Antimicrobial-related medication safety incidents: a regional retrospective study in West of Scotland hospitals.

BACKGROUND: Medication-related incidents are an important consideration in enhancing patient safety in hospital care. The wide use of antimicrobial therapy in this population renders these medications particularly vulnerable to errors and adverse events. AIM: To analyse the characteristics of antimicrobial-related incident reports across a group of secondary care hospitals. METHODS: Reports for antimicrobial-related incidents from April 2010 to December 2013 were obtained from a regional area of hospitals in National Health Service Scotland. Reports were analysed as a full set, and with subset analyses of incidents resulting in patient harm/injury and those included in a multi-variable regression adjusted by occupied bed-days and defined daily doses to better ascertain areas to target for antimicrobial safety. FINDINGS: In total, 1345 incidents were reported at a crude rate of 0.98 reports/day [95% confidence interval (CI) 0.93-1.03 reports/day]. Penicillins (371 reports; 27.6%), aminoglycosides (358; 26.6%) and glycopeptides (210; 15.6%) were the most commonly involved classes of medications. Most incidents involved no injury/harm (514; 38.2%), but 72 reports (5.4%) did result in patient harm. The rehabilitation/assessment [relative rate (RR) 2.61, 95% CI 1.70-4.03] and women/childrens (RR 2.04, 95% CI 1.39-2.99) directorates had higher incident reporting rates compared with other directorates, likely as a function of at-risk patient populations. Among the types of incidents reported, those involving issues with administration/supply were most common (RR 2.07, 95% CI 1.51-2.84). CONCLUSION: Incident reporting for antimicrobials identified several key areas for quality improvement in the hospital setting, which can guide safety efforts.

A comparison of medication adherence/persistence for asthma and chronic obstructive pulmonary disease in the United Kingdom.

AIM: To describe and compare adherence and persistence with maintenance therapies in patients with asthma or chronic obstructive pulmonary disease (COPD) in the United Kingdom (UK). METHODS: A retrospective prescribing database cohort was obtained from 44 general practitioner surgeries in National Health Service Forth Valley Scotland. Patients with physician-diagnosed asthma or COPD who received maintenance therapy between January 2008 and December 2009 were included. Five classes of therapy were assessed: inhaled corticosteroids, long-acting beta-agonists, combination therapy inhalers, theophyllines and long-acting muscarinic antagonists. Adherence was calculated using the medication possession ratio (MPR) and persistence was determined using Kaplan-Meier survival analysis for the time to discontinuation (TTD) over 1 year. Two step-wise logistic regressions were performed to assess the contribution of diagnosis to adherence/persistence. RESULTS: A total of 13,322 patients were included in the analysis: 10,521 patients with asthma and 2801 patients with COPD. 25.2% of medication episodes for asthma and 45.6% of medication episodes for COPD were classified as having an adequate medication supply (MPR of 80-120%). The overall median TTD was 92 days (IQR, interquartile range: 50-186 days) for patients with asthma and 116 days (IQR: 58-259 days, comparison p < 0.001) for patients with COPD. Patients with COPD were found to be more likely to achieve an MPR of at least 80% (OR: 1.27, 95% CI: 1.15-1.40), but had a similar likelihood of persistence at 1 year to patients with asthma. CONCLUSION: Adherence and persistence with respiratory therapies in the UK is relatively low. There is suggestion that patients with COPD may display more adherent behaviours than patients with asthma.

Characterisation and evaluation of UK websites on attention deficit hyperactivity disorder.

