Ceftizoxime use in trauma celiotomy: pharmacokinetics and patient outcomes.

Seriously injured patients undergo vigorous resuscitation upon arrival at the emergency department and through the immediate perioperative period. Although resuscitation leads to volume loading and fluid shifts, drug dosing and dosing intervals are often not altered to account for changes in total body volume or circulatory volume. To address this, a prospective study of pharmacokinetics of ceftizoxime in 53 injured adults who underwent emergency celiotomy was conducted. Further, the relationship between serum ceftizoxime concentrations and infectious outcomes was evaluated. Per protocol, injured adults undergoing emergency celiotomy received prophylactic ceftizoxime treatment according to standard dosing regimens. Of the patients, 6 (11.5%) experienced postoperative infections and had lower peak serum ceftizoxime levels in the recovery room than patients not experiencing infection. For severely injured adults with extensive blood loss or undergoing lengthy operations requiring rigorous volume resuscitation, doses of ceftizoxime, and indeed all antibiotics, may need to be increased beyond conventional standards to minimize infectious complications.

A comparison of the anti-hypertensive effectiveness of two triameterene/hydrochlorothiazide combinations: Maxzide versus Dyazide.

The hydrochlorothiazide component of Maxzide (Lederle Laboratories, Pearl River, NY) has been shown to be more bioavailable than the hydrochlorothiazide component of Dyazide (Smith, Kline and French Laboratories, Philadelphia, PA). The authors compared the antihypertensive effectiveness of a half-tablet of Maxzide (25 mg of hydrochlorothiazide and 37.5 mg of triamterene) to one capsule of Dyazide (25 mg of hydrochlorothiazide and 50 mg of triamterene) to determine if the difference in bioavailability would be reflected in differences in blood pressure control and metabolic changes. Thirty patients were studied in a randomized open-label crossover design study. There was a significant reduction in systolic blood pressure for both treatments although there was no difference in blood pressures at any time during the study between the two agents. There were no statistically significant differences between Maxzide and Dyazide in terms of metabolic changes for potassium, magnesium, glucose, cholesterol, triglycerides, uric acid, or calcium. Although the hydrochlorothiazide component of Maxzide is more bioavailable than that of Dyazide this did not translate into enhanced hypotensive efficacy.

Individualized pharmacokinetic versus standard dosing of amikacin: a comparison of therapeutic outcomes.

We compared the therapeutic outcome in patients with normal renal function managed with either individualized pharmacokinetic (PK) dosing or standard (every 12 h) dosing of amikacin. A total of 82 patients with confirmed or suspected infectious processes were entered into the study. There was no difference in therapeutic outcomes (P = 0.47) with one patient from each group dying. The duration of hospital stay (15.8 days vs 11.3 days, P = 0.052) and the mean duration of therapy (8.9 days vs 7.4 days, P = 0.20) were not significantly different, although a trend was seen towards longer time periods in the PK group. The incidence of nephrotoxicity (3 vs 1, P = 0.61), and calculated PK parameters were not different between the PK and standard groups, respectively. Upon evaluation of amikacin serum concentrations in individual patients, we found that five of 82 patients (6.1%) were or might have been at risk for toxicity with standard, unmonitored doses of amikacin, when compared to published literature. Although equivalent therapeutic outcomes may be achieved with standard or individualized PK dosing, the risk of toxicity with standard dosing is substantial. The routine use of standard dosing regimens cannot be recommended. Definition of specific patients subtypes in whom standard regimens utilizing lower doses can safely and effectively be used is necessary.

Overestimating clinical functions of distributive staff pharmacists.

An unexpected outcome was obtained when an evaluation of the clinical functions performed by distributive staff pharmacists was completed. A random survey of clinical functions was completed by using a pharmacist activity log sheet. Direct observations made by pharmacy administration and information received through discussions with the staff pharmacists, over-estimated the actual amount of time being spent on clinical functions. Use of an integrated approach to pharmacy services requires that enough time for both distributive activities and clinical activities be appropriately balanced to assure effective intervention. PRN clinical pharmacy functions will produce sub-optimal results and negative long-term effects for the profession. Pharmacy administrators must prospectively monitor the clinical activities performed by members of their integrated staff and assure that adequate time is available for effective intervention in the drug use process. Subjective observations and information may not reflect the actual situation and should be considered extremely inaccurate.

The Clinical Pharmacology Consultation Service: results of a physician survey before and after implementation.

A total of 175 physicians were surveyed by questionnaire before a Clinical Pharmacology Consult Service was started. Of those that responded, 72% thought the service would be helpful, although 40% said they would use the service no more than once a month. Most physicians (75%) preferred self-initiated consultations to automatic surveillance. Ninety-two percent believed a physician should be involved in making drug recommendations. A second questionnaire was circulated 30 months later. Actual use of the service closely paralleled the results of the first survey. There was an increased preference for automatic surveillance (5% vs 32%) and many physicians (48%) indicated they felt comfortable accepting drug consultations from a pharmacist or clinical pharmacist. Despite a general attitude of acceptance, the majority of respondents ranked the Clinical Pharmacology Consult Service last as a source of drug information.

Implementing clinical pharmacy services in an outpatient oncology clinic.

The implementation of clinical pharmacy services in an outpatient oncology clinic is described. An oncologist hired by the department of internal medicine and the director of the department of pharmacy designed the program. Both departments agreed that the pharmacists should have central responsibility for the antineoplastic agents. Pharmacists for the program were selected from the existing staff. They were trained in an established i.v. therapy certification course offered by the hospital. The biweekly clinics are staffed by a team consisting of two pharmacists, three nurses, two faculty physicians, and a rotating resident physician. The pharmacists provide clinical and distributive services including patient monitoring and medication storage, delivery, preparation, administration, and disposal. A survey showed that the pharmacists were well accepted by the other members of the team. After a trial period, principles of break-even analysis and differential accounting were used to justify the costs of the program. This program will remain an integral part of this hospital's pharmaceutical services.