Search PubMed⌕ Search

Biomedical subjects

Bradley A Boucher

Publications and source records attributed to Bradley A Boucher.

16 recordsLinked to original sources
PubMed2006

A comprehensive approach to faculty development.

The purpose of this report was to describe the development, implementation, and outcomes from 3 complementary programs to facilitate the development of faculty members. The Faculty Development Committee (FDC) at the University of Tennessee developed 3 new complementary programs: the Individual Faculty Development Program to encourage faculty members to assess and identify their own specific developmental needs; the Seed Research Grant Program to fund scholarly activities by faculty; and the Technology Support Program to foster financial support of technology upgrades crucial for meeting the research, education, and service needs of faculty members. Eighteen faculty members participated in the Individual Faculty Development Program during the first 2 academic years and all provided positive feedback about their experiences. The Seed Research Grant Program funded 6 projects during its inaugural year. Limited outcome data from these 2 programs are extremely favorable relative to grant submissions and publications, and enhanced educational offerings and evaluations. The Technology Support Fund was initiated in the 2005-2006 academic year. The 3 faculty development programs initiated are offered as examples whereby faculty members are given a high degree of self-determination relative to identifying programs that will effectively contribute to their growth as academicians. Other colleges of pharmacy are encouraged to consider similar initiatives to foster individual faculty development at this critical period of growth within academic pharmacy.

Capital Financing↗
PubMed2006

Candida sp. isolated from bronchoalveolar lavage: clinical significance in critically ill trauma patients.

OBJECTIVE: Based on limited data, Candida sp. isolates from bronchoalveolar lavage (BAL) cultures in immunocompetent patients are thought to be contaminants rather than pathogens. The objective of this study was to determine the clinical significance of Candida sp. isolated from BAL cultures in critically ill trauma patients. DESIGN AND SETTING: Retrospective study in a level 1 trauma intensive care unit. PATIENTS AND PARTICIPANTS: All patients with Candida sp. isolated from BAL cultures over a 3-year period; 85 Candida positive BAL cultures from 62 patients were studied. MEASUREMENTS AND RESULTS: The primary outcomes were the incidence of Candida sp. in BAL, antifungal use, course of the possible infection, and mortality. Of 1077 BAL cultures 85 (8%) grew Candida sp., representing 64 episodes of possible Candida sp. ventilator-associated pneumonia. No colony counts exceeded the diagnostic threshold for bacterial VAP (>or=10(5) cfu/ml). Only 2 of 64 episodes (3%) were treated with systemic antifungals. Three other episodes (5%) were treated because of concomitant therapy for Candida sp. at other sites. The majority of episodes were not treated with antifungals and were considered contaminants (59/64, 92%). No patients developed subsequent candidemia, and most follow-up BALs (74%) were negative for Candida sp. Overall mortality (17%) was similar to previous patients with similar severity of injury at the study center (18%). CONCLUSIONS: The results of this study suggest that isolation of Candida sp. from BAL in quantities below the diagnostic threshold for VAP in this population does not require antifungal therapy.

Adult↗
PubMed2006

Pharmacokinetic changes in critical illness.

Physiologic alterations in critically ill patients can significantly affect the pharmacokinetics of drugs used in the critically ill patient population. Understanding these pharmacokinetic changes is essential relative to optimizing drug therapy. This article outlines the major differences seen in the absorption, distribution, metabolism, and excretion of drugs in critically ill patients. Important strategies for drug therapy dosing and monitoring in these patients are also addressed.

Biological Availability↗
PubMed2006

The futility of the clinical pulmonary infection score in trauma patients.

INTRODUCTION: The Clinical Pulmonary Infection Score (CPIS) has received much attention recently. Advocates have touted its use for the diagnosis and duration of therapy in patients with ventilator-associated pneumonia (VAP). However, little has been written about its utility in trauma patients. The clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury. Quantitative cultures of the lower airway have been shown to be efficacious in differentiating VAP from the systemic inflammatory response syndrome (SIRS). In this study, we evaluated the potential use of CPIS as the sole means for diagnosis of VAP in critically injured patients. METHODS: Patients were identified from the VAP database maintained in our Level I trauma center. Only those who had CPIS calculated at the time of bronchoscopy with BAL were included. VAP required >or=10 colonies/mL on quantitative BAL for diagnosis. Antibiotic therapy was based on quantitative BAL results. Patients with <10 colonies/mL were diagnosed with SIRS. Sensitivity and specificity of a CPIS>6 for VAP diagnosis (confirmed by BAL) were calculated. RESULTS: In all, 158 patients underwent 285 BALs. The overall incidence for VAP was 42%. Patients with episodes of VAP and SIRS were well matched for age, Injury Severity Score, APACHE II score, and Glasgow Coma Scale score. The average CPIS was 6.8 in patients with SIRS and 6.9 for those with VAP. Using a CPIS>6 as the threshold for VAP only yielded a sensitivity of 61% and a specificity of 43%. CONCLUSIONS: CPIS cannot differentiate VAP from SIRS in critically injured patients. Using CPIS to initiate antibiotic therapy in trauma patients could be harmful. Whether CPIS is useful to determine duration of antibiotic therapy is unknown.

