[Role of a Pharmacist in AST Activity and Pharmaceutical Education in a Mid-sized Japanese Community Hospital].

At small or mid-sized medical institutions, such as Japanese community hospitals, adequate infectious disease physicians (IDP) are lacking, mainly due to shortages of full-time pharmacists and IDPs who support antimicrobial stewardship team (AST) activities. With our hospital AST, we developed a multidisciplinary approach based on the interim reports of culture results or detected resistant bacteria for physicians, which are written by pharmacists and clinical laboratory technicians. At the AST conference, a pharmacist works as a chairman and reviews abstracts of cases which need to be discussed. We performed a retrospective analysis of the process and outcome of AST implementation, and introduced the use of reduction data for our hospital, obtained from Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE). This program is important for pharmacists to promote the diagnostic process and comprehensive judgment necessary for bedside practice with infectious disease cases. We offer opportunities for pharmacy students to participate in the AST conference to learn how pharmacists consult with doctors about diagnosis and treatment. At present, the cooperation between AS and diagnostic stewardship (DS) has been emphasized, and improvements in a pharmacist's overall judgment regarding infectious disease cases are required to appropriate antimicrobial use. In addition, improving communication skills is essential for building a multidisciplinary approach. Regardless of the size of the facility, the role of pharmacists in AST should be implemented for the guidance of pharmacy students, which will help develop and secure future human resources at the facility.

[Practice of drug monitoring based on comprehensive pharmaceutical judgment].

With the revisions to the pay for performance of pharmaceutical service of inpatients in April 2012, the ward permanent time of pharmacists grew longer than previously; however, there are as yet few reports on the pharmaceutical outcome of the new medical service. To improve the pharmaceutical service requires that pharmacists collect useful medical information and extract the problems of pharmaceutical care for inpatients. Since many cases of treatment with multidrug regimens are regularly performed, pharmacists cannot contribute to medical treatment only by knowledge of a single disease. Therefore quick and comprehensive judgment of pharmacists is necessary in addition to acquisition of pharmaceutical knowledge. We especially highlight medical emergencies such as severe cases of sepsis and infection to which physicians require rapid judgment. Pharmacists alike require appropriate knowledge of drug administration to avoid medical treatment failure. Moreover, it is necessary for pharmacists to apply advanced drug monitoring in difficult cases. On the other hand, integrated team medical treatment is now advancing, although pharmacists' roles in clinical decision making are increasing, and pharmacists have a greater burden of responsibility than before.

[The pharmacokinetics and safety of oxaliplatin in a hemodialysis patient treated with mFOLFOX6 therapy].

A postoperative rectum cancer patient with lung metastasis undergoing hemodialysis was treated with mFOLFOX6 therapy. The primary dose of oxaliplatin (L-OHP) ranged from 60 mg/m(2) to 85 mg/m(2), and adverse reactions and serum platinum concentration were monitored. The free platinum concentration (f-Pt), was eliminated efficiently using dialysis. The patient was tolerant of L-OHP doses of 60 mg/m(2) and 70 mg/m(2), but grade 2 neutropenia and grade 3 hemoglobin decrease developed with an L-OHP dose of 85 mg/m(2). The f-Pt after hemodialysis was higher than that before hemodialysis with a dose of 85 mg/m(2). But even with an 85 mg/m(2) dose, mFOLFOX6 therapy could be continued by extending the dosing interval. The monitoring of serum platinum concentrations, as well as therapeutic monitoring based on pharmacokinetics, contributes to safety management of cancer chemotherapy.

[Need for pharmacists to contribute to infection control and building patient safety].

With the revisions to the Japanese medical institutions law of April 2006, an improved medical care security system in a medical institution is indispensable. More and more medical institutions are now assigning full-time pharmacists to the task of medical safety. Hospital pharmacy sections are utilizing a valid evaluation system developed by the Japan Council for Quality Health Care. Pharmaceutical specialists who contribute to medical security, such as certified oncology pharmacists and certified infection control pharmacists (CICPha) are much awaited. In addition, the DPC (Diagnosis Procedure Combination) system has now become widespread in Japan, and the call is for pharmaceutical care that can decrease medical costs. It is imperative for health care systems to assure the appropriate use of drugs to decrease medical costs without reducing medical services. CICPha can contribute to the antimicrobial management program, and has also focused on medical care security. Several antimicrobial management programs of broad-spectrum agents, i.e., formulary restriction and prior approval, are gradually being enforced in Japan. The CICPha role is far-reaching, and it should make a concerted effort to prevent the injudicious use of antimicrobial agents resulting in the emergence of drug resistance; this must be handled by infection control doctors and nurses along with microbiological technicians. The CICPha must regulate the appropriate use of these agents, and perform surveillance of antimicrobial use and resistance (AUR). We describe the necessity and evaluation of AUR, and also underscore the necessity of training clinical pharmacists who will contribute to patient safety in days to come.