Nationwide antibiogram analysis using NCCLS M39-A guidelines

This is the published version, also available here: http://dx.doi.org/10.1128/JCM.43.6.2629-2634.2005.Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported 0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution

INSTRUCTIONAL DESIGN AND ASSESSMENT An Elective Course in Adult Acute Care Medicine Using a Hybrid Delivery System

Objective. To develop and assess the effectiveness of an elective course modeled after activities students encounter on internal medicine advanced pharmacy practice experiences (APPEs). Design. This hybrid elective course used a Web-based course management system linking pre-class lectures and assignments, classroom discussions, and projects to promote active student learning. Assessment. Assessment of student performance was based on assignments, quizzes, and participation in classroom discussions. Students were surveyed to ascertain their opinion of the elective. Conclusion. This elective in adult acute care medicine increased student exposure to inpatient settings and provided students additional opportunities to communicate effectively, evaluate medical literature, and think critically

Ability of online drug databases to assist in clinical decision-making with infectious disease therapies

<p>Abstract</p> <p>Background</p> <p>Infectious disease (ID) is a dynamic field with new guidelines being adopted at a rapid rate. Clinical decision support tools (CDSTs) have proven beneficial in selecting treatment options to improve outcomes. However, there is a dearth of information on the abilities of CDSTs, such as drug information databases. This study evaluated online drug information databases when answering infectious disease-specific queries.</p> <p>Methods</p> <p>Eight subscription drug information databases: American Hospital Formulary Service Drug Information (AHFS), Clinical Pharmacology (CP), Epocrates Online Premium (EOP), Facts & Comparisons 4.0 Online (FC), Lexi-Comp (LC), Lexi-Comp with AHFS (LC-AHFS), Micromedex (MM), and PEPID PDC (PPDC) and six freely accessible: DailyMed (DM), DIOne (DIO), Epocrates Online Free (EOF), Internet Drug Index (IDI), Johns Hopkins ABX Guide (JHAG), and Medscape Drug Reference (MDR) were evaluated for their scope (presence of an answer) and completeness (on a 3-point scale) in answering 147 infectious disease-specific questions. Questions were divided among five classifications: antibacterial, antiviral, antifungal, antiparasitic, and vaccination/immunization. Classifications were further divided into categories (e.g., dosage, administration, emerging resistance, synergy, and spectrum of activity). Databases were ranked based on scope and completeness scores. ANOVA and Chi-square were used to determine differences between individual databases and between subscription and free databases.</p> <p>Results</p> <p>Scope scores revealed three discrete tiers of database performance: Tier 1 (82-77%), Tier 2 (73-65%) and Tier 3 (56-41%) which were significantly different from each other (p < 0.05). The top tier performers: MM (82%), MDR (81%), LC-AHFS (81%), AHFS (78%), and CP (77%) answered significantly more questions compared to other databases (p < 0.05). Top databases for completeness were: MM (97%), DM (96%), IDI (95%), and MDR (95%). Subscription databases performed better than free databases in all categories (p = 0.03). Databases suffered from 37 erroneous answers for an overall error rate of 1.8%.</p> <p>Conclusion</p> <p>Drug information databases used in ID practice as CDSTs can be valuable resources. MM, MDR, LC-AHFS, AHFS, and CP were shown to be superior in their scope and completeness of information, and MM, AHFS, and MDR provided no erroneous answers. There is room for improvement in all evaluated databases.</p

Hospital-wide Analysis of Preprinted Medication Order Sets at a Tertiary Community Hospital

Objective. To standardize the process for using preprinted order sets which will enhance accurate communication, promote patient safety, and help to build the framework for future Computerized Physician Order Entry (CPOE) implementation. Background. A preprinted order set is a tool to assist the practitioner in choosing the most appropriate medical management of patients. They often accompany clinical practice guidelines and are recommended to reduce communication errors by targeting the ordering stage of medications, where most medication errors occur. They provide continuity of care, educate institutional personnel regarding evidence-based guidelines, increase compliance with Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and enhance workflow processes. Currently, many of the existing order sets belong to individual physicians and there is potential for little variation as different physicians may have similar order sets for a particular procedure or diagnosis. Methods. Preprinted order sets will be collected from all units of the hospital and scanned for duplicates. Each original will be analyzed using a data collection sheet that was developed based on The Institute for Safe Medication Practices (ISMP) and the USP Center for the Advancement of Patient Safety preprinted order set recommendations. Descriptive statistics will be used to summarize data and inferential statistics will be used to analyze the results according to “disease-specific” or “doctor-specific.” Order sets that are found to contain inappropriate or duplicate information will be revised using an interdisciplinary approach. This standardization will decrease the risk of error that comes with multiple versions. Results and Conclusion. In progress

