Medication-related problems during transfer from hospital to home care: baseline data from Switzerland.

Background The shift from inpatient to ambulatory care has resulted in an increase in home care patients. Little is known regarding medication safety associated with patient transfer from hospital to home care. Objective To evaluate medication-related problems in patients transferring from hospital to home care in Switzerland. Setting A non-for-profit home care organization in the city of Lucerne/Switzerland. Methods We conducted a prospective observational study, including patients aged ≥ 64 years and receiving ≥ 4 medications at hospital discharge. Two structured questionnaires assessing the transfer process were completed by home care nurses. Prescription quality was assessed using a PCNE Type 2b Medication Review. Main outcome measures The quality of the transfer process was measured comparing agreed-upon with reported parameters. Prescription quality was analyzed assessing the unambiguity of the prescription. Potentially inappropriate medications (Priscus® list), contraindications, duplications and interactions, and clinical pharmacist-identified potential medication-related problems were collected. Results Study patients (n = 100) received 8.6 ± 3.5 regularly administered medications. Only 5/100 patients had a complete set of written discharge information. At the time of the first visit, 13/100 patients had no written medication information available. Discharge medication prescriptions were clear to nurses in 62% of patients. In 20 patients, the required medications were unavailable, resulting in 19 medication errors. Assessment by a clinical pharmacist revealed only 33/100 patients had a clear discharge prescription. Of a total of 984 prescribed drugs, 16% were considered to be ambiguous, 22 (2.2%) were potentially inappropriate. 7/984 drugs were contraindicated, 8 were duplicates. Conclusion In addition to the known risk factors in patients transferring from hospital to home care (age, polymedication, multiple providers), 3 major problems impacted upon medication safety: fragmented communication, unreliable medication availability and a poor prescription quality. Clinical pharmacists are an important option to improve medication safety ass.

The scope of drug-related problems in the home care setting.

Introduction While drug-related problems (DRPs) in the inpatient setting are well known, the scope of these problems in home care has not been critically evaluated. Aim of the Review Our primary objective was to evaluate the incidence and demographics of DRPs in home care. Our specific aims were to characterize the rate of potentially inappropriate medications (PIMs), medication errors (MEs) and adverse drug events (ADEs) and to identify risk factors which contribute to DRPs in the home care setting. Methods Pubmed, Embase and CiNAHL databases were systematically searched from January 2000 to December 2016 for all publications which quantitatively characterized DRPs in the home care setting. Results The most commonly reported DRPs characterized in studies were PIMs (n = 16), MEs (n = 4) and the ME-subcategory medication-related discrepancies (n = 7). The frequency of PIMs ranged from 19.8 to 48.4%; up to 26% PIMs were considered severe. Polypharmacy (≥ 9 drugs) and increasing age were the most common risk factors for DRPs. Insufficient interdisciplinary teamwork and inconsistent performance of medication reviews were also risks factors for DRPs. Patients and/or caregivers were responsible for 42.3% of DRPs. Discussion Compared with acute inpatient care, DRPs are more frequently reported in home care. The rate of DRPs varies depending upon the reference used to define the problem. Conclusion Transfer of complete medical records and the use of an interdisciplinary team have the potential to reduce DRPs, including MEs, specifically when integrating a pharmacist providing regular medication review. Importantly, patients and informal caregivers must be significant partners with this interdisciplinary team.

Incidence and Risk Factors for Vancomycin Nephrotoxicity in Acutely Ill Pediatric Patients.

Background: Particularly with the current increased vancomycin dosing trends, the true risk of the agent's nephrotoxicity is not well characterized and remains of concern. Objective: To determine the incidence of vancomycin nephrotoxicity in acutely ill hospitalized children and to secondarily characterize the risk factors for this complication. Methods: A single-center retrospective cohort study conducted at UCSF Benioff Children's Hospital from June 2012 to June 2015. Inpatients 3 months to <19 years who received intravenous vancomycin for ≥48 hours were included. The primary outcome was incidence of nephrotoxicity, defined as an increase in serum creatinine by ≥50% from baseline. Univariate and multivariate analyses were conducted to identify risk factors for vancomycin nephrotoxicity. Results: A total of 291 patients (272 nonnephrotoxic and 19 nephrotoxic) were included in the analysis. Of the 19 patients, 12 (4.1%) were found to have moderate to severe toxicity. The median duration of therapy was 3 (3-5) and 4 (3-6) days for the group with "no nephrotoxicity" and "nephrotoxicity," respectively. The mean time for the serum creatinine to return to normal in patients with nephrotoxicity was 5.1 days. In the multivariate analysis, only final trough concentration ≥15mg/dL (odds ratio = 3.49, 95% confidence interval = 1.2-10.1; P = .021) and receipt of piperacillin/tazobactam (odds ratio = 3.14, 95% confidence interval = 1.02-9.6; P = .046) were significantly associated with nephrotoxicity. Conclusion: The rate of moderate to severe vancomycin-associated nephrotoxicity in acutely ill children is relatively uncommon and reversible. Kidney injury is associated with increased vancomycin trough concentrations and concomitant receipt of nephrotoxins, particularly piperacillin/tazobactam.

