Positive Impact of a Pilot Pharmacist-Run Diabetes Pharmacotherapy Clinic in Solid-Organ Transplant Recipients.

PURPOSE: Post-transplant diabetes mellitus (PTDM) can lead to significant morbidity and cardiovascular death with a functioning graft. A paucity of literature exists regarding glycemic control in solid-organ transplant (SOT) recipients, including pharmacist management of PTDM. This study aimed to assess the impact of pharmacist interventions on diabetes management in a pharmacist-run PTDM clinic. METHODS: This was a single-center, prospective, observational study of 24 adult SOT recipients enrolled in a pilot pharmacist-managed PTDM clinic from 1 January to 30 June 2015. RESULTS: Improvements were realized in markers of glycemic control, including changes in A1C, average daily self-monitoring of blood glucose (SMBG) results, fasting SMBG results, and pre-lunch SMBG results from enrollment through at least 3 months of follow-up. Median A1C decreased significantly from 8.05% (interquartile range [IQR] 6.33-11.75) at baseline to 6.45% (IQR 6.05-7.3) at the last follow-up encounter (P = 0.0010). Average daily SMBG results decreased significantly from a median of 191 mg/dL (IQR 138-232 mg/dL) at baseline to 125 mg/dL (IQR 111-167 mg/dL) at the final encounter (P = 0.0023). Median fasting and pre-lunch SMBG results decreased significantly from 153 mg/dL (IQR 117-208 mg/dL) at baseline to 120 mg/dL (IQR 102-134 mg/dL) (P = 0.0064) and from 212 mg/dL (IQR 159-258 mg/dL) to 122 mg/dL (IQR 110-169 mg/dL) (P = 0.0161), respectively. Changes from baseline in other SMBG values, lipid levels, and BMI were not statistically significant. CONCLUSION: The results of our study demonstrate that a pharmacist-managed PTDM clinic can significantly affect glycemic control in SOT recipients.

Impact of a pharmacist-led vaccine recommendation program for pediatric kidney transplant candidates.

Pediatric transplant recipients commonly have deficient vaccination status at the time of transplantation. Utilizing transplant pharmacists to improve vaccination rates has not previously been described. This single-center, retrospective study evaluated the impact of transplant pharmacist interventions on the completion rate of vaccination schedules at time of kidney transplant. Patients who received pharmacist-led vaccination recommendations prior to transplant were compared to patients without pharmacist recommendations. Forty-seven pediatric patients were included: 24 intervention patients and 23 control patients. The median percentage of up-to-date vaccinations at time of transplant was significantly higher in intervention group (91%; IQR 86%-100%) vs. control group (80%; IQR 71%-80%) (P<.0001). The median change in up-to-date vaccinations from time of evaluation to time of transplant was also significantly higher in the intervention group (7.5%) compared to the control group (0%) (P<.0001). There was no difference in live vaccination rates. No patients in either group were readmitted for a vaccine-preventable disease within 6 months post-transplant. With pharmacist intervention, significantly more patients were up to date with vaccination schedules at the time of transplant. These results suggest that a transplant pharmacist may serve as a valuable resource to increase vaccination schedule compliance between time of evaluation and transplantation.

Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis.

BACKGROUND: The use of intravenous bicarbonate in diabetic ketoacidosis (DKA) may be considered for patients with a pH less than 6.9 according to the American Diabetes Association. The impact of this therapy on resolution of acidosis in patients with DKA is unclear. OBJECTIVE: To determine whether the use of intravenous bicarbonate therapy was associated with improved outcomes in patients with severe DKA who were seen in the emergency department. METHODS: This review was conducted from 2007 to 2011 in the emergency department of a tertiary teaching hospital. Adults diagnosed with DKA with an initial pH less than 7.0 were included. Patients were stratified into 2 groups based on receipt of intravenous bicarbonate. The primary study outcome was time to resolution of acidosis, defined as return to pH greater than 7.2. Secondary outcomes included length of stay; continuous infusion insulin use; and intravenous fluid, po tas si um, and insulin requirements within the first 24 hours of hospital admission, beginning upon admittance to the emergency department. We also conducted a subgroup analysis of patients with an initial pH less than 6.9. RESULTS: There was no significant difference in time to resolution of acidosis (8 hours vs 8 hours; p = 0.7) or time to hospital discharge (68 hours vs 61 hours; p = 0.3) between patients who received intravenous bicarbonate (n = 44) compared with those who did not (n = 42). The median dose of intravenous bicarbonate was 100 mEq (100-150) for patients who received intravenous bicarbonate. Insulin and fluid requirements in the first 24 hours were significantly higher in patients who received intravenous bicarbonate compared with those who did not (100 units vs 86 units; p = 0.04 and 7.6 L vs 7.2 L; p = 0.01, respectively). There was no significant difference in hours of continuous insulin infusion (27 hours vs 26 hours; p = 0.09) or potassium requirements in the first 24 hours of hospital stay (135 mEq vs 120 mEq; p = 0.84). CONCLUSIONS: Intravenous bicarbonate therapy did not decrease time to resolution of acidosis or time to hospital discharge for patients with DKA with an initial pH less than 7.0.

Retrospective analysis of levetiracetam compared to phenytoin for seizure prophylaxis in adults with traumatic brain injury.

BACKGROUND: Phenytoin is standard of care for seizure prophylaxis following traumatic brain injury (TBI). Levetiracetam, an alternative antiepileptic drug, is utilized for seizure prophylaxis despite limited data supporting its use. OBJECTIVE: Our primary outcome was post-TBI seizure activity measured by electroencephalogram (EEG) for levetiracetam versus phenytoin. Secondary outcomes were length of intensive care unit (ICU) stay, requirement for additional antiepileptic drugs (AED), and drug and monitoring costs. METHODS: A retrospective review was performed of patients admitted to neurosurgical or surgical trauma ICU. Adult patients with at least 1 day of EEG monitoring were included. Patients were excluded if they had history of epilepsy, prior TBI, less than 48 hours of AED therapy, or additional AED prior to EEG monitoring. RESULTS: A total 90 patients met inclusion criteria, with 18 receiving levetiracetam and 72 receiving phenytoin. Prevalence of EEG-confirmed seizure activity was similar between the levetiracetam and phenytoin groups (28% vs 29%; P = .99). ICU length of stay (13 vs 18 days; P = .28), time to EEG-confirmed seizure activity (4 vs 6 days; P = .24), and duration of seizure prophylaxis (9 vs 14 days; P = .18) were also similar. The median daily cost of levetiracetam therapy was $43 compared to $55 for phenytoin therapy and monitoring (P = .08). When all anticonvulsant therapy and monitoring were included, costs were lower for the levetiracetam group ($45 vs $83; P = .02). CONCLUSION: Levetiracetam may provide an alternative treatment option for seizure prevention in TBI patients in the ICU. Total antiepileptic drug and monitoring costs were lower for levetiracetam patients.

Pravastatin versus simvastatin for prevention of contrast-induced nephropathy.

Contrast-induced nephropathy (CIN) is associated with long-term morbidity, mortality, and increased health care costs. It has been suggested that statins have pleiotropic effects countering inflammatory and oxidative stress involved in CIN. Several studies support this theory; however, previously published studies have not evaluated the potential differences between statins in reducing the incidence of CIN. The purpose of this retrospective, single-center trial was to compare the incidence of CIN in patients receiving simvastatin or pravastatin therapy undergoing percutaneous coronary intervention (PCI). A total of 261 patients were included (145 received simvastatin and 116 received pravastatin) with the majority undergoing elective PCI. The population was predominantly male (65%), Hispanic (65%), and diabetic (62%), with a mean age of 59 years and a low-density lipoprotein (LDL) of 85 mg/dL. No significant differences were found between groups for risk factors or prophylactic strategies (eg, hydration). Contrast-induced nephropathy occurred in 26 patients (17.9%) in the simvastatin group versus 10 (8.6%) in the pravastatin group (P < .05). No patients required dialysis as a result of contrast administration. Acute kidney injury (AKI) occurred in 21 patients (14.5%) in the simvastatin group compared to 8 (6.9%) in the pravastatin group (P < .05). In multivariate analysis, the difference between statins remained an independent predictor for the development of CIN. In conclusion, patients on pravastatin had a significantly lower incidence of CIN compared to patients on simvastatin.

