Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy

Knowledge, attitudes and perceptions of Latin American healthcare workers relating to antibiotic stewardship and antibiotic use: a cross-sectional multi-country study

BACKGROUND

The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers' (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region.

METHODS

HCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March-April 2023.

FINDINGS

Overall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% "other"). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term "antibiotic stewardship". Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians' opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions.

CONCLUSIONS

Although HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.

A survey on the knowledge and attitudes of pharmacists towards the application of antimicrobial therapeutic drug monitoring and its challenges in Qatar

INTRODUCTION

Therapeutic drug monitoring (TDM) is an integral part of pharmaceutical care. Antimicrobials are amongst the most commonly monitored medications. Therefore, identifying the gaps in antimicrobial pharmacokinetics and TDM knowledge and skills among pharmacists is crucial to optimize TDM application.

RESEARCH QUESTION

What is the current knowledge, attitudes and perceived barriers of pharmacists in Qatar towards the application of antimicrobial TDM?

STUDY DESIGN

Cross-sectional survey.

METHODS

The psychometric validation of the survey underwent 3 stages: domain identification and item generation, content validation, and pilot test. The survey was divided into 4 domains (participant characteristics, knowledge, attitudes, and perceived barriers). It was developed in Survey Monkey and distributed to all pharmacists in Hamad Medical Corporation (HMC) hospitals via email. Data was analyzed using IBM Statistical Package for the Social Sciences (SPSS). Categorical and quantitative variables were expressed as frequencies with percentages and medians with interquartile ranges, respectively. Mann-Whitney U-test was used to test the effect of demographic and professional parameters on the knowledge scores. P values less than 0.05 were considered significant.

RESULTS

Forty-nine responses were collected. The median age of respondents was 34 years and 51% of them were males. Most respondents were clinical pharmacists (47%). On average, 44% of knowledge questions were correct, whereas 32% were incorrect and 23% were not sure of the answer. The median knowledge score was 5 out of 10 (interquartile range 2.5-6). Participants with post-graduate degrees or prior pharmacokinetic training showed trends towards higher knowledge scores. Online pharmacokinetics calculators were the most frequently used dose adjustment method. The top perceived barriers for the implementation of antimicrobial TDM were lack of knowledge and lack of educational sessions.

CONCLUSIONS

Albeit pharmacists in Qatar had modest level of knowledge about antimicrobial TDM, they had positive attitudes towards TDM and its implications in the clinical practice. Future plans should include providing TDM-related education activities.

Quantifying Critical Care Pharmacist Interventions in COVID-19

Purpose/Background: Pharmacists have been shown to play an important role in the medication management of critically ill patients. Pharmacist interventions in the care of critically ill patients with coronavirus disease 2019 (COVID-19) have not been quantitatively described. Methodology: A single center, retrospective, observational study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. All adult patients admitted to the COVID-19 intensive care unit (ICU) or Medical ICU with a COVID-19 diagnosis between March 1, 2020, and June 30, 2021, were included. All interventions made by pharmacists were documented electronically, collected, categorized, and analyzed. The primary outcome of this study was the median number of interventions by pharmacists per patient. The secondary outcome was the number of different types of interventions performed. Results: A total of 768 patients were included in the analysis. The median age was 63 years old; 63% of patients were male and 71% were Caucasian. Median hospital length of stay (LOS) was 12 days (interquartile range (IQR) 7-21) and ICU LOS was 5 days (IQR 1-11). The median Sequential Organ Failure Assessment score was 4 (IQR 2-7) and Charlson Comorbidity Index was 3 (IQR 2-5). Mortality at 60 days occurred in 352 patients (46%). Pharmacists performed a total of 7027 interventions for 655 patients with a median number of pharmacist interventions per patient of 6 (IQR 3-14). The most common pharmacist interventions were medication discontinuation (24%), completion of components of the ICU liberation bundle (19%), medication dose adjustment (18%), therapeutic drug monitoring (15%), and medication initiation (10%). Conclusions: Pharmacists made multiple interventions related to medication use and management in critically ill patients with COVID-19. This study adds important information of the evolving role clinical pharmacists play in the care of critical illness, specifically during the COVID-19 pandemic.

Pharmacist-Driven Dosing Services and Pharmaceutical Care Increase Probability of Teicoplanin Target Concentration Attainment and Improve Clinical and Economic Outcomes in Non-Critically Ill Patients

INTRODUCTION

Pharmacist-driven (PD) dosing and monitoring services have been shown to improve the clinical and economic outcomes in patients treated with different antibiotics, other than teicoplanin. This study investigates the impact of PD dosing and monitoring services on the clinical and economic outcomes of non-critically ill patients receiving teicoplanin treatment.

METHODS

A single-center retrospective study was conducted. Patients were divided into the PD group and the non-PD (NPD) group. Primary outcomes included the achievement of target serum concentration, and a composite endpoint of all-cause mortality, intensive care unit (ICU) admission, and sepsis or septic shock development during hospitalization or within 30 days of hospital admission. The cost of teicoplanin, overall medication cost, and total cost during hospital stay were also compared.

RESULTS

A total of 163 patients from January to December 2019 were included and assessed. Seventy patients were assigned to the PD group and 93 to the NPD group. The PD group had a higher percentage of patients reaching the target trough concentration (54% versus 16%, p < 0.001). Around 26% of the patients in the PD group and 50% of the patients in the NPD group met the composite endpoint during their hospital stay (p = 0.002). The PD group exhibited a significantly lower incidence of sepsis or septic shock, shorter hospital stays, reduced drug costs, and lower total expenses.

CONCLUSIONS

Our study demonstrates that pharmacist-driven teicoplanin therapy can improve the clinical and economic outcomes for non-critically ill patients.

TRIAL REGISTRATION

https://www.chictr.org.cn ; identifier, ChiCTR2000033521.

A Brief Review of Pharmacokinetic Assessments of Vancomycin in Special Groups of Patients with Altered Pharmacokinetic Parameters

Vancomycin is considered the drug of choice against many Gram-positive bacterial infections. Therapeutic drug monitoring (TDM) is essential to achieve an optimum clinical response and avoid vancomycin-induced adverse reactions including nephrotoxicity. Although different studies are available on vancomycin TDM, still there are controversies regarding the selection among different pharmacokinetic parameters including trough concentration, the area under the curve to minimum inhibitory concentration ratio (AUC24h/MIC), AUC of intervals, elimination constant, and vancomycin clearance. In this review, different pharmacokinetic parameters for vancomycin TDM have been discussed along with corresponding advantages and disadvantages. Also, vancomycin pharmacokinetic assessments are discussed in patients with altered pharmacokinetic parameters including those with renal and/or hepatic failure, critically ill patients, patients with burn injuries, intravenous drug users, obese and morbidly obese patients, those with cancer, patients undergoing organ transplantation, and vancomycin administration during pregnancy and lactation. An individualized dosing regimen is required to guarantee the optimum therapeutic responses and minimize adverse reactions including acute kidney injury in these special groups of patients. According to the pharmacoeconomic data on vancomycin TDM, pharmacokinetic assessments would be cost-effective in patients with altered pharmacokinetics and are associated with shorter hospitalization period, faster clinical stability status, and shorter courses of inpatient vancomycin administration.

