Hospital Pharmacy最新文献

Coumarin derivatives, including warfarin and acenocoumarol, are widely used oral anticoagulants that inhibit vitamin K-dependent coagulation factors. They are commonly prescribed for the prophylaxis of thromboembolic disorders. Although effective, these agents are associated with many adverse drug reactions, which include hemorrhagic complications, warfarin-induced skin necrosis, hypersensitivity reactions, and, rarely, leukocytoclastic vasculitis (LCV). LCV is an immune-mediated small-vessel vasculitis characterised by palpable purpura, often triggered by drugs, infections, or autoimmune conditions. Here, we present the case of a 53-year-old female with a history of rheumatic heart disease and mechanical mitral valve replacement who developed LCV after 5 years on acenocoumarol. The reaction persisted despite adjunct therapy and worsened upon switching to warfarin, suggesting possible cross-reactivity between these coumarin derivatives. Ultimately, transitioning to apixaban led to the complete resolution of symptoms. This case underscores the importance of early recognition of drug-induced vasculitis and highlights the need for individualised anticoagulation strategies in patients with hypersensitivity reactions.

Background: Although 2019 EACTS Guidelines on Cardiopulmonary Bypass in Adult Cardiac Surgery recommend against routine use of prophylactic corticosteroids, perioperative glucocorticoids are still often used to mitigate hypotension, cardiac arrhythmias and respiratory failure following surgery with cardiopulmonary bypass (CPB). Limited data exists on safety and efficacy of intravenous (IV) hydrocortisone in this setting.

Objectives: To assess the impact of intravenous hydrocortisone on postoperative complications after on-pump coronary artery bypass grafting (CABG).

Methods: This was a single-center, retrospective chart review between 2021 and 2023. Adult patients with on-pump CABG requiring vasopressor therapy postoperatively were included.

Results: Of 153 patients included, 39 received IV hydrocortisone and 114 did not. The hydrocortisone group had significantly lower cortisol levels (15.8 mcg/dL vs 23.9 mcg/dL, P < 0.001) and higher incidence of a past medical history of atrial fibrillation (23.1% vs 2.6%, P < 0.001) compared to the control group. Rates of postoperative atrial fibrillation (POAF) were similar between groups with 23.1% in the hydrocortisone group and 21.9% in the control group (P = 0.88), which maintained after controlling for age, history of atrial fibrillation, sex, and propensity score (P = 0.86). Mean cumulative norepinephrine equivalents (NEE) were similar between hydrocortisone group and control (10.4 mcg/min vs 8.9 mcg/min, P = 0.12). Hydrocortisone administration was associated with longer durations of vasopressor therapy (45.8 vs 28.9 hours, P = 0.001), insulin therapy (149.4 vs 82.2 hours, P = 0.003), and total mechanical ventilation time (59.3 vs 19.4 hours, P = 0.049). There were no differences in surgical site infections between the hydrocortisone group versus control group (5.2% vs 5.2%, P = 1.00), including both non-infectious (2.6% vs 2.6%, P = 1.00) and infectious surgical site complications (2.6% vs 2.6%, P = 1.00).

Conclusion: After controlling for sex, age, history of atrial fibrillation/flutter, and propensity score, there was no significant association between the administration of IV hydrocortisone and POAF in patients receiving vasopressor support following on-pump CABG. Further prospective studies are needed to confirm these findings.

Background: Since 2017, guidelines recommend a four-drug prophylactic antiemetic regimen-5HT3 receptor antagonist (5HT3RA), NK1 receptor antagonist (NK1RA), dexamethasone, and olanzapine-for patients receiving highly emetogenic chemotherapy (HEC). This study examines prophylactic olanzapine prescribing in patients initiating HEC and associated sociodemographic, clinical, and contextual factors.

Methods: A retrospective cohort study was conducted using electronic health record data from an academic cancer center and affiliated community practices across the state of North Carolina, joined with geocoded community factors. Adults ≥21 years initiating cisplatin, carmustine, dacarbazine, mechlorethamine, streptozocin, or cyclophosphamide plus anthracycline (AC) in 2022 were included. Antiemetic orders placed before HEC administration were classified as three-drug (5HT3RA, NK1RA, dexamethasone) or four-drug (plus olanzapine). Late olanzapine use (within 30 days post-HEC) was also assessed. Multivariable logistic regression evaluated factors associated with regimen type.

