Journal of Pharmacy Technology最新文献

Universal Licensing Recognition (ULR) laws have emerged as a key policy tool to improve license mobility by allowing licensure obtained in one state to be more easily recognized in another. While these reforms have increased access to licensure and employment opportunities, they generally apply only to initial licensure, not to renewal. Nearly all state boards of pharmacy require continuing education (CE) for license renewal, yet CE requirements vary significantly across states in terms of hours, topics, formats, reporting frequency, and approved providers. These discrepancies create substantial administrative burdens for pharmacists maintaining active licenses in multiple jurisdictions. This article examines the implications of extending ULR principles to license renewal, using a case study of a pharmacist licensed in West Virginia and neighboring states. The analysis suggests that pharmacists working across state lines often default to the most restrictive CE standards to ensure compliance, incurring unnecessary cost and complexity. We highlight Idaho's 2024 reform to its ULR statute, which exempts multistate licensees from duplicative CE requirements if they comply with their home state's CE standards and limits overall CE burdens based on regional averages. These reforms offer a promising model for pharmacy regulators seeking to reduce administrative friction, support workforce flexibility, and enhance access to care without compromising professional standards.

Objective: Therapeutic plasma exchange (TPE) may enhance the elimination of drugs from human plasma. Removal of apixaban during TPE has not been extensively described previously. Case: This is a retrospective report of a 76-year-old man admitted to the hospital on apixaban with acute worsening of respiratory and bulbar symptoms due to myasthenia gravis. On hospital day (HOD) 1, TPE was initiated for management of myasthenic crisis. Apixaban levels were obtained before and after a TPE session on HOD 3. On HOD 3, the patient's apixaban plasma level decreased from 88 ng/mL before TPE to 81 ng/mL after. Apixaban displayed an elimination half-life of 65.5 hours with intervening TPE. Discussion/conclusions: We report no clinically significant apixaban removal in a patient undergoing TPE for myasthenic crisis. This differs from previous reports. Supplemental dosing or rescheduling of apixaban doses around TPE sessions may be unnecessary, though more data are needed.

Background: The increased utilization of oral factor Xa inhibitors (FXaI) has led to a growing interest in the clinical utility of FXaI-specific anti-Xa concentrations. Critically ill populations are at risk of bleeding secondary to FXaI accumulation in the setting of end-organ dysfunction. To mitigate this risk, an FXaI anti-Xa concentration-guided approach to transitioning between oral and parenteral anticoagulation has been explored. Objective: To compare the incidence of bleeding upon intensive care unit (ICU) admission between 2 different FXaI transition strategies: concentration versus non-concentration-guided. Methods: We performed a retrospective chart review of patients admitted between January 2019 and May 2022 with objective evidence of FXaI exposure within 48 hours preceding ICU admission. Patients were excluded if they were admitted to the ICU with a primary diagnosis related to a bleeding event, received a non-FXaI anticoagulant 48 hours preceding ICU admission, remained off anticoagulation during their ICU admission, or underwent surgical procedures. The primary outcome was the incidence of major bleeding within 5 days of ICU admission. Thromboembolic events were evaluated as a secondary endpoint. Results: A total of 433 patients (184 concentration-guided vs 249 non-concentration-guided) were included. There was no difference in major bleeding between groups (2.7% in concentration-guided vs 3.6% in non-concentration-guided; P = 0.79). Thromboembolic complications were similar between groups (1.6% in concentration-guided vs 2.0% in non-concentration-guided; P = 1.00) despite a longer time from last FXaI dose to anticoagulant transition in the concentration-guided group (29.9 hours vs 19.4 hours; P < 0.01). Conclusion and relevance: Use of FXaI concentrations to guide anticoagulation transition in the ICU had no impact on major bleeding events or thromboembolic complications. Further analyses are needed to validate FXaI concentration-guided strategies and solidify anti-Xa cutoffs to create a standardized approach to FXaI transitions in the critically ill patient population.

Background: The 2021 Centers of Disease Control and Prevention (CDC) sexually transmitted infection treatment guidelines recommend a 7-day course of metronidazole or single-dose tinidazole for women with trichomoniasis due to improved patient outcomes compared with single-dose metronidazole therapy. A health system antimicrobial stewardship program implemented an interruptive electronic health record (EHR) alert to promote optimal trichomoniasis prescribing when nonrecommended treatment is ordered. Objective: To determine the impact of an interruptive EHR alert on optimal trichomoniasis prescribing for women. Methods: This was an institutional review board-approved, single pretest, posttest quasi-experiment of women ≥15 years with a microbiologically confirmed Trichomonas vaginalis infection from 10/2023 to 12/2023 (preintervention) and 10/2024 to 12/2024 (postintervention). An EHR alert was implemented 9/2024 that notifies prescribers that single-dose metronidazole 2 g is not recommended and suggests CDC-recommended treatments. The primary outcome was the proportion of single-dose metronidazole 2 g orders before and after EHR alert implementation. A secondary cross-sectional evaluation of all alerts triggered from 10/2024 to 12/2024 was performed and included the number of alerts, location of alert, and provider response. Results: A total of 285 patients were included, 49.8% pre-intervention and 50.2% postintervention. Metronidazole 2 g was prescribed for 8.45% of pre-intervention and 2.80% of postintervention patients (P = 0.038). The clinical support alert fired 102 times for 75 patients during the 3-month postimplementation period. The alert was associated with a change in intended prescription to a metronidazole 7-day course in greater than 60% of patients over 3 months. Conclusion: The implementation of an interruptive alert was associated with high acceptance and improved prescribing for women treated for trichomoniasis.

