Melanie W. Pound

Effect of pharmacists on medication errors in an emergency department

PURPOSE The frequency of medication errors in an emergency department (ED) before and after an ED pharmacist was assigned to check medication orders was studied. METHODS A retrospective chart review was conducted for any patient admitted to the ED of a large rural hospital between November 6, 2005, and December 6, 2005 (control group), or between November 6, 2006, and December 6, 2006 (intervention group). For the control group, no pharmacist was present in the ED to check drug orders; for the intervention group, a pharmacist was present. Potential errors in medication orders were identified and validated. RESULTS A total of 490 medication orders written for 198 patients were evaluated for errors. The control group (n = 94) and the intervention group (n = 104) did not differ significantly with respect to age, sex, race, or number of medication orders. A total of 37 and 14 medication errors were identified for the control and intervention groups, respectively. The rate of errors was 16.09 per 100 medication orders for the control group compared with 5.38 per 100 orders for the intervention group, a 66.6% difference (p = 0.0001). The ED pharmacists made 183 recommendations, of which 98.6% were accepted. CONCLUSION The rate of medication errors in the ED decreased significantly when pharmacists prospectively reviewed ED medication orders.

Recent advances in the epidemiology, prevention, diagnosis, and treatment of fungal pneumonia.

Although pneumonia caused by fungi is not a common occurrence in the general population, disease in an enlarging immunocompromized population is encountered with increasing frequency. Fungal pneumonias are most frequently caused by Aspergillus spp., dimorphic fungi and Cryptococcus neoformans. Recent studies have identified risk factors of thrombocytopenia, environmental events (such as construction or renovation) and immunosuppressive drug therapies as being specific risk factors for invasive fungal disease in select patient populations. Diagnostic strategies to detect circulating antigens and polymerase chain reaction based detection systems have been explored to improve identification prior to the progressive advanced disease. Advances in prophylactic strategies include increased use of aerosolized formulations of amphotericin B, usually in conjunction with new and old systemic antifungal agents. Despite recent published guidelines for treatment of fungal pneumonia based on etiology, mortality remains high in some infections with advanced disease. Caspofungin, a new echinocandin antifungal, has recently been approved by the US Food and Drug Administration for the treatment of invasive Aspergillus infections in patients unresponsive to or unable to receive amphotericin B. A triazole antifungal, voriconazole, has shown promise in phase III clinical trials in patients with refractory fungal infections and is expected to be available in early 2002. Other echinocandin and triazole antifungals are under development in attempts to provide improved effective therapy for fungal pneumonia.

Tigecycline: a new glycylcycline antimicrobial.

Tigecycline is a new glycyclcycline antimicrobial recently approved for use in the USA, Europe and elsewhere. While related to the tetracyclines, tigecycline overcomes many of the mechanisms responsible for resistance to this class. It demonstrates favourable in vitro potency against a variety of aerobic and anaerobic Gram‐positive and Gram‐negative pathogens, including those frequently demonstrating resistance to multiple classes of antimicrobials. This includes methicillin‐resistant Staphylococcus aureus, penicillin‐resistant S. pneumoniae, vancomycin‐resistant enterococci, Acinetobacter baumannii, beta‐lactamase producing strains of Haemophilis influenzae and Moraxella catarrhalis, and extended‐spectrum beta‐lactamase producing strains of Escherichia coli and Klebsiella pneumoniae. In contrast, minimum inhibitory concentrations for Pseudomonas and Proteus spp. are markedly elevated. Tigecycline is administered parenterally twice daily. Randomised, controlled trials have demonstrated that tigecycline is non‐inferior to the comparators for the treatment of complicated skin and skin structure infections, as well as complicated intra‐abdominal infections. The most frequent and problematic side effect associated with its administration to date has been nausea and/or vomiting.

Overview of treatment options for invasive fungal infections

The introduction of several new antifungals has significantly expanded both prophylaxis and treatment options for invasive fungal infections (IFIs). Relative to amphotericin B deoxycholate, lipid-based formulations of amphotericin B have significantly reduced the incidence of nephrotoxicity, but at a significant increase in drug acquisition cost. Newer, broad-spectrum triazoles (notably voriconazole and posaconazole) have added significantly to both the prevention and treatment of IFIs, most notably Aspergillus spp. (with voriconazole) and the treatment of some emerging fungal pathogens. Finally, a new class of parenteral antifungals, the echinocandins, is employed most frequently against invasive candidal infections. While the role of these newer agents continues to evolve, this review summarizes the activity, safety and clinical applications of agents most commonly employed in the treatment of IFIs.

