European journal of hospital pharmacy : science and practice最新文献

Background: Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia remains a major clinical challenge with high mortality, despite guideline-recommended vancomycin therapy. Although a ratio of the area under the curve to the minimum inhibitory concentration (AUC/MIC) ≥400 mg·hour/L is advocated for efficacy, the association between pharmacokinetic/pharmacodynamic (PK/PD) target attainment and clinical outcomes remains uncertain.

Objective: To determine the in-hospital mortality rate among patients with MRSA bacteraemia receiving vancomycin. The secondary objectives were to (1) evaluate the association between patient characteristics and in-hospital mortality, (2) examine the relationship between in-hospital mortality and secondary treatment outcomes, and (3) assess the impact of vancomycin AUC/MIC target attainment on in-hospital mortality.

Methods: A retrospective cohort study was conducted at a tertiary hospital in Malaysia involving adults with MRSA bacteraemia treated from 2014 to 2024. AUC/MIC data were analysed for patients receiving intermittent vancomycin dosing. Multivariable logistic regression identified independent predictors of mortality.

Results: Among 148 patients included, the in-hospital mortality rate was 32.4% (n=48/148). Four factors were independently associated with in-hospital mortality: organ failure (adjusted OR (aOR) 19.28, 95% CI 5.14 to 72.26), recent antibiotic exposure (aOR 5.24, 95% CI 1.90 to 14.51), hypoalbuminaemia <30 g/L (aOR 4.56, 95% CI 1.69 to 13.06) and cerebrovascular disease (aOR 4.24, 95% CI 1.15 to 15.60). Subgroup analysis of patients on intermittent dosing revealed six independent predictors of in-hospital mortality: cerebrovascular disease (aOR 26.9, 95% CI 2.76 to 261.98), hypoalbuminaemia <30 g/L (aOR 10.68, 95% CI 1.54 to 74.29), organ failure (aOR 48.15, 95% CI 4.27 to 542.81), polymicrobial bacteraemia (aOR 24.28, 95% CI 3.09 to 190.64), persistent bacteraemia (aOR 90.08, 95% CI 2.85 to 2845.83) and intensive care unit admission (aOR 0.09, 95% CI 0.01 to 0.91), the latter showing a protective effect. Only 22.2% (n=26/117) achieved the target AUC/MIC, which was not significantly linked to mortality reduction.

Conclusions: Vancomycin AUC/MIC attainment was suboptimal, and mortality was primarily influenced by host factors and disease severity. Early risk stratification and timely intervention are critical to improve outcomes and guide resource prioritisation, particularly in settings with limited access to AUC-guided dosing.

Introduction: Medication errors during hospital discharge are a leading source of avoidable patient harm and healthcare resource strain. Pharmacist-led medicines reconciliation in hospital has demonstrated benefits in improving patient safety and reducing adverse drug events post-discharge.

Aim: The aim of this study was to evaluate the clinical and financial implications of a pharmacist discharge service on a surgical ward in an Irish hospital setting.

Method: A prospective single-centre pilot study was conducted to evaluate the impact of a clinical pharmacist discharge medication reconciliation service. The study was conducted over 8 weeks on a 31-bed surgical ward. Eligible patients were discharged during pharmacy working hours, on ≥3 medications, with pharmacist admission medicines reconciliation completed. A clinical pharmacist reviewed draft discharge prescriptions and communicated interventions to prescribers prior to discharge. Identified discrepancies were assessed by an expert panel for severity (visual analogue score), probability of adverse drug events and potential remedial healthcare use. Financial impact was estimated using cost avoidance modelling.

Results: Of 50 discharge prescriptions reviewed (646 medications), 184 discrepancies were identified in 40 prescriptions (126 prescribing and 58 communication errors). Most errors (84.8%) were rated as having moderate potential harm; 2.2% were classified as severe. Expert panel assessments indicated that pharmacist interventions prevented adverse drug events likely to result in additional healthcare utilisation by 74.7%. A potential annual net cost benefit of €554 921.53 and a cost-benefit ratio of 52.5 was calculated for the provision of a clinical pharmacist discharge service when all discharge prescriptions from the surgical ward (n=665) are reviewed.

Conclusion: The results show the clinical and financial benefits of a pharmacist-led discharge medication reconciliation service, resolving high-risk prescribing errors and reducing downstream healthcare utilisation. This represents a highly cost-effective intervention with potential for substantial system-wide savings by enhancing patient safety and resource efficiency at transitions of care.