The Development, Implementation, and Evaluation of a Pharmacist-Managed Therapeutic Drug Monitoring (TDM) Service for Vancomycin-A Pilot Study

BACKGROUND

In recent years, pharmacists in Australia have been able to expand their scope to include the provision of a range of services. Although evidence has demonstrated the benefits of pharmacist-managed TDM services, recent studies have shown that these services are not prominent within Australia and that the current TDM workflow may not be optimal.

METHODS

An interventional pilot study was conducted of a pharmacist-managed TDM program for vancomycin at a tertiary hospital in Australia.

RESULTS

In total, 15 pharmacists participated in the program. They performed 50.5% of the medication-related pathology over the intervention period. Pharmacist involvement in the TDM process was more likely to lead to appropriate TDM sample collection (OR 87.1; 95% CI = 11.5, 661.1) and to an appropriate dose adjustment (OR 19.1; 95% CI = 1.7, 213.5). Pharmacists demonstrated increased confidence after the education and credentialling package was provided.

CONCLUSIONS

This study demonstrated that a credentialling package for pharmacists can improve knowledge, skills, and confidence around the provision of pharmacist-managed TDM services for vancomycin. This may lead to the evolution of different roles and workflows enabling pharmacists to contribute more efficiently to improving medication safety and use.

Pharmacist-driven renal dose optimization practice—outcomes of a retrospective study in ambulatory care settings

Objectives

Previous studies indicate a higher prevalence of inappropriate drug usage in patients with renal disease in ambulatory care settings and a higher rate of non-compliance with the renal dose adjustment protocol. This study aimed to investigate the number of renal dose adjustments recommended by pharmacists in ambulatory care settings, acceptance rate by the physicians and medications involved.

Methods

This two-year retrospective study was conducted in an ambulatory care pharmacy in a Saudi Arabian tertiary care hospital. Based on the renal protocol at the study site, the pharmacists recommended dose adjustments for inappropriate medication orders, and the outcomes were documented electronically. A quantitative descriptive analysis of this practice was performed by retrieving the pharmacists’ documentation from electronic health records. Only protocol-compliant recommendations with proper documentation were included in the study.

Key findings

A total of 302 renal dose adjustments were recommended by pharmacists for 269 patients involving 47 medications, with an average of 1.12 recommendations per patient. The average monthly recommendation was 12.58 (median: 11; SD: 5.174; 95% Confidence Interval (CI), 12 to 13.16). Of the 302 recommendations, 219 (72.52%) were accepted by the physician, and 71 (23.51%) were not. The most common medications accepted for renal dosage adjustment included levofloxacin (8.94%), metformin (5.29%), amoxicillin-clavulanate (5.29%), cetirizine (4.97%), diclofenac (4.64%), ciprofloxacin (3.97%) and nitrofurantoin (3.31%).

Conclusions

The pharmacist’s renal dose recommendations have a high acceptance rate in ambulatory care. This study demonstrated that ambulatory care pharmacists play a substantial clinical role in reducing inappropriate drug use in patients with renal disease.

Clinical Response and Hospital Costs of Therapeutic Drug Monitoring for Vancomycin in Elderly Patients

Cost-effectiveness analysis has been widely used to assess and compare the costs and benefits of a clinical service. The cost-effectiveness of vancomycin therapeutic drug monitoring (TDM) has not been studied in the elderly, who are susceptible to vancomycin-induced adverse effects. This study was performed to evaluate if vancomycin TDM is cost-effective in elderly patients in the Republic of Korea. Using the electronic medical records at a tertiary university hospital, we performed a retrospective observational study to evaluate the cost-effectiveness of vancomycin TDM in 850 elderly patients who underwent vancomycin TDM with an appropriate, recommended dosing regimen and 1094 elderly patients who did not. Cost-effectiveness variables such as clinical outcomes and medical expenses were evaluated using univariate and multivariate analyses. The TDM group spent significantly less than the non-TDM group per patient for total medical expenses (by USD 841.40) and medication expenses (by USD 16.70). However, no significant difference was noted between the TDM and non-TDM groups in clinical outcomes such as microbiological cure, prevention of nephrotoxicity, or reduced mortality, irrespective of admission to the intensive care unit. Vancomycin TDM in elderly patients was associated with economic benefits, but not with better clinical outcomes.

Continued professional development: A comparison of online vs. in-person workshops

INTRODUCTION

Pharmacy practice continues to change and therefore requires lifelong health professions education. These practice changes require academics and leaders in pharmacy to identify how to best teach and train pharmacists to manage patient care services. This study assessed whether an online training module is as effective as an in-person workshop to train pharmacists to apply dosing and therapeutic monitoring of vancomycin.

METHODS

The primary endpoint measured the difference in average assessment score change between pre- and post-training between intervention groups. All pharmacists completed: (1) a baseline pretest, (2) Session 1 online, (3) Session 2 (an online training module or in-person workshop), (4) a posttest, and (5) a voluntary survey of perceptions on training.

RESULTS

A total of 56 pharmacists completed the training, 43% online and 57% in-person. The multiple linear regression included pretest, training method, and pharmacists' role on posttest (R² = 0.1041 and P = .34). A voluntary anonymous survey about perceptions on the training was completed by 20 participants. On average, perceptions were agreeable on an eight-item Likert scale between groups (Cronbach's alpha = 0.77). The total scores for the Likert scale were 27 ± 3.3 vs. 23 ± 1.6, P = .001, in the online and in-person sessions, respectively. More participants in the online group agreed that they had enough time to comprehend and apply the material, 4 vs. 3 (on the Likert scale).

CONCLUSIONS

An online training module is as effective as an in-person workshop at training pharmacists to apply vancomycin dosing and monitoring.

Optimizing Treatment of Hand Infections: Is MRSA Coverage Always Necessary?

Multiple publications have highlighted the prevalence of methicillin resistant Staphylococcus aureus (MRSA) as a cause of hand infections. We hypothesized that these publications have shifted the empiric treatment of hand infections. The aim of this study was to identify the current standard of care, the most common causative bacteria, and factors leading to extended length of stay for hand infection patients at a suburban hospital to improve treatment and establish an optimized care protocol.

Methods

Retrospective cohort analysis was conducted to identify all patients admitted for hand infections over an 8-year period. A comprehensive chart review of each patient's hospital course was completed.

Results

A total of 70 patients were included. Maximum white blood cell count ≥ 12 was associated with a significantly longer hospital length of stay (9.1 days versus 5.4 days) compared to WBC values < 12 (P < 0.05). Also, 11 out of 23 (47.8%) underwent two or more incision and drainages (I&D's), compared with patients with maximum WBC < 12. Vancomycin use as an empiric antibiotic was widespread (68 patients, 97.1%), despite only 14 (20%) having MRSA positive cultures. Univariate analysis identified a significant increased likelihood for increased length of stay (P < 0.05) and rise in creatinine (P < 0.05) in patients with an initial vancomycin trough level > 20.