Written Versus Oral Recommendations Made by Pharmacy Students During Internal Medicine Rotations

Background: Pharmacy students use a variety of methods to communicate with physicians during clinical rotations regarding pharmacotherapy concerns. Documented acceptance rates for oral or written recommendations, when studied individually, range between 64% and 95%. Objective: To compare the acceptance rates of written versus oral recommendations made by pharmacy students on internal medicine (IM) rotations. Methods: Fourth-year pharmacy students completing an IM rotation made oral or written recommendations to physicians at a large, community-based medical center from November 2005 through April 2006 (excluding December). The types of recommendations and outcomes of the interventions were recorded using a data collection form. The primary endpoint was to determine differences in acceptance rates for written versus oral recommendations. Secondary endpoints included comparing the recommendation types and their corresponding acceptance rates. Additionally, the acceptance rates for evidence-based medicine (EBM) interventions were determined. Results: A total of 625 recommendations were made by 10 pharmacy students during the 5 month study period; 47.5% of these were oral. A total of 82.8% of oral recommendations were accepted compared with 54.2% of written recommendations (p< 0.0001). Over 90% of the total recommendations were drug related. Overall, 68% of these recommendations were accepted. The major types of drug-related recommendations were indication for use (42.7%), inappropriate dose (17.2%), inappropriate route (11.3%), inappropriate drug (8.5%), and duplicate therapy (6.5%). The remaining types of interventions were laboratory related (6.4%) and requests for drug information (3.2%). A total of 227 (36.3%) recommendations were based on EBM guidelines, with an acceptance rate of 67.8%. Conclusions: Pharmacy student recommendations are well received by IM physicians. Oral recommendations are accepted at a statistically significantly higher percentage compared with written recommendations. High acceptance rates for recommendations may have the ability to positively impact patient care.

Multidrug-Resistant Ewingella Americana: A Case Report and Review of the Literature

Objective: To describe and report a case of multidrug-resistant Ewingella americana associated with exacerbation of chronic obstructive pulmonary disease (COPD). Case Summary: A 77-year-old female presented to her physician with shortness of breath and an initial assessment of pneumonia. Her past medical history included COPD, Mycobacterium tuberculosis infection, recent Mycobacterium avium infection, and Crohns disease. Blood and urine cultures revealed no growth; however, a sputum culture later revealed multidrug-resistant E. americana. The patient was ultimately treated with trimethoprim/sulfamethoxazole (TMP/SMX), with complete resolution of symptoms following a 10 day course. Discussion: E. americana is a rare gram-negative bacillus that has infrequently been reported to cause infection. This organism has been reported in humans in the blood, sputum, conjunctiva, wounds, and peritoneal fluid. In several of these cases, as well as in our case, this organism appeared to occur more frequently in immunocompromised patients. Although generally susceptible to most antibiotics, our patients organism was resistant to all antibiotics tested, with the exception of TMP/SMX, ticarcillin/clavulanate, and cefotetan. Conclusions: To our knowledge, this is only the second case of an E. americana respiratory infection, and the only one in which multidrug resistance has been reported.

Recent advances in the treatment of life-threatening, invasive fungal infections

Introduction: Invasive fungal infections (IFIs) pose significant morbidity and are often life-threatening to many high-risk patients. Timely diagnosis and treatment of these infections with optimal therapy is imperative. Areas covered: Advances have been made in diagnostic biomarkers such as peptide nucleic acid fluorescent in situ hybridization, β-D-glucan and galactomannan, although more research is needed in this area to assist with both diagnosis and monitoring for improvement of IFI management. Novel antifungal agents (azole antifungals and echinocandins) are being investigated that have activity against Candida spp. and Aspergillus spp. Optimizing the pharmacodynamics (PD) of our current antifungal therapies through such strategies as continuous infusion of amphotericin B and dose escalation of echinocandins and liposomal formulations of amphotericin B have also been investigated with mixed results. Therapeutic drug monitoring (TDM) shows promise as evident from data with such agents as flucytosine, itraconazole, voriconazole and posaconazole. Expert opinion: The goal for the future of biomarkers in IFIs will be to have excellent sensitivity and specificity to ideally identify a particular fungus causing the infection or eliminate its existence to prevent unnecessary costs, resistance and antifungal usage. In addition, further developments of new antifungals are needed and judicious use of the current regimens needs to be optimized through antifungal PD properties and TDM.

