Formulary Guidelines Research Articles

P-168. Antimicrobial Resistance Patterns at a Private Referral Hospital in Blantyre, Malawi

Abstract Background Antimicrobial resistance (AMR) is expected to be a global health security risk in Africa in coming decades. While AMR data is available from Malawi public hospitals, data from Malawi’s burgeoning private hospital sector is limited. Initial Hospital Antibiogram Data, Fall 2021 - Spring 2022 Methods An antibiogram was obtained for clinical blood and urine cultures from October 2021 through April 2022 at a private referral hospital in southern Malawi (n=684). Logistic regression was used to assess for patient-related determinants of AMR, as well as effects on patient outcomes. Tests of Association for AMR Determinants Results High AMR rates were seen in E. coli (37.4% ceftriaxone, 35.8% ciprofloxacin, 32.5% trimethoprim), as well as unexpected carbapenem resistance (7.4% of tested isolates). Statistically significant tests of association linked both fluoroquinolone (X2 = 4.91, p=0.027) and third-generation cephalosporin resistance (X2 = 3.67, p=0.05) to patients who had increased numbers of antecedent hospital encounters. Fluoroquinolone resistance was associated with increased risk for acute-care follow up within 30 days of antibiotic prescription (X2 = 4.73, p=0.03). Third-generation cephalosporin resistance (suggestive of ESBL production) showed association with older age (X2 = 20.009, p=< 0.001) and female gender (X2 = 5.58, p=0.018) A multiple logistic regression model examining variables associated with ceftriaxone-resistant Enterobacterales showed increased risk of patient death (OR 5.99, CI 1.37–26.17, p=0.017), as well as higher Charlson comorbidity index (OR 1.14, CI 1.02-1.28, p=0.024). Over 40% of patients with culture-positive results were treated empirically, without follow up for review of sensitivities. Choice of empiric antibiotic differed from national guidelines, with only 32% UTI patients and 8.4% pharyngitis patients receiving recommended first-line regimens. Local point-prevalence data sometimes appeared to be discordant with national data. As one example, all three recommended cystitis regimens on national formulary guidelines displayed >=30% resistance rates on local antibiogram data, including ciprofloxacin, nitrofurantoin, and cefuroxime. Logistic Regression for Determinants of ESBL Enterobacterales Multiple logistic regression model Conclusion Further research needs to assess best practices for stewardship in regional private hospitals, as well as determinants for AMR that encompass markers of healthcare utilization. Demographic Descriptive Statistics Disclosures All Authors: No reported disclosures

A Brief Overview of the Diagnosis and Treatment of Cobalamin (B12) Deficiency.

An increasing number of adult individuals are at risk of vitamin B12 deficiency, either from reduced nutritional intake or impaired gastrointestinal B12 absorption. This study aims to review the current best practices for the diagnosis and treatment of individuals with vitamin B12 deficiency. A narrative literature review of the diagnosis and treatment of vitamin B12 deficiency. Prevention and early treatment of B12 deficiency is essential to avoid irreversible neurological consequences. Diagnosis is often difficult due to diverse symptoms, marked differences in diagnostic assays' performance and the unreliability of second-line biomarkers, including holo-transcobalamin, methylmalonic acid and total homocysteine. Reduced dietary intake of B12 requires oral supplementation. In B12 malabsorption, oral supplementation is likely insufficient, and parenteral (i.e. intramuscular) supplementation is preferred. There is no consensus on the optimal long-term management of B12 deficiency with intramuscular therapy. According to the British National Formulary guidelines, many individuals with B12 deficiency due to malabsorption can be managed with 1000 µg intramuscular hydroxocobalamin once every two months after the initial loading. Long-term B12 supplementation is effective and safe, but responses to treatment may vary considerably. Clinical and patient experience strongly suggests that up to 50% of individuals require individualized injection regimens with more frequent administration, ranging from daily or twice weekly to every 2-4 weeks, to remain symptom-free and maintain a normal quality of life. 'Titration' of injection frequency based on measuring biomarkers such as serum B12 or MMA should not be practiced. There is currently no evidence to support that oral/sublingual supplementation can safely and effectively replace injections. This study highlights the interindividual differences in symptomatology and treatment of people with B12 deficiency. Treatment follows an individualized approach, based on the cause of the deficiency, and tailored to help someone to become and remain symptom-free.

