Antimicrobial stewardship for hospitalized patients with viral respiratory tract infections.

BACKGROUND: The purpose of this study was to implement a targeted antimicrobial stewardship intervention for patients with a viral respiratory tract infection. METHODS: This was a quasi-experimental before and after audit and feedback intervention of adult inpatients with a positive polymerase chain reaction for a respiratory virus in 2 acute care hospitals in Vancouver, Canada. Audit and feedback was implemented based on 2 criteria: microbiology (no positive bacterial cultures) and chest imaging (absence of pneumonia or consolidation on radiology dictation). A chart review was conducted to assess for days of antibiotics postviral diagnosis. Outcomes including length of stay, intensive care unit admission within 14 days, mechanical ventilation within 14 days, antibiotics prescribed within 14 days, Clostridium difficile infection diagnosed within 30 days, and readmission within 30 days were also reviewed in comparison with the previous year. RESULTS: Antimicrobial stewardship recommendations for hospitalized patients with viral respiratory tract infections were accepted for 77% of cases. This targeted approach based on easily assessed parameters translated into a 1.3-day (95% confidence interval, 0.3-2.3; P < .01) decrease in mean days of antibiotics postviral diagnosis compared with the previous year without systematic interventions. Compared with the previous year, no differences were identified for adverse outcomes associated with the intervention. CONCLUSIONS: A targeted antimicrobial stewardship intervention integrating virology testing with the treating physician facilitated a reduction in duration of antibiotic treatment for viral respiratory tract infections.

Impact of PharmaNet-Based Admission Medication Reconciliation on Best Possible Medication Histories for Warfarin.

BACKGROUND: Inaccurate documentation of medication histories may lead to medication discrepancies during hospital admissions. Obtaining a best possible medication history (BPMH) for warfarin can be challenging because of frequent dosage changes and nonspecific directions of use (e.g., "take as directed"). On February 27, 2012, the study hospital implemented an admission medication reconciliation (MedRec) process using a form that compiled the most recent 6 months of outpatient prescription dispensing history from a provincial electronic database called PharmaNet. It was unclear whether admission MedRec had improved the process of obtaining warfarin BPMHs and the quality of their documentation. OBJECTIVE: To compare the rates of complete warfarin BPMH documentation before and after implementation of PharmaNet-based admission MedRec. METHODS: A single-centre, retrospective chart review was conducted using the health records of patients receiving warfarin who were admitted to the hospital's Internal Medicine service before and after implementation of admission MedRec. The study periods were October 1, 2009, to February 26, 2012, and February 27, 2012, to July 31, 2014, respectively. The primary outcome was the rate of complete warfarin BPMH documentation during each period. RESULTS: Data were recorded for 100 patients in the pre-implementation phase and 100 patients in the post-implementation phase. The rates of complete warfarin BPMH documentation were 65% and 84% in these 2 phases, respectively (p = 0.002). CONCLUSION: Implementation of PharmaNet-based admission MedRec was associated with a statistically significant increase in the rate of complete warfarin BPMH documentation.

La consignation inexacte des schémas thérapeutiques peut mener à des divergences au chapitre des médicaments durant l'hospitalisation. Il peut être difficile d'établir un meilleur schéma thérapeutique possible (MSTP) pour la warfarine à cause de fréquents changements de posologie et de modes d'emploi imprécis (par exemple, « usage connu ¼). Le 27 février 2012, l'hôpital où s'est déroulée l'étude a mis en place un processus de bilan comparatif des médicaments (BCM) à l'admission. Celui-ci emploie un formulaire dressant la liste des médicaments d'ordonnance délivrés aux patients externes au cours des six derniers mois selon PharmaNet, une base de données numérique provinciale. On ignorait si les BCM à l'admission avaient amélioré le processus d'obtention et la qualité de la consignation des MSTP liés à la warfarine.

Measuring adverse drug events on hospital medicine units with the institute for healthcare improvement trigger tool: a chart review.

BACKGROUND: An adverse drug event (ADE) is a noxious, unintended response to a drug, occurring at doses used in humans for prophylaxis, diagnosis, or treatment of disease or for modification of physiological function. ADEs account for about one-quarter of all adverse events in Canadian hospitals. Canadian data on specific types of ADEs and commonly implicated drugs are lacking. In particular, there is a paucity of data on ADEs that occur during hospital admissions. OBJECTIVES: The primary objective was to identify the incidence of ADEs in a sample of adult general medicine inpatients over a 1-year period. The secondary objective was to identify the 5 drugs most frequently responsible for ADEs in this setting. METHODS: A retrospective chart analysis was conducted for general medicine patients discharged from St Paul's Hospital in Vancouver, British Columbia, from January to December 2011. ADEs were identified using the Institute for Healthcare Improvement (IHI) Trigger Tool for Measuring Adverse Drug Events. The Naranjo criteria were applied to assess causality, and a physician independently authenticated the ADEs for preventability and harm using the categories of harm set out by the US National Coordinating Council for Medication Error Reporting and Prevention. RESULTS: Of the 204 patient encounters reviewed, 15 involved ADEs, which represented an incidence of 7% over the 1-year study period. The 5 drugs most frequently implicated in ADEs were vancomycin, ciprofloxacin, ceftriaxone, piperacillin-tazobactam, and moxifloxacin. CONCLUSIONS: The rate of ADEs during hospital admissions was substantial. These events may necessitate additional investigations and interventions and may prolong the hospital stay. The authors do not recommend the IHI Trigger Tool for Measuring Adverse Drug Events for efficient prospective detection of ADEs in manual chart reviews. Possible modifications to improve the utility of this tool might include incorporating it into a compatible electronic health record system with automated trigger detection.

