Clinically Significant Bradycardia and Hypotension Following Consumption of Betel Leaf in a Patient Treated for Chronic Atrial Fibrillation.

Purpose: A case of new onset bradycardia and hypotension following betel leaf consumption in combination with verapamil and metoprolol in an atrial fibrillation (AF) patient. Summary: A 66-year-old Nigerian woman presented to the emergency department for evaluation of multiple near syncope episodes with underlying AF and slow ventricular response. After initial evaluation, the patient disclosed she had ingested several betel leaves that morning. She was admitted for observation of severe, progressive hypotension and symptomatic bradycardia. Her past medical history included AF, type 2 diabetes, asthma, obesity, hypertension and hypothyroidism. Her home medications consisted of spironolactone, metoprolol succinate, and verapamil ER. Upon admission, her home medications were held. She received IV fluids and atropine .4 mg IV as needed for symptomatic bradycardia. Approximately 18 h following admission, her vital signs stabilized and her labs returned to baseline. She remained stable and was discharged with a recommendation to continue her home medications at prescribed doses with reduced doses of verapamil and metoprolol and to follow-up with her primary care provider. Conclusion: A patient with a history of AF developed significant hypotension and symptomatic bradycardia after betel leaf consumption resulting in an overnight critical care unit admission. The use of betel leaf is not common in the United States; however, practitioners should be cognizant of the use of complementary and alternative medications like betel leaf and incorporate this knowledge in patient evaluation. Patients consuming betel leaf or betel nut should be evaluated for cardiovascular effects as well as laboratory evaluation for organ damage.

Evaluation of a Clinical Pharmacist Specialist Transition of Care Pathway to Manage Heart Failure Readmissions During a Provider Shortage.

BACKGROUND: Evidence supports scheduling early follow-up after heart failure (HF) hospitalization with a provider capable of managing hypervolemia. Often this service is provided by cardiologists or specialty nurse practitioners. Continuity or "familiar" providers may be better positioned to identify decompensating HF in patients who have advanced HF and/or multiple complicating medical problems. The objective of this study was to evaluate whether a clinical pharmacy specialist (CPS) service, covering the role of a "familiar" provider in an advanced HF specialty clinic (AHFC) during a staffing shortage, may prevent readmission metrics from worsening. METHODS: We evaluated the entire, eligible concurrent cohorts, representing 175 AHFC-CPS and 273 control patient-admissions, respectively. Study- and disease-specific predictors for readmission were assessed. A matched cohort of 202 patient-admissions (101 AHFC-CPS:101 NO-CPS) were evaluated. RESULTS: Subjects were predominantly white, elderly males. While overall "clinic [performance] profiling" outcomes for readmissions (p = 0.43) and mortality (p = 0.66) did not statistically differ between the AHFC-CPS and NO-CPS groups, an imbalance in severity of illness persisted. A survival curve and analysis were constructed, and the hazard ratio for all-cause mortality was 0.69 (p = 0.033). CONCLUSIONS: This retrospective project supports the premise that AHFC-CPS intervention may be a suitable alternative to maintain the volume status for AHFC patients during a staffing short-fall. More work needs to be done to determine intervention effect size, predictors for readmission, specifically in advanced cardiovascular disease, and to evaluate CPS opportunities in the provision of independent HF care, particularly for patients with advanced HF.

The Impact of a Pharmacist-Driven Staphylococcus aureus Bacteremia Initiative in a Community Hospital: A Retrospective Cohort Analysis.

PURPOSE: Staphylococcus aureus is a leading cause of bacteremia with a 30-day mortality of 20%. This study evaluated outcomes after implementation of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) initiative in a community hospital. METHODS: This retrospective cohort analysis compared patients admitted with SAB between May 2015 and April 2018 (intervention group) to those admitted between May 2012 and April 2015 (historical control group). Pharmacists were notified of and responded to blood cultures positive for Staphylococcus aureus by contacting provider(s) with a bundle of recommendations. Components of the SAB bundle included prompt source control, selection of appropriate intravenous antibiotics, appropriate duration of therapy, repeat blood cultures, echocardiography, and infectious diseases consult. Demographics (age, gender, and race) were collected at baseline. Primary outcome was in-hospital mortality. Compliance with bundle components was also assessed. RESULTS: Eighty-three patients in the control group and 110 patients in the intervention group were included in this study. Demographics were similar at baseline. In-hospital mortality was lower in the intervention group (3.6% vs. 15.7%; p = 0.0033). Bundle compliance was greater in the intervention group (69.1% vs. 39.8%; p < 0.0001). CONCLUSIONS: We observed a significant reduction in in-hospital mortality and increased treatment bundle compliance in the intervention cohort with implementation of a pharmacist-driven SAB initiative. Pharmacists' participation in the care of SAB patients in the form of recommending adherence to treatment bundle components drastically improved clinical outcomes. Widespread adoption and implementation of similar practice models at other institutions may reduce in-hospital mortality for this relatively common and life-threatening infection.

