Hospital Pharmacy最新文献

Introduction: Stress dose hydrocortisone is recommended in septic shock. Discontinuation can lead to withdrawal after prolonged durations of therapy. There is no guidance on the use of steroid tapers. Our objective was to assess prescribing practices and evaluate stress dose hydrocortisone tapers in septic shock. Methods: Retrospective review of patients admitted to the intensive care unit (ICU), with septic shock, who received hydrocortisone for at least 24 hours from January 1, 2020 through December 31, 2023. The primary outcome was the percentage of patients who received a hydrocortisone taper. Secondary outcomes included duration of stress dose hydrocortisone, method and duration of taper, and rate of increased vasopressors at 24 and 48 hours of hydrocortisone taper initiation or discontinuation. Results: Two hundred seventy-six patients were included. The initial duration of hydrocortisone was 2 (1.5-3) days. One hundred thirty-nine (50.4%) patients received a hydrocortisone taper, with a taper duration of 2 (1-3) days. The primary method of taper was a reduction in frequency (56.8%). Patients who received a taper required an increase in vasopressor rate at 24 (37.4% vs 21.3%, P = .004) and 48 hours (20.3% vs 12.9%; P = .14). The steroid taper group showed a decreased hospital (OR 0.55; 95% CI, 0.33-0.92) and ICU mortality rate (OR 0.47; 95% CI, 0.27-0.81), albeit an increased ICU length of stay (OR 1.04; 95% CI, 1.02-1.06), increased duration of mechanical ventilation (OR 1.08; 95% CI, 1.03-1.12), and increased vasopressor rate at 24 hours (OR 2.21; 95% CI, 1.29-3.77). Conclusions: In patients admitted to an ICU for septic shock started on stress dose hydrocortisone there was heterogeneity in the duration of stress dose hydrocortisone and the implementation, method, and length of a taper. This highlights a need for additional attention to methods of discontinuation of stress dose steroids and implications on patient centered outcomes.

Purpose: This study serves to evaluate the potential benefit of pharmacist intervention in ensuring appropriate treatment of urinary tract infections (UTI) in adult patients in a community hospital. Methods: This was a single-center, quasi-experimental design, institutional review board (IRB)-approved study comparing antimicrobial use and UTI treatment guidance adherence before (11/2021-1/2022) and after (11/2022-1/2023) pharmacist prospective audit and feedback at a community non-teaching hospital. Inpatients were included if they had a positive urine culture and no other concomitant infection or other exclusion criteria. The primary outcome was time to appropriate antibiotic therapy (as determined by the institutional treatment guidance). Overall appropriateness of empiric antimicrobials was also assessed. Results: A total of 194 patients were included in the study (101 pre-intervention group and 86 post). There was no significant difference in median time to appropriate antimicrobial therapy between groups (20.1 vs 22.6 hours, P = .907) or appropriateness of empiric therapy (50% vs 55%, P = .483). Missing indication and agent choice for higher severity infections were the two most common reasons for inappropriate empiric therapy. A total of 55 pharmacist interventions were made with an overall acceptance rate of 31%. Conclusion: In this study, pharmacist intervention did not have a significant effect on the primary outcome. Promotion of utilization of the UTI order set that aligns with the institution guideline would likely improve the appropriateness of empiric therapy. However, the institutional guidance criteria also seemed to over-recommend broad spectrum agents and may need to be revisited.

The widespread administration of local anesthetics such as benzocaine necessitates understanding their lesser-known adverse effects. Acquired methemoglobinemia (MetHb) is a rare but life-threatening complication associated with the routine use of benzocaine spray prior to endoscopic procedures such as transesophageal echocardiography (TEE). Recognizing the manifestation of MetHb is critical to early detection and appropriate management of this condition. We present a case of MetHb in a patient with sepsis and anemia, resulting in respiratory failure, and offer an overview of the existing literature on the subject.

Background: Correction scale insulin therapy is commonly used in hospitals. There is limited data evaluating the relationship between correction scale administration timing and morning hypoglycemic episodes. Objective: To evaluate the association between morning hypoglycemic episodes in patients who receive their correction scale insulin before meals (AC) or before meals and at bedtime (ACHS). Methods: This is a single-center, retrospective, cohort study of hospitalized patients with a history of diabetes receiving at least 1 long-acting insulin agent. The primary endpoint was the occurrence of hypoglycemia that occurred in the morning. Secondary endpoints included hyperglycemia, hypoglycemia at any time, glycemic variability (quantified as coefficient of variation, CV), and mortality. Since subjects were not randomly assigned to the exposure, inverse probability of treatment weighting (IPTW) was used to balance factors between the study groups. Multivariable analysis for hypoglycemia was conducted using logistic regression weighted by stabilized IPTW. Results: A total of 614 subjects were included in the study with 556 subjects in the ACHS group and 58 subjects in the AC group. Significant differences in the frequency of morning hypoglycemia were not observed between the ACHS and AC groups (30.6% vs 32.8%, respectively) and this finding persisted after IPTW (OR 0.89, 95% CI 0.63-1.25). Secondary outcomes (after IPTW) showed less morning hyperglycemia (OR 0.39, 95% CI 0.26-0.60) and hyperglycemia at any time (OR 0.2, 95% CI 0.11-0.38) in the ACHS group. No difference was observed in hypoglycemia at any time (OR 0.8, 0.57-1.12), glycemic variability (P = .99), and mortality was infrequent (0.5% vs 0%). Conclusion: We did not observe an association between ACHS correction scale and morning hypoglycemia. Hyperglycemia was less frequent in the ACHS group. Our results support the continued use of ACHS correction scale insulin.

