Specialized Pharmacist Roles and Perspectives in the Collaborative Management of COVID-19.

The COVID-19 pandemic poses a multitude of unprecedented challenges to the healthcare system and broader public policy arena. Comprehensive guidelines and recommendations have been slow to develop as each community and medical institution face unique challenges due to a dissimilarity in demographics and resources. We seek to describe the experience at our institution to highlight challenges that others may encounter with an emphasis on the value that specialized pharmacists can provide at various levels of the healthcare system.

Using the Theory of Planned Behavior to Evaluate Factors That Influence PharmD Students' Intention to Attend Lectures.

Objective. To use the theory of planned behavior (TPB) to evaluate the contribution of attitude, subjective norm, and perceived behavioral control in predicting students' intention to attend class lectures in a Doctor of Pharmacy (PharmD) curriculum in which lecture recordings were available. Methods. A survey instrument based on the TPB was developed from focus groups with PharmD students. The survey was then distributed to first through third year students at the conclusion of the 2017-2018 academic school year. Respondents were asked to evaluate their beliefs regarding lecture attendance and their intention to attend lectures during the upcoming fall semester. Predictors of intention were evaluated using descriptive statistics and multiple logistic regression analyses. Results. Responses from 198 of 383 students contained usable data (52% effective response rate). The TPB constructs of attitude and subjective norm were predictors of high intention to attend lectures. Students with a positive attitude towards lecture attendance (eg, believed that purposeful active learning is desirable and occurs during class) were nearly 30% more likely to have high intention to attend lectures. Students with a positive subjective norm (ie, perceived social pressure from professors and classmates to attend lectures) were 66% more likely to have high intention to attend lectures. Perceived behavioral control was not associated with high intention to attend lectures. Conclusion. Interventions aimed at improving students' attitudes and subjective norm may be beneficial in improving students' intention to attend class lectures.

Corrigendum to "In Vivo Resistance to Ceftolozane/Tazobactam in Pseudomonas aeruginosa Arising by AmpC- and Non-AmpC-Mediated Pathways".

[This corrects the article DOI: 10.1155/2018/9095203.].

Self-perceived impact of stroke: A longitudinal comparison between one and five years post-stroke.

OBJECTIVE: To investigate different aspects of self-perceived impact of stroke 1 and 5 years after stroke onset, with a focus on self-perceived participation. DESIGN: Longitudinal cohort study. PARTICIPANTS: Forty-five persons diagnosed with first-time stroke included in the Stroke Arm Longitudinal study at University of Gothenburg (SALGOT). METHODS: Participants responded to the Stroke Impact Scale, the Impact on Participation and Autonomy and the European Quality of Life 5 dimensions at 1 year and 5 years post-stroke. Wilcoxon signed-rank test was used to check for differences in changes over time between groups. RESULTS: In general, the perceived consequences of stroke were more severe after 5 years compared with at 1 year. Strength, emotion and participation were the areas most affected, along with restrictions in social life and autonomy indoors. Global disability (mRS) was moderately correlated with quality of life. CONCLUSION: The perceived impact of stroke becomes more prominent with time, even for persons with mild-to-moderate stroke. This study highlights the need for long-term support for persons with stroke.

Economic health care costs of blood culture contamination: A systematic review.

BACKGROUND: Blood culture contamination with gram-positive organisms is a common occurrence in patients suspected of bloodstream infections, especially in emergency departments. Although numerous research studies have investigated the cost implications of blood culture contamination, a contemporary systematic review of the literature has not been performed. The aim of this project was to perform a systematic review of the published literature on the economic costs of blood culture contamination. METHODS: PubMed was searched (January 1, 1978, to July 15, 2018) using the search terms "blood culture contamination" or "false-positive blood cultures." Articles were title searched and abstracts were reviewed for eligible articles that reported immediate or downstream economic costs of blood culture contamination. RESULTS AND DISCUSSION: The PubMed search identified 151 relevant articles by title search, with 49 articles included after abstract review. From the studies included, overall blood culture contamination rates ranged from 0.9%-41%. Up to 59% of patients received unnecessary treatment with parenteral vancomycin as a result of blood culture contamination, resulting in increased pharmacy charges between $210 and $12,611 per patient. Increases in total laboratory charges between $2,397 and $11,152 per patient were reported. Attributable hospital length of stay increases due to blood culture contamination ranged from 1-22 days. CONCLUSIONS: This systematic review of the literature identified several areas of health care expenditure associated with blood culture contamination. Interventions to reduce the risk of blood culture contamination would avoid downstream economic costs.