Factors Associated With Prolonged Antibiotic Use in the Setting of Suspected Pneumonia and Negative Bronchoalveolar Lavage Cultures.

Background: Diagnostic criterion for pneumonia includes clinical data and bronchoalveolar lavage cultures (BALCx) to identify pathogens. Although ~60% of BALCx are negative, there may be reluctance to discontinue antibiotics, leading to prolonged antibiotic use (PAU). Objective: The purpose of this study is to compare outcomes of subjects with negative BALCx with PAU versus without prolonged antibiotic use (nPAU). Methods: A retrospective cohort study was conducted including subjects admitted to the intensive care unit (ICU), with suspected pneumonia, and negative BALCx. Data were compared based on length of exposure to antibiotics, PAU (antibiotics >4 days) versus nPAU (antibiotics <4 days). Results: A total of 128 subjects were included, 57 in the PAU group and 71 in the nPAU group. Baseline demographics were similar between groups. Severity of illness measured by multiple organ dysfunction scores at time of bronchoalveolar lavage (BAL) collection to final result showed a statistically significant decrease in the PAU group but not in the nPAU group. No differences were found in ICU days, ventilator-free days, or mortality; however, length of stay was longer for PAU (23 vs. 17, p = .04). In the PAU group, there were fewer BALCx results of "no growth" (23% vs. 45%, p = .04), more positive gram stains (83% vs. 60%, p = .01) and more positive non-BALCx (40% vs. 14%, p = .01). In a multivariate analysis, factors associated with PAU were positive BAL gram stains (adjusted odds ratio [aOR] 3.1, p = .037) and positive non-BALCx (aOR 4.7, p = .002). Conclusion: For subjects with suspected pneumonia and negative BALCx, positive non-BALCx and positive BALCx gram stain influenced the length of exposure of antibiotics.

Comparison of pharmacist- and provider-managed lithium in an inpatient medical center: A 6-month review.

BACKGROUND: Lithium is commonly used for the treatment of mood disorders and possesses a narrow therapeutic index. A medication utilization evaluation performed regarding its use at an academic medical center found that only 89.9% of patients received a lithium level within 24 hours of admission. This review prompted development of the evaluated protocol. OBJECTIVE: To compare pharmacist- and provider-managed safety and biochemical monitoring outcomes in a medical and psychiatric hospital population. METHODS: A retrospective chart review was conducted to identify hospitalized medical or psychiatric patients who received lithium therapy during a 6-month period. Patients were excluded if younger than 16 years or if lithium therapy was ordered but never administered. For cohort comparisons, descriptive statistics were used for baseline characteristics, and chi-square test or t test was used for outcomes. RESULTS: Pharmacists managed 67 patients versus 63 provider-managed patients. Pharmacist-managed patients were more likely to receive a lithium level within 24 hours of admission (100% vs. 89.1%, P = 0.012); receive a pregnancy test if indicated (90.5% vs. 41.7%, P < 0.001); have an identified drug interaction affecting lithium levels (47.8% vs. 27%, P = 0.014); and receive pharmacy-provided education (71.6% vs. 34.9%, P < 0.001). CONCLUSION: Patients initiated or maintained on lithium therapy require a unique level of management within the inpatient realm. The addition of lithium management to existing pharmacy services creates the opportunity to deliver safer and more complete patient care while expanding practice offerings for clinical pharmacists.

Retrospective Analysis of Oxcarbazepine in Pregnant Women With Substance Use Disorders: Focus on Safety.

BACKGROUND: Published safety data in pregnant epileptic women suggests that oxcarbazepine (OXC) may be a treatment option in nonepileptic pregnant women with substance use disorders (SUDs) and psychiatric symptomatology. OBJECTIVE: To compare safety outcomes associated with OXC exposure versus non-exposure in nonepileptic pregnant women with SUD and comorbid psychiatric symptomatology. METHODS: A retrospective chart review was conducted to identify pregnant women 18 years or older with a SUD who delivered at the study site. Exclusion criteria included a current diagnosis of epilepsy/seizure disorder; concurrent use of lithium, anticonvulsants, medications with a Risk Evaluation and Mitigation Strategy program or a black box warning for potential fetal toxicity; and multi-parity. Eligible patients were divided into two groups based on OXC exposure. RESULTS: The OXC group included 94 mother-neonate pairs versus 194 mother-neonate pairs in the non-OXC group. Baseline characteristics differed in mean number of prior pregnancies (2.8 vs 2.2 in the OXC and non-OXC group, respectively, P = .03). No significant differences were found regarding emergent cesarean or maternal hyponatremia. Average gestational age at OXC initiation was 19.8 weeks. No significant differences were found in the rates of prematurity, physical characteristics, malformation, and neonatal abstinence syndrome. CONCLUSION: OXC may be considered for management of SUD with comorbid psychiatric symptomatology in nonepileptic pregnant women. Further studies should be conducted to determine statistical significance in larger sample sizes.

