Journal of pharmacy practice最新文献

Purpose: Prior literature evaluating the importance of timely second-dose antibiotics in patients with sepsis has led to better outcomes and a possible reduction in mortality, length of mechanical ventilation, and length of time requiring vasopressors. Objective: To evaluate the impact of a newly developed pharmacist-led two-dose cefepime protocol implemented within an emergency department (ED) service. Methods: This was a retrospective, single-center, pre-post observational cohort study. Institutional review board approval was obtained. The primary endpoint was a reduction in time between the first and the second doses of antibiotics for patients with sepsis who present to the emergency department. Secondary endpoints included length of vasopressor therapy, intensive care unit (ICU) length of stay, hospital length of stay, duration of mechanical ventilation, and mortality. Results: A total of 84 patients were included in the pharmacist-led two-dose hospital protocol and 79 patients were included in the historical control. In the control cohort, the median time between the first and second dose of antibiotics was 12 hours vs 8.5 hours in the tested cohort. The average time requiring vasopressors was 1.20 days for the control cohort vs .46 days for the post-implementation group. Lastly, the median hospital length of stay in days was 8 for the control group vs 7 for the tested cohort. Conclusion: Implementation of a pharmacist-led two-dose cefepime protocol was associated with a numerically lower duration between second-dose antibiotics, days requiring vasopressors, and a slight reduction in hospital length of stay.

Purpose: This study evaluated glycemic outcomes for hospitalized patients after reduction in bedtime correctional insulin dosing. Methods: This was a retrospective, single-center analysis of a protocol change that reduced bedtime correctional insulin scale. Comparable cohorts pre- and post-protocol change were created which included patients who were ordered correctional insulin with at least 1 blood glucose (BG) reading. The primary outcome was number of nocturnal hypoglycemia readings. Secondary outcomes included, but were not limited to, mean fasting BG, BG within various ranges, and length of stay. Results: 3 percent of patients in the post-protocol change group (N = 100) experienced nocturnal hypoglycemia compared to 6% of patients in the pre-change group (N = 100) (P = .507). There were no significant differences in BG ranges <110 mg/dL, <140 mg/dL, 140 to 180 mg/dL, and >180 mg/dL. However, 19% of patients in the post-protocol change group had BG of >250 mg/dL as compared to 9% in the pre-change group (P = .033). Mean fasting BG was higher in the post-protocol change group compared to the pre-change group (156.5 mg/dL vs 139.3 mg/dL [P = .002]), as was hospital length of stay (5.17 vs 4.6 days, [P = .024]). Conclusions: A decreased bedtime correctional insulin scale had mixed results with more patients achieving goal fasting BG but also more patients experiencing BG > 250 mg/dL and longer length of stay. Larger prospective studies are required to evaluate the safety and efficacy of this type of intervention and its long-term impact.

Objectives: To investigate the perception of community pharmacists on the down-scheduling of 5-HT3 antagonists to pharmacist-only-medicine for treatment of acute nausea and/or vomiting in Australia. Methods: A nationwide anonymous survey targeting Australian community pharmacists was conducted from April to May 2023. Responses were collected and analysed quantitively or qualitatively, where appropriate. Key findings: Participants reported that 5-HT3 antagonists were effective at treating nausea and/or vomiting and would likely recommend their use. Training is required to manage supply due to concerns related to their side effects. Conclusion: Participants supported down-scheduling of 5-HT3 antagonists for the treatment of nausea and/or vomiting in Australia. A pilot study on the provision of 5-HT3 antagonists by pharmacists is recommended as is the development of guidelines for pharmacist-only supply before down-scheduling is considered.

Invasive aspergillosis (IA) is a rare and often fatal complication of immunosuppression following orthotopic heart transplant. Prophylaxis plays a crucial role in preventing the emergence of this opportunistic infection. The azole class of medications are the bellwether agents utilized in this patient population. Unfortunately, given their impact on the Cytochrome P450 enzyme system, significant fluctuations in serum tacrolimus concentrations occur when initiating and stopping azole therapy, increasing the risk for prolonged periods of sub-optimal immunosuppression. While there are recommended dosing adjustments for these transition periods based on small data sets primarily with fluconazole, there is no published literature on recommended dosing adjustments for posaconazole. Given our institution utilizes posaconazole as the primary therapeutic for aspergillosis prophylaxis, we aimed to explore and report our local data to better guide dosing decisions during these transition periods.

