Penicillin de-labelling in vancouver, British Columbia, Canada: comparison of approaches, outcomes and future directions.

BACKGROUND: Inaccurate penicillin allergy labels lead to inappropriate antibiotic prescriptions and harmful patient consequences. System-wide efforts are needed to remove incorrect penicillin allergy labels, but more health services research is required on how to best deliver these services. METHODS: Data was extracted from five hospitals in Vancouver, British Columbia, Canada from October 2018-May 2022. The primary outcomes of this study were to outline de-labelling protocol designs, identify the roles of various healthcare professionals in de-labelling protocols and identify rates of de-labelling penicillin allergies and associated adverse events at various institutions. Our secondary outcome was to describe de-labelling rates for special populations, including pediatric, obstetric and immunocompromised subpopulations. To achieve these outcomes, participating institutions provided their de-labelling protocol designs and data on program participants. Protocols were then compared to find common themes and differences. Furthermore, adverse events were reviewed and percentages of patients de-labelled at each institution and in total were calculated. RESULTS: Protocols demonstrated a high level of variability, including different methods of participant identification, risk-stratification and roles of providers. All protocols used oral and direct oral challenges, heavily involved pharmacists and had physician oversight. Despite the differences, of the 711 patients enrolled in all programs, 697 (98.0%) were de-labelled. There were 9 adverse events (1.3%) with oral challenges with mainly minor symptoms. CONCLUSIONS: Our data demonstrates that de-labelling programs effectively and safely remove penicillin allergy labels, including pediatric, obstetric and immunocompromised patients. Consistent with current literature, most patients with a penicillin allergy label are not allergic. De-labelling programs could benefit from increasing clinician engagement by increasing accessibility of resources to providers, including guidance for de-labelling of special populations.

Management of cardiovascular health in acute leukemia: a national survey.

Cardiovascular (CV) disease is a common comorbidity in acute leukemia (AL) patients and can be worsened by the use of anthracyclines. Interruptions and underutilization of CV medications during AL treatments may negatively impact the CV health of these patients. A 30-question electronic survey was distributed to Canadian hematologists who treat adults with AL to determine the frequency, timing and rationale for interruptions in statins, antiplatelets and angiotensin antagonists in patients undergoing intensive chemotherapy. Strategies for mitigating anthracycline cardiotoxicity, methods of establishing baseline CV risk and utilization of clinical pharmacists were also assessed. Results indicate that it is common for AL patients undergoing intensive chemotherapy to require CV medication interruptions. This highlights the need for collaboration between hematology and cardiology healthcare teams and utilization of multidisciplinary healthcare professionals to improve CV care during AL.

Evaluation of a Once-Daily Vancomycin Regimen in an Outpatient Leukemia/Bone Marrow Transplant Clinic (OD-VANCO Study).

BACKGROUND: The Leukemia/Bone Marrow Transplant Program of British Columbia manages patients with high-risk febrile neutropenia and those with non-neutropenic immunocompromised states in an outpatient clinic setting. Because the program treats outpatients only, once-daily administration of IV antibiotics is desirable. A high-dose, once-daily vancomycin nomogram was developed and implemented as part of the antibiotic treatment regimen. OBJECTIVE: To determine if therapeutic vancomycin trough levels could be achieved with a high-dose, once-daily regimen in this outpatient setting. METHODS: A prospective, single-centre, observational cohort study was conducted over a 7-month period. Outpatients in the Leukemia/Bone Marrow Transplant Program were started on IV vancomycin with the high-dose, once-daily vancomycin nomogram, and outcomes were assessed. RESULTS: Of 48 outpatients treated over the 7-month period, 10 (21%) had therapeutic vancomycin trough concentrations (i.e., greater than 10 mg/L). Thirty-five (90%) of the 39 patients with suspected clinical infection experienced clinical cure, and 6 (67%) of the 9 patients with documented microbiological infection experienced microbiological cure. Thirty (62%) of the 48 patients experienced symptoms of "red man syndrome", and 7 (15%) experienced some degree of nephrotoxicity. Two of 3 patients with laboratory-reported minimum inhibitory concentration (MIC) for identified pathogens had a calculated area under the curve to MIC ratio greater than or equal to 400. CONCLUSION: The high-dose, once-daily vancomycin nomogram was effective in attaining trough levels greater than 10 mg/L in only 21% of patients in this study. A substantial number of adverse drug reactions were observed. Given these results, high-dose, once-daily vancomycin is no longer recommended for outpatient therapy.

