Empiric management of cyanide toxicity associated with smoke inhalation.

Enclosed-space smoke inhalation is the fifth most common cause of all unintentional injury deaths in the United States. Increasingly, cyanide has been recognized as a significant toxicant in many cases of smoke inhalation. However, it cannot be emergently verified. Failure to recognize the possibility of cyanide toxicity may result in inadequate treatment. Findings suggestive cyanide toxicity include: (1) a history of an enclosed-space fire scene in which smoke inhalation was likely; (2) the presence of oropharyngeal soot or carbonaceous expectorations; (3) any alteration of the level of consciousness, and particularly, otherwise inexplicable hypotension (systolic blood pressure ≤90 mmHg in adults). Prehospital studies have demonstrated the feasibility and safety of empiric treatment with hydroxocobalamin for patients with suspected smoke inhalation cyanide toxicity. Although United States Food and Drug Administration (FDA)-approved since 2006, the lack of efficacy data has stymied the routine use of this potentially lifesaving antidote. Based on a literature review and on-site observation of the Paris Fire Brigade, emergency management protocols to guide empiric and early hydroxocobalamin administration in smoke inhalation victims with high-risk presentations are proposed.

Call to action: Integrating student pharmacists, faculty, and pharmacy practitioners into emergency preparedness and response.

OBJECTIVES: To describe the pharmacist experience in emergency preparedness and response and to provide information and resources to help practitioners engage in this public health effort in their local communities. SETTING: Spokane, WA, health care community, 1998 through 2009. PRACTICE DESCRIPTION: The College of Pharmacy at Washington State University, Spokane, has developed partnerships with local public health and community providers to address emergency preparedness and response needs. Working through the Metropolitan Medical Response System has created opportunities to participate in emergency preparedness planning and exercises. Collaboration with local agencies has provided opportunities for faculty and student pharmacists to respond to meet emergency needs in the community. PRACTICE INNOVATION: Emergency preparedness and response education, training, and service implemented in partnership with public health and community providers prepared student pharmacists and experienced pharmacy practitioners to respond to emergency needs in our community. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Not applicable. CONCLUSION: Colleges and schools of pharmacy can take a lead in preparing student pharmacists for this role by incorporating emergency preparedness training into curricula. Community pharmacists can develop their knowledge and skills in emergency preparedness through individualized continuing education plans and integration into community teams through volunteerism. Partnerships developed with local public health and emergency response agencies provide opportunities for pharmacists to become integral members of planning and response teams. Training exercises provide opportunities to test preparedness plans and provide professional education and experience. Actual emergency response activities demonstrate the value of the pharmacist as an important member of the emergency response team.

Dalbavancin for the management of gram-positive osteomyelitis: Effectiveness and potential utility.

Dalbavancin is approved by the US Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections. It has promising pharmacokinetic/pharmacodynamic profiles in treating bone infections and safety data after multiple weekly dosing. The primary objective of this study is to describe the effectiveness and tolerability of dalbavancin in the treatment of osteomyelitis in adults. This study is a multicenter retrospective review, designed to identify patients with osteomyelitis who were treated with dalbavancin. Thirty-six patients with confirmed diagnosis of osteomyelitis who received dalbavancin were identified. Thirty-one patients met inclusion criteria for evaluation of clinical success at the end of the antibiotic course and 3 months after the completion of therapy. Twenty-eight (90%) patients achieved clinical success and there were no adverse events noted. Dalbavancin appears to be safe and effective in the treatment of osteomyelitis. More studies are needed to validate these findings.

Training student pharmacists to administer emergency pediatric influenza vaccine: A comparison of traditional vs. just-in-time training.

INTRODUCTION: This study compared traditional training (TT) and just-in-time training (JITT) of P3 student pharmacists regarding interest, confidence, and comfort pre- and post-training (primary objective); and assessment and administration competency (secondary objective) during a simulated influenza vaccination clinic. METHODS: Student pharmacists were randomized 1:1 to receive either TT or JITT, completed pre- and post-training surveys assessing interest, confidence and comfort; and evaluated on performance during a simulated emergency infant vaccination. An infant manikin simulated a child <1 year of age, and an actor role-played the mother. All students received a briefing about the simulated mass vaccination prior to their performance assessment. Survey differences between groups were analyzed by ANOVA. The competency assessment was analyzed by a Chi-square or Fisher's exact test for individual steps and Student t-test for mean scores. RESULTS: Pre-training interest was high and maintained post-training. Pre-training confidence and comfort levels were low and improved in both groups. Mean competency scores were comparable between the TT and JITT groups. Comparing groups, TT students more commonly missed proper injection site selection and care; while JITT missed distracting the infant and administration documentation. DISCUSSION AND CONCLUSIONS: JITT for student pharmacists to learn skills required to immunize infants elicits similar outcomes (interest, confidence, comfort, and administration competency) as TT for emergency pediatric influenza vaccination.

Antibiotic selection and resistance issues with fluoroquinolones and doxycycline against bioterrorism agents.

Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia), Coxiella burnetti (Q fever), and Brucella sp (brucellosis) are all potential bioterrorism agents. Their known virulence, potential lethality, and ability to develop resistance to known antibiotic treatments make these pathogens particularly dangerous. We reviewed the scientific literature by searching MEDLINE databases and published abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infectious Diseases Society of America from 1989-2005 for studies of each of these biologic agents with the specific aim of examining whether doxycycline or a fluoroquinolone should be stockpiled for mass-scale postexposure prophylaxis. An evidence-based approach was used to determine whether doxycycline or fluoroquinolones were efficacious (both in vitro and in vivo) against these biologic agents and to examine these drugs' respective susceptibility patterns and differences in cost, based on available data. Little published data are available on these pathogens, and much of the data are from studies that used older strains obtained from patient or animal sources in outbreaks decades ago. Doxycycline appears to show comparable minimum inhibitory concentrations to those of the fluoroquinolone class in most clinical and in vitro studies, perhaps with the exception of inhalation plague. Studies also suggest that development of antibiotic resistance is less likely to occur with doxycycline. Doxycycline is several-fold less expensive than most fluoroquinolones and appears to have similar efficacy in most scenarios based on clinical case studies and established Clinical and Laboratory Standards Institute (formerly known as the National Committee for Clinical Laboratory Standards) breakpoints for staphylococci. Therefore, doxycycline should be considered as a first-line antibiotic in the management of bioterrorism agents.

Bioterrorism: pivotal clinical issues. Consensus review of the Society of Infectious Diseases Pharmacists.

OBJECTIVES: To discuss specific facts regarding use as a bioweapon, epidemiology, microbiology, clinical manifestations, diagnosis, antimicrobial therapy, immunization, and isolation precautions for five most likely agents of bioterrorism; to review and provide recommendations for health care clinicians on the management of these bioterrorism agents; and to share information on the pharmacist's role in preparedness and response. PARTICIPANTS: The manuscript was drafted by the three authors, reviewed by a group of selected members of the Society of Infectious Diseases Pharmacists, and approved by its Board of Directors. EVIDENCE: The primary focus was to review and summarize recent and key articles on bioterrorism. Preference was given to peer-reviewed journal information and government-sponsored journals, such as the MMWR, Morbidity and Mortality Weekly Report. CONSENSUS PROCESS: Written comments were requested from each reviewer. Comments were incorporated into the final draft. CONCLUSION: Pharmacists play an integral role in disaster preparedness and response and should be involved in planning committees. As drug information specialists, pharmacists can assist other health care providers and emergency personnel, as well as provide counseling to calm, comfort, and empower the public.