Purpose: The Joint Commission standards for titrated infusions require specification of maximum rates of infusion. This practice has led to the development of protocolized maximum doses that can be overridden by provider order ("soft maximums") and to dose caps that cannot be superseded ("hard maximums"). The purpose of this study was to determine the prevalence of and attitudes towards dose capping of norepinephrine. Methods: A 20-item cross-sectional survey assessing norepinephrine dose capping practices, perceptions of norepinephrine protocols, and respondent and practice site demographics was distributed electronically to the mailing list of an international medical podcast. Responses were stratified according to use of weight-based dosing (WBD) or non-WBD of norepinephrine. The primary objective was to characterize norepinephrine dosing practices including protocolized maximum doses and/or dose capping. Categorical and continuous variables were compared using the Chi-square test and Mann-Whitney U test, respectively, with P < .05 indicating statistical significance. Results: The survey was completed by 586 physicians, nurses, pharmacists, and advanced practice providers. WBD was used by 51% and non-WBD by 47%. A standardized titration protocol was reported by 65% and dose capping was reported by 19%. The protocolized maximum dose ranged from 20-400 mcg/min for respondents using non-WBD (median [interquartile range] 30 [30-50]) and ranged from .2-10 mcg/kg/min for respondents using WBD (1 [.5-3]). The dose cap was 50 (40-123) mcg/min with non-WBD and 2 (1-3) mcg/kg/min with WBD. Conclusions: An international, multi-professional survey of critical care and emergency medicine clinicians revealed wide variability in norepinephrine dosing practices including maximum doses allowed.

Patients with immune thrombocytopenic purpura (ITP) presenting with indications for dual antiplatelet therapy (DAPT) can be difficult to manage due to the precarious balance of managing the need for increased platelet counts as well as inhibition of platelet activity. This case represents a 65 year old woman with ITP who presented with a bilateral subarachnoid hemorrhage secondary to a left ophthalmic aneurysm that required placement of a pipeline embolization device (PED) necessitating DAPT. After treatment of her ITP with pulse dexamethasone for four days, she was safely discharged on one month of DAPT with aspirin and ticagrelor then switched to aspirin monotherapy without any immediate complications. During her period of DAPT, she did not receive additional medical treatment for her ITP. This case successfully presents a high-risk ITP patient requiring DAPT for a neurosurgical procedure and illustrates that these patients can be safely and successfully treated with DAPT once their ITP is stabilized.

Background: Cefazolin is guideline recommended for perioperative prophylaxis in orthopedic surgery. Despite its unique R1 side chain, cefazolin is often avoided in patients with beta-lactam allergy with concern for cross reactivity. Objectives: The primary outcome was the percentage of patients who received cefazolin perioperatively. Secondary outcomes included the percentage of patients with a beta-lactam allergy clarified following the telephone interview and clinical outcomes including acute kidney injury, surgical site infection, Clostridioides difficile infection, and re-admission at 30 and 90 days. Methods: This single-center, quasi-experimental study evaluated a pilot program in which a pharmacist phoned patients > 18 years of age with a scheduled orthopedic surgery and a documented beta-lactam allergy to assess their allergy preoperatively. Recommendations to use cefazolin were based on an algorithm. Patients were divided into pre- and post-intervention cohorts. Results: A total of 832 patients were screened for inclusion with 135 and 66 patients included in the pre- and post-intervention cohorts. No significant difference was identified in the primary outcome. In the post-intervention cohort, 62% had a beta-lactam reaction updated in the electronic medical record. Those with a beta-lactam allergy delabeled or made less severe were numerically more likely to receive cefazolin than those with an unchanged reaction or a reaction made more severe (95.2% vs 68% vs 65%). There were no differences in clinical outcomes between groups. Conclusion: A pharmacist-conducted preoperative beta-lactam allergy interview in adult patients undergoing elective orthopedic surgery improved beta-lactam allergy documentation but, did not result in increased utilization of cefazolin.

