Itraconazole for COVID-19: preclinical studies and a proof-of-concept randomized clinical trial

BACKGROUND

The antifungal drug itraconazole exerts in vitro activity against SARS-CoV-2 in Vero and human Caco-2 cells. Preclinical and clinical studies are required to investigate if itraconazole is effective for the treatment and/or prevention of COVID-19.

METHODS

Due to the initial absence of preclinical models, the effect of itraconazole was explored in a clinical, proof-of-concept, open-label, single-center study, in which hospitalized COVID-19 patients were randomly assigned to standard of care with or without itraconazole. Primary outcome was the cumulative score of the clinical status until day 15 based on the 7-point ordinal scale of the World Health Organization. In parallel, itraconazole was evaluated in a newly established hamster model of acute SARS-CoV-2 infection and transmission, as soon as the model was validated.

FINDINGS

In the hamster acute infection model, itraconazole did not reduce viral load in lungs, stools or ileum, despite adequate plasma and lung drug concentrations. In the transmission model, itraconazole failed to prevent viral transmission. The clinical trial was prematurely discontinued after evaluation of the preclinical studies and because an interim analysis showed no signal for a more favorable outcome with itraconazole: mean cumulative score of the clinical status 49 vs 47, ratio of geometric means 1.01 (95% CI 0.85 to 1.19) for itraconazole vs standard of care.

INTERPRETATION

Despite in vitro activity, itraconazole was not effective in a preclinical COVID-19 hamster model. This prompted the premature termination of the proof-of-concept clinical study.

FUNDING

KU Leuven, Research Foundation - Flanders (FWO), Horizon 2020, Bill and Melinda Gates Foundation.

Ultra-performance liquid chromatography for quantification of amphotericin B plasma concentrations after use of liposomal amphotericin B

OBJECTIVES

Liposomal amphotericin B is widely used to treat life-threatening invasive fungal infections and has replaced conventional amphotericin B deoxycholate due to its more favourable toxicity profile. Despite the fact that liposomal amphotericin B has been licensed for several decades, there is still a paucity of clinical pharmacokinetic data. An assay for the quantification of amphotericin B is necessary to allow the study of its pharmacokinetics.

METHODS

A UPLC-photodiode array (PDA) analytical method was developed and validated (linearity, accuracy, precision, dilution integrity, carry-over, selectivity and stability) in accordance with EMA requirements.

RESULTS

The analytical method was validated over a concentration range of 0.5-50.0 mg/L. Accuracy ranged from 97.6% to 112.1% and within-day repeatability and between-day reproducibility from 1.0% to 6.6% and from 0.4% to 4.6%, respectively, dependent on the concentration. Originally, the goal was to develop an analytical method to separate the liposomal and free amphotericin B fractions, but this was not achieved. Difficulties and bottlenecks encountered are presented.

CONCLUSIONS

A UPLC-PDA analytical method was developed to quantify total amphotericin B in plasma after the use of liposomal amphotericin B.

Prevalence of Antibiotic Allergy Labels in a Tertiary Referral Center in Belgium

BACKGROUND

Antibiotic (AB) allergies are among the most frequently occurring adverse drug reactions. In US literature, AB allergy labels (AAL) are reported in 10% to 15% of patients' charts; however, large-scale European analyses are scarce.

OBJECTIVES

To retrospectively assess the prevalence of AAL in a tertiary referral hospital in Belgium between 2010 and 2018.

METHODS

Patients who consulted and/or were hospitalized during the study period, who had been labeled with an AB allergy, were selected for further analysis.

RESULTS

Of 1,009,598 unique patients (outpatients, n = 736,469; inpatients, n = 273,129), 28,147 patients (3%) were registered with 1 or more AAL, being 1% of outpatients (n = 9562) and 7% of inpatients (n = 18,585). Women were more likely to carry an AAL (68%) compared with men (32%, P < .001). In patients with an AAL, 9% had multiple labels and 5% had labels for multiple AB classes. Most frequently, beta-lactams were involved (84% of AAL), followed by quinolones (7%) and sulfonamides and macrolides (both 3%). Moreover, 88% of the reactions were self-reported, mostly being an unspecified rash (53%), whereas only 3% were considered confirmed AAL.