Utilization Review of Antibiotics in the Treatment of Urinary Tract Infection

Aim: To evaluate the rationality of pharmacotherapy of UTI and to identify drug related problems (DRPs) in the treatment of UTI. Methodology:, a prospective study was perfomed in Ayub Teaching Hospital Abbottabad Pakistan for a period of three months (December 2019 to March 2020) on 62 patients suffering from UTI. Data of patient disease and treatment was collected from patient medical chart record file and then pharmacotherapy was evaluated for accessing rationality and identification of DRP using standard book like British national formulary and standard treatment guidelines. Statistical analysis of the data was performed by using SPSS. Results: Result of this study showed that prevalence of UTI was more in female (67.74%) than males (32.25%). Patients belonging to the age group of 20-40 years were more prone to UTI. The most frequent problems were presence of drug interactions, dosage problems cases, overprescribing cases, therapeutic duplication cases and lack of cost effectiveness cases. After analyzing the use of antibiotics it was found that most widely used antibiotics in the treatment of UTI was ceftriaxone, followed by levofloxacin and ciprofloxacin. Culture Sensitivity test for appropriate selection of antibiotics was not perfomed in 80% of cases. Wrong dose of antibiotics was prescribed in 27.4% cases; therapeutic duplication of antibiotics was found in 6% of patient prescription and over usage of antibiotics was observed in 18% of cases. Conclusion: Irrational use of drugs especially antibiotics in the treatment of UTI can adversely affect desired therapeutic outcome, lead to therapy failure and emergence of resistance of antibiotics which is a major concern. Drugs for the treatment of UTI should be used rationally according to the need and standard prescribing protocol to improve patient therapeutic outcome and to decrease the adverse consequences of drug therapy. . Keywords: Urinary tract infection, drug related problems and antibiotic use

402 - An audit of Lithium Prescribing Practices in an Old Age PsychiatryService highlighting renal impairment in this cohort

AbstractAims:To compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West ofIreland among adults aged 65 years and over with best practice guidelines.Methods:Review of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary(2019) and Maudsley Prescribing Guidelines (2018). Data was collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past year.Results:At the time of audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n=9) had depression, 44% (n=8) had bipolar affective disorder (BPAD) and 6% (n=1) schizoaffective disorder.78% (n= 14) of patients met the NICE standard of 3-monthly lithium level. Lithium levels were checkedon average 4.5 times in past year, average lithium level was 0.61mmol/L across the group and 39% (n=7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% of patients (n=15) met the NICE standards of 3 monthly renal tests. Taking into consideration mostrecent blood test results, 100% (n=18) had abnormal renal function.Half (n=9) were initiated on lithium by POA service and of these, 56% (n=5) had documented renal impairment prior to initiation. Of patients on long term lithium at time of referral (n=9), almost half (n=4) had a documented history of lithium toxicity.Conclusions:The results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function. This is an important finding given the associations between those admitted to hospital with COVID-19 and co- morbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in elderly prescribed lithiumgiven the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort

AimsTo compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

Long-term nitrofurantoin: an analysis of complication awareness, monitoring, and pulmonary injury cases.

BackgroundLong-term nitrofurantoin (NF) treatment can result in pulmonary and hepatic injury. Current guidelines do not outline the type or frequency of monitoring required for detection of these injuries.AimTo assess 1) awareness of NF complications among prescribers; 2) monitoring practice; and 3) to describe the pulmonary sequelae of NF-related complications.Design & settingEvaluation of prescribing habits by questionnaires and review of GP databases, and case-note review in secondary care.MethodThe following study procedures were undertaken: 1) an electronic questionnaire was distributed to prescribers, interrogating prescribing and monitoring practices, and awareness of complications; 2) an analysis was undertaken (June–July 2020) of NF monitoring among GPs in the local clinical commissioning group (CCG); and 3) a case review was carried out of patients diagnosed with NF-induced interstitial lung disease (NFILD) at the interstitial lung disease (ILD) centre (2014–2020).ResultsA total of 125 prescribers of long-term NF responded to the questionnaire (82.4% GPs; 12.0% urologists). Many were unaware of the potential for liver (42.4%) and lung (28.0%) complications; 40.8% and 52.8% never monitored for these, respectively. Only 53.3% of urologists believed themselves responsible for arranging monitoring, while nearly all GPs believed this to be the prescriber’s responsibility (94.2%). One-third of all responders considered current British National Formulary (BNF) guidelines 'not at all sufficient/clear', with mean clarity scoring of 2.2/5. Among patients with NFILD (n = 46), NF had been prescribed most often (69.6%) for treatment of recurrent UTI and 58.6% (n = 27) were prescribed for >6 months. On withdrawal of the medication 61.4% displayed resolution (completely or minimal fibrosis), while 15.9% of patients had progressive lung fibrosis.ConclusionNF can cause marked or irreversible lung complications and there is currently a shortfall in awareness and monitoring. Existing monitoring guidelines should be augmented.