Potential role of tigecycline in the treatment of community-acquired bacterial pneumonia.

Tigecycline is a member of the glycylcycline class of antimicrobials, which is structurally similar to the tetracycline class. It demonstrates potent in vitro activity against causative pathogens that are most frequently isolated in patients with community-acquired bacterial pneumonia (CABP), including (but not limited to) Streptococcus pneumoniae (both penicillin-sensitive and -resistant strains), Haemophilus influenzae and Moraxella catarrhalis (including β-lactamase-producing strains), Klebsiella pneumoniae, and ‘atypical organisms’ (namely Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila). Comparative randomized clinical trials to date performed in hospitalized patients receiving tigecycline 100 mg intravenous (IV) × 1 and then 50 mg IV twice daily thereafter have demonstrated efficacy and safety comparable to the comparator agent. Major adverse effects were primarily gastrointestinal in nature. Tigecycline represents a parenteral monotherapy option in hospitalized patients with CABP (especially in patients unable to receive respiratory fluoroquinolones). However, alternate and/or additional therapies should be considered in patients with more severe forms of CABP in light of recent data of increased mortality in patients receiving tigecycline for other types of severe infection.

Comparing point-of-care A1C and random plasma glucose for screening diabetes in migrant farm workers

OBJECTIVE To compare point-of-care (POC) glycosylated hemoglobin (A1C) and random plasma glucose (RPG) as a POC screening tool for prediabetes and diabetes in migrant farm workers of eastern North Carolina. DESIGN Prospective, observational, single-center study. SETTING Federally qualified community health center in eastern North Carolina, from August to October 2011. PARTICIPANTS Migrant farm workers 18 years or older who resided in a migrant camp in eastern North Carolina. INTERVENTION Diabetes screening using POC A1C and RPG via fingerstick followed by venipuncture A1C and basic metabolic panel in individuals with a positive screening. MAIN OUTCOME MEASURES Positive predictive value (PPV) of POC A1C and RPG, incidence of positive screening, incidence of confirmed diagnosis, concordance rate of the screening tools, and correlation between POC A1C and laboratory A1C. RESULTS 206 workers participated in the screenings; screening identified 39 individuals with a POC A1C greater than 5.7% and 1 individual with both an RPG of 200 mg/dL or more and a POC A1C greater than 5.7%. Of the 39 individuals found to have a positive screening, 24 presented to Carolina Family Health Centers, Inc., for follow-up venipuncture; however, 1 participant did not have a venipuncture A1C, leaving 23 individuals with complete data. Two participants were diagnosed with diabetes and 17 with prediabetes. POC A1C had a PPV of 82.6%; however, the PPV of RPG could not be calculated due to the number of participants lost to follow-up. POC A1C correlated well with laboratory A1C regardless of time to follow-up. CONCLUSION POC A1C should be considered for diabetes screening in high-risk populations. If the screening had been performed with RPG alone, 38 individuals would have gone undetected. Early identification of individuals with elevated blood glucose will likely decrease the risk of long-term complications.

Emerging Treatment Options for Complicated Skin and Skin Structure Infections: Oritavancin

Oritavancin is a semisynthetic lipoglycopeptide with in vitro activity against a variety of aerobic Gram-positive pathogens (including drug-resistant forms of staphylococci, streptococci, and enterococci) and select anaerobic organisms. Available published clinical efficacy and safety studies in humans to date focus primarily in the treatment of complicated skin and skin structure infections. While oritavancin doses in these studies varied, single daily doses of 200 mg (300 mg in patients >100 kg) for 3–7 days have demonstrated efficacy similar to comparators (such as vancomycin followed by cephalexin). The most frequent adverse events reported to date include gastrointestinal complaints, insomnia, dizziness, itching, and rash. Further safety and efficacy data are needed to better define its potential place in therapy.