CONCLUSION

With an overall prevalence of 3%, the burden of AAL is less in our Western European center compared with US reports. However, this prevalence most likely still represents an overestimation of genuine AB allergic patients because most labels lack confirmation and/or specifications. Our work indicates that knowledge of the local epidemiology of AAL is necessary to estimate the impact of better allergy labeling and delabeling strategies.

Guidance for Demonstrating the Societal Value of new Antibiotics

Given that antibiotic use is associated with externalities, standard economic evaluation which considers costs and health gains accruing to patients under-values antibiotics. Informed by a scoping review, this discussion paper aims to identify the societal value elements of antibiotics and to provide guidance on how these value elements can be incorporated in economic evaluation. With a view to appropriately quantify the societal value of antibiotics, there is a need for good practice guidelines on the methodology of economic evaluation for such products. We argue that it is important to assess antibiotics at population level to account for their transmission, diversity, insurance, spectrum, novel action and enablement values. In addition to the value of antibiotics to infected patients, economic evaluations need to use modeling approaches to explore the impact of different modes of employing new and existing antibiotics (for example, as last resort treatment) on disease transmission and resistance development in current and future patients. Hence, assessing the value of antibiotics also involves an ethical dimension. Further work is required about how the multiple value elements of antibiotics are linked to each other and how they can be aggregated.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis

BACKGROUND

Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing.

METHODS

A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period.

RESULTS

At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p < .0001) in pain-related residual PIPs. A significant decreasing time trend was observed during the post-implementation period. Post-implementation, 1683 recommendations were given over 1 year with an acceptance rate of 74.3%.

CONCLUSIONS

We proved that the CMA approach reduced the number of pain-related residual PIPs. More pharmacist involvement and the use of clinical rules during hospital stay should be further promoted to optimize appropriate prescribing of analgesics.

SIGNIFICANCE

Prescribing of analgesics should be improved in inpatients to optimize pain control and to reduce iatrogenic harm. The Check of Medication Appropriateness (CMA) approach, comprising a clinical rule-based screening for patients at risk and a targeted medication review by pharmacists, reduced the number of pain-related potentially inappropriate prescriptions in a highly significant and sustained manner. This study presents the opportunities of a centralized clinical pharmacy service to help clinicians to further improve analgesic prescribing.

Favipiravir at high doses has potent antiviral activity in SARS-CoV-2-infected hamsters, whereas hydroxychloroquine lacks activity

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly spread around the globe after its emergence in Wuhan in December 2019. With no specific therapeutic and prophylactic options available, the virus has infected millions of people of which more than half a million succumbed to the viral disease, COVID-19. The urgent need for an effective treatment together with a lack of small animal infection models has led to clinical trials using repurposed drugs without preclinical evidence of their in vivo efficacy. We established an infection model in Syrian hamsters to evaluate the efficacy of small molecules on both infection and transmission. Treatment of SARS-CoV-2-infected hamsters with a low dose of favipiravir or hydroxychloroquine with(out) azithromycin resulted in, respectively, a mild or no reduction in virus levels. However, high doses of favipiravir significantly reduced infectious virus titers in the lungs and markedly improved lung histopathology. Moreover, a high dose of favipiravir decreased virus transmission by direct contact, whereas hydroxychloroquine failed as prophylaxis. Pharmacokinetic modeling of hydroxychloroquine suggested that the total lung exposure to the drug did not cause the failure. Our data on hydroxychloroquine (together with previous reports in macaques and ferrets) thus provide no scientific basis for the use of this drug in COVID-19 patients. In contrast, the results with favipiravir demonstrate that an antiviral drug at nontoxic doses exhibits a marked protective effect against SARS-CoV-2 in a small animal model. Clinical studies are required to assess whether a similar antiviral effect is achievable in humans without toxic effects.

Physician's feedback on a clinical pharmacy program on geriatric wards

OBJECTIVES

As clinical pharmacy (CP) services can improve drug use and clinical outcome in older inpatients, a dedicated CP program was installed at the geriatric wards of an academic hospital. The aim of this study was to evaluate and potentially improve the CP program, by obtaining physician's feedback.