Conclusions

This analysis of hand infection treatment in a suburban hospital demonstrates the incidence of MRSA hand infections may not be universally high across institutions. Each hospital should review its own data to optimize hand infection treatment and its associated costs.

Impact and barriers of a pharmacist-led practice with computerized reminders on intravenous to oral antibiotic conversion for community-acquired pneumonia inpatients

WHAT IS KNOWN AND OBJECTIVE

Intravenous to oral (IV-PO) antibiotic conversion, one of the critical elements in antimicrobial stewardship (AMS), is not well implemented in China. Studies on the strategy to apply the IV-PO conversion are needed. Our objective was to evaluate the impact and its barriers of a pharmacist-led practice with computerized reminders on IV-PO antibiotic conversion for community-acquired pneumonia (CAP) inpatients.

METHOD

This was a retrospective, observational pre- and post-intervention study. Interventions were introduced in 2 sequential 12-month phases: Phase 1: pharmacists implemented the conventional practice of reviewing patient charts and medication records every 24 h and verbally informed the prescribers on eligible IV-PO conversions; Phase 2: pharmacists implemented a new intervention practice to inform the prescribers with a computerized reminder in electronic medical record system on eligible IV-PO conversions.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients who converted to oral therapy on the day patients were eligible for the conversion. The secondary outcomes were length of IV antibiotic therapy days, total length of antibiotic therapy days and length of hospital stay.

RESULTS

A total of 524 patients were studied (256 in phase 1 and 268 in phase 2). The proportion of patients who converted to oral therapy on the day patients were eligible for the conversion was significantly increased from 34.77% (89/256) in phase 1 to 62.69% (168/268) in phase 2 (p < 0.05). Length of IV antibiotic therapy days in phase 2 was shortened by 1.23 days, which was 5.52 days compared to 6.75 days in phase 1 (p < 0.05). Total length of antibiotic therapy days was 12.05 days in Phase 1, compared to 10.75 days in phase 2 (p > 0.05). Length of hospital stay for patients in phase 2 was significantly shorter, with a difference of 1.38 days (6.02 days vs. 7.40 days, p < 0.05). The most common barrier of not converting IV-PO was the presence of co-morbidity.

CONCLUSION

The pharmacist-led IV-PO antibiotic conversion practice with computerized reminders was successful and feasible in Chinese hospitals. More IV-PO intervention studies in patients with other infections are needed in the future.

Position Paper on Critical Care Pharmacy Services: 2020 Update

OBJECTIVES

To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred.

DESIGN

The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development.

MAIN RESULTS

There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development.

CONCLUSIONS

Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Evaluating the Impact of Education on Pharmacist Tobramycin Dose Recommendations for Cystic Fibrosis and a Review of Perceptions on Pharmacist-Led Charting

BACKGROUND

Pharmacists routinely interpret and optimize tobramycin dosing for people with cystic fibrosis (PwCF).

OBJECTIVES

To determine the impact of tobramycin therapeutic drug monitoring (TDM) education on pharmacist dose recommendations, and to explore nurses' and medical doctors' perceptions toward pharmacist-led TDM charting.

METHODS

This study involved 3 phases: a 12-month retrospective audit of PwCF prescribed tobramycin to identify the appropriateness of pharmacists' dose recommendations, a pharmacist tobramycin educational intervention utilizing a voiceover presentation with pre- and post-online tobramycin TDM assessment (involving multiple choice pharmacokinetics and case-based scenario questions), and a cross-sectional survey of respiratory nurses' and doctors' perceptions toward pharmacist-led TDM charting. The pharmacists' dose recommendations, in the audit and case-based questions, were considered appropriate if subsequent levels achieved the targeted area under the curve (AUC).

RESULTS

Audit results revealed that 44.4% of the 277 pharmacist dose recommendations identified were appropriate. The pre- and post-interventional assessments were completed by 51 and 52 pharmacists, respectively. Post intervention, correct scores were significantly higher than pre-intervention, evident in both the pharmacokinetics (median score 75% vs 100%; P = 0.048) and case-based scenario (median score 60% vs 90%; P < 0.0001) questions. Of the 54 nurses and medical doctors surveyed, 92.6% supported the implementation of pharmacist-led tobramycin charting.

CONCLUSION

The study demonstrated an increased accuracy and appropriateness of pharmacists' tobramycin pharmacokinetics knowledge and TDM dose recommendations post-educational intervention and highlighted nurses' and medical doctors' support of pharmacist-led tobramycin TDM charting.

Integrating targeted consultant pharmacists into a new collaborative care model to reduce the risk of falls in older adults owing to the overuse of opioids and benzodiazepines

Using central nervous system (CNS)-active medications increases older adults' risk for falls and fall-related injuries. Opioids and benzodiazepines are among the most widely used CNS-active medications and because of their addictive potential and widespread use for common ailments such as chronic pain, anxiety, or sleep, are also among the most difficult to deprescribe. Reducing the dose burden of these 2 medication classes in older adults-to balance safety with efficacy-is a challenge that requires persistence and strategic support structures to be successful. We propose a novel care model that uses the support of targeted consultant pharmacist services to help primary care providers reduce the unnecessary use of opioids and benzodiazepines in their patients who are older adults. This care model holds promise to not only offer providers additional time-saving clinical support but to help their practices improve patient outcomes, such as a reduction in medication-related falls and excess opioid use.

Interventions to optimize antimicrobial stewardship

Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.

The role of the critical care pharmacist during the COVID-19 pandemic

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The COPIL allowed the restructuring of the ICU in record time to double its capacity.

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The CCP, integrated in the COPIL and already a member of the ICU team for a few years, provided an essential link between the ICU and the pharmacy during the COVID-19 pandemic.

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The CCP implemented actions to avoid health products shortages, to secure practices and played a key role in the critical analysis of emerging published data in COVID-19 potential treatments.

On January 4 2020, the World Health Organization (WHO) reported the emergence of a cluster of pneumonia cases in Wuhan, China due to a new coronavirus, the SARS-CoV-2. A few weeks later, hospitals had to put in place a series of drastic measures to deal with the massive influx of suspected COVID-19 (COronaroVIrus Disease) patients while securing regular patient care, in particular in the intensive care units (ICU). Since March 12th, 77 of the 685 COVID-19 patients admitted to our hospital required hospitalization in the ICU. What are the roles and the added-value of the critical care pharmacist during this period? His missions have evolved although they have remained focused on providing health services for the patients. Indeed, integrated into a steering committee created to organize the crisis in the intensive care units, the role of the clinical pharmacist was focused on the organization and coordination between ICU and the pharmacy, the implementation of actions to secure practices, to train new professionals and the adaptation of therapeutic strategies. He participated to literature monitoring and increased his involvement in the clinical research team. He provided a link between the ICU and the pharmacy thanks to his knowledges of practices and needs.

