High incidence of Pneumocystis jirovecii pneumonia in allogeneic hematopoietic cell transplant recipients in the modern era.

BACKGROUND: International guidelines for Pneumocystis jirovecii pneumonia (PJP) prevention recommend prophylaxis for ≥6 months following allogeneic hematopoietic cell transplantation, and longer in patients with graft-versus-host disease (GVHD) or on immunosuppressive therapy (IST). These recommendations are based on cohorts of patients who did not routinely receive anti-thymocyte globulin (ATG) for GVHD prophylaxis. METHODS: We performed a retrospective chart review of 649 patients, all of whom received ATG as part of GVHD prophylaxis. RESULTS: The cumulative incidence of definite PJP was 3.52% at both 3 and 5 years (median follow up, 1648 days for survivors). PJP occurred in 13 non-GVHD patients between days 207 and 508, due in part to low CD4 T-cell counts (<200 CD4 T cells/µL). PJP occurred in eight GVHD patients between days 389 and 792, due in part to non-adherence to PJP prophylaxis guidelines (discontinuation of PJP prophylaxis at <3 months after discontinuation of IST). Breakthrough PJP infection was not observed in patients receiving prophylaxis with cotrimoxazole, dapsone or atovaquone, whereas three cases were observed with inhaled pentamidine. DISCUSSION: In conclusion, for non-GVHD patients receiving ATG-containing GVHD prophylaxis, 6 months of PJP prophylaxis is inadequate, particularly if the CD4 T-cell count is <200 cells/µL or if there is a high incidence of PJP in the community. For patients with GVHD receiving ATG-containing GVHD prophylaxis, continuing PJP prophylaxis until ≥3 months post-discontinuation of IST is important. Cotrimoxazole, dapsone and atovaquone are preferred over inhaled pentamidine.

Pharmacological treatment for mental health illnesses in adults receiving dialysis: A scoping review.

BACKGROUND: Pharmacologic management of mental health illnesses in patients receiving dialysis is complex and lacking data. OBJECTIVE: Our objective was to synthesize published data for the treatment of depression, bipolar and related disorders, schizophrenia or psychotic disorders, and anxiety disorders in adults receiving hemodialysis or peritoneal dialysis. METHODS: We undertook a scoping review, searching the following databases: Medline, Embase, CINAHL, PsycINFO, Cochrane Library, Scopus, and Web of Science. Data on patients who received only short-term dialysis, a kidney transplant, or non-pharmacologic treatments were excluded. RESULTS: Seventy-three articles were included: 41 focused on depression, 16 on bipolar disorder, 13 on schizophrenia and psychotic disorders, 1 on anxiety disorders, and 2 addressing multiple mental health illnesses. The majority of depression studies reported on selective serotonin reuptake inhibitors (SSRIs) as a treatment. Sertraline had the most supporting data with use of doses from 25 to 200 mg daily. Among the remaining SSRIs, escitalopram, citalopram, and fluoxetine were studied in controlled trials, whereas paroxetine and fluvoxamine were described in smaller reports and observational trials. There are limited published data on other classes of antidepressants and on pharmacological management of anxiety. Data on treatment for patients with bipolar disorder or schizophrenia and related disorders are limited to case reports. CONCLUSION: Over half of the studies included were case reports, thus limiting conclusions. More robust data are required to establish effect sizes of pharmacological treatments prior to providing specific recommendations for their use in treating mental health illnesses in patients receiving dialysis.

Effects of a Computerized Prescriber Order Entry System on Pharmacist Prescribing.