Background: Intravenous unfractionated heparin is commonly used to treat venous thromboembolism; however, dosing in obese patients is challenging due to unpredictable pharmacokinetics and conflicting guidance. Methods: This single center, retrospective cohort study was conducted to evaluate the achievement of therapeutic heparin correlation values (HCV), a standardized version of the activated partial thromboplastin time (aPTT), with heparin infusions dosed utilizing total body weight (TBW) versus adjusted body weight (ABW) in obese patients. The primary outcome was to determine the percentage of initial HCV within the therapeutic range after heparin initiation. Key secondary outcomes included incidence of supratherapeutic HCV at any time and major bleeding events. Results: A total of 477 patients were included, with 94.9% (n = 453) of patients in the TBW cohort (mean body mass index (BMI) 36.8 ± 7.4 kg/m²) and 5.1% (n = 24) in the ABW cohort (mean BMI 42.1 ± 9.3 kg/m²). Initial HCV was within the therapeutic range in 41.9% (n = 190) and 54.2% (n = 13) of patients in the TBW cohort and ABW cohort, respectively (P = .238). Supratherapeutic HCV during any point in therapy occurred in 64.7% (n = 293) of the TBW cohort and 41.7% (n = 10) of the ABW cohort (P = .022). Major bleeding occurred in 15.2% (n = 69) of patients in the TBW cohort and 12.5% (n = 3) in the ABW cohort (P = .716). Conclusions: In obese patients receiving a heparin infusion, dosing based on ABW compared to TBW did not result in a higher likelihood of achieving a therapeutic initial HCV, but the rate of supratherapeutic HCV was reduced.

Background: Alcohol intolerance, characterized by adverse reactions following alcohol consumption, can occur due to interactions between alcohol and certain medications. Despite its clinical significance, evidence for alcohol intolerance induced by commonly prescribed drugs remains limited. This study aimed to identify signals for drug-associated alcohol intolerance using the United States Food and Drug Administration (USFDA) Adverse Event Reporting System (AERS). Methods: A disproportionality analysis was conducted on the USFDA AERS spanning the first quarter of 2004 to the second quarter of 2024. Cases were identified using the Preferred Term "alcohol intolerance". Duplicate reports were excluded, and only drugs classified as primary suspects were analyzed. The key disproportionality measures included frequentists (reporting odds ratio [ROR]) and Bayesian methods. Top 10 drugs associated with alcohol intolerance were identified using volcano plot. Subgroup analyses by age and gender were performed, and clinical outcomes were evaluated. Results: Among 29 153 222 reports, 406 cases of drug-associated alcohol intolerance were identified, predominantly in adults aged 18 to 65 years. Multiple drug classes demonstrated significant signals including antimicrobials (metronidazole [ROR: 27.4], cefoperazone [ROR: 290.6]), and ketoconazole [ROR: 27.6]), respiratory medications (salmeterol [ROR: 6], mometasone [ROR: 6], and dupilumab [ROR: 6.1]), and psychoanaleptics (bupropion [ROR: 8.1] and several selective serotonin reuptake inhibitors). The Volcano plot analysis highlighted 10 drugs with particularly strong associations, including cefoperazone, spiramycin, metronidazole, and dupilumab. Outcomes included hospitalization (16%), disability (6.4%), and death (1.7%). Conclusion: This study highlights significant associations between several medications and alcohol intolerance, emphasizing the need for further research to confirm these findings and inform clinical guidelines to optimize patient safety.

