Adherence to international guidelines for the treatment of meningitis infections in Lebanon.

OBJECTIVES: To assess meningitis treatment in Lebanon's compatibility with the Infectious Diseases Society of America (IDSA) guidelines and the effect of non-compliance on mortality. Methods: This is a retrospective study, conducted in 5 Lebanese hospitals, and enrolling all patients diagnosed with meningitis who presented to the involved hospitals from January 2008 to December 2016.  Results: A total of 252 participants were enrolled in the study. Of these patients, 205 (82.7%) were diagnosed with viral meningitis and 47 (17.3%) with bacterial meningitis, which was confirmed using laboratory tests. For patients with viral meningitis, 128 (62.4%) remained on the initial prescribed antibiotics despite the negative cerebrospinal fluid (CSF) and blood culture results. For bacterial meningitis patients, 30.8% received treatment regimen incompatible with the IDSA guidelines. The most common reason for the treatment incompatibility was the definitive drug choice after the culture results (49.1%) and the least common reason was inappropriate hospital stay days (25.9%). The mortality rate was 13.5%. Having low proteins values in the CSF (odds ratio=0.095) was associated with lower mortality compared to patients with normal protein values. Conclusion: This study shows a high percentage of inappropriate treatment in Lebanese hospitals despite these hospitals having adopted international treatment guidelines. This inappropriate management was associated with an increasing rate of mortality and neurological complications.

Assessment of vancomycin utilization among Lebanese hospitals.

OBJECTIVES: To assess the appropriateness of vancomycin dosing and monitoring at Lebanese hospitals. METHODS: This was a multicenter retrospective study conducted at 3 Lebanese hospitals between January and March 2018. Patients 18 years of age and older treated with vancomycin for a systemic infection or prophylaxis were eligible for study enrollment. Consistency with the Infectious Diseases Society of America guidelines was evaluated to determine whether the dose of vancomycin was appropriate, as well as for the time of trough measurement, and the target concentration obtained. RESULTS: From a total of 120 patients who met the inclusion criteria, only 11 (12%) were given the appropriate maintenance dose of vancomycin with respect to actual body weight. The trough levels were monitored for 67 (55.8%) patients, with 20 (29.9%) of these patients achieving appropriate therapeutic trough levels of 15-20 mg/l. The trough concentration time measurement before the fourth dose was only carried out in 28 (41.8%) of the 67 patients. CONCLUSION: This study reveals a gap between the appropriate utilization of vancomycin with respect to the international guidelines in the studied Lebanese hospitals. It highlights the need for dosing and monitoring protocols suitable for vancomycin utilization in these hospitals.

The Community Pharmacist's Role in Reducing Cardiovascular Risk Factors in Lebanon: A Longitudinal Study.

OBJECTIVE: To assess the role of the pharmacist in modifying risk factors for cardiovascular disease (CVD) among Lebanese adults in urban and rural areas. METHODS: In a prospective survey, 865 out of 1,000 participants aged ≥45 years, previously interviewed, agreed to be followed at 1 and 2 years time points. Parameters including blood pressure, lipid profile, blood glucose, average number of risk factors, and atherosclerotic CVD (ASCVD) risk were assessed and evaluated at the beginning of the study, then after 1 and 2 years. RESULTS: During both follow-ups, the mean average body mass index and systolic blood pressure decreased significantly and the lipid profile improved significantly. Further significant improvements in ASCVD risk occurred during the second follow-up. Monitoring parameters revealed significant improvements as well. CONCLUSION: This study showed that a plan that includes pharmacists, who regularly monitor and follow-up patients, could improve CVD prevention through the reduction of risk factors.

A multicenter, prospective study evaluating the impact of the clinical pharmacist-physician counselling on warfarin therapy management in Lebanon.