METHODS

An anonymous e-questionnaire was sent to all physicians who were active between October 2014 and March 2018 on the acute geriatric wards (80 beds) of the University Hospitals Leuven, Belgium. Thematic content analysis was applied. Six themes were defined: satisfaction with the service, time allocation of the clinical pharmacists, content and clinical relevance of pharmaceutical interventions, communication, time savings for the treating physician and future perspectives.

RESULTS

A total of 45 physicians (59%) completed the e-questionnaire. All respondents were satisfied with the content of the provided pharmaceutical recommendations. A minority (44%) found that a 0.8 full-time equivalent clinical pharmacist presence was sufficient in terms of the expected workload. The provided CP interventions improved quality of care according to 38 (84%) physicians. Oral and written communication were considered necessary by 89% and 82% of physicians, respectively. On average, an estimated 30 minutes physician time (IQR: 15-60) per patient was saved as a result of the program. The majority (87%) preferred clinical pharmacist presence for discharge support in all geriatric patients.

CONCLUSION

Physician's satisfaction with the CP service was very high. CP services in geriatric inpatients were perceived to be clinically relevant as well as time-saving by the involved physicians.

Preoperative joint aspiration culture results and causative pathogens in total hip and knee prosthesis infections: mind the gap

OBJECTIVES

In prosthetic joint infections (PJIs), there is no consensus about the utility of the preoperative joint aspiration culture to guide antimicrobial treatment. The main objective of this retrospective study was to investigate the value of these preoperative samples to narrow immediate postoperative empirical antimicrobial treatment in patients with a knee or hip PJI.

METHODS

Adult patients admitted for an exchange procedure between June 2007 and July 2016 for whom a preoperative joint aspiration within 6 months prior to the procedure was available and with an antibiotic-free interval before sampling, were eligible. Per PJI, taking both preoperative joint aspiration and intraoperative deep samples into account, causative pathogen(s) were assessed by the current Infectious Diseases Society of America (IDSA) guidelines. Per PJI, agreement of preoperative joint aspiration cultures corresponding to the causative pathogen(s) was investigated both on species and on Gram/fungi level.

RESULTS

From the 85 PJIs, on species level, the total agreement was found in 58 (68%) PJIs. On Gram/fungi level, when preoperative joint aspiration cultures yielded exclusively Gram-positive microorganisms (n = 61), a 100% predictive value for Gram positive causing pathogens was attained. Insufficient predictive value was observed in PJIs with preoperative joint aspiration yielding Gram-negative microorganisms (n = 4), a fungus (n = 1) or with sterile results (n = 19).

CONCLUSION

In the immediate postoperative setting, the treating team might consider a broad spectrum empirical antibiotic regime, guided by the local epidemiology and susceptibility, which can be narrowed to Gram-positive coverage if preoperative joint aspiration cultures yield exclusively Gram-positive microorganisms.

Review of influenza-associated pulmonary aspergillosis in ICU patients and proposal for a case definition: an expert opinion

PURPOSE

Invasive pulmonary aspergillosis is increasingly reported in patients with influenza admitted to the intensive care unit (ICU). Classification of patients with influenza-associated pulmonary aspergillosis (IAPA) using the current definitions for invasive fungal diseases has proven difficult, and our aim was to develop case definitions for IAPA that can facilitate clinical studies.

METHODS

A group of 29 international experts reviewed current insights into the epidemiology, diagnosis and management of IAPA and proposed a case definition of IAPA through a process of informal consensus.

RESULTS

Since IAPA may develop in a wide range of hosts, an entry criterion was proposed and not host factors. The entry criterion was defined as a patient requiring ICU admission for respiratory distress with a positive influenza test temporally related to ICU admission. In addition, proven IAPA required histological evidence of invasive septate hyphae and mycological evidence for Aspergillus. Probable IAPA required the detection of galactomannan or positive Aspergillus culture in bronchoalveolar lavage (BAL) or serum with pulmonary infiltrates or a positive culture in upper respiratory samples with bronchoscopic evidence for tracheobronchitis or cavitating pulmonary infiltrates of recent onset. The IAPA case definitions may be useful to classify patients with COVID-19-associated pulmonary aspergillosis (CAPA), while awaiting further studies that provide more insight into the interaction between Aspergillus and the SARS-CoV-2-infected lung.