Developing a multidisciplinary HCV direct-acting antivirals utilization management and assessment program

BackgroundThe introduction of direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infections has revolutionized outcomes for patients with HCV. Cost-effective use of these antivirals in addition to ensuring patient adherence is of paramount importance. ObjectivesThe goal of this article is to describe the processes by which a tertiary care, multisite institution managed the complexities involved in administering DAA treatment and managing the increased cost of therapy. Specifically, the objectives of this article are to describe the development of a multidisciplinary HCV management program and the role of pharmacists in this program, including formulary management strategies and monitoring of DAAs use in our institution, development of guidelines, electronic prescribing protocols and order sets, and specific outcomes based on a concurrent medication use evaluation. Practice descriptionKing Faisal Specialist Hospital and Research Centre is a tertiary care referral hospital. As a tertiary referral hospital, it offers primary and highly specialized inpatient and outpatient medical care. The process of selecting and developing institutional HCV management program is described. Practice innovationThis article provides key details regarding how a multidisciplinary HCV program using DAAs can be implemented successfully at a tertiary care facility. Key facets of our innovation include establishing formulary guidelines, setting up eligibility criteria for patients, and establishing an HCV taskforce and multidisciplinary HCV program clinic. EvaluationMedication use evaluations were regularly conducted to monitor sustained virologic response rates, adherence to guidelines, adverse reactions, and drug interactions. Methods: Formulary guidelines, setting up an eligibility criterion for patients, and an HCV taskforce and multidisciplinary HCV program clinic were established. ResultsThe involvement of pharmacists in a multidisciplinary HCV program in outpatient settings resulted in improved formulary decision making, reduction of costs, and improvement of adherence to institutional guidelines. Practice implicationsThe role of a pharmacist in the management of patients with HCV with DAAs is important. Pharmacists play an integral part in medication management and overall reduction in health care expenditure. Many disease management programs can be complemented with pharmacists to improve patient care and reduce cost. ConclusionHCV treatment is challenging, and a multidisciplinary approach to treat HCV is critical. It is a rapidly evolving field; therefore, it requires dynamic formulary management and collaborative practice approaches to monitor pharmacotherapy carefully and efficiently. Clinical pharmacists play a pivotal role within the multidisciplinary team by providing support to both patients and health care providers with regard to the treatment of HCV.

Insights on developing a field hospital formulary and medication distribution process in preparation for a second surge of COVID-19 cases

PurposeThe coronavirus disease 2019 (COVID-19) pandemic has caused health systems across the country to plan for field hospitals to care for patients outside of traditional healthcare settings in the event of a second surge. Here we describe key considerations for the implementation of pharmacy operations and a field hospital formulary at an offsite location within a 2-week time frame.SummaryDevelopment of an offsite field hospital formulary is first dependent on the location and patient population defined for the field hospital. Creation of a limited formulary for a planned field hospital in Michigan involved reviewing physical space limitations and drug distribution workflows, assessing current prescribing trends, creating drug categories, and creating formulary guidelines to limit formulary options in each therapeutic category. Ultimately, our institution developed a 140-medication field hospital formulary, a process to enable appropriate use of nonformulary drugs, and a mixed operations model including automated dispensing cabinets and a manual cart-fill process. Although the institution did not have to open the field hospital, the process used for developing the formulary and determining distribution models will allow for an immediate implementation if a second surge occurs.ConclusionA methodical approach to developing limited formularies and pharmacy operations in a field hospital setting will allow health systems to establish efficient and effective medication distribution services in the event of a second surge of COVID-19 cases.