Adult↗
PubMed2005

Evaluation of a clinical pathway for ventilator-associated pneumonia: changes in bacterial flora and the adequacy of empiric antibiotics over a three-year period.

BACKGROUND: Evaluation of causative pathogens is vital for optimizing empiric antibiotic therapy of ventilator-associated pneumonia (VAP). Based on previous data (Ann Surg 1998;227:743-755), empiric antibiotics for our VAP clinical pathway were modified to target early and late occurring pathogens (ampicillin/sulbactam during the first week of hospitalization; cefepime plus vancomycin afterwards). The objectives of this study were to compare organisms causing VAP over a three-year period to previous data, and to determine the adequacy of the empiric antibiotic regimens. METHODS: A total of 299 critically ill trauma patients with VAP over a three-year period were studied retrospectively. The incidence of pathogens causing VAP in the study period were compared to a previously published study of a two-year period in our intensive care unit (ICU). Sensitivities of Pseudomonas aeruginosa and Acinetobacter baumannii were evaluated over the study period. The adequacy of empiric antibiotic therapy for each episode of VAP was determined. Therapy was considered to be adequate if one or more antibiotics had in vitro activity against the organism causing VAP. RESULTS: Statistically significant changes in pathogens included increased Staphylococcus aureus (incidence 17% vs. 11%, p = 0.024) and decreased Acinetobacter baumannii (11% vs. 22%, p < 0.001). Susceptibility patterns were statistically unchanged except for increased resistance of P. aeruginosa to extended-spectrum penicillins (p = 0.016). Empiric therapy was adequate in 76% of VAP episodes. CONCLUSIONS: The clinical pathway's empiric antibiotic regimen was associated with only modest changes in organisms causing VAP and provided a high rate of adequate empiric coverage.

Adult↗
PubMed2005

Effect from multiple episodes of inadequate empiric antibiotic therapy for ventilator-associated pneumonia on morbidity and mortality among critically ill trauma patients.

BACKGROUND: Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). The impact of inadequate empiric antibiotic therapy (IEAT) may vary among critically ill populations. The purpose of this retrospective study was to determine the effect of IEAT on the outcome for adult trauma patients with VAP. METHODS: This study enrolled 82 patients with multiple VAP episodes (200 VAP episodes; mean, 2.4 +/- 0.65 per patient; range, 2-5 episodes). An episode of IEAT was a VAP episode with empiric therapy having no in vitro activity against causative bacteria. Overall, there were 78 (39%) IEAT episodes involving 54 patients. Most often, IEAT was attributable to the presence of Acinetobacter spp, Stenotrophomonas maltophilia, or Alcaligenes xylosoxidans. All the patients received appropriate definitive therapy according to the final culture. The patients were classified by number of IEAT episodes: 0 (n = 28), 1 (n = 34), and more than 1 (n = 20). RESULTS: Demographics and injury severity were similar among the groups. The mortality rate was 3.6% for no episodes, 8.8% for one episode, and 45% for more than one episode (p < 0.001). On the basis of multiple logistic regression, experiencing multiple IEAT episodes was independently associated with the risk of death (odds ratio, 4.28; 95% confidence interval, 1.44-12.71). Additionally, experiencing multiple IEAT episodes was associated with prolonged intensive care unit stay (p = 0.007) and prolonged mechanical ventilation (p = 0.005). CONCLUSIONS: Critically ill trauma patients experiencing multiple episodes of IEAT for VAP have increased morbidity and mortality. These findings reinforce the importance of developing and refining a unit-specific pathway for the empiric management of VAP.

Adult↗
PubMed2004

The appropriate diagnostic threshold for ventilator-associated pneumonia using quantitative cultures.

