Economic impact of treatment for surgical site infections in cases of total knee arthroplasty in a tertiary public hospital in Brazil

The aim of this study was to estimate the additional cost of treatment of a group of nosocomial infections in a tertiary public hospital. A retrospective observational cohort study was conducted by means of analyzing the medical records of 34 patients with infection after total knee arthroplasty, diagnosed in 2006 and 2007, who met the criteria for nosocomial infection according to the Centers for Disease Control and Prevention. To estimate the direct costs of treatment for these patients, the following data were gathered: length of hospital stay, laboratory tests, imaging examinations, and surgical procedures performed. Their costs were estimated from the minimum values according to the Brazilian Medical Association. The estimated cost of the antibiotics used was also obtained. The total length of stay in the ward was 976 days, at a cost of US$18,994.63, and, in the intensive care unit, it was 34 days at a cost of US$ 5,031.37. Forty-two debridement procedures were performed, at a cost of US$5,798.06, and 1965 tests (laboratory and imaging) were also performed, at a cost of US$ 15,359.25. US$20,845.01 was spent on antibiotics and US$ 1,735.16 on vacuum assisted closure therapy, microsurgical flaps, implant removal, spacer use, and surgical revision. The total additional cost of these cases of hospital infection in 2006 and 2007 was of US$ 91,843.75. Based on that, we demonstrate that the high cost of treatment for hospital infections emphasizes the importance of taking measures to prevent and control hospital infection

Carbapenem stewardship: positive impact on hospital ecology

INTRODUCTION: Excessive group 2 carbapenem use may result in decreased bacterial susceptibility. OBJECTIVE: We evaluated the impact of a carbapenem stewardship program, restricting imipenem and meropenem use. METHODS: Ertapenem was mandated for ESBL-producing Enterobacteriaceae infections in the absence of non-fermenting Gram-negative bacilli (GNB) from April 2006 to March 2008. Group 2 carbapenems were restricted for use against GNB infections susceptible only to carbapenems and suspected GNB infections in unstable patients. Cumulative susceptibility tests were done for nosocomial pathogens before and after restriction using Clinical and Laboratory Standards Institute (CLSI) guide-lines.Vitek System or conventional identification methods were performed and susceptibility testing done by disk diffusion according to CLSI.Antibiotic consumption (t-test) and susceptibilities (McNemar's test) were determined. RESULTS: The defined daily doses (DDD) of group 2 carbapenems declined from 61.1 to 48.7 DDD/1,000 patient-days two years after ertapenem introduction (p = 0.027). Mean ertapenem consumption after restriction was 31.5 DDD/1,000 patient-days. Following ertapenem introduction no significant susceptibility changes were noticed among Gram-positive cocci. The most prevalent GNB were P. aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. There was no change in P. aeruginosa susceptibility to carbapenems. Significantly improved P. aeruginosa and K. pneumoniae ciprofloxacin susceptibilities were observed, perhaps due to decreased group 2 carbapenem use. K. pneumoniae susceptibility to trimethoprim-sulfamethoxazole improved. CONCLUSION: Preferential use of ertapenem resulted in reduced group 2 carbapenem use, with a positive impact on P. aeruginosa and K. pneumoniae susceptibility

Gram-negative osteomyelitis: clinical and microbiological profile

Introduction: Despite the growing interest in the study of Gram-negative bacilli (GNB) infections, very little information on osteomyelitis caused by GNB is available in the medical literature. Objectives and methods: To assess clinical and microbiological features of 101 cases of osteomyelitis caused by GNB alone, between January 2007 and January 2009, in a reference center for the treatment of high complexity traumas in the city of Sao Paulo. Results: Most patients were men (63%), with median age of 42 years, affected by chronic osteomyelitis (43%) or acute osteomyelitis associated to open fractures (32%), the majority on the lower limbs (71%). The patients were treated with antibiotics as inpatients for 40 days (median) and for 99 days (median) in outpatient settings. After 6 months follow-up, the clinical remission rate was around 60%, relapse 19%, amputation 7%, and death 5%. Nine percent of cases were lost to follow-up. A total of 121 GNB was isolated from 101 clinical samples. The most frequently isolated pathogens were Enterobacter sp. (25%), Acinetobacter baumannii (21%) e Pseudomonas aeruginosa (20%). Susceptibility to carbapenems was about 100% for Enterobacter sp., 75% for Pseudomonas aeruginosa and 60% for Acinetobacter baumannii. Conclusion: Osteomyelitis caused by GNB remains a serious therapeutic challenge, especially when associated to nonfermenting bacteria. We emphasize the need to consider these agents in diagnosed cases of osteomyelitis, so that an ideal antimicrobial treatment can be administered since the very beginning of the therapy. (C) 2012 Elsevier Editora Ltda. All rights reserved.Merck Sharp and DohmeMerck Sharp and Dohm

