Comparison of the rates of Clostridium difficile and bacteremia after delaying fluoroquinolone prophylaxis from day 0 to day +3 post autologous stem cell transplantation.

Prophylactic fluoroquinolones are routinely administered after stem cell transplantation (SCT) to prevent bacterial infection; however, fluoroquinolones may increase the risk of Clostridium difficile infection, particularly in immunocompromised patients. This study is designed to evaluate the effect of a delay by 3 days in fluoroquinolone prophylaxis after autologous SCT (ASCT) on the rates of C. difficile infection and bacteremia. A single-center retrospective cohort study was performed in 118 patients who received levofloxacin prophylaxis following ASCT at our institution between November 2014 and October 2015. In efforts to reduce the rate of C. difficile, initiation of levofloxacin prophylaxis was delayed from day 0 to day +3 of SCT beginning April 30, 2015. The incidence of C. difficile infection and of bacteremia in patients who initiated levofloxacin on day 0 was compared with those who started prophylaxis on day +3. We found no difference in the rates of C. difficile (7.9% vs 5.5%, P=.593) and bacteremia (7.9% vs 3.6%, P=.323) in patients who initiated levofloxacin on day 0 compared with those who initiated prophylaxis on day +3. Delaying the initiation of levofloxacin prophylaxis by 3 days post ASCT showed no difference in the incidence of C. difficile or bacteremia. Future studies are warranted to show feasibility of delaying the initiation of antibiotic prophylaxis until neutropenia post ASCT, to further minimize the duration of antibiotic exposure.

Reducing excessive medication administration in hospitalized adults with renal dysfunction.

Medication errors are common and harm hospitalized patients. The authors designed and implemented an automated system to complement an existing computerized order entry system by detecting the administration of excessive doses of medication to adult in-patients with renal insufficiency. Its impact, in combination with feedback to prescribers, was evaluated in 3 participating nursing units and compared with the remainder of a tertiary care academic medical center. The baseline rate of excessive dosing was 23.2% of administered medications requiring adjustment for renal insufficiency given to patients with renal impairment on the participating units and 23.6% in the rest of the hospital. The rate fell to 17.3% with nurse feedback and 16.8% with pharmacist feedback in the participating units (P<.05 for each, relative to baseline). The rates of excessive dosing for the same time periods were 26.1% and 24.8% in the rest of the hospital. Automated detection and routine feedback can reduce the rate of excessive administration of medication in hospitalized adults with renal insufficiency.

Use of biological based therapy in patients with cardiovascular diseases in a university-hospital in New York City.

BACKGROUND: The use of complementary and alternative products including Biological Based Therapy (BBT) has increased among patients with various medical illnesses and conditions. The studies assessing the prevalence of BBT use among patients with cardiovascular diseases are limited. Therefore, an evaluation of BBT in this patient population would be beneficial. This was a survey designed to determine the effects of demographics on the use of Biological Based Therapy (BBT) in patients with cardiovascular diseases. The objective of this study was to determine the effect of the education level on the use of BBT in cardiovascular patients. This survey also assessed the perceptions of users regarding the safety/efficacy of BBT, types of BBT used and potential BBT-drug interactions. METHOD: The survey instrument was designed to assess the findings. Patients were interviewed from February 2001 to December 2002. 198 inpatients with cardiovascular diseases (94 BBT users and 104 non-users) in a university hospital were included in the study. RESULTS: Users had a significantly higher level of education than non-users (college graduate: 28 [30%] versus 12 [12%], p = 0.003). Top 10 BBT products used were vitamin E [41(43.6%)], vitamin C [30(31.9%)], multivitamins [24(25.5%)], calcium [19(20.2%)], vitamin B complex [17(18.1%)], fish oil [12(12.8%)], coenzyme Q10 [11(11.7%)], glucosamine [10(10.6%)], magnesium [8(8.5%)] and vitamin D [6(6.4%)]. Sixty percent of users' physicians knew of the BBT use. Compared to non-users, users believed BBT to be safer (p < 0.001) and more effective (p < 0.001) than prescription drugs. Forty-two potential drug-BBT interactions were identified. CONCLUSION: Incidence of use of BBT in cardiovascular patients is high (47.5%), as is the risk of potential drug interaction. Health care providers need to monitor BBT use in patients with cardiovascular diseases.

Investigation of correlation between house-staff work hours and prescribing errors.

PURPOSE: The possible correlation between the frequency and significance of prescribing errors and the number of hours worked during a 24-hour shift by hospital house staff was studied. METHODS: A prospective observational trial was conducted in two internal medicine units at an academic medical center. Orders written by medical house staff covering the study units between January 8 and March 10, 2001, were collected daily and evaluated for obvious prescribing errors, the type and significance of the errors, and the number of hours the resident had worked during a 24-hour shift at the time of the prescribing error. RESULTS: A total of 45,366 orders (including orders for medications, laboratory tests, diagnostic procedures, and nursing care) were entered on the study units during the study period. A total of 498 erroneous prescribing orders were identified. A majority of the erroneous orders (77%) could have resulted in significant morbidity or mortality had they reached the patient. The most common errors involved the wrong dose (18%), the wrong dosage frequency (15%), and duplicate orders (15%). There was no statistically significant correlation between the number of hours worked and the frequency or significance of the errors. CONCLUSION: The number of hours worked by medical house staff during a 24-hour shift did not appear to affect the frequency or significance of their prescribing errors.