Assessment of blood-brain barrier penetration of miltefosine used to treat a fatal case of granulomatous amebic encephalitis possibly caused by an unusual Balamuthia mandrillaris strain.

Balamuthia mandrillaris, a free-living ameba, causes rare but frequently fatal granulomatous amebic encephalitis (GAE). Few patients have survived after receiving experimental drug combinations, with or without brain lesion excisions. Some GAE survivors have been treated with a multi-drug regimen including miltefosine, an investigational anti-leishmanial agent with in vitro amebacidal activity. Miltefosine dosing for GAE has been based on leishmaniasis dosing because no data exist in humans concerning its pharmacologic distribution in the central nervous system. We describe results of limited cerebrospinal fluid (CSF) and serum drug level testing performed during clinical management of a child with fatal GAE who was treated with a multiple drug regimen including miltefosine. Brain biopsy specimens, CSF, and sera were tested for B. mandrillaris using multiple techniques, including culture, real-time polymerase chain reaction, immunohistochemical techniques, and serology. CSF and serum miltefosine levels were determined using a liquid chromatography method coupled to tandem mass spectrometry. The CSF miltefosine concentration on hospital admission day 12 was 0.4 µg/mL. The serum miltefosine concentration on day 37, about 80 h post-miltefosine treatment, was 15.3 µg/mL. These are the first results confirming some blood-brain barrier penetration by miltefosine in a human, although with low-level CSF accumulation. Further evaluation of brain parenchyma penetration is required to determine optimal miltefosine dosing for Balamuthia GAE, balanced with the drug's toxicity profile. Additionally, the Balamuthia isolate was evaluated by real-time polymerase chain reaction (PCR), demonstrating genetic variability in 18S ribosomal RNA (18S rRNA) sequences and possibly signaling the first identification of multiple Balamuthia strains with varying pathogenicities.

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

Direct observation was used to detect medication errors and Bar Code Medication Administration (BCMA) workarounds on two pediatric units and one neonatal unit at UCSF Benioff Children's Hospital. The study (1) measured the frequency of nursing medication administration-related errors, (2) characterized the types of medication errors, (3) assessed compliance with the institution's six medication administration safety processes, and (4) identified observed workarounds following BCMA implementation. The results of the direct observation were compared to medication administration-related incident reports (IRs) for the same period. The frequency of medication errors was 5% for the three units. Compliance with the process measures was achieved 86% of the time (range 23-100%). Seven medication administration-related IRs were submitted during the same observation period. Three BCMA workarounds were identified; (1) failure to visually confirm patient's identification, (2) failure to compare the medication to the electronic medication administration record at least twice before administration, and (3) charting administration of medication before actual administration. The direct observation methodology identified a low frequency of medication administration errors (MAEs) consistent with post-BCMA implementation. The incident reporting system identified different MAEs than direct observation suggesting that both methods should be used to better characterize the scope of MAEs.

Patterns of antibacterial use and impact of age, race/ethnicity, and geographic region on antibacterial use in an outpatient medicaid cohort.

STUDY OBJECTIVES: To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors-age, race/ethnicity, state county, and population density-on those patterns. DESIGN: Retrospective analysis of administrative claims data. DATA SOURCE: Medi-Cal fee-for-service system claims database. PATIENTS: All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim. MEASUREMENTS AND MAIN RESULTS: Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial/ethnic, and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = -0.971, p=0.0012; τ-b = -1.00, p=0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ(2) (2) = 320,000, p<0.001); among racial/ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ(2) (5) = 197,000, p<0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1-28.2%) to 32.7% (95% CI 32.6-32.8%) over the study period. Senior age groups and whites received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5-54.3%] and 36.6% [95% CI 36.6-36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = -0.432, p=0.0018) and broad-spectrum antibacterial prescribing (ρ = -0.359, p<0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent. CONCLUSION: Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial/ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.

