Empirical antimicrobial therapy based on active surveillance cultures in ICU patients

Objetivo: Avaliar o valor preditivo da colonização prévia por Acinetobacter baumannii (CRAB) e Pseudomonas aeruginosa (CRPA) resistente a carbapenêmicos estabelecida em culturas de vigilância para infecção subsequente por esses patógenos em pacientes internados em UTI. Métodos: Foi realizado um estudo de coorte com pacientes internados na unidade de terapia intensiva por pelo menos 48 h. Foram medidos os valores preditivos negativos e positivos, sensibilidade e especificidade das culturas de vigilância em CRAB e CRPA. Resultados: Foram incluídos 693 pacientes infectados. Pacientes previamente colonizados por CRAB e CRPA tiveram maior probabilidade de serem infectados por esses patógenos: OR ajustado: 10,34 (6,58 - 16,45; p < 0,001) e 2,30 (3,88 - 10,26; p < 0,001), respectivamente. Encontramos altos valores preditivos negativos de culturas de vigilância para CRAB (87,18%) e CRPA (88,30%) e alta especificidade 91,96% e 90,13%, respectivamente. Conclusões: Pacientes não colonizados por CRAB e CRPA mostraram-se menos propensos à infecção por esses patógenos. Esses achados podem contribuir para a escolha da terapia antimicrobiana empírica e desencorajar a prescrição de antibióticos contra esses patógenos em pacientes sem colonização prévia.

Objective: To assess the predictive value of prior carbapenem-resistant Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA) colonization established in surveillance cultures for subsequent infection by these pathogens in ICU patients. Methods: A cohort study was performed with patients admitted to the intensive care unit for at least 48 h. Negative and positive predictive values, sensitivity, and specificity of surveillance cultures in CRAB and CRPA were measured. Results: 693 infected patients were included. Patients previously colonized by CRAB and CRPA were more likely to be infected by these pathogens: adjusted OR: 10.34 (6.58 - 16.45; p < 0.001) and 2.30 (3.88 - 10.26; p < 0.001), respectively. We found high negative predictive values of surveillance cultures for CRAB (87.18%) and CRPA (88.30%) and high specificity 91.96% and 90.13%, respectively. Conclusions: Patients not colonized by CRAB and CRPA were less prone to infection by these pathogens. These findings may contribute to the choice of empirical antimicrobial therapy and discourage the prescription of antibiotics against these pathogens in patients without previous colonization.

Tratamiento farmacológico para tromboembolismo pulmonar dirigido a pacientes con fibrilación auricular / Pharmacologic treatment for pulmonary thromboembolism in patients with atrial fibrillation / Tratamento farmacológico para tromboembolismo pulmonar em pacientes com fibrilação atrial

La fibrilación auricular es una de las arritmias cardiacas más frecuentes. Afecta a 1 de cada 200 personas de entre 40 y 50 años de edad, pero puede llegar a afectar a más de 1 de cada 10 personas de 80 años. Objetivo. Proponer una guía de tratamiento farmacológico para evitar el tromboembolismo pulmonar en pacientes con fibrilación auricular con respuesta ventricular. Materiales y métodos. Los métodos utilizados fueron de nivel teórico como histórico lógico, modelación, hipotético- deductivo, dialectico, holístico-holográfico y sistémico estructural- funcional. Como métodos empíricos. se aplicaron la revisión de documentos guías, historias clínicas, encuestas a médicos y farmacéuticas, también se realizó la observación científica, los resultados se reflejaron la revisión de las historias clínicas de los 38 pacientes con diagnóstico de fibrilación auricular crónica. Resultados. Se representa el tipo de tratamiento con un predominio de 24 pacientes que toman anticoagulantes (63,16%), los pacientes en su mayoría no estaban anti coagulados, pacientes anti coagulados (34,62%), además se elaboró la propuesta de una guía de tratamiento farmacológico para evitar el tromboembolismo pulmonar en pacientes con fibrilación auricular con respuesta ventricular rápida, de acuerdo a los estándares internacionales para para prevenir las complicaciones tromboembólicas de la fibrilación auricular. Conclusiones. Debido a su prevalencia creciente, al impacto en la supervivencia, la calidad de vida de los pacientes, los elevados costos sanitarios que conlleva su tratamiento y el incesante avance en nuevos tratamientos de la fibrilación auricular con respuesta ventricular rápida, hace que sea necesario actualizar de manera periódica las recomendaciones basadas en la evidencia.