Evaluation of a trough-only extrapolated area under the curve vancomycin dosing method on clinical outcomes

Background Vancomycin dosing strategies targeting trough concentrations of 15-20 mg/L are no longer supported due to lack of efficacy evidence and increased risk of nephrotoxicity. Area-under-the-curve (AUC₂₄) nomograms have demonstrated adequate attainment of AUC₂₄ goals ≥ 400 mg h/L with more conservative troughs (10-15 mg/L). Objective The purpose of this study is to clinically validate a vancomycin AUC₂₄ dosing nomogram compared to conventional dosing methods with regards to therapeutic failure and rates of acute kidney injury. Setting This study was conducted at a tertiary, community, teaching hospital in the United States. Method This retrospective, cohort study compared the rates of therapeutic failures between AUC₂₄-extrapolated dosing and conventional dosing methods. Main outcome measure Primary outcome was treatment failure, defined as all-cause mortality within 30 days, persistent positive methicillin-resistant Staphylococcus aureus blood culture, or clinical failure. Rates of acute kidney injury in non-dialysis patients was a secondary endpoint. Results There were 96 participants in the extrapolated-AUC₂₄ cohort and 60 participants in the conventional cohort. Baseline characteristics were similar between cohorts. Failure rates were 11.5% (11/96) in the extrapolated-AUC₂₄ group compared to 18.3% (11/60) in the conventional group (p = 0.245). Reasons for failure were 6 deaths and 5 clinical failures in the extrapolated-AUC₂₄ cohort and 10 deaths and 1 clinical failure in the conventional group. Acute kidney injury rates were 2.7% (2/73) and 16.4% (9/55) in the extrapolated-AUC₂₄ and conventional cohorts, respectively (p = 0.009). Conclusion Extrapolated-AUC₂₄ dosing was associated with less nephrotoxicity without an increase in treatment failures for bloodstream infections compared to conventional dosing. Further investigation is warranted to determine the relationship between extrapolated-AUC₂₄ dosing and clinical failures.

Three ways to advocate for the economic value of the pharmacist in health care

Numerous studies have demonstrated positive therapeutic and economic outcomes associated with pharmacist-provided care. However, public policy on provider status with subsequent payment for non-dispensing services has been slow to reflect an expanded pharmacist role. It is important for the public to understand the value of a pharmacist outside of the drug distribution system. Pharmacists and other health care and public health practitioners must share this information to further knowledge and affect policies and systems that can most effectively include pharmacists fully in the health care system. The 3 main areas identified in which the pharmacist has economic impact are decreased total health expenditures, decreased unnecessary care, and decreased societal costs. Evidence supports the economic value of the pharmacist; however, public opinion and political movements supporting patients' access to pharmacist-provided care are variable. Strategies to advocate and effect change include advocating to elected leaders for policy change and advocating to other health professionals, patients, and community members to better their understanding of the positive economic value of pharmacist-provided care. Through prioritizing community outreach and legislator education, pharmacist advocates can leverage 3 key areas in which pharmacists have economic value to advance policy and increase patients' access to care.

Vancomycin therapeutic drug monitoring in paediatrics

AIM

Vancomycin guidelines for therapeutic drug monitoring (TDM) aim to maximise efficacy while minimising toxicity and resistance. Vancomycin is effective against Staphylococcus aureus when it achieves area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) > 400. Studies in children have shown that target trough concentrations poorly correlate to AUC/MIC > 400; however, they are used in practice for clinical convenience. This review in paediatric inpatients aims to audit performance against TDM guidelines and consider what changes are needed to optimise vancomycin monitoring.

METHODS

Vancomycin prescriptions in patients younger than 18 years old were collected over a 15-month period. Primary outcome measures were vancomycin initial dose (mg/kg/day) and the timing and result of first trough concentration (mg/L). Secondary outcome measures were the numbers achieving recommended targets and whether appropriate dose adjustments were made in response to TDM.

RESULTS

A total of 133 courses reached the time when TDM should occur. Average patient age was 6.5 years, and the average initial dose was 52.55 mg/kg/day (range 19.05-86.54 mg/kg). Only 25% of courses (n = 34) had a trough concentration measured at the recommended time. The mean trough concentration was 11.6 mg/L (range < 2.0-39.7). Of 40 patients with a low trough concentration, 50% continued without dose adjustment.

CONCLUSION

As shown in the literature, there is a poor correlation between the vancomycin dose given and the trough concentration achieved. Given that recommendations for trough concentration monitoring are designed to simplify the process yet are poorly adhered to, a strategic plan to address these issues is needed.

Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports

Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV vancomycin use, including the need to have an accurate patient weight for dosing, to provide close monitoring to ensure appropriate drug levels, to monitor renal function, and to continue delivery of the medication at prescribed intervals. There are numerous healthcare system factors, including workflow processes, policies, health information technology, and clinical knowledge that impact the safe use of IV vancomycin. Past literature has identified several safety hazards associated with IV vancomycin use and there are some proposed solutions. Despite this literature, IV vancomycin–related safety issues persist. We analyzed patient safety event reports describing IV vancomycin–related issues in order to identify where in the medication process these issues were appearing, the type of medication error associated with each report, and general contributing factor themes. Our results demonstrate that recent safety reports are aligned with the issues already identified in the literature, suggesting that improvements discussed in the literature have not translated to clinical practice. Based on our analysis and current literature, we have developed a shareable infographic to improve clinician awareness of the complications and safety hazards associated with IV vancomycin and a self-assessment tool to support identification of opportunities to improve patient safety during IV vancomycin therapy. We also recommend development of clear guidelines to optimize health information technology systems to better support safe IV vancomycin use.

Is Computer-Assisted Aminoglycoside Dosing Managed by a Pharmacist a Safety Tool of Pharmacotherapy?

This pilot prospective study verified the hypothesis that use of computer-assisted therapeutic drug monitoring of aminoglycosides by pharmacists leads to better safety therapeutic outcomes and cost avoidance than only concentration measurement and dose adjustments based on a physician’s experience. Two groups of patients were enrolled according to the technique of monitoring. Patients (Group 1, n=52) underwent monitoring by a pharmacist using pharmacokinetic software. In a control group (Group 2, n=11), plasma levels were measured but not interpreted by the pharmacist, only by physicians. No statistically significant differences were found between the groups in factors influenced by therapy. However, the results are not statistically significant but a comparison of the groups showed a clear trend towards safety and cost avoidance, thus supporting therapeutic drug monitoring. Safety limits were achieved in 76 % and 63 % of cases in Groups 1 and 2, respectively. More patients achieved both concentrations (peak and trough) with falling eGFR in Group 1. In present pilot study, the pharmacist improved the care of patients on aminoglycoside therapy. A larger study is needed to demonstrate statistically significantly improved safety and cost avoidance of aminoglycoside therapy monitoring by the pharmacist using pharmacokinetic software.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance

OBJECTIVES

To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU.

DESIGN

A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics.

METHODS

The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results.

RESULTS

The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written.

CONCLUSIONS

This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Vancomycin Therapeutic Regime Adjustment in Newborns and Infants with Bacterial Infection: Case Series

Background:

Vancomycin is used mostly to overcome infections caused by methicillinresistant microorganisms. There are no well-established administration protocols for neonates and infants, so the leak of a specific administration regime in that population may lead to serum concentrations beyond the specified range.