Adherence to the treatment with proton pump inhibitors in patients with gastroesophageal reflux disease

Introdução: A Doença do Refluxo Gastroesofágico (DRGE) possui elevada prevalência e morbidade. O tratamento clínico consiste em recomendações quanto ao estilo de vida e, essencialmente, no uso de inibidores da bomba protônica (IBP). A aderência (Ad) dos pacientes com DRGE à prescrição, embora fundamental para o sucesso terapêutico, tem sido pouco estudada. Objetivo: Avaliar a Ad ao tratamento com IBP e possíveis variáveis relacionadas em pacientes com DRGE. Métodos: Estudo transversal e prospectivo com 240 pacientes adultos consecutivos com DRGE erosiva e não-erosiva (ne-DRGE) que haviam recebido dose padrão ou dose dobrada de omeprazol em uso contínuo. Todos os pacientes foram classificados conforme o grau, segundo os achados da endoscopia digestiva alta (EDA) em ne-DRGE (162; 67,5%), classificação endoscópica de Los Angeles (LA) A (48; 20,0%), LA B (21; 8,6%), LA C (1; 0,4%), LA D (1; 0,4%) e Barrett (7; 2,9%). Foi aplicado o questionário de Morisky et al constituído de 4 questões com respostas dicotômicas para avaliar a Ad, classificando-a como baixa (0-2 pontos) e alta ad (3-4 pontos). Foi também aplicado o questionário QS-DRGE para a avaliação dos sintomas, com 10 questões com escores de 0 a 50, conforme a frequência menor ou maior dos sintomas. Os resultados de Ad foram relacionados com os dados sócio-demográficos, polifarmácia (PF) (uso de mais de cinco medicamentos diariamente), comorbidades (CM), tempo de tratamento (TT), escore QS-DRGE, presença de sintomas descrita em prontuário, achados da EDA e conhecimento do paciente sobre a doença. Resultados: (1) 126 pacientes (52,5%) apresentaram alta Ad e 114 (47,5%) baixa Ad; (2) Os pacientes mais jovens (p = 0,002) foram menos aderentes; (3) Pacientes sintomáticos de acordo com relato em prontuário apresentaram maior percentual de baixa Ad e 2 vezes maior probabilidade de ter baixa Ad em relação aos assintomáticos (p = 0,02); (4) Os pacientes casados apresentam probabilidade 2,41 vezes maior de ter baixa Ad do que os viúvos. (5) As demais variáveis estudadas não influenciaram a Ad ao tratamento. Conclusões: Pacientes em uso de IBP em tratamento ambulatorial em hospital terciário em São Paulo apresentaram grande percentual de baixa Ad ao tratamento, sendo esta uma possível causa da falha da terapia com IBP. Idade < 60 anos e estado civil casado podem ser fatores de risco para a baixa AdIntroduction: The Gastroesophageal Reflux Disease (GERD) is a highly prevalent disease and a major cause of morbidity. Clinical treatment is based on lifestyle recommendations and, essentially, in the use of a proton pump inhibitor (PPI). Adherence (Ad) of GERD patients to the prescribed treatment, although critical for therapeutic success, has been little studied. Objective: Assess adherence to the PPI treatment and potential associated variables in patients with GERD. Case studies and Methods: Transversal and prospective study with 240 consecutive adult patients, diagnosed with erosive GERD (e-GERD) and non-erosive GERD (ne-GERD) for whom continuous use of the standard dose or the double dose of omeprazol had been prescribed. Patients were ranked according to the findings of high digestive endoscopy (HDE) in ne-GERD (162; 67.5%); e-GERD: Los Angeles (LA) endoscopic classification A (48; 20.0%), LA B (21; 8.6%), LA C (1; 0.5%), and LA D (1; 0.5%) and Barretts esophagus (7; 2.9%). The Morisky questionnaire, that includes four questions with dicotomic responses to assess Ad, was applied. Ad was classified as low (0-2 points) and high (3-4 points). In addition, the QS-GERD questionnaire was applied to assess symptoms, using 10 questions with score 0 to 50, according to the greater or lesser symptom frequency. Ad results were correlated with personal data (gender and age), demography, polypharmacy (PF), comorbidities (CM), treatment time (TT), QS-GERD scores, symptoms described in the patients record, HDE findings and patient awareness about the disease. Results: (1) 126 patients (52.5%) exhibited high Ad and 114 (47.5%) low Ad; (2) younger patients (p = 0,002) were less compliant; (3) married patients had a 2.41 greater probability to exhibit low Ad as compared to widowers (p = 0.03); (4) patients with symptoms indicated in the patients record exhibited a lower Ad rate and twice greater probability of exhibiting low Ad as compared to asymptomatic patients (p = 0.02); (5) the other variables studied had no influence on treatment adherence. Conclusion: Patients using PPI as out-patients in third care hospital in São Paulo exhibited high rate of reduced treatment adherence, and this may be a potential cause of PPI therapy failure. Age < 60 years and marital status may be risk factors for low adherenc

