Optimizing Heart Failure Management: A Review of the Clinical Pharmacist Integration to the Multidisciplinary Health Care Team.

Heart failure (HF) stands as a prevalent chronic ailment, imposing a substantial burden on global healthcare systems due to recurrent hospitalizations, intricate management, persistent symptoms, and polypharmacy challenges. The augmentation of patient safety and treatment efficacy across various care stages, facilitated by a multidisciplinary HF team inclusive of a clinical pharmacist, emerges as paramount. Evidence underscores that the collaborative engagement of a physician and a clinical pharmacist engenders proficient and secure management, forestalling avoidable adversities stemming from drug reactions and prescription inaccuracies. This synergistic approach tailors treatments optimally to individual patients. Post-discharge, the vulnerability of HF patients to re-hospitalization looms large, historically holding sway as the foremost cause of 30-day readmissions. Diverse strategies have been instituted to fortify patient well-being, leading to the formulation of specialized transitional care programs that shepherd patients effectively from hospital to outpatient settings. These initiatives have demonstrably curtailed readmission rates. This review outlines a spectrum of roles assumed by clinical pharmacists within the healthcare cohort, spanning inpatient care, transitional phases, and outpatient services. Moreover, it traverses a compendium of studies spotlighting the affirmative impact instigated by integrating clinical pharmacists into these fields.

Impact of the Five-Year Intervention of an Antimicrobial Stewardship Program on the Optimal Selection of Surgical Prophylaxis in a Hospital without Antibiotic Prescription Restrictions in Costa Rica: A Retrospective Study.

This study aims to characterize the impact of the implementation of an antimicrobial stewardship program (AMS) on the optimal selection of surgical antibiotic prophylaxis in adult patients. This is a retrospective quasi-experimental study that compared the selection and duration of antibiotics for all surgical prophylaxis prescriptions over six months, both before (pre-AMS) and after a five-year intervention of AMS (post-AMS). In addition, data related to the consumption of antibiotics, adverse drug reactions, and surgical site infections throughout the years of the intervention were analyzed. The rate of appropriate selection of antibiotic prophylaxis in surgical procedures improved to 80% during the post-AMS period. The percentage of optimal duration increased from 69.1% (N = 1598) in the pre-AMS period to 78.0% (N = 841) in the post-AMS period (p < 0.001). The consumption of ceftriaxone significantly decreased, while the use of cefazolin increased more than nine times. No severe adverse reactions or increases in surgical site infections were detected after the intervention. The implementation of an AMS in the surgical ward demonstrated a trend towards a positive overall impact on the selection and duration of prophylactic antibiotics for surgery, with positive results also observed in other variables associated with the prescription of these antibiotics.

Assessing pharmaceutical consultations: Comparing pharmacy-recommended medications for minor ailments and regulatory compliance in a Latin American healthcare network.

Background: The importance of access to medicines in promoting global health cannot be overstated, particularly as an estimated 2 billion people lack access to basic medicines, particularly in developing nations. While over-the-counter (OTC) medications are relatively safe and cost-effective, there is a risk of misuse due to factors such as inaccurate self-diagnosis, inadequate dosing, addiction, adverse drug reactions, and drug interactions. To ensure proper use and prevent irrational self-medication, pharmacists can play a crucial role in guiding patients. However, the legislation in Costa Rica only covers OTC and prescription drugs, and health authorities are proposing a new decree to include a list of drugs that can be recommended by pharmacists without a prescription to treat minor ailments, which would be classified as behind-the-counter (BTC). Objective: Characterize the pharmaceutical consultation, compare the medications recommended by pharmacy professionals for minor ailments with the legislation in force in Costa Rica, and determine whether the current OTC medications are sufficient to treat minor ailments. Material and methods: This study is a descriptive, observational, cross-sectional study that focuses on a sample of the Costa Rican population that comes to consult with a pharmacist in one of the four pharmacies of the Hospital Clínica Bíblica (HCB) in San José, Costa Rica. Consultations included users over 18 years of age or caregivers of underage patients seeking advice or assistance from publicly accessible pharmacies, excluding consultations that involved information related to other hospital departments. This study aims to analyze the pharmaceutical consultation for minor ailments and compare the medications recommended by pharmacists with the list of medications allowed in Costa Rica. The study also aims to determine if the current OTC medications are adequate for treating minor ailments. Results: A total of 1537 consultations were gathered, which were divided into four categories: pharmaceutical recommendation (48%), medication information (31%), other consultations (18%), and referrals to another health professional (3%). Among the consultations classified as pharmaceutical recommendations, 90% were related to minor ailments. Prescription drugs accounted for 75.3% of the medications recommended and consulted. However, when the BTC category was included, the percentage of recommended prescription drugs decreased to 29.6%, while BTC drugs constituted 45.7%. Finally, the chi-square test rejected the null hypothesis that there was no association between the availability of OTC drugs and the minor ailments for which patients sought consultation. Conclusions: Most cases of pharmacy consultations involve minor illnesses such as digestive symptoms, joint pain, and respiratory issues. The proposed decree by health authorities in Costa Rica is noteworthy as it establishes standardized protocols for the prescription of BTC medications to ensure the safety of patients.

Evaluation of Systemic Antifungal Use in a Latin American General Care Hospital: A Retrospective Study.

BACKGROUND: Invasive fungal infections significantly contribute to mortality and morbidity rates. Despite the presence of all four major classes of antifungal medications, it is estimated that these infections result in the death of 1.5 million people each year, and death rates are increasing at an alarming rate. With increasing concerns about the emergence of antifungal resistance, there is a growing consideration in many countries to incorporate antifungal stewardship into existing antimicrobial stewardship programs. This approach aims to address issues hindering the appropriate use of antifungal drugs and to optimize their utilization. METHODS: An analytical retrospective study of 48 hospitalized patients was conducted to assess factors related to the use of systemic antifungals and develop and implement an internal protocol to improve its use. RESULTS: All patients with severe comorbidity had SOFA scores linked with a mortality risk of more than 10%. Based on 48 evaluations of antifungal orders, 62.5% were considered appropriate, 14.6% were considered debatable, and 22.9% were considered inappropriate. Infectious disease physicians made most of the prescriptions considered appropriate in this study. CONCLUSIONS: Comorbidities and risk factors in patients receiving systemic antifungals can be associated with the development of more serious fungal infections; hence, the implementation of antifungal stewardship as a complement to antimicrobial stewardship programs can help facilitate decision-making when dealing with a suspected case of fungal infection.