Objective:

This case series evaluated the pharmacokinetics adjustment from a vancomycin therapeutic regimen prescribed to neonates and infants with bacterial infection at a neonatal public hospital intensive- care-unit, with the primary purpose to verify cases of nephrotoxicity.

Methods:

Three neonates and four infants taking vancomycin therapy, hospitalized in a public hospital from November 2014 to March 2015, were included in the study. Vancomycin serum concentrations were determined by particle-enhanced-turbidimetric inhibition-immunoassay. The vancomycin concentrations were used for dose adjustment by USC*Pack-PC-Collection®, a non-parametric maximization program. The trough serum concentration range of 10 to 20mg.L-1 was considered therapeutic.

Results:

Three patients had serum concentration outside the reference-range, one with subtherapeutic, and two with supratherapeutic concentrations. All patients had concomitant use of drugs which interfered with vancomycin distribution and excretion pharmacokinetics parameters, including drugs that may enhance nephrotoxicity. One patient showed signs of acute renal damage, by low vancomycin and creatinine estimated clearances.

Conclusion:

The pharmacokinetic adjustment has been proven to be a useful and necessary tool to increase therapeutic efficacy and treatment benefits. The standard dose of vancomycin can be used to initiate therapy in neonates and infants admitted to the ICU, but after reaching the drug steady state, the dosing regimen should be individualized and guided by pharmacokinetic parameters.

Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring

Many hospitals face barriers in the implementation of TDM services, this study aimed to evaluate a pharmacist-led TDM service to optimize patients' outcomes. Adult patients who were administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a retrospective assessment of patients and the intervention phase consisted of an educational program. The post-phase assessed patients based on TDM services provided by inpatient pharmacists on a 24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion of correct initial doses of prescribing orders. Secondary outcomes included assessing the mean differences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five patients in each phase were eligible. Patients who received optimal initial dosing in the post-phase showed a higher statistical significance, mean difference of 0.31, [95% CI (0.181⁻0.4438), p < 0.0001]. Patients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI (-0.560⁻0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean difference of 0.03, [95% CI (-0.129⁻0.189), p = 0.7110]. This study demonstrated the important role of TDM services led by pharmacists in optimizing the initial dosing for these antibiotics.

Clinical and Procedural Evaluation of a Pharmacy Pharmacokinetic Consult Service

PURPOSE

Though previous studies have shown benefit with pharmacist-managed dosing of antibiotics, many institutions still do not offer such services. Our objective was to determine and report novel outcomes associated with the implementation of a pharmacist-managed pharmacokinetic/pharmacodynamic consult service and to assess the impact of direct pharmacist involvement in therapeutic drug monitoring.

METHODS

Retrospective cohort study of patients who received vancomycin or an aminoglycoside in the medical intensive care unit from January 5, 2013, to January 6, 2015, divided into 2 groups: before/after implementation of the consult service on January 6, 2014.

RESULTS

Nine-hundred sixty-two patients were included. Groups were similar at baseline. There were fewer critical values after implementation of the consult service (40.8% vs 27.3%, P < .001). The intervention group had significantly more vancomycin troughs within therapeutic range (15.4% vs 32.8%, P = .019). Time from order entry to medication administration was shorter when pharmacists entered the medication order, although this difference was nonsignificant (103 minutes vs 77 minutes, P = .054).

CONCLUSION

Implementation of a pharmacist-managed dosing and monitoring program led to significantly decreased rates of critical value drug concentrations and increased rates of therapeutic concentrations, with a 25% (NS) decreased time-to-antibiotic administration, therefore demonstrating the additive value of the pharmacist-managed over pharmacist-monitored approach.

Appropriate use of antibiotics: an unmet need

Increasing bacterial resistance combined with a steady decline in the discovery of new antibiotics has resulted in a global healthcare crisis. Overuse of antibiotics, for example, in the poultry and cattle industry, and misuse and improper prescription of antibiotics are leading causes of multidrug resistance (MDR). The increasing use of antibiotics, particularly in developing countries, is a big concern for antibiotic resistance and can cause other health threats such as increased risk of recurrent infections and increased risk of cardiovascular death with chronic use of macrolides. Carbapenems are the last line of defense in many cases of resistant infection, but trends show that resistance against these agents is also increasing. This narrative review is based on relevant literature according to the experience and expertise of the authors and presents an overview of the current knowledge on antibiotic resistance, the key driving factors, and possible strategies to tackle antibiotic resistance. Collectively, studies show that hospital-wide antibiotic stewardship programs are effective in decreasing the spread of antibacterial resistance. As resistance varies according to local patterns of use, it is essential to observe the epidemiology at both a regional and an institutional level. Furthermore, adaptation of clinical guidelines is necessary, particularly for inpatient care. Future guidelines should include a justification step for continued treatment of antibiotic treatments and criteria for selection of antibiotics at the start of treatment. Nonantibiotic prevention strategies can limit infections and should also be considered in treatment plans. Vaccines against MDR organisms have shown some efficacy in phase II trials in critical care patients. Nonimmunogenic and microbiologic treatment options such as fecal transplants may be particularly important for elderly and immune-compromised patients.

The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions

PURPOSE OF REVIEW

The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions.

RECENT FINDINGS

AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.

The Hospital Antimicrobial Use Process: From Beginning to End

Hospital antimicrobial stewardship (AMS) programs are responsible for ensuring that all antimicrobials are utilized in the most appropriate and safe manner to improve patient outcomes, prevent adverse drug reactions, and prevent the development of antimicrobial resistance. This Perspectives article outlines the hospital antimicrobial use process (AUP), the foundational system that ensures that all antimicrobials are utilized in the most appropriate and safe manner. The AUP consists of the following steps: antimicrobial ordering, order verification, preparation and delivery, administration, monitoring, and discharge prescribing. AMS programs should determine how each step contributes to how an antimicrobial is used appropriately or inappropriately at their institution. Through this understanding, AMS programs can integrate stewardship activities at each step to ensure that every opportunity is taken to optimize antimicrobial use during a patient's treatment course. Hence, approaching AMS through the framework of a hospital's AUP is essential to improving appropriate antimicrobial use.

Design and short-term impact of an event to promote careers in clinical pharmacy

BACKGROUND AND PURPOSE

There is a role for local pharmacy organizations to promote clinical pharmacy and increase awareness to both potential and current pharmacy students. The Greater Milwaukee College of Clinical Pharmacy (GMCCP) chapter sought to promote clinical pharmacy amongst current and prospective pharmacy students to increase the knowledge, awareness, and interest in clinical pharmacy.

EDUCATIONAL ACTIVITY AND SETTING

Subcommittee members designed programming to introduce the basics of clinical pharmacy. Students from three schools of pharmacy and more than 40 colleges in the region were invited to the event. Didactic and discussion-based content was developed. Pharmacists from GMCCP were solicited as presenters, along with a current pharmacy student and resident. Participants were asked to complete pre-event and post-event surveys to assess their awareness of and interest in clinical pharmacy. Volunteer pharmacists were also surveyed after the event.