Background: Legionella pneumonia is a significant cause of community-acquired pneumonia that often requires timely and effective treatment. While fluoroquinolones and macrolides are the recommended first-line therapies, doxycycline offers an alternative with favorable pharmacokinetics, safety, and minimal drug-drug interactions. Methods: We describe three hospitalized patients with Legionella pneumonia who received doxycycline monotherapy.Clinical outcomes, including symptom resolution and survival, were assessed at 60 days. A literature review was also performed for studies published between 1980 and 2025 that evaluated doxycycline for Legionella infection. Results: All three patients achieved clinical improvement with doxycycline monotherapy, with resolution of presenting symptoms and survival at 60 days post-hospitalization. The literature review identified limited clinical data on doxycycline for Legionella pneumonia. In vitro data suggested that doxycycline may have lower bactericidal activity than fluoroquinolones, although its pharmacological profile and tolerability support its consideration in select cases. Conclusion: Doxycycline monotherapy was associated with favorable outcomes in three cases of Legionella pneumonia. Although the evidence remains sparse, doxycycline may represent a viable alternative when first-line therapy is contraindicated. Further research is required to define its role in the treatment of Legionella pneumonia.

Background: Cirrhosis is a major cause of morbidity and mortality in the United States, with spontaneous bacterial peritonitis (SBP) being a serious complication. Established SBP risk factors include gastrointestinal bleeding and low ascitic protein, but the role of proton pump inhibitors (PPIs) remains unclear. Objective: This study evaluated the impact of PPI use on primary SBP development in hospitalized patients with cirrhosis. Additional objectives included reviewing PPI prescribing patterns and associated clinical outcomes. Methods: An institutional review board-approved, retrospective chart review was conducted on adults (≥18 years) with cirrhosis admitted for presumed SBP between June 1, 2022, and June 30, 2024. Exclusion criteria included pregnancy, incarceration, and recent or current upper gastrointestinal bleeding. Patients were grouped by PPI exposure, defined as PPI use prior to admission. The primary outcome was SBP incidence; secondary outcomes included mortality and hepatic decompensation events. Results: Eighty-one patients were included: 42 reported home PPI therapy, and 39 did not. SBP incidence was 33.3% in the PPI group versus 20.5% in the no PPI group (χ² = 0.249, P = 0.618). Worsening ascites occurred in 99%, encephalopathy in 42%, varices in 11%, and suspected hepatorenal syndrome in 21%. In-hospital mortality was 9.9%. PPI indications were often undocumented. Conclusion and Relevance: Although no significant association was found between home PPI use and SBP, frequent undocumented use and potential overuse of PPIs underscore the need for targeted intervention. Pharmacists are well-positioned to lead stewardship efforts by reviewing indications and minimizing unnecessary therapy to enhance safety and outcomes.

Background: Refeeding syndrome (RS) is a potentially life-threatening condition, marked by decreases in serum phosphorus, potassium, or magnesium, that commonly occurs in patients who receive parenteral nutrition (PN) after a period of inadequate caloric intake. Objective: To compare the occurrence and severity of RS in hospitalized patients who received intravenous (IV) electrolyte supplementation versus those who did not receive IV electrolyte supplementation prior to initiation of PN. Methods: This single-center, retrospective cohort study included adult patients hospitalized over a 10-year period who received PN. The primary outcome was the occurrence of RS in each group (decrease in serum phosphorus, potassium, or magnesium of 10% or more from baseline within 5 days of PN initiation). Results: A total of 124 patients were included in the study, with 62 patients in each group. Fifty-two patients (83.9%) in the IV electrolyte supplementation group developed RS of any severity compared to 48 patients (77.4%) in the no IV electrolyte supplementation group (odds ratio [OR] = 1.52, 95% confidence interval [CI] = 0.62 to 3.74, P = 0.4). The IV electrolyte supplementation group developed more mild cases of RS (OR = 2.48, 95% CI = 1.14 to 5.40, P = 0.02), had a lower median decrease in serum phosphorus (median difference [MD] = -6.0, 95% CI = 10.9 to <-0.1, P = 0.03), and had lower in-hospital mortality (OR = 0.25, 95% CI = 0.09 to 0.74, P = 0.008). There were no significant differences for other secondary outcomes. Conclusion: Overall occurrence of RS was not significantly different between groups. However, some findings were suggestive of benefit associated with IV electrolyte supplementation.

