Evidence of clinical and economic impact of pharmacist interventions related to antimicrobials in the hospital setting.

The purpose of this paper was to review the literature regarding the clinical and economic impact of pharmacist interventions (PIs) related to antimicrobials in the hospital setting. A PubMed literature search from January 2003 to March 2016 was conducted using the terms pharmacist* or clinical pharmacist* combined with antimicrobial* or antibiotic* or anti-infective*. Comparative studies that assessed the clinical and/or economic impact of PIs on antimicrobials in the hospital setting were reviewed. Outcomes were classified as: treatment-related outcomes (TROs), clinical outcomes (COs), cost and microbiological outcomes (MOs). Acceptance of pharmacist recommendations by physicians was collected. PIs were grouped into patient-specific recommendations (PSRs), policy, and education. Studies' risk of bias was analyzed using Cochrane's tool. Twenty-three studies were evaluated. All of them had high risk of bias. The design in most cases was uncontrolled before and after. PSRs were included in every study; five also included policy and four education. Significant impact of PI was found in 14 of the 18 studies (77.8%) that evaluated costs, 15 of the 20 studies (75.0%) that assessed TROs, 12 of the 22 studies (54.5%) that analyzed COs, and one of the two studies (50.0%) that evaluated MOs. None of the studies found significant negative impact of PIs. It could not be concluded that adding other strategies to PSRs would improve results. Acceptance of recommendations varied from 70 to 97.5%. Pharmacists improve TROs and COs, and decrease costs. Additional research with a lower risk of bias is unlikely to change this conclusion. Future research should focus on identifying the most efficient interventions.

Conciliación de la medicación en el paciente crítico / Medicines reconciliation in critically ill patients

OBJETIVO: La conciliación de la medicación se considera un elemento clave en la seguridad del paciente, no existiendo apenas datos sobre cómo afecta al paciente crítico. En este estudio, se evalúa un programa de conciliación en el paciente crítico liderado por el farmacéutico adscrito a la Unidad de Cuidados Intensivos (UCI).DISEÑO: Estudio prospectivo sobre los errores de conciliación en 50 pacientes. Ámbito: UCI médico-quirúrgica. PACIENTES: Se incluyó a todos los pacientes con estancia en UCI, excluyendo a los pacientes sin tratamiento habitual. INTERVENCIONES: La conciliación de la medicación se realizó en las primeras 24 h tras el ingreso en UCI. En caso de encontrar discrepancias, se contactó con el médico responsable. Variables principales: Se analizó la incidencia, tipo y gravedad de los errores, sus características, las intervenciones realizadas y su aceptación por el médico responsable. RESULTADOS: El 48% de los pacientes presentó algún error de conciliación. La omisión de fármacos supuso el 74% de los mismos, afectando principalmente a fármacos antihipertensivos (33%). El58% de los errores de conciliación corresponden a la categoría D de gravedad. Se realizaron sugerencias al prescriptor en el 98% de los pacientes con discrepancias, aceptándose el 81% de las intervenciones. CONCLUSIONES: Los errores de conciliación en UCI tienen una incidencia y características similares a los referenciados en pacientes no críticos, afectando a grupos terapéuticos de gran significación clínica. Nuestros datos apoyan la incorporación de los procesos de conciliación al cuidado habitual del paciente crítico. El farmacéutico adscrito a la unidad puede llevar a cabo el proceso adecuadamente. (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. CONCLUSIONS: The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately

OBJECTIVE: Medicines reconciliation plays a key role in patient safety. However, there is limited data available on how this process affects critically ill patients. In this study, we evaluate a program of reconciliation in critically ill patients conducted by the Intensive Care Unit's (ICU)pharmacist. DESIGN: Prospective study about reconciliation medication errors observed in 50 patients. Scope: ICU. PATIENTS: All ICU patients, excluding patients without regular treatment. INTERVENTIONS: Reconciliation process was carried out in the first 24 h after ICU admission. Discrepancies were clarified with the doctor in charge of the patient. Main variable: We analyzed the incidence of reconciliation errors, their characteristics and gravity, the interventions made by the pharmacist and their acceptance by physicians. RESULTS: A total of 48% of patients showed at least one reconciliation error. Omission of drugs accounted for 74% of the reconciliation errors, mainly involving antihypertensive drugs (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. CONCLUSIONS: The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately

[Medicines reconciliation in critically ill patients]. / Conciliación de la medicación en el paciente crítico.

