Journal of pharmacy practice最新文献

Objective: Levetiracetam (LEV) is a guideline-recommended antiepileptic that has been shown to be effective in the termination of status epilepticus. Traditionally, LEV is diluted in 100 mL of compatible fluid and administered as an intravenous (IV) piggyback over 15-60 minutes. Recent data supports the administration of LEV as an undiluted IV push. However, there is limited literature supporting the safety and tolerability of undiluted IV push administration of high dose LEV (2500 mg to 4500 mg). The purpose of this study was to further investigate safety and tolerability of IV push levetiracetam at doses 2500 mg and greater. Methods: A retrospective chart review was conducted to evaluate adverse drug reactions following IV push administration of levetiracetam at a dose of 2500 mg or greater between the dates 8/5/2021 to 6/30/2022. During chart review, each patient was evaluated for any adverse events that occurred utilizing provider documentation, significant event forms, and/or allergy list documentation following administration of IV push LEV. Results: Throughout the study period, 340 doses of LEV 2500 mg and greater were evaluated. Most common total dose was 3000 mg and weight-based dose was 50-59.99 mg/kg. 119 doses of 4000 mg or greater were evaluated. 338/340 (99.4%) doses were considered to be well-tolerated. One patient experienced erythema at the injection site and another patient was noted to have nystagmus. Significance: This study adds to the body of literature that rapid administration of undiluted LEV, including doses of 2500 mg to 4500 mg is safe and tolerable.

Introduction: Growing evidence suggests that non-physician providers (NPPs) can effectively and safely manage warfarin therapy. This systematic review and meta-analysis aimed to evaluate warfarin management by NPPs compared to usual medical care (UMC) in ambulatory patients. Methods: We conducted a systematic search of PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, CINAHL (EBSCO), and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to January 2024. Studies were included if they were randomized controlled trials or quasi-experimental designs comparing warfarin management across professions. Two independent reviewers performed title and abstract screening, full-text review, data extraction, and risk of bias assessment. Results were pooled using random effects models. Results: Of 19 122 citations identified, 6 met the inclusion criteria. NPPs included pharmacists (4), nurse practitioners (1), and multidisciplinary teams (1). Meta-analysis showed no significant difference in time spent in therapeutic range (TTR) (mean difference [MD] 1.64%; 95% confidence interval [CI]-1.86 to 5.16, I² = 0%)) for NPPs vs UMC. There were no differences in thrombosis (relative risk [RR] 1.23; 95% CI 0.36 to 4.23, I² = 0%), hemorrhage (RR = 1.07; 95% CI 0.44 to 2.63, I² = 0%), mortality (RR = 0.94; 95% CI 0.33 to 2.67, I² = 0%), or patient satisfaction (standardized mean difference [SMD] 0.56; 95% CI -0.04 to 1.15, I² = 85%). Conclusion: NPP management resulted in similar TTR as UMC. Due to few thromboembolic and hemorrhagic events, more studies are needed to determine the effects of NPP warfarin management on clinical outcomes.

Acute pharyngitis is mostly viral in origin, but antibiotics are commonly prescribed to cover group A streptococcus (GAS) which is the cause in 5%-30% of pharyngitis episodes. Patients are increasingly utilizing community pharmacy test and treat programs to diagnose and treat acute respiratory infections. There are several Clinical Laboratory Improvement Amendment (CLIA)-waived point-of-care tests (POCT) available to quickly identify GAS. The objective of this article is to explore the 11 antigen and two molecular CLIA-waived GAS POCTs currently available in the United States (U.S.) and the studies that assessed their use in pharmacy test and treat programs. Nine studies evaluated their use in community pharmacy test and treat programs and support their use, especially for decreasing unnecessary antibiotic prescriptions and providing access to care for patients without a primary care provider or after regular business hours. As medication dispensing margins continue to shrink, community pharmacists continue to seek additional ways to serve their patients and develop new revenue streams. Additionally, test and treat services are a means to improve access to care and promote outpatient antimicrobial stewardship. Recently, patients have expressed an increased willingness to receive care for various illnesses, including acute pharyngitis, at community pharmacies. Acute pharyngitis is well-suited for management in a community pharmacy since treatment recommendations are well established and straightforward. Overprescribing of antibiotics from traditional health care settings is higher than desired and pharmacy-based models have demonstrated the ability to decrease unwarranted antibiotic use. A pharmacy-based acute pharyngitis management model makes strong medical and business sense.