BACKGROUND: The use of quantitative cultures of the bronchoalveolar lavage (BAL) effluent to distinguish between posttraumatic inflammatory response and ventilator-associated pneumonia (VAP) is becoming more common. However, the diagnostic threshold of either 10 or 10 colonies/mL remains debatable. Because mortality from VAP is related to treatment delay, some have chosen a lower diagnostic threshold (>10 colonies/mL). This may result in unnecessary antibiotic use with its sequelae: increased resistant organisms, antibiotic-related complications, and increased costs. The purpose of this study is to determine the optimal diagnostic threshold for VAP diagnosis using quantitative cultures of the BAL effluent. METHODS: Data on patients with fiberoptic bronchoscopy with BAL are maintained in a prospectively collected database at our Level I trauma center. This database was reviewed for timing and frequency of BAL and the colony counts of each organism identified. Indication for bronchoscopy was clinical evidence of VAP. VAP was defined as >10 colonies/mL in the BAL effluent. A false-negative BAL was defined as any patient who had <10 colonies/mL and developed VAP with the same organism up to 7 days after the previous culture. RESULTS: Over a 46-month period, 526 patients underwent 1,372 fiberoptic bronchoscopy procedures with BAL. Of these, 72% were male patients, 91% followed blunt injury, and mean age and Injury Severity Score were 43 years and 30, respectively. Overall mortality was 14%. There were 1,898 organisms identified (42% were gram-positive and 58% were gram-negative). VAP was diagnosed in 38% of BAL. Overall, there were 43 episodes in 38 patients defined as false-negative (3%). The false-negative rate was 9% in patients with 10 organisms. The most common false-negative organisms were Pseudomonas and Acinetobacter species. CONCLUSION: The VAP diagnostic threshold for quantitative BAL in trauma patients should be >10 colonies/mL. One may consider a threshold of >10 colonies/mL in severely injured patients with Pseudomonas or Acinetobacter species.

Adult↗
PubMed2003

Tetracyclines for treating multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia.

OBJECTIVE: To report the use of tetracyclines for the treatment of multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia (VAP). DESIGN: Observational case series. SETTING: . The Presley Regional Trauma Center located within the Regional Medical Center, Memphis, Tennessee, USA. PATIENTS AND PARTICIPANTS: Seven critically ill trauma patients with VAP caused by A. baumannii isolates that were resistant to all antibiotics tested except for doxycycline or minocycline. INTERVENTIONS: Patients were treated with IV doxycycline or minocycline for an average of 13.5 (range 9-20) days. MEASUREMENTS AND RESULTS: Doxycycline or minocycline was successful in six of seven patients. CONCLUSIONS: Doxycycline or minocycline may be effective for treating multidrug-resistant A. baumannii VAP.

APACHE↗
PubMed2003

The predictive value of preliminary bacterial colony counts from bronchoalveolar lavage in critically ill trauma patients.

A common strategy for the diagnosis of ventilator-associated pneumonia (VAP) includes quantitative cultures from bronchoalveolar lavage (BAL). Often, empiric antibiotic therapy is initiated and continued until the final culture report. However, approximately 60 per cent of BAL cultures rule out VAP. Preliminary BAL results, obtained earlier, may identify these patients and allow early discontinuation of empiric antibiotics. This is desirable because unnecessary antibiotic therapy results in increased bacterial resistance, adverse drug events, and increased costs. The purpose of this study was to determine the value of preliminary BAL results for predicting final BAL results. A total of 1579 isolates from 868 BAL cultures over a 3-year period were analyzed. Preliminary and final colony counts for each isolate were categorized as either no growth (NG), insignificant (1-99,999 cfu/mL), or significant (> or = 100,000 cfu/mL). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preliminary results were calculated based on individual isolates and individual BAL samples. The presence of concurrent antibiotic therapy was collected for all false-negative isolates. On preliminary report, there were 367 isolates with NG, 820 isolates with insignificant growth, and 392 isolates with significant growth. Overall preliminary culture results had a sensitivity of approximately 90 per cent and specificity of >90 per cent for the presence of VAP. Preliminary culture results accurately predicted the presence or absence of VAP in 838 (96.5%) of the BALs performed. Individual isolates and BAL samples with insignificant preliminary growth had greater reliability in predicting the absence of VAP than those with NG. There was no difference in the number of false-negative isolates that were taken while concurrent antibiotic therapy was present between insignificant and NG groups. Preliminary culture results yielding either insignificant or significant growth are highly predictive for final colony counts of similar magnitude. BALs with preliminary results demonstrating no growth are not as reliable. Isolates with significant preliminary growth should be considered clinically important, and antibiotic therapy should be changed, if necessary, to target such organisms. Isolates with insignificant preliminary growth have a low rate of false negatives; therefore, empiric antibiotic therapy specific for such organisms could be discontinued before obtaining final results. Empiric antibiotics should be continued until the final results are available in those patients with NG BALs.

Adult↗
PubMed2002

Risk factors for late-onset nosocomial pneumonia caused by Stenotrophomonas maltophilia in critically ill trauma patients.