Significant Publications on Infectious Diseases Pharmacotherapy in 2017.

PURPOSE: The most significant peer-reviewed articles pertaining to infectious diseases (ID) pharmacotherapy, as selected by panels of ID pharmacists, are summarized. SUMMARY: Members of the Houston Infectious Diseases Network (HIDN) were asked to nominate peer-reviewed articles that they believed most contributed to the practice of ID pharmacotherapy in 2017, including the areas of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). A list of 33 articles related to general ID pharmacotherapy and 4 articles related to HIV/AIDS was compiled. A survey was distributed to members of the Society of Infectious Diseases Pharmacists (SIDP) for the purpose of selecting 10 articles believed to have made the most significant impact on general ID pharmacotherapy and the single significant publication related to HIV/AIDS. Of 524 SIDP members who responded, 221 (42%) and 95 (18%) members voted for general pharmacotherapy- and HIV/AIDS-related articles, respectively. The highest ranked articles are summarized below. CONCLUSION: Remaining informed on the most significant ID-related publications is a challenge when considering the large number of ID-related articles published annually. This review of significant publications in 2017 may aid in that effort.

Estimated Clinical and Economic Impact through Use of a Novel Blood Collection Device To Reduce Blood Culture Contamination in the Emergency Department: a Cost-Benefit Analysis.

Blood culture contamination results in increased hospital costs and exposure to antimicrobials. We evaluated the potential clinical and economic benefits of an initial specimen diversion device (ISDD) when routinely utilized for blood culture collection in the emergency department (ED) of a quaternary care medical center. A decision analysis model was created to identify the cost benefit of the use of the ISDD device in the ED. Probabilistic costs were determined from the published literature and the direct observation of pharmacy/microbiology staff. The primary outcome was the expected per-patient cost savings (microbiology, pharmacy, and indirect hospital costs) with the routine use of an ISDD from a hospital perspective. The indirect costs included those related to an increased hospital length of stay, additional procedures, adverse drug reactions, and hospital-acquired infections. Models were created to represent hospitals that routinely or do not routinely use rapid diagnostic tests (RDT) on positive blood cultures. The routine implementation of ISDD for blood culture collection in the ED was cost beneficial compared to conventional blood culture collection methods. When implemented in a hospital utilizing RDT with a baseline contamination rate of 6%, ISDD use was associated with a cost savings of $272 (3%) per blood culture in terms of overall hospital costs and $28 (5.4%) in direct-only costs. The main drivers of cost were baseline contamination rates and the duration of antibiotics given to patients with negative blood cultures. These findings support the routine use of ISDD during blood culture collection in the ED as a cost-beneficial strategy to reduce the clinical and economic impact of blood culture contamination in terms of microbiology, pharmacy, and wider indirect hospital impacts.

Effect of elevated imipenem/cilastatin minimum inhibitory concentrations on patient outcomes in Gram-negative bloodstream infections.

OBJECTIVES: Carbapenem minimum inhibitory concentration (MICs) are known to predict outcomes for patients with Gram-negative bacteraemia. However, limited data exist on how MICs influence such outcomes when organisms are classified as carbapenem-resistant. The purpose of this study was to evaluate the effect of increasing imipenem/cilastatin MICs on mortality in patients with Gram-negative bloodstream infection (BSI). METHODS: Patients with an imipenem/cilastatin-resistant (MIC>4mg/L) monomicrobial Gram-negative BSI were eligible for inclusion in the study and were assessed for baseline characteristics, organ function, microbiological data, timing and type of therapeutic treatment, and in-hospital mortality. RESULTS: A total of 62 patients with imipenem/cilastatin-resistant bacterial isolates (MIC>4mg/L) were retrospectively studied. Time to event analyses found no difference between patients who received carbapenem therapy and those who did not (P=0.10). After adjustment, patients receiving directed therapy were less likely to die (adjusted hazard ratio=0.35, 95% confidence interval 0.15-0.83; P<0.01), whereas higher modified Acute Physiology and Chronic Health Evaluation (APACHE) II score and days to positive culture were associated with non-survival. CONCLUSION: This study did not demonstrate a relationship between receipt of a carbapenem and mortality in patients with carbapenem-resistant Gram-negative BSI.

