Includes bibliographical references.

Repurposed Drugs Against COVID-19: Safety Concerns and Stockout / Jehan Zeb Khan, Iftikhar Ali and Zair Hassan -- Anti-infective Waste in a Pediatric Institution: Pinpointing Problems in the Process -- The Use of Aerosolized Ribavirin in Respiratory Syncytial Virus Lower Respiratory Tract Infections in Adult Immunocompromised Patients: A Systematic Review -- Chloral Hydrate Sedation in a Dexmedetomidine Era -- Effect of a Standardized Treatment Panel on Hypoglycemic Events in Hospitalized Acute Hyperkalemic Patients Treated With Intravenous Regular Insulin -- Evaluation of Basal Insulin Dose Reductions in Hospitalized Patients With Diabetes While Unable to Eat -- A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center -- Evaluation of Antibiotic Utilization in an Emergency Department After Implementation of an Antimicrobial Stewardship Pharmacist Culture Review Service -- Fidaxomicin Compared With Oral Vancomycin for the Treatment of Severe Clostridium difficile–Associated Diarrhea: A Retrospective Review -- Evaluation of Intraoperative, Local Site Injections of Liposomal Bupivacaine as an Alternative to Standard Local Anesthetics in Patients Undergoing Total Hip Arthroplasty.

[Article Title: Repurposed Drugs Against COVID-19: Safety Concerns and Stockout / Jehan Zeb Khan, Iftikhar Ali and Zair Hassan, p. 218-219]

Abstract:

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2 or COVID-19) first surfaced in Wuhan (China) in December 2019 and subsequently spread to other countries.1,2 Since then, it has been recognized as a public health emergency of global concern. This global expansion of COVID-19 is on a dangerous trajectory and poses to wreak havoc on the lives of people. The outbreak has caused concerns for health care systems across the globe and mounted fear and anxiety as the situation continues to worsen. From a standard public health perspective, every effort is being made to reduce person to person transmission.

https://doi.org/10.1177/0018578720925387

[Article Title: Anti-infective Waste in a Pediatric Institution: Pinpointing Problems in the Process / Christine E. MacBrayne, Manon C. Williams, Haley Obermeier, Jason Child, Justin W. Heizer, Matt Millard, Kelly Pearce, Casey Dugan and Sarah K. Parker, p. 220-223]

Abstract:

Purpose: At Children’s Hospital Colorado (CHCO), there are approximately 40 000 inpatient anti-infective orders every year resulting over 100 000 dispenses. Significant quantities of anti-infectives are wasted, incurring roughly $100 000 in waste annually. Identifying areas for improvement will result in cost savings and ameliorate the impact of drug shortages.

Summary: This descriptive report discusses the reasons for anti-infective waste at a free-standing, quaternary-care, pediatric hospital. The anti-infectives with the highest cost in waste ($) included meropenem ($38 084), micafungin ($21 690), amphotericin B liposome ($15 913). An internal audit of CHCO anti-infective waste revealed that drugs are wasted for the following reasons: patient discharge, medication order discontinuation or change, and misplaced doses.

Conclusion: The CHCO Antimicrobial Stewardship Program and the Pharmacy have proposed 4 process improvement measures that will target anti-infective waste to reduce pharmaceutical waste and hospital costs. These measures may be applicable to other drug classes that likely suffer from a similar proportion of waste.

https://doi.org/10.1177/0018578719844164

[Article Title: The Use of Aerosolized Ribavirin in Respiratory Syncytial Virus Lower Respiratory Tract Infections in Adult Immunocompromised Patients: A Systematic Review / Lisa Avery and Karen M. Whalen, p. 224-235]

Abstract:

Introduction: Respiratory syncytial virus (RSV)–associated lower respiratory tract infection (LRTI) is a concern in immunocompromised patients. Aerosolized ribavirin (RBV AER) is used for treatment of RSV LRTI; however, adverse events and rising drug costs remain a challenge for patient management. The purpose of this systematic review is to summarize the efficacy and adverse event profile of RBV AER for the treatment of hospitalized RSV LRTI in immunocompromised adult patients.

Methods: A Medline/PubMed, Embase, Google Scholar, Clinicaltrials.gov, and Cochrane Library database search was conducted from 1966 to January 2019 for the use of RBV AER. Search strategy: [(ribavirin OR ICN1229) AND (“administration, oral” OR “oral” OR “administration, inhalation” OR “inhalation)] AND (“respiratory tract infection” OR “pneumonia”). Studies were reviewed if adult patients were hospitalized, immunocompromised, had RSV LRTI, received RBV AER, and included the outcome of mortality and/or adverse reactions. Methodological quality was assessed using the Cochrane Collaboration GRADE approach.