Purpose: Telemedicine has been essential during the coronavirus disease 2019 (COVID-19) pandemic. In March 2020, pharmacist-led chronic disease state management services at our family care centers and primary care clinics were converted to telemedicine. This study aimed to determine the impact of expanding telemedicine services on appointment adherence, clinical outcomes, and financial reimbursement. Methods: This was a single-center, retrospective, quasi-experimental study of the impact of expanding telemedicine services on adult patients with diabetes, hypertension, and/or hyperlipidemia. The study included patients scheduled with a pharmacist at a hospital-based (HB) or physician-based (PB) clinic. The primary outcome was the difference in the mean no-show rate. The secondary outcomes were differences in mean change in HbA1c, LDL, blood pressure, and reimbursement. Mean differences between pre- and post-telemedicine groups of each clinic were measured for all outcomes. Results: The mean difference (SE) in the no-show rate in the HB clinic was -12.09% (4.862; P = .014), compared to 2.88% (3.656; P = .431) in the PB clinic. The mean difference (SE) in the change in HbA1c in the HB clinic was .00% (.338; P = .992), compared to .01% (.239; P = .945) in the PB clinic. The mean difference (SE) in reimbursement in the HB clinic was $1.93 (4.209; P = .647), compared to $20.46 (3.210; P < .0001) in the PB clinic. Conclusion: Expansion of pharmacy telemedicine services provided evidence for improved appointment adherence in the HB clinic and increased reimbursement in the PB clinic. No change in healthcare outcomes was observed.

Background: Azithromycin is a commonly prescribed antibiotic included in many first-line regimens for pneumonia. Azithromycin also carries an FDA warning for increased risk for abnormal cardiac electrical activity, including QTc prolongation. Objective: To examine the effect of intravenous azithromycin on the QT interval in a cohort of patients receiving antibiotic therapy for community acquired pneumonia. Methods: A single-center, retrospective chart review of patients admitted to the Intensive Care Unit (ICU). The primary endpoint was change in QTc 48-72 hours after antibiotic initiation. The primary outcome was analyzed using ANOVA matched comparison. Results: Between 6/1/2019 and 3/31/2020, 241 total ICU patients received doses of either antibiotic. After application of exclusion criteria, the total number of patients included in analysis was 93, including 75 azithromycin patient and 18 doxycycline patients. The baseline QTc in the azithromycin group was 449 (95% CI 438-461) and the 72-hour QTc was 442 (95% CI 427-453) with an average change in QTc of -4 ms (P = .14). No statistically significant difference was found in QTc interval change between azithromycin and doxycycline. Conclusion: In this study, azithromycin use was not associated with a statistically significant increase in QTc interval. Based on these results, for the majority of patients receiving azithromycin, QTc prolongation is not likely a major concern. However, caution may still be warranted in patients considered high risk.

Background: The conventional dose of 10 units of intravenous (IV) regular insulin to treat hyperkalemia has been associated with hypoglycemia. There have been retrospective studies evaluating weight-based dose vs conventional dose of IV regular insulin but the comparative efficacy and safety is not well established. Objective: Evaluate the difference in weight-based dosing of IV regular insulin between patients who experienced hypoglycemia vs. patients who did not experience hypoglycemia after the administration of IV regular insulin. Methods: This was a retrospective, electronic chart review at a single academic medical center which included patients ≥18 years of age with an emergency department or inpatient encounter who were administered IV regular insulin within 6 hours of a pre-treatment potassium of ≥5 mmol/L. Results: There was no significant difference in the weight-based insulin dose between patients who experienced a hypoglycemic event and patients who did not experience a hypoglycemic event (.14 vs .22 units/kg; P = .44). The potassium-lowering effect was similar between the two groups (1.02 vs .96 mmol/L; P = .56). A regression analysis revealed that female sex, low baseline blood glucose (glucose <140 mg/dL), and those who received a repeat dose of IV regular insulin were independent risk factors for development of hypoglycemia. Conclusion: This study found no difference in hypoglycemic events and potassium lowering based on IV weight-based regular insulin dosing, however other risk factors may predict hypoglycemia.