Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study.

BACKGROUND: Medication reconciliation is one of the more challenging aspects of inpatient care, and its accuracy is paramount to safe transitions of care. Studies have shown that pharmacists have a role in medication reconciliation through improving patient safety and avoiding costs associated with medication errors. The wide-scale use of pharmacists in this process has been limited by time constraints, cost, and lack of resources. OBJECTIVE: This study evaluates the impact of pharmacists in resolving medication errors, decreasing readmission rates, and reducing institutional costs during the discharge medication reconciliation process. METHODS: Pharmacists evaluated discharge medication reconciliation documentation for patients to determine its accuracy, the accuracy of the admission reconciliation documentation, and any potential issues unrelated to accuracy. Analysis of these data determined the time required for pharmacist involvement, the number of errors identified by pharmacists, the quality of pharmacist interventions, the cost avoidance for each error, and the overall impact on hospital readmission. RESULTS: During the 7-week study period, pharmacists performed 67 discharge medication reviews and identified 84 errors. Seventy-five percent were considered to be significant and 6% were considered to be serious. The 30-day readmission rate in the study cohort was 18% compared with 20% in the control group. Based on the clinical severity scale and pharmacist salaries, pharmacist interventions resulted in $42,300 in cost avoidance. CONCLUSION: Pharmacists involved in this pilot discharge process identified and resolved significant errors on medication reconciliation orders that resulted in a financial benefit to the institution.

Long-term Safety and Tolerability of Omadacycline for the Treatment of Mycobacterium abscessus Infections.

Background: Mycobacterium abscessus is a virulent human pathogen. Treatment is complex and often poorly tolerated with suboptimal rates of eradication, highlighting the need for improved therapeutics. This study reports clinical experience with omadacycline for treatment of M abscessus infections at five large nontuberculous mycobacterial (NTM) disease clinics across the United States to better understand long-term safety and tolerability. Methods: We conducted a multicenter retrospective chart review of adults with M abscessus infections. All patients treated with omadacycline as part of a multidrug therapeutic regimen through December 2021 were included. Clinical data from time of omadacycline initiation and up to 12 months of follow-up were collected. Descriptive statistics were performed. Results: Analysis included 117 patients. Among patients with M abscessus isolate subspeciation, 58 of 71 (81.7%) were M abscessus spp abscessus. In isolates with reported drug susceptibility testing, 15 of 70 (21.4%) had confirmed susceptibility to macrolides. The most common site of infection was lungs. Median duration omadacycline treatment was 8 months (range, 0.25-33 months; interquartile range, 4-15 months). Omadacycline was discontinued in 60 patients (51.3%); 20 completed planned treatment course, 23 experienced intolerance or adverse event leading to drug cessation, and 17 stopped due to cost, death (unrelated to NTM infection or therapy), or another reason. In those with pulmonary disease, 44 of 95 (46%) had 1 or more negative cultures at time of final microbiological assessment, with 17 of 95 (18%) achieving culture conversion. Conclusions: This study reports data supporting long-term safety and tolerability of omadacycline along with signal of effectiveness in treatment of M abscessus infections.

Antimicrobial resistance: Concerns of healthcare providers and people with CF.

BACKGROUND: Chronic lung infections and their treatment pose risks for the development of antimicrobial resistance (AMR) in people with cystic fibrosis (PWCF). In this study, we evaluated the attitudes of healthcare providers' (HCP) and PWCF or their parents' toward AMR within the international CF community. METHODS: HCP and PWCF identified through listservs and CF-related organizations were asked to complete an AMR centered survey, with additional questions on antimicrobial stewardship (AMS) for HCP. Descriptive analyses are reported. RESULTS: The responding 443 HCP and 464 PWCF/Parents were from 30 and 25 countries, respectively. Sixty-two percent of HCP and 56% of PWCF stated they were "very concerned" about AMR, with Pseudomonas spp. and Burkholderia spp. considered the most concerning organisms for both HCP and PWCF/Parents. Non-tuberculous mycobacteria were of greater concern to HCP compared to PWCF/Parents. There was a discrepancy regarding AMR education to PWCF, with 80% of HCP stating having discussed this with PWCF/Parents, but only 50% of PWCF recalling such discussions. CONCLUSION: These results highlight that AMR is relevant to CF HCP and PWCF internationally, indicating that educational tools and research are warranted.

Drug-Induced Ototoxicity: A Comprehensive Review and Reference Guide.