Results: A total of 1787 records were identified and 15 articles met inclusion criteria: hematopoietic stem cell transplant (HSCT)/bone marrow transplant (n = 8), other malignancy/neutropenic (n = 2), solid organ transplant (n = 5). All of the trials are observational with a low quality rating; therefore, a meta-analysis was not performed. The 30-day mortality in studies that contain >10 patients with HSCT, malignancy, and transplant range from 0 to 15.4%, 6.3%, and 0 to 27%, respectively. Improved mortality was cited in 4 studies when RBV AER started before mechanical ventilation or within 2 weeks of symptom onset. Only 3 studies had comparative mortality data with RBV AER and RBV PO. Adverse reactions were reported in 5 studies and included psychiatric manifestations (anxiety, depression, feeling of isolation; n = 14), wheezing/bronchospasm (n = 6), snowflakes/hail blowing in face (n = 6), and precipitation in ventilator tubing (n = 5).

Conclusion: There is a lack of high quality, comparative trials on the use of RBV AER for the treatment of RSV LRTI in adult hospitalized immunocompromised patients. There may be a mortality benefit when RBV AER is initiated early after diagnosis or prior to mechanical ventilation, but requires further study. Patient isolation and psychological effects must be weighed against the benefit of therapy.

https://doi.org/10.1177/0018578719836646

[Article Title: Chloral Hydrate Sedation in a Dexmedetomidine Era / Kimberley M. Farr, Brady S. Moffett, Jennifer L. Jones, Amber P. Rogers and Corrie E. Chumpitazi, p. 236-239]

Abstract:

Brief Overview: The use of chloral hydrate as the primary sedation agent has declined across the nation after commercial production of the liquid formulation ceased. Although alternative sedatives have gained popularity, some pharmacies have continued to provide oral chloral hydrate by compounding it from raw ingredients. Thus, oral chloral hydrate use has continued in children despite the availability of alternative effective agents.

Objective: The purpose of this investigation was to evaluate institutional chloral hydrate utilization as the primary agent for procedural sedation.

Design/Methods: We conducted a retrospective study of patients given chloral hydrate for procedural sedation from October 2010 to December 2016. The hospital pharmacy database of chloral hydrate use at our 2 free-standing children’s hospitals was reviewed and matched to procedure billing data.

Results: There were 5874 chloral hydrate administrations for procedural sedation during the study period. The highest rates of use occurred in 2014, when there were 1420 chloral hydrate orders within our hospital. The large majority of sedations were for cardiac studies/procedures (n = 4250, 72.4%).

Conclusions: Despite significant declines in use of chloral hydrate for procedural sedation across the country, local utilization of oral chloral hydrate remains high. Recent declines may be due to high-use clinical sites transitioning to alternative sedatives such as intranasal dexmedetomidine.

https://doi.org/10.1177/0018578719836639

[Article Title: Effect of a Standardized Treatment Panel on Hypoglycemic Events in Hospitalized Acute Hyperkalemic Patients Treated With Intravenous Regular Insulin / Allison Zuern, Luke A. Probst, William Darko, Peter Rosher, Christopher D. Miller, Lori Gordon and Robert Seabury, p. 240-245]

Abstract:

Purpose: Regular insulin is a commonly utilized treatment option for acute hyperkalemia. Despite its benefit, hypoglycemia and associated morbidity/mortality remain important concerns. This institution recently created a treatment panel to standardize regular insulin dosing (0.1 unit/kg) and blood glucose (BG) monitoring in patients with acute hyperkalemia. The purpose of this study is to investigate whether the order panel reduces hypoglycemic events in adults treated with intravenous (IV) regular insulin for hyperkalemia and to determine the effect the treatment panel has on regular insulin dosing, serum potassium, BG monitoring, and dextrose supplementation.

Methods: This retrospective study was performed at a single academic medical center. Adults receiving IV regular insulin for acute hyperkalemia were included if BG was assessed prior to and following regular insulin administration. Primary outcome was hypoglycemia within 4 hours of regular insulin administration. Secondary outcomes were the change from baseline serum potassium, frequency of severe hypoglycemia, BG checks within 30 minutes prior to and within 4 hours following insulin administration, regular insulin dosing, and administration of dextrose 50% in water (D50W) following regular insulin administration. Hypoglycemia and severe hypoglycemia were defined as a BG concentration of <70 mg/dL and <50 mg/dL, respectively.

Results: One hundred sixty-five patients were included; 75 using the treatment panel and 90 not. Patients using the treatment panel received a lower median (interquartile range [IQR]) regular insulin dose (.10 [0.09-0.10 unit/kg] vs 0.11 [0.09-0.14 unit/kg], P = .004) and had more frequent BG checks during the 4 hours following regular insulin administration (median [IQR]: 4 [3-5] vs 2 [1-3], P < .001). Hypoglycemia (13.3% vs 27.8%, P = .024) and severe hypoglycemia (2.7% vs 11.1%, P = .038) occurred less frequently with the treatment panel. Similar decreases in serum potassium were noted following IV regular insulin administration.