Ethanol locks in the prevention and treatment of catheter-related bloodstream infections.

OBJECTIVE: To evaluate the evidence regarding the use of ethanol lock therapy (ELT) for catheter-related bloodstream infection (CRBSI) prophylaxis and treatment. DATA SOURCES: A literature search was conducted using PubMed (August 2003-January 2013) with search terms: ethanol lock, ethanol locks, ethanol lock therapy, prophylaxis, prevention, catheter-related bloodstream infection, and catheter-related infection. Additional sources were identified through a subsequent review of relevant articles. STUDY SELECTION AND DATA EXTRACTION: All English-language studies with >1 patient and a primary outcome of rates of infection, clinical cure, catheter removal or line salvage were evaluated. Studies where ELT was not used for CRBSI prophylaxis or treatment, review articles, and in vitro studies were excluded. Data were abstracted through an independent review of all articles by 2 authors. Discrepancies were discussed and resolved. DATA SYNTHESIS: 13 prophylaxis studies evaluated 617 patients; all studies reported decreased rates of infection and catheter removal with ELT. The ELT regimen associated with the most consistent benefit was 70% ethanol, a 2- to 4-hour dwell time, and daily exchange for ≥1 month. 9 treatment studies evaluated 213 catheters, with 90% (192/213) cure and 84% (179/213) line salvage. ELT was always used in combination with systemic antibiotics. The most common ELT treatment regimen was 70% ethanol, a 12- to 24-hour dwell time, and a duration of 1-5 days. No serious adverse events were reported. CONCLUSION: The current literature suggests that prophylactic ELT decreases the rates of infection and catheter removal, and ELT treatment appears efficacious in combination with systemic antibiotics.

Desired vancomycin trough serum concentration for treating invasive methicillin-resistant Staphylococcal infections.

Vancomycin area under the curve/minimal inhibitory concentration (AUC/MIC) >400 best predicts the outcome when treating invasive methicillin-resistant Staphylococcus aureus infection; however, trough serum concentrations are used clinically to assess the appropriateness of dosing. We used pharmacokinetic modeling and simulation to examine the relationship between vancomycin trough values and AUC/MIC in children receiving vancomycin 15 mg/kg every 6 hours and methicillin-resistant Staphylococcus aureus MIC of 1 µg/mL. A trough of 7-10 µg/mL predicted achievement of AUC/MIC >400 in >90% of children.

Gentamicin pharmacokinetics and dosing in neonates with hypoxic ischemic encephalopathy receiving hypothermia.

STUDY OBJECTIVE: To evaluate the pharmacokinetics of gentamicin in neonates with hypoxic ischemic encephalopathy (HIE) receiving hypothermia and to identify an empiric gentamicin dosing strategy in this population that optimizes achievement of target peak and trough concentrations. DESIGN: Population pharmacokinetic study using retrospective medical record data. SETTING: Tertiary neonatal intensive care unit. PATIENTS: A total of 29 full-term neonates diagnosed with HIE treated with hypothermia who received gentamicin and underwent therapeutic drug monitoring MEASUREMENT AND MAIN RESULTS: Patient demographics and gentamicin concentration data were retrospectively collected over a 2-year period. A population-based pharmacokinetic model was developed using nonlinear mixed-effects modeling (NONMEM). Using the developed model, Monte Carlo simulations were performed to evaluate the probability of achieving target peak (> 6 mg/L) and trough (< 2 mg/L) gentamicin concentrations for various potential dosing regimens. A one-compartment model best described the available gentamicin concentration data. Birthweight and serum creatinine significantly influenced gentamicin clearance. For the typical study neonate (birthweight 3.3 kg, serum creatinine 0.9 mg/dl), clearance was 0.034 L/hour/kg and volume was 0.52 L/kg. At a 24-hour dosing interval, Monte Carlo simulations predicted target gentamicin peak and trough concentrations could not be reliably achieved at any dose. At a 36-hour dosing interval, a dose of 4-5 mg/kg is predicted to achieve target gentamicin peak and trough concentrations in more than 90% of neonates. CONCLUSIONS: Gentamicin clearance is decreased in neonates with HIE treated with hypothermia compared with previous reports in nonasphyxiated normothermic full-term neonates. A prolonged 36-hour dosing interval will be needed to achieve target gentamicin trough concentrations in this population. Further prospective evaluation of this dosing recommendation is needed.

