P02 Novel pharmacy roles strengthen the multidisciplinary hospital infection team

Background

Pharmacists have an essential role to play in the NHS Long Term Plan. Hospital pharmacy departments need to develop novel roles to strengthen teams and improve patient care. In September 2017, Mid Yorkshire Hospitals NHS Trust appointed a consultant antimicrobial pharmacist along with an administrative apprentice to strengthen pharmacy and infection leadership and support the delivery of the antimicrobial resistance national targets. From January 2018 to June 2020, the infection team worked with locums but no substantive consultant microbiologists.

Objectives

To describe the benefits of developing novel pharmacy roles to strengthen an infection multidisciplinary team

Methods

A shortage of consultant microbiologists provided opportunities to develop and enhance other infection roles. These included one year of funding from Pathology for a Band 6 Specialist Pharmacy Technician. The role was subsequently funded by the Adult Community Services team to support the home intravenous antibiotic service. Senior support was provided by the Pathology Group Manager, Head of Infection Prevention and Control and Director of Pharmacy. The apprenticeship levy supported a Level 4 Data analyst qualification to develop the pharmacy administrator role. Two other infection roles were developed: Advanced Clinical Practitioner and Trainee Clinical Scientist, both of which could not be sustained for lack of adequate consultant microbiologist resources for clinical supervision within the team.

Results

The Specialist Pharmacy Technician coordinates the home intravenous antibiotic service. Clinical responsibility remains with the discharging consultant medical officer. The antimicrobial pharmacy team led the introduction of antibiotic elastomeric pumps for home use, saving 2500 inpatient bed days. Patient and staff feedback on the novel pharmacy roles has been positive. Band 5 Pharmacy Data Analyst – Antimicrobials responsibilities include clinical trial participation, data collection and analysis including ward level working, reporting and coordination of the audit programme. The role has enabled contribution to national research studies, including Antibiotic Review Kit (ARK-Hospital) and Procalcitonin: Evaluation of Antibiotic Use in COVID-19 Hospitalised Patients (PEACH). Through a new strategy, consultant microbiologist workforce has progressively grown back to three full time equivalents and a 4th post advertised, enabling an increase in participation in ward rounds, multidisciplinary team meetings, antimicrobial stewardship, infection prevention & control, Director of Infection Prevention and Control role and leading NIHR research trials. The consultant pharmacist remains in post as a senior leader, and also has a Trust role as Director of Innovation. This change provided funding for an increase from Band 3 to Band 5 data analyst, promotion of a senior Band 7 pharmacist to a Band 8a advanced clinical pharmacist, and conversion of a part time Band 7 pharmacist to a full-time role.

Discussion

An innovative approach to development of pharmacy, data, nurse and scientist roles has strengthened the infection service in a regional hospital and community services Trust. Pharmacy-led team meetings are now routine in the Trust allowing for more efficient use of consultant microbiologist time.

Conclusions

Potential future roles are further administrative support, pharmacy assistant, clinical nurse specialist – antimicrobials, and antimicrobial pharmacy team leader.

Daptomycin in the Clinical Setting: 8-Year Experience with Gram-positive Bacterial Infections from the EU-CORE(SM) Registry

INTRODUCTION

The aim of this study was to evaluate the clinical outcomes and safety of daptomycin therapy in patients with serious Gram-positive infections.

METHODS

Patients were enrolled in the European Cubicin(®) Outcomes Registry and Experience (EU-CORE(SM)), a non-interventional, multicenter, observational registry. The real-world data were collected across 18 countries (Europe, Latin America, and Asia) for patients who had received at least one dose of daptomycin between January 2006 and April 2012. Two-year follow-up data were collected until 2014 for patients with endocarditis, intracardiac/intravascular device infection, osteomyelitis, or orthopedic device infection.

RESULTS

A total of 6075 patients were enrolled. The most common primary infections were complicated skin and soft tissue infection (31.7%) and bacteremia (20.7%). Staphylococcus aureus was the most frequently reported pathogen (42.9%; methicillin-resistant S. aureus [MRSA], 23.2%), followed by Staphylococcus epidermidis and other coagulase-negative staphylococci (CoNS, 28.5%). The most commonly prescribed dose of daptomycin was 6 mg/kg/day (43.6%), and the median duration of therapy was 11 (range 1-300) days. Overall clinical success rate was 80.5%, and was similar whether daptomycin was used as first-line (82.9%) or second-line (79.2%) therapy. Clinical success rates were high in patients with S. aureus (83.9%; MRSA 83.0%) and CoNS (including S. epidermidis, 82.5%) infections. The majority of patients with endocarditis or intracardiac/intravascular device infection (86.7%) or osteomyelitis/orthopedic device infection (85.9%) had a sustained response during the 2-year follow-up period. There were no new or unexpected safety findings.