Uncommon Progressive Systemic Tetanus: A Case Report.

Tetanus is a bacterial infection caused by the toxin of Clostridium tetani. While it primarily affects newborns, people with incomplete vaccination schedules, it can also impact people of any age, especially in developing countries. Even though in the last 20 years several initiatives have been implemented worldwide to reduce the impact of this disease, regions like South Asia and sub-Saharan Africa have registered mortality rates highest since 2015-2019. In Latin America, regional immunization coverage rates were reported at 89% in 2017 for diphtheria-tetanus toxoid and pertussis (DTP-3), although Costa Rica has reported decreased coverage rates of the national immunization schedule from 2019 to 2021. In this case study, we present a 53-year-old woman from Puntarenas, Costa Rica diagnosed with progressive systemic tetanus who developed status epilepticus. She previously was assessed in a central hospital of Costa Rica for paresthesia in her right upper limb of three months of duration, myoclonus and difficulty walking in the last weeks; the presumed diagnosis was Guillain-Barré syndrome. During her hospitalization she had three generalized tonic-clonic seizures treated with diazepam and phenytoin. Since there was no improvement, she was transferred to our medium-sized private hospital for the treatment of painful spasms and weakness in the lower limbs. On initial evaluation, no injury was found. She was initially treated with midazolam and magnesium sulfate for presenting seizures-like spasms in the lower limbs and then generalized without loss of consciousness for up to 15 minutes, mainly associated with desaturation, tachycardia and tachypnea. In the differential diagnosis, muscle contractions linked to hypocalcemia, neurosyphilis and epilepsy were ruled out. Despite this, magnetic resonance imaging showed fractures in T11, L1 and L2. Mainly due to the presence of spasms, opisthotonos and history of seizures and a wound on the hand four months ago, she was diagnosed with tetanus.  Among the initial management, tetanus toxoid (Td), antimicrobial therapy, and human antitetanic immunoglobulin (HTIG) were administered, which partially improved the patient's condition, although she remained dependent on the infusions. On the sixth week of hospitalization, the patient developed status epilepticus which is explained by the magnetic resonance findings that show subacute bi-occipital infarcts caused by hypoxia from the previous crises. Lacosamide therapy reversed the condition and kept the patient free of seizures.  It was necessary to carry out a lumbar osteosynthesis which was highly favorable to stabilize the patient's condition. The frequency and intensity of the spasms were gradually reduced, which allowed the gradual suspension of the infusions and the benzodiazepine overlap intravenous (IV) to oral (PO). The patient now has only self-limiting spasms and her maintenance therapy consists of lacosamide and oral clonazepam.  This case highlights the importance of considering tetanus in the differential diagnosis even if the vaccination schedule is complete, especially if there are spasms, convulsions, or a history of wounds or bites. It is important to monitor this type of report to reconsider and update the key elements in the prevention, diagnosis, management, and treatment of tetanus; as well as improve access to essential medicines, including the HTIG, and the patient's prognosis in terms of symptom resolution and associated sequelae.

From End-of-Life Care to Improved Quality of Life and Better Prognosis by Using Vericiguat: A Case Report From Costa Rica.

In this case report, we present the evolution of a heart failure with reduced ejection fraction (HFrEF) patient who was set to receive end-of-life care but demonstrated improvement following treatment with vericiguat in combination with foundational therapy. Vericiguat is a novel soluble guanylate cyclase stimulant that has been proven helpful for treating decompensated heart failure with HFrEF, decreasing hospitalization rates and mortality of cardiovascular causes. This medication is currently indicated in patients who require IV diuretics administration or hospitalization due to decompensated heart failure. This is a case study of a 62-year-old woman with dilated heart failure and reduced left ventricular ejection fraction (LVEF), who was a wheelchair user due to severe cardiovascular symptoms and various comorbidities, who was referred to our heart failure program for treatment. Despite previous treatment, the patient experienced persistent cardiovascular symptoms and required palliative care. After optimizing the foundational therapy, the patient's condition improved but continued to require hospitalization. Vericiguat was initiated as an add-on. After six months, the patient's LVEF improved by 9%, and she is now asymptomatic with a considerable decrease in pro-B-type natriuretic peptide levels and is wheelchair independent due to enhance exercise resistance. However, the echocardiogram revealed a progression in the dysfunction of both the mitral and aortic valves. The patient's renal function and quality of life scores also changed over time. Vericiguat therapy, as an adjunct to foundational therapy, improved exercise tolerance and symptom relief. However, further investigation is necessary to assess the effects of vericiguat on renal function and disease progression in individuals with HFrEF.

Prescribing Trends in Psychotropic Medications Among Outpatients of a Latin American Healthcare Setting: A Five-Year Retrospective Study.

Introduction Mental health problems affect millions worldwide, and the prescription of psychotropic drugs is increasing globally. The World Health Organization (WHO) has emphasized the need for proper monitoring of psychotropic drug prescriptions. This study aims to characterize and find trends in the prescription of psychotropics in a Latin American General Hospital. Methods The study analyzed the dispensation of psychotropic prescriptions to outpatients at three pharmacies in the central headquarters of Hospital Clínica Bíblica in San José, Costa Rica, from 2017 to 2021. Psychotropic drugs were classified by the Anatomical Therapeutic Chemical (ATC) code, and the amount of each medication dispensed was standardized using the defined daily dose per 10,000 population per day metric. Patients' ages were categorized into four groups: under 18 years, 18 to 39 years, 40 to 64 years, and 65 years and above. The prescriptions were categorized according to medical specialty. Regression analyses were performed to determine the significance of trends observed in the data Results A total of 5793 psychotropic prescriptions were recorded. The average age of the patients was 58 years. The total consumption of psychotropics decreased by 33.94% from 2017 to 2021, with the most significant decline until 2020. However, there was an increase in consumption in 2021. Clonazepam was the most consumed medication, followed by bromazepam and alprazolam, which was the sole drug to exhibit an escalation in usage between 2017 and 2021. Regression analysis showed that only alprazolam and zopiclone had statistically significant trends. The highest number of prescriptions was dispensed to patients aged between 40 and 64 years, followed by those aged over 65 years. Anxiolytics were also the most commonly prescribed group of drugs. General medicine (20.22%), psychiatry (19.95%), and internal medicine (12.73%) were the primary specialties that prescribed psychotropic; 38.6% of prescriptions were associated with the 10th decile of patients, and 44.9% of prescriptions were issued by the 10th decile of physicians.  Conclusion The consumption of psychotropic drugs decreased from 2017 to 2020 but increased in 2021, with alprazolam being the only drug that showed an increase in consumption throughout the entire period. General practitioners and psychiatrists were found to be the specialties that most commonly prescribe these medications. The study found significant trends only for the consumption of alprazolam and zopiclone and for prescription patterns among psychiatrists and internal medicine physicians.