Co-administration of a commonly used Zimbabwean herbal treatment (African potato) does not alter the pharmacokinetics of lopinavir/ritonavir.

OBJECTIVE: African potato (Hypoxis obtusa) is commonly used in Sub-Saharan Africa as a complementary herbal remedy for HIV-infected patients. It is unknown whether or not co-administration of African potato alters the pharmacokinetics of protease inhibitor antiretrovirals. The objective of this study was to investigate the impact of the African potato on the steady-state pharmacokinetics of ritonavir-boosted lopinavir (LPV/r). METHODS: Sixteen adult volunteers were administered LPV/r 400/100 mg twice a day for 14 days, followed by concomitant administration with African potato given once daily for 7 days. Lopinavir plasma exposure as estimated by the area under the concentration-time curve over the 12-h dosing interval (AUC(0-12h), AUCτ) was determined on day 14 and again on day 21. Lopinavir in plasma was analyzed using a validated liquid chromatography with tandem mass spectrometry (LC-MS/MS) method. Steady-state AUCτ and the maximum concentration following dose administration (C(max)) were determined using non-compartmental methods using WinNonlin Professional version 5.2.1. Statistical analyses were performed using Stata version 12.1. RESULTS: Co-administration of African potato was not associated with any change in lopinavir AUCτ, C(max), or C(trough). CONCLUSIONS: African potato when taken concomitantly with LPV/r is well-tolerated and not associated with clinically significant changes in lopinavir pharmacokinetics.

Impact of a pharmacist-driven protocol to improve drug allergy documentation at a university hospital.

BACKGROUND: An internal evaluation of the inpatient pharmacy order entry database (WORx) at a university hospital revealed that the nature of the reaction was documented for only 47% of patients with reported drug allergies/intolerance. Insufficient documentation of drug allergy/intolerance may result in administration of drugs that should not be prescribed. Similarly, valuable agents that should be used may not be prescribed due to an unnecessary fear of adverse drug reaction. More complete description of drug allergy/intolerance may result in more correct prescribing of medications. OBJECTIVE: Evaluate the impact of a pharmacist-driven protocol on the quality of drug allergy/intolerance documentation. METHODS: Four pre-intervention evaluations were conducted every 2 weeks documenting the completeness of drug allergy/intolerance information in the pharmacy order entry database. One week following the implementation of a pharmacist-driven protocol intended to improve the completeness of drug allergy/intolerance information, a series of 4 postintervention evaluations was repeated. Proportional analysis of pre- and postinterventional data was performed to evaluate the effectiveness of the intervention. RESULTS: A total of 1,686 allergies from 2,174 patients were reviewed pre and post intervention. The frequency of complete drug allergy/intolerance documentation pre intervention was 52% to 62%. Following implementation of the hospitalwide, pharmacist-driven protocol, this rate increased to 60% to 76%. Pediatric services demonstrated the most substantial improvement, increasing from 53% to 79% to 67% to 93%. Blank reaction fields decreased by 10% in both age groups. CONCLUSION: A pharmacy-driven initiative intended to improve the completeness of drug allergy/intolerance documentation was associated with modest success. Other mechanisms, including electronic health record systems with computerized physician order entry and decision support, are needed to improve the completeness of drug allergy/intolerance information.

Improved antiretroviral refill adherence in HIV-focused community pharmacies.

OBJECTIVE: To determine differences in patient characteristics, antiretroviral therapy (ART) regimen characteristics, and regimen refill adherence for human immunodeficiency virus (HIV)-focused pharmacy (HIV-P) versus traditional pharmacy (TP) users. DESIGN: Retrospective cohort study. SETTING: California Walgreens pharmacies from May 2007 to August 2009. PARTICIPANTS: HIV-positive patients with greater than 30 days of antiretroviral prescription claims. INTERVENTION: Deidentified prescription records for patients filling any ART prescription at any California Walgreens pharmacy during the study period were assessed. MAIN OUTCOME MEASURES: ART regimen refill adherence (calculated by modified medication possession ratio [mMPR]) and dichotomous measure of optimal adherence of 95% or greater. RESULTS: 4,254 HIV-P and 11,679 TP users were included. Compared with TP users, HIV-P users traveled farther to pharmacies (5.03 vs. 1.26 miles, P < 0.01). A greater proportion of HIV-P users filled prescriptions for chronic diseases (35% vs. 30%) and received fixed-dose combination antiretroviral tablets (92% vs. 83%) (all P < 0.01). Median mMPR was higher for HIV-P users (90% vs. 77%, P < 0.0001). After adjusting for age, gender, insurance, medication use, and distance from pharmacy, use of HIV-P (odds ratio 1.90 [95% CI 1.72-2.08]) and fixed-dose combination antiretroviral tablets (3.34 [2.84-3.96]) were most strongly associated with having 95% or greater ART regimen refill adherence. CONCLUSION: For HIV-positive patients struggling with antiretroviral adherence, clinicians may consider minimizing pill burden with combination tablets and referral to an HIV-focused pharmacy.

Impact of HIV-specialized pharmacies on adherence and persistence with antiretroviral therapy.

Patient adherence (the degree to which patients follow their therapeutic regimen as prescribed within a set period of time) and persistence (the time to treatment discontinuation, with a permissible gap) with drug therapy are essential components of HIV/AIDS treatment. Select community pharmacies offer specialized services for HIV/AIDS patients to help combat some of the barriers to adherence and persistence. We assessed adherence and persistence with antiretroviral therapy (ART) for patients using HIV-specialized pharmacies in nine cities from seven states compared to traditional community pharmacy users over a 1-year period. Data were limited to one pharmacy chain. Propensity scoring was used to obtain 1:1 matches for "Specialized" and "Traditional" pharmacy users based on age, gender, number of prescription-inferred chronic conditions (obtained by mapping a patient's prescriptions to the Medi-Span Drug Indications Database), and presence of prescription anxiety and/or depression medication, resulting in 7064 patients in each group. Proportion of days covered (PDC) was used to measure adherence. Specialized pharmacy users had a significantly greater mean (74.1% versus 69.2%, p<0.0001) and median (90.3% versus 86.3%, p<0.0001) PDC. A greater percentage of patients in the Specialized group were able to obtain a PDC of 95% or better (39.3% versus 35.5%). Patients in the Specialized group were significantly more persistent (p=0.0117). Community pharmacies specialized in HIV services may be effective avenues for helping patients achieve greater adherence and persistence with ART. Given the value of specialized community pharmacies, payers should consider implementing policies to encourage the use of such pharmacies for filling ART.

Short term impact of guidelines on vancomycin dosing and therapeutic drug monitoring.

BACKGROUND: After medical center implementation of 2009 ASHP/IDSA guidelines, we evaluated the appropriateness of vancomycin dosing and TDM. OBJECTIVE: Our primary objectives were to assess short term effects on (1) appropriateness of initial vancomycin dosing, (2) appropriateness of sampling of plasma levels, before and after implementation of guidelines. METHOD: The study was conducted in two phases, pre-guideline and post-guideline implementation. The interventions included (1) Nurses and phlebotomist education regarding the appropriate timing of vancomycin sampling, (2) A nomogram for appropriate initial dosing that was distributed to medical staff. Patient demographics, dosing and timing of sampling were collected in eligible patients and assessed for appropriateness. RESULTS: The appropriateness of the prescribed dose increased from 51% (128/253) of patients during the pre period to 78% (155/200) (p < 0.0001) during the post period. Similarly, overall appropriateness of sampling of vancomycin troughs at steady state improved from 36% (63/173) pre to 55% (106/191) (p < 0.03) post. Specifically, the appropriate timing of troughs (within 30 min of the next dose) increased from 37% (64/173) during the pre period to 78% (149/191) during the post period (p < 0.0001). Conclusion Adoption of the guidelines with associated training resulted in significant short term improvement in vancomycin dosing and TDM.

A critical appraisal of and recommendations for faculty development.

The 2009-2010 American Association of Colleges of Pharmacy (AACP) Council of Faculties Faculty Affairs Committee reviewed published literature assessing the scope and outcomes of faculty development for tenure and promotion. Relevant articles were identified via a PubMed search, review of pharmacy education journals, and identification of position papers from major healthcare professions academic organizations. While programs intended to enhance faculty development were described by some healthcare professions, relatively little specific to pharmacy has been published and none of the healthcare professions have adequately evaluated the impact of various faculty-development programs on associated outcomes.The paucity of published information strongly suggests a lack of outcomes-oriented faculty-development programs in colleges and schools of pharmacy. Substantial steps are required toward the development and scholarly evaluation of faculty-development programs. As these programs are developed and assessed, evaluations must encompass all faculty subgroups, including tenure- and nontenure track faculty members, volunteer faculty members, women, and underrepresented minorities. This paper proposes AACP, college and school, and department-level recommendations intended to ensure faculty success in achieving tenure and promotion.