Journal of pharmacy practice最新文献

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.

Cardiovascular disease remains the leading cause of death; however, advances in the acute management of cardiovascular events have resulted in a greater number of patients who require chronic management to prevent future events. The care of these patients in the post-acute care phase was historically referred to as stable ischemic heart disease (SIHD) but is now collectively referred to as chronic coronary disease (CCD). In 2023, the chronic coronary disease guidelines were released and consolidated prior guidelines on secondary prevention and managing stable ischemic heart disease. The role of pharmacotherapy for CCD has expanded significantly in recent decades due to emerging evidence from clinical trials and the development of novel drug therapies. This manuscript summarizes key articles and guidelines that will serve as an important resource for clinicians responsible for caring for patients with chronic coronary disease.

Background: Cephalosporins are increasingly used to treat severe urinary tract infections (sUTI) due to rising resistance with standard antibioics. When switching from intravenous to oral cephalosporins there is limited clinical outcome data to guide selection. Objective: To compare the failure rate between cephalexin and cefdinir when used as oral step-down therapy in sUTI. Methods: In this retrospective study, we assessed patients admitted to 3 hospitals for sUTI over a 1-year period. Cases were identified using ICD-10 codes N10, N39.0, and A41.9. Patients who received intravenous antibiotics for >24 hours and completed treatment with cephalexin or cefdinir were included. The primary composite outcome was death, rehospitalization for UTI in 30 days, unplanned clinic or emergency visit for UTI in 30 days, hospitalization for any reason in 90 days, or Clostridoides difficile infection. Secondary outcomes included each individual composite outcome element. Results: Overall, 75 cefdinir and 135 cephalexin cases were included. Patients were similar in baseline characteristics. Pyelonephritis occurred among the cephalexin group (30.2% vs 46.7%, P = 0.024). Composite failure occurred in 8% of patients receiving cefdinir and 14.1% receiving cephalexin (P = 0.193). Secondary outcomes did not differ except clinic or emergency visit for UTI was lower among patients receiving cefdinir than cephalexin (0% vs 7.2%; P = 0.028). Logistic regression revealed no significant variable associations with treatment failure, except for cephalexin use, which was associated with clinic or emergency visit for UTI (r² = 0.075). Conclusions: Treatment failure rates did not differ between cefdinir and cephalexin; however, patients receiving cephalexin had more unplanned clinic and emergency visits.

Medications account for nearly two-thirds of all cases of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Numerous psychotropics including antipsychotics have been associated with SIADH but it is difficult to show a causal relationship. We report a unique case where a patient developed hyponatremia and upon rechallenge with aripiprazole resulted in a second incidence. There is limited literature recognizing aripiprazole induced SIADH and especially any focused on medication rechallenge.

Background: Methocarbamol is a central nervous system depressant with antispasmodic properties used as a skeletal muscle relaxant as part of a multimodal analgesia regimen in critically ill patients. Intravenous (IV) methocarbamol contains polyethylene glycol (PEG) 300 and propylene glycol (PG) which have been associated with acute kidney injury (AKI). To mitigate AKI risk, IV methocarbamol is limited to 72 consecutive hours, followed by a 48-hour drug-free interval (DFI). Objective: To characterize the incidence of AKI in intensive care unit (ICU) patients receiving IV methocarbamol. Methods: This is a single-center, retrospective evaluation of adult trauma or surgical ICU patients who received at least 3 consecutive doses of IV methocarbamol. The primary outcome was the difference in SCr from day 1 through day 7 after IV methocarbamol initiation. Results: A total of 68 patients met inclusion criteria. Four patients were classified in the non-DFI group. There was no difference in the median (IQR) SCr (mg/dL) measured at any time point from day 1 through day 7 after IV methocarbamol initiation in the entire cohort [0.83 (0.71, 1.08) vs 0.74 (0.62, 1.33), P = 0.55]. There was no difference between the median (IQR) SCr (mg/dL) from day 1 through day 7 in patients that had no DFI [1.04 (0.89, 2.56) vs 1.20 (0.79, 2.92), P = 0.84]. Conclusion: No statistically significant change in SCr was observed over time in critically ill patients receiving IV methocarbamol regardless of DFI use.

Introduction: Intravenous (IV) regular insulin treats acute hyperkalemia. No guideline recommendations exist on the appropriate dose to be administered to maximize safety and efficacy. Objectives: The objective of this study was to evaluate the safety and efficacy of IV regular insulin in patients who received 5 units of IV regular insulin to any dose greater than 5 units for acute hyperkalemia treatment. Methods: This was a single-center, retrospective, observational, cohort study. Patients were included if they were at least 18 years old, received greater than or equal to 5 units IV regular insulin, had pre-insulin potassium greater than or equal to 5.1 mEq/L and blood glucose measured within three hours before and 12 hours after insulin administration. The primary outcome was the incidence of hypoglycemia within 12 hours of insulin administration. Results: Eight-hundred and ninety-six charts were reviewed and 290 patients were included; 126 patients received 5 units and 164 patients received more than 5 units of IV regular insulin. Six patients (4.7%) who received 5 units experienced hypoglycemia compared to 23 patients (14%) who received greater than 5 units (P = 0.0014). Twenty-six of 29 (90%) who experienced hypoglycemia had renal impairment. Groups had a similar baseline mean potassium of 5.9 mEq/L (P = 0.32) and follow-up mean potassium of 5.3 mEq/L (P = 0.87). Conclusion: Patients who received 5 units of IV regular insulin had a lower incidence of hypoglycemia with a similar reduction in serum potassium when compared to patients who received doses greater than 5 units.

