HIV Pharmacist's Impact on Inpatient Antiretroviral Errors.

OBJECTIVES: Transitions in care between out-patient and in-patient settings provide ample opportunity for medication errors to occur in HIV-infected patients. The purpose of this study was to examine the effectiveness of an HIV pharmacist monitoring service in decreasing antiretroviral medication errors in a large south central teaching hospital in the USA. METHODS: A retrospective, observational study was conducted to examine the frequency of antiretroviral medication errors in HIV-seropositive patients with hospital admissions between 1 September 2011 and 30 September 2013 at a single tertiary care centre in Oklahoma. Patient assignment to the 12-month pre-intervention and intervention study periods was determined by admission date. Demographic, laboratory, and in-patient medication data were collected. Bivariate analyses were conducted using χ2 analysis with the Yates correction factor for continuity to examine frequencies in specific antiretroviral classes and error categories. A multivariable Poisson regression was employed to examine the frequency of medication errors before and after initiation of the pharmacist service. RESULTS: Medication errors were examined in a total of 330 patient admissions during the 2-year study period. A multivariable-adjusted decrease of 73.9% in the number of errors was observed between the pre-intervention and intervention periods (P < 0.001). Patients on protease inhibitor regimens or with impaired renal function had 2.6-fold and 2.8-fold higher numbers of errors, respectively (P < 0.001). CONCLUSIONS: HIV pharmacist monitoring can decrease medication errors in HIV-infected patients as they transition between out-patient and in-patient care. Patients receiving protease inhibitor-based therapy or with renal insufficiency are at higher risk for medication errors upon admission.

Utilisation of Crotalidae polyvalent immune fab (ovine) for Viperidae envenomations in children.

Snakebite envenomations occur in 45,000 patients in the USA annually and are associated with morbidity especially in children and the elderly. Crotalidae polyvalent immune fab (ovine; FabAV) is a polyvalent antivenom derived from sheep for crotalid envenomations. Limited clinical trials are available in paediatric patients. A literature search using MEDLINE (1950-February 2008), International Pharmaceutical Abstracts (1970-February 2008), EMBASE (1988-February 2008) and Cochrane Library (1996-June 2008) was conducted using key words including: antivenom OR snakebites OR children OR Crotalid OR envenomations. All English-language articles were identified from data sources. Pertinent studies pertaining to FabAV in children and adolescents with crotalid envenomations were included for analysis. Ten papers were included for review, representing 47 children. Initial doses ranging from 2 to 18 g were administered and initial control was achieved in most children. Maintenance dosing was continued in 63.8% (30/47) of patients; 4.3% (2/47) of patients had episodes of venom recurrence. Adverse events were noted in 8.5% of children (4/47) when pooled for data analysis. FabAV appears to be a safe and effective agent for children with crotalid envenomations. Clinicians should adapt dosing recommendations used for adults until future large, well-designed trials can confirm the efficacy and safety from observation studies and case reports.

Vicia tetrasperma (four-seeded vetch) ingestion by a 3-year-old child.

We report an ingestion of Vicia tetrasperma (four-seeded vetch), initially misidentified as crown vetch (Coronilla varia). Vicia tetrasperma is not listed in POISINDEX; little is known of its toxic effects and we found no published human case reports. The child suffered only minor gastrointestinal effects which lasted a few hours and had no residual effects upon 24- and 96-hour followups.

Integration of clinical and administrative strategies to reduce expenditures for antimicrobial agents.

A comprehensive program of clinical and administrative strategies to reduce expenditures for antimicrobial agents is described. Clinical intervention strategies include the use of antimicrobial order sheets, standardized dosage regimens, restriction policies for certain antimicrobial agents, and position statements on the use of restricted agents. A cornerstone of the program is the support for cost-reduction interventions offered by the pharmacy and therapeutics committee and its subcommittee on therapeutics; that support is demonstrated through endorsement and enforcement of pharmacy programs. Physicians are reminded of the cost-reduction programs through periodic articles in the pharmacy newsletter and an "antibiogram" card supplied by the division of epidemiology. The effectiveness of these interventions has been demonstrated by progressive decreases in expenditures for antimicrobial agents during 1987 and 1988. Antimicrobial agents also account for increasingly smaller percentages of the total drug budget. This combination of clinical and administrative strategies reduced expenditures for antimicrobial agents by more than $700,000 over two years without the use of clinical specialists or any apparent sacrifice in the quality of patient care.