1023. Isavuconazonium Use at an Academic Transplant Center

BackgroundIsavuconazonium is an appealing anti-fungal due to its broad spectrum of activity, predictable pharmacokinetics, oral bioavailability, and lack of QTc prolongation, but real-world experience with it is limited. At our academic medical center, isavuconazonium is restricted to the infectious diseases (ID) service for treatment of invasive fungal infections, including endemic mycoses due to high prevalence, and is recommended for patients intolerant of first-line agents. The purpose of this study was to describe isavuconazonium use at our institution and assess adherence to its formulary guidelines.MethodsInpatients with an order for isavuconazonium between June 2016 and November 2018 were analyzed via retrospective chart review. Prescribing team, indication, and rationale for use were evaluated.ResultsThere were 97 inpatient encounters with an isavuconazonium order among 57 patients. Of those, 30 were solid-organ transplants and 9 had bone marrow transplants. Indications for isavuconazonium were: histoplasmosis 25%, high-risk fungal prophylaxis 21%, invasive aspergillosis 9%, candidiasis 2%, and other 44% (Table 1). Preceding anti-fungal therapy included: voriconazole 49%, posaconazole 12%, fluconazole 9%, micafungin 7%, amphotericin B 5%, itraconazole 4%, and none 35%. The rationale for the use of isavuconazonium is described in Table 2. ID consultation occurred in 79% of patients. Those without a consult had an indication of prophylaxis or were continuation of therapy started outpatient or at an outside hospital (OSH).ConclusionHistoplasmosis was the most common infection treated with isavuconazonium, despite limited data for that indication. Further investigation of the clinical course for these patients is warranted. Reasons for use most commonly centered on concern for QTc prolongation, clinical failure, and drug interactions. Over one-third of patients received no anti-fungal therapy prior to initiation. Adherence to required ID consultation was high. Patients on isavuconazonium for prophylaxis or as continuation therapy without a consult may still benefit from ID review to assess the appropriateness of therapy. Disclosures All authors: No reported disclosures.

Off-label drugs use in neurology outpatient department: A prospective study at a tertiary care teaching hospital.

Background:Off-label drug use refers to any use of an approved or cleared drug that is not included in that product's approved labeling or cleared indications for use. It may be in terms of indication, age group, dosage, or route of administration. Off-label drug prescriptions are common neurology practice.Aim:The aim of the study is to evaluate the prevalence pattern of off-label drug use in neurology.Subjects and Methods:A prospective, observational, cross-sectional study was carried out in the neurology outpatient department of tertiary care teaching hospital. Data of patients above 18 years were recorded after obtaining their informed consent. The National Formulary of India (NFI) and British National Formulary (BNF) guidelines were used as tools for evaluation of the prevalence of off-label drug use.Results:A total of 709 drugs were recorded from the prescription data of 205 patients collected in the duration of 2 months. The results reported 145 (20.45%) and 317 (44.71%) drugs as off-label as per the NFI and BNF, respectively. Prescriptions with minimum 1 off-label drug use were 78.05% – BNF and 46.83% – NFI. The indication was one of the most common causes of drugs being off-label. Out of the total 317 off-label drug uses reported, 84 were unlicensed drug use as per the BNF. There is strong and positive correlation established between the age of the patients, number of drugs prescribed, and total off-label drugs prescribed per patient in the given study. The most common off-label drug use noted was with clonazepam and amitriptyline.Conclusion:Off-label prescriptions practice is common in the field of neurology.

Impact of a Special National Antimicrobial-Stewardship Campaign in China: Irrational Antibiotics Use Was Greatly Decreased But Formidable Problems Remain to Be Overcome

Background: China is a major antibiotics consumer globally and has significant bacterial resistance to antibiotics. To contain antimicrobial resistance, the Chinese government initiated a special national antibiotics-stewardship campaign (SNC) in all hospitals in 2011. The impact of this campaign on irrational antibiotics use is reported. Methods: In 2011-2016, all hospitals established an antibiotics-stewardship task force under SNC management. They each produced an antibiotics formulary and clinical antibiotics guidelines, hired clinical pharmacists to review antibiotics prescriptions, and established bacterial-resistance monitoring system Data from national hospital surveillance networks in 2010 and 2016 served to determine the impact of the SNC on the antibiotics consumption of and bacterial resistance in Chinese hospitals. Findings: By 2016, all hospitals had established an antimicrobialstewardship task force; 88.8-97.5% completed the other tasks. The amount of money spent on antibiotics relative to total drug procurement costs dropped from 22.4% in 2010 to 12.0% in 2016. There were sharp drops in the median rates of antibiotics use in hospitalized patients (from 67.8% in 2010 to 40.8% in 2016) and outpatients (19.5% to 8.5%), the rate of prophylactic antibiotics use in clean surgeries (97.9% to 38.3%), and the antibiotics use intensity (85.3±29.8 to 48.5 ±8.0 defined daily dosages/100 patient days). Guideline compliance by surgeons was still very limited in 2016 (12.6%). Clinicians continued to favor broadspectrum antibiotics. Methicillin-resistant Staphylococcus aureus prevalence decreased from 52.6% to 34.4%. However, the carbapenem-resistant Klebsiella pneumoniae prevalence rose rapidly from 2.7% to 8.7%. Interpretation: The SNC associated with great reductions in the antibiotics consumption of Chinese hospitals, their irrational antibiotics use, and their prevalence of resistant bacteria. However, factors that associate with irrational antibiotics use remained prevalent, including clinician preference for broad-spectrum antibiotics and low guideline compliance. To establish a sustainable antimicrobial-stewardship system in China, these factors must be tackled urgently. Funding Statement: The study was granted in part by the National Key Research and Development Program of China（2017YFC1200203） the National Natural Science Foundation of China (81361138021, 81711530049), Key Research and Development Program of Zhejiang Province (2015C03032). Declaration of Interests: We declare no competing interests.