OBJECTIVE: In an era of increasing polypharmacy, adverse drug effects such as ototoxicity have significant public health implications. Despite the availability of evidence, many health care professionals may not know the risk of ototoxicity in common medications. Therefore, the aim of this review is to provide a comprehensive, easy to use, ototoxic profile of medications with an assessment of supporting evidence. METHODS: Medications of interest were identified through adverse drug reaction reports derived from Micromedex (IBM), Lexicomp (Wolters Kluwer), and the textbook, Drug Induced Diseases: Prevention, Detection, and Management. Additional evidence was identified though a query of PubMed and the Cochrane database. Evidence of causality was graded according to the following: A (randomized, controlled clinical trials), B (nonrandomized clinical trials, prospective observational studies, cohort studies, retrospective studies, case-controlled studies, and/or postmarketing surveillance studies), and C (case reports/case series). RESULTS: A total of 194 systemically administered medications associated with ototoxicity were identified, most commonly antimicrobials (53), psychotropics (21), antihypertensive/antiarrhythmics (19), nonsteroidal antiinflammatory drugs (18), and antineoplastics (16). There was evidence of cochleotoxicity in 165 medications (evidence grading A [22], B [77], C [69]), vestibulotoxicity in 100 medications (evidence grading A [23], B [47], and C [30]), and dizziness in 142 medications (evidence grading A [50], B [76], and C [16]). In addition, a review of the evidence of ototoxicity in ototopical medications is also reviewed. CONCLUSION: The effect and severity of ototoxicity can vary immensely depending on pharmacological and individual patient risk factors. The intent of this comprehensive review was to help health care providers of all sectors obtain a deeper knowledge of drug-induced ototoxicity to make more informed management decisions for their patients.

Valproic acid-induced eosinophilic pleural effusion: a case report and review of the literature.

OBJECTIVE: To report a case of valproic acid-induced eosinophilic pleural effusion and to review the existing literature. CASE SUMMARY: A 25-year-old African-American man receiving valproic acid, 250 mg/d, had a moderate-sized right pleural effusion. Pleural fluid analysis revealed 75% eosinophils. The patient had no evidence of parasitic infection, hemothorax, or pneumothorax. One month after valproic acid was discontinued, there was no evidence of a pleural effusion by both chest radiography and thoracic ultrasonography. DISCUSSION: Valproic acid-induced pleural effusions have been reported in the medical literature in 5 case reports. Pleural fluid eosinophilia is almost always related to pneumothorax, hemothorax, parasitic infection, or drug toxicity; therefore, when the first 3 causes have been eliminated, a drug should be suspected. Only a few medications are known to cause pleural fluid eosinophilia, one being valproic acid. The Naranjo probability scale rated this adverse reaction as probably drug-related. CONCLUSIONS: In all 6 patients discussed in this review, the pleural effusions resolved after discontinuation of the valproic acid. None of these patients had associated pulmonary infiltrates. Valproic acid eosinophilia may be associated with peripheral blood eosinophilia. Valproic acid should be added to the list of medications that can cause an eosinophilic pleural effusion.

Riociguat: a novel new drug for treatment of pulmonary hypertension.

Riociguat is the first approved medication from the novel class of soluble guanylate cyclase (sGC) stimulators and the only agent approved for treating both chronic thromboembolic hypertension (CTEPH) and pulmonary arterial hypertension (PAH). The novel mechanism of riociguat lies in its ability to restore the homeostatic and therapeutic effects of nitric oxide that are diminished as a result of phenotypic alterations associated with pulmonary hypertension (PH). Improvements in 6-minute walk distance (6MWD) in patients with PAH during the phase 3 PATENT-1 trial were comparable to other oral agents approved for the treatment of PAH. Improvements in 6MWD in patients with CTEPH during the phase 3 CHEST-1 trial were greater than those previously observed with other oral PAH-directed therapies. Hypotension is the dose-limiting adverse effect of riociguat and dose titration is performed gradually according to systolic blood pressure. Riociguat was tolerated at maximal doses by most patients during PATENT-1 and CHEST-1 and was well tolerated during long-term extension studies. Key factors to consider with riociguat are a patient's systolic blood pressure, drug interactions mediated by CYP1A1, CYP3A4, and P-glycoprotein, cost, and teratogenicity requiring enrollment in a Risk Evaluation and Mitigation Strategy program. Recently published guidelines recommend riociguat monotherapy as an option for treatment-naïve patients with World Health Organization Functional Class (WHO FC) II or III symptoms or as add-on therapy for patients with persistent WHO FC III or IV symptoms being treated with an ERA or inhaled prostanoid. Postmarketing experience and ongoing clinical investigations will further define the safety and role of riociguat in patients with PAH and other types of PH.

Timing of inhaled tobramycin affects assessment of intravenous tobramycin pharmacokinetic monitoring.