Background: In Alberta, pharmacists are eligible to obtain additional prescribing authority (APA). At the University of Alberta Hospital, a transition was made from a paper-based prescriber order entry system to a computerized prescriber order entry (CPOE) system. Objectives: The primary objective was to quantify any change in pharmacist prescribing after CPOE implementation. The secondary objective was to compare the paper-based and CPOE systems in terms of drug schedule, order type, medication class, and the pharmacist's area of clinical practice. Methods: A retrospective comparative review of pharmacist orders was completed using 2-week periods of data from each of the paper-based order entry system and the CPOE system, spaced 1 year apart (in January 2019 and January 2020). Results: Pharmacists prescribed a mean of 3.76 (95% confidence interval 1.97-5.96) more orders per day within the CPOE system than in the paper-based system (p < 0.001). Schedule I medications accounted for a higher proportion of pharmacists' prescriptions in the CPOE system than in the paper-based system (77.7% versus 70.5%, p < 0.001). In terms of order type, discontinuation orders accounted for a much higher proportion of pharmacists' orders in the CPOE system than in the paper-based order entry system (58.0% versus 19.8%, p < 0.001). Conclusions: This study showed that a CPOE system resulted in more use of APA by pharmacists, with schedule I medications accounting for a higher proportion of pharmacists' prescriptions. With the CPOE system, pharmacists used their prescribing privileges to discontinue a higher proportion of orders than was the case with the paper-based system. Therefore, the CPOE system is a potential facilitator of pharmacist prescribing.

Contexte: En Alberta, les pharmaciens peuvent obtenir des pouvoirs de prescription supplémentaires (PPS). À l'hôpital de l'Université de l'Alberta, le système de saisie des ordonnances est passé d'un système sur papier à un système de saisie électronique des ordonnances (SSEO) par les prescripteurs. Objectifs: L'objectif principal consistait à quantifier tout changement dans la prescription des pharmaciens après la mise en place du SSEO. L'objectif secondaire visait à comparer le système sur papier et le SSEO en matière d'annexe des médicaments, de type d'ordonnance, de catégorie de médicament et de domaine de pratique clinique du pharmacien. Méthodes: Un examen comparatif rétrospectif des ordonnances des pharmaciens a été réalisé à l'aide de périodes de données de 2 semaines provenant de chacun des systèmes (papier et électronique), avec un intervalle d'un an (janvier 2019 et janvier 2020). Résultats: Les pharmaciens prescrivaient en moyenne 3,76 (intervalle de confiance à 95 % 1,97­5,96) ordonnances de plus par jour avec le SSEO qu'avec le système sur papier (p < 0,001). La part des ordonnances de médicaments de l'annexe I était plus importante avec le SSEO qu'avec le système sur papier (77,7 % contre 70,5 %, p < 0,001). En ce qui concerne le type d'ordonnance, la part des ordonnances de cessation était beaucoup plus élevée avec le SSEO qu'avec le système de saisie sur papier (58,0 % contre 19,8 %, p < 0,001). Conclusions: Cette étude a démontré un plus grand recours au PPS lorsque les pharmaciens utilisaient un SSEO et les médicaments de l'annexe I représentant une proportion plus élevée des ordonnances. Avec le SSEO, les pharmaciens ont utilisé leur pouvoir de prescription pour interrompre une part plus élevée d'ordonnances que ce n'était le cas avec le système sur papier. Le SSEO est donc un facilitateur potentiel de la prescription par les pharmaciens.

The use of concurrent long-acting injectable antipsychotic therapy with paliperidone palmitate and aripiprazole monohydrate in a patient with schizophrenia.

International schizophrenia guidelines endorse seeking the patient's preference for guiding antipsychotic therapy. There exists a small niche of patients who prefer, or are required to use, long-acting injectable antipsychotic medications due to the adherence benefit. However, they may not be able to achieve adequate symptom reduction prior to experiencing treatment-limiting adverse effects from a single agent. Here, we present a patient case prescribed concurrent long-acting injectable antipsychotic therapy with paliperidone palmitate and aripiprazole monohydrate due to patient preference in the setting of a history of nonadherence to oral medications, treatment-limiting adverse effects to long-acting injectable paliperidone, and failure to achieve adequate symptom reduction with long-acting injectable aripiprazole monotherapy.