Atrial fibrillation is one of the most common cardiac arrhythmias. It affects 1 in 200 people between 40 and 50 years of age, but may affect more than 1 in 10 people in their 80s. Objective. To propose a pharmacological treatment guideline to prevent pulmonary thromboembolism in patients with atrial fibrillation with ventricular response. Materials and methods. The methods used were of theoretical level as historical-logical, modeling, hypothetical- deductive, dialectical, holistic-holographic and systemic-structural-functional. As empirical methods, the review of guidelines documents, clinical histories, surveys to physicians and pharmacists were applied, as well as scientific observation, the results were reflected in the review of the clinical histories of the 38 patients with a diagnosis of chronic atrial fibrillation. Results. The type of treatment is represented with a predominance of 24 patients taking anticoagulants (63.16%), most of the patients were not anti coagulated, anti coagulated patients (34.62%), also the proposal of a pharmacological treatment guide to avoid pulmonary thromboembolism in patients with atrial fibrillation with rapid ventricular response was elaborated, according to international standards to prevent thromboembolic complications of atrial fibrillation. Conclusions. Due to its increasing prevalence, the impact on survival, the quality of life of patients, the high health care costs involved in its treatment, and the incessant advance in new treatments for atrial fibrillation with rapid ventricular response, it is necessary to periodically update the evidence-based recommendations.

A fibrilação atrial é uma das arritmias cardíacas mais comuns. Afeta 1 em cada 200 pessoas entre 40 e 50 anos de idade, mas pode afetar mais de 1 em cada 10 pessoas em seus 80 anos. Objetivo. Propor uma diretriz de tratamento farmacológico para prevenir o tromboembolismo pulmonar em pacientes com fibrilação atrial com resposta ventricular. Materiais e métodos. Os métodos utilizados foram de um nível teórico, como histórico-lógico, modelagem, hipotético-dedutivo, dialético, holístico-holográfico e sistêmico-estrutural-funcional. Como métodos empíricos, a revisão de documentos de orientação, históricos clínicos, pesquisas de médicos e farmacêuticos foram aplicados, assim como a observação científica, os resultados foram refletidos na revisão dos históricos clínicos dos 38 pacientes com um diagnóstico de fibrilação atrial crônica. Resultados. O tipo de tratamento é representado com uma predominância de 24 pacientes tomando anticoagulantes (63,16%), a maioria dos pacientes não era anticoagulante, anticoagulante (34,62%), e uma proposta de um guia de tratamento farmacológico para prevenir o tromboembolismo pulmonar em pacientes com fibrilação atrial com resposta ventricular rápida foi elaborada, de acordo com as normas internacionais para prevenir complicações tromboembólicas da fibrilação atrial. Conclusões. Devido a sua crescente prevalência, o impacto na sobrevivência, a qualidade de vida dos pacientes, os altos custos de saúde envolvidos em seu tratamento e o incessante avanço em novos tratamentos para fibrilação atrial com resposta ventricular rápida, é necessário atualizar periodicamente as recomendações baseadas em evidências.

An analysis of pharmaceutical care for critical patients of an adult Intensive Care Unit

Abstract This work analyzed the pharmacotherapeutic problems identified by the clinical pharmacist in an intensive care unit (ICU) and the acceptance of pharmaceutical interventions in solving these problems. This is a descriptive cross-sectional retrospective study, carried out in the adult ICU of a public hospital. All patients hospitalized during the study period had their pharmacotherapy monitored and those whose stay at the ICU lasted less than 24 hours were excluded. The pharmacotherapeutic problems were classified according to type, cause, acceptability/implementation, mode of intervention, outcome and related pharmacotherapeutic group. 302 patients were followed up and 350 pharmacotherapeutic problems were identified. Most of them were classified as unnecessary drug-treatment (n=186; 53.1%). The most frequent causes were excessive drug administration (n=181; 97.3%), and antimicrobials was the main group of drugs associated to that type of problem. 350 pharmaceutical interventions were performed, highlighting "prescriber informed only" (n=178; 50.9%), with an average acceptability of 90.7%, with those carried out on site being more effective (93.4%). The number of pharmacotherapeutic problems that were totally solved was 282 (80.6%). Clinical pharmacy activities in the ICU identified, prevented and corrected pharmacotherapeutic problems, contributing to the optimization of pharmacotherapy in aspects related to the need, efficacy and safety of treatments.

