare‐eligible Veterans with AF at high risk of stroke initiated an OAC within 90 days. We found lower initiation rates for patients enrolled in Medicare Part D and those ineligible for drug co‐payment subsidies. OAC initiation rates increased during the study among VHA‐reliant patients but not among dual VHA‐Part D enrollees. Conclusions One‐third of elderly Veterans at risk of stroke are not receiving recommended therapy. Increased coordination between Medicare and VHA providers may lead to improvements in anticoagulation quality and stroke prevention.

There are few treatment options for patients with extensively drug-resistant gram-negative infections. Cefiderocol is a novel β-lactam with excellent in vitro activity against multidrug-resistant gram-negative isolates, including carbapenem-resistant strains. However, this drug performed poorly versus best available therapy in an open-label randomized study of carbapenem-resistant gram-negative infections. Here, we present a case of a 32-year-old man with necrotizing ventilator-associated pneumonia caused by Pseudomonas aeruginosa who developed resistance to meropenem and ceftolozane/tazobactam while on therapy. Addition of expanded-access cefiderocol to his antimicrobial regimen contributed to successful microbiological cure while limiting exposure to nephrotoxic therapeutic agents.