Significant Publications on Infectious Diseases Pharmacotherapy in 2016.

PURPOSE: This is a summary of the most important articles on infectious diseases (ID) pharmacotherapy published in peer-reviewed literature in 2016 as selected by clinical pharmacists with ID expertise. SUMMARY: The Houston Infectious Diseases Network (HIDN) was asked to identify articles published in peer-reviewed literature in 2016 that were believed to contribute significantly to ID pharmacotherapy, including human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). A list of 46 articles on general ID pharmacotherapy and 8 articles on HIV/AIDS were nominated. Members of the Society of Infectious Diseases Pharmacists (SIDP) were surveyed to select 10 general ID articles believed to have made a significant impact on general ID pharmacotherapy and 1 article most significant to HIV/AIDS pharmacotherapy. Of 445 SIDP members surveyed, 212 (47.6%) and 95 (21.3%) members voted for general ID pharmacotherapy- and HIV/AIDS-related articles, respectively. The 11 highest-ranked papers (10 general ID-related articles and 1 HIV/AIDS-related article) are summarized here. CONCLUSION: With the large number of ID-related articles published each year, it can be challenging to stay current with the most relevant ID publications. This review of significant publications in 2016 may provide a starting point for that process.

In Vivo Resistance to Ceftolozane/Tazobactam in Pseudomonas aeruginosa Arising by AmpC- and Non-AmpC-Mediated Pathways.

Two pairs of ceftolozane/tazobactam susceptible/resistant P. aeruginosa were isolated from 2 patients after exposure to ß-lactams. The genetic basis of ceftolozane/tazobactam resistance was evaluated, and ß-lactam-resistant mechanisms were assessed by phenotypic assays. Whole genome sequencing identified mutations in AmpC including the mutation (V213A) and a deletion of 7 amino acids (P210-G216) in the Ω-loop. Phenotypic assays showed that ceftolozane/tazobactam resistance in the strain with AmpCV213A variant was associated with increased ß-lactamase hydrolysis activity. On the other hand, the deletion of 7 amino acids in the Ω-loop of AmpC did not display enhanced ß-lactamase activity. Resistance to ceftolozane/tazobactam in P. aeruginosa is associated with changes in AmpC; however, the apparent loss of ß-lactamase activity in AmpC∆7 suggests that non-AmpC mechanisms could play an important role in resistance to ß-lactam/ß-lactamase inhibitor combinations.

Prediction of inventory sustainability during a drug shortage.

PURPOSE: A methodology for predicting how long the on-hand inventory of a given medication will last during a supply shortage is described; a practical example of application of the methodology is provided. METHODS: Single-site data on consumption of i.v. tobramycin over an eight-month evaluation period were collected using commercial software that tabulates barcode-assisted medication administration (BCMA) events; administered doses were standardized as 1200-mg "vial-equivalents" and summed over the review period. The total number of vial-equivalents consumed was divided by the number of "non-zero weeks of consumption" (i.e., weeks during which any tobramycin use occurred) to obtain a mean ± S.D. weekly consumption rate; this rate was multiplied by the total i.v. tobramycin on-hand supply (in vial-equivalents) to determine the mean number of potentially sustainable weeks of therapy in the event a shortage were to restrict the future supply of the drug. RESULTS: Overall, 99.6 vial-equivalents of i.v. tobramycin were used during the evaluation period. The mean ± S.D. number of vial-equivalents used per non-zero week of consumption was 3.11 ± 1.26. A manual count of pharmacy inventory revealed that 102.9 vial-equivalents were available at the time of analysis. The mean predicted duration of supply was 33 weeks (95% confidence interval, -126 to 192 weeks). CONCLUSION: Available BCMA data on tobramycin consumption over eight months were used to calculate the mean number of weeks the on-hand supply of the drug could be expected to last during a persistent drug shortage.

Development of a pharmacy student research program at a large academic medical center.