Construction of pharmacogenomics-guided individualized medication list for elderly patients / 中国药房

OBJECTIVE To develop an individualized medication list for elderly patients by evidence-based pharmacy method， and to support clinical decisions on rational use of METHODS　Firstly， drugs with risk genetic information were screened out by systematically reviewing evidence-based pharmacy information. Secondly， researchers investigated the included drugs in lists from different data E- sources. Drugs included in three or more data sources and drugs proposed by the expert committee were then included in the medication list. Thirdly， for the drugs included in two data sources， researchers designed questionnaires to investigate the necessity of drug-related gene testing. According to the scoring results of the expert questionnaire， drugs with higher scores were included in the list. Data sources included real-world data （list of high frequency medication in hospitals， high frequency medication for elderly outpatients and inpatients in National Health Care Claims Data， drugs related to frequent medication errors and so on） and evidence-based pharmacy evidence （the websites of Clinical Pharmacogenomics Implementation Consortium， Dutch Pharmacogenetics Working Group， Food and Drug Administration and so on）. RESULTS　The study obtain 68 drugs with risk genetic information which were included in three data sources. Combined with 23 drugs proposed by the expert committee， a list containing 74 drugs was preliminarily formed after de-duplication. A total of 37 drugs included in two databases with risk genetic information were scored through the questionnaire survey to form a supplementary list of 26 drugs. This is the final composition of the list of 100 drugs developed in this study. Among them， there are 43 drugs for the central nervous system， 15 drugs for the cardiovascular system， 12 anti-tumor drugs and so on. Twelve drugs were included in six or more data sources， which mainly consisted of drugs for digestive system， all proton pump inhibitors. CONCLUSION　In this study， a list of 100 commonly used drugs which require individualized medication for the elderly was developed by evidence-based pharmacy method. The drug list will be updated in time as available evidence changes， and can provide guidance for rational use of medicines for elderly patients.

Protocol for the implementation of pharmaceutical care in geriatrics: strategy for safety in health care / Protocolo para la implementación de la atención farmacéutica en geriatría: estrategia de seguridad en la atención sanitaria / Protocolo da implantação do cuidado farmacêutico na geriatria: estratégia para segurança na assistência à saúde

ABSTRACT Objective: To describe the experience of the implementation of pharmaceutical care in a geriatric hospital unit and to propose an instructional protocol for the practice. Methods: Experience report that became the practice manual of pharmaceutical care in geriatrics (MaP-CFarmaGeri) of a Brazilian hospital and was structured in three topics (1. Situational diagnosis; 2. Adequacy of the procedure and service provision; 3. Practice exercise). Results: The situational diagnosis comprised the collection of data on the structure of the ward and the epidemiological profile. The pharmaceutical services provided included pharmacotherapeutic follow-up, medication reconciliation and pharmacotherapy review. The certification of the content of this procedure was attested by specialists from a multiprofessional team and the technique served more than 60 patients in practice, with good acceptance by the participants. Final considerations: The MaP-CFarmaGeri proved to be a satisfactory strategy in the implementation of pharmaceutical care in geriatrics and can support this insertion in similar locations.

RESUMEN Objetivo: Describir la experiencia de implementar la atención farmacéutica en una unidad hospitalaria geriátrica y proponer un protocolo instructivo para la práctica. Métodos: Informe de experiencia que se convirtió en el manual de la práctica de la atención farmacéutica en geriatría (MaP-CFarmaGeri) de un hospital brasileño y se estructuró en tres temas (1. Diagnóstico situacional; 2. Adecuación del procedimiento y prestación del servicio; 3. Ejercicio de práctica). Resultados: El diagnóstico situacional comprendió el relevamiento de datos sobre la estructura de la sala y el perfil epidemiológico. Los servicios farmacéuticos ofrecidos incluyeron seguimiento farmacoterapéutico, conciliación de medicamentos y revisión de farmacoterapia. La certificación del contenido de este procedimiento fue certificada por especialistas de un equipo multidisciplinario y la técnica trató a más de 60 pacientes en la práctica, con buena aceptación por parte de los participantes. Consideraciones finales: El MaP-CFarmaGeri demostró ser una estrategia satisfactoria en la implementación de la atención farmacéutica en geriatría y puede apoyar esta inserción en lugares similares.

RESUMO Objetivo: Descrever a experiência da implantação do cuidado farmacêutico em uma unidade hospitalar de geriatria e propor um protocolo instrutivo da prática. Métodos: Relato de experiência que se converteu no manual da prática do cuidado farmacêutico na geriatria (MaP-CFarmaGeri) de um hospital brasileiro e foi estruturado em três tópicos (1. Diagnóstico situacional; 2. Adequação do procedimento e oferta do serviço; 3. Exercício da prática). Resultados: O diagnóstico situacional compreendeu o levantamento dos dados sobre a estrutura da enfermaria e o perfil epidemiológico. Os serviços farmacêuticos ofertados incluíram o acompanhamento farmacoterapêutico, com a conciliação de medicamentos e a revisão da farmacoterapia. A certificação do conteúdo desse procedimento foi atestada por especialistas de uma equipe multiprofissional e a técnica atendeu mais de 60 pacientes na prática, com boa aceitação dos participantes. Considerações finais: O MaP-CFarmaGeri mostrou ser uma estratégia satisfatória na implantação do cuidado farmacêutico na geriatria e pode amparar essa inserção em locais semelhantes.