Piperacillin-Tazobactam Versus Carbapenems for the Treatment of Nonbacteremic Urinary Tract Infections due to Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae.

Background: Carbapenems are the drug of choice for treatment of infections due to extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. Current evidence regarding piperacillin-tazobactam (PTZ) as an effective treatment alternative remains controversial. The purpose of this study was to determine the efficacy of PTZ versus carbapenems for treatment of nonbacteremic urinary tract infections (UTIs) due to ESBL-producing Enterobacteriaceae. Methods: A retrospective cohort study of patients treated for ESBL-related UTIs was conducted at three medical centers in the greater Middle Tennessee area. Patients were included if they were ≥ 18 years old, had a positive urine culture with an ESBL-producing organism, and received ≥ 48 hours of treatment with PTZ or carbapenem. Patients with bacteremia as well as those with isolates resistant to the treatment regimen selected were excluded. The primary objective was to determine the difference in clinical response between PTZ and carbapenem for treatment of ESBL-related UTIs. Clinical response was defined as absence of all of the following: (1) repeat admission for UTI caused by the same organism within 6 months, (2) repeat urine culture within 6 months showing growth of the same organism, or (3) a change in antimicrobial regimen due to subjective failure as determined by the ordering provider. Results: A total of 180 patients were included in the analysis (PTZ = 39; carbapenem = 141). There was no difference in clinical response between patients receiving PTZ and carbapenem (74.4% versus 80.9%; P = .38). Conclusion: PTZ may be an effective alternative to carbapenems for treatment of nonbacteremic UTIs due to ESBL-producing Enterobacteriaceae.

Treatment of Alcohol Withdrawal Syndrome: Phenobarbital vs CIWA-Ar Protocol.

BACKGROUND: Benzodiazepine-based therapy for alcohol withdrawal is associated with agitation and respiratory depression. Treatment can be complicated by a need for adjunctive therapy to control these symptoms and in patients requiring mechanical ventilation. Strong evidence for the effectiveness of alternative treatment modalities is lacking, despite the availability of promising pharmacological agents such as phenobarbital. OBJECTIVE: To compare the standard of care for the treatment of alcohol withdrawal-a symptom-triggered benzodiazepine protocol used in conjunction with the revised Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scale-with a phenobarbital protocol. METHODS: Retrospective cohort study conducted from January 2016 through June 2017 at a 42-bed medical intensive care unit in a private teaching hospital in Nashville, Tennessee. The primary outcome was intensive care unit length of stay. Secondary outcomes included hospital length of stay, incidence of invasive mechanical ventilation, and use of adjunctive pharmacotherapy. RESULTS: Patients who received phenobarbital had significantly shorter stays in the intensive care unit than did those who received therapy based on the CIWA-Ar scale (mean [SD], 2.4 [1.5] vs 4.4 [3.9] days; P < .001). Those who received phenobarbital also had significantly shorter hospital stays (4.3 [3.4] vs 6.9 [6.6] days; P = .004). The incidence of invasive mechanical ventilation was lower in the phenobarbital group (1 [2%] vs 14 [23%] patients; P < .001), as was use of adjunctive agents for symptom control, including dexmedetomidine (4 [7%] vs 17 [28%] patients; P = .002). CONCLUSION: A phenobarbital protocol for the treatment of alcohol withdrawal is an effective alternative to the standard-of-care protocol of symptom-triggered benzodiazepine therapy.

The Role of Computerized Clinical Decision Support in Reducing Inappropriate Medication Administration During Epidural Therapy.

Background: The use of epidural anesthesia has been shown to improve outcomes in the postoperative setting. To minimize risk of complications, avoiding certain medications with epidural anesthesia is advised. Objective: This study sought to determine the role of a computerized clinical decision support module implemented into the computerized physician order entry (CPOE) system on the incidence of administration of medications known to increase complications with epidural anesthesia. Methods: This study was a retrospective cohort chart review in adult patients receiving epidural anesthesia for at least 1 day. Patients were identified retrospectively and divided into 2 cohorts, those receiving an epidural 3 months prior to initiation of the module and those receiving an epidural 3 months following implementation. The primary end point was incidence of inappropriate medication administration before and after implementation. Complications of therapy were collected as secondary end points. Results: There was a reduction in the incidence of inappropriate medication administration in the postimplementation group versus the preimplementation group (6.3% vs 12.8%) although statistical significance was not achieved. In addition, the incidence of enoxaparin administration was significantly lower postimplementation than the preimplementation (0% vs 3.9%). There were no significant differences in other complications of therapy. Conclusions: This study demonstrated that application of decision support for this high-risk procedural population was able to eliminate the incidence of the most common inappropriate medication for epidural analgesia, enoxaparin. A reduction in incidence of other inappropriate medications was also observed; however, statistical significance was not reached. The use of computerized clinical decision support can be a powerful tool in reducing or ameliorating medication errors, and further study will be required to determine the most appropriate and effective implementation strategies.