OBJECTIVES: To identify, characterise and evaluate UK websites providing information about attention deficit hyperactivity disorder (ADHD) and its pharmacological management. DESIGN: Cross-sectional survey of websites identified by entering "ADHD" into five search engines. DATA SOURCE: 48 websites. MAIN OUTCOME MEASURES: Each website was scored against 26 criteria using a bespoke instrument to evaluate (a) quality of information on the disorder and its drug treatment and (b) physical characteristics of the site. RESULTS: Most sites (n = 22) were hosted by charities and support groups, 12 were by commercial organisations, nine were from government or professional bodies, and five were categorised as miscellaneous. Mean total scores per host category ranged from 18.8 to 21 out of 46, with mean (SD) scores of 5.5 (4.2) out of 28 for content and 14.8 (3.0) out of 18 for physical properties. The government/professional sites scored highest for both content and physical properties. Descriptions of the disorder and its drug treatment were poor and lacking in detail. Although most sites mentioned stimulants, only eight discussed atomoxetine and described how both types of drug worked. Ten sites provided detailed information about side effects. The role of different stimulant brands and formulations was discussed on six sites. Authorship details were generally vague. Physical properties related to navigation and layout performed well. Only four sites used language deemed suitable for consumer-orientated health information. CONCLUSIONS: Information on UK websites about drug treatment for ADHD is basic and incomplete. Websites by government and professional bodies perform better than those in other categories.

Determination of rifampicin in human plasma and blood spots by high performance liquid chromatography with UV detection: a potential method for therapeutic drug monitoring.

A high performance liquid chromatography method has been developed that allows quantification of concentrations of rifampicin in human plasma and blood spots. Rifampicin and papaverine hydrochloride (internal standard) were extracted from plasma using a Strata-X-CW extraction cartridge. These analytes were also extracted into acetonitrile from blood spots dried onto a specimen collection card. The recovery of rifampicin from plasma and blood spots was 84.5% and 65.0%, respectively. Separation was achieved by HPLC on a Kromasil C(18) column with a mobile phase composed of ammonium acetate (20 mM, pH 4.0) and acetonitrile, delivered on a gradient programme. Optimum detection was at 334 nm. The assay was linear over the concentration range of 0.5-20 microg/ml. The limit of quantification was 0.5 microg/ml in plasma; 1.5 microg/ml in blood spots. Both intraday and interday precision data showed reproducibility (R.S.D.< or =8.0, n=9). Stability studies showed rifampicin was stable in plasma for up to 9h after thawing; the samples were also stable for up to 9h after preparation. Five patient samples were analysed using the methods described. A correlation was found between the concentrations of RIF in plasma and blood spots (r(2)=0.92). This method is proposed as a means of therapeutic drug monitoring of rifampicin in patients with tuberculosis.

Pharmacy-implemented guidelines on switching from intravenous to oral antibiotics: an intervention study.

BACKGROUND: A high proportion of medical in-patients in the UK receive intravenous (IV) antibiotic therapy. This may be inappropriate in non-severe infections, or unnecessarily prolonged. AIM: To assess the impact of guideline implementation on IV antibiotic prescribing in medical admissions to a general hospital. DESIGN: Observational intervention study. METHODS: Data relating to infection and antibiotic therapy were collected for 4 weeks pre-intervention (group 1) and 4 weeks post intervention (group 2). Six months later, data were collected for a further 4 weeks following a second intervention (group 3). Interventions consisted of pharmacy-led implementation of guidelines incorporating criteria for IV therapy and switching to the oral route. The second intervention also included pharmacy-initiated feedback on prescribing. The main outcome measures were IV antibiotic duration, and appropriateness of the IV route and switching. RESULTS: Of 2365 admissions, 757 (32%) had 806 treated episodes. IV therapy was used in 40%, 46% and 36% (groups 1, 2 and 3, respectively) and was appropriate in 92% vs. 100% (group 1 vs. 2). In groups 2 and 3, oral switch timing was appropriate in 90% and 88%, vs. 17% in group 1 (p < 0.001). Between groups 1 and 2, median duration of IV therapy was reduced from 3 to 2 days (p = 0.01). More patients in group 2 received appropriate exclusively IV therapy (65% vs. 96%, p < 0.01). Duration of stay in IV-treated patients reduced from 13 to 10 days in groups 2 and 3 (p = 0.047). IV antibiotic expenditure reduced by 13% per patient admitted between groups 1 and 2. DISCUSSION: Pharmacy-led introduction of antibiotic guidelines appears to result in clinically appropriate reductions in IV therapy.