Evidence-based Pharmaceutical Practice Responding for Novel Coronavirus Pneumonia Epidemic / 中国药房

OBJECTIVE：To p rovide reference for related pharmacy work for developing evidence-based pharmacy information support to respond for novel coronavirus pneumonia （COVID-19） epidemic. METHODS ：The PubMed，CNKI and Wanfang database were consulted to obtain treatment progress of COVID-19，prohibited for use with lopinavir/ritonavir and adverse drug reactionas until February 12，2020；so were package insert and UpToDate at the same time. Those information were summarized and evaluated. RESULTS & CONCLUSIONS ：Totally 14 literatures introduced chemical drugs for COVID- 19，involving 7 categories， 20 kinds of chemical drugs as antiviral drugs （interferon α/interferon α-2 β ， lopinavir/litonavir， etc.）， immunomodulatory agents （such as glucocorticoid ，gamma globulin ），antimalarial drugs （such as chloroquine phosphate ）. The existing evidence of drug treatment mainly comes from in vitro cell test or currently progressing RCT ，with low-level evidence and recommendation intensity （Oxford evidence level is level 5，recommendation intensity is level D ）. For lopinavir/ritonavir that recommended in the diagnosis and treatment recommendations for COVID- 19 published by the National Health Commission ，it is a CYP3A inhibitor ，which resulted in increased plasma concentrations of some medications such as antiarrhythmic drugs ，antitumor targeted drugs and antibacterial drugs ，and should not be used in combination with drugs such as afzosin ，ivabradine，amiodarone， etc. Its common adverse reactions mainly involved igestive system （diarrhea，taste disorders ，vomiting，etc.），respiratory system （upper respiratory tract infection ），endocrine and metabolic system （hypercholesterolemia，etc.），skin and its appendents （skin rash），which should be monitored clinically.

Practice of Medication Consultation Service Based on the Platform of “Our Pharmacist ” / 中国药房

OBJECTIVE： To summarize the practice of medication consultation service based on the platform of “Our Pharmacist”， and to provide reference for pharmacists participating in pharmaceutical care. METHODS： The 502 medication consultation service for children， pregnant women and lactating women were collected from the platform of “Our Pharmacist” during Oct. 2017-Jul. 2018. General information， main medication， types of drugs， types of questions， types of irrational drug use were analyzed statistically. The practice of rational drug use patient guidance service based on evidence-based concept was introduced with typical examples. RESULTS： Among 502 cases of consultation， 147 （29.3％） were males and 355 （70.7％） were females， and the age was mainly 20-40 years old （291 case， 58.0％）. The proportions of patients taking 1-2， 3-4， 5 types or more drugs were 45.4％， 41.4％ and 13.2％， respectively， and those who took 5 or more drugs at the same time were all children’s patients. In respect of medication consultation content， children medication consultation， pregnant medication consultation and lactating medication consultation accounted for 42.0％， 40.6％， 17.4％， respectively. Antibiotics， Chinese patent medicines and antivirals accounted for the largest proportion of consulting drugs， being 25.6％， 17.8％， 12.1％， respectively. The question types of medication consultation included indication， dosage and course of treatment， drug safety and ADR， accounting for 31.9％， 17.5％， 13.6％， respectively. The types of irrational drug use mainly included improper drug selection， repeated drug use and no indication， accounting for 44.1％， 21.0％， 14.9％， respectively. In typical cases， pharmacists conducted systematic evidence inquiry and answered patient consultation strictly in accordance with the evidence-based concept. The main evidence-based process included formulating retrieval strategies， retrieving relevant literature， strictly evaluating evidence （authenticity， reliability and adaptability）， screening evidence according to its evidence level from high to low， evaluating evidence comprehensively and applying it to practice. Medication guidance information provided by pharmacists based on evidence not only corrected the irrational drug use of patients， but also received good feedback from patients. Five-star score accounts for 95.5％ of the satisfaction evaluation. CONCLUSIONS： Based on evidence-based concept， the platform of “Our Pharmacist” provides medication consultation service， which provides references for pharmacists to carry out targeted pharmaceutical care.

