HIV pharmacotherapy: A review of integrase inhibitors.

Integrase strand transfer inhibitors (INSTIs) are a class of antiretroviral agents used to treat HIV. These drugs--raltegravir, elvitegravir, and dolutegravir--are preferred options for treatment-naïve patients when used in combination with two nucleoside reverse transcriptase inhibitors. Based on clinical trials, INSTIs have been proven to be effective with minimal safety concerns. This article reviews the pharmacologic profile, role in therapy, and safety and efficacy of each agent.

Impact of an antimicrobial stewardship initiative on time to administration of empirical antibiotic therapy in hospitalized patients with bacteremia.

PURPOSE: The impact of an antimicrobial stewardship initiative on time to first antibiotic dose and clinical outcomes in bacteremic patients was evaluated. METHODS: A single-center, retrospective study was conducted for adult inpatients who received antibiotics before and after implementation of a rapid administration of antimicrobials by an infectious diseases specialist (RAIDS) protocol. Patients admitted to an inpatient service from June to October 2011 (pre-RAIDS protocol) and from December 2011 to February 2012 (post-RAIDS protocol) were eligible for inclusion if (1) they were age 18 years or older, (2) their infection occurred two or more days after hospital admission, and (3) they had a blood culture growing an organism other than common skin contaminants (i.e., coagulase-negative staphylococci, Bacillus species). The primary outcome was the time to the first antibiotic dose (TFAD), defined as the time that elapsed from a positive blood culture result to administration of the first empirical antimicrobial dose. RESULTS: A total of 111 bacteremic patients were included in the analysis. Implementation of the RAIDS protocol led to significantly faster antibiotic order entry, verification, and administration of empirical antibiotics in patients with bacteremia. The median TFAD was approximately 8 hours faster in the post-RAIDS group than in the pre-RAIDS group (9:09 hr:min versus 1:23 hr:min, p < 0.001). Patients in the post-RAIDS group had a significant reduction in infection-related mortality (p = 0.047), though all-cause 30-day mortality was similar. CONCLUSION: Early notification of an infectious diseases pharmacist about positive blood cultures using the RAIDS protocol led to increased appropriateness of empirical drug selection and a dramatic reduction in the administration of antibiotics and was associated with decreased infection-related mortality.

Administration of a survey to evaluate the attitudes of house staff physicians towards antimicrobial resistance and the antimicrobial stewardship programme at a community teaching hospital.

Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians' perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn Hospital Center (TBHC) and (ii) measure physicians' beliefs and attitudes to the current system of prior authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents significantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P=0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics, only 26% (34/129) agreed that they themselves were contributing to the current problem (P=0.0003). Fifty-seven percent of respondents agreed that individual patient care is improved by having an antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical residents were more likely (33% vs. 13%; P=0.02) to feel that the antibiotic approval programme forced them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the survey, there was no difference in score when stratified by specialty or years of postgraduate training. Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP is valuable for patient care.

Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-Morbidities.

Treatment of HIV now occurs largely within the primary care setting, and the principal focus of most visits has become the management of chronic disease states. The clinical pharmacist's potential role in improving chronic disease outcomes for HIV patients is unknown. A retrospective cohort study was performed for HIV-positive patients also diagnosed with diabetes, hypertension, or hyperlipidemia. Characteristics and outcomes in 96 patients treated by an interdisciplinary team that included a clinical pharmacist (i.e., the intervention group) were compared to those in 50 patients treated by an individual healthcare provider (i.e., the control group). Primary outcomes were changes from baseline over 18 months of HbA1c, low density lipoprotein (LDL), and blood pressure, respectively. Secondary outcomes included number of drug-drug interactions, HIV viral load, CD4 count, percent change in smoking status, and percent of patients treated to cardiovascular guideline recommendations. The interdisciplinary team had a significant improvement in lipid management over the control group (LDL: -8.8 vs. +8.4 mg/dL; p=0.014), and the smoking cessation rate over the study period was doubled in the interdisciplinary group (20.4% vs. 11.8%). Among those with an indication for aspirin, a significantly higher percentage of patients were prescribed the medication in the interdisciplinary group compared to the control group (85.5% vs. 64.9%; p=0.014). An informal cost analysis estimated savings of more than $3000 per patient treated by the interdisciplinary team. Based on these results, pharmacist involvement in an HIV primary care clinic appears to lead to more appropriate management of chronic co-morbidities in a cost-effective manner.