Viral encephalitis is a hazardous central nervous system disorder requiring immediate antiviral intervention. Acyclovir is the standard treatment for herpes simplex virus (HSV) encephalitis; nevertheless, improper dosing or administration can lead to nephrotoxicity and neurotoxicity. This case describes a 54-year-old male patient admitted for an allergic reaction, who thereafter had incoherent speech, instability and involuntary motions suggestive of HSV encephalitis. Intravenous acyclovir treatment was initiated empirically following cerebrospinal fluid examination. On the third day of therapy, the patient exhibited acute renal impairment, accompanied by hallucinations and significant psychomotor agitation. Following the clinical pharmacist's recommendations, the dosage was adjusted and the infusion period was prolonged to at least 1 hour, predicated on an estimated glomerular filtration rate of 20 mL/min/1,73 m². Subsequent to these surgeries, renal function and neurological status steadily enhanced, enabling a successful resolution of treatment. This example highlights the crucial role of clinical pharmacists in reducing acyclovir-related toxicities via personalised dosage and infusion management.

Purpose: Hyponatraemia is a common cause of hospital admissions, and correcting sodium levels should be done gradually to avoid complications, including osmotic demyelination syndrome. Desmopressin can be used to prevent rapid fluctuations in sodium. While effective, limited evidence exists regarding its use in patients with renal dysfunction, and package inserts recommend avoiding use in patients with a creatinine clearance (CrCl) of <50 mL/min. The aim of this study was to determine the safety and efficacy of desmopressin in patients with renal dysfunction compared with those with no renal dysfunction.

Methods: This retrospective cohort study was conducted at a single academic medical centre. Adult patients with an initial sodium concentration of <125 mmol/L who received desmopressin were included. The primary outcome was the rate of sodium overcorrection (>8 mmol/L) 24 hours after desmopressin in patients with renal dysfunction (CrCl <50 mL/min) versus those with no renal dysfunction. Secondary outcomes included proportion of patients achieving a 5-10 mEq/L increase within 24 hours and overcorrection rates at 24 and 48 hours. Data were analysed using the test χ², t test and Mann-Whitney U test.

Results: 72 patients were included in the study and 20 had renal dysfunction. The most common desmopressin dosing strategy in both groups was rescue. Baseline sodium was comparable between the groups: 113.8±7.5 versus 115.6±3.73 mmol/L. However, sodium before desmopressin administration was more elevated in the renal dysfunction group (124.1±9.8 vs 129.3±7.8 mmol/L; p=0.04) who also received more sodium through intravenous fluids (284.2 vs 90.7 mEq; p=0.001). There was no significant difference in overcorrection by >8 mmol/L, 24 hours post-desmopressin (9.6% vs 20%; p=0.43), but patients with renal dysfunction had higher rates of overcorrection at 24 hours post-admission (11.5% vs 35%; p=0.048).

Conclusions: This study did not show a significant difference in sodium overcorrection after desmopressin in patients with renal dysfunction. Further studies assessing the safety and efficacy of desmopressin in renal dysfunction are needed.

A 78-year-old Han Chinese woman (height 150 cm, weight 55 kg) underwent left knee prosthesis revision and developed an infection during hospitalisation. Subsequently, the patient developed restlessness and hallucinations. A consultation by a psychiatrist diagnosed postoperative delirium, whereas a clinical pharmacist attributed these symptoms to voriconazole-related adverse effects. The patient had an inadequate response to delirium-targeted treatments, and a voriconazole concentration of 5.0 mg/L was measured. Following the pharmacist's recommendation to discontinue the drug, the symptoms resolved within 4 days. The adverse effects were classified as 'possible' according to the Naranjo Adverse Drug Reaction Probability Scale. To our knowledge, this is the first case highlighting the divergent perspectives between specialist physicians and clinical pharmacists during consultations.

We present the case of a man in his 70s admitted to the intensive care unit (ICU) after mitral valve replacement and coronary artery bypass graft surgery requiring extracorporeal membrane oxygenation support due to haemodynamic instability. He received anticoagulation therapy with heparin sodium and, after 5 days, the patient presented with thrombocytopenia and deep venous thrombosis. Heparin-induced thrombocytopenia was suspected based on a positive 4T score and confirmed by antiplatelet factor 4/heparin antibodies, so argatroban was initiated as an alternative anticoagulation therapy. In the following days the patient developed severe neutropenia requiring discontinuation of argatroban and the administration of granulocyte colony-stimulating factor. According to the Naranjo Adverse Drug Reaction Probability Scale, this event would be classified as a 'probable' argatroban-related adverse event. Argatroban should be conisdered as a possible cause of neutropenia and appropriate interventions need to be implemented due to the gravity of this adverse event in the ICU.

Objective: This study aims to evaluate the risk of occupational exposure to hazardous medicinal products (HMPs) when utilising robotic compounding systems for the preparation of antineoplastic sterile medications. Specifically, it assesses the levels of HMPs present on the surfaces of ready-to-use preparations and on the gloves worn by personnel involved in the compounding process.

