Kathryn Slayter

Nursing home-acquired pneumonia : treatment options

SummaryNursing home-acquired pneumonia (NHAP) is a diagnostic and therapeutic challenge, and antimicrobial therapy represents only 1 facet of the treatment of this disease. The nursing home population consists of a mixture of well, frail and dependent elderly. For some residents, supportive care may be the best therapeutic option.A variety of antimicrobial regimens have been proposed for the empirical therapy of NHAP; however, there are still very few data from controlled clinical trials that assess outcome. The clinical trials that have been completed support the concept that an early switch from intravenous to oral therapy can be successfully used to treat pneumonia affecting frail, often seriously ill, groups of patients.Annual influenza vaccine should be offered to all nursing home residents. This practice is about 50% effective in preventing hospitalisation and pneumonia, and about 80% effective in preventing death. The same level of evidence is not available to support the use of pneumococcal vaccine in this group; however, current practice suggests that all nursing home residents receive this vaccine on admission and once every 6 years thereafter.Frequently, knowledge about pneumonia is not applied as optimally as should be done. Care maps have been shown to reduce length of stay and shorten the time from emergency room entry until administration of antibiotic therapy by up to 3 hours.Areas for urgent research attention in patients with NHAP are: (a) proper studies to define the microbiological aetiology of NHAP (this requires bron-choscopy with sampling of the distal airways using a protected bronchial brush); (b) randomised controlled clinical trials of sufficient size to determine whether one antibiotic regimen is superior to another (currently most trials are designed to show that the agent under study is equivalent to a currently used agent); and (c) end-of-life decision making in the nursing home population.

Clinical benefits and economic impact of post-surgical care provided by pharmacists in a Canadian hospital

Clinical pharmacists improve the quality of patient care by reducing adverse drug events (ADEs), length of stay and mortality. This impact is currently not well described in surgery. The objective was to evaluate clinical and economic outcomes after clinical pharmacist services were added to two general surgical wards in an adult hospital.

Hazards of Doubling Phenytoin Dose in the Face of an Unrecognized Interaction with Ciprofloxacin

OBJECTIVE: To underscore the need for caution when making dramatic changes in phenytoin dosing, and to report a possible ciprofloxacin interaction in which failure of seizure control led to inappropriately high phenytoin dosing and subsequent intoxication. CASE SUMMARY: A 61-year-old African-American man receiving long-term therapy with phenytoin 100 mg po tid for seizures secondary to a stroke was admitted for community-acquired pneumonia. His serum phenytoin concentration at admission was therapeutic at 12.6 μg/mL. Eight days after admission, ciprofloxacin 750 mg po bid was started for possible aspiration. Two days later he experienced a seizure; the serum phenytoin concentration was 2.5 μg/mL. In response to the 80% decline in phenytoin concentration, the dosage was gradually titrated upward to produce a serum concentration of 12.6 μg/mL. This eventually required a doubling of the original phenytoin dosage and he was discharged on 200 mg po tid. The patient subsequently developed severe ataxia and sustained a head injury for which he was seen again in the emergency department. Serum phenytoin concentration at that time was 42.8 μg/mL. Concentrations declined at a normal rate when phenytoin was withheld. CONCLUSIONS: It appears that a rapid decline in phenytoin concentration during the first admission was related to coadministration of ciprofloxacin, either through inhibition of absorption or induction of metabolism. In a conscientious effort to titrate phenytoin concentrations back to therapeutic values, the issue as to why this required such a dramatic change in dosage was ignored. Thus, in trying to prevent further seizures, the patient was unknowingly placed in jeopardy a second time when his usual dosage of phenytoin was doubled. As a result, phenytoin intoxication ensued after discharge when the ciprofloxacin was discontinued. This case illustrates a potentially dangerous interaction between ciprofloxacin and phenytoin, and it underscores the need to maintain a high index of clinical suspicion for drug interactions in any patient requiring a substantial change in drug dosage.

