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

Objective: To determine the prevalence, severity and characteristics of potential drug-drug interactions (DDIs) in a homogeneous cohort of patients with early-stage breast cancer receiving adjuvant or neoadjuvant chemotherapy.

Methods: We performed a retrospective observational study of patients treated with systemic chemotherapy at a tertiary hospital. All medications prescribed during chemotherapy were recorded. Potential DDIs were identified using the Lexicomp database and classified by risk level, clinical severity, quality of evidence and mechanism of action. Associations between patient-related factors and DDIs were analysed.

Results: A total of 273 patients were included (median age 52 years) and 56% had at least one comorbidity. Overall, 2842 drugs were prescribed (median 10 per patient), resulting in 2287 potential DDIs. All patients presented at least one DDI; 89% had at least one type D interaction and 14.6% at least one type X interaction. Most DDIs were classified as type C (75.3%), followed by type D (21.7%) and type X (3.0%). The total number of DDIs was significantly associated with age, comorbidity burden and number of prescribed drugs.

Conclusions: Potential DDIs are highly prevalent in patients with early-stage breast cancer receiving chemotherapy, with a substantial proportion involving clinically significant or contraindicated combinations. Polypharmacy, age and comorbidities are key risk factors, highlighting the importance of systematic medication review and interdisciplinary collaboration to improve treatment safety.

Objectives: Clinical pharmacy care in German hospitals has recently evolved, driven by digitalisation and legal reforms. The only comprehensive overview of clinical pharmacy care in Germany was published in 2019. The current survey aims to update and describe the status quo of clinical pharmacy services in Germany, highlighting developments in this field since the previous publication.

Methods: In 2024, an online survey with 45 questions was carried out among chief pharmacists, organised within the German Federal Association of Hospital Pharmacists (ADKA) e.V. (n=328). The survey collected structural data (eg, beds and workforce), as well as information on the extent and range of clinical pharmacy services.

Results: The survey received 135 responses, resulting in a response rate of 41%. The provision of clinical pharmacy services (CPS) was already well established in 114 pharmacies (85.7%), meaning at least 32.4% of all German hospital pharmacies offer CPS. The average number of full-time equivalents dedicated to these services per hospital pharmacy is 4.3, which is an increase of1.9 full-time equivalents compared with the first survey. Regular visits (at least once a week) are reported in the range of 80% for most surgical disciplines, haematology/oncology and critical care/anaesthesia. The regular patient-centred services were offered daily or 2-3 times weekly, respectively.

Conclusions: This follow-up survey provides a comprehensive overview of the developments since the initial survey, offering a detailed analysis of the current status of CPS in German hospitals. A general improvement has been observed regarding the range of services offered, utilisation of workforce resources and frequency of service delivery. Despite this positive development, further measures are necessary to ensure the enhancement and improvement of CPS in all hospitals.

Objectives: Drug shortages, particularly in anaesthesia, pose a risk to patient care. Propofol, a widely used anaesthetic, is formulated as an emulsion requiring a complex industrial manufacturing and pharmaceutical supply chain, making propofol vulnerable. Cyclodextrins can enhance the aqueous solubility of lipophilic drugs and may provide an alternative approach. The objective of this study was to develop and evaluate a ready-to-use cyclodextrin-based propofol formulation that could be prepared in a hospital pharmacy using standard equipment.

Methods: A 1% (w/v) propofol solution was prepared using hydroxypropyl-β-cyclodextrin (HP-β-CD). The association constant (Ka) was calculated using the Higuchi and Connors method. The solution was sterilised by 0.22 µm filtration or by autoclaving at 121°C for 15 min. Stability was assessed over 90 days at 2-8°C and 20-25°C. A validated HPLC-UV method was used to quantify propofol and detect degradation products. Additional quality controls included pH, osmolality, subvisible particles, sterility and endotoxin levels.

Results: The Ka was 1288±32 M⁻¹. A clear 1% (w/v) solution was obtained with 17% (w/v) HP-β-CD and 0.35% (w/v) sodium chloride, without pH adjustment. Both sterilisation methods preserved drug integrity. The formulation remained stable for 3 months under refrigeration. At room temperature, degradation occurred after 14 days.

Conclusion: This study demonstrates the feasibility of a hospital-based preparation of a sterile injectable propofol solution using cyclodextrins. These results support the role of hospital pharmacies in addressing drug shortages by enabling locally controlled and resilient production capacity.

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition associated with seizures, visual disturbances and altered mental status. It is commonly linked to immunosuppressive therapies such as ciclosporin, widely used in recipients of a haematopoietic stem cell transplant (HSCT). Neuroimaging, especially MRI, is the most important diagnostic tool for PRES, as it typically shows bilateral and symmetrical involvement of the occipital and parietal regions with white matter oedema.Electroencephalography may be useful for the detection of (non-convulsive) epileptic seizures, status epilepticus and may play a role in the evaluation of encephalopathy. We present the case of a 12-year-old boy who developed PRES during ciclosporin treatment for graft versus host disease prophylaxis following allogeneic HSCT. After early recognition, discontinuation of ciclosporin and appropriate management, full clinical recovery was achieved. This case highlights the importance of early detection and multidisciplinary management to prevent permanent neurological damage in paediatric recipients of a transplant.

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.