Anticoagulation stewardship: Descriptive analysis of a novel approach to appropriate anticoagulant prescription.

Background: Anticoagulants are a leading cause of morbidity among hospitalized patients, with prescription errors commonly reported. Literature surrounding anticoagulation stewardship is scarce despite its documented effectiveness in the antimicrobial realm. Objective: To determine the proportion of accepted recommendations on inappropriate anticoagulant prescriptions suggested by a multidisciplinary anticoagulation stewardship program (ASP). Methods: We conducted a descriptive cohort study of hospitalized patients using therapeutic anticoagulation at a large Canadian tertiary care center between September 1, 2019, and February 28, 2020. A multidisciplinary ASP, composed of physicians and pharmacists, was implemented on June 1, 2019. Patient-, anticoagulant-, and admission-related characteristics were collected. The primary outcome was the proportion of accepted ASP team recommendations by the prescribing team. Results: A total of 381 patients were enrolled during the study period, resulting in 553 anticoagulant reviews (1.56 reviews/patient) by the ASP. The most common indications for anticoagulation were atrial fibrillation (n = 276, 72%) and venous thromboembolism (n = 84, 22%). Direct oral anticoagulants were most frequently prescribed (n = 253, 67%), followed by vitamin K antagonists (n = 88, 23%). Among the reviewed prescriptions, 355 of 553 (64%) generated a recommendation; 299 of 355 (84%) recommendations were accepted by the treating team. Dose adjustments were the leading category of recommendations (31%), followed by alerts regarding drug interactions (19%). Conclusion: Inpatient anticoagulant prescriptions were optimized following recommendations by the ASP team. The most frequent types of prescription changes concerned dose adjustments and drug interactions. Further research is required to assess the effect of an ASP on clinical outcomes.

Interdisciplinary Systems-Based Intervention to Improve IV Hydration during Parenteral Administration of Acyclovir.

BACKGROUND: Intravenous (IV) hydration is considered a protective factor in reducing the incidence of acyclovir-induced nephrotoxicity. A systems-based review of cases of acyclovir-associated acute kidney injury can be used to examine institution-, care provider-, and task-related factors involved in administering the drug and can serve as a basis for developing a quality improvement intervention to achieve safer administration of acyclovir. OBJECTIVES: To explore the effectiveness of the study institution's inter-disciplinary quality improvement intervention in increasing the dilution of acyclovir before IV administration. METHODS: After conducting a systems-based review for intervention development, a retrospective analysis was undertaken to compare IV administration of acyclovir in the 6-month periods before and after implementation of the intervention. The study population was a sequential sample of all patients over 18 years of age who were seen in the emergency department or admitted to a ward and who received at least one IV dose of acyclovir at the study institution. The primary outcome was the volume in which each acyclovir dose was delivered. The secondary outcomes were the hourly rate of fluid administration, the frequency of an increase in hourly hydration rate, and the incidence of acute kidney injury. RESULTS: Eighty-four patients (44 in the pre-intervention period and 40 in the post-intervention period) received IV acyclovir and had evaluable data for the primary outcome. The median volume in which the acyclovir dose was administered was significantly higher in the post-intervention group (250 mL versus 100 mL, p < 0.001). CONCLUSIONS: In this study, an easily implemented intervention significantly increased the volume of IV fluid administered to patients receiving acyclovir. Adequately powered prospective studies are suggested to investigate the effectiveness of this intervention on the clinically relevant incidence of acyclovir-induced nephrotoxicity.

CONTEXTE: L'hydratation par voie intraveineuse est considérée comme un facteur de protection aidant à réduire l'incidence des cas de néphrotoxicité associés à l'acyclovir. Une analyse de systèmes des cas d'insuffisance rénale aiguë associés à l'acyclovir peut servir à examiner les facteurs liés aux établissements, aux fournisseurs de soins et aux tâches qui touchent l'administration du médicament et à générer ainsi une mesure visant l'amélioration de la qualité qui rendra l'administration d'acyclovir plus sûre. OBJECTIF: Étudier l'efficacité de la mesure interdisciplinaire visant l'amélioration de la qualité qui a été mise en œuvre dans l'établissement de l'étude et qui encourageait à diluer davantage l'acyclovir avant son administration par voie intraveineuse. MÉTHODES: Après avoir procédé à une analyse de systèmes pour générer une mesure d'intervention, une analyse rétrospective a été réalisée afin de comparer l'administration d'acyclovir par voie intraveineuse au cours des six mois précédant et suivant la mise en œuvre de la mesure. La population de l'étude était composée d'un échantillon progressif de tous les patients de plus de 18 ans ayant séjourné aux urgences ou dans un service intra-hospitalier et ayant reçu au moins une dose d'acyclovir par voie intraveineuse dans l'établissement concerné. Le principal paramètre d'évaluation était le volume de liquide contenant chaque dose d'acyclovir administrée. Les paramètres d'évaluation secondaires comprenaient : le débit horaire de liquide administré, la fréquence d'ajustement à la hausse du débit liquidien horaire et la fréquence des cas d'insuffisance rénale aiguë. RÉSULTATS: Quatre-vingt-quatre patients (44 dans la période précédant l'application de la mesure et 40 dans la période la suivant) ont reçu de l'acyclovir par voie intraveineuse et présentaient des données évaluables pour le paramètre principal. Le volume médian avec lequel chaque dose d'acyclovir était administrée était significativement supérieur dans le groupe suivant l'application de la mesure (250 mL contre 100 mL, p < 0,001). CONCLUSIONS: Cette étude montre qu'une mesure facile à mettre en place augmentait de façon significative le volume de liquides intraveineux administré aux patients recevant de l'acyclovir. L'on suggère de réaliser des études prospectives d'une puissance suffisante pour évaluer l'efficacité de cette mesure en ce qui a trait à la fréquence cliniquement significative des cas de néphrotoxicité associés à l'acyclovir.

Significantly improved performance of a multitarget assay over a commercial SCCmec-based assay for methicillin-resistant Staphylococcus aureus screening: applicability for clinical laboratories.

Detection of the SCCmec gene is a common strategy for methicillin-resistant Staphylococcus aureus (MRSA) screening assays. However, if SCCmec is used alone, it may not be specific for detecting MRSA. Herein, we describe an in-house MSRA PCR-based screening assay involving detection of three targets (nuc, coa, and mecA). The assay is suitable for a wide range of real-time PCR platforms used in clinical microbiological laboratories. Performance characteristics of the in-house assay were significantly improved compared with the commercial assay, leading to an increase of positive predictive value by 40%. Compared with the bacterial culture, the sensitivity, specificity, and positive and negative predictive values of the in-house PCR assay were 100% (95% CI >83.2%), 99.2% (95% CI = 98.2% to 99.8%), 80% (95% CI = 59.3% to 93.2%), and 100% (95% CI >99.2%), respectively.