Background: Current guidelines and the package insert do not define the appropriate body weight to dose calcitonin and there is a lack of literature evaluating dosing via ideal body weight (IBW). Objective: The objective of this study is to compare calcium reduction among patients with severe hypercalcemia treated with calcitonin via total body weight (TBW) versus IBW. Methods: This was a single-center retrospective analysis of data gathered within a quality improvement project to standardize parenteral calcitonin utilization. The primary outcome was to compare calcium reduction within 24 hours of treatment initiation. Secondary outcomes included calcium reduction within 48, 72, and 96 hours, the incidence of hypocalcemia, the incidence of rebound hypercalcemia, and the average wholesale price (AWP) expenditure. Results: A total of 48 patients met inclusion criteria, with 25 patients in the TBW group and 23 patients in the IBW group. The primary outcome of change in corrected calcium within 24 hours was not statistically significant between groups (1.1 mg/dL vs 1.7 mg/dL, P = .12). Serum calcium levels and change from baseline were followed up to 96 hours, and no difference was noted between groups. Additional secondary outcomes were not significant, with the exception of AWP expenditure, which was statistically lower in the IBW group ($11 274.0 vs $7516.0, P = .02). While no difference was found in the total number of doses administered or total units consumed (600.0 units vs 400.0 units, P = .06), a significant difference was found in the average dose (364.0 units vs 239.0 units, P < .00001). Conclusion: This study suggests that dosing parenteral calcitonin via IBW achieved a similar reduction in calcium compared to TBW. Moreover, dosing via IBW resulted in a significant reduction in average dose and in AWP expenditure when compared to TBW. This approach offers an alternative dosing strategy that uses less medication, without compromising efficacy.

Purpose: Advances have been made with delivery of medications via continuous intrathecal irrigating ventricular drains such as IRRAflow (IRRAS). Medications including vancomycin, tobramycin, daptomycin and nicardipine are currently being used as ventricular irrigations via the IRRAflow device. The purpose of this study was to evaluate the chemical stability of minute concentrations of daptomycin, nicardipine, tobramycin, and vancomycin for administration via IRRAflow intrathecal catheters. Methods: Commercially available formulations of daptomycin, nicardipine, tobramycin, and vancomycin were each diluted in separate normal saline (NS) 1000 mL bags to final concentrations of daptomycin 2 mg/1000 mL NS, nicardipine 2.5 mg/1000 mL NS, tobramycin 4 mg/1000 mL NS, and vancomycin 4 mg/1000 mL NS. Samples from each compound were transferred into 2.5 mL glass vials and evaluated in triplicate fashion using ultra-performance liquid chromatography and tandem mass spectrometry (LC-MS/MS). Each injection was analyzed in comparison to its respective calibration curve and a mean result for each time point was determined. The concentration of the samples was tested at 0, 6 and 12-hours for vancomycin, daptomycin, and tobramycin and 0, 4 and 8-hours for nicardipine. All irrigations were kept at room temperature and were not protected from light. Results: All samples tested were found to be chemically stable at various testing time points. Daptomycin retained a mean of 94.3% of initial concentration at 12 hours while tobramycin retained 93.1% of its initial concentration at 12 hours. Vancomycin samples were found to be 92.9% of initial concentration at 12 hours and nicardipine maintained a mean of 90.6% of initial concentration at 8 hours. Future studies could assess these conditions to potentially further stability data. Conclusion: With use of LC-MS, we demonstrated that dilute concentrations of vancomycin, daptomycin, and tobramycin maintain at least 90% of initial concentration for 12 hours at room temperature, whereas nicardipine remained chemically stable for 8 hours at room temperature.

Objectives: Lacerations are one of the most widespread and common emergencies among children, addressed by doctors in emergency room admissions. The aim of this study was to optimize the formulation of a pre-existing anaesthetic gel known as LAT gel (Lidocaine 4%, Adrenaline 0.05%, Tetracaine 0.5% gel), in order to allow the paediatric emergency department of the Policlinico A. Gemelli (Rome) to improve the management of lacerations, while avoiding the mandatory use of infiltrative anaesthesia. The aim of the study was also to assess the stability over time of the active ingredients (lidocaine, adrenaline, tetracaina) in the galenic preparation. Methods: LAT gel is a formulation prepared using: a poloxamer, Lutrol F127 (or Kolliphor P407), two anaesthetics (lidocaine and tetracaine), together with adrenaline. The formulation was prepared in a Grade A laminar flow hood and in a Grade B environment for microbial load. Batches were subjected to microbiological analysis by hospital hygiene as indicated in FU XII ("Official Italian pharmacopoeia XII edition"). The chemical stability of the gel was assessed by high-performance liquid chromatography. Results: Analysis showed that the lidocaine, tetracaine and adrenaline content in the LAT gel remained constant when stored in a refrigerator at 2 to 8°C for up to 120 days. The non-need for additional anaesthetic methods was considered as a parameter of effectiveness. 83 children were evaluated. In the cases recorded, 83.1% (69/83) of patients did not require an additional anaesthesia. Patients who required additional anaesthesia 16.9% (14/83) were those with deep and extensive lacerations. The results show that an effective, sterile, stable preparation with excellent applicability was prepared. Conclusion: This product lends itself to application to the wound surface with a better anaesthetic and haemostatic effect and, unlike injectable lidocaine, is an optimal treatment for increasing compliance in paediatric emergency rooms.