A rapid and sensitive method for the determination of the amount of theophylline in blood spots.

Monitoring of drugs (such as theophylline) with a narrow therapeutic window could be simplified if patients were able to submit blood spots for analysis. This could reduce clinic attendance for venous blood sampling and save staff time. A rapid sensitive method utilizing liquid chromatography-mass spectrometry has been developed to determine the amount of theophylline in blood spots. The lowest level of theophylline analysed in a blood spot was 15 ng extracted into 250 microL and this was still considerably above the limit of quantification (3 ng in 250 microL). The levels of theophylline in blood spots correlated well with theophylline levels in plasma samples obtained from the same patients. The assay might be of use in therapeutic drug monitoring of theophylline and blood spot sampling could be applied to other drugs where therapeutic monitoring is required.

Feasibility of an outpatient and home parenteral antibiotic therapy (OHPAT) programme in Tayside, Scotland.

Outpatient and home parenteral antibiotic therapy (OHPAT) is under-utilized in the U.K. We performed a feasibility study over a 5-month period in a regional U.K. infection unit. After exclusions, 183 antibiotic treated patients were evaluated. Ninety-five received intravenous (i.v.) therapy, of whom 32 received at least 4 days. Prolonged i.v. therapy was most frequent in soft tissue infections. In these patients, length of stay and duration of i.v. treatment were correlated (r = 0.74, 0.51-0.87). Eighty-three (86%) of patients who received IV therapy judged OHPAT to be an acceptable alternative to hospitalization. Those who did not were older (mean age 64 vs. 46 years, P<0.001) and were less likely to have a carer willing to administer the antibiotic at home (8/28 vs. 117/151, P<0.001). Twenty-five of 32 (79%) patients treated with prolonged parenteral therapy and 27/95 (28%) treated with any length of parenteral therapy met criteria for OHPAT. Thirteen of these were safely and successfully managed as outpatients by ward staff, OHPAT is an acceptable alternative to inpatient therapy in Tayside and may reduce the duration of hospitalization or prevent admission in certain patients.

A jaundiced farmer.

A previously well farmer became deeply jaundiced after dipping sheep with organophosphate sheep dips. He had failed to wear adequate protective clothing and presumably absorbed toxic compounds through his skin. There is currently major interest in these compounds because of their protean clinical manifestations.

Evaluation of an antibiotic prescribing protocol for treatment of acute exacerbations of chronic obstructive airways disease in a hospital respiratory unit.

A prescribing protocol for infective exacerbations of chronic obstructive airways disease (COAD), specifying the use of oral amoxycillin 500 mg tid (or erythromycin 500 mg qid if allergic) as first line therapy, and oral ciprofloxacin 500 mg bd as second line treatment, was introduced in 1991. Every third sequential admission was screened for the year preceding (1990) and the year after (1991) the protocol was implemented. Only those patients with a discharge diagnosis of infective exacerbation of COAD, but without pneumonia, were included in the analysis. The two groups (1990 and 1991) were matched in terms of age, sex and pre-treatment given by their General Practitioner (GP), but differed with respect to severity score, with 1991 being more severe. The outcome measures showed that duration of hospital stay was comparable as was duration of treatment. Response to first line therapy was 68% and 67% for 1990 and 1991, respectively. Of those who had received antibiotics from their GP, 67% responded to first line therapy, while of those who had not received antibiotics from their GP 75% responded. Duration of therapy was shorter in first line responders (mean and 95% CI: 7.3 (6.3-8.3) days vs 12.7 (10.1-15.3) days). The mean cost per day antibiotic treatment was reduced by 54.6% (95% CI 52.3-56.9%) from 3.77 pounds to 1.71 pounds. In conclusion, the introduction of antibiotic prescribing guidelines for treatment of infective exacerbations of COAD showed no detrimental effect on outcome measures, but was associated with a significant reduction in the cost of antibiotic therapy.