Patients with nosocomial pneumonia caused by Stenotrophomonas maltophilia often receive inadequate empiric antibiotic therapy, potentially increasing mortality. Knowledge of the risk factors associated with S. maltophilia pneumonia may better guide the selection of empiric antibiotic therapy. Potential risk factors for S. maltophilia pneumonia were retrospectively analyzed for critically ill trauma patients with late-onset gram-negative pneumonia. The effects of S. maltophilia infection and inadequate empiric antibiotic therapy on patient outcomes were also assessed. By multivariate analysis, S. maltophilia pneumonia was found to be associated with cefepime exposure and tracheostomy in patients with a single pneumonia episode and with higher Injury Severity Score and pulmonary contusion in patients with multiple pneumonia episodes. S. maltophilia pneumonia was associated with increased patient morbidity; only inadequate empiric antibiotic therapy was associated with a higher mortality rate. In critically ill trauma patients with late-onset ventilator-associated pneumonia and these risk factors, empiric antibiotic therapy should include agents active against S. maltophilia.

Adult↗
PubMed2002

Comparison of ampicillin-sulbactam and imipenem-cilastatin for the treatment of acinetobacter ventilator-associated pneumonia.

Acinetobacter organisms, which are a common cause of ventilator-associated pneumonia (VAP) in some health care centers, are becoming more resistant to such first-line agents as imipenem-cilastatin (Imi-Cil). Sulbactam has good in vitro activity against Acinetobacter organisms; thus, ampicillin-sulbactam (Amp-Sulb) may be a viable treatment alternative. The outcomes for critically ill trauma patients with Acinetobacter VAP treated with either Amp-Sulb or Imi-Cil were compared retrospectively. A total of 77 episodes in 75 patients were studied. Fourteen patients were treated with Amp-Sulb, and 63 patients were treated with Imi-Cil. Treatment efficacy was similar in the Amp-Sulb and Imi-Cil groups (93% vs. 83%, respectively; P>.05). No statistically significant differences between groups were noted with regard to associated mortality, duration of mechanical ventilation, or length of stay in the intensive care unit or hospital. However, adjunctive aminoglycoside therapy was used more often in the Amp-Sulb group. Patients generally received Amp-Sulb because of imipenem resistance. Amp-Sulb was effective in treating a small number of patients with Acinetobacter VAP; however, more data are needed.

Acinetobacter↗
PubMed2002

Aerosolized ceftazidime for prevention of ventilator-associated pneumonia and drug effects on the proinflammatory response in critically ill trauma patients.

STUDY OBJECTIVES: To evaluate the safety and efficacy of aerosolized ceftazidime for prevention of ventilator-associated pneumonia (VAP) and to evaluate the effects of the drug on the proinflammatory response. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: University teaching hospital. PATIENTS: Forty critically ill trauma patients at high risk for VAP Intervention. Within 48 hours of admission to the intensive care unit (ICU), patients were randomly assigned to receive aerosolized ceftazidime 250 mg every 12 hours or placebo (normal saline) for up to 7 days. Bronchoalveolar concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, IL-6, and IL-8 were determined at baseline and the end of therapy (days 4-7). MEASUREMENTS AND MAIN RESULTS: The frequency of VAP in patients receiving aerosolized ceftazidime was 73% lower than that in patients receiving placebo at ICU day 14 (15% vs 55%, p = 0.021), and 54% lower for the entire ICU stay (30% vs 65%, p = 0.022). No clinically significant changes in bacterial culture and sensitivity patterns were observed. No adverse events from aerosolized ceftazidime were reported. Pulmonary TNF-alpha, IL-beta, and IL-8 concentrations were attenuated in the ceftazidime group compared with those in the placebo group (p < 0.001, p = 0.02, and p = 0.003). The frequency of VAP was related directly to changes in TNF-alpha and IL-beta (p < 0.001, p = 0.02). CONCLUSIONS: Aerosolized ceftazidime decreased the frequency of VAP in critically ill trauma patients, without adversely affecting ICU flora. Aerosolized ceftazidime also may attenuate the proinflammatory response in the lung.

Adult↗
PubMed2002

Lactobacillus species as a cause of ventilator-associated pneumonia in a critically ill trauma patient.

Lactobacillus species are ubiquitous inhabitants of the human gastrointestinal and genitourinary tracts and rarely cause infections. Pneumonia caused by Lactobacillus has been reported only in immunocompromised patients and in one patient with structural lung disease. A 39-year-old, immunocompetent, critically ill woman developed ventilator-associated pneumonia, which was found to be caused by Lactobacillus. To our knowledge, this is the first such report. The infection was treated successfully with 14 days of intravenous vancomycin. Based on this case, Lactobacillus should be considered a possible cause of ventilator-associated pneumonia in immunocompetent, critically ill patients.

Accidents, Traffic↗