Economic impact of pharmaceutical interventions in a medium complexity Brazilian university hospital

Clinical pharmacists have been increasing their participation mainly through actions aimed at patient care, with international studies demonstrating favorable cost-benefit ratio from pharmacists interventions. However, there are few studies carried out in Brazil about the subject. This study aims to assess the economic impact of pharmaceutical interventions (PIs) in a hospital setting performed in October 2018. Each performed PI was registered and associated with the direct cost of drugs for economic impact analysis. A total of 185 PIs were evaluated, comprising 106 patients. The most intervened drugs were antibiotics, presenting the greatest economic impact, R$2,370. The total economic impact was R$2,578, mainly in the Pediatric Intensive Care Unit that represented R$1,701. Regarding the economic impact by PI as the “Suspension of drug without indication” saved R$1,360 while the “Inclusion of required drugs” cost R$807. It was estimated that the savings would be R$30,936 and, if PIs were performed at day zero, the savings would be R$79,728 per year. An average of 1.75 PI per patient was performed with an economic impact of R$14 per PI. Our results showed that clinical pharmacist’s role in the evaluation of pharmacotherapy is important for patients’ health and represents a positive economic impact

Patient Factors Associated with Pharmaceutical Interventions for Inpatients at a Brazilian Teaching Hospital

Background: Pharmaceutical interventions aim to correct or prevent a drug-related problem (DRP) that might lead to negative clinical consequences and increase health care costs. Objective: To identify variables associated with the provision of pharmaceutical interventions by clinical pharmacists during hospitalization. Methods: In this retrospective cohort study, adult inpatients of the medical ward of the University Hospital of the University of São Paulo in São Paulo, Brazil, were followed from admission to discharge. Logistic regression models were used to evaluate the association between occurrence of at least 1 pharmaceutical intervention and the following baseline characteristics: sex, age, Charlson comorbidity index, renal failure, electrolyte imbalance, hemoglobin, platelet count, and use of a nasoenteric tube, as well as the number, second-level Anatomical Therapeutic Chemical (ATC) code, and administration route of prescribed medications. Results: A total of 148 patients were included in the study, of whom 75 (50.7%) were men. The mean age was 62.8 (95% confidence interval [CI] 59.9–65.8) years, and the mean length of the hospital stay was 10.7 (95% CI 8.4–13.1) days. Analgesics (ATC code N02), the most common type of medication, were prescribed to 144 (97.3%) of the patients. Pharmaceutical interventions were performed for only 49 (33.1%) of the patients. One out of every 4 of these interventions was intended to obtain information not provided in the prescription, to allow the prescription to be completed and dispensing to proceed. According to the multivariate analysis, the odds ratio (OR) of occurrence of at least 1 pharmaceutical intervention increased for patients with electrolyte imbalance (OR 2.68, 95% CI 1.09–6.63; p = 0.033), patients using 5 to 8 medications (OR 8.73, 95% CI 1.07–71.36; p = 0.043), patients using 9 or more medications (OR 10.39, 95% CI 1.28–84.05; p = 0.028), and patients using at least 1 systemic antibacterial (ATC code J01; OR 2.76, 95% CI 1.30–5.84; p = 0.008). Conclusions: The findings of this study could allow the identification, at the time of admission and possibly before the occurrence of a DRP, of patients at higher risk of requiring a pharmaceutical intervention later during their hospital stay. To optimize patient care, clinical pharmacists should closely follow inpatients with electrolyte imbalance, polypharmacy, and/or use of systemic antibacterials. RÉSUMÉ Contexte : Les interventions pharmaceutiques visent à corriger ou à prévenir un problème lié aux drogues (PLD), qui pourrait entraîner des conséquences cliniques négatives et accroître les coûts des soins de santé. Objectif : Déterminer les variables associées aux interventions pharmaceutiques des pharmaciens cliniques lors d’une hospitalisation. Méthodes : Dans cette étude de cohorte rétrospective, les patients adultes hospitalisés au Service de médecine de l’Hôpital universitaire de São Paulo au Brésil ont été suivis dès leur admission et jusqu’à leur sortie. Des modèles de régression logistique ont été utilisés pour évaluer l’association entre au moins une intervention pharmaceutique et les caractéristiques de base suivantes : sexe, âge, indice de comorbidité de Charlson, insuffisance rénale, déséquilibre électrolytique, hémoglobine, numération plaquettaire et utilisation d’un tube nasoentérique, et l’ensemble du groupe a subi une évaluation selon le nombre de médicaments prescrits au deuxième niveau des classifications du Système de classification anatomique thérapeutique chimique (ATC) et leur voie d’administration. Résultats : Cent-quarante-huit (148) patients ont été inclus dans cette étude; 75 d’entre eux (50,7 %) étaient des hommes. L’âge moyen était de 62,8 ans (95 % intervalle de confiance [IC] 59,9 - 65,8), et la durée moyenne du séjour à l’hôpital était de 10,7 jours (95 % IC 8,4 – 13,1). Des analgésiques (code ATC N02), type de médicament le plus répandu, ont été prescrits à 144 patients (97,3 %). Seuls 49 patients (33,1 %) ont fait l’objet d’une intervention pharmaceutique. Une de ces interventions sur quatre avait pour but d’obtenir des informations absentes dans la prescription mais indispensables à l’obtention de la validation de la prescription et de l’autorisation de distribution des médicaments. Selon l’analyse multivariée, le rapport de cotes (RC) de la nécessité d’au moins une intervention pharmaceutique augmentait pour les patients ayant un déséquilibre électrolytique (RC 2,68, 95 % IC 1,09 - 6,63; p = 0,033), les patients prenant entre cinq et huit médicaments (RC 8,73, 95 % IC 1,07 - 71,36; p = 0,043), les patients prenant au moins neuf médicaments (RC 10,39, 95 % IC 1,28 - 84,05; p = 0,028) et ceux utilisant au moins un antibactérien systémique (code ATC J01; RC 2,76, 95 % IC 1,30–5,84; p = 0,008). Conclusions : Les résultats de cette étude pourraient permettre d’identifier, à l’admission à l’hôpital et probablement avant l’apparition d’un PLD, les patients présentant des risques plus élevés, qui pourraient nécessiter une intervention pharmaceutique plus tard lors de leur séjour. Pour optimiser les soins aux patients, les pharmaciens cliniques doivent suivre étroitement les patients hospitalisés ayant un déséquilibre électrolytique, ceux qui nécessitent une polypharmacie et ceux qui utilisent des antibactériens systémiques

