Journal of Pharmacy Practice

To describe antimicrobial stewardship programs (ASPs) of acute and long-term acute care (LTAC) hospitals in Houston, Texas.

Two-part survey to clinical pharmacists and pharmacy directors. All acute care and LTAC facilities from the Harris County Medical Society database were invited to participate.

In part 1 of the telephone survey, 82 facilities within Houston, Harris county, were contacted by telephone of which 51 responded (response rate: 62%). Of respondents, 55% (n = 28) reported having an active ASP and 8% (n = 4) planned implementation within 12 months. Acute care and LTAC hospitals reported ASPs in 57% and 67% of facilities, respectively. Physician champions were involved in 71% (n = 20) of active ASPs; clinical pharmacists were involved in 75% (n = 21) of programs. In part II, 22 (43%) facilities completed the online survey; postprescription review with feedback was used in facilities with an ASP and medical training program (5 of 5) while formulary restriction was in facilities without stewardship or medical training (6 of 8).

This is the first major survey of ASP in a major metropolitan area. The stewardship effort in the city of Houston is encouraging; we expect the number of stewardship programs in all facilities will continue to rise as focus on antimicrobial resistance grows.

To evaluate the concordance of the Modified Morisky Scale (MMS) with a pharmacist assessment of medication adherence during a medication review.

This retrospective study examined the electronic medical records (EMRs) of patients ≥18 years who received a medication review by a pharmacist from October 2008 to September 2009 at a homeless behavioral health clinic. In addition to the 6-item MMS, adherence was assessed using the first 4 items of the MMS, which comprise the original Morisky Scale. A final pharmacist assessment of adherence based upon the medication review was documented in the EMR. The McNemar test was used to assess the agreement between the MMS (6 and 4 items) and the pharmacist assessment of medication adherence.

A total of 288 patients were eligible for the study, which included 449 medication reviews. Nonadherence was identified in 61.7% and 49.7% of medication reviews using the 6 and 4 items of the MMS. The pharmacist assessment determined nonadherence in 23.8% of medication reviews. There were significant differences between the pharmacist adherence assessment and the 6 (P < .0001) and 4 (P < .0001) items of the MMS.

A combination of methods including self-report and pharmacist assessment may provide the greatest insight into adherence.

Rifaximin is approved for the reduction of hepatic encephalopathy (HE) recurrence in patients with chronic liver disease (CLD); however, few studies have evaluated the benefit of adding rifaximin to lactulose for treatment of acute HE. The aim of this study was to determine the impact of combination therapy with lactulose and rifaximin on hospital length of stay (LOS) and readmission rates.

A retrospective study of patients admitted to an adult hospital within the Methodist LeBonheur Healthcare (MLH) System in Memphis, Tennessee, between 2007 and 2012 was conducted. Patients were identified via International Classification of Diseases, Ninth Revision (ICD-9) coding for liver cirrhosis.

Of the 173 patients included, 87 (50%) received lactulose monotherapy and 62 (36%) combination therapy, while 24 (14%) underwent therapy escalation. Median LOS was 6 days in monotherapy group and 8 days in combination group (P = .9). At 180 days, patients receiving combination therapy had fewer readmissions for HE than those receiving monotherapy (2.4% vs 16.2%, P = .02).

Addition of rifaximin to lactulose for treatment of acute HE did not reduce hospital LOS; however, it did result in lower readmission rates for HE at 180 days.

Coagulation abnormalities in end-stage liver disease may preclude patients from receiving venous thromboembolism (VTE) prophylaxis immediately following orthotopic liver transplantation.

To identify risk factors for VTE and death following liver transplantation, a retrospective chart review was conducted in adult liver transplant recipients from January 1, 2001, to October 1, 2011.

In 716 transplantations in 701 patients, the overall incidence of VTE was 2.1%. The incidence was 3.6% in patients who received chemoprophylaxis compared to 1.4% in those without chemoprophylaxis (P = .06). Most patients (69.5%) did not receive chemoprophylaxis postsurgery during their hospitalization. Multivariate logistic regression modeling revealed no association between the use of chemoprophylaxis (adjusted odds ratio [OR] 1.5 [0.45-4.7], P = .53) and VTE. A significant positive association was observed between the use of chemoprophylaxis (adjusted OR 3.2 [1.3-8.0], P = .01) and death.

Use of chemoprophylaxis and increasing amounts of blood products following orthotopic liver transplant was associated with increased mortality. A significant positive association was observed between blood product administration and VTE, while chemoprophylaxis use was not significantly associated with VTE. Larger prospective studies are necessary to further examine the significance of this finding.

Pharmacy internships provide students with practical experiences that lead to enhancement of clinical skills and personal growth.

To describe the design and implementation of a structured 10-week summer pharmacy internship program in a supermarket chain pharmacy.

The pharmacy leadership team developed and piloted a new format of the pharmacy internship during the summer of 2013. Pharmacy students in professional year 1 (P1), 2 (P2), and 4 (P4) were invited to apply for a paid internship. Pharmacy students were recruited from all colleges of pharmacy in the state of Michigan. The goal of the new program was to create a focused learning opportunity that encouraged students to develop knowledge, skills, and abilities about patient care, pharmacy management, and working within a team.