Implementation of a Perioperative Insulin Protocol in an Advanced Practice Provider (APP)–Led Limb Salvage Hospitalist Team

We implemented a standardized perioperative insulin management protocol (PIP) for patients with hyperglycemia and acute diabetic foot problems. Our multidisciplinary quality improvement (QI) project retrospectively compared outcomes in the APP-led hospitalist team (TU) using the PIP vs. other hospitalist teams (OT) managing similar patients. We chose glargine U100 as the basal insulin to simplify preoperative dose adjustments. There were no statistical differences in either arm with respect to mean age (53-57 years), female distribution (26-27%), mean weight (85-94 kg) and race/ethnicity (Hispanic 52-62%, Black 34-21% and non-Hispanic white 11-17%). Patients in TU (n=44) and OT (n=42) were started on basal/bolus insulin 80 v 74% of the time, respectively. Initial basal insulin doses (units) were similar (24 ± 12 v 26 ± 24), while initial prandial insulin amounts were higher in TU than OT (21 ± 10 v 13 ± 12; p<0.01), respectively. Use of insulin types were consistent with PIP protocol and hospital formulary guidelines, with TU using glargine and aspart in 89% and 82% of patients, while OT used NPH and Regular in 69% and 76% of patients, respectively. Mean admission A1C (9.1±2.3 v 9.2±2.2 %) and capillary blood glucose (CBG in mg/dl) (239±117 v 257±123) were similar for TU and OT. Mean CBG during hospitalization was lower for TU (163 ± 31 v 187 ± 44; p<0.01). Pre-op (145 ± 49 v 153 ± 50; p=0.48) and immediately post-op (153 ± 74 v 162 ± 81; p=0.59) CBGs were similar for TU and OT, respectively. Hypoglycemia (CBG<70) occurred in 32% of TU and 19% of OT (p=0.18) with only one CBG<50 recorded in each arm. There were no differences in ER visits or readmissions within 30 days of discharge; there was a trend for shorter hospital LOS in TU (14±8 v 18±9 days; p=0.08). A standardized PIP improved perioperative glycemic control without increasing hypoglycemia risk. Wider implementation of this protocol through incorporation into electronic order sets will be the next step in our QI initiative. Disclosure K. Odedosu: None. K.K. OConnell: None. M.C. Jordan: Employee; Spouse/Partner; Accenture. U. Gunasekaran: None. P.E. Fox: None. J.N. McNulty: None. S. Harder: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Sanofi US, Novo Nordisk Inc.. Advisory Panel; Self; Intarcia Therapeutics, Inc.. Other Relationship; Self; American Diabetes Association.

Pharmacovigilance for pediatric outpatient prescriptions in tripoli children hospital

Background: Pharmacovigilance for pediatric drug therapy is lacking among Libyan patients. Hence, pediatric patients are at risk of unpredictable drug effects as a result of prescription fault. Therefore, this study was aimed to determine the drug prescribing errors for children attending the pediatric outpatient clinic at Tripoli Children Hospital, Libya. Materials and Methods: A retrospective study was carried out using the given prescription for patients who attended the hospital between July 2 and November 30, 2012. Patients aged below 13 years were included in the study. Drug use indicators were assessed using the British National Formulary guidelines. Results: There were 600 prescriptions (75.9%) collected for both, female patients (303 prescriptions, 50.5%) and male patients (297 prescriptions, 49.5%) with a total of 1167 prescribed drugs (on average 1.9 ± 1.2 items/prescription). Five hundred and eighty-six prescriptions are found which had at least one type of error, and this correlated with increased number of drugs per prescription. The error rate was 97.7%. Prescribing by inadequately dosing was done in 3.3% of all the prescribed medications, while 3.8% had inadequate durations. Furthermore, diagnosis, dosage, frequency, duration, and instruction were omitted in 96.5%, 5.7%, 10.2%, 42.8%, and 89.6% overall prescribed drugs, respectively. Drug–drug interactions were found in 63 prescriptions (10.5%) and involved mostly antiepileptic medications. Conclusion: Our study demonstrates that pediatric patients are at high risk of both, treatment failure, and adverse drug reactions. Hence, pharmacovigilance for pediatric prescriptions is critically needed. As well, a continuous medical education, in particular rational drug prescription, with much focus on the pediatric doctors, is strongly recommended.