BACKGROUND: Aerosolized tobramycin inhalation solution (TIS) may be absorbed and result in measurable serum concentrations. We assessed the significance of TIS dosing in the latter portion of the IV dosing interval on the calculation of pharmacokinetic (PK) parameters and dosing. METHODS: Twenty adult CF patients admitted to the hospital for treatment of a pulmonary exacerbation were enrolled. PK parameters of tobramycin were calculated before and after introduction of TIS, which was given 5-9 h after the IV dose. RESULTS: Nine patients had a clinically significant change in tobramycin trough concentration. Fourteen patients had a reduced calculated elimination rate constant after TIS administration, which may be misinterpreted as a decreased clearance of IV tobramycin. CONCLUSION: Trough tobramycin concentrations were significantly influenced in some CF patients (45%), suggesting that timing of the inhaled dose should be considered when interpreting PK measures of IV tobramycin dosing.

Nutritional supplements in critical illness.

Poor nutritional intake during critical illness can contribute to increased morbidity and mortality. Although nutrition strategies for critically ill patients attempt to provide essential macronutrients, recent evidence suggests that certain micronutrients and supplements may improve wound healing and decrease infectious and inflammatory complications. This review will focus on mechanism of action, adverse effects and drug interactions reported in the literature, and appropriate dosing and outcomes data for specific nutritional supplements in various critically ill adult populations.

Pharmacotherapy for pulmonary sarcoidosis: a Delphi consensus study.

BACKGROUND: Most issues concerning pharmacotherapy of pulmonary sarcoidosis have not been resolved in clinical trials. The objective was to survey sarcoidosis experts concerning the treatment of pulmonary sarcoidosis and attempt to reach a consensus by these experts using a Delphi method. METHODS: A 6-item questionnaire was developed. Experts were identified at the Diffuse Lung Disease Network at the annual CHEST meeting in October 2008. Three rounds of questionnaires were presented to the experts. Respondent feedback and supporting literature was incorporated into the questionnaires of subsequent rounds. RESULTS: Experts reached a consensus concerning the following issues: (a) corticosteroids are the initial therapy of choice; (b) initial use of inhaled corticosteroids are not recommended; (c) methotrexate was the preferred second-line drug; (d) 40mg of daily prednisone equivalent was the maximum dose recommended for the treatment of acute pulmonary sarcoidosis; (e) tapering to 10mg of daily prednisone equivalent for chronic pulmonary sarcoidosis was considered a successful taper. The experts could not resolve the following issues: (a) the initial corticosteroid dose for the treatment of acute pulmonary sarcoidosis; (b) the decision and timing of corticosteroid therapy in a patient with mild, Stage 2 pulmonary sarcoidosis. CONCLUSIONS: This Delphi study revealed that sarcoidosis experts reached a consensus concerning several aspects of the treatment of pulmonary sarcoidosis; these could be considered as appropriate approaches to therapy. Other issues concerning the therapy of pulmonary sarcoidosis remain unresolved by experts, and are areas where further clinical research could be directed.

Efficacy of short-course, low-dose corticosteroid therapy for acute pulmonary sarcoidosis exacerbations.

BACKGROUND: Although corticosteroids are the drug of choice for acute exacerbations of pulmonary sarcoidosis, the dose and duration of therapy is not standardized. We reviewed the short-term treatment outcome (median duration = 21 days) of 36 patients with acute exacerbations of pulmonary sarcoidosis using low-dose corticosteroid therapy (20 mg or less of daily prednisone equivalent). To the best of our knowledge, this is the shortest period of time over which the treatment of pulmonary sarcoidosis with corticosteroids has been assessed. METHODS: Patients were identified retrospectively from an institution-approved database. Patient symptoms and spirometry were obtained from chart review. Additional clinical data were obtained from chart and database review. RESULTS: Follow-up visits occurred a median of 21 days after the date of the exacerbation (mean 25 +/- 3 standard error of mean). The average prednisone dose was 19 mg +/- 0.4 standard error of mean. Patients had significant improvement in spirometry on this low-dose treatment regimen by the time of their short-term follow-up (forced vital capacity percent predicted improved from 68 to 82 [P < 0.0001] and was not significantly different from baseline; forced expiratory volume in 1 second percent predicted improved from 57 to 72 [P < 0.0001] and was not significantly different from baseline). Pulmonary symptoms also improved. CONCLUSIONS: Treatment of acute exacerbations of pulmonary sarcoidosis with 20 mg prednisone for a median of 21 days improved spirometry back to baseline and improved clinical symptoms. These data suggest that this corticosteroid dose can be safely used initially, and an attempt at tapering can be considered within the first month.