CONCLUSION

A consensus case definition of IAPA is proposed, which will facilitate research into the epidemiology, diagnosis and management of this emerging acute and severe Aspergillus disease, and may be of use to study CAPA.

Saliva for Precision Dosing of Antifungal Drugs: Saliva Population PK Model for Voriconazole Based on a Systematic Review

Precision dosing for many antifungal drugs is now recommended. Saliva sampling is considered as a non-invasive alternative to plasma sampling for therapeutic drug monitoring (TDM). However, there are currently no clinically validated saliva models available. The aim of this study is firstly, to conduct a systematic review to evaluate the evidence supporting saliva-based TDM for azoles, echinocandins, amphotericin B, and flucytosine. The second aim is to develop a saliva population pharmacokinetic (PK) model for eligible drugs, based on the evidence. Databases were searched up to July 2019 on PubMed^® and Embase^®, and 14 studies were included in the systematic review for fluconazole, voriconazole, itraconazole, and ketoconazole. No studies were identified for isavuconazole, posaconazole, flucytosine, amphotericin B, caspofungin, micafungin, or anidulafungin. Fluconazole and voriconazole demonstrated a good saliva penetration with an average S/P ratio of 1.21 (± 0.31) for fluconazole and 0.56 (± 0.18) for voriconazole, both with strong correlation (r = 0.89–0.98). Based on the evidence for TDM and available data, population PK analysis was performed on voriconazole using Nonlinear Mixed Effects Modeling (NONMEM 7.4). 137 voriconazole plasma and saliva concentrations from 11 patients (10 adults, 1 child) were obtained from the authors of the included study. Voriconazole pharmacokinetics was best described by one-compartment PK model with first-order absorption, parameterized by clearance of 4.56 L/h (36.9% CV), volume of distribution of 60.7 L, absorption rate constant of 0.858 (fixed), and bioavailability of 0.849. Kinetics of the voriconazole distribution from plasma to saliva was identical to the plasma kinetics, but the extent of distribution was lower, modeled by a scale factor of 0.5 (4% CV). A proportional error model best accounted for the residual variability. The visual and simulation-based model diagnostics confirmed a good predictive performance of the saliva model. The developed saliva model provides a promising framework to facilitate saliva-based precision dosing of voriconazole.

Impact of concomitant acid suppressive therapy on pazopanib efficacy and dose reductions in patients with metastatic renal cell carcinoma

PURPOSE

The aim of this study was to investigate the impact of acid suppressive therapy on clinical efficacy and safety of pazopanib in patients with metastatic renal cell carcinoma (mRCC).

METHODS

A single-center retrospective study was carried out. Charts of mRCC patients who received pazopanib as first-line treatment were reviewed and concomitant use of proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) was studied. Two groups of patients were identified, namely patients receiving PPI/H2RA and patients without acid suppressive therapy. Both groups were compared with regard to progression free survival (PFS), overall survival (OS), tumor response, and time to dose reduction of pazopanib.

RESULTS

Ninety-one patients were included. Median PFS was 8 months in the PPI/H2RA group vs. 7 months in the no PPI/H2RA group (hazard ratio (HR) 0.76 (95% confidence interval (CI) 0.42-1.35)), p = 0.35. Median OS was 27 months in the PPI/H2RA group vs. 23 months in the no PPI/H2RA group (HR 0.87 (95% CI 0.46-1.66)), p = 0.68. Mean tumor response was 17% (95% CI 8-25%) in the PPI/H2RA group vs. 11% (95% CI 0-21%) in the no PPI/H2RA group, p = 0.52. Median time to first dose reduction was 9 months in both subgroups (HR 1.25 (95% CI 0.65-2.39)), p = 0.51. Median time to second dose (< 600 mg) reduction was 17 months in the PPI/H2RA group vs. 7 months in the no PPI/H2RA group (HR 0.26 (95% CI 0.07-0.89)), p = 0.03.

