Intermittent hemodialysis: a review of the top antimicrobial stewardship practices to be employed.

The vulnerability of patients on hemodialysis (HD) to infections is evident by their increased susceptibility to infections in general and to resistant organisms in particular. Unnecessary, inappropriate, or suboptimal antimicrobial prescribing is common in dialysis units. This underscores the need for dedicated antimicrobial stewardship (AMS) interventions that can be implemented both in the inpatient and outpatient settings. In this review, we provide a comprehensive approach for clinicians with the most updated coordinated AMS principles in HD setting in six areas: prevention, diagnosis, treatment, education and empowerment, monitoring, and research.

Anti-tuberculosis drug-induced hepatitis in renal transplant patient with pulmonary and extra pulmonary tuberculosis.

Hepatotoxicity is a major side-effect of the medicines used in tuberculosis therapy. Although the guidelines for the management of antituberculosis drug induced hepatitis have been published from varieties of health institutes and organizations, they are to a great extent highly similar, there are nevertheless some important differences. We report a case of hepatitis in a renal transplant recipient admitted with pulmonary and extra pulmonary (abdominal) tuberculosis and review the literature on this topic. The introduction of antimicrobial teams, including specialist pharmacists, microbiologists and infectious disease physicians, is a major factor to improve the quality of care and faces the overcoming of antimicrobial resistance. Reintroducing one antituberculosis drug at a time with close monitoring of liver enzymes seems to be the optimal approach in the management of antituberculosis drug induced hepatitis. With multi-disciplinary clinical approach the patient has been successfully cured and has returned to normal active life.

Clinical Audit of Pharmaceutical Care provided by a Clinical Pharmacist in Cardiology and Infectious Disease in-patients at the Royal Hospital, Muscat/Oman.

OBJECTIVES: To characterise the pharmaceutical care provided by a clinical pharmacists working in a tertiary health care institute, where the extent to which the pharmacist contributes to changes in prescribing patterns use of medications, and patient knowledge was described. METHODS: A retrospective single cohort study design was used. Qualitative and quantitative evaluation of a documented pharmaceutical care plan was undertaken. Electronic pharmaceutical care descriptor (Microsoft Access® database) was used for analysis. 167 patients [mean age of 53 yrs, 70% male] from a Medical Health Centre in a tertiary hospital where a clinical pharmacist had provided a medication review. The study patients were those who had either been admitted to cardiology or infectious disease wards. RESULTS: There were 291 pharmaceutical care issues [PCIs; mean per patient (2)] comprising of 67% (n=194) relating to treatment monitoring and 33% (n=97) relating to treatment changes, representing a total of 291 drug therapy problems [DTPs; mean per patient (2)]. The resolution rate of DTPs was 70%, where 61% of recommended changes and 75% of recommended monitoring were implemented. CONCLUSION: The clinical pharmacist successfully addressed most PCIs while attending ward rounds, reviewing in-patient prescriptions and counselling discharged patients. The electronic pharmaceutical care plan was very effective in recording the pharmacist's ward activities and the pharmaceutical care provided. However, further studies are required in order to explore long-term clinical pharmacists in-put using a well established electronic care plan; part of Al-Shifa computer system in Omani health centres.

A Study of Prescribing Valsartan in Out-patient Clinics at the Royal Hospital, Muscat, Oman.

OBJECTIVES: Angiotensin Receptor Blockers such as Valsartan, are a newer class of drugs associated with significant reductions in cardiovascular morbidity and mortality. They are commonly used in hypertension, chronic heart failure, diabetes-related nephropathy and post-myocardial infarction in patients who are intolerant to Angiotensin Converting Enzyme inhibitors (ACEi). A review of medicines used in Royal Hospital (an Omani tertiary health care centre) during 2004 and 2005 showed that Valsartan was one of 20 most expensive drugs used. The main objective of this study was to evaluate the pattern of prescribing valsartan in out-patient clinics. METHODS: a retrospective study, applying medicines use evaluation, to describe the pattern of prescribing Valsartan in comparison with international guidelines. The study carried out in the outpatient pharmacy setting, Royal Hospital from 15th May to 30th June 2006. It included 120 adult patients who had been prescribed Valsartan at the outpatient clinics during the study period. RESULTS: among the 120 patients only 109 patients were finally included in the study. Elevenpatients who had had duplicated prescriptionswere excluded from the study. 78% of the patients were on Valsartan for its FDA-approved indications while 22% of patients were for other non-approved indications. Half of the patients were initiated on an ACEi before shifting to Valsartan. The other half of the patients was started with Valsartan as a first line choice without any clinical justification. CONCLUSION: The study showed that half of the patients were initiated on Valsartan without being prescribed an ACEi prior to that, while the recommendation in most of the international guidelines based on indication stated that ARBs are used in patients who are intolerant to ACEi. The study emphasizes the need for further research to highlight the need for developing national guidelines and adhering to these guidelines for rational prescribing.