A Comprehensive Review of Sulfonamide Hypersensitivity: Implications for Clinical Practice.

Sulfonamides, which are drugs commonly prescribed in hospital and outpatient settings, have historically been associated with a high incidence of hypersensitivity reactions. It is believed that there is an increased risk of cross-reactions with other drugs that contain this functional group in their structure. However, it has not been conclusively established that the sulfonamide group is the sole cause of hypersensitivity reactions, as non-antibiotic sulfonamides do not share the same accessory groups with antibiotic sulfonamides. Therefore, cross-reactivity between different types of sulfonamides and sulfonamide-type antibiotics is not clearly demonstrated, and allergic reactions may involve other mechanisms. Misinformation about this topic can lead to inappropriate use of alternative antibiotics with lower efficacy or higher adverse effects, contributing to antibiotic resistance. It is crucial to individualize and monitor patients with a history of allergies to sulfonamide-type antibiotics when introducing a new drug containing sulfa and manage any adverse reactions promptly. Desensitization protocols may be a viable option for patients who specifically benefit from these antibiotics, particularly those who are immunosuppressed. This article provides a descriptive bibliographic review to update information on sulfa allergy, its prevalence, management, and recommendations to prevent such reactions and optimize pharmacotherapy, without underusing these drugs.

The risk of treatment-induced QT interval prolongation.

OBJECTIVE: QT interval prolongation can increase patients' hospital stay and  mortality rate. This study aims to determine the incidence of drug-induced QT  interval prolongation and establish which QT interval measurement method is  the most appropriate for electrocardiographic monitoring. METHOD: A retrospective observational study was conducted of patients admitted to the Clínica Bíblica Hospital during 2018. The electronic  medical records of patients hospitalized for longer than 48 hours and whose drug regimen included at least one drug potentially able to prolong the  QT interval were reviewed. Manually-measured QT intervals were corrected using Fridericia's and Rautaharju's formulae, while automatically- measured QT intervals were corrected with Bazett's formula. Risk was assessed  using the RISQ-PATH scale. RESULTS: Of the 141 patients analyzed, 23 had arrhythmia as per their clinical  history and 14 suffered a complication during their stay in hospital. A total of  113 (80%) had a high RISQ-PATH score and only 64 were subjected to an  electrocardiogram on admission. Patients received a mean of three potentially  QT interval prolonging drugs. Most of the QT intervals measured automatically  were shorter than those obtained manually. Of all corrections, the longest QTc  interval values were obtained with Bazett's formula, and the shortest with  Rautaharju's formula. None of the patients developed TdP or complex  ventricular tachycardia. CONCLUSIONS: Every effort should be made to implement strategies conducive to more effective monitoring of the QT interval to prevent QT  nterval prolongation related complications in hospitalized patients.

OBJETIVO: La prolongación del intervalo QT puede aumentar la estancia hospitalaria y la tasa de mortalidad de los pacientes. Esta  investigación determina la incidencia de prolongación del intervalo QT debido al  uso de medicamentos y evalúa el método más apropiado para realizar el  monitoreo electrocardiográfico.Método: Se realizó un estudio observacional retrospectivo en pacientes hospitalizados en el Hospital Clínica Bíblica durante el año 2018. Se revisaron los expedientes de los pacientes con hospitalización superior a 48  horas cuya historia clínica incluyera al menos tratamiento con un medicamento que prolongara el intervalo QT y que las medidas manuales del intervalo QT  fueran corregidas con la fórmula Fridericia y Rautaharju, y las medidas  automáticas con la fórmula Bazett. La valoración del riesgo se realizó con la  escala RISQ-PATH. RESULTADOS: De los 141 pacientes analizados, 23 tenían una arritmia previa en  su historia clínica y 14 de ellos sufrieron complicaciones durante la  hospitalización. Un total de 113 (80%) pacientes tenían un valor alto  RISQ­PATH y sólo a 64 se les realizó un electrocardiograma al ingreso. En  promedio, los pacientes recibieron tres medicamentos que aumentaban el  intervalo QT. La mayoría de los QT obtenidos automáticamente fueron más  cortos que aquellos obtenidos en forma manual. De todas las correcciones, los  valores del intervalo QT más largos se obtuvieron con la fórmula de Bazett, y  los más cortos con la fórmula Rautaharju. No ocurrieron eventos como  taquicardia ventricular compleja o torsade de pointes durante el estudio. CONCLUSIONES: Es necesario implementar estrategias que permitan una mejor  monitorización del intervalo QT con el fin de prevenir las complicaciones derivadas en los pacientes hospitalizados.

The Pharmacist's Role in the Implementation of FASTHUG-MAIDENS, a Mnemonic to Facilitate the Pharmacotherapy Assessment of Critically Ill Patients: A Cross-Sectional Study.

FASTHUG is a mnemonic used by intensive care physicians to ensure the proper management of patients admitted to an Intensive Care Unit (ICU). FASTHUG-MAIDENS is a modified version that incorporates key pharmacotherapeutic elements such as delirium management, drug dosing, and drug interactions for an appropriate medication assessment of critically ill patients. An analytical cross-sectional study of hospitalized patients was carried out to determine aspects related to the pharmacotherapeutic management of critically ill patients that required to be optimized, to design and implement a protocol based on the FASTHUG-MAIDENS mnemonic. A total of 435 evaluations were performed to assess the status of current critical patient management. The main parameters with opportunities to be improved were analgesia, feeding, and sedation. With the implementation of MAIDENS, the parameters of analgesia, sedation, and thromboprophylaxis showed an increase in the percentage of optimal management. Furthermore, 103 drug-related problems were detected, and most of them were associated with feeding (21.3%), glucose control (11.7%), and delirium (9.7%). The FASTHUG MAIDENS protocol implementation allows for the evaluation of more vital aspects in the management of critically ill patients. The daily review of patients admitted to the ICU by a clinical pharmacist (CP) using the FASTHUG-MAIDENS checklist instead of the FASTHUG mnemonic facilitates the identification of DRPs for the performance of possible interventions by the CP to improve the pharmacotherapeutic management.