CONCLUSION

Results from real-world clinical experience showed that daptomycin is a valuable therapeutic option in the management of various difficult-to-treat Gram-positive infections.

FUNDING

This study was funded by Novartis Pharma AG.

Study of Anomalies Associated With Labiopalatine Clefting

Background and aims: Cleft lip with or without cleft palate are the most common congenital malformations of the head and neck accounting for about 65% of all anomalies of this region. Approximately 70% of cleft cases are non-syndromic and occur as isolated condition, while remaining 30% cases are associated with systemic defects involving cardiovascular, musculoskeletal, genitourinary system and other structural anomalies. The purpose of this study is to assess the various anomalies associated with labiopalatine clefting. Materials and methods: Sixty four cases of cleft lip with or without cleft palate attending the OPD of Department of Plastic Surgery and Pediatric Surgery, Gauhati Medical College and Hospital, were studied. Among them three cases were found to be associated with other anomalies. Results: One case of cleft lip and palate presented with multiple anomalies like tongue tie, malformed external ear and micrognathia. Another one had acyanotic heart disease associated with cleft lip. A case of cleft lip and palate was also found to be associated with hydrocephalus. Conclusion : Proper knowledge and details of anomalies associated with orofacial cleft will help to provide necessary treatment and improve survival of these children.

A three-dimensional pharmacophore modelling of ITK inhibitors and virtual screening for novel inhibitors

Interleukin-2-inducible T-cell kinase (ITK) is a key member of the Tec family of non-receptor tyrosine kinases, and has been found to be a novel target for a number of inflammatory and autoimmune diseases. A three-dimensional pharmacophore model has been generated for protein ITK from its known inhibitors. The best HypoGen model consisted of four pharmacophore features: one hydrogen bond acceptor, one hydrogen bond donor and two hydrophobic rings. This model showed a correlation coefficient of 0.947, a root mean square deviation of 0.914 and a configuration cost of 16.866. The model was validated using test set prediction and Fischer's test. A test set containing 204 compounds showed an r(2) of 0.745 between estimated activity and activity measured experimentally. Fisher's test gave a confidence level of 95%. The best pharmacophore model (Hypo1) was then employed for virtual screening (3D database searching), including Lipinsiki's filter, to obtain a pool of more drug-like molecules. The molecular pool thus retrieved was subjected to docking analysis with a study protein to remove any molecules showing false positive activity for ITK.

Effect of moderate walnut consumption on lipid profile, arterial stiffness and platelet activation in humans

Background/Objectives

A large intake of walnuts may improve lipid profile and endothelial function. The effect of moderate walnut consumption is not known. We investigated whether a moderate intake of walnuts would affect lipid profile, arterial stiffness and platelet activation in healthy volunteers.

Subjects/Methods

Thirty healthy males were recruited into a single-blind randomised controlled crossover trial of 4 weeks dietary walnut supplementation (15 g/day) and 4 weeks control (no walnuts). Arterial stiffness was assessed using pulse waveform analysis to determine the augmentation index and augmented pressure. Platelet activation was determined using flow cytometry to measure circulating platelet-monocyte aggregates.

Results

There were no differences in lipid profile after 4 weeks of walnut supplementation compared with control. Dietary intake of alpha-linolenic acid was increased during the walnut diet (2.1±0.4 g/day versus 0.7±0.4 g/day, P<0.0001). There were no differences in augmentation index or augmented pressure during walnut supplementation. Walnut supplementation did not affect platelet-monocyte aggregation .

Conclusions

Dietary intervention with a moderate intake of walnuts does not affect lipid profile, arterial stiffness or platelet activation in man. Our results suggest that the potentially beneficial cardiac effects of walnuts may not be apparent at lower and more practical levels of consumption.

Functional interplay between platelet activation and endothelial dysfunction in patients with coronary heart disease