Impact of pharmacists as immunizers on influenza vaccination coverage in Nova Scotia, Canada

ABSTRACT Immunization coverage in Canada has continued to fall below national goals. The addition of pharmacists as immunizers may increase immunization coverage. This study aimed to compare estimated influenza vaccine coverage before and after pharmacists began administering publicly funded influenza immunizations in Nova Scotia, Canada. Vaccination coverage rates and recipient demographics for the influenza vaccination seasons 2010-2011 to 2012-2013 were compared with the 2013-2014 season, the first year pharmacists provided immunizations. In 2013-2014, the vaccination coverage rate for those ≥5 years of age increased 6%, from 36% in 2012-2013 to 42% (p<0.001). Pharmacists administered over 78,000 influenza vaccinations, nearly 9% of the provinces population over the age of five. Influenza vaccine coverage rates for those ≥65 increased by 9.8% (p<0.001) in 2013-2014 compared to 2012-2013. Influenza vaccination coverage in Nova Scotia increased in 2013-2014 compared to previous years with a universal influenza program. Various factors may have contributed to the increased coverage, including the addition of pharmacists as immunizers and media coverage of influenza related fatalities. Future research will be necessary to fully determine the impact of pharmacists as immunizers.

Antimicrobials in acute exacerbations of chronic obstructive pulmonary disease - An analysis of the time to next exacerbation before and after the implementation of standing orders.

OBJECTIVE To compare the mean time to next exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) before and after the implementation of standing orders. SETTING Tertiary care hospital, Halifax, Nova Scotia, Canada. POPULATION STUDIED The records of 150 patients were analyzed, 76 were in the preimplementation group, 74 in the postimplementation group. INTERVENTION The management and outcomes of patients admitted with an acute exacerbation of COPD before and after the implementation of standing orders were compared. DESIGN A retrospective chart review. MAIN RESULTS THERE WAS NO DIFFERENCE IN THE MEAN TIME TO NEXT EXACERBATION BETWEEN TREATMENT GROUPS (PREIMPLEMENTATION GROUP: 310 days, postimplementation group: 289 days, P=0.53). Antibiotics were used in 90% of the cases (preimplementation group: 87%, postimplementation group: 93%). The postimplementation group had a 20% increase in the use of first-line agents over the preimplementation group. Overall, first-line agents represented only 37% of the antibiotic courses. CONCLUSIONS The implementation of standing orders encouraged the use of first-line agents but did not influence subsequent symptom resolution, length of hospital stay, or the infection-free interval in patients with acute exacerbations of COPD.

Survey of vaccine administration to splenectomized patients: Are guidelines being followed?

To the Editor: Asplenic patients are at risk for developing overwhelming postsplenectomy infection (OPSI), in particular with encapsulated organisms, such as Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type B (Hib) (1). Vaccination against these organisms substantially decreases the risk of infection, and is considered the standard of care in these patients (2). The sixth edition of the Canadian Immunization Guide (3) recommends polysaccharide pneumococcal vaccine for all asplenic individuals who have not been previously immunized. A single booster five years after initial vaccination is recommended. Individuals should also receive Hib conjugate vaccine and immunization for meningococcal disease (3). Despite these guidelines, studies have reported low adherence to the recommendations. Ramachandra et al (4) reported that 72% of 76 splenectomized patients received the pneumococcal polysaccharide vaccine, 59% received Hib and only 39% received the meningococcus vaccine (4). A Canadian survey (5) reported that 111 of 164 (68%) patients received the pneumococcal vaccine during hospitalization for splenectomy, only four received Hib and two received the meningococcal vaccine. A Scottish study (6) of 974 splenectomized patients reported data on vaccination status for 73% of patients, with only 47% of patients having received all three vaccinations. We undertook a review to determine whether splenectomized patients at our institution were receiving the appropriate vaccinations and were being counselled about the risk of OPSI. All patients who underwent a splenectomy between January 2002 and December 2004 at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, were included. Information was collected on age, sex, indication for splenectomy, receipt, timing and documentation of vaccinations, documentation of the surgical discharge summary including report of the splenectomy, documentation of administered vaccines, recommendations for future vaccines, recommendations for Medic Alert bracelets and counselling about the risk of OPSI. In addition, a letter was sent to general practitioners of living patients requesting details about the administration of vaccines outside the hospital if these data were not available from hospital records. If no response was received after the first letter was mailed, a second letter was mailed six weeks later. If patients had not received all recommended vaccinations, a subsequent letter was sent to the general practitioner so that they could arrange for vaccine administration according to the current standard of care. Of 70 patients reviewed, 28 (40%) were male and were between 17 and 84 years of age (median age 53 years). The most common indication for splenectomy was idiopathic thrombocytopenic purpura (n=28). Other indications included trauma (n=13), hemolytic anemia (n=7), thrombotic thrombocytopenic purpura (n=3) and other causes (n=19). Five patients who had died were excluded from the analysis because of incomplete information. The response rate from general practitioners was 94%. Vaccination had been received by 91% of patients for S pneumoniae, 75% for N meningitidis and 68% for Hib. However, only 27% of surgical discharge summaries included documentation of vaccine administration or recommendations for future vaccinations. Only 6% of discharge summaries documented the risk of infection postsplenectomy and that recommendations were given to patients about this risk. Vaccination rates at our institution are better than previous reports. However, some patients are still not receiving the recommended vaccinations, particularly for Hib and N meningitidis. Implementation of an institutional standing order for the administration of vaccines may improve vaccination rates and should be evaluated. Although our vaccination rates are relatively high, the documentation regarding vaccinations, recommendations for follow-up vaccination and documentation about the risk of infection in the surgical discharge summary was lacking for most patients. Further studies are planned in our institution to assess the usefulness of a ‘checklist’ to improve these deficits.