Evaluación de las características de la prescripción de opioides mayores otorgados por las farmacias de un Hospital General Latinoamericano / Evaluation of the prescription characteristics of major opioids dispensed by the pharmacies of a Latin American General Hospital

Resumen: Introducción: Los opioides se han utilizado para el alivio del dolor en diversos contextos. Su uso puede favorecer efectos indeseables. Actualmente los países industrializados viven una crisis de opioides. Objetivos: Caracterizar los opioides mayores despachados en términos de especialidad médica y de dosis total en miligramos equivalentes a morfina (MME) en un Hospital General Latinoamericano. Material y métodos: Se realizó un estudio retrospectivo y observacional de prescripciones de opioides mayores despachadas en las Farmacias de un Hospital General Latinoamericano entre el año 2017 y 2020. Se tomó información de la base de datos del Ministerio de Salud. Se excluyeron las recetas que contenían estupefacientes no opioides y fentanilo inyectable. Se realizó una estandarización a MME para analizar la distribución de la prescripción según médicos y pacientes. Resultados: La cantidad total de recetas despachadas correspondientes a opioides mayores fue de 5,366 prescripciones. La morfina inyectable fue el medicamento más prescrito (46%) y como principio activo obtuvo 54% de todas las recetas estudiadas (considerando todas las vías de administración). Medicina general prescribió la mayoría de las recetas con un 48%, lo que representó 42% del total de MME. Conclusiones: La morfina es el principio activo preferido por los médicos evaluados en este estudio, la vía de administración parenteral es la más utilizada. Medicina general es el área que más prescribe opioides. Es pertinente crear políticas educativas en materia de opioides; por ello, resulta conveniente caracterizar la prescripción de manera cualitativa considerando información como el diagnóstico y las dosis diarias utilizadas.

Abstract: Introduction: Opioids have been used for pain relief in various settings. Its use can promote undesirable effects. Industrialized countries are currently experiencing an opioid crisis. Objective: To characterize the prescription of major opioids considering the medical area that made the prescription and total dose in milligrams morphine equivalents (MME) at a general hospital in Latin America. Material and methods: A retrospective and observational study was carried out. The number of prescriptions for major opioids dispensed in the pharmacies of a general hospital in Latin America, between 2017 and 2020, were documented. Information was taken from the database of the Ministry of Health. Prescriptions containing non-opioid narcotic drugs and injectable Fentanyl were excluded. A standardization to MME was carried out to analyze the distribution of prescriptions. Results: The total number of prescriptions filled for major opioids was 5,366 prescriptions. Injectable morphine was the most prescribed drug (46%) and as an active principle it obtained 54% of all the prescriptions studied (considering all routes of administration). General medicine prescribed most prescriptions (48%), which represented 42% of the total MME. Conclusions: Morphine is the substance preferred by the doctors evaluated in this study, the parenteral route of administration is the most used. General medicine is the area that prescribes most of the opioids. It is pertinent to create educational policies on opioids; therefore, it is convenient to characterize the prescription qualitatively considering information such as the diagnosis and the daily doses used.

Riesgo de prolongación del intervalo QT asociado al tratamiento / The risk of treatment-induced QT interval prolongation

Objetivo: La prolongación del intervalo QT puede aumentar la estanciahospitalaria y la tasa de mortalidad de los pacientes. Esta investigacióndetermina la incidencia de prolongación del intervalo QT debido al usode medicamentos y evalúa el método más apropiado para realizar elmonitoreo electrocardiográfico.Método: Se realizó un estudio observacional retrospectivo en pacienteshospitalizados en el Hospital Clínica Bíblica durante el año 2018. Serevisaron los expedientes de los pacientes con hospitalización superiora 48 horas cuya historia clínica incluyera al menos tratamiento con unmedicamento que prolongara el intervalo QT y que las medidas manualesdel intervalo QT fueran corregidas con la fórmula Fridericia y Rautaharju,y las medidas automáticas con la fórmula Bazett. La valoración del riesgose realizó con la escala RISQ-PATH.Resultados: De los 141 pacientes analizados, 23 tenían una arritmia previaen su historia clínica y 14 de ellos sufrieron complicaciones durante la hospitalización.Un total de 113 (80%) pacientes tenían un valor alto RISQ‑PATHy sólo a 64 se les realizó un electrocardiograma al ingreso. En promedio,los pacientes recibieron tres medicamentos que aumentaban el intervalo QT.La mayoría de los QT obtenidos automáticamente fueron más cortos queaquellos obtenidos en forma manual. De todas las correcciones, los valoresdel intervalo QT más largos se obtuvieron con la fórmula de Bazett, y los máscortos con la fórmula Rautaharju. No ocurrieron eventos como taquicardiaventricular compleja o torsade de pointes durante el estudio.Conclusiones: Es necesario implementar estrategias que permitan una mejor monitorización del intervalo QT con el fin de prevenir las complicacionesderivadas en los pacientes ospitalizados

Objective: QT interval prolongation can increase patients’ hospitalstay and mortality rate. This study aims to determine the incidence ofdrug-induced QT interval prolongation and establish which QT intervalmeasurement method is the most appropriate for electrocardiographicmonitoring.Method: A retrospective observational study was conducted of patientsadmitted to the Clínica Bíblica Hospital during 2018. The electronic medicalrecords of patients hospitalized for longer than 48 hours and whosedrug regimen included at least one drug potentially able to prolong the QTinterval were reviewed. Manually-measured QT intervals were correctedusing Fridericia’s and Rautaharju’s formulae, while automatically-measuredQT intervals were corrected with Bazett’s formula. Risk was assessed usingthe RISQ-PATH scale.Results: Of the 141 patients analyzed, 23 had arrhythmia as per theirclinical history and 14 suffered a complication during their stay in hospital.A total of 113 (80%) had a high RISQ-PATH score and only 64 were subjectedto an electrocardiogram on admission. Patients received a meanof three potentially QT interval prolonging drugs. Most of the QT ntervalsmeasured automatically were shorter than those obtained manually. Of allcorrections, the longest QTc interval values were obtained with Bazett’sformula, and the shortest with Rautaharju’s formula. None of the patientsdeveloped TdP or complex ventricular tachycardia.Conclusions: Every effort should be made to implement strategies conducive to more effective monitoring of the QT interval to prevent QT intervalprolongation related complications in hospitalized patients