PARENTERAL ANTIBIOTIC USAGE PATTERNS AND EFFECTS OF INTRAVENOUS TO ORAL SWITCHING ON THE LENGTH AND COST OF HOSPITALIZATION

Objective: The prolonged use of intravenous antibiotics might increase the length and cost of hospitalization. The research objective, therefore, was toevaluate the effect of switching antibiotics on the length of hospital stay and hospitalization cost. The prospective cohort research design was adopted.The inclusion criteria were in patients who had received intravenous antibiotics.Methods: The sample comprised 39 patients who switched antibiotics as an exposed group and 39 patients who did not switch as an unexposedgroup. The data were collected using the patient medical records and the financial data from the hospital information system. The Mann–Whitney testand Chi-square or Fisher’s exact test was applied in the analysis.Results: The results revealed that the antibiotics most commonly switched were intravenous ceftriaxone (83.3%) and oral cefixime (94.8%). From thefive switching patterns observed, the most common switch was from intravenous ceftriaxone to oral cefixime in patients with acute gastroenteritis.All antibiotics were administered in accordance with the National Formulary (NF) guidelines. Only metronidazole (5 mg/ml dose) was inconsistentwith NF. Switching antibiotics did not impact the length of hospital stay and hospitalization cost; however, comorbidities did have an influence here.Conclusions: Further, switching antibiotics impacted the duration over which intravenous antibiotics were administered and the cost of antibiotics.

Long-term benzodiazepine and Z-drugs use in England: a survey of general practice [corrected

Current British National Formulary (BNF) guidelines state that benzodiazepines and zolpidem, zopiclone, and zaleplon, commonly known as Z-drugs (BZD), be prescribed for no more than 4 weeks, although anecdotal data suggest that many patients are prescribed BZDs for much longer. As there are no recent, evidence-based estimates of long-term (>12 months) BZD use in the UK, the scale of this potential problem is unknown. To produce the first reliable, evidence-based estimate of long-term BZD use in the UK. Estimates of UK long-term BZD use were projected from data obtained from a survey conducted in 2014-2015 by the Bridge Project, a prescribed-drug withdrawal support charity in the North of England (Bradford). Percentages of long-term users of BZD were derived from the survey, by sampling primary care GP surgeries with around 100 000 registered patients, and these were applied to UK-wide NHS patient numbers. The data were filtered to exclude the very young and old, and those with other health issues. The mean percentage of registered patients prescribed BZDs for more than a year in the survey sample is 0.69% (95% confidence interval [CI] = 0.54 to 0.84). Applying this value to national patient numbers yields a mean projection of 296 929 (95% CI = 232 553 to 361 305) long-term users of BZD in the UK. The data also suggest that as many as 119 165 of these patients may be willing to accept prescribed drug dependency withdrawal services. More than a quarter of a million people in the UK are likely to be taking highly dependency-forming hypnotic medication far beyond the recommended time scales. As there is evidence that long-term use of BZDs causes adverse physiological and neurological effects, and protracted withdrawal (with associated complications), this represents a serious public health problem.

Evaluation of Anti-Infectives on Acute Respiratory Infection in Patients at Three Primary Health Cares Centres in Depok, Indonesia