Treatment of Recurrent Aphthous Ulcers in an HIV Patient – An Emerging Use for Pentoxifylline

Patients with human immunodeficiency virus (HIV) infection often suffer from persistent, painful ulcers that commonly occur on the soft palate, buccal mucosa, tonsillar area or tongue, which are referred to as aphthous ulcers. This paper reports the case in which pentoxifylline was successfully used to treat recurrent aphthous ulcers in an HIV patient.

Importance and Role of Pharmacokinetics, Pharmacodynamics and Stability in Nonhospital, Community-Based Parenteral Antimicrobial Therapy

Several variables including the likely infecting organism, pharmacokinetic (PK) and pharmacodynamic factors (PD), and drug stability must be considered when selecting antimicrobials. The goal of antibiotic therapy is to provide adequate drug concentration at the site of infection long enough to eliminate the pathogen. Almost any antimicrobial can be used for outpatient therapy, but drugs with long half-lives are the best suited. The use of agents that can be administered once or twice daily minimized the disruption of daily activities and limited the number of intravenous line manipulations, lessening the potential for catheter-associated complications (1-3). Ceftriaxone (Rocephin, Hoffmann La Roche Limited, Mississauga, Ontario) and other cephalosporins have been the most common drugs reported in the literature (4). If the antibiotic must be given every 2, 4, or 6 h, it may become impractical to give at home without the aid of an infusion pump. Not all Canadian centres use pumps because they are complicated for patients to use and are expensive (1,5).

Patient criteria and selection for nonhospital, community-based, parenteral antimicrobial therapy

PATIENT SELECTION AND EDUCATION The primary goal of nonhospital community-based parenteral antimicrobial therapy (NHCoPAT) is to allow patients to complete treatment in the comfort of their own home environment safely and effectively, thereby avoiding the inconveniences and complications of prolonged hospitalization. There are several important criteria that must be considered when selecting a patient for NHCoPAT. Factors related to the clinical status of the patient are by far the most essential. Variables to consider include how serious the infection is, whether a patient truly requires intravenous antibiotics or if oral antimicrobials would suffice, the presence of other comorbid conditions that may otherwise keep the patient hospitalized and the degree of nursing care that they require. A patient’s overall condition must be stable, and the risk of sudden, lifethreatening changes in clinical status must be low. The minimal assessment, therefore, includes not only determining the status of the infectious process but also other concomitant conditions that may affect the safety of continuing care outside the institution (1-3). The list of clinical conditions that can be treated outside of the hospital is constantly expanding. NHCoPAT often enables the completion of a course of therapy started in the hospital, but NHCoPAT may be initiated in an emergency department, outpatient clinic or office setting. For instance, for patients who develop cytomegalovirus retinitis, hospitalization is usually not required and teaching sessions can be accomplished in the outpatient setting (4). Patients with endocarditis or meningitis, however, should be hospitalized for the initiation of parenteral antibiotic therapy until the infection is under control (5,6). The overall condition of the patient may make it medically inappropriate to release them from the hospital. However, for those who are medically fit, home intravenous therapy is an important option (7). The selection of patients for NHCoPAT requires consideration of a number of factors in addition to the disease involved and the patient’s clinical status. These include the patient’s capabilities and willingness to participate in the program as well as available support systems in the home environment