PURPOSE: A program to promote research by pharmacy students created through the collaboration of an academic medical center and a college of pharmacy is described. SUMMARY: In 2009, Midwestern University Chicago College of Pharmacy and Northwestern Memorial Hospital (NMH) expanded their existing partnership by establishing a program to increase opportunities for pharmacy students to conduct clinical-translational research. All professional year 1, 2, or 3 students at the college, as well as professional year 4 students on rotation at NMH, can participate in the program. Central to the program's infrastructure is the mentorship of student leads by faculty- and hospital-based pharmacists. The mentors oversee the student research projects and guide development of poster presentations; student leads mentor junior students and assist with orientation and training activities. Publication of research findings in the peer-reviewed literature is a key program goal. In the first four years after program implementation, participation in a summer research program grew nearly 10-fold (mainly among incoming professional year 2 or 3 students, and student poster presentations at national pharmacy meetings increased nearly 20-fold; the number of published research articles involving student authors increased from zero in 2009 to three in 2012 and two in 2013. CONCLUSION: A collaborative program between an academic medical center and a college of pharmacy has enabled pharmacy students to conduct research at the medical center and has been associated with increases in the numbers of poster presentations and publications involving students.

Microbiologic clearance following transition from standard infusion piperacillin-tazobactam to extended-infusion for persistent Gram-negative bacteremia and possible endocarditis: A case report and review of the literature.

INTRODUCTION: We sought to describe a case of pharmacodynamically-optimized dosing of piperacillin-tazobactam in a patient that cleared their infections after treatment with high-dose, extended-infusion piperacillin-tazobactam and summarize the literature on the benefits of extended-infusion of beta-lactams. CASE REPORT: At an outside hospital, a 78 year-old male presented with fevers and shortness of breath. He was empirically initiated on standard doses of vancomycin and piperacillin-tazobactam for suspected pneumonia and sepsis. Blood and sputum cultures identified Elizabethkingia meningosepticum sensitive only to piperacillin-tazobactam by E-test susceptibility testing. After 10 days of empiric therapy with piperacillin-tazobactam dosed at 3.375 g IV every 8 h over 30 min, the patient transferred to our institution and was initiated on piperacillin-tazobactam at 3.375 g IV every 8 h administered as a 4 h infusion. The patient failed to improve; piperacillin-tazobactam was changed to 4.5 g IV over 4 h every 8 h and later changed to the hospital protocol dose of 3.375 g IV over 4 h every 6 h. The patient achieved negative blood cultures within 24 h of optimized dosing. DISCUSSION: We present the first case to our knowledge that describes failure to respond and subsequent response within a single patient where beta-lactam dosing was altered to optimize pharmacokinetics and pharmacodynamics (PK-PD). Our patient received non-standard dose-escalation for piperacillin-tazobactam. Drug exposure was estimated post-hoc utilizing robust mathematical simulations to describe alterations in disposition over time. This case demonstrates that extended-infusion administration of beta-lactams may provide improved microbiological activity.

Peramivir: an intravenous neuraminidase inhibitor.

INTRODUCTION: Peramivir (BCX-1812, RWJ-270201) is a highly selective inhibitor of influenza A and B neuraminidase that has recently been approved in the USA by the FDA to treat acute, uncomplicated influenza in adults. AREAS COVERED: This review examines the discovery and development of peramavir as well as its role in the treatment of influenza. Peramivir is currently the only FDA-approved anti-influenza agent that can be given as an intravenous injection, granting it a unique role in therapy with the potential to improve adherence and outcomes in patients who are unable to tolerate oral agents. In vitro, animal, human and safety data are presented as well as information regarding special populations, resistance and drug approval. EXPERT OPINION: Clinical trial data support the use of peramivir to relieve influenza symptoms in acute, uncomplicated influenza, with improvements over placebo similar to those of other approved anti-influenza treatments. The ability to give a one-time injectable dose offers improved adherence over currently available oral regimens. While not approved for hospitalized patients, available data suggest that multiple dose peramivir may also have a role in treatment of severally ill, hospitalized patients. Supportive data for the use of peramivir in special patient populations such as pediatrics and those especially at-risk to develop severe influenza symptoms are promising; however, they require further study.

Drug shortages and patient safety: an overview of essential information for the infusion nurse.

Drug shortages present a growing problem in the United States, with the majority of shortages occurring among sterile injectable medications. Although the impact of shortages has been shown to adversely affect patient care in a variety of settings, those who are dependent on outpatient or home infusion therapy are especially vulnerable. Legislative action and the efforts of the U.S. Food and Drug Administration have helped reduce the occurrence of new shortages; however, the problem is not likely to be eliminated in the short term and requires effective management strategies.

Projections for antiinfective drug shortages and time to actual resolution.