Evaluation of the Treatment and Safety of High Dose Intravenous Narcotics for Acute Pain in an Inpatient Setting

Objective. The primary objective of this study is to evaluate adverse drug events associated with intravenous morphine and hydromorphone at doses greater than 8 mg IV Q3 hours and 2 mg IV Q3 hours. Secondary objectives include: [1] percentage of subjects on oxygen saturation monitoring, [2] percentage of subjects prescribed and/or administered naloxone, and [3] percentage of physician orders with a PRN / as needed indication as required by the Joint Commission Standard MM.04.01.01. Methods. A computer generated list of patients prescribed high doses of intravenous morphine and/or hydromorphone will be collected and evaluated for study inclusion. Adverse drug events will be defined as one or more of the following: a reported Ramsay sedation score ≥5, respiratory rates less than 12 breaths per min, or oxygen saturation less than 95% at room air. Descriptive statistics will be used to summarize data and inferential statistics will be used to compare data. Results. At study midpoint (n=6), only one subject has displayed an adverse effect currently associated to the administration of hydromorphone 2mg intravenously; subject displayed with an oxygen saturation below normal. Conclusion. No trend is available for analysis this far; however study subject recruitment is still ongoing at this time

Need for Investigational Drug Services at a Tertiary Community Hospital

Introduction. Investigational drug services (IDS) include procurement, storage, dispensing, and disposal of investigational medications along with providing education, participating in research committees and maintaining protocol records. The investigational drug workload at our institution is expected to increase after increased participation in H. Lee Moffit Cancer Center & Research Institute protocols and pursuit of teaching facility status. Our institution lacks formal IDS, with limitations of the current system causing missed opportunities for proper nursing education, miscommunication regarding investigational medications, and lack of organization to ensure all study medications are dispensed through the pharmacy as required by JCAHO. Purpose. To evaluate the amount of time currently dedicated to investigational drug pharmacy services. The current system effectiveness will be evaluated with protocol log audits for completeness. A secondary analysis will be conducted to determine the financial feasibility of accommodating a full time position through the budgeted pharmacy funds. Methodology. There will be three parts evaluated during this study. Prospective analysis of investigational pharmacist’s additional workload from IDS will be performed via daily activity logs for three months. Retrospective audits of completeness of log records to assess the current system will be collected for the period of three months. Pharmacy budgets in protocols from the 2007 fiscal year will be evaluated. Descriptive statistics will be used to summarize data analyzed

Incidence of Adverse Drug Reactions Related to Propofol in an Intensive Care Setting

Objective. The purpose is to monitor mechanically ventilated patients on propofol for signs and symptoms of adverse drug effects (ADE). Secondary objectives include: comparison of the incidence of hypertriglyceridemia, evaluation of the appropriate use of propofol, and assessment of the impact of a clinical pharmacist. Methods. A daily report was generated profiling propofol patients during a three month period. An IRB approved data collection tool gathered patient demographic information . Rate/dose and duration of propofol was also collected. If an ADE was discovered, the physician was notified and information regarding the ADE was also collected. Acceptance of pharmacy interventions were evaluated. Data were summarized and at study completion inferential statistics will be used to compare data. Results. At study midpoint (n=15), there were 66% male patients averaging 50.7 years (25-75 years). Propofol therapy averaged 5.37 days with 3.17 mg/kg/min (31.7 mcg/kg/min)average dose . In 20% of the subjects, the physician ordered a triglyceride level `appropriately, whereas the primary investigator ordered a triglyceride level in 47% of the patients. The average triglyceride level was 168.9mg/dl (77- 296mg/dL). Co-morbid diseases included hyperlipidemia, hypertension, coronary artery disease, and heart failure. One subject was HIV positive on a protease inhibitor. Three subjects were also receiving TPN, with one subject being administered TPN with lipids. Thirty-three subjects were receiving a HMGCOA Inhibitor. Conclusion. No ADEs have been identified this far, however education of monitoring triglycerides has been addressed with prescribing physicians. Subject selection and data analysis is still ongoing at this time

Assessment of the First Annual Roadmap to a Pharmacy Residency Workshop by a Student Society of Health-Systems Pharmacy