OBJECTIVE: Medicines reconciliation plays a key role in patient safety. However, there is limited data available on how this process affects critically ill patients. In this study, we evaluate a program of reconciliation in critically ill patients conducted by the Intensive Care Unit's (ICU) pharmacist. DESIGN: Prospective study about reconciliation medication errors observed in 50 patients. SCOPE ICU PATIENTS: All ICU patients, excluding patients without regular treatment. INTERVENTIONS: Reconciliation process was carried out in the first 24h after ICU admission. Discrepancies were clarified with the doctor in charge of the patient. MAIN VARIABLE: We analyzed the incidence of reconciliation errors, their characteristics and gravity, the interventions made by the pharmacist and their acceptance by physicians. RESULTS: A total of 48% of patients showed at least one reconciliation error. Omission of drugs accounted for 74% of the reconciliation errors, mainly involving antihypertensive drugs (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. CONCLUSIONS: The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately.

Effects of hepatic function on vancomycin pharmacokinetics in patients with cancer.

Vancomycin is widely used in the prophylaxis and treatment of infections in neutropenic patients with cancer. The objective of this study was to analyze liver damage effects on vancomycin pharmacokinetics and determine the necessity for liver function evaluation when selecting vancomycin dosing schedules in these patients. A population pharmacokinetic analysis was performed using the global two-stage method. To this purpose serum vancomycin concentrations from 154 cancer patients were measured and individual vancomycin pharmacokinetic parameters were estimated by the Sawchuk and Zaske method. Mean and standard deviation of the vancomycin pharmacokinetic parameters were estimated for various subgroups of patients classified according to the degree of liver damage. Then a multiple linear regression analysis was performed to select the best predictive models for vancomycin clearance (Clvan) and steady state distribution volume (V). Results revealed that Clvan is not influenced by liver failure. Differences in V between patients with and without hepatic failure were initially observed, but these disappeared when patients with ascites were excluded. In conclusion, vancomycin dosing schedule does not need to be modified for patients with liver failure, with the exception of patients with ascites.

Cost-effectiveness analysis of tropisetron vs. chlorpromazine-dexamethasone in the control of acute emesis induced by highly emetogenic chemotherapy in children.

OBJECTIVE: To perform a cost-effectiveness analysis (CEA) between a standard antiemetic regimen-chlorpromazine + dexamethasone (CPM-DEX)- and a 5-HT3 receptor antagonist-tropisetron (TROP)--in the control of acute emesis induced by highly emetogenic chemotherapy in children, considering two analytic perspectives: hospital and patients. METHODS: The CEA was performed by constructing a decision tree, for both analytic perspectives, of the possible outcomes of treatment with TROP (single 0.2 mg/kg i.v.) or CPM (5-15 mg i.v. infusion for 3 doses) plus DEX (2 mg/m2 i.v. bolus i.v. x2). The patients were stratified by age in two groups (2-12 and 13-17). To estimate the probability of each endpoint at the decision tree we have taken as a base a trial developed in the Department of Pediatrics. Direct medical cost of primary therapy, failure, complications and side effects were included in the cost calculations. RESULTS: From patients' analytic perspective, TROP was more cost-effective than CPM-DEX for both groups of patients. Discrepancy between both analytic perspectives in 13-17 year-old patient's group was resolved in favour of the option chosen from the patients' analytic perspective (TROP). Sensitivity analysis showed the reliability of the results. CONCLUSIONS: 1. TROP was more cost-effective than CPM-DEX. 2. Taking into account the patients' analytic perspective is essential when we compare antiemetics pharmacoeconomically. 3. It seems necessary to increase the effectiveness of TROP in pediatric patients receiving highly emetogenic chemotherapy with strategies such as the addition of a steroid.