Pharmacist intervention classification systems: a systematic review protocol of the validity and methodological procedures

Pharmacist intervention (PI) is an important strategy for reducing the risks associated with pharmacotherapy. Thus, when properly developed and validated, PI classification systems can be useful for measuring the clinical, economic and humanistic impact of PIs. To date, there has been no systematic review of the literature describing the psychometric properties of the PI classification systems and the quality assessment of the validation studies. The proposed systematic review aims to identify and analyze PI classification systems in a hospital setting and to assess the validity and quality of the methodological procedures adopted

Medication reconciliation and adherence: a call for clinical pharmacist

Introduction and Objectives: With the population ageing, there is a growing number of people who have several comorbidities and make use of a variety of drugs. These factors lead to a greater predisposition to adverse drug events, as well as to medication errors. The clinical pharmacist is the most indicated health professional to target these issues. The aims of this study were to analyze the profile of medication reconciliation and assess the role of the clinical pharmacist regarding medication adherence. Material and Methods: Prospective observational cohort study conducted from Jan-Mar 2013 at the Surgical Clinic of the University Hospital of the University of Sao Paulo. 117 admitted patients - over the age of 18 years, under continuous medication use and with length of hospitalization up to 120h - were included. Discrepancies were classified as intentional/unintentional and according to their risk to cause harm, and interventions were divided into accepted/not accepted. Medication adherence was measured by Morisky questionnaire. Results and Conclusions: Only 30% of hospital prescriptions showed no discrepancies between the medications that the patient was using at home and those which were being prescribed at the hospital and more than one third of those had the potential to cause moderate discomfort or clinical deterioration. One third of total discrepancies were classified as unintentional. About 90% of the interventions were accepted by the medical staff. In addition, about 63% of patients had poor adherence to drug therapy. The study revealed the importance of the medication reconciliation at patient admission, ensuring greater safety and therapeutic efficacy of the treatment during hospitalization, and orienting the patient at discharge, assuring the therapy safety

The Impact of Ertapenem Use on the Susceptibility of Pseudomonas aeruginosa to Imipenem: A Hospital Case Study

We sought to evaluate the indirect impact of ertapenem use for the treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in our hospital on the susceptibility of Pseudomonas aeruginosa to imipenem. The use of ertapenem was mandated for treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in the absence of nonfermenting gram-negative bacilli for 1 year. The use of imipenem was restricted. Imipenem consumption decreased 64.5%. Ertapenem consumption was 42.57 defined daily doses per 1,000 patient-days. None of the 18 P. aeruginosa isolates recovered after ertapenem introduction were imipenem-resistant, compared with 4 of the 20 P. aeruginosa isolates recovered in the previous year.Merck Sharp Dohm