Penetrating neck injuries: experience with selective exploration.

Although many authors have stated that surgical exploration should be mandatory for all neck wounds that penetrate the platysma, recent reports from many centers now claim that selective exploration is both safe and reasonable. A policy of selective exploration based on clinical presentation, anatomic location, and results of diagnostic studies has been followed at The Cooper Green Hospital in Birmingham, Alabama, for the past 13 years. We report a study of penetrating neck wounds in 136 consecutive patients admitted to The Cooper Green Hospital from 1972 to 1984. Seventy-seven patients (57%) had exploration immediately, with one death, while the remaining 59 (43%) were admitted and observed. Of these 59 patients, ten had arch aortography and nine had esophagography, all of which yielded normal results. The remainder of the patients observed had no clinical signs or symptoms to suggest a major injury. There were no deaths or complications related to the neck wounds in the 59 patients observed. Results of 27 explorations (35%) were negative. We conclude that selective exploration of penetrating neck wounds is both safe and reasonable.

Newer antihistamines and histamine-release inhibitors.

Traditional H1 receptor antagonists are a mainstay of drug therapy for the allergic state, but cause numerous discomforting side effects which often hinder compliance. Newer H1 antagonists, including astemizole and terfenadine, appear remarkably free of central side effects and may provide a therapeutic breakthrough for clinicians. H2 antagonists have revolutionized drug therapy for hypersecretory states. Ranitidine appears to have fewer side effects than cimetidine at this stage in its utilization history, but has not been used as extensively. Other antisecretory agents of promise include some tricyclic antidepressants, prostaglandin derivatives, and potassium-hydrogen ATPase inhibitors. Newer histamine-release inhibitors (ketotifen, oxatimide e.g.) are effective orally and offer better patient compliance.

Cephalosporin-use restrictions in teaching hospitals.

A survey of pharmacy directors in teaching hospitals was conducted in March 1983 to ascertain policies for management of cephalosporin use. Surveys were sent to 298 institutions in each of the United States except Alaska. Respondents were asked various questions regarding hospital policies on cephalosporin use. Responses were received from 179 hospitals that had formularies; 99 of these had formal restriction policies, more frequently for second- and third-generation agents than for first-generation agents, and 13 planned to institute restriction policies. In 68% of hospitals with restriction policies, restricted drugs were released only after consultation with the infectious disease service. Chart review was the most frequently reported method of monitoring use of restricted cephalosporins. Approximately 40% of respondents had therapeutic equivalence policies, and more than 40% had recently deleted one or more cephalosporins from the formulary. The percentage of hospitals with formal restriction policies (55%) was greater than in a 1979 survey (32%). Many teaching hospitals have initiated policies to curb rising drug costs associated with the use of cephalosporin antibiotics.

Restricted cephalosporin use in teaching hospitals.

The approaches of teaching hospitals toward limiting the number of cephalosporin drug products on formularies were studied in a mail survey. Pharmacy department directors of 128 teaching hospitals with 200 beds or more responded to teh survey. Forty-two of 128 (33%) hospitals had established formal restriction policies (FRPs) for cephalosporins (CS). Cephalexin and cephradine were the predominant formulary oral CS. Few hospitals had established "therapeutic equivalents" policies, yet the majority of hospitals had a single oral CS on the formulary. Cefazolin was the predominant injectable CS on all formularies; cefamandole and cefoxitin were the predominant restricted CS. In hospitals without restriction policies, these newer CS were on the formulary in 55% of the cases; in FRP hospitals, the figure was 15%. The occurrence of a single, formulary, unrestricted CS was much more likely in FRP hospitals (38%) than in hospitals with no restriction policy (NRP) (8%). FRP hospitals tended to have fewer unrestricted formulary CS. Eighty-three percent of FRP hospitals and 41% of NRP hospitals monitored CS use.