CONTEXTE: Un événement indésirable lié à un médicament (EIM) est une réaction nocive et non intentionnelle à un médicament qui survient lorsque que le médicament est utilisé selon les doses normales chez l'humain aux fins de la prévention, du diagnostic ou du traitement d'une maladie ou de la modification d'une fonction physiologique. Les EIM représentent environ le quart des événements indésirables dans les hôpitaux canadiens. Or, il n'y a pas assez de données canadiennes qui portent sur les catégories précises d'EIM et sur les médicaments qui y sont normalement associés. De plus, les données sur les EIM se produisant durant l'hospitalisation sont très rares. OBJECTIFS: L'objectif principal visait à identifier sur une période d'une année la fréquence des EIM dans un échantillon composé de patients adultes hospitalisés au service de médecine générale. L'objectif secondaire visait à découvrir quels étaient les cinq médicaments les plus souvent responsables d'EIM dans ce contexte. MÉTHODES: Une analyse rétrospective des dossiers médicaux de patients ayant obtenu leur congé du service de médecine générale du St Paul's Hospital de Vancouver entre janvier et décembre 2011 a été menée. Le Trigger Tool for Measuring Adverse Drug Events (outil déclencheur permettant de détecter les EIM) de l'Institute for Healthcare Improvement (IHI) a servi à repérer les cas d'EIM. L'algorithme de Naranjo a été utilisé pour en évaluer la causalité. De plus, un médecin indépendant a validé les EIM quant à leurs caractères évitable et préjudiciable, et ce, à l'aide des catégories de préjudice du US National Coordinating Council for Medication Error Reporting and Prevention. RÉSULTATS: Parmi les 204 hospitalisations évaluées, 15 présentaient des EIM, soit une fréquence de 7 % au cours de la période d'étude d'une année. Les cinq médicaments le plus souvent en cause dans les événements indésirables étaient la vancomycine, la ciprofloxacine, la ceftriaxone, la pipéracilline-tazobactam et la moxifloxacine. CONCLUSIONS: Le taux d'EIM durant les hospitalisations était important. Ces événements pourraient exiger des évaluations et des interventions supplémentaires et ils pourraient prolonger le séjour à l'hôpital. Les auteurs ne recommandent pas l'utilisation du Trigger Tool for Measuring Adverse Drug Events de l'IHI pour procéder à une détection prospective efficace des EIM lors d'une analyse manuelle des dossiers médicaux. L'un des moyens qui permettraient d'améliorer l'utilité de cet outil serait de l'inclure dans un système de dossiers de santé informatisés muni d'une fonction pour détecter automatiquement les éléments déclencheurs. [Treduction par l'éditeur].

Is gentamicin ototoxic to the fetus?

BACKGROUND: Gentamicin is used in pregnancy to treat infections that cause complications to the mother and fetus if left untreated. In 2003, Schering, the manufacturer of Garamycin Injectable, amended the product monograph in the Compendium of Pharmaceuticals and Specialties to state that gentamicin should be avoided in pregnancy due to cases of "total irreversible bilateral congenital deafness" in babies exposed to gentamicin in utero. Because we have identified, after an intensive literature search, only two cases over many years of availability, it is questionable whether the outcome can be attributed to drug use rather than other factors. OBJECTIVES: The main objective of this study was to determine whether any infant exposed in utero to intravenous gentamicin and born between January 2002 and April 2006 at Victoria General Hospital demonstrated audiologic deficits on routine hearing testing. Such testing has been universally available since late 2001. Our secondary objectives were to examine patterns of gentamicin use, including indication, dosage, duration, and to determine whether or not monitoring of serum gentamicin levels was done. METHODS: Women who had received gentamicin were identified through pharmacy records and their charts reviewed for factors that might contribute to fetal deafness including substance abuse, use of other potentially ototoxic medications, genetic predisposition, and intrauterine infections. We reviewed audiology test result and the infants' charts for potential confounding factors, including prematurity, low birth weight, low Apgar scores, anoxia, hyperbilirubinemia, sepsis, and meningitis. RESULTS: Fifty-two charts were reviewed, 40 of which documented live births. There was no case of hearing loss documented. Of the eight fetal losses, six (11.5%) were preterm births before viability, and two were elective terminations. Pyelonephritis was the main indication for gentamicin use (48%), followed by chorioamnionitis (31%) and other miscellaneous indications (21%). Three times daily dosing was used for a mean duration of 2.7 +- 2.3 days, resulting in an average cumulative dose of 764 +- 600 mg gentamicin. The average gestational age at exposure was 28 weeks. Maternal serum gentamicin levels were obtained in 72.5% of cases, and no trough level was above 2 mg/L. Other potentially ototoxic medications were administered to the mother in 17.5% of pregnancies, and to 17.5% of babies in the immediate newborn period. With the exception of one infant who died before additional testing could be carried out, all the infants passed hearing tests, 89% on initial screening. CONCLUSION: In utero exposure to gentamicin did not cause an increase in audiologic impairment in the infants tested in this cohort.