FINDINGS

Twenty-eight individuals attended the event. Nineteen students completed both the pre- and post-survey. The comparison between median score pre- and post-event was analyzed with the Wilcoxon Signed-Rank test. Students' awareness and knowledge of clinical pharmacy improved after attending the event. Students' interest in a career in clinical pharmacy also increased after attending the event. Nine of the thirteen volunteer breakout session pharmacists (69%) responded to the post-event survey. The majority strongly agreed that participants were interested in learning about their area of practice and asked meaningful questions appropriate for their area of practice.

DISCUSSION AND CONCLUSIONS

The Exploring Careers in Clinical Pharmacy event increased awareness of clinical pharmacy career choices available within the profession of pharmacy. Local, regional, and national pharmacy organizations may consider utilizing the diverse talent of their membership and collaborate with colleges of pharmacy or other organizations to impact the knowledge, awareness, and interest in clinical pharmacy as a future career choice for pre-pharmacy and current pharmacy students.

Impact of electronic health record-based, pharmacist-driven valganciclovir dose optimization in solid organ transplant recipients

BACKGROUND

Prophylaxis with valganciclovir reduces the incidence of cytomegalovirus (CMV) infection following solid organ transplant (SOT). Under-dosing of valganciclovir is associated with an increased risk of CMV infection and development of ganciclovir-resistant CMV.

METHODS

An automated electronic health record (EHR)-based, pharmacist-driven program was developed to optimize dosing of valganciclovir in solid organ transplant recipients at a large transplant center. Two cohorts of kidney, pancreas-kidney, and liver transplant recipients from our center pre-implementation (April 2011-March 2012, n = 303) and post-implementation of the optimization program (September 2012-August 2013, n=263) had demographic and key outcomes data collected for 1 year post-transplant.

RESULTS

The 1-year incidence of CMV infection dropped from 56 (18.5%) to 32 (12.2%, P = .05) and the incidence of breakthrough infections on prophylaxis was cut in half (61% vs 34%, P = .03) after implementation of the dose optimization program. The hazard ratio of developing CMV was 1.64 (95% CI 1.06-2.60, P = .027) for the pre-implementation group after adjusting for potential confounders. The program also resulted in a numerical reduction in the number of ganciclovir-resistant CMV cases (2 [0.7%] pre-implementation vs 0 post-implementation).

CONCLUSIONS

An EHR-based, pharmacist-driven valganciclovir dose optimization program was associated with reduction in CMV infections.

Evidence of clinical and economic impact of pharmacist interventions related to antimicrobials in the hospital setting

The purpose of this paper was to review the literature regarding the clinical and economic impact of pharmacist interventions (PIs) related to antimicrobials in the hospital setting. A PubMed literature search from January 2003 to March 2016 was conducted using the terms pharmacist* or clinical pharmacist* combined with antimicrobial* or antibiotic* or anti-infective*. Comparative studies that assessed the clinical and/or economic impact of PIs on antimicrobials in the hospital setting were reviewed. Outcomes were classified as: treatment-related outcomes (TROs), clinical outcomes (COs), cost and microbiological outcomes (MOs). Acceptance of pharmacist recommendations by physicians was collected. PIs were grouped into patient-specific recommendations (PSRs), policy, and education. Studies' risk of bias was analyzed using Cochrane's tool. Twenty-three studies were evaluated. All of them had high risk of bias. The design in most cases was uncontrolled before and after. PSRs were included in every study; five also included policy and four education. Significant impact of PI was found in 14 of the 18 studies (77.8%) that evaluated costs, 15 of the 20 studies (75.0%) that assessed TROs, 12 of the 22 studies (54.5%) that analyzed COs, and one of the two studies (50.0%) that evaluated MOs. None of the studies found significant negative impact of PIs. It could not be concluded that adding other strategies to PSRs would improve results. Acceptance of recommendations varied from 70 to 97.5%. Pharmacists improve TROs and COs, and decrease costs. Additional research with a lower risk of bias is unlikely to change this conclusion. Future research should focus on identifying the most efficient interventions.

Implementation of a prioritized scoring tool to improve time to pharmacist intervention

PURPOSE

The implementation of a prioritized scoring tool to improve time to pharmacist intervention is described.

SUMMARY

At the Ohio State University Wexner Medical Center, pharmacists are accepted providers of therapeutic drug monitoring of vancomycin and aminoglycosides. At the onset of this initiative and despite the implementation of an integrated electronic medical record (EMR), management of pharmacokinetically monitored medications was conducted using a paper monitoring form. The potential for transcription errors during this process provided an opportunity for improvement. For these reasons, the department of pharmacy focused its initial efforts for a patient scoring system on the pharmacokinetics scoring module. Adjustment of associated medications based on pharmacokinetic values was a core function of pharmacists of the institution and was expected to be conducted without fail. Vancomycin was used as the index surrogate pharmacokinetically monitored medication within the module for testing and validation because of the clear expectations and standardized resources available to pharmacists to complete the task. The pharmacokinetics scoring module was designed specifically for the function of dosing management, searching throughout the EMR and concisely displaying the information a pharmacist needs to make a clinical decision. Importantly, integration of the scoring module reduced the time to intervention from hours to minutes. The median time to intervention was reduced to within a clinical working shift (8 hours) with the scoring module versus 24 hours or longer with the paper monitoring system.

CONCLUSION

The implementation of an internally developed pharmacokinetics scoring module built into the EMR substantially reduced the time to clinical intervention for pharmacokinetic monitoring of vancomycin drug levels.

Impact of Pharmacy Practice Model Expansion on Pharmacokinetic Services: Optimization of Vancomycin Dosing and Improved Patient Safety

Background: The impact of pharmacy interventions on optimizing vancomycin therapy has been described, however interventions vary among studies and the most optimal pharmacy practice model (PPM) for pharmacokinetic (PK) services has not been established. Objective: The purpose of this study is to demonstrate the value of 24 hours a day, 7 days a week (24/7) PK services. Methods: New PK services were implemented in 2 phases with institutional PPM expansion. Phase 1 included universal monitoring by pharmacists with recommendations made to prescribers during business hours. Phase 2 expanded clinical pharmacists' coverage to 24/7 and provided an optional 24/7 pharmacist-managed PK consult service. We compared vancomycin therapeutic trough attainment, dosing, and clinical and safety outcomes between phases 1 and 2 in adult inpatients receiving therapeutic intravenous vancomycin. Results. One hundred and fifty patients were included in each phase. Phase 2 had a greater proportion of vancomycin courses with therapeutic initial trough concentrations (27.5% vs 46.1%; p = 0.002), higher initial trough concentrations (10.9 mcg/mL vs 16.4 mcg/mL; p < 0.001), and optimized initial vancomycin dosing (13.5 mg/kg vs 16.2 mg/kg; p < 0.001). Phase 2 also saw significant reduction in the incidence of vancomycin-associated nephrotoxicity (21.1% vs 11.7%; p = 0.038). Dose optimization and improvement in initial target trough attainment were most notable among intensive care unit (ICU) patients. Conclusions. Our study demonstrated that 24/7 PK services implemented with institutional PPM expansion optimized vancomycin target trough attainment and improved patient safety.