Psychotropic drug versus psychotropic drug-update.

Psychotropic drugs are not necessarily the drugs of psychiatry. Seventy percent of antidepressants, and 90% of anxiolytics are prescribed by nonpsychiatric physicians. Since psychotropic medications are so frequently employed by nonpsychiatric physicians, e.g., neurologists, primary care physicians, internists, and because large numbers of their patients are concurrently on medical drugs for somatic reasons, the interactions of psychotropic versus medical drugs and psychotropic versus psychotropic drugs as listed below must be understood before primary care physicians or psychiatrists prescribe psychotropic medications, especially to the medically ill. Seventy commonly prescribed psychotropic drugs were examined for their interactions with other psychotropic medications using six reference tools: 1) MEDLINE (PubMed) employing the first generic psychotropic drug name, the second generic psychotropic drug name, and the term "interaction;" 2) Hanston's Drug Interaction Analysis and Management Text (quarterly updated version); 3) Drug Interactions Facts (Facts and Comparisons) (July 2001 quarterly updated version); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; and 6) Food and Drug Administration (MedWatch) (Dear Doctor Letters and new labeling) ( for (1999, 2000, and 2001). The authors recognized that all of the above sources do not necessarily cover the entire information database regarding drug-drug interactions. (Citations regarding children, reports in foreign languages or concerning food, animals, in vitro experiments, analgesics, and naturalistic-herbal or natural products-treatment interactions were excluded).

Comparison of three methods for identifying medical drug-psychotropic drug interactions.

Three methods for examining drug-drug interactions were compared to understand advantages and disadvantages of each: ePocrates; Interact; The Mount Sinai multiple source for the evaluation of drug-drug interactions (MS). ePocrates is a commonly employed software system utilized in a hand held computer, the PalmPilot. Interact is on a CD-ROM, and promoted by the American Psychiatric Association Press. The MS system was developed by the authors and utilizes six separate references sources to ascertain the presence and significance of drug-drug interactions. Commonly prescribed neurology and psychotropic medication interactions were compared using the three systems. ePocrates did not list the significance level of the interaction, e.g., (major, moderate, minor), often did not include a mechanism of action, and several commonly employed medications were not included. It did permit examining several drugs at the same time, and was easily carried on the person of the physician. Interact often contained old references, several drugs were not included, was not adapted to a hand held computer format, and had no update since 1999. The MS system listed level of significance, provided mechanism of action, and advice to the practitioner including recommendations. It is not portable, requiring a laptop or desk top computer or hard copy, and only searches one drug at a time. It is hoped that the advantages of each of these three systems may be incorporated into systems of the future.

Neurologic drug-psychotropic drug update.

It is essential that both the neurologist and the psychiatrist be aware of the neurology drug-psychotropic drug interactions because neurologists prescribe many psychotropic medications and psychiatric consultants often recommend the use of psychotropic drugs for neurology patients. Six methods of examining drug-drug interactions were employed: 1) PubMed (MEDLINE); 2) Hanston's Drug Interaction Analysis and Management Text (July 2001 quarterly updated version); 3)Drug Interactions Facts (quarterly updated version through July 2001); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; 6) Food and Drug Administration (MedWatch) Dear Doctor Letters and new labeling. Over eighty important interactions of significance level 1 (major), or significance level 2 (minor) were found. Furthermore, over one-third of the neurologist's most commonly administered medications were those also employed by the psychiatrist, but not necessarily for the same reason, e.g., carbamazepine, for seizure control (neurologist) or mood stabilization (psychiatrist).

Cardiac drug-psychotropic drug update.

This is an update from the report-Cardiac Drug and Psychotropic Drug Interactions: Significance and Recommendations-published in this journal in November-December 1999. As mentioned in that article there has been an explosion of new drugs both in psychiatry and cardiology without a sufficient understanding of their potential interactions. Also there is a need for methods to update drug interactions on an ongoing basis. This report describes: 1) examples of actual adverse interactions from clinical cases that move beyond some of the hypothesized contraindications included in the 2000 millennium publication; 2) confirmation of previous adverse interactions reported if they strengthen the earlier findings; 3) listing of new drugs, e.g., sildenafil (viagra) now commonly prescribed by psychiatrists and cardiologists; 4) reports explaining and/or refining mechanisms of adverse interactions; and 5) cautions and important associated phenomenon of either a cardiac or a psychotropic drug, e.g., valproic acid and cases of life-threatening pancreatitis. Methods of publicizing the new knowledge of cardiac drug-psychotropic drug interactions, e.g., the Internet and web sites are described.