CONCLUSION

In this limited patient series, no evidence of a negative impact of PPI/H2RA on clinical outcome and time to first dose reduction was observed. These results suggest that PPI/H2RA might be considered, when there is a clinical need, in patients treated with pazopanib for mRCC. However, a prospective study is warranted to confirm these results.

Software Tools for Model-Informed Precision Dosing: How Well Do They Satisfy the Needs?

Model-informed precision dosing (MIPD) software tools are used to optimize dosage regimens in individual patients, aiming to achieve drug exposure targets associated with desirable clinical outcomes. Over the last few decades, numerous MIPD software tools have been developed. However, they have still not been widely integrated into clinical practice. This study focuses on identifying the requirements for and evaluating the performance of the currently available MIPD software tools. First, a total of 22 experts in the field of precision dosing completed a web survey to assess the importance (from 0; do not agree at all, to 10; completely agree) of 103 pre-established software tool criteria organized in eight categories: user-friendliness and utilization, user support, computational aspects, population models, quality and validation, output generation, privacy and data security, and cost. Category mean ± pooled standard deviation importance scores ranged from 7.2 ± 2.1 (user-friendliness and utilization) to 8.5 ± 1.8 (privacy and data security). The relative importance score of each criterion within a category was used as a weighting factor in the subsequent evaluation of the software tools. Ten software tools were identified through literature and internet searches: four software tools were provided by companies (DoseMeRx, InsightRX Nova, MwPharm++, and PrecisePK) and six were provided by non-company owners (AutoKinetics, BestDose, ID-ODS, NextDose, TDMx, and Tucuxi). All software tools performed well in all categories, although there were differences in terms of in-built software features, user interface design, the number of drug modules and populations, user support, quality control, and cost. Therefore, the choice for a certain software tool should be made based on these differences and personal preferences. However, there are still improvements to be made in terms of electronic health record integration, standardization of software and model validation strategies, and prospective evidence for the software tools’ clinical and cost benefits.

Quantitative determination of colistin A/B and colistin methanesulfonate in biological samples using hydrophilic interaction chromatography tandem mass spectrometry

Colistin (polymyxin E) is a polycation antibiotic which is increasingly used (administered as colistin methanesulfonate, CMS) as a salvage therapy in critically ill patients with multidrug resistant Gram-negative infections. Even though colistin has been used for more than 50 years, its metabolic fate is poorly understood. One of the current challenges for studying the pharmacokinetics (PK) is the precise and accurate determination of colistin in in vitro and in vivo studies. In the present study, we developed and validated a series of sensitive and robust liquid chromatography tandem mass spectrometry (LC-MS/MS) methods for analysing biological samples obtained from in vitro and in vivo disposition assays. After a zinc acetate-mediated precipitation, hydrophilic-lipophilic-balanced solid phase extraction (HLB-SPE) was used for the extraction of colistin. The compounds were retained on a hydrophilic interaction liquid chromatography (HILIC) column and were detected by MS/MS. CMS was quantified by determining the produced amount of colistin during acidic hydrolysis. The developed methods are sensitive with lower limits of quantification varying between 0.009 μg/mL and 0.071 μg/mL for colistin A, and 0.002 μg/mL to 0.013 μg/mL for colistin B. The intra- and inter-day precision and accuracy were within ±15%. Calibration curves of colistin were linear (0.063 μg/mL to 8.00 μg/mL) within clinically relevant concentration ranges. Zinc acetate-mediated precipitation and the use of a HILIC column were found to be essential. The developed methods are sensitive, accurate, precise, highly efficient and allow monitoring colistin and CMS in biological samples without the need for an internal standard.

European confederation of medical mycology expert consult-An ECMM excellence center initiative

OBJECTIVES

Difficult-to-treat invasive fungal infections require infectious diseases expert consultation to improve treatment outcome and increase survival rates.

METHODS

The European Confederation of Medical Mycology (ECMM) intends to provide expert help free of charge by a newly founded ECMM Expert Consultation Service for medical centres around the globe seeking advice when there is no fungal infection consultant available. The expert consult will provide recommendations and broad expertise on difficult-to-treat invasive fungal infections (eg azole-resistant Aspergillus species, Candida auris, mucormycosis) to improve diagnostic and therapeutic management and outcome.