[Pharmacoeconomics of meropenem versus imipenem/cilastatin]. / Farmacoeconomía de meropenem versus imipenem/cilastatina.

The Pharmacy and Therapeutics Committee of our hospital regulates the use of antimicrobial drugs every year. With the coming into the market of the new antibiotic carbapenem meropenem, comparative meropenem, it was assigned to the Drug Information Center the elaboration of comparative report on the two antibiotics, including as well cost analysis. We have analyzed the activities to be made since an antimicrobial drug is purchased until it is administered. We have only assessed on the direct costs that differ in the two antibiotics that are: the pre-use preparation in the pharmacy service and the preparation and administration in hospital floors. We have classified the direct cost in: goods and services, purchases and supplies costs costs and staff costs. We have calculated the daily cost of both antibiotics in the treatment of serious infections and even in more serious, life threatening infections. On top of that, we have a reviewed the use of imipenem/cilastatin and meropenem in our hospital. The information obtained shows that the saving in serious infections is of 34.6% and of 4.5% in more serious infections with vital compromise. The Pharmacy and Therapeutic Commission taking into account the report elaborated, has considered convenient the choice of meropenem as a representative of carbapenem drugs.

Cost-evaluation model for clinical trials in a hospital pharmacy service.

A cost-evaluation model was applied to clinical trial protocols to estimate their cost for the hospital pharmacy service. The steps taken in the drug management of clinical research were identified. Fixed costs (common to all clinical trials) and variable costs (peculiar to each clinical trial) were determined for each step. The number of patients, the number of operations, the planned services (receptions, storage, drug dispensing), the timing and difficulty of the study (randomization) were included in the variable costs. The economic assessment of these items was based on the costs of the materials and means used, the cost of staff time and finally the cost of drug storage during the clinical trial. This model was applied to 24 clinical trials carried out in the University Clinic of Navarra. 83% of all pharmacy costs of a clinical trial were variable. Drug dispensing, stock management and return drugs account for 94% of the time expended. The approximate cost of the pharmacy providing investigational services was $1,766 per trial or $174 per patient. Drug storage costs were not an important source of expenditure among the variable costs (7.4%). The best way to determine the cost of a trial is to calculate the number of operations.

Computer-assisted antimicrobial-use monitoring.

The development and use of a hospital-pharmacy-based, computer-assisted antimicrobial monitoring program are described. In the pharmacy department of a teaching hospital in Spain, a manual system for collecting data on use of antimicrobial agents was replaced with a computer-assisted program that compiles data on culture and sensitivity results, the number of patients receiving antimicrobial or bacteriostatic agents (including combination therapy), and the specific agents used by hospital ward, clinical department, and physician. The antimicrobial report is reviewed daily by a pharmacist, and identified problems are discussed with the prescribing physician; about two hours per day is spent in this activity. Data for 1984 compiled by the computer program regarding the use of antimicrobial agents by group and by hospital ward and the relationship between cost and use of antimicrobial agents were evaluated. Based on the computer-generated data, guidelines for antibiotic use in surgical prophylaxis were proposed, and the pharmacy and therapeutics committee approved a new antibiotic policy that led to a reduction in the use of cephalosporins and to subsequent cost savings. Antimicrobial use at this hospital is similar to that reported at other institutions. In 1984 penicillins were the most commonly used agents, followed by aminoglycosides and cephalosporins. Antimicrobial agents accounted for 24.4% of all drug costs. This computer-assisted system of antimicrobial monitoring was used effectively to assess both individual patient therapy and overall antimicrobial use in a teaching hospital.