Medication prescribing patterns in ambulatory haemodialysis patients: comparisons of USRDS to a large not-for-profit dialysis provider.

BACKGROUND: End-stage renal disease (ESRD) patients are prescribed numerous medications. The United States Renal Data System (USRDS) reported on medication prescribing patterns in 1998. Since then, several new medications, treatment guidelines and recommendations have been introduced. The objective was to analyse and compare haemodialysis (HD) patient medication prescribing patterns between the Dialysis Clinic, Inc. (DCI) database and the USRDS report. METHODS: Point-prevalent (01/01/03) medication use data from the DCI national database was obtained. Data collected included patient demographics, reason for and duration of ESRD, and medication listed on profile. All medications were classified similar to the USRDS and by where taken (clinic vs home). Medication prescribing patterns were compared between DCI and USRDS databases. Comparisons between age groups (<65 and >or=65 years) and diabetic status [diabetes mellitus (DM) vs non-DM] were made. RESULTS: There were 128 477 medication orders categorized in 10 474 patients. DCI patient demographics were similar to present USRDS patients except for fewer Hispanics (P<0.001). Patients were prescribed 12.3+/-5.0 (median 12) different medications (2.6+/-1.4 clinic medications and 10.0+/-4.5 home medications). This is higher than reported by USRDS (median 9 medications). Patient age did not influence number of medications used (P = 0.54). DM patients are prescribed more medications than non-DM (13.3+/-5.0 DM vs 11.6+/-4.8 non-DM; P<0.00001). All medication class prescribing patterns were markedly different. CONCLUSION: The data suggest that medication prescribing patterns in HD patients have changed. The audit identified appropriate and questionable prescribing patterns. Various prescribing patterns identified areas for improvement in care (e.g. increased use of aspirin, beta-blockers and hyperlipidaemia medications) and areas requiring further investigation (e.g. high use of anti-acid, benzodiazepine and non-aluminum/non-calcium phosphate-binding medications).

Recombinant human activated protein C for use in severe sepsis.

OBJECTIVE: To review the efficacy and safety of drotrecogin alfa (recombinant human activated protein C) in the treatment of sepsis. DATA SOURCES: Literature was identified through a MEDLINE search (1966-January 2002), the product manufacturer, and the Food and Drug Administration. STUDY SELECTION/DATA EXTRACTION: All relevant information identified from the data sources was evaluated. DATA SYNTHESIS: Drotrecogin alfa reduces coagulation and inflammation in septic patients. A large placebo-controlled clinical trial (n = 1690) of drotrecogin alfa in severely septic patients demonstrated a reduction in mortality (24.7% vs. 30.8%; p = 0.005), with increased bleeding risks (24.9% vs. 17.7%; p <0.001). Patients with more severe sepsis appeared to gain the most benefit. The complete clinical and economic impact of this agent requires further analysis. CONCLUSIONS: Drotrecogin alfa offers a significant advance in the treatment of severe sepsis. Judicious use in appropriate patients is necessary to control cost and maximize clinical benefits.

Trimethoprim-sulfamethoxazole activity and pharmacodynamics against glycopeptide-intermediate Staphylococcus aureus.

STUDY OBJECTIVE: To determine the activity of trimethoprim-sulfamethoxazole (TMP-SMX) against glycopeptide-intermediate Staphylococcus aureus (GISA). DESIGN: In vitro study. SETTING: University laboratory. MEASUREMENTS AND MAIN RESULTS: Minimum inhibitory concentrations (MICs) of TMP-SMX were determined for three GISA strains. Time-kill assays were conducted at 1 x MIC and at simulated peak serum concentrations (Cmax). Two dosing regimens of TMP-SMX were investigated: TMP-SMX 8 mg (TMP)/kg/day and TMP-SMX 15 mg/kg/day, each divided into two doses/day Both dosages were studied against each strain in a two-compartment in vitro model to determine concentration-related activity. All isolates were susceptible to TMP-SMX. In time-kill studies at 1 x MIC, TMP-SMX was bacteriostatic against all isolates and bactericidal against two of three strains at simulated Cmax. The 15 mg/kg/day (divided-dose) regimen provided the best overall reduction in colony-forming units/ml. CONCLUSION: All GISA strains were susceptible to TMP-SMX. In addition, it appears that TMP-SMX may have concentration-dependent antibacterial activity against these organisms. As an option in the management of GISA infection, TMP-SMX merits further study.