Platelet-monocyte binding and surface P-selectin expression are sensitive markers of platelet activation. Endothelium-derived factors are known to inhibit platelet activation and may confer important anti-atherothrombotic effects. We assessed the relationship between platelet activation and endothelium-dependent vasomotion in patients with coronary heart disease (CHD). Twenty male patients with stable CHD were compared with 20 healthy men. Platelet-monocyte binding and platelet surface expression of P-selectin were assessed using two-colour flow cytometry on whole blood. Forearm blood flow was assessed in patients using venous occlusion plethysmography during intra-arterial infusions of substance P, acetylcholine and sodium nitroprusside. Platelet activation was higher in patients than healthy men (platelet-monocyte binding, 27 +/- 3 vs. 20 +/- 1%; P < 0.05). In patients with CHD, there was an inverse correlation between maximal substance P induced vasodilatation and both platelet-monocyte binding (P = 0.003) and P-selectin expression (P = 0.02). A similar correlation was observed between platelet-monocyte binding and the vasomotor response to acetylcholine (P = 0.08) but not with sodium nitroprusside. In patients with stable coronary heart disease, there is a strong inverse relationship between markers of platelet activation and endothelium-dependent vasomotor function. This may explain the pathophysiological mechanism linking endothelial vasomotor dysfunction and the risk of acute atherothrombotic events.

Promotion of proinflammatory interactions between platelets and monocytes by unfractionated heparin

OBJECTIVES

To determine the in vitro effects of unfractionated heparin, fractionated heparin and direct thrombin inhibition on platelet-monocyte aggregation, and to establish the in vivo effects of unfractionated heparin and direct thrombin inhibition on platelet-monocyte aggregates in patients scheduled for percutaneous coronary intervention (PCI).

DESIGN

Platelet-monocyte aggregates were assessed in whole blood from 18 healthy volunteers after the addition of unfractionated heparin (1 U/ml), enoxaparin (0.8 U/ml) or lepirudin (5.6 microg/ml), and in 28 patients scheduled for elective PCI before and after administration of 100 U/kg of unfractionated heparin or 0.75 mg/kg bivalirudin. The influence of P-selectin-mediated platelet-monocyte aggregation was assessed with specific blocking antibodies.

RESULTS

Addition of unfractionated heparin in vitro was associated with a higher level of platelet-monocyte aggregates than in controls (20.1 (1.9)% v 16.2 (1.6)%, respectively, p < 0.001). However, platelet-monocyte aggregation was not affected by enoxaparin or lepirudin (16.9 (2.0)% and 17.0 (2.2)%, respectively, NS). Intravenous unfractionated heparin in vivo also resulted in an increase in platelet-monocyte aggregates (absolute Delta 7.1 (2.7)%, p < 0.01), whereas intravenous bivalirudin had no effect (absolute Delta -1.5 (2.4)%, NS). The addition of P-selectin blockade abolished any increase in platelet-monocyte aggregates associated with heparin.

CONCLUSIONS

In vitro and in vivo unfractionated heparin is associated with increased platelet-monocyte aggregation through a P-selectin-dependent mechanism. These findings provide a potential explanation for the superior cardiovascular outcomes associated with fractionated heparins and direct thrombin inhibitors.

Increased CD40 ligand and platelet–monocyte aggregates in patients with type 1 diabetes mellitus

BACKGROUND

Diabetes mellitus is a major risk factor for cardiovascular disease and is associated with a proinflammatory and prothrombotic state. We investigated whether CD40 ligand (L) expression and platelet-monocyte aggregation are increased in patients with type 1 diabetes.

METHODS

Serum C-reactive protein (CRP) and soluble (s) CD40L concentrations, platelet surface CD40L expression and platelet-monocyte aggregates were measured in 22 patients with uncomplicated type 1 diabetes and 22 age- and sex-matched non-diabetic control subjects.

RESULTS

In comparison to controls, patients with type 1 diabetes had higher serum CRP concentrations (3.29 +/- 0.9 mg/L versus 0.99 +/- 0.2mg/L, P = 0.01), serum sCD40L concentrations (10.0 +/- 1.4 ng/mL versus 4.6 +/- 0.6 ng/mL, P = 0.006), and platelet surface expression of CD40L (13.8 +/- 0.9% versus 8.5 +/- 1.1%, P < 0.001). Platelet-monocyte aggregates were also significantly elevated in type 1 diabetes (35.9 +/- 3.3% versus 26.4 +/- 2.9%, P = 0.005; n = 10). We also observed a significant correlation between plasma glucose and serum CRP (r = 0.53, P = 0.01) as well as platelet-monocyte aggregates (r = 0.69, P = 0.03).

CONCLUSIONS

Type 1 diabetes is associated with increased CD40L expression and platelet-monocyte aggregation, which may contribute to the proinflammatory and prothrombotic state as well as the accelerated atherogenesis associated with this disorder.

Upregulation of the CD40/CD40 Ligand Dyad and Platelet-Monocyte Aggregation in Cigarette Smokers

BACKGROUND

Smoking is a potent cardiovascular risk factor and is associated with proinflammatory and prothrombotic responses. The CD40/CD40 ligand (CD40L) dyad and platelet-monocyte aggregation mediate a range of proinflammatory and prothrombotic processes thought to be important in atherothrombosis. We investigated whether expression of the CD40/CD40L dyad and platelet-monocyte aggregation are altered in cigarette smokers.

