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: Inappropriate prescriptions are known to cause medication-related problems, but little is known about the prevalence of this issue in paediatric patients. This systematic review provides an overview of the prevalence of potentially inappropriate prescriptions identified through tools developed for the paediatric population and delineates the strengths and limitations of the identification tools.

Methods: Literature from PubMed, CINAHL, Cochrane database and Google Scholar was searched with a combination of medical subject headings (MeSH) and free-text terms related to inappropriate prescriptions, paediatrics and potentially inappropriate prescription tools. Studies reported in English and published from inception of the databases until May 2023 were selected based on fulfilment of eligibility criteria. All eligible articles were assessed for methodological quality and examined using thematic analysis.

Results: Twelve studies met the inclusion criteria. The majority of the studies were of high quality. Four themes emerged-namely, evaluation tools and calculation methods of inappropriate prescriptions, prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and predictors of PIM and PPO in children. Among the nine tools identified, the original and modified version of the POPI tool was most commonly used. The prevalence of PIM and PPO ranged from 0.04% to 69% and from 1.5% to 55.9%, respectively. Age was the most common predictor reported, whereby PIMs and PPOs were more likely in children aged 2-6 and 6-12 years, respectively.

Conclusions: Potentially inappropriate prescriptions in paediatric patients is highly prevalent, despite the wide variation in the reported prevalence range and limited implementation of the available tools in practice. Future efforts need to be focused on the development and implementation of age-, disease- or country-specific tools to effectively evaluate and further determine the economic impact of PIMs in children.

Thrombotic microangiopathy is a serious condition that can be precipitated by exposure to certain medications. Although rare, it is life threatening and requires a high index of clinical suspicion, appropriate laboratory testing and immediate cessation of the offending agent. We present a case of a 75-year-old man with a history of ischaemic heart disease treated with clopidogrel and aspirin. One month after initiating the treatment he developed microangiopathic haemolytic anaemia and thrombocytopenia. Extensive clinical and laboratory investigations suggested thrombotic microangiopathy secondary to clopidogrel. The drug was immediately discontinued and treatment with intravenous corticosteroids was started. Within a week the patient's laboratory parameters normalised, indicating successful recovery. This case highlights the role of early detection and immediate discontinuation of suspected medication in the effective management of clopidogrel-induced thrombotic microangiopathy. Healthcare professionals should consider drug-induced thrombotic microangiopathy as a possible diagnosis in patients receiving clopidogrel who present with thrombocytopenia and microangiopathic haemolytic anaemia.