BackgroundEnterobacteriaceae, which include Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis, are identified as the infectious etiology in the majority of urinary tract infections (UTIs) in community hospitals across the United States. The minimum inhibitory concentration (MIC) is a useful tool when choosing an appropriate antibacterial agent. Recent changes to the 2014 Clinical and Laboratory Standards Institute (CLSI) guidelines included reporting a urine-specific cefazolin breakpoint for enterobacteriaceae (susceptible ≤16 mcg/mL). The purpose of this study was to determine the clinical and financial impact of implementing the 2014 CLSI urine-specific breakpoints for cefazolin in a community-based teaching hospital in the Southern U.S.A.MethodsA retrospective review of patients hospitalized from January 1, 2010 through October 1, 2014 was performed. Patients that met inclusion criteria had a documented initial clinical isolate of E. coli, K. pneumoniae, or P. mirabilis from urine cultures during each year. Descriptive statistics and two-proportion test of hypothesis were used in the analysis to compare susceptibility rates before and after implementation of the updated CLSI breakpoints for cefazolin.ResultsA total of 190 clinical isolates from patients were included in the study. E. coli was the most common organism isolated (63.7%), followed by K. pneumoniae (22.1%), and P. mirabilis (14.2%). 86% of the included isolates were susceptible to cefazolin using the 2010 breakpoints. Implementation of the 2014 breakpoints did not significantly impact susceptibility results for E. coli, K. pneumoniae, or P. mirabilis. ConclusionModification of breakpoints did not significantly impact susceptibility rates of cefazolin. Substituting cefazolin may decrease the overall drug cost by 77.5%. More data is needed to correlate in vitro findings with clinical outcomes using cefazolin for UTIs.

Background: Psychological insulin resistance (PIR) refers to psychological opposition towards insulin therapy. Although not a formal psychological diagnosis, PIR is an under-recognized issue clinicians may encounter when treating patients with diabetes requiring insulin therapy. Methods: Review articles, clinical trials, and practice guidelines were located using online databases. A total of 39 abstracts were reviewed and 11 articles were included in the analysis. Results: Eleven articles were included. Proposed strategies used to mitigate the occurrence of PIR include: identifying the patient's personal obstacles via administration of PIR questionnaires, use of insulin pens as opposed to conventional syringe and needle, education on the risk of hypoglycemia and continuous emphasis of the importance of self-monitoring of blood glucose (SMBG) readings. Discussion: The management of type 2 diabetes mellitus (T2DM) in patients requiring insulin may present challenges such as PIR. Tailoring a patient's treatment plan to account for physiological, psychological, social and financial needs may thwart some of these challenges. Other factors to consider include the cost of the agent and/or devices required. Insulin-dependent patients with T2DM should be assessed for both physiological and psychological changes. Conclusion: Current treatment strategies for clinicians treating T2DM patients with PIR include administering the PIR or BIT questionnaire, initiating lower doses of insulin, switching from insulin vials to insulin pens, including assessment results in individualized treatment plans and using clinical outcomes to screen patients who are at risk for refusing the use of insulin. Further research evaluating clinical outcomes associated with treatment strategies is necessary.

respectively. The mean age for men and women were 62.6 and 61.5, respectively. Several patients demonstrated multiple emboli; to wit, 273 distinct PEs were noted among the 160 individual patients. 107 right sided emboli were found (39.2%), 50 left sided (18.3%), and 116 patients demonstrated bilateral PEs (42.5%). Conclusions: Incidence of right-sided PE exceeded left-sided PE and bilateral involvement exceeded both. Additionally, PE were more common in lower segments (24.9%) than upper segments (17.6%). The increased size of the right lung compared to the left may contribute to the tendency of emboli to locate to the right side. The clinical significance of the right-sided preference suggests an elevated PE-associated mortality risk in patients with unilateral left lung disease.Learning Objectives: Treatment of Acute Exacerbated Chronic Obstructive Pulmonary Disease (AECOPD) consists of multiple therapies including systemic steroids. AECOPD may require hospitalization and mechanical ventilation. Controversial literature exists regarding optimal dosing and duration for steroid therapy. The primary objective was to clarify the dosing of methylprednisolone (MP) for AECOPD by assessing re-intubation rates within 30 days of extubation. Secondary objectives include ICU length of stay, time on mechanical ventilation, duration of steroid therapy, insulin requirements and mortality. Methods: A retrospective review of medical intensive care unit (MICU) patients admitted at WVU Healthcare from January 1, 2009 through December 31, 2014. Patients receiving ≥72 hr of MP during hospitalization were screened. Selected patients were stratified by the initial daily MP dosing regimen -(low dose-LD ≤ 160mg, medium dose-MD 161 -239mg and high dose-HD ≥ 240mg). Descriptive statistics were used for baseline characteristics and to compare variables between groups. Results: Total of 157 patients screened, 116 were enrolled (LD [n=47], MD [n=7] and HD [n=62]). Included patients had a history of smoking (29%), home oxygen therapy (46%) and diabetes (35%). Only 1% of patients (n=2) were re-intubated within 30 days of initial extubation and 2 patients died. There was no difference in ICU length of stay or days on the ventilator in all groups (3-6 days). Overall, patients received 7-9 days of therapy. Interestingly, 25% of patients had changes to insulin therapy and 11 patients (LD [n=4] and HD [n=7]) received an insulin drip. Conclusions: Results failed to demonstrate a difference in re-intubation rates between groups. No differences in ICU length of stay, time on ventilation, duration of steroid therapy, insulin requirements and mortality was seen. These results warrant prospective dose finding studies to determine the appropriateness of a LD regimen in order to achieve optimal clinical outcomes in this population.