CONTEXTE: Le programme sur la leucémie et la greffe de moelle osseuse de la Colombie-Britannique (Leukemia/Bone Marrow Transplant Program of British Columbia) traite en consultation externe des patients avec une neutropénie fébrile à risque élevé et d'autres en états non neutropéniques d'immunovulnérabilité. Comme le programme s'adresse uniquement à des patients externes, une administration intraveineuse (IV) uniquotidienne d'antibiotiques est souhaitée. Pour cette raison, un nomogramme posologique pour la vancomycine à dose uniquotidienne élevée a été élaboré et mis en place dans le cadre du schéma d'antibiothérapie. OBJECTIF: Déterminer s'il est possible d'atteindre des concentrations minimales thérapeutiques de vancomycine à l'aide d'un schéma thérapeutique à dose uniquotidienne élevée dans ce service de consultation externe. MÉTHODES: Une étude de cohorte prospective observationnelle a été menée dans un seul centre sur une période de sept mois. Le nomogramme posologique a servi à commencer le traitement IV par la vancomycine à dose uniquotidienne élevée de patients externes participant au programme sur la leucémie et la greffe de moelle osseuse, et les résultats ont été évalués. RÉSULTATS: Parmi les quarante-huit patients externes traités pendant une période de sept mois, des concentrations minimales thérapeutiques de vancomycine (c.-à-d. plus de 10 mg/L) ont été atteintes chez dix (21 %) d'entre eux. Trente-cinq (90 %) des trente-neuf patients chez qui l'on soupçonnait une infection clinique ont obtenu une guérison clinique et une éradication microbiologique a été notée chez six (67 %) des neuf patients présentant une infection microbiologique attestée. Trente (62 %) des 48 patients ont présenté un syndrome de l'homme rouge et sept patients (15 %) ont manifesté un certain degré de néphrotoxicité. Deux des trois patients pour qui le laboratoire avait déterminé une concentration minimale inhibitrice (CMI) contre les agents pathogènes en cause avaient un rapport aire sous la courbe sur CMI égal ou supérieur à 400. CONCLUSION: Le nomogramme posologique pour la vancomycine à dose uniquotidienne élevée a permis d'atteindre des concentrations minimales de plus de 10 mg/L chez seulement 21 % des patients de cette étude. Un nombre considérable d'effets indésirables liés au médicament a été observé. Compte tenu de ces résultats, il n'est plus recommandé de donner des doses uniquotidiennes élevées de vancomycine à titre de traitement aux patients externes. [Traduction par l'éditeur].

Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study.

BACKGROUND: Medication-related visits to the emergency department are an important but poorly understood phenomenon. We sought to evaluate the frequency, severity and preventability of drug-related visits to the emergency department. METHODS: We performed a prospective observational study of randomly selected adults presenting to the emergency department over a 12-week period. Emergency department visits were identified as drug-related on the basis of assessment by a pharmacist research assistant and an emergency physician; discrepancies were adjudicated by 2 independent reviewers. RESULTS: Among the 1017 patients included in the study, the emergency department visit was identified as drug-related for 122 patients (12.0%, 95% confidence interval [CI] 10.1%-14.2%); of these, 83 visits (68.0%, 95% CI 59.0%-76.2%) were deemed preventable. Severity was classified as mild in 15.6% of the 122 cases, moderate in 74.6% and severe in 9.8%. The most common reasons for drug-related visits were adverse drug reactions (39.3%), nonadherence (27.9%) and use of the wrong or suboptimal drug (11.5%). The probability of admission was significantly higher among patients who had a drug-related visit than among those whose visit was not drug-related (OR 2.18, 95% CI 1.46-3.27, p < 0.001), and among those admitted, the median length of stay was longer (8.0 [interquartile range 23.5] v. 5.5 [interquartile range 10.0] days, p = 0.06). INTERPRETATION: More than 1 in 9 emergency department visits are due to drug-related adverse events, a potentially preventable problem in our health care system.