Impacto de la atención clínica suministrada por los farmacéuticos a los pacientes atendidos en el servicio de Onco-Hematología en un hospital privado en Costa Rica / Impact of the clinical care provided by pharmacists to patients treated in the Onco-Hematology service in a private hospital in Costa Rica

Introducción: El cáncer es una enfermedad que se caracteriza por el crecimiento no controlado de las células, el cual puede tratarse de muy diversas maneras. Es necesario prescribir tratamientos farmacológicos de soporte, a pacientes que sufren síndromes asociados con la enfermedad; así como premedicaciones para manejar efectos adversos de la terapia principal. Objetivo: Evaluar el impacto del farmacéutico y de los servicios de farmacia clínica oncológica en los pacientes atendidos en el Hospital. Material y Métodos: El presente proyecto es un estudio observacional descriptivo de corte retrospectivo. La información del estudio se obtuvo de los registros clínicos electrónicos, de los pacientes tratados por cáncer y que fueron atendidos entre enero 2017 y diciembre 2019. Resultados: Se analizaron 54 expedientes, y se incluyeron en el estudio 40. El cáncer de mama y Linfoma no Hodgkin fueron los cánceres de mayor incidencia. El protocolo de premedicación más utilizado fue el que incluía dexametasona y antihistamínicos, el cual se usó en el 70.6% y 64.7% respectivamente. Se realizaron un total de 25 intervenciones a los médicos tratantes. Se destaca que se logró un 100% de aprobación de las intervenciones realizadas por el farmacéutico del servicio de hemato-oncología. La mayoría de las intervenciones fueron recomendaciones de terapia de soporte, seguido por intervenciones debido a las interacciones detectadas. Conclusiones: En este estudio se evidencia la utilidad del farmacéutico clínico como parte del equipo multidisciplinario que aborda a los pacientes, con el fin de optimizar el tratamiento farmacológico asegurando la seguridad y eficacia de los medicamentos.(AU)

Introduction: In cancer treatment it is essential to evaluate the need of premedication in order to avoid toxicity and adverse effects of chemotherapies. This is why, the role of the pharmacist is important for the detection and management of adverse effects, dose verification, controlling pharmacological interactions, drug preparation and guaranteeing the stability of preparations.Objective:To evaluate the impact of the pharmacist and the oncology clinical pharmacy services in the patients treated at the Hospital. Methods: The present project is a retrospective, descriptive and observational study. The information was obtained from electronic clinical records of oncological patients treated between January 2017 and December 2019. Results: From the 40 patients included in the study, 37 were prescribed supportive therapy for a total of 51 individual protocols,46 (92.2%) of them had premedication that included corticosteroids (n=39; 76.5%) such as dexamethasone and antihistamine (n =36: 70.6%). Interventions associated with the recommendation of supportive therapy (n =7; 28.0%) and detection of drug interactions (n = 6; 24.0%) were mainly performed. 100% acceptance was obtained by hemato-oncologists. Conclusions: The interventions of the clinical pharmacist prevent, identify and optimize the management of problems related to the medication of the patients of theOnco-Hematology service. Therefore, they have an impact on their health and reaffirm the fact that an approach from a multidisciplinary perspective provides relevant clinical advantages.(AU)

Impact of a pharmacist-driven antimicrobial stewardship program in a private hospital in Costa Rica.

OBJECTIVE: To measure the impact generated by the implementation of the pharmacy-driven antimicrobial stewardship program of the Clínica Bíblica Hospital. METHODS: This is a retrospective observational study that evaluates the consumption of antibiotics for the periods before and during implementation of the Clínica Bíblica Hospital antimicrobial stewardship program, calculated by means of defined daily dose per 1 000 patient-days and days of therapy per 1 000 patient-days. In addition, bacterial resistance patterns for the periods 2014-2015 and 2016-2017 were compared. RESULTS: Consumption of most-used antibiotics was calculated, looking for trends that might be associated with the activities implemented by the Clínica Bíblica Hospital antimicrobial stewardship program. Comparing some of the antibiotics with the highest consumption in periods I and II, use of levofloxacin and ceftriaxone showed a decrease of 54.0% (p < 0.001) and 14.6% (p = 0.003), respectively, whereas there was an increase in the use of cefazolin of 4 539.3% (p < 0.001). Regarding percentage of bacterial resistance, in most bacterial isolates no statistically significant changes were observed between the two periods. CONCLUSIONS: A reduction in the overall consumption of antibiotics has been achieved over time, most likely attributable to the antimicrobial stewardship program. However, this trend was not observed for all the antibiotics studied. The pattern of resistance among the commonly isolated microorganisms did not vary greatly between the periods studied, which suggests that either the antimicrobial stewardship program may have prevented an increase in bacterial resistance since its implementation, or that it is too soon to see impact on bacterial resistance.

Impact of a pharmacist-driven antimicrobial stewardship program in a private hospital in Costa Rica

[ABSTRACT]. Objective. To measure the impact generated by the implementation of the pharmacy-driven antimicrobial stewardship program of the Clínica Bíblica Hospital. Methods. This is a retrospective observational study that evaluates the consumption of antibiotics for the periods before and during implementation of the Clínica Bíblica Hospital antimicrobial stewardship program, calculated by means of defined daily dose per 1 000 patient-days and days of therapy per 1 000 patient-days. In addition, bacterial resistance patterns for the periods 2014–2015 and 2016–2017 were compared. Results. Consumption of most-used antibiotics was calculated, looking for trends that might be associated with the activities implemented by the Clínica Bíblica Hospital antimicrobial stewardship program. Comparing some of the antibiotics with the highest consumption in periods I and II, use of levofloxacin and ceftriaxone showed a decrease of 54.0% (p < 0.001) and 14.6% (p = 0.003), respectively, whereas there was an increase in the use of cefazolin of 4 539.3% (p < 0.001). Regarding percentage of bacterial resistance, in most bacterial isolates no statistically significant changes were observed between the two periods. Conclusions. A reduction in the overall consumption of antibiotics has been achieved over time, most likely attributable to the antimicrobial stewardship program. However, this trend was not observed for all the antibiotics studied. The pattern of resistance among the commonly isolated microorganisms did not vary greatly between the periods studied, which suggests that either the antimicrobial stewardship program may have prevented an increase in bacterial resistance since its implementation, or that it is too soon to see impact on bacterial resistance.