BACKGROUND: Health care professionals (HCP) are known key elements of effective patient's counselling and education. For patients taking warfarin, education about the dose, side effects, and toxicity is clearly identified as a cornerstone of achieving improved health and quality of life. The study objective was to evaluate the patients' knowledge about warfarin and assess the impact of the health care professionals' counselling in enhancing patients' knowledge in achieving warfarin therapeutic outcomes. METHOD: A six-month prospective multicentered study was conducted in three hospitals, enrolling 300 patients admitted to the cardiac care unit and internal medicine departments. Patients' warfarin knowledge and INR levels were assessed before and after the clinical pharmacist counselling. The main therapeutic outcome was the impact of the clinical pharmacist-physician counselling on improving patient's education and achieving therapeutic INR level. RESULTS: A higher mean knowledge about warfarin score was found after counselling as compared to before counselling (4.82 vs 13.2; p < 0.001). Likewise, the drug dose (1.05 vs 1.88), drug toxicity (0.41 vs 1.92), drug-drug and food-drug interactions (0.02 vs 1.89), therapeutic INR and general drug knowledge scores (2.66 vs 4.68) were significantly higher after as compared to before counselling (p < 0.001 for all variables). The percentages of patients who achieved therapeutic INR levels pre/post counselling was 37.2% and 74.4% respectively (p < 0.001). CONCLUSION: Based on the study findings, HCP play a major role in enhancing patients' knowledge about the factors that affect warfarin therapeutic outcomes. This study highlights the need to establish and develop strategies for appropriate warfarin utilization in Lebanon.

Anticoagulant therapy in pediatrics.

Thromboembolic episodes are disorders encountered in both children and adults, but relatively more common in adults. However, the occurrence of venous thromboembolism and use of anticoagulants in pediatrics are increasing. Unfractionated Heparin (UH) is used as a treatment and prevention of thrombosis in adults and critically ill children. Heparin utilization in pediatric is limited by many factors and the most important ones are Heparin Induced Thrombocytopenia (HIT) and anaphylaxis. However, Low Molecular Weight Heparin (LMWH) appears to be an effective and safe alternative treatment. Hence, it is preferred over than UH due to favorable pharmacokinetic and side effect profile. Direct Thrombin Inhibitors (DTI) is a promising class over the other anticoagulants since it offers potential advantages. The aim of this review is to discuss the differences between adult and pediatric thromboembolism and to review the current anticoagulants in terms of pharmacological action, doses, drug reactions, pharmacokinetics, interactions, and parameters. This review also highlights the differences between old and new anticoagulant therapy in pediatrics.

Practice of switch from intravenous to oral antibiotics.

Hospitalized patients initially on intravenous antibiotics can be safely switched to an oral equivalent within the third day of admission once clinical stability is established. This conversion has many advantages as fewer complications, less healthcare costs and earlier hospital discharge. The three types of intravenous to oral conversion include sequential, switch, and step-down therapy. The aim of the study was to evaluate the practice of switching from intravenous to oral antibiotics, its types and its impact on the clinical outcomes. This was a retrospective observational study conducted in three Lebanese hospitals over a period of six months. Adult inpatients on intravenous antibiotics for 2 days and more were eligible for study enrollment. Excluded were patients admitted to care or surgery units, or those with gastrointestinal diseases, infections that require prolonged course of parenteral therapy, or malignancies. The study showed that among 452 intravenous antibiotic courses from 356 patients who were eligible for conversion, only one third were switched and the others continued on intravenous antibiotics beyond day 3 (P <0.0001). The mean duration of intravenous therapy of converted patients was markedly shorter than the non-converted (P <0.0001) with no significant change in the mean length of stay. Fluoroquinolones and macrolides were the most commonly converted antibiotics. However, the sequential therapy was the major type of conversion practiced in this study. Based on the study findings, a significant proportion of patients can be considered for switch. This emphasizes an important gap in the field of conversion from intravenous to oral antibiotic therapy and the need for integration and reinforcement of the appropriate Antibiotic Stewardship Programs in hospitals.