RESULTS

The initiative plans global outreach through video conferencing between ECMM Excellence Centers and treating physicians. FungiScope^® registries will be used to structure case information and to evaluate the impact of the collegial advice system at regular intervals. Advice will follow recent guidelines, and EQUAL Scores will be used to measure guideline adherence.

CONCLUSIONS

Infectious diseases expert consultation should be an integral component of care for patients with difficult-to-treat invasive fungal infections. The ECMM Expert Consult will attend to this matter on a global scale.

Antifungal drugs: What brings the future?

The high burden and growing prevalence of invasive fungal infections (IFIs), the toxicity and interactions associated with current antifungal drugs, as well as the increasing resistance, ask for the development of new antifungal drugs, preferably with a novel mode of action. Also, the availability of oral or once-weekly alternatives would enable ambulatory treatment resulting in an improved patient's comfort and therapy adherence. However, only one new azole and two new posaconazole-formulations were marketed over the last decade. This review focuses on the antifungal drugs in the pipeline undergoing clinical evaluation. First, the newest azole, isavuconazole, with its improved safety profile and reduction in DDIs, will be discussed. Moreover, there are two glucan synthase inhibitors (GSIs) in the antifungal pipeline: rezafungin (CD101), a long-acting echinocandin with an improved stability that enables once weekly administration, and SCY-078, an orally available GSI with efficacy against azole- and echinocandin resistant isolates. A new oral formulation of amphotericin B will also be presented. Moreover, the first representative of a new antifungal class, the orotomides, with a broad spectrum and no cross-resistance with current antifungal classes, will be discussed. Finally, an overview of other antifungals that are still in earlier clinical development phases, is provided.

Bacteriophage Application for Difficult-to-treat Musculoskeletal Infections: Development of a Standardized Multidisciplinary Treatment Protocol

Bacteriophage therapy has recently attracted increased interest, particularly in difficult-to-treat infections. Although it is not a novel concept, standardized treatment guidelines are currently lacking. We present the first steps towards the establishment of a "multidisciplinary phage task force" (MPTF) and a standardized treatment pathway, based on our experience of four patients with severe musculoskeletal infections. After review of their medical history and current clinical status, a multidisciplinary team found four patients with musculoskeletal infections eligible for bacteriophage therapy within the scope of Article 37 of the Declaration of Helsinki. Treatment protocols were set up in collaboration with phage scientists and specialists. Based on the isolated pathogens, phage cocktails were selected and applied intraoperatively. A draining system allowed postoperative administration for a maximum of 10 days, 3 times per day. All patients received concomitant antibiotics and their clinical status was followed daily during phage therapy. No severe side-effects related to the phage application protocol were noted. After a single course of phage therapy with concomitant antibiotics, no recurrence of infection with the causative strains occurred, with follow-up periods ranging from 8 to 16 months. This study presents the successful outcome of bacteriophage therapy using a standardized treatment pathway for patients with severe musculoskeletal infection. A multidisciplinary team approach in the form of an MPTF is paramount in this process.

External validation of a clinical pharmacy intervention in geriatric inpatients: a controlled study

Background Clinical pharmacist interventions have been shown to improve drug use in older adults. Study findings are seldom externally validated however. Objective First, to validate a minimized iteration of a previously tested intervention of clinical pharmacists in a non-academic setting with limited staffing resources. Second, to compare the potentially inappropriate medication (PIM) reduction to two previous controlled interventional studies. Methods A controlled study was performed at geriatric wards. The control group received usual care. The intervention group was exposed to a clinical pharmacist led medication review, based on the use of the RASP list, (the Rationalization of Home Medication by an Adjusted STOPP list in Older Patients). Drug use on admission and at discharge were evaluated, including the number of RASP-identified potentially inappropriate medications (PIMs). The PIM reduction was compared to two previous controlled study findings using a linear mixed model. Results Drug use declined during hospital stay, without differences between control (n = 29) and intervention group (n = 32). Antidepressants and hypnotic drugs were discontinued more frequently in IG patients. More PIMs were reduced in the intervention patients (control vs. intervention: 1.0 vs. 3.0, p < 0.001). Across three controlled studies, a robust reduction of 1.56 PIMs (95% confidence interval 1.10-2.02, p < 0.001) was observed in favor of the CP interventions. Conclusion The minimal CP intervention resulted in fewer RASP PIMs. No net reduction of drug use was observed, yet fewer antidepressants and hypnotic drugs were used. The RASP PIM reduction was comparable to previous investigations.

