Analysis of Factors That Interrupt With INR Control in the First Anticoagulation Clinic Monitoring Jordanian Patients.

Multiple factors such as vitamin K consumption, drug interactions, herbs interactions, disease states, and alcohol intake affect international normalized ratio (INR) values and thus warfarin dosing. These variables have been described in general and for all patients in the literature. In contrast, the factors that affect INR control in a specific population are rarely studied. Being aware of these factors contributes a lot in maintaining an INR control and avoiding the supratherapeutic or subtherapeutic anticoagulation and the associated risks of hemorrhage or thromboembolism. The aim of this study is to recognize the specific population factors in Jordanian patients that interrupt INR control. Such recognition provides clinical pharmacists managing the anti-coagulation clinic (ACC) with necessary tools and predictors of dose adjustment, nontarget INR handling, and points to add on to the educational session. A total of 2788 patients were referred to the first clinical pharmacists managed ACC at Queen Alia Heart Institute-the only official referral hospital for cardiac patients in Jordan-for education and monitoring between November 1, 2013, and November 1, 2016. We evaluated specific population factors that interrupt INR control using a pretested, structured clinical data collection form. The patients were followed up regularly for achieving target INR (TINR). For patients who were not achieving TINR, the possible cause was examined thoroughly by reviewing the patient's medical file for recent medication intake, comorbidities, and laboratory results. Then the patients or their caregiver were asked direct questions regarding their diet, food supplements, cigarette smoking, shisha smoking, alcohol intake, herbs, and complementary medicine use and compliance, in addition to performing pharmacogenetic testing (polymorphisms of vitamin K-epoxide reductase complex [VKORC1] and cytochrome P450 2C9 [CYP2C9] genes) in special cases. For a total of 2788 patients, 89 488 INR values were included in the study. Of all, 20 365 (22.8%) were non-TINR values, 13 145 (14%) were subtherapeutic, and 7220 (8.1%) were supratherapeutic. All patients included in the study had a non-TINR at least 3 times (n = 65, 2.3%) and as frequent as 50 times (n = 21, 0.8%) during the study period. Non-TINR values ranged from 1 to 11. Serious side effects reported in 7 patients with uncontrolled INR, 6 were bleeding, which required hospitalization (2 upper gastrointestinal [GI] bleeding, 3 nasal bleeding, and 1 eye bleeding), 1 was cerebrovascular accident (CVA thrombolytic). Factors that interrupted INR control in our population, arranged in descending sequence, were concurrent medication use 46.9% (mainly Salicylates and Amiodarone), smoking cigarettes and shisha 17% (represented the most frequent single factor that caused non-TINR in the present study), a nonbalanced dietary vitamin K intake 16.88% caused changes in INR (lower) was related to an increase in the intake of vitamin K-rich food, were noticed to be much more in the spring season in Jordan (end of March and April mainly), herbal supplements 15.02%; Hawthorn (Crataegus, الزعرور) is an herb that lives widely in Jordan, and shockingly we found that it is used very commonly in our ACC patients and corresponded to an elevated INR <8 in 11 patients, and serious bleeding events that required hospitalization in 2 cases), noncompliance 1.49%, comorbid diseases 1%, malabsorption 0.53%, alcohol intake 0.39%, and VKORC1 A/G and CYP2C9 *1*1 genotype 0.15%. The analysis of factors that interrupted with INR control in our patients were both predicted and distinctive; most of these factors were reported previously by other researchers. On the other hand, many of the previously reported factors were not frequently detected in our patients, and the frequency of each of the realized factors was contributed differently to non-TINR in our population. Alarming factors causing non-TINR detected in our study include smoking both cigarettes and shisha, herbal use (Hawthorn and Ginseng), increased intake of vitamin K rich food in the spring season, and concurrent medication use (Salicylates, Amiodarone, Ciprofloxacin, nonsteroidal anti-inflammatory drugs [NSAIDS], Azithromycin, Clarithromycin: although the use of these drugs is mandatory sometimes, it can be replaced by an alternative, eg, antibiotics or monitored closely together with warfarin).

Adherence to international antimicrobial prophylaxis guidelines in cardiac surgery: a Jordanian study demonstrates need for quality improvement.

BACKGROUND: Antimicrobial prophylaxis in cardiac surgery has been demonstrated to lower the incidence of surgical site infection (SSI). Inappropriate antimicrobial prophylaxis, such as inappropriate selection of the antimicrobial agent or inappropriate dosing regimen, can increase the prevalence of antibiotic resistant strains, prolong hospital stay, cause adverse reactions, and negatively affect an institution's pharmacy budget for antibiotics. In developing countries such as Jordan, where the role of clinical pharmacists is still in its primary stages, the first step in establishing an organized clinical pharmacy service is the evaluation of current practice to determine the need for improvement. OBJECTIVE: To assess the degree of adherence to international guidelines for antimicrobial prophylaxis practice in cardiac surgery performed at Queen Alia Heart Institute (QAHI) in Amman, Jordan, as part of an attempt to determine opportunities for clinical pharmacist intervention. METHODS: For a total of 236 patients who were admitted for cardiac surgery to QAHI - the only official referral hospital for cardiac patients in Jordan - between November 19, 2006, and January 22, 2007, the antimicrobial prophylaxis indication, choice, duration, dose, dosing interval, and timing appropriateness were assessed against 3 international guidelines using a pre-tested, structured clinical data collection form that was completed by 2 of the authors who work at QAHI. The study design was prospective. All patients who were scheduled for surgery were monitored daily during their inpatient stay until discharge and then were tracked in the outpatient clinic for 2 months following surgery. Data regarding antimicrobial prophylaxis indication, choice, duration, dose, dosing interval, and timing appropriateness were collected during the patient's inpatient stay; data collection was performed periodically thereafter as data became available until the end of the 2-month follow-up. The 3 guidelines agreed that (a) antimicrobial prophylaxis should be given to all patients undergoing cardiac surgeries; (b) the first- or second-generation cephalosporins (cefazolin or cefuroxime) are the antibiotics of choice, and vancomycin use is reserved for cases of allergy to beta-lactams or if presumed or known methicillin-resistant Staphylococcus aureus (MRSA) colonization is present; (c) the timing of the first dose should be within 60 minutes prior to the skin incision; and (d) the duration of antimicrobial prophylaxis should not be longer than 48 hours. RESULTS: Adherence to all antimicrobial prophylaxis guidelines was not achieved for any study patients. For the 6 evaluated criteria, (1) indication: in 100% of patients the appropriate decision was made to use antimicrobial prophylaxis in concordance with guidelines; (2) choice: only 1.7% of patients received the antibiotic of choice; (3) duration: 39.4% of patents received antimicrobial prophylaxis for a total duration of 48 hours or less in concordance with guidelines, and for 58.9% of patients, duration was longer than recommended; (4) dose: 27.9% of patients received an appropriate dose; (5) dosing interval: only 13.0% of patients received an appropriate dosing interval, and none of the doses of antimicrobial prophylaxis used at induction of anesthesia was repeated in operations that lasted longer than the half-life of the antibiotic used; and (6) timing: 99.1% of patients received antimicrobial prophylaxis dose within 60 minutes prior to skin incision as recommended by guidelines, but 97.0% of patients received an unnecessary midnight dose of intravenous antibiotic the night before surgery. CONCLUSION: Study findings indicate that adherence to international guidelines for antimicrobial prophylaxis is far from optimal in QAHI, leading to the inappropriate administration of many antibiotics. Developing local hospital guidelines, as well as giving the clinical pharmacist a central role in the administration, monitoring, and intervention of antimicrobial prophylaxis may improve the current practice.