Conclusions: Acute hyperkalemic patients utilizing a standardized treatment panel for the dosing and monitoring of IV regular insulin experienced fewer hypoglycemic and severe hypoglycemic episodes and had similar potassium lower effects. The treatment panel decreased regular insulin dosing and increased BG monitoring prior to and following regular insulin administration.

https://doi.org/10.1177/0018578719841035

[Article Title: Evaluation of Basal Insulin Dose Reductions in Hospitalized Patients With Diabetes While Unable to Eat / Sarah E. Petite, Joseph Huenecke and Natalie Tuttle, p. 246-252]

Abstract:

Background: The American Diabetes Association guidelines recommend a basal plus correction or basal insulin regimen for patients with type 2 diabetes mellitus (T2DM) receiving nothing by mouth (NPO; nil per os) in the non–intensive care unit setting. In the perioperative setting, 60% to 80% of long-acting insulin or half-dose morning insulin NPH is recommended.

Objective: The goal of this study was to determine the impact of basal insulin dose reduction for hospitalized patients with insulin-dependent T2DM while NPO.

Methods: This retrospective, single-center study evaluated patients admitted to the non–intensive care unit setting. Administration of >50% of home basal insulin was compared with administration of ≤50% of home basal insulin. The primary outcome was the difference in hypoglycemic events (blood glucose [BG] < 70 mg/dL). Secondary outcomes included comparing severe hypoglycemic events (BG < 40 mg/dL), hyperglycemic events (BG > 180 mg/dL), and hospital length of stay (LOS).

Results: Two hundred fifty-eight patient encounters were included, of which 85 and 173 patients received ≤50% and >50% of their home basal insulin dose, respectively. There were no significant differences in hypoglycemia (21.2% vs 21.4%; P = .97), severe hypoglycemia (1.2% vs 2.9%; P = .67), and hospital LOS (3 [IQR 2.13-6.74] days vs 4.66 [IQR 2.94-8.17] days; P = .74). Hyperglycemia occurred at a higher rate in patients receiving ≤50% of their home basal insulin dose (97.6% vs 89%; P = .02).

Conclusions: No differences were observed in hypoglycemic events between those patients receiving ≤50% and >50% of their home basal insulin.

https://doi.org/10.1177/0018578719841029

[Article Title: A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center / Linda P. Nguyen, Lam Nguyen and Jared P. Austin, p. 253-260]

Abstract:

Background: Following availability in the United States in 2011, intravenous acetaminophen (IV APAP) was added to many hospital formularies for multimodal pain control. In 2014, the price of IV APAP increased from $12/g to $33/g and became a top 10 medication expenditure at our institution.

Objective: To promote appropriate IV APAP prescribing and reduce costs.

Design, Setting, Participants: Quality improvement project at a 562-bed academic medical center involving all inpatient admissions from 2010 to 2017.

Interventions: Using Plan-Do-Study-Act (PDSA) methodology, our Pharmacy & Therapeutics (P&T) committee aimed to reduce inappropriate use of IV APAP by refinement of restriction criteria, development of clinical decision support in the electronic medical record, education of clinical staff on appropriate use, and empowerment of hospital pharmacists to enforce restrictions.

Measurements: Monthly IV APAP utilization and spending were assessed using statistical process control charts. Balancing measures included monthly usage of IV opioid, IV ketorolac, and oral ibuprofen.

Results: Five PDSA cycles were conducted during the study period. Monthly spending on IV APAP decreased from the highest average of $56 038 per month to $5822 per month at study conclusion. Interventions resulted in an 80% annual cost savings, or an approximate savings of $600 000 per year. Usage of IV opioids, IV ketorolac, and oral ibuprofen showed no major changes during the study period.

Conclusions: IV APAP can be restricted in a safe and cost effective manner without concomitant increase in IV opioid use.

https://doi.org/10.1177/0018578719841054

[Article Title: Evaluation of Antibiotic Utilization in an Emergency Department After Implementation of an Antimicrobial Stewardship Pharmacist Culture Review Service / Megan E. Giruzzi, John C. Tawwater Chris and Jennifer L. Grelle, p. 261-267]

Abstract:

Background: Antimicrobial stewardship programs (ASP) have been widely implemented in hospitals to improve antimicrobial use and prevent resistance. However, the role of ASP in the emergency department (ED) setting is not well defined.

Objective: The objective of this study is to evaluate the impact of an ASP pharmacist culture review service in an ED.

Methods: This was a retrospective, quasi-experimental study of all patