Implementation and evaluation of a standardized herpes simplex virus prophylaxis protocol on a leukemia/bone marrow transplant unit.

OBJECTIVE: To assess the impact of a standardized acyclovir prophylaxis protocol for the prevention of herpes simplex virus (HSV) infection and disease in bone marrow transplant and leukemic patients. DESIGN: Two-phase, open sequential study involving prospective patient monitoring and retrospective health record review. SETTING: Tertiary care teaching hospital. PATIENTS: Fifty-seven patients (35 preprotocol, 22 postprotocol) who received acyclovir for HSV prophylaxis during an 18-month study period. INTERVENTIONS: An acyclovir HSV prophylaxis protocol was developed and implemented. Under this protocol, all HSV immunoglobulin G-seropositive hematology patients received an acyclovir regimen of 125 mg/m2 i.v. q6h or 600 mg p.o. q6h (if tolerated) from day -5 to day 30. Regimens not matching protocol were modified by pharmacists in conjunction with the prescriber. All treatment courses were followed daily by pharmacists to modify dosage according to renal function and assess appropriateness of the i.v. route. Tablets, capsules, or suspensions were promoted if the patient was considered tolerant of the oral route. MAIN OUTCOME PARAMETERS: Outcome parameters included (1) incidence of parenteral, oral, or combined therapy; (2) total prophylactic acyclovir dose per patient; (3) mean prophylactic acyclovir daily dose; (4) mean duration of acyclovir prophylaxis; and (5) HSV reactivation rate. RESULTS: Following implementation of the protocol, the mean total i.v. acyclovir dose per patient decreased from 20.1 g (range 3.6-109.5) to 11.7 g (range 1.0-43.0; p = 0.1162). The mean cumulative oral dose increased from 12.1 g (range 0.4-70.0) to 33.1 g (range 2.4-93.6; p = 0.0007). Mean duration of therapy increased from 27.6 to 33.5 days (p = 0.23). The mean duration of oral therapy increased from 10.5 days (+/- SD 10.9) to 17.2 days (+/- SD 12.1) (p = 0.034). The appropriateness of use of the i.v. dosage form increased from 53 to 88 percent of treatment days (p = 0.013). No difference in HSV reactivation rate was observed when comparing patients prior to and following protocol implementation. A drug acquisition savings of $1112.00 (CDN) per patient was realized. CONCLUSIONS: The implementation of a standardized HSV acyclovir prophylaxis protocol has resulted in significant drug acquisition cost savings without an apparent negative impact on patient outcome.

Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices.

OBJECTIVE: To assess inhalation technique in patients after written instruction alone, written and verbal instruction, and clinical use of two new inhalation devices. DESIGN: Randomized, crossover evaluation of the albuterol Diskhaler and the terbutaline Turbuhaler. SETTING: Canadian tertiary-care hospital. PATIENTS: Twenty hospitalized adults with asthma or chronic obstructive pulmonary disease currently using an albuterol metered-dose inhaler (MDI). Nineteen patients received Diskhaler, 16 received Turbuhaler, 15 received both inhalers, and 10 patients used both inhalers for three days each. INTERVENTIONS: Patients were randomized to receive either Diskhaler or Turbuhaler for three days. Inhaler technique was assessed after written instruction, written plus verbal instruction, at the first scheduled dose after instruction, and after three days of clinical use. Patients remaining in the hospital after three days crossed over to the other study inhaler and the same protocol was followed. MAIN OUTCOME MEASURES: Patient inhalation technique was assessed and compared for the MDI, Diskhaler, and Turbuhaler. RESULTS: Assessment of MDI technique revealed that 35 percent of patients used their MDI correctly on the first puff, and 42 percent used it correctly on the second puff. Following written instruction alone, correct technique was demonstrated by 32 percent of patients with Diskhaler and 6 percent with Turbuhaler. Technique significantly improved following verbal instruction, although 40 percent of the patients required up to three attempts to demonstrate correct technique on at least one of the study inhalers. After three days of clinical use, correct technique was demonstrated in only 54 percent of the Diskhaler and 64 percent of the Turbuhaler assessments. Performance at this assessment was, however, significantly better on the Turbuhaler than on the MDI (p = 0.01). Performance on the Diskhaler was not significantly different from the performance on the other inhalers. CONCLUSIONS: Written instruction alone is inadequate in teaching correct inhalation technique. Verbal instruction and technique assessment are essential for patients to achieve proper technique. Patients may perform better on the Turbuhaler than on other inhalation devices.