Purpose. Only 10-15% of pharmacy students continue postgraduate training even though the pharmacy profession is recognizing the value of residency training. Various studies have evaluated the impact of professional development programs in regards to pharmacy residencies, resulting in a significant effect on students’ decisions to pursue a residency. Factors and barriers that attribute to students’ decisions to pursue a residency have been identified such as, family and financial commitments, previous job obligations, and lack of interest to invest further into their education. This study investigated the importance of a student-driven professional development workshop and evaluated the workshops influence on increasing student interest and motivation in regards 20 to pursuing a residency. Methods. In November 2008, a student society of health-systems pharmacy hosted a residency workshop and residency showcase. A 21-item questionnaire was distributed at the end of the workshop and a follow-up 23-item questionnaire was given to graduating pharmacy students to further evaluate the long-term effect the workshop had towards students’ decision in pursuing residency. Descriptive and inferential statistics were performed to evaluate and compare results. Results. 132 students participated in the workshop, where most of them were in their third professional year (35%). Of those that participated, the workshop made no statistically significant difference in their pursuit of post-graduate training opportunities. Conclusion. The residency workshop did not influence student’s motivation to pursue a residency significantly. Based upon our analysis, future professional development programs may be modified to improve pharmacy student’s point of view and motivation in pursuing postgraduate training. Grants. The workshop was sponsored by the National American Society of Health System Pharmacists SEED Grant for $500 and Health Professions Division Grant for$3,800

EFFICACY AND TOLERABILITY OF DIPEPTIDYL PEPTIDASE-4 INHIBITORS IN PATIENTS WITH DIABETES MELLITUS AND RENAL IMPAIRMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective. Evaluate efficacy and tolerability of DPP-4 inhibitors (DPP-4I) in patients with type 2 diabetes mellitus (T2DM) and chronic renal failure (CRF) using a systematic review and meta-analysis of available literature. Background. CRF is commonly found in patients with T2DM and the list of antidiabetic medications that can be used in this population is limited. Methods. Eight published randomized, clinical trials were identified from multiple databases. Qualitative assessment and quantitative analyses were performed. Results. Studies of DPP-4I included sitagliptin, saxagliptin, linagliptin and vildagliptin with 995 patients analyzed (average age 65 years, 56.4% males, 56.5% Caucasians, baseline A1c 7.9%). When compared with placebo, DPP-4I caused a reduction in A1c at 12 (-0.51%) and 52 (-0.72%) weeks, respectively, p\u3c0.00001, but reduction was not significantly different compared with glipizide. Subgroup analyses by severity of renal impairment showed DPP-4I caused a significant reduction in A1c with moderate (0.79) and severe (-0.62) renal impairment (p\u3c0.02). When compared with glipizide, DPP-4I were associated with weight loss at 12 and 54 weeks by 0.54Kg and 1.51Kg, respectively (p \u3c 0.01). DPP-4I were associated with a numerical increase in rate of hypoglycemic events versus placebo (20.4% versus 16.4%, p=NS) but not when compared with glipizide (6.2% versus 15.5%, p=0.0009). There were no differences between DPP-4I and comparator for any adverse events (AE) (73.7% versus 75.1%), serious AE (19.1% versus 18.9%), any drugrelated AE (19.8% versus 21.1%) and withdrawals due to AE (7.6% versus 8.1%), respectively. Conclusion. Metaanalysis suggests that DPP-4I are effective and well-tolerated in patients with T2DM with CRF. Grants. N/

Recognition of Advanced Pharmacy Practice Experience Student Participation Within Antimicrobial Stewardship Activities

Background: Antimicrobial stewardship is important in managing patients with infectious diseases. Limited data exist documenting the extent of pharmacy student involvement within antimicrobial stewardship activities. Objectives: The purpose of this study was to document the types of hospital-based antimicrobial stewardship activities in which Advanced Pharmacy Practice Experience (APPE) students are involved. Methods: A questionnaire was developed using the most current guideline for developing an institutional antimicrobial stewardship program. It was designed to collect preceptor-reported perceptions and APPE student involvement in antimicrobial stewardship activities. Pharmacist preceptors of APPE students from 2 Florida Colleges of Pharmacy were surveyed in October 2011. Questionnaires fully completed by hospital pharmacists currently serving as an APPE preceptor were included. Results: Forty-eight questionnaires met all inclusion criteria, collectively reporting APPE student participation within every element of antimicrobial stewardship. The most common areas of student participation were dose optimization based on patient characteristics (n = 40, 83%), acquiring patient information for prospective audit with feedback (n = 39, 81%), intravenous to oral conversion (n = 37, 77%), and pharmacokinetic services (n = 36, 75%). Anti-infective subcommittee participation (n = 3, 6%) was uncommon. Respondent perceptions were overall favorable regarding student participation in antimicrobial stewardship activities. Conclusion: With supervision from pharmacist preceptors, APPE students from 2 Florida colleges of pharmacy were reported to participate in each element and activity of antimicrobial stewardship as set forth by current guidelines. The role and value of such involvement is not fully understood. Future research investigating activity-specific outcomes and policy creation are needed to guide appropriate use of APPE students as a resource for optimizing antimicrobial use in hospitals