Introduction: The high prevalence of Acute Respiratory Infection (ARI) in Indonesia can increase anti-infective use and affect their patterns of use. Objective: This study aimed to evaluate anti-infective use in 2015 at 3 primary health care centres, Limo Primary Health Care (LPHC), Bojongsari Primary Health Care (BPHC), and Cipayung Primary Health Care (CPHC). Material and methods: This study was descriptive analytic research using retrospective data. Samples consisted of 20,41 ARI patients’ prescriptions containing anti-infective drugs during 2015. Anti-infective drugs were classified using the anatomical therapeutic chemical (ATC) classification system. Drug use was measured as Daily Defined Dose (DDD)/1000 patients/day. Drug use 90% and adherence to the National Formulary was evaluated as an indicator of the quality of prescribing drugs. Results: The highest amount of anti-infective use for ARI patients was at CPHC with a total quantity of 0.95 DDD/1000 patient/day. While at the LPHC amount of anti-infective use was 0.76 DDD/1000 patients/day and at BPHC was only 0.65 DDD/1000 patients/day. The most anti-infectives use at all primary health cares was amoxicillin. Ten anti-infectives were use at LPHC, 11 at BPHC and 7 at CPHC. Anti-infectives in the DU 90% segment at LPHC were amoxicillin, co-trimoxazole, and cefadroxil while amoxicillin was the only DU90% anti-infective used at CPHC and BPHC. The adherence to National Formulary were 70.00% at LPHC, 71.43%, at BPHC, and 63.64% at CPHC. Conclusion: The use of anti-infective varied and it showed that some did not adhere to National Formulary guidelines. Key words: Adherence, Anti-infective, ATC/DDD, National Formulary, Primary health care

Evaluation of rational drug use based on World Health Organization core drug use indicators in selected public hospitals of eastern Ethiopia: a cross sectional study

BackgroundDespite the complexity of drug use, a number of indicators have been developed, standardized and evaluated by the World Health Organization (WHO). These indicators are grouped in to three categories namely: prescribing indicators, patient care indicators and facility indicators. The study was aimed to evaluate rational drug use based on WHO-core drug use indicators in Dilchora referral hospital, Dire Dawa; Hiwot Fana specialized university hospital, Harar and Karamara general hospital, Jigjiga, eastern Ethiopia.MethodsHospital based quantitative cross sectional study design was employed to evaluate rational drug use based on WHO core drug use indicators in selected hospitals. Systematic random sampling for prescribing indicators and convenient sampling for patient care indicators was employed. Taking WHO recommendations in to account, a total of 1,500 prescription papers (500 from each hospitals) were investigated. In each hospital, 200 outpatient attendants and 30 key essential drugs were also selected using the WHO recommendation. Data were collected using retrospective and prospective structured observational check list. Data were entered to EPI Data Version 3.1, exported and analyzed using SPSS version 16.0. Besides, the data were evaluated as per the WHO guidelines. Statistical significance was determined by one way analysis of variance (ANOVA) for some variables. P-value of less than 0.05 was considered statistically significant. Finally, tabular presentation was used to present the data.ResultsMean, 2.34 (±1.08) drugs were prescribed in the selected hospitals. Prescriptions containing antibiotics and that of injectables were 57.87 and 10.9% respectively. The average consultation and dispensing time were 276.5 s and 61.12 s respectively. Besides, 75.77% of the prescribed drugs were actually dispensed. Only 3.3% of prescriptions were adequately labeled and 75.7% patients know about the dosage of the prescription. Not more than, 20(66.7%) key drugs were available in stock while only 19(63.3%) of key drugs had adequate labeling. On average, selected key drugs were out of stock for 30 days per year. All of the hospitals included in the study used the national drug list, formulary and standard treatment guidelines but none of them had their own drug list or guideline.ConclusionMajority of WHO stated core drug use indicators were not met by the three hospitals included in the study.

Improving malodour management in advanced cancer: a 10-year retrospective study of topical, oral and maintenance metronidazole

ObjectivesTo explore the relative effectiveness of topical or oral metronidazole used for malodour in necrotic cancers and to propose a protocol for metronidazole usage in managing malodour.MethodsA retrospective case note...

Specialist Pediatric Palliative Care Prescribing Practices: A Large 5-year Retrospective Audit.

Introduction:There is a gradual increasing trend in childhood cancers in India and pediatric palliative care in India is an emerging specialty. Prescribing pain and symptom control drugs in children with cancer requires knowledge of palliative care formulary, dosing schedules, and prescription guidelines. This study is a retrospective audit of prescribing practices of a specialist palliative care service situated in a tertiary cancer center.Methods:A total of 1135 medication records of children receiving specialist pediatric palliative care services were audited for 5 years (2010–2014) to evaluate prescribing practices in children with advanced cancer.Results:A total of 51 types of drugs were prescribed with an average of 4.2 drugs per prescription. 66.9% of the prescriptions had paracetamol, and 33.9% of the prescriptions had morphine. Most common nonsteroidal anti-inflammatory drugs prescribed was ibuprofen (23.9%), and more than 50% of the prescriptions had aperients. The most commonly prescribed aperient was a combination of liquid paraffin and sodium-picosulfate. Dexamethasone was prescribed in 51.9% of patients and in most cases this was part of oral chemotherapy regimen. Generic names in prescription were used only in 33% of cases, and adverse effects of the drugs were documented in only 9% of cases. In 25% of cases, noncompliance to the WHO prescription guidelines was seen, and patient compliance to prescription was seen in 40% of cases.Conclusions:Audit of the prescribing practices in specialist pediatric palliative care service shows that knowledge of pediatric palliative care formulary, rational drug use, dosing, and prescribing guidelines is essential for symptom control in children with advanced life-limiting illness. Noncompliance to WHO prescribing guidelines in one fourth of cases and using nongeneric names in two-thirds of prescription indicates poor prescribing practices and warrants prescriber education. Prescription noncompliance by almost two-thirds of patients is alarming and necessitates intense patient, family, and caregiver education and empowerment.