Implementation and Assessment of a Pharmacy Educational Program Concerning Laboratory Monitoring for Medications

BACKGROUND

The pharmacist's role in monitoring medication therapy, including the ability to order laboratory tests as a delegated medical function, has increased dramatically over the past 20 years.

OBJECTIVES

To implement and assess the impact of an intervention designed to educate pharmacists about appropriate medication-related laboratory monitoring and clinical interpretation of results.

METHODS

This pilot project had a pretest-posttest study design. The intervention was an educational program comprising 8 self-directed learning modules, each with a corresponding seminar. Evaluation of the program included scoring of the appropriateness and significance of clinical interventions related to laboratory monitoring, pre- and post-program test scores, and participants' subjective assessments of their abilities to order and assess the results of medication-related laboratory investigations. Descriptive statistics, the Wilcoxon signed rank test, the Student t-test, and the paired Student t-test were used where appropriate. Associations were assessed with the Pearson or Spearman rho correlation coefficient. All statistical tests were 2-tailed, and the p value for significance was established a priori at 0.05.

RESULTS

There was no statistically significant difference with regard to the appropriateness (p = 0.70) or significance (p = 0.94) of clinical interventions undertaken before and after the educational program. Among the 21 pharmacists who completed the program, the average test score (± standard deviation) was 27.2 ± 8.1 before the program, increasing to 39.2 ± 8.7 after the program (p < 0.001). There was a statistically significant improvement in the perceived level of knowledge for each individual module (p < 0.05 for all).

CONCLUSIONS

The establishment of an educational program led to improvements in both subjective and objective measures of knowledge and perceived abilities to order and assess the results of medication-related laboratory tests.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

Independent prescribing by hospital pharmacists: Patterns and practices in a Canadian province

PURPOSE

Results of a survey to determine the frequency of prescribing by Canadian hospital pharmacists with independent prescribing authority are reported.

METHODS

A Web-based questionnaire was used to collect data on the prescribing activities of a designated group of hospital-affiliated pharmacists in the province of Alberta who had been granted "additional prescribing authorization" (APA) through a peer-review process and were providing clinical pharmacy services in inpatient and/or outpatient settings at the time of the survey (January-March 2014). Descriptive statistics and logistic regression analysis were used to determine the median weekly frequency of prescribing, factors associated with increased use of APA, and perceived prescribing barriers and enablers.

RESULTS

The survey response rate was about 50% (77 of 153 eligible pharmacists). The median self-reported number of prescriptions and medication orders written during an average week was 4.2 (interquartile range, 2.0-10.0) per 10 patients. Antibiotics and anticoagulants were the most commonly prescribed medications. Interdisciplinary care team dynamics was rated as a leading enabler of prescribing but also a leading barrier to the exercise of APA. The greatest motivators to apply for APA were the potential for increased efficiency and the potential for enhanced patient care.

CONCLUSION

The survey results indicated that, in an average week, hospital pharmacists with APA prescribed for almost half of the patients they cared for as part of the interdisciplinary team. Prescribing most frequently occurred after team discussion and most often involved adjusting dosages based on organ function and clinical assessment.

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Adding value through pharmacy validation: a safety and cost perspective

RATIONALE, AIMS AND OBJECTIVES

Prescribing errors (PE) are frequent, cause significant harm to patients and prove costly. Few studies demonstrate the impact of pharmacist interventions. The objectives of this study were to characterize the severity and cost of the potential outcome of PE that pharmacists can prevent and to develop an economic analysis.

METHOD

We performed a non-randomized, prospective, observational study of all prescriptions made to adult patients admitted to a 1300-bed tertiary teaching hospital in Madrid (Spain) by means of a computerized physician order entry tool combined with a clinical decision support system. We analysed PE intercepted through the pharmacist validation process between January and June 2013. An independent team determined the severity of the potential adverse drug event (ADE) and the probability of causing an ADE (PAE). We estimated the cost avoidance and performed an economic analysis. A kappa statistic was used to verify inter-observer agreement.

RESULTS

484 PE were intercepted: 36.2% of PE were classified as being of minor severity, 59.1% as moderate and 4.7% as serious. The most common type of moderate-serious PE found was excessive dose (30%, 94/309), followed by insufficient dose (20%, 62/309), and omission (19%, 58/309). The most frequent families of drugs involved in moderate-serious PE were antineoplastic agents (22.3%, 69/309) and antimicrobials (17.2%, 53/309). The PAE was higher than 40% in 49% of PE. We estimated a cost avoidance of €291,422 and a return on investment of €1.7 for each €1 spent on a pharmacist's salary. The overall inter-rater agreement for the participants was moderate for severity (κ = 0.57; P <0.005) and strong for the PAE (κ = 0.77; P <0.005).

CONCLUSIONS

Pharmacists add important value in preventing PE, and their interventions are financially beneficial for the institution.

Implementation of the systems approach to improve a pharmacist-managed vancomycin dosing service

PURPOSE

Quality improvements achieved by applying the systems approach to assess the clinical effectiveness, operational efficiency, and financial feasibility of a pharmacist-managed vancomycin dosing service are described.

SUMMARY

Faced with increased patient volumes and resource demands, the pharmacy department at Tufts Medical Center conducted an evaluation of its adult inpatient vancomycin dosing service using the systems approach, which emphasizes multidisciplinary assessment of system inputs, processes, and outcomes and consensus-building methods to identify needed changes and recommended action steps. A multidisciplinary committee composed of representatives of the medical center's pharmacy, internal medicine, infectious diseases, nursing, phlebotomy, and clinical laboratory services was assembled; in a series of three moderated monthly sessions, committee members deliberated and ultimately reached consensus on a list of action items. Relative to a concurrent intradepartmental assessment of the vancomycin dosing service based solely on pharmacist feedback, the systems approach identified a greater number and wider array of needed improvements in key program areas. Quality improvements implemented as a direct result of the systems-based analysis included a policy change authorizing pharmacists to order serum vancomycin determinations without physician cosignature and inclusion of a vancomycin dosing algorithm in the institutional antibiotic dosing guide. Future changes based on deliverable action items will result in a structured process to help direct program resources toward the patients most in need of pharmacist-managed vancomycin dosing services.

CONCLUSION

The systems approach allowed for a comprehensive multidisciplinary evaluation of the service, as indicated by the identification of process improvements not identified by the department of pharmacy alone.

Optimization of time to initial vancomycin target trough improves clinical outcomes

BACKGROUND

Outcomes data for the efficacy of interventions designed to decrease the time to initial target vancomycin troughs are sparse.

OBJECTIVE

A vancomycin therapeutic drug monitoring (TDM) program was initiated to reduce the time to initial target troughs and to examine the impact on clinical outcomes.

METHODS

Single-center, pre- and post-intervention observational study in a 250 bed teaching facility. Adult inpatients treated with physician-guided, vancomycin therapy (historical control, CTRL) were compared to high trough, pharmacist-guided vancomycin therapy (TDM). Nephrotoxicity analyses were conducted to the ensure safety of the TDM. Clinical outcome analysis was limited to patients with normal renal function and culture-confirmed gram positive infections and a pre-defined MRSA subset.