Clinical pharmacists promoted rational use of human serum albumin in tumor patients based on evidence-based pharmacy / 药学实践杂志

Objective To improve the rational use of human serum albumin(HSA)in cancer patients by the interventions of clinical pharmacists.Methods Literature search of HSA was performed by clinical pharmacists for clinical indications and appropriate usage.The HSA use protocol was implemented by clinical pharmacists and related clinical experts.The protocol adaptation was reinforced by clinical pharmacists.Results The rate of the rational use of HSA has been improved.Conclusion Clinical pharmacists play an important role in the clinical rational use of HSA based on evidence-based pharmacy.

Application of Evidence-based Pharmacy in Anticoagulant Treatment Strategies during Continuous Renal Re-placement Therapy / 中国药房

OBJECTIVE:To explore the role of clinical evidence-based pharmacy in anticoagulant treatment strategies during continuous renal replacement therapy (CRRT). METHODS:Taking a thrombocytopenia patient of anticoagulant treatment during CRRT for instance,clinical pharmacists analyzed the evidence of taken argatroban anticoagulant therapy during CRRT for high risk blooding and thrombocytopenia patients based on evidence-based pharmacy combined with clinical data,monitored the efficacy and safety and evaluated the treatment process. RESULTS:Totally five literature about anticoagulant treatment strategies during CRRT for high risk blooding and thrombocytopenia patients were obtained,including one systematic review,one RCT and three cohort studies. Based on the above evidences,good results were achieved in the clinical practice of this patient,no thrombotic or hemor-rhagic complications occurred in this patient,platelet count and coagulation indicators of patients also improved. CONCLUSIONS:Evidence-based pharmacy plays an important role in anticoagulant treatment strategies during CRRT.

Discussion on Evidence-based Pharmacy Service Mode in Medical College and University Libraries / 医学信息学杂志

The paper discusses the reasons for the slow development of evidence-based pharmacy in hospitals, analyzes the necessi-ty and feasibility of evidence-based pharmacy services in medical college and university libraries.It also elaborates how to construct ef-fective and feasible evidence-based pharmacy service mode according to the advantages and characteristics of medical college and uni-versity libraries.

Evidence-based pharmacy evaluation of Ruyi Jinhuang Powder for treating phlebitis / 中国药学杂志

OBJECTIVE: To evaluate the therapeutic effect and safety of Ruyi Jinhuang Powder for phlebitis. METHODS: The Cochrane Library, PubMed database, Embase database, ISI database, CBM database, CNKI database, VIP Database, and Wanfang database were searched. Randomized controlled trials (RCT), systematic reviews (SR)and meta-analysis of treating phlebitis by Ruyi Jinhuang Powder and 50% magnesium sulfate were included. Methodological quality assessment and meta-analysis of randomized controlled trials were carried out, and the conclusions of the included systematic reviews and meta-analyses were referred to. RESULTS: Ten RCTs comparing Ruyi Jinhuang Powder and 50% magnesium sulfate for treatment of phlebitis were included into the analysis. The total efficiencies of the two drugs had statistical significance [RR 12.96, 95% CI (5.81, 28.89), P 0.05]. CONCLUSION: Ruyi Jinhuang Powder is effective for treating phlebitis, the therapeutic effect is better than 50% magnesium sulfate, and no adverse drug reaction has been reported.

On Evidence-based Pharmacy and the Emergency Management of Pharmaceutical Affair Safety / 中国药房

OBJECTIVE:To provide reference for upgrading emergency management of pharmaceutical affairs and enhancing the safety and effectiveness of clinical medication.METHODS:The guiding effect of evidence-based parmacy(EBP)on emergency management of pharmaceutical affair security especially on the choice of drugs in clinical medication were discussed by elaborating the example of seeking sovereign remedy for tetramine acute poisoning.RESULTS & CONCLUSIONS:Emplying the principle of EBP to guide clinical medication can help to choose more effective and safe drugs and to find the best emergency treatment scheme.

Development and Improvement of Clinical Pharmacy and Specialized Clinical Pharmacist in Our Hospital / 中国药房

OBJECTIVE: To explore the way of developing and improving clinical pharmacy. METHODS: According to the experience of specialized clinical pharmacist, the matters that must be resolved were found out in order to probe into suitable resolutions. RESULTS & CONCLUSION: Specialized clinical pharmacist is the direction of developing clinical pharmacist. Clinical pharmacist’s round and consultation obtain achievements, which should be continued. A lot of things should be put into practice including pharmacoeconomics,evidence-based pharmacy, pharmaceutical care to promote the development of clinical pharmacy. Clinical pharmacist should overcome various difficulties and promote rational use of drugs and clinical pharmacy to guarantee the safety of drug use.