Methods: The study was conducted over three consecutive days during routine production with a robotic compounding system. Each day, wipe samples were collected from the surfaces of 20 HMPs preparations and from the gloves of the operator involved in the compounding process. Analyses were performed using an Ultra-High Performance Liquid Chromatography (UHPLC) system to detect and quantify 25 commonly used anticancer molecules in hospital pharmacies.

Results: Throughout the study, the robot compounded 60 bags of 19 different drugs, including 5-fluorouracil, bevacizumab, carboplatin, cisplatin, cyclophosphamide, docetaxel, doxorubicin, eribulin, etoposide, gemcitabine, irinotecan, nivolumab, oxaliplatin, paclitaxel, panitumumab, pembrolizumab, pemetrexed, trastuzumab, and vinorelbine. Only negligible amounts of gemcitabine, below the quantification limit (<0.0025 ng/cm²), were detected on the surfaces of 10 out of the 60 bags and on two of the operator's gloves.

Conclusion: The results demonstrate that surface contamination levels of HMPs in robotic compounding are exceedingly low and, in most cases, undetectable. Occupational exposure to HMPs remains consistently below 0.1 ng/cm², a threshold deemed safe according to various studies. These findings assure the safety of compounding personnel and other hospital staff involved in cancer treatment.

Objectives: Critically ill newborn infants often require simultaneous administration of multiple intravenous (IV) solutions through the same catheter lumen, making compatibility of these solutions crucial in neonatal intensive care units (NICUs). This study aimed to investigate the physical compatibility of insulin aspart, lidocaine, alprostadil and vancomycin with individualised two-in-one parenteral nutrition (PN).

Methods: The study was conducted at the hospital pharmacy's drug compounding facility of the University Medical Centre Utrecht. Two PN formulations were prepared with different electrolyte concentrations (PN1 with high electrolytes and PN2 with low electrolytes), each with either 0% or 30% w/v glucose, resulting in four solutions for testing. Each solution was then mixed with the selected IV drugs in a 1:1 ratio. Compatibility was assessed through visible particle testing, pH measurements and subvisible particle testing at multiple time points (T=0, T=1, T=4 hours).

Results: No visible particles were detected in any combinations. However, insulin and lidocaine combinations exceeded the subvisible particle threshold of 6000 particles ≥10 µm per container volume at T=0 hours, with insulin also exceeding the threshold in a specific PN combination at T=4 hours. pH measurements indicated minimal shifts in the PN solutions, suggesting significant buffering capacity.

Conclusion: Alprostadil and vancomycin IV solutions are physically compatible with two individualised neonatal PN solutions, with high as well as low glucose concentrations. Combinations of PN with lidocaine or insulin form subvisible particles, which could have clinical implications if administered in large volumes over extended periods of time. In clinical scenarios where there is no other option but to administer lidocaine or insulin through the same catheter lumen as PN using a Y-site connector, the use of an in-line filter is advised. Our study adds important compatibility data that can guide clinical practice in NICU settings. However, the broader application of these results requires careful consideration of the unique characteristics of each neonatal PN solution and drug combination.

Objectives: Medication reconciliation (MR) has been identified by the French High Health Authority (HHA) as an advanced criterion for improving the quality of care. Although this activity has been widely developed and evaluated in conventional establishments, few studies have looked at its implementation in 'hospitalisation at home' (HAH) settings. HAH is considered to be an alternative to conventional hospitalisation that requires slight changes to be made to the medication process, such as the prominent role of the patient and their caregivers, the intermittent presence of numerous members of multidisciplinary staff in the home environment, and the patient's own home. So, this study aims to provide an overview of the implementation of MR in our HAH using activity indicators, and to measure the clinical impact of the pharmaceutical procedures carried out as part of this activity.

Methods: A retrospective observational study was conducted. A process and MR materials were developed based on HHA tools. The clinical impact of the pharmaceutical procedure was determined using the Clinical Economic and Organisational (CLEO) scale.

Results: 29 patients benefited from MR on admission, carried out by a pharmacy intern with a pharmacy assistant. A total of 38 unintentional discrepancies were identified. The average number of unintentional discrepancies per patient with at least one unintentional discrepancy in their MR was 2.1. The mean time to complete MR was 2.5 hours. 30 (79%) pharmaceutical procedures were accepted by the clinicians, of which 6 (20%) were considered to have a major clinical impact.

Conclusion: MR for hospitalised patients at home is valuable to ensure safe medication management at this stage of the care pathway. Despite the small sample size of our study, each pharmaceutical procedure has a significant clinical impact. This activity contributed to the certification of our home care facility by the French HHA.