The Veterans Choice Act and Dual Health System Use.

T he Veterans Access, Choice and Accountability Act (Choice Act), formally enacted on August 7, 2014, arose largely in response to outrage about delays in veteran access to health care and falsification of wait time records by Veterans Administration (VA) employees. The law includes a number of provisions to improve care for veterans, including increasing health care staffing and residency training positions, streamlining employee disciplinary procedures, improving treatment of military sexual trauma, and establishing a Presidential Commission on Care to evaluate access to VA health care. The most well-known, and perhaps controversial, provision is the Choice Program, which established a mechanism for eligible veterans to receive care outside the VA for 3 years. Veterans unable to schedule an appointment within 30 days of their preferred date or who live more than 40 miles from a VA facility are now eligible to receive care from non-VA providers. However, many of these veterans will also continue to use VA facilities and services, and this ‘dual use’ of health care systems may lead to care fragmentation and its ensuing adverse consequences. This commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and some ideas for ensuring its safe and effective implementation. The challenges surrounding the implementation of the Choice Program have been monumental. In the 90 days between passage of the law and the start of the program on November 5, 2014, the VA developed a system for identifying and reaching out to eligible veterans, tracking Choice Program visits, and paying for services through the program. As of April 2015, the VA had coordinated more than 45,000 Choice Program medical appointments and dispensed more than 3,200 Choice prescriptions. However, this implementation has received tremendous public criticism because of the relatively low uptake of services compared to the perceived need for immediate care. In response, in May of 2015, the U.S. Senate unanimously voted to amend the Choice Act, expanding access to veterans living within 40 miles of a VA facility if it does not offer them the needed medical care. The measure, however, has not passed the U.S. House of Representatives. The Choice Program is not the first time that an expansion of non-VA care for veterans has increased the complexity or fragmentation of care. In 2006, the rollout of Medicare Part D prescription drug coverage gave millions of VA patients the opportunity to obtain prescription drugs through the private health care system. Despite almost 10 years having elapsed since Part D’s implementation, however, and the concerns related to dual use, there are limited data on its impact on care fragmentation among veterans. In 2014, the Affordable Care Act (ACA) again expanded access for veterans to non-VA care through both the private insurance marketplace and Medicaid. Similar concerns have been raised about increased care fragmentation with dual use as a consequence of the ACA, although the full impact will not be known for some time. Even before these insurance expansions, veterans with Medicare coverage were known to receive care through both Medicare and VA. Prior work has documented convincing evidence that dual use of Medicare and VA services comes with inherent risks of care fragmentation and duplication of services, including, for example, higher rates of hospitalization for ambulatory care-sensitive conditions, higher cost and worse outcomes in cancer, and higher rates of rehospitalization. 4 Despite the best efforts, care received outside the VA cannot be seamlessly integrated into the sophisticated electronic medical record (EMR) and decision support systems that unify the VA. Physicians outside the VA do not have access to the VA’s EMR and ordering systems, leading to risks of duplication of services, errors, and inefficient care. These risks of care fragmentation with dual use extend to the Choice Program, especially given its complexity. As an example, consider how prescription drugs are dispensed through Choice. Under the Program, non-VA providers must prescribe within the same formulary rules that guide VA providers. Choice providers do not have access to the electronic ordering with decision support that helps VA providers prescribe within formulary guidelines. In 2003, when VA temporarily implemented the Transitional Pharmacy Benefit for patients waiting more than 30 days for their initial primary care appointment, roughly 40% of prescriptions received from non-VA providers were non-formulary, substantially increasing the workload and costs for VA pharmacy. Each Choice prescription must be faxed, mailed, or delivered in person to a VA facility to be processed; verbal and telephone prescriptions Published online August 20, 2015