Results: Among 878 patients, all received orders for the three-drug regimen, but only 300 (34.2%) had olanzapine ordered within 30 days before first HEC. After adjusting for covariates, olanzapine prescribing was less likely in patients with breast (OR = 0.13, 95%CI = 0.07-0.23), gastrointestinal (OR = 0.20, 95%CI = 0.04-0.94), gynecological (OR = 0.14, 95%CI = 0.03-0.69), and head and neck (OR = 0.17, 95%CI = 0.05-0.66) compared to hematological cancers, in those receiving cisplatin (OR = 0.20, 95%CI = 0.06-0.70) and carmustine (OR = 0.02, 95%CI = 0.00-0.48) compared to AC, and in community (OR = 0.40, 95%CI = 0.27-0.61) versus academic settings. Prescribing was also lower among patients residing in low- (OR = 0.49, 95%CI = 0.25-0.93) or lower-middle income (OR = 0.50, 95%CI = 0.32-0.78) areas, but higher among those living >6 miles from treatment facilities (OR = 1.95, 95%CI = 1.08-3.58). Among patients without prophylactic olanzapine, 12.5% were prescribed it within 1 to 30 days post-HEC.

Conclusions: Despite guideline recommendations, prophylactic olanzapine use in HEC remains suboptimal, influenced by clinical and non-clinical contextual factors. Targeted efforts at information dissemination and updated prescribing systems are needed to promote equitable, evidence-based supportive care.

Background: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have become cornerstone drugs for the treatment of T2DM. Comprehensive direct comparisons between the effects of different SGLT2 inhibitors are rare in Chinese studies. We aimed to compare the effects of empaglifllozin (EMPA) and dapaglifllozin (DAPA) in Chinese patients with T2DM.

Methods: The study used real-world data for retrospective analysis. The hospitalized patients treated with EMPA or DAPA in our hospital between December 1, 2022 and October 31, 2024 were screened. The matching of 1:1 propensity score (PS) balanced the baseline of EMPA and DAPA groups. To compare the effects of EMPA and DAPA in T2DM patients.

Results: The study retrospectively enrolled 5171 patients and finally screened 199 patients (EMPA group) and 179 patients (DAPA group). After 1:1 PS matching, 124 pairs were found successfully. The changes of HbAlc, FBG, HbAl, eAG, TG, TC, HDL-c, LDL-c, AST, ALT, TBiL, DBiL, eGFR and BUN, or the control rates of HbAlc < 7%, FBG < 7 mmol/L, FBG < 6.5 mmol/L, TG, TC, HDL-c, LDL-c, AST, ALT, eGFR, BUN between EMPA and DAPA groups were not significantly different (P > 0.05). There was no significant difference in the incidence of CHD, DN, DR, DPVD, DPN, thyroid nodule, osteoporosis, urinary tract infection, chronic gastritis and oral inflammatory diseases (P > 0.05). The DAPA group showed a significantly lower incidence of MAFLD compared to the EMPA group during the observation period (P < 0.01).

Conclusions: DAPA and EMPA showed parallel effects on glycolipid metabolism, liver and kidney function.

Purpose: Pneumonia polymerase chain reaction panels are diagnostic tools that allow rapid identification of respiratory pathogens and bacterial resistance genes. These panels are frequently used as an antimicrobial stewardship tool to optimize antimicrobial therapy for patients with suspected pneumonia. The purpose of this study is to evaluate the appropriate utilization of pneumonia panels and how their results influence clinicians to make changes to antibiotic regimens for patients with suspected pneumonia.

Methods: This was a retrospective cohort study conducted within a single academic medical center. Adult patients with pneumonia panel results reported between February 1, 2024, and October 1, 2024, were included in the study. The primary outcome was the percentage of pneumonia panels inappropriately ordered. Secondary endpoints were the percentage of patients with pneumonia panels inappropriately ordered, the percentage of patients receiving appropriate antibiotics, patients with antibiotics appropriately escalated, or deescalated within 24 hours, median hospital and intensive care unit length of stay, in-hospital mortality, and 30-day hospital readmissions.

Results: A total of 712 patients were included for analysis, with 810 total pneumonia panel results reported in the study population. Bacteria were detected on 52.6% of panels, viruses were the only pathogens detected on 12.3% of panels, and no pathogens were detected on 35.1% of panels. Overall, 61.6% of pneumonia panels ordered were inappropriate. Within 24 hours of panel results, appropriate antibiotic escalation occurred in 14.9% of patients, and appropriate antibiotic de-escalation or discontinuation occurred in 19.5% of patients.

Conclusions: In this study, inappropriate ordering of pneumonia panels occurred in more than half of cases. The overall impact on antimicrobial prescribing was limited, with appropriate antibiotic escalation or de-escalation occurring in a small number of patients. These findings highlight the importance of targeted ordering strategies and antimicrobial stewardship interventions to optimize the clinical utility of pneumonia panels.

Background: In 2019, the Infectious Diseases Society of America (IDSA) released updated guidelines for the treatment of community-acquired pneumonia (CAP). These guidelines recommend a new preferred duration of therapy of no less than a total of five days if the patient has achieved clinical stability. This quality improvement project will determine whether comprehensive education to pharmacists and providers impacts the total duration of antibiotic therapy for patients treated for CAP.

Objectives: The primary endpoint was to evaluate the impact of the intervention on antibiotic duration of therapy for patients with CAP in the post-intervention group. The secondary endpoints were the impact on duration of therapy for patients with an antibiotic switch or patients with an outpatient prescription for antibiotics for CAP at discharge.

