Implementation of a Pharmacist-Driven Vancomycin and Aminoglycoside Dosing Service in a Pediatric Hospital.

OBJECTIVE: Pharmacy-driven antibiotic dosing services have been shown to improve clinical outcomes in adult patients. This study evaluated the effect of a pharmacist-driven antimicrobial dosing service on the percentage of therapeutic serum concentrations achieved following initial vancomycin or aminoglycoside dosing regimens. A secondary objective was to determine the effect of the dosing service on nephrotoxicity in pediatric patients. METHODS: This single-center, retrospective study used data obtained from an electronic medical record to evaluate the utility of a pharmacist-driven vancomycin or aminoglycoside dosing protocol. Assessments of target, subtherapeutic, and supratherapeutic serum concentrations were evaluated. The occurrence of changes in serum creatinine and presentation of acute kidney injury (AKI) were also determined. RESULTS: The incidence (n [%]) of a therapeutic initial serum concentration was not statistically significant between pre-protocol and post-protocol groups (21 [46.7%] vs 22 [48.9%], respectively; p = 0.834). The incidence of initial supratherapeutic concentrations (19 [42.2%] vs 7 [15.6%]; p = 0.005) and the average number of supratherapeutic concentrations per antibiotic course (0.76 vs 0.26; p = 0.01) were higher in the pre-protocol group compared with the post-protocol group. The incidence of AKI was significantly lower in the post-protocol group (2.2% vs 13.3%; p = 0.049). CONCLUSIONS: Implementation of a pharmacist-driven dosing service did not affect the likelihood of achieving an initial therapeutic concentration. However, it did reduce the likelihood of both supratherapeutic concentrations and AKI. Additional studies in pediatric patients are needed to affirm the use of pharmacist dosing services.

Treatment Considerations for CNS Infections Caused by Vancomycin-Resistant Enterococcus faecium: A Focused Review of Linezolid and Daptomycin.

OBJECTIVE: To review the current literature describing pharmacology, pharmacokinetics/pharmacodynamics (PK/PD), efficacy, and safety of linezolid and daptomycin for the treatment of central nervous system (CNS) infections caused by vancomycin-resistant Enterococcus (VRE) faecium. DATA SOURCES: A literature search of PubMed/MEDLINE databases was conducted (from 1950 to April 2020) utilizing the following key terms: vancomycin-resistant Enterococcus, VRE, meningitis, ventriculitis, CNS infection, daptomycin, and linezolid. STUDY SELECTION AND DATA EXTRACTION: All relevant studies and case reports describing the treatment of VRE faecium from the CNS with linezolid or daptomycin were included. DATA SYNTHESIS: A total of 17 reports describing 22 cases were identified. There were 15 of 19 cases involving linezolid that reported clinical cure, of which 53.3% were monotherapy. Only 5 of 9 cases involving intravenous (IV) daptomycin resulted in cure; all 4 cases reporting daptomycin administration via the intrathecal or intraventricular route achieved clearance from the cerebrospinal fluid (CSF). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The preferred treatment option for VRE faecium infections involving the CNS remains unclear. Supporting evidence through observational case reports have described varying outcomes with linezolid and daptomycin. This review compares reported outcomes between the 2 agents and provides a thorough discussion on drug- and patient-specific variables to consider. CONCLUSIONS: Linezolid monotherapy appears to be safe and effective for the treatment of susceptible-VRE faecium CNS infections, with consideration of therapeutic drug monitoring in special populations and with prolonged treatment duration. Daptomycin is an effective treatment option via intrathecal or intraventricular administration when neurosurgical access is available. The role of IV daptomycin remains inconclusive.

Global Health Education in Doctor of Pharmacy Programs in the United States.

Objective. To determine the extent and manner in which global health education is taught at US PharmD programs. Methods. A pre-tested 40-question electronic survey instrument was developed and sent to each of the 127 accredited or candidate-status US doctor of pharmacy (PharmD) programs. Results. Twenty-eight public and 27 private PharmD programs responded to the survey (43.3%). Twenty-five (45.5%) programs had integrated global health topics into their required didactic curriculum, and 30 of 52 programs (57.7%) offered at least one standalone global health elective course. Of the 52 programs that provided details regarding experiential education, 41 (78.8%) offered introductory and/or advanced pharmacy practice experiences (IPPEs and/or APPEs) in global health, and 34 (65.4%) programs offered medical mission trips. Conclusion. Doctor of pharmacy programs participating in global health education most commonly educate students on global health through experiential learning, while inclusion of required and elective coursework in global health was less common. To adequately prepare students for an increasingly global society, US PharmD programs should consider expanding global health education.

Patiromer: The First Potassium Binder Approved in Over 50 Years.

For over 50 years, there have been limited options for the management of hyperkalemia, especially among patients with chronic kidney disease (CKD), diabetic nephropathy, hypertension, and heart failure, who were receiving concomitant renin-angiotensin-aldosterone system (RAAS) inhibitor therapy. Hyperkalemia is a potential, life-threatening electrolyte abnormality that frequently challenges clinicians from maximizing the mortality benefit and organ-protective properties of RAAS inhibitors especially in CKD and heart failure populations. Patiromer is a novel nonabsorbed, cation-exchange polymer that binds and exchanges potassium for calcium, predominantly in the gastrointestinal tract. It has demonstrated potassium-lowering effects in normo- or hyperkalemic patients on concomitant RAAS inhibitors with heart failure, diabetic nephropathy, and CKD, in the PEARL-HF, AMETHYST-DN, and OPAL-HK studies, respectively. Across all studies, it appears to be generally effective and well tolerated, with adverse events predominantly gastrointestinal in nature. Additional investigational studies are needed to explore its use for an extended duration of treatment and in larger patient populations, as well as exploring drug-drug interactions. Overall, patiromer demonstrates a promising role in the chronic management of hyperkalemia that will allow optimization of RAAS inhibitor therapy, thus delaying progression of CKD and improving the mortality benefit in heart failure patients.