RESULTS

340 patients met initial inclusion criteria for the nephrotoxicity analysis (TDM, n = 173; CTRL, n = 167). Acute kidney injury occurrence was similar between the CTRL (n = 20) and TDM (n = 23) groups (p = 0.7). Further exclusions yielded 145 patients with gram positive infections for clinical outcomes evaluation (TDM, n = 66; CTRL, n = 75). The time to initial target trough was shorter in the TDM group (3 vs. 5 days, p < 0.001). Patients in the TDM group discharged from the hospital more rapidly, 7 vs. 14 days (Hazards Ratio (HR), 1.41; 95% Confidence Interval [CI] 1.08-1.83; p = 0.01), reached clinical stability faster, 4 vs. 8 days (HR, 1.51; 95% CI 1.08-2.11; p = 0.02), and had shorter courses of vancomycin, 4 vs. 7 days (HR, 1.5; 95% CI 1.15-1.95; p = 0.003). In the MRSA infection subset (TDM, n = 36; CTRL, n = 35), patients in the TDM group discharged from the hospital more rapidly, 7 vs. 16 days (HR, 1.89; 95% CI 1.08-3.3; p = 0.03), reached clinical stability faster, 4 vs. 6 days (HR, 2.69; 95% CI 1.27-5.7; p = 0.01), and had shorter courses of vancomycin, 5 vs. 8 days (HR, 2.52; 95% CI 1.38-4.6; p = 0.003). Attaining initial target troughs in <5 days versus ≥5 days was associated with improved clinical outcomes. All cause in-hospital mortality, and vancomycin treatment failure occurred at comparable rates between groups.

CONCLUSIONS

Interventions designed to decrease the time to reach initial target vancomycin troughs can improve clinical outcomes in gram positive infections, and in particular MRSA infections.

Impact of a phenytoin loading dose program in the emergency department

PURPOSE

The use of a combined physician-and pharmacist-directed phenytoin loading dose program in an emergency department (ED) was evaluated.

METHODS

This single-center, observational, preimplementation-postimplementation study evaluated adult patients who received a phenytoin loading dose in the ED. The primary outcome compared the proportion of optimal phenytoin loading doses in the preimplementation and postimplementation groups. The postimplementation group was further stratified into pharmacist- and prescriber-dosing groups. Other outcomes evaluated included the numbers of appropriate serum phenytoin concentrations measured, adverse drug reactions (ADRs), and recurrence of seizures within 24 hours of loading dose administration in the preimplementation and postimplementation groups.

RESULTS

There was no difference in the proportion of optimal phenytoin loading doses between the preimplementation and postimplementation groups (50% versus 62%, respectively; p=0.19). When stratified by individual groups, the rate of optimal phenytoin loading doses increased by 64% in the postimplementation pharmacist group (50% versus 82%, p=0.007), while the rate in the prescriber-dosing group remained relatively unchanged (50% versus 49%, p=0.91). The number of appropriate serum phenytoin concentrations significantly improved in the postimplementation versus preimplementation group (65% versus 40%, p=0.025). Rates of ADRs and recurrence of seizures did not differ across the study groups.

CONCLUSION

No change in the percentage of optimal phenytoin loading doses in the ED was observed after implementation of a combined pharmacist- and physician- dosing program. When stratified into pharmacist or prescriber dosing, the pharmacist-led dosing program significantly improved the proportion of patients who received optimal phenytoin loading doses.

Impact of clinical decision support guidelines on therapeutic drug monitoring of gentamicin in newborns

BACKGROUND

Our institution's gentamicin dosing and therapeutic drug monitoring (TDM) practices for newborns were suspected to be very heterogeneous. Once-daily dosing (ODD) or extended-interval dosing (EID) and trough concentration measurement were recommended. Clinical decision support guidelines were developed and implemented as clinical decision support in the computerized prescriber order entry system. Impact on dosing, TDM practices, and blood sampling were evaluated.

METHODS

A 1-year retrospective historically controlled study before (April 2008-March 2009) and after the implementation of guidelines (January 2010-December 2010) for newborns (<30 days of life) receiving gentamicin. Blood concentrations (% of peak concentrations sampled, % of patients with zero or one concentration sampled, % of trough concentrations ≤1 mg/L) and dose regimen (ODD/EID) were compared between groups. Factors potentially associated with gentamicin concentration were analyzed (multivariate analysis).

RESULTS

One hundred thirty-two (postguidelines) versus 102 (preguidelines) patients were included (median gestational age: 34.3 versus 35.8 weeks, P > 0.05). After implementation of the guidelines, an ODD/EID regimen was almost exclusively used (97.7% versus 61.6%, P < 0.001), the percentage of peak concentrations (0.9% versus 17.2%, P < 0.001) and the number of blood samples per patient (87.1% having 0 or 1 concentration measured versus 48.0, P < 0.001) sharply reduced. A significantly higher percentage of trough concentrations were ≤1 mg/L (68.5% versus 33.0%, P < 0.001). The probability of a trough concentration ≤1 mg/L increased with an ODD/EID regimen (odds ratio, 7.23; 95% confidence interval: 3.48-15.0, P < 0.001) and in the postguidelines group (odds ratio, 2.02; 95% confidence interval: 1.01-4.02, P = 0.045).

CONCLUSIONS

Guideline implementation generated a sharp reduction in blood sampling. Clinical benefits of better gentamicin dosing and TDM practices were evident. Cost-effectiveness and clinical benefit of reduced blood sampling should be evaluated.

Practice of switch from intravenous to oral antibiotics

Hospitalized patients initially on intravenous antibiotics can be safely switched to an oral equivalent within the third day of admission once clinical stability is established. This conversion has many advantages as fewer complications, less healthcare costs and earlier hospital discharge. The three types of intravenous to oral conversion include sequential, switch, and step-down therapy. The aim of the study was to evaluate the practice of switching from intravenous to oral antibiotics, its types and its impact on the clinical outcomes. This was a retrospective observational study conducted in three Lebanese hospitals over a period of six months. Adult inpatients on intravenous antibiotics for 2 days and more were eligible for study enrollment. Excluded were patients admitted to care or surgery units, or those with gastrointestinal diseases, infections that require prolonged course of parenteral therapy, or malignancies.

The study showed that among 452 intravenous antibiotic courses from 356 patients who were eligible for conversion, only one third were switched and the others continued on intravenous antibiotics beyond day 3 (P <0.0001). The mean duration of intravenous therapy of converted patients was markedly shorter than the non-converted (P <0.0001) with no significant change in the mean length of stay. Fluoroquinolones and macrolides were the most commonly converted antibiotics. However, the sequential therapy was the major type of conversion practiced in this study. Based on the study findings, a significant proportion of patients can be considered for switch. This emphasizes an important gap in the field of conversion from intravenous to oral antibiotic therapy and the need for integration and reinforcement of the appropriate Antibiotic Stewardship Programs in hospitals.