Development of clinical pharmacy in Belgian hospitals through pilot projects funded by the government

Objectives The goal is to develop clinical pharmacy in the Belgian hospitals to improve drug efficacy and to reduce drug-related problems. Methods From 2007 to 2014, financial support was provided by the Belgian federal government for the development of clinical pharmacy in Belgian hospitals. This project was guided by a national Advisory Working Group. Each funded hospital was obliged to describe yearly its clinical pharmacy activities. Results In 2007, 20 pharmacists were funded in 28 pilot hospitals; this number was doubled in 2009 to 40 pharmacists over 54 institutions, representing more than half of all acute Belgian hospitals. Most projects (72%) considered patient-related activities, whereas some projects (28%) had a hospital-wide approach. The projects targeted patients at admission (30%), during hospital stay (52%) or at discharge (18%). During hospital stay, actions were mainly focused on geriatric patients (20%), surgical patients (15%), and oncology patients (9%). Experiences, methods, and tools were shared during meetings and workshops. Structure, process, and outcome indicators were reported and strengths, weaknesses, opportunities, and threats were described. The yearly reports revealed that the hospital board was engaged in the project in 87% of the cases, and developed a vision on clinical pharmacy in 75% of the hospitals. In 2014, the pilot phase was replaced by structural financing for clinical pharmacy in all acute Belgian hospitals. Conclusion The pilot projects in clinical pharmacy funded by the federal government provided a unique opportunity to launch clinical pharmacy activities on a broad scale in Belgium. The results of the pilot projects showed clear implementation through case reports, time registrations, and indicators. Tools for clinical pharmacy activities were developed to overcome identified barriers. The engagement of hospital boards and the results of clinical pharmacy activities persuaded the government to start structural financing of clinical pharmacy.

Impact of an oral nutrition protocol in patients treated with elective radical cystectomy: a long term follow-up

Background After radical cystectomy, delayed return of bowel function is relatively common. Although studies investigating on the best modality for delivering nutritional support to this patient group are limited, parenteral nutrition was standard of care in those patients at the urological ward of the University Hospitals Leuven. In 2015, we published the findings from our study conducted in patients undergoing elective regular radical cystectomy at the urological ward of the University Hospitals Leuven comparing the length of hospital stay in patients with early postoperative parenteral nutrition (n = 48) versus an immediate oral nutrition protocol (n = 46). It was demonstrated that the implementation of an oral nutrition protocol was associated with a significant reduced length of hospital stay (median [IQR] of 18 [15-22] to 14 [13-18] days (p < 0.001)). The sample size was however too small to investigate the impact of the oral nutrition protocol on the incidence of catheter-related bloodstream infection, a common parenteral nutrition related complication. Objective To investigate the long term impact of an oral nutrition protocol on the incidence of catheter-related bloodstream infection, duration of catheterization and the length of hospital stay. Method Retrospectively, before (parenteral nutrition group) and after the implementation of the oral nutrition protocol (since March 10th 2010), two cohorts of 549 patients who underwent an elective regular radical cystectomy were included. The incidence of a catheter-related bloodstream infection and the length of stay were compared. A central venous catheter was present in every patient, which is standard of care. Results Catheter-related bloodstream infection was reduced from 22 (4%) to 10 (1.8%) (p = 0.031). The median duration of catheterization was 10 [7-13] days for the parenteral nutrition versus 7 [7-7] days for the oral nutrition group (p < 0.001). The median length of stay between both groups, 20 [17-25] before versus 17 [14-21] days after the implementation of the oral nutrition protocol, also differed significantly (p < 0.001). Implementing the oral nutrition protocol resulted in a parenteral nutrition associated cost saving of €470 per patient. Conclusion This large follow-up study showed that the oral nutrition protocol is associated with a reduction in catheter-related bloodstream infection. Besides, postponing parenteral nutrition in favour of oral nutrition enhances recovery.