[RESUMEN]. Objetivo. Medir el impacto de la ejecución de un programa de optimización del uso de antimicrobianos conducido por la farmacia del Hospital Clínica Bíblica. Métodos. En este estudio retrospectivo y de observación se evaluó el consumo de antibióticos antes y después de la ejecución del programa de optimización del uso de antimicrobianos en el Hospital Clínica Bíblica. El consumo se calculó tomando como base la dosis diaria por 1.000 días-paciente y los días de tratamiento por 1.000 días-paciente. Además, se compararon los perfiles de resistencia bacteriana en los períodos 2014-2015 y 2016-2017. Resultados. Se calculó el consumo de los antibióticos más usados para establecer las tendencias que podrían estar relacionados con las actividades ejecutadas por el programa de optimización del uso de antimicrobianos del Hospital Clínica Bíblica. Se compararon algunos de los antibióticos de mayor consumo en los períodos I y II, el uso de la levofloxacina y la ceftriaxona mostró una disminución de 54,0% (p < 0,001) y 14,6% (p = 0,003), respectivamente, mientras que se evidenció un aumento en el uso de la cefazolina de 4.539,3% (p < 0,001). Con respecto al porcentaje de resistencia bacteriana, no se encontró ningún cambio estadísticamente significativo entre los dos períodos para la mayoría de las cepas bacterianas aisladas. Conclusiones. Con el transcurso del tiempo se ha logrado una disminución en el consumo de antibióticos en general, probablemente relacionada con el programa de optimización del uso de antimicrobianos. Sin embargo, esta tendencia no se observó en todos los antimicrobianos analizados. No se evidenció una variación significativa en los patrones de resistencia entre los microorganismos aislados comúnmente entre los períodos comparados, lo que puede significar dos cosas: que el programa de optimización del uso de antimicrobianos podría haber evitado un aumento de resistencia bacteriana desde que se puso en marcha o que es demasiado pronto para que se evidencie un impacto en la resistencia bacteriana.

[RESUMO]. Objetivo. Mensurar o impacto da implantação de um programa de gerenciamento do uso de antimicrobianos por profissionais farmacêuticos em um hospital particular. Métodos. Trata-se de um estudo observacional retrospectivo para avaliar o uso de antibióticos no período anterior e posterior à implantação do programa de gerenciamento do uso de antimicrobianos no Hospital Bíblica Clínica, em San José, Costa Rica. O consumo dos medicamentos foi calculado com base na dose diária definida por 1.000 pacientes-dia e dias de tratamento por 1.000 pacientes-dia. Foi realizada uma comparação dos padrões de resistência bacteriana entre os períodos 2014–2015 e 2016–2017. Resultados. O consumo dos antibióticos mais utilizados foi calculado visando identificar possíveis tendências associadas às ações do programa de gerenciamento do uso de antimicrobianos implantado no hospital. A comparação do consumo de alguns dos antibióticos mais utilizados no primeiro e no segundo períodos considerados apontou uma redução de 54,0% no uso de levofloxacina (p < 0,001) e 14,6% no uso de ceftriaxona (p = 0,003), com um aumento de 4.539,3% no uso de cefazolina (p < 0,001). Com relação à resistência bacteriana, não se observou variação estatisticamente significativa na maioria dos isolados bacterianos entre os dois períodos. Conclusões. Houve redução no consumo de antibióticos em geral, provavelmente atribuível ao programa de gerenciamento do uso de antimicrobianos. Porém, esta mesma tendência não foi observada para todos os antibióticos estudados. Não houve variação importante no padrão da resistência dos microrganismos mais frequentemente isolados entre os períodos estudados. Isso indica que o programa de gerenciamento do uso de antimicrobianos implantado possivelmente evitou o aumento da resistência bacteriana ou que é ainda muito cedo para se observar o impacto na resistência bacteriana.

Farmacoterapia de la insuficiencia cardíaca: análisis de casos de pacientes hospitalizados en un centro de salud privado en Costa Rica / Pharmacotherapy of heart failure: analysis of cases of hospitalized patients in a private health center in Costa Rica

Resumen Introducción y objetivos: La insuficiencia cardíaca es una patología que afecta a la población adulta mundial; se estima que más de 23 millones de personas en el mundo la padecen, siendo esta una de las principales causas de mortalidad cardiovascular. Dicha investigación buscó evaluar la terapia utilizada en un ambiente hospitalario privado y su correlación con respecto a las guías internacionales; todo esto con el fin de proyectar el posible impacto sobre la morbimortalidad del paciente. Métodos: Se llevó a cabo un estudio observacional retrospectivo analizando múltiples variables obtenidas de los expedientes físicos y electrónicos de todos los pacientes adultos hospitalizados por insuficiencia cardiaca en el Hos pital Clínica Bíblica enero 2014 y diciembre 2016, para comparar la farmacoterapia utilizada con la definida por las guías terapéuticas seleccionadas. Resultados: Se analizaron 72 pacientes, de los cuales 35% estaba entre 81-90 años, 58% eran hombres; 61% estuvieron hospitalizados entre 1-5 días (61%), 9 ingresaron por rehospitalización y el resto fue por primera vez; 69 fueron egresados y 3 fallecieron. La estrategia terapéutica más utilizada en estos pacientes fue un betabloqueador en conjunto con un antagonista del receptor de angiotensina y un diurético de asa. Un 78% mantuvo un tratamiento adecuado según las guías. Conclusiones: El abordaje farmacoterapéutico de los pacientes con falla cardiaca fue satisfac torio, estuvo en la mayoría de los casos de acuerdo con las guías clínicas, por lo que se podría esperar beneficios en torno a la mortalidad, tiempo de hospitalización y tasa de rehospitalización.

Abstract Pharmacotherapy of heart failure: analysis of cases of hospitalized patients in a private health center in Costa Rica Objective: Heart failure is a disease that affects a highly proportion of the adult population worldwide; about 23 million people endure this ailment, being one of the main causes of cardiovascular mortality. Therefore, the aim was to evaluate the correlation between the current therapy in a hospital setting and international guidelines, as well as the impact on morbidity and mortality. Methods: Observational prospective study, to analyze multiple variables from physical and electronic registers from all hospitalized patients for heart failure at Hospital Clínica Bíblica from January 2014 to December 2016, with the intention to compare the prescribed therapy at the hospital with selected therapeutical guidelines. Results: There were 72 patients, from which 35% were between 81 and 90 years old, 58% were men, 61% were hospitalized between 1-5 days, 9 were readmitted and 63 had their first admission, 69 were discharged and 3 perished. Conclusions: The pharmacotherapeutic approach in patients with heart failure has had a satisfactory evolution, and it's according to clinical guidelines, which could have repercussions regarding the reduction of mortality rates, hospitalization stays and rehospitalization rates.

Análisis comparativo de las herramientas usadas para la prescripción potencialmente inapropiada de medicamentos en adultos mayores en un hospital privado en Costa Rica / Comparative analysis of tools used to detect drugs' potentially inappropriate prescriptions in the elderly at a private hospital in Costa Rica

Objetivos: En Costa Rica existe una proporción importante de adultos mayores y esta población se ve mayormente afectada por prescripciones inapropiadas, especialmente durante su estancia en un ambiente hospitalario. El objetivo del estudio fue establecer la mejor herramienta para detectar prescripciones potencialmente inapropiadas en los adultos mayores en un hospital privado de Costa Rica. Métodos: El estudio se realizó mediante la aplicación y comparación de tres herramientas: los criterios STOPP (2015), los criterios Beers’ (2015) y los criterios IPET (2002) a un total de 4866 prescripciones provenientes de un grupo de 388 adultos mayores hospitalizados, con el análisis posterior de los datos mediante pruebas estadísticas de chi-cuadrado (p<0.05). Resultados: los criterios Beers’ permitieron la detección de una mayor cantidad de prescripciones potencialmente inapropiadas que las dos otras herramientas en la población analizada. Conclusiones: los criterios Beers son la herramienta más apropiada para ser utilizada en el ámbito hospitalario estudiado, tanto por su mayor sensibilidad como por el tipo de información que es posible obtener de los expedientes en la institución, su construcción concisa y su practicidad a la hora de ser aplicada

Objective: There is an important proportion of elderly people in Costa Rica and they tend to be more affected by inappropriate prescriptions, especially during their hospital stay. The objective of this study is to establish the best tool to detect these potentially inappropriate prescriptions in an elderly population attended in a Costa Rica’s private hospital. Methods: Three tools were applied and compared: STOPP (2015), Beers’ (2015) and IPET (2002) criteria in a total sample of 4866 prescriptions from a group of 388 elderly hospitalized patients, with a subsequent chi-square analysis (p<0.05). Results: Beers’ criteria allowed a larger detection of potentially inappropriate prescriptions than the other tools applied in the study population. Conclusions: Beer ́s criteria allow to identify the greatest quantity of potentially inappropriate prescriptions because of the concise construction and practicality, as well as the information that can be gathered in this particular hospital setting

Analysis of the concordance between the estimated values of creatinine clearance using the Cockcroft-Gault equation and the real value determined in patients from the Hospital Clínica Bíblica.

OBJECTIVE: to analyze the effect of the modifications in the Cockcroft-Gault equation for creatinine clearance rate determination (CrCl) and its concordance with the real value determined from 24-hours urine collection in a sample of Latin American patients hospitalized in San José de Costa Rica. METHOD: an observational, retrospective study, with patients submitted to a 24-hour urine collection test, and who met the inclusion criteria. The real and estimated values of creatinine clearance were determined, and their concordance was measured by applying the Intraclass Correlation Coefficient; a descriptive analysis of data was also conducted. RESULTS: there were 507 subjects (61% men); their age was described (ME = 60 years SD = 17 years), as well as their height (ME = 1.66 m SD = 0.09 m), current weight (ME =75 kg SD = 15 kg), body mass index (ME = 27.3 kg/m2 SD = 4.76 kg/m2) and endogenous creatinine clearance rates (ME = 69.72 ml/min SD = 33 ml/min). The best concordance with the equation was obtained with current weight values and serum creatinine without rounding. CONCLUSIONS: the application of the Cockcroft-Gault equation that matches more closely the real value is the one that uses current weight and does not round creatinine values below 1 mg/dL. It is suggested to conduct a prospective analysis, determining other variables that could affect CrCl real measures, and to replicate this methodology in specific populations. *ME: Mean **SD: Standard Deviation.

Objetivo: analizar el efecto de las modificaciones en la fórmula de Cockcroft-Gault en la medición del aclaramiento de creatinina (CrCl) y su concordancia con el valor real calculado con la orina de 24 horas en una muestra de pacientes latinoamericanos hospitalizados en San José de Costa Rica. Método: estudio observacional, retrospectivo, con pacientes en quienes se midió la creatinina sérica en orina de 24 horas y que cumplieran los criterios de inclusión. Se determinaron los valores de aclaramiento de creatinina reales y calculados, y se estableció la concordancia entre estos, aplicando la prueba del Coeficiente de Correlación Intraclase; se realizó un análisis descriptivo de los datos. Resultados: un total de 507 pacientes (61% hombres), de los cuales se describió la edad (*ME = 60 años**DE = 17 años), estatura (*ME = 1,66 metros**DE = 0,09 metros), peso actual (*ME = 75 kg **DE = 15 kg), índice de masa corporal (*ME = 27,3 Kg/m2**DE = 4,76 Kg/m2), y valores de aclaramiento endógeno (*ME = 69,72 ml/min **DE = 33 ml/min). Se obtuvo la mejor concordancia para la fórmula con valores de peso actual y creatinina sérica sin redondeo. Conclusiones: la aplicación de la fórmula de Cockcroft-Gault que mejor concuerda con el valor real es aquella que utiliza el peso actual y no redondea valores de creatinina inferiores a 1 mg/dL. Se sugiere realizar un análisis prospectivo, determinando otras variables que podrían afectar a la medición real del CrCl, y replicar la metodología en poblaciones específicas. *ME: Media **DE: Desviación Estándar.

Analysis of the concordance between the estimated values of creatinine clearance using the Cockcroft-Gault equation and the real value determined in patients from the Hospital Clínica Bíblica / Análisis de la concordancia entre los valores estimados de aclaramiento de creatinina utilizando la fórmula de Cockcroft-Gault y el valor real determinado en pacientes del Hospital Clínica Bíblica

Objective: to analyze the effect of the modifications in the Cockcroft-Gault equation for creatinine clearance rate determination (CrCl) and its concordance with the real value determined from 24-hours urine collection in a sample of Latin American patients hospitalized in San José de Costa Rica. Method: an observational, retrospective study, with patients submitted to a 24-hour urine collection test, and who met the inclusion criteria. The real and estimated values of creatinine clearance were determined, and their concordance was measured by applying the Intraclass Correlation Coefficient; a descriptive analysis of data was also conducted. Results: there were 507 subjects (61% men); their age was described (ME = 60 years SD = 17 years), as well as their height (ME = 1.66 m SD = 0.09 m), current weight (ME =75 kg SD = 15 kg), body mass index (ME = 27.3 kg/m2 SD = 4.76 kg/m2 ) and endogenous creatinine clearance rates (ME = 69.72 ml/min SD = 33 ml/min). The best concordance with the equation was obtained with current weight values and serum creatinine without rounding. Conclusions: the application of the Cockcroft-Gault equation that matches more closely the real value is the one that uses current weight and does not round creatinine values below 1 mg/dL. It is suggested to conduct a prospective analysis, determining other variables that could affect CrCl real measures, and to replicate this methodology in specific populations (AU)

Objetivo: analizar el efecto de las modificaciones en la fórmula de Cockcroft-Gault en la medición del aclaramiento de creatinina (CrCl) y su concordancia con el valor real calculado con la orina de 24 horas en una muestra de pacientes latinoamericanos hospitalizados en San José de Costa Rica. Método: estudio observacional, retrospectivo, con pacientes en quienes se midió la creatinina sérica en orina de 24 horas y que cumplieran los criterios de inclusión. Se determinaron los valores de aclaramiento de creatinina reales y calculados, y se estableció la concordancia entre estos, aplicando la prueba del Coeficiente de Correlación Intraclase; se realizó un análisis descriptivo de los datos. Resultados: un total de 507 pacientes (61% hombres), de los cuales se describió la edad (*ME = 60 años**DE = 17 años), estatura (*ME = 1,66 metros**DE = 0,09 metros), peso actual (*ME = 75 kg **DE = 15 kg), índice de masa corporal (*ME = 27,3 Kg/m2 **DE = 4,76 Kg/m2 ), y valores de aclaramiento endógeno (*ME = 69,72 ml/min **DE = 33 ml/min). Se obtuvo la mejor concordancia para la fórmula con valores de peso actual y creatinina sérica sin redondeo. Conclusiones: la aplicación de la fórmula de Cockcroft-Gault que mejor concuerda con el valor real es aquella que utiliza el peso actual y no redondea valores de creatinina inferiores a 1 mg/dL. Se sugiere realizar un análisis prospectivo, determinando otras variables que podrían afectar a la medición real del CrCl, y replicar la metodología en poblaciones específicas (AU)

Caracterización farmacoterapéutica de los anticoagulantes orales utilizados en pacientes hospitalizados / Characterization of oral anticoagulant prescription in patients hospitalized (Costa Rica)

Justificación: los anticoagulantes orales requieren una estricta farmacovigilancia; describir y analizar la utilización de estos medicamentos es importante para editar guías, recomendaciones y advertencias ante el uso de esta terapia, y así brindar al personal médico una herramienta de apoyo para su adecuada utilización. Métodos: se seleccionaron pacientes a quienes durante su estancia hospitalaria se les prescribiera algún anticoagulante oral. Se recolectó la información específica que facilitara el análisis. Para validar lo recopilado se utilizaron las guías del Colegio Americano de Cirujanos Torácicos y las guías americanas y europeas de los colegios de cardiología. Resultados: se recopiló la información de un total de 176 pacientes. Los especialistas que prescriben estos medicamentos son ortopedistas (40%), internistas (14%), cardiólogos (13%) e intensivistas (11%), para el tratamiento de tromboprofilaxis de accidente cerebrovascular, tromboprofilaxis postoperatoria, tratamiento del tromboembolismo pulmonar y de trombosis venosa profunda; el 84% de los pacientes que usó estos medicamentos, lo hizo en indicaciones aprobadas. Se reportó un 3,4% de sangrados. Conclusión: la mayoría de las prescripciones se realizaron de acuerdo con lo establecido por las guías; a pesar de esto, existe una evidente incongruencia con respecto a los exámenes solicitados y su monitorización. La mayor proporción de los sangrados reportados se asoció a warfarina; aún así, seguirá siendo el estándar para el manejo de este tipo de pacientes, hasta que se apruebe tratamientos de reversión para los nuevos anticoagulantes y métodos adecuados para su monitorización, en los casos que se requiera.

Background: Oral anticoagulants require a strict pharmacovigilance; it is important to describe and analyze use of these drugs in order to draft guidelines, recommendations and warnings, and thus provide medical personnel with a tool for their adequate use. Methods: Inpatients that received oral anticoagulants were selected and the specific information for this analysis was collected. The guidelines of the American College of Chest Physicians, as well as those of the American and European professional associations of cardiology were used. Results: Information from 176 patients was collected. The specialists that prescribe these drugs are orthopedists (40%), internal medicine (14%), cardiologists (13%) and intensive care (11%), for the treatment of stroke thromboprophylaxis, postoperative thromboprophylaxis, treatment of pulmonary embolism and deep vein thrombosis; 84% of the patients that used these drugs did so in approved prescriptions. Bleeding related to these drugs was reported in 3.4 % of the cases. Conclusion: Most prescriptions were administered according to the guidelines, despite this there is a clear inconsistency between tests ordered and their monitoring. Most bleeding reports were associated to warfarin, yet it remains the standard treatment for this kind of patients until reversion treatments for new oral anticoagulants and suitable methods for monitoring, when required, are approved.