Background: Bayesian modeling of vancomycin can estimate 24-hour area under the curve (AUC₂₄) using pre-steady-state concentrations. Limited literature exists comparing Bayesian AUC₂₄ calculations derived from steady-state versus pre-steady-state concentrations. Objective: To assess the agreement between vancomycin AUC₂₄ calculations using pre-steady-state versus steady-state concentrations, employing Bayesian modeling. Methods: This retrospective within-subjects cohort study included patients with at least 1 pre-steady-state and 1 steady-state vancomycin concentration. Patients with age >100 years, weight <40 kg, height <60 inches, or renal dysfunction were excluded. The steady-state AUC₂₄ from dosing software was documented with and without hiding steady-state levels from calculations. The primary outcome was agreement between AUC₂₄ without levels hidden compared with AUC₂₄ with steady-state levels hidden from analysis. Secondary outcomes included the agreement between AUC₂₄ with pre-steady-state levels hidden and the percentage of patients with matching AUC₂₄ categories. The AUC₂₄ agreement was evaluated via Bland-Altman plot and bias via linear regression. Statistical tests were performed using SPSS statistics software (IBM Corp). Results: A total of 93 patients were included. The mean difference in AUC₂₄ compared to AUC₂₄ with steady-state levels hidden was 8.8 mg*h/L, and with pre-steady-state levels hidden, it was -3.7 mg*h/L. Linear regression analysis indicated a proportional bias when steady-state levels were hidden (β = 0.22; P = 0.038) but not when pre-steady-state levels were hidden. Category mismatch occurred more often when steady-state levels were hidden vs when pre-steady-state levels were hidden (26% vs 8%; P < 0.001). Conclusion and Relevance: The study demonstrated overall agreement between AUC₂₄ compared to AUC₂₄ with steady-state levels hidden. The mean differences in AUC₂₄ estimates were small, no matter which level was hidden, although tighter limits of agreement were observed when steady-state levels were utilized in Bayesian calculations. Further research with larger sample sizes is necessary.

Background: The use of warfarin is complicated by a narrow therapeutic window, requiring close monitoring to prevent serious adverse events. Literature has shown that pharmacist-led warfarin management improves patient outcomes and decreases hospitalization length of stay. This study assessed the impact of the recently implemented pharmacist-driven warfarin consult service at 3 hospitals within the Cleveland Clinic Health System. Methods: This was a retrospective, multi-centered study which included 64 adult patients admitted to Cleveland Clinic Hospitals between June 1, 2023, and July 31, 2024 who received at least 3 doses of warfarin. Exclusion criteria included an elevated international normalized ratio (INR) upon admission, argatroban use, active cancer, or warfarin ordered by both managing services. Results: The primary outcome, rate of supratherapeutic INR values, did not significantly differ between groups (P = .84). In addition, the secondary outcomes including rate of subtherapeutic INRs, INR ≥0.7 within 24 hours, therapeutic INR at discharge, and major bleeding showed no significant difference. However, pharmacists were twice as likely to order an initial starting dose of <5 mg compared to physicians (62.5% vs 31.3%). In addition, physician-managed patients were observed more frequently for the INR ≥0.7 within 24 hours (11 vs 4 events). Conclusion: Overall, there was not a significant difference found in patient outcomes when comparing pharmacist versus physician warfarin management. Future studies with a larger sample size are needed to explore the potential differences in dosing regimens and its effect on the rate of significant INR elevations.

Introduction: Methicillin-resistant Staphylococcus aureus pneumonia (PNA) can be ruled out via methicillin-resistant Staphylococcus aureus (MRSA) culture and polymerase chain reaction (PCR) nasal screening, facilitating the de-escalation of empiric anti-MRSA agents like intravenous vancomycin. This study evaluated the impact of transitioning from culture to PCR-based MRSA nasal screening in patients with PNA. Methods: This Institutional Review Board (IRB)-approved retrospective quasi-experimental study was conducted at a 5-hospital system and included adult, nonpregnant hospitalized patients from September to December 2021 ("culture group") and September to December 2022 ("PCR group") and diagnosed with PNA. Exclusion criteria were ventilator-acquired PNA or positive MRSA respiratory culture. The primary endpoint was the number of vancomycin levels obtained. Secondary endpoints were vancomycin duration as well as acute kidney injury (AKI) and all-cause 30-day readmission rates. Results: Two-hundred patients were included: 100 in each group. Baseline characteristics were similar. There were 117 vancomycin levels obtained: 67 (67) and 50 (50) in the culture and PCR group, respectively (P = .021). Median vancomycin duration was 50% shorter in the PCR group: 2 days (1-3) versus 3 days (2-4), P < .001. After adjusting for confounders, the culture group was more likely to have vancomycin levels obtained compared to the PCR group: adjusted odd ratio (aOR) (95% confidence interval [CI])] = 1.833 (1.016-3.309). Long-term obstructive pulmonary disease was associated with reduced risk of ordering vancomycin levels: aOR [95% CI] = 0.426 (0.218-0.831). Readmission and AKI rates were comparable. Conclusion: Transitioning from culture to PCR-based MRSA nasal screening significantly reduced vancomycin levels obtained from patients and shortened vancomycin duration without negatively impacting patient outcome.