In this episode I’ll:
1. Discuss an article about double carbapenem use in severe carbapenemase-producing Klebsiella pneumoniae infections.
2. Answer the drug information question “What is the dose of dexamethasone in cerebral edema associated with a brain tumor or craniotomy?”
3. Share a resource for therapeutic hypothermia.
The article for this episode recently appeared in a weekly literature digest for members of my Critical Care Pharmacy Academy. Every week I send Academy members a summary of the most important critical care pharmacy articles, including my analysis of where the article fits in practice. You can find out more at pharmacyjoe.com/academy.
Article
Lead author: Gennaro De Pascale
Published in Critical Care July 2017
Background
Severe infections due to carbapenem-resistant Klebsiella pneumoniae carry a high risk of mortality. Alternative antibiotics are either highly toxic (such as colistin or gentamicin) or bacteriostatic (such as tigecycline). Case reports have suggested the efficacy of a double carbapenem combination, including ertapenem, for the treatment of carbapenem-resistant Klebsiella pneumoniae infections. The authors of this study sought to evaluate the clinical impact of a double carbapenem regimen in critically ill patients.
Methods
The study was a case-control, observational, two-center study involving critically ill adults with a documented carbapenem-resistant Klebsiella pneumoniae invasive infection. Patients were treated with a double carbapenem regimen or a standard treatment such as colistin, tigecycline, or gentamicin.
Results
Forty-eight patients treated with a double carbapenem regimen were matched with 96 controls treated with standard therapy. The primary end point was 28-day mortality and secondary end points were clinical cure, microbiological eradication, duration of mechanical ventilation, duration of vasopressors, and 90-day mortality.
The double carbapenem group may have had more severe infection as the initial occurrence of septic shock and elevated procalcitonin levels were significantly more frequent in patients receiving double carbapenem treatment (p < 0.01). However, the 28-day mortality was 47.9% in patients receiving standard treatment compared with 29.2% in the double carbapenem group. This difference was statistically significant. Clinical cure and microbiological eradication were also significantly higher in the double carbapenem group.
Conclusion
The authors concluded:
Improved 28-day mortality was associated with the DC regimen compared with ST for severe CR-Kp infections. A randomized trial is needed to confirm these observational results.
Discussion
It seems that a double carbapenem regimen is an appropriate treatment option for carbapenem-resistant Klebsiella pneumoniae. The double carbapenem regimen used in this study was meropenem and ertapenem. Meropenem was given every 8 hours as an extended infusion for a total daily dose of 6 grams. Ertapenem was given as an extended infusion every 12 or 24 hours for a total daily dose of 2 grams.
Drug information question
Q: What is the dose of dexamethasone in cerebral edema associated with a brain tumor or craniotomy?
A: 10 mg IV dexamethasone once, then 4 mg IV every 6 hours until edema subsides.
The dexamethasone can then be switched to an enteral regimen and tapered over a few days. This dose is empirical, and patient specific factors may warrant a change in dosage regimen.
Resource
The resource for this episode is the Post-Cardiac Arrest Care/Therapeutic Hypothermia Resource Page provided by the University of Pennsylvania. The resource page includes protocols, research citations, and educational material for clinicians as well as families. The majority of content on these resource pages focus on therapeutic hypothermia and practical issues of how hospitals can develop protocols for use.
Also found in these pages is a phone number for the hypothermia research group at UPenn. I’ve called this number previously with a difficult hypothermia with concomitant CRRT rewarming case and was quickly put in touch with a clinician who consulted with a UPenn nephrologist and pharmacist to give guidance on the case. Shoutout to “NP Meagan” for the idea of calling UPenn!
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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