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OBJECTIVE: To review the treatment options for extended-spectrum beta-lactamase (ESBL) urinary tract infections (UTIs) in the long-term care facility setting.<br/> DATA SOURCES: A PubMed search from January 1, 1990, through December 31, 2018, using terms "extended spectrum beta lactamase" and "urinary tract infection" was performed. Current guidelines, drug databases, and manufacturer package inserts were also used.<br/> STUDY SELECTION: All English-language articles during the above time frame appearing in these searches were reviewed for relevance to this paper. In addition, their bibliographies were reviewed to identify any articles not originally identified.<br/> DATA SYNTHESIS: ESBL UTIs are a growing concern in the long-term care facility as these pathogens are becoming more prevalent. Patients residing in long-term care facilities have fewer treatment modalities because of medication administration and care issues. This review highlights the data on different antibiotics and their efficacy toward ESBLs in the setting of UTI.<br/> CONCLUSIONS: Despite the challenges and limitations, there are still options for clinicians to provide optimal care, including antibiotics with different routes of administration, as well as different administration techniques. Clinicians can be successful with treating ESBL UTIs in older adults.

Background: Antimicrobial stewardship programs (ASP) have been widely implemented in hospitals to improve antimicrobial use and prevent resistance. However, the role of ASP in the emergency department (ED) setting is not well defined. Objective: The objective of this study is to evaluate the impact of an ASP pharmacist culture review service in an ED. Methods: This was a retrospective, quasi-experimental study of all patients discharged from the ED with a positive culture. Patients discharged from the ED from February 1, 2015 to October 31, 2015 were managed by ED providers (pre-ASP), and those discharged from February 1, 2016 to October 31, 2016 were managed by a pharmacist-driven ASP (post-ASP implementation). The primary outcome was median time to change of antibiotic(s) in patients with inadequate antimicrobial therapy based on culture results. Secondary outcomes included time to culture evaluation, appropriateness of antimicrobials, and 30-day readmissions. Results: A total of 790 patients were included in the analysis (398 in pre-ASP group vs 392 in post-ASP implementation group). Median time to modification of inadequate antibiotic therapy decreased from 6.79 days in the pre-ASP group to 1.99 days in the post-ASP implementation group ( P < .0001). Median time to culture review decreased in the post-ASP implementation group from 9.83 to 0.32 days ( P < .0001). Appropriateness of culture-guided therapy increased in the post-ASP implementation group from 85.7 to 91.8% ( P = .047). The rate of combined ED revisits and hospital readmissions was similar between groups ( P = .367). Conclusion: ASP pharmacist evaluation of positive cultures in the ED was associated with a significant decrease in the time to appropriate therapy in patients discharged with inadequate therapy and higher rates of appropriate antimicrobial therapy.

Purpose Patients treated with therapeutic hypothermia (TH) and continuous insulin may be at increased risk of hyperglycemia or hypoglycemia, particularly during temperature transitions. This study aimed to evaluate frequency of glucose excursions during each phase of TH and to characterize glycemic control patterns in relation to survival. Methods Patients admitted to a tertiary care hospital for circulatory arrest and treated with both therapeutic hypothermia and protocol-based continuous insulin between January 2010 and June 2013 were included. Glucose measures, insulin, and temperatures were collected through 24 hours after rewarming. Results 24 of 26 patients experienced glycemic excursions. Hyperglycemic excursions were more frequent during initiation versus remaining phases (36.3%, 4.3%, 2.5%, and 4.0%, p = 0.002). Hypoglycemia occurred most often during rewarming (0%, 7.7%, 23.1%, and 3.8%, p = 0.02). Patients who experienced hypoglycemia had higher insulin doses prior to rewarming (16.2 versus 2.1 units/hr, p = 0.03). Glucose variation was highest during hypothermia and trended higher in nonsurvivors compared to survivors (13.38 versus 9.16, p = 0.09). Frequency of excursions was also higher in nonsurvivors (32.3% versus 19.8%, p = 0.045). Conclusions Glycemic excursions are common and occur more often in nonsurvivors. Excursions differ by phase but risk of hypoglycemia is increased during rewarming.