Systemic Steroid and Nebulized Budesonide Combination Therapy Versus Systemic Steroid Monotherapy in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in a Community Hospital: A Retrospective Cohort Study.

Purpose: To evaluate clinical outcomes and costs of inhaled corticosteroid (ICS) and systemic corticosteroid combination therapy versus systemic corticosteroid monotherapy for treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Methods: Hospitalized patients aged 41 to 85 years old who received ≥40 mg/day of systemic prednisone equivalents between April 3, 2017 to July 31, 2017 and April 3, 2018 to July 31, 2018 with a primary discharge diagnosis of AECOPD. Two cohorts were identified: those who received >2 doses of ICS (combination therapy) and those who received ≤2 doses of ICS (monotherapy) while on systemic corticosteroid therapy. Primary outcomes were progression of respiratory support or ≥20% increase in daily dose of systemic corticosteroids. Secondary outcomes were hospital length of stay (LOS), COPD 30-day readmissions, in-hospital mortality, and nebulized budesonide costs. Results: One hundred twenty-eight patients met inclusion criteria. Daily corticosteroid dose increases were similar between the combination and monotherapy cohorts (4% vs. 5%, P = 0.76) as was progression in ventilatory support (12% vs. 8%, P = 0.53). In-hospital mortality (4% vs. 1%, P = 0.36) and COPD 30-day readmissions (16% vs. 9%, P = 0.22) were not significantly different, however, patients in the combination arm had longer lengths of stay (4.8 days vs. 3.9 days, P = 0.04). Total nebulized budesonide costs were $1857 with a mean of $37 per patient stay for combination therapy cohort. Conclusion: Outcomes showed no clinical difference between combination therapy and monotherapy. This study suggests monotherapy may be more cost-effective while providing similar outcomes for the treatment of hospitalized patients with AECOPD.

Fecal microbiota transplantation for recurrent Clostridioides difficile infection.

PURPOSE: Randomized controlled trials investigating the efficacy and safety of fecal microbiota transplantation (FMT) for recurrent Clostridioides difficile infection (CDI) are reviewed, and practical issues for pharmacists to consider are discussed. SUMMARY: Eight randomized controlled trials evaluating the use of FMT for recurrent CDI were analyzed. The trials varied in the type of sample (fresh, frozen, lyophilized), route of administration (nasogastric tube, colonoscopy, enema, oral), and comparator agent (different type of FMT, vancomycin). Efficacy rates ranged from 43.8% to 96.2% with FMT, and safety data were relatively similar. With these favorable data, pharmacists are likely to be involved at multiple steps in the delivery of FMT to patients with recurrent CDI, including the procurement, documentation, and administration of various products and patient education. CONCLUSION: FMT is an option for recurrent CDI that is supported by findings of randomized controlled trials, although a preferred method for the delivery remains to be defined. Pharmacists can play an important role in the successful management of patients with recurrent CDI who may benefit from FMT.

Economic impact and chronic obstructive pulmonary disease outcomes of a comprehensive inhaler to nebulization therapy protocol implementation in a large multi-state healthcare system.

Objective: There are currently 39 FDA-approved metered-dose (MDI) or dry-powder inhalers (DPI) on the US market. Most are high cost with significantly more drug in the device than needed for a typical average length of stay in acute care hospitals, which leads to significant waste. The objective was to assess the financial impact and chronic obstructive pulmonary disease (COPD) outcomes of a comprehensive inhaler to nebulization protocol implemented in a large multi-state US health system. Methods: The retrospective study evaluated respiratory drug costs at 28 hospitals in the health system after a phased implementation of the automatic inhaler to nebulization protocol. Purchasing data was collected for all respiratory medications impacted by the protocol for the twelve months preceding as well as the two subsequent twelve-month periods following implementation at each facility. COPD length of stay (LOS) and 30 day readmissions were also reviewed. An attempt was made to evaluate the impact on respiratory therapy (RT) department workload. Results: Compared to pre-implementation, system-wide drug expenditures declined $1,561,011 (38.5%) and $1,646,411 (40.6%) in post-implementation year 1 (PY1) and post-implementation year 2 (PY2), respectively. COPD LOS and 30 day readmissions were not adversely affected and remained relatively stable in comparative periods. Objective impact on RT productivity and labor statistics was not ascertained due to complicated variables and multiple service lines. Conclusions: In an era of increased drug costs incurred by hospitals, a comprehensive inhaler to nebulization protocol significantly decreased costs without incurring any negative observed trends in COPD LOS or readmissions.

Acute renal failure after high-dose antibiotic bone cement: case report and review of the literature.

High-dose antibiotic-loaded bone cement (ALBC) spacers are commonly used to treat prosthetic joint infections following total hip and knee arthroplasties. This methodology can provide high local antibiotic concentrations while minimizing systemic exposure and toxicity. The occurrence of acute kidney injury (AKI) is rarely reported. Available literature suggests that the rate may be higher than previously thought. We report a case of significant systemic tobramycin absorption with concomitant acute renal failure in a 69-year-old female following the implantation of a high-dose ALBC spacer containing both tobramycin and vancomycin. The tobramycin level 24 h post-surgery was 5.8 mcg/mL. Due to concomitant renal failure, antibiotic clearance was poor and resulted in prolonged exposure to elevated aminoglycoside levels. Recovery of renal function occurred, but clinicians should be vigilant in considering the potential impact ALBC spacers can have on post-operative renal function if antibiotic elution is higher than expected.

Critical analysis of common canister programs: a review of cross-functional considerations and health system economics.

Respiratory inhalers constitute a large percentage of hospital pharmacy expenditures. Metered-dose inhaler (MDI) canisters usually contain enough medication to last 2 to 4 weeks, while the average hospital stay for acute hospitalizations of respiratory illnesses is only 4-5 days. Hospital pharmacies are often unable to operationalize relabeling of inhalers at discharge to meet regulatory requirements. This dilemma produces drug wastage. The common canister (CC) approach is a method some hospitals implemented in an effort to minimize the costs associated with this issue. The CC program uses a shared inhaler, an individual one-way valve holding chamber, and a cleaning protocol. This approach has been the subject of considerable controversy. Proponents of the CC approach reported considerable cost savings to their institutions. Opponents of the CC approach are not convinced the benefits outweigh even a minimal risk of cross-contamination since adherence to protocols for hand washing and disinfection of the MDI device cannot be guaranteed to be 100% (pathogens from contaminated devices can enter the respiratory tract through inhalation). Other cost containment strategies, such as unit dose nebulizers, may be useful to realize similar reductions in pharmacy drug costs while minimizing the risks of nosocomial infections and their associated medical costs. The CC strategy may be appropriate for some hospital pharmacies that face budget constraints, but a full evaluation of the risks, benefits, and potential costs should guide those who make hospital policy decisions.