Methemoglobinemia typically presents as functional anemia and hypoxemia. It is often recognized by a discordance between the pulse oximeter reading and the oxygen saturation measured on arterial blood gas. Methemoglobinemia can be inherited or acquired, with some commonly-used medications recognized as causative agents. In patients with hemolytic anemia such as in glucose-6-phosphate dehydrogenase deficiency, hemolysis may be the main clinical presentation, with acquired methemoglobinemia after exposure to oxidizing agents. We present a case report of methemoglobinemia in the setting of hemolysis, with a new approach to coordinate with laboratory services to create a reflex lab to test for methemoglobinemia under certain conditions. This may improve time to recognition and treatment for patients with methemoglobinemia, as patient presentation as well as SpO2 and PaO2 discordance may be missed by less experienced providers.

Many patients living with human immunodeficiency virus (HIV) may develop long-term metabolic complications due to various reasons, such as chronic inflammation and adverse effects from antiretrovirals (ARVs). A particularly significant metabolic complication is type 2 diabetes (T2DM); however, limited evidence is available regarding the management of this disease state among people living with HIV (PLWH). We review the available resources and evidence on the management of T2DM among PLWH. Diagnosis and monitoring of T2DM are slightly different from the general population as hemoglobin A1c may underestimate the level of glycemia PLWH experience. Although PLWH are typically not reported within landmark clinical trials for antidiabetic medications, treatment is likely similar to those without the virus. There are several drug-drug interactions to note between ARVs and antidiabetic medications with one of the most notable being between dolutegravir and metformin. This interaction requires the maximum daily dose of metformin to be reduced. Additionally, modifications may be considered to a patient's ARV regimen in order to reduce metabolic disturbances as these medications may affect fat redistribution, lipids, weight, and insulin resistance. This review article is intended to aide clinicians in clinical decision making when treating PLWH diagnosed with T2DM.

Background: Several strategies described in the literature regarding the role of pharmacist-led educational interventions to healthcare providers, however, evidence available on the role of education in the Emergency Department (ED) setting on discharge prescriptions is limited. The purpose of this study was to evaluate the impact of pharmacist-led education on antimicrobial prescribing at discharge from the ED. Objective: To determine whether pharmacist-led provider education improves patient outcomes by reducing medication-related errors in the ED when prescribing antimicrobials at discharge for skin and soft tissue infections (SSTIs), urinary tract infections (UTIs), and community-acquired pneumonia (CAP). Methods: This was a retrospective pre-vs post-intervention cohort study at Maimonides Medical Center (MMC). A total of 192 patients in the pre-intervention period and 181 patients in the post-intervention period were included. The primary endpoint was appropriateness of antimicrobial discharge prescriptions pre- and post-intervention. Results: In the pre-intervention period, 17.7% of patients had an SSTI, 47.4% had a UTI, and 34.9% had CAP. In the post-intervention period, 15.5% of patients had an SSTI, 51.4% had a UTI, and 33.1% had CAP. After implementation of pharmacist-led provider education, there was a statistically significant increase in the number of appropriate antimicrobial discharge prescriptions in the post-intervention period, 86.7% vs 75.5% respectively (P = .008). While there was no statistically significant difference in recurrent infections, there was a trend towards improvement in post-intervention period, 3.9% vs 5.7% respectively (P = .473). Conclusion: Pharmacist-led provider education significantly improved prescribing patterns for antimicrobial discharge prescriptions.