METHODS AND RESULTS

C-reactive protein (CRP), soluble (s) CD40L, and surface expression of CD40L on platelets and T cells and of CD40 on monocytes and platelet-monocyte aggregates were compared in 25 cigarette smokers and 25 age- and gender-matched nonsmokers. Cigarette smokers had increased serum CRP (2.47+/-2.60 versus 0.94+/-0.96 mg/L, P=0.008) and appeared to have elevated plasma sCD40L (0.8+/-1.09 versus 0.37+/-0.21 ng/mL, P=0.07) concentrations. Smokers also had increased surface expression of CD40 on monocytes (45.9+/-7.7% versus 39.9+/-6.5%, P=0.006), of CD40L on platelets (2.9+/-1.0% versus 2.3+/-0.6%, P=0.03), and of platelet-monocyte aggregates (26.6+/-10.9% versus 19.7+/-8.6%, P=0.02). Plasma cotinine concentrations correlated with monocyte CD40 expression, platelet CD40L expression, and platelet-monocyte aggregates.

CONCLUSIONS

Cigarette smokers have upregulation of the CD40/CD40L dyad and platelet-monocyte aggregation that may account for the atherothrombotic consequences of this major cardiovascular risk factor.

Realistic model for the output beam profile of stripe and tapered superluminescent light-emitting diodes

We present a new model to analyse the spatial characteristics of the output beam of conventional (straight-stripe) and tapered superluminescent light-emitting diodes. The device model includes both spontaneous and stimulated emission processes as well as a nonuniform carrier density distribution to correctly represent current spreading and carrier diffusion effects. Near- and far-field intensity profiles computed with this model are accurately verified over a wide range of injection currents by comparisons with experimental results measured from in-house fabricated devices.

Characterization of angled tapered superluminescent LEDs

We present a detailed analysis of the output beam of high-power edge-emitting angled tapered superluminescent LEDs (A-TSLEDs). A device model, including spontaneous and stimulated emission processes as well as the typical nonuniform carrier-density distribution due to current spreading and carrier diffusion, has been developed and used to interpret the experimentally obtained characteristics of inhouse-fabricated A-TSLEDs. The good match between measured and theoretical results indicates that the model reproduces the A-TSLED operation very satisfactorily and clearly explains the role of the collecting lens on the pronounced asymmetry of some of the measured optical intensity profiles.

Multicentre, prospective, randomized trial of 4 vs. 6 French catheters in 410 patients undergoing coronary angiography

The aim of this study was to assess the quality of angiograms obtained using 4 Fr catheters compared with 6 Fr catheters, the ease of use of the 4 Fr catheters, and the safety of patient mobilization 1 hr following 4 Fr angiography. Details of catheter performance and procedural details were recorded at the time of the angiogram. The angiographic images were scored on the quality and completeness of vessel opacification throughout systole and diastole. A total of 410 patients were recruited. There was no difference between 4 and 6 Fr for procedural variables. All angiograms were considered to be of diagnostic quality. The angiographic scores for the right coronary artery and left ventricular injections were no different between 4 and 6 Fr. However, the angiographic scores for the left anterior descending and circumflex arteries were lower with 4 than with 6 Fr (both P < 0.05). Patients who had 4 Fr angiography mobilized safely at 1 hr and reported significantly less discomfort and bruising than 6 Fr patients. Good-quality diagnostic coronary angiograms can be achieved using 4 Fr catheters with the advantage of earlier postprocedural mobilization and reduced discomfort and bruising for the patient.

Effect of centrally administered nitric oxide modulators in Brewer's yeast-induced nociception in rats

Possible modulation of Brewer's yeast-induced nociception by centrally (icv) administered nitric oxide (NO) modulators, viz., NO synthase (NOS) inhibitors, NO precursor, donors, scavengers and co-administration of NO donor (SIN-1) with NOS inhibitor (L-NAME) and NO scavenger (Hb) was investigated in rats. Administration of NOS inhibitors and NO scavenger Hb increased the pain threshold capacity significantly, whereas NO donors SIN-1, SNP and NO precursor L-arginine were found to be hyperalgesic. D-arginine, the inactive isomer of L-arginine and methylene blue, inhibitor of soluble guanylate cyclase failed to alter the nociceptive behaviour in rats. Co-administration of SIN-1 with L-NAME and Hb found to increase the nociceptive threshold. The results indicate, that centrally administered NO modulators alter the nociceptive transmission induced by Brewer's yeast in rats.