Methods: This study was an IRB-approved, retrospective cohort study. Education was provided to clinical pharmacists during scheduled monthly meetings for a 6-month period starting in August 2024. Hospitalists were educated in a separate meeting prior to post-intervention data collection. Data were collected from February 1, 2024 to July 31, 2024 and September 1, 2024 to February 28, 2025 for the pre- and post-intervention cohorts, respectively.

Results: The pre- and post-intervention cohorts include 116 and 145 patients, respectively. Total duration of therapy decreased by 0.9 days after the intervention (7.3 ± 2.7 and 6.4 ± 2 days, respectively, in the pre- and post-intervention groups; P = .005). Duration of therapy decreased by 1 day for patients with an antibiotic switch after the intervention (seven days [6-10] and six days [5-8] in the pre- and post-intervention groups, respectively; P < .001). Duration of therapy for patients with an outpatient antibiotic prescription decreased by 1.5 days after the intervention (8.8 ± 3 and 7.3 ± 2.3 days, respectively, in the pre- and post-intervention groups; P < .01).

Conclusions: The pharmacist-led education resulted in a statistically significant reduction in the duration of therapy for patients treated for CAP. There was a statistically significant reduction in the duration of therapy after the intervention in patients who had an antibiotic switch and those who had an outpatient antibiotic prescription for CAP at discharge.

Background: Acute kidney injury (AKI) is a critical concern in intensive care unit (ICU) patients, especially those treated with colistin. However, existing research often includes mixed patient populations, including non-ICU patients, and lacks stratification of factors associated with varying severities of AKI. The AKI prevalence and predicting variables should be further explored due to the diversity in AKI development and outcomes in colistin-treated ICU patients.

Methods: This study analyzed electronic medical records of 174 surgical and medical ICU patients treated with intravenous colistin at a tertiary university hospital. Multinomial regression analysis was used to analyze the prevalence of AKI stages using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria and identify predictive factors across different stages of AKI.

Results: Among 174 colistin-treated ICU patients, 83.9% developed AKI with a median stage of 3. The presence of AKI did not significantly influence the mortality rates. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score was a consistent predictor across AKI stages (P < 0.05). Colistin dosage was as a significant predictor when distinguishing Stage 1 AKI from no AKI (adjusted OR 1.46, 95% CI: 1.09-1.94), but was not identified as a significant predictor for the progression to Stages 2 to 3 AKI.

Conclusion: The impact of colistin-associated nephrotoxicity in ICU patients is primarily at the initial stage of AKI and does not extend to more advanced stages. Patient safety may be enhanced by using the APACHE II score as one of the deciding variables when deciding between colistin and other antibiotic treatments, particularly for vulnerable critically ill patients.

Introduction: Traditional estimations of kidney function relying on serum creatinine (SCr) have significant limitations, as SCr is affected by many non-kidney determinants, such as body composition, age, nutritional status, volume status, etc. While cystatin C (cysC) is not without its own limitations, support for cysC use as an alternative or additional method of kidney function assessment is developing. The role of cysC-based estimations of kidney function in acutely ill, hospitalized patients has not been fully established.

Objective: The objective of this study was to determine the incidence of discordance in estimated glomerular filtration rate (eGFR) between SCr-based calculations and SCr/cysC-based calculations of kidney function.

Methods: This was a single-center, retrospective, observational cohort study at an academic medical center including adult inpatients admitted in 2023 with SCr and CysC ordered. The primary outcome was discordance, defined as an occurrence of a 30% or greater difference between Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFR SCr-cysC (eGFRcr-cys) and Cockcroft Gault (CG). Data was collected via chart review. Descriptive statistics were used. Nominal data (%) was analyzed by Fisher's exact test and continuous data (median [IQR]), including discordance, was analyzed via Wilcoxon matched pair signed ranked sum. For comparison, eGFRcr-cys was individualized for patients' body surface area.

Results: The study included 463 patients (49% female, age 61 [48-72] years, 50.1% critically ill) with SCr 1.14 [0.68-1.82] mg/dL and cysC 2.00 [1.33-2.78] g/dL. Clearance was 60.0 [34.0-100.5] mL/min by CG and 43.0 [24.5-71.0] mL/min by eGFRcr-cys. Discordance rate was 44.3% (205/463). Compared to patients without discordance, patients with discordance were younger (55 years [44-65] vs 65 years [55-74]; P < .001) and had lower median SCr (0.93 mg/dL [0.48-1.58] vs 1.35 mg/dL [0.85-2.10], P < .001). Discordance occurred more often in critically ill patients (52.2%; 121/232 patients) than general medicine/surgical patients (36.4%; 84/231 patients, P < .001).

Conclusion: In hospitalized patients, eGFRcr-cys was discordant with CG in 44.3% of the population. Discordance in kidney function estimates likely impacts clinical care, including drug dosing. Further studies are needed to determine optimal use of each estimation.