Ibuprofen and ketorolac are nonsteroidal anti-inflammatory drugs (NSAIDs) commonly used to treat acute back pain in the Emergency Department (ED). Data comparing pain relief between oral and intramuscular administration at their proposed ceiling doses is lacking. The aim of this study was to compare oral (PO) ibuprofen 400 mg to intramuscular (IM) ketorolac 10 mg for the treatment of acute, atraumatic, musculoskeletal back pain. This single-center, double-blind, double-placebo, randomized study compared PO ibuprofen 400 mg to IM ketorolac 10 mg for acute, atraumatic musculoskeletal back pain in adult patients presenting to an urban ED. Subjects were randomized to receive PO ibuprofen 400 mg suspension plus IM placebo injection or IM ketorolac 10 mg plus PO placebo suspension. The primary outcome was absolute reduction in pain score 1 hour after medication administration, as measured by visual analog scale (VAS). Secondary outcomes included rescue analgesia administration at 60 minutes and adverse drug reactions. The author's enrolled 93 patients; 47 in the ibuprofen group and 46 in the ketorolac group. VAS score reduction from baseline to 1 hour with ibuprofen or ketorolac was 35 vs 32, respectively (95% Confidence Interval: -8.03 to 15.03). Rescue analgesia administration at 60 minutes was similar between both groups; adverse reactions were reported in the ketorolac group only as pain at injection site in two patients. In this prospective analysis, PO ibuprofen 400 mg and IM ketorolac 10 mg provide comparable pain relief for the treatment of acute, atraumatic, musculoskeletal back pain.

Background: Optimizing early antimicrobial therapy and incorporating clinical pharmacists into sepsis treatment strategies are essential for improving patient outcomes. Objective: To examine the appropriateness of empiric antimicrobial selection for patients presenting with community onset sepsis with confirmed bacteremia, to characterize de-escalation practices, and to evaluate pharmacy involvement throughout the sepsis care process. Methods: We conducted a retrospective review of adult patients with community-onset sepsis and confirmed bacteremia who presented to the Emergency Department (ED) between 9/2022 and 5/2023 at our hospital. The primary outcome was the percent of patients with ineffective empiric antimicrobials. Secondary outcomes included time to de-escalation, sepsis outcomes, sepsis guidelines adherence, and pharmacy interventions. Results: 109 patients were included. Median Charlson Comorbidity Index (CCI) was 6 (IQR 3-8) and Pitt bacteremia score 0 (IQR 0-1). Median time to first antibiotic administration was 29 minutes (IQR 15-50). Ineffective empiric antimicrobials occurred in 13.7% of cases, with median time to effective antibiotics at 24 h. De-escalation occurred in 84% of cases. The median time for discontinuation was 2 days for antimicrobial coverage against MRSA and atypical organisms and 4 days for coverage against P. aeruginosa. Initial therapy adhered to guidelines in 70.6% of cases, with deviation primarily due to vancomycin administration in the absence of MRSA risk factors. Antibiotic-related pharmacy recommendations were made in 40% (n = 44/109) of ED patients and 96% (n = 105/109) of hospitalized patients. In-hospital mortality, ICU admission, 30-day infection related re-admission and C. difficile infection within 6 months were 8.3% (n = 9), 42.2% (n = 46), 8.3% (n = 9), and 1.8% (n = 2), respectively. Conclusion: Pharmacist involvement led to appropriate antimicrobial selection in the ED, effective de-escalation, and favorable sepsis outcomes.

Emergency department (ED) practitioners frequently prescribe antibiotics for sepsis and other infections, with quality and performance metrics often influencing broad-spectrum antibiotic selection. This study objective was to evaluate improvements in antibiotic selection in the ED following implementation and revision of sepsis order sets designed to adhere to Centers for Medicare and Medicaid Services sepsis performance measure bundle across time periods. This single-center, retrospective analysis assessed antibiotic orders in the ED across three periods of order set availability: no sepsis order set (period 1), general broad-spectrum order set (period 2), and infectious-source specific order set (period 3). Order rates of narrow-spectrum β-lactams, extended-spectrum cephalosporins, antipseudomonal β-lactams, fluoroquinolones, clindamycin, and other agents were assessed. Individual patient encounters with antibiotic orders for period 1 (n = 4228), period 2 (n = 4407), and period 3 (n = 5129) were assessed. Order set use for antibiotic ordering increased across time periods (4% vs 20.6% vs 53.3%; P < 0.001). Period 3 was associated with an increase in narrow spectrum β-lactam use (3% vs 3% vs 15.2%; P < 0.001), a decrease in antipseudomonal β-lactam use (30.1% vs 36.1% vs 27.7%; P < 0.001), and a decrease in targeted antibiotics associated with high risk for adverse effects (28% vs 16% vs 6.9%; P < 0.001). The creation and utilization of an infectious source-specific sepsis antibiotic order set was associated with improved antibiotic ordering trends in the emergency department. This intervention should be considered by hospital antimicrobial stewardship programs.