A total of 19 interns were recruited (P1 = 7, P2 = 7, and P4 = 5). Students practiced 40 hours per week and participated in the medication dispensing process and employee biometrics screening program. Interns provided approximately 500 assessments on pharmacy employees and all P1 and P2 interns completed a patient care project.

The restructured internship program provided pharmacy students with a 10-week program that exposed them to many aspects of community pharmacy practice. The program needs future refinement and assessment measures to verify interns improve skills throughout the program.

This article serves as a review of the current literature regarding the role of edoxaban for the prevention of stroke in patients with nonvalvular atrial fibrillation (AF) and the treatment of venous thromboembolism (VTE).

Until recent years, oral treatment options for both treatment and prevention of VTE and stroke were limited to warfarin. Dabigatran was the first new oral anticoagulant approved in over 50 years followed by rivaroxaban and apixaban. These new oral anticoagulants offer many benefits over warfarin. Edoxaban is the newest member among the oral anticoagulants and exerts its action by direct inhibition of factor Xa. It may offer some advantages in that it is the second Food and Drug Administration-approved once-daily anticoagulant available and does not interact with the cytochrome P450 (CYP450) system. However, there are concerns in patients with AF and preserved renal function (>95 mL/min), as these cohorts experienced a higher incidence of stroke in trials.

Based on the 3 clinical trials, edoxaban appears to be a safe and effective factor Xa inhibitor in patients with a creatinine clearance of <95 mL/min. It will serve as an alternative anticoagulant for those with a preference for once-daily dosing and/or taking medications that interact with the CYP450 system.

To report a case of hypothermia in a patient with intellectual disability treated with thioridazine.

A 59-year-old female presented to the emergency department with altered mental status, generalized weakness, chills, and fatigue and was diagnosed with a urinary tract infection. Upon completion of a history and physical examination, the patient was found to be hypothermic with a temperature of 91 F. A Bair Hugger protocol was initiated to manage hypothermia, and a taper schedule for thioridazine was initiated as it was identified as a possible culprit for the patient’s hypothermia. According to the Naranjo probability scale, thioridazine was a possible cause of this adverse effect. Other patient-specific risk factors for hypothermia were evaluated and ruled out.

This case indicates a possible correlation between hypothermia and the use of phenothiazine antipsychotics such as thioridazine. Appropriate measures, including early detection and identification of possible causative agents, should be taken to prevent and treat this adverse event in patients taking these medications, specifically in patients with the inability to participate in self-care.

To report a case of isolated daptomycin-induced acute liver injury without elevations in creatine kinase (CK) levels or kidney dysfunction.

A 49-year-old female with a history of pancreatitis, lupus, diabetes, congestive heart failure, hypertension, and chronic pain syndrome presented to the emergency department with alteration in mental status and acute liver failure. The patient had been treated with daptomycin for methicillin-resistant Staphylococcus aureus (MRSA) endocarditis for 3 weeks. After ruling out other possible etiologies, daptomycin was suspected as a cause of acute liver failure. Her liver failure resolved gradually following withdrawal of daptomycin.

Although hepatic abnormalities caused by daptomycin are rare, a handful of cases with daptomycin-induced liver injury have been reported in the literature. Of note, in most cases, patients on daptomycin therapy developed liver damage with elevations in CK levels. Our case report suggests possible severe liver injury associated with high-dose and long-term daptomycin treatment in the absence of rhabdomyolysis. Future research is warranted to further investigate the relationship between daptomycin use and liver injury, yet it is reasonable to monitor liver function tests at baseline and weekly thereafter along with CK levels, especially in patients requiring long-term daptomycin therapy.

To report 3 cases of subdural bleeding associated with rivaroxaban managed by 3-factor prothrombin complex concentrate (PCC3).

Case 1 presented with a 1-cm thick subdural hematoma (SDH) 12 hours after her last dose of rivaroxaban. Case 2 presented with a right 1-cm acute right SDH with 2 to 3 mm of midline shift 24 hours after his last dose of rivaroxaban. Case 3 presented with a 1.8-cm thick right cerebral convexity hematoma 12 hours after her last dose of rivaroxaban. All patients received 23 to 35 units/kg PCC3 with 1 to 3 units of fresh frozen plasm (FFP) and demonstrated no progression in lesions measured by repeat computed tomography (CT). Two patients were discharged to rehabilitation facilities and 1 patient ultimately died due to the location of the lesion.

Rivaroxaban has no specific antidote. Current bleeding management strategies are based on expert opinion. The risks and benefits for differing strategies are unclear, and no clinical experience has been reported to date. These cases begin to illuminate differences among choices for managing bleeding associated with Xa inhibitors.

In this case series, 25 to 35 units/kilogram PCC3 and FFP 1 to 3 units ceased rivaroxaban-associated bleeding without thrombogenic complications.