Effects of therapeutic drug monitoring criteria in a computerized prescriber-order-entry system on the appropriateness of vancomycin level orders.

PURPOSE: The effects of therapeutic drug monitoring (TDM) criteria in a computerized prescriber-order-entry (CPOE) system on the appropriateness of orders for vancomycin levels were evaluated. METHODS: Vancomycin TDM criteria were developed and implemented in a CPOE system. These criteria were displayed via a pop-up alert message when vancomycin levels were ordered and included directions for appropriate timing and justification for routine monitoring. Data for two groups of adult inpatients who had vancomycin levels ordered before and after criteria implementation were compared. Medical records were retrospectively reviewed for these patients to collect information regarding patient demographics, vancomycin dosage and indication, concurrent antibiotics and nephrotoxic agents during vancomycin therapy, length of stay, duration of vancomycin therapy, and number of vancomycin levels drawn. The primary outcome was the percent change in appropriate vancomycin levels ordered after criteria implementation. RESULTS: A total of 200 patients were analyzed, 100 in each group. The percentage of appropriate orders for vancomycin levels significantly increased after criteria implementation (from 58% to 68%, p = 0.02). The greatest effect on appropriateness occurred with the first level ordered (52% versus 70% in the preimplementation and postimplementation groups, respectively; p = 0.01). The majority of inappropriate levels were due to improper timing of sample collections, accounting for 55% of the inappropriate levels evaluated. CONCLUSION: A significant increase in the number of appropriately ordered and drawn serum vancomycin levels occurred after implementation of TDM criteria in the hospital's CPOE system. The majority of orders that were deemed inappropriate were due to improper timing of laboratory collection.

Continuous versus intermittent infusion of oxacillin for treatment of infective endocarditis caused by methicillin-susceptible Staphylococcus aureus.

Infective endocarditis (IE) is the fourth leading cause of life-threatening infection in the United States and imposes significant morbidity and mortality. The American Heart Association guidelines for the diagnosis and treatment of IE do not address continuous-infusion (CI) oxacillin. This retrospective study compares outcomes between CI oxacillin and intermittent-infusion (II) oxacillin in the treatment of IE caused by methicillin-susceptible Staphylococcus aureus (MSSA). A total of 709 medical records were reviewed for inpatients with definitive IE treated between 1 January 2000 and 31 December 2007. Continuous data were analyzed by Student's t test or the Wilcoxon rank sum test. The chi-square test or Fisher's exact test was used to compare nominal data. A multivariate logistic model was constructed. One hundred seven patients met eligibility criteria for inclusion into the study. Seventy-eight patients received CI oxacillin, whereas 28 received II oxacillin. CI and II groups were similar with respect to 30-day mortality (8% versus 10%, P = 0.7) and length of stay (20 versus 25 days, P = 0.4) but differed in 30-day microbiological cure (94% versus 79%, P = 0.03). Sixty-three patients received synergistic gentamicin, whereas 44 did not. The gentamicin and no-gentamicin groups were similar with respect to 30-day mortality (11% versus 4%, P = 0.2) and 30-day microbiological cure (90% versus 89%, P = 0.8); however, times to defervescence (4 versus 2 days, P = 0.02) were significantly different. CI oxacillin is an effective alternative to II oxacillin for the treatment of IE caused by MSSA and may improve microbiological cure. This convenient and pharmacodynamically optimized dosing regimen for oxacillin deserves consideration for patients with IE caused by MSSA.