PURPOSE: The results of a national study of projected versus actual times to resolution of temporary U.S. shortages of antiinfective drugs are presented. METHODS: Descriptive data on antiinfective drug shortages, including differences between manufacturer-estimated and actual times to shortage resolution, were collected over a one-year period via regular monitoring of the websites of ASHP and the Food and Drug Administration. Inventory data from one large hospital in the Midwest were collected in order to characterize realized shortages (i.e., those for which mitigation was required). RESULTS: During the study period, there were 47 transient shortages of antiinfective medications involving 381 unique products or formulations, of which 40% (n = 19) were emergent shortages. Generic-only and brand-only medications accounted for 53% (n = 25) and 21% (n = 10) of the evaluated shortages, respectively; the median shortage duration was 40 days (interquartile range [IQR], 22-91 days). The reasons for shortages most frequently cited by manufacturers were product or formulation discontinuation (21%), increased demand (12%), and raw material shortfalls (8%). Some shortages were resolved sooner than originally projected, but overall, actual shortage durations exceeded manufacturer-projected durations by a median of 17 days (IQR, 0-52.5 days). Ten realized shortages occurred at the hospital study site, compelling the antimicrobial stewardship team to recommend alternative therapies or restrict the use of drugs in short supply. CONCLUSION: The actual durations of evaluated antiinfective drug shortages during the study period were longer than the manufacturer-projected durations by a median of 17 days.

Developing a Method for Reporting Patient Harm Due to Antimicrobial Shortages.

INTRODUCTION: The number of drug shortages in the United States has increased in recent years. While some literature exists on factors that contribute to antimicrobial shortages, the need remains to accurately gage the level of patient harm incurred as a result of realized antimicrobial shortages. Furthermore, current methods of reporting adverse drug events are known to under-report instances of patient harm. We sought to develop an ongoing and accurate method of reporting patient harm due to antimicrobial shortages, which was convenient, anonymous, and allowed clinicians to estimate the causality due to a shortage. METHODS: We distributed a public SurveyMonkey(®) (SurveyMonkey, Palo Alto, CA, USA) link to gather information regarding institution (for de-duplicating purposes), patient age, sex, antimicrobial product on shortage, type of infection requiring treatment or prophylaxis, adverse event, and patient outcome. RESULTS: To date complete data were reported on four patients being treated for infections that included Stenotrophomonas maltophilia bacteremia, Pneumocystis jirovecii pneumonia, neonatal sepsis of unknown etiology, and cytomegalovirus colitis. Antimicrobials that were unavailable to patients included sulfamethoxazole-trimethoprim, gentamicin, and foscarnet. Two adverse events (a delay in treatment and an inability to treat with other antimicrobials due to resistance) were attributed with probable causality due to a shortage, while the remaining adverse events (death and an inability to tolerate high oral doses) were attributed to have unlikely and possible causalities due to a shortage, respectively. CONCLUSION: These methods encourage reports of antimicrobial shortage harms.

Residency Information Preferences of Recent Pharmacy Residency Applicants.

Background: The increasing number of both postgraduate year (PGY)-1 and PGY-2 residency programs and applicants requires all parties to discriminate among the many options available in the marketplace. Studies assessing the information preferences of pharmacy students searching for residencies, including the utility and popularity of information sources (eg, school brochures, program Web sites, etc), are lacking. Objective: The preferences of recent residency applicants for types and sources of residency program information were assessed to improve the recruitment strategies of residency programs. Methods: A survey was distributed to 1515 residency program directors (RPDs). Questions solicited information regarding use of electronic resources and preference of information used to discriminate between residency programs prior to and during the application/interviewing process. Results: One hundred ninety-two RPDs responded and forwarded the survey to 522 PGY-1 residents and 207 PGY-2 residents. Completed surveys were submitted by 75.7% (n = 395) of PGY-1 residents and 57.5% (n = 119) of PGY-2 residents (overall response rate 71.3%). Participants ranked the program's Web site followed by a flash drive containing information about the program as the most preferred sources of information. Participants noted that required (n = 464) and elective learning experiences (n = 463) and current positions of past residents (n = 310) were very important information when deciding to apply to a program. Overall, 68.3% (n = 341) of participants indicated that they agreed or strongly agreed that electronic information sources were preferred over paper information sources. Conclusion: Residency programs should dedicate resources to ensuring that their Web site includes information regarding learning experiences and the current positions of past residents.