Purpose: There is extensive evidence linking Potentially Inappropriate Medication (PIM) use and adverse health outcomes. The VIONE core team and VA multidisciplinary partners created, implemented and disseminated the VIONE methodology across VA sites nationwide to facilitate and track deprescribing, through coaching, medical informatics and integration with the electronic health record. The purpose of this article is to report 3 sites in the federal health system (2 VA and 1 Indian Health Services) unique experiences of implementing and adapting VIONE locally while maintaining fidelity to fundamental VIONE intervention strategies. Methods: Three VA sites reported experiences of implementing VIONE, including an overview of the clinical workflow, clinicians involved, facilitators and barriers of implementation, and results. Results: The VIONE intervention was adapted for site-specific implementation. Personnel included trainees, clinical pharmacists, and home based primary care programs. Local and national dashboards were used to identify Veterans at high risk for polypharmacy and to track deprescribing. Implementation remained consistent with the VIONE core characteristics and facilitated education and conversations about medications with patients and caregivers. Adaptations were made at each site to meet that site's needs. Implementation resulted in safe deprescribing practices and staff empowerment with significant cost savings. Conclusion: The VIONE methodology and tools are adaptable across clinical settings with inherent flexibility to local workflows and practice preferences by end users. VIONE presents a standardized, easy-to-use method for promoting medication review for older adults. Further evaluation may help identify best practices to promote positive outcomes related to deprescribing and reducing polypharmacy in older adults.

Purpose: In observational trials, midodrine decreased vasopressor duration, length of stay (LOS), and mortality but not in randomized controlled trials. The goal of this study is to assess the efficacy and safety of using midodrine to wean intravenous (IV) vasopressors in patients with septic shock. Materials and Methods: This single-center, retrospective study was conducted at a 505-bed community teaching hospital between September 2021 and December 2022. Patients were ≥18 years of age with septic shock, admitted to the intensive care unit (ICU), required IV vasopressors for hemodynamic support, and demonstrated clinical stability. Outcomes were compared across patients receiving IV vasopressors with midodrine vs. IV vasopressors alone. Results: Among 139 patients, midodrine was associated with increased time to IV vasopressor discontinuation, 5.5 ± 6.5 days vs. 2.4 ± 1.6 days (mean difference 3.1, 95% confidence interval 1.5 to 4.7, P = 0.0003). In patients started on midodrine within 48 hours of stability, time to IV vasopressor discontinuation was similar to the vasopressor alone cohort. Secondary outcomes including ICU and hospital LOS after vasopressor initiation, ICU and in-hospital mortality, and ICU readmission were similar between groups. Twenty patients were discharged from the hospital on midodrine. Incident bradycardia was increased in the midodrine group, but hypertension was similar between groups. Conclusions: Patients in the midodrine group exhibited a longer time to vasopressor discontinuation; however, this difference was only apparent in those with midodrine initiation more than 48 hours after hemodynamic stability in a post-hoc subgroup analysis. These outcomes may be attributed to midodrine being used as salvage therapy.

Background: Venous thromboembolism (VTE) treatment with apixaban uses a higher 10 mg twice daily regimen for 7 days (lead-in therapy). But, in patients with initial parenteral anticoagulation treatment or those with higher bleeding risk, clinicians may not always adhere to the full 7-day lead-in duration. Methods: This retrospective cohort study included adult patients admitted to the Veterans Affairs Health care System from January 2011 to April 2022, who received at least 24 hours of parenteral anticoagulation followed by lead-in apixaban therapy for VTE. The primary outcome evaluated bleeding among patients treated with shortened lead-in apixaban (study group) compared to the standard 7-day duration (control group). Results: Seventy-eight patients were included in the control and 65 in the study group. Most patients were treated for PE (72%) and received initial treatment with enoxaparin (71%). Duration of parenteral anticoagulation was longer in the study group (3.6 days ± 3.2 vs 2.5 days ± 1.9; P < .01), and length of apixaban lead-in therapy was decreased (4.1 days ± 2.2 vs 7 days; P < .01). The primary outcome of bleeding was higher in the study group (18.5% vs 5.1%; P = .02), with no difference in VTE recurrence. P2Y₁₂ and P-gp inhibitor use, and increased creatinine and age were predictors of bleeding. Conclusion and Relevance: Bleeding events were increased in the study group, and patients with bleeding risk factors may not benefit from apixaban 10 mg twice daily. Larger studies are needed where apixaban lead-in therapy is omitted following parenteral anticoagulation in patients with bleeding risk factors.

Utilization of cangrelor following coronary artery stent placement as a bridge to cardiac surgery has been previously described in the literature. However, the use of cangrelor as bridge therapy to cardiac surgery for endovascular revascularization is lacking. We describe a case involving a 47-year-old female who developed a left lower extremity tibioperoneal trunk non-obstructing arterial dissection following extracorporeal membrane oxygenation decannulation, requiring repair with a Viabahn endoprosthesis. To maintain stent patency, as well as treat the patient's multi-vessel coronary disease and left ventricular thrombus, triple therapy with cangrelor, aspirin, and bivalirudin was utilized as the patient was optimized for a coronary artery bypass procedure. Our case describes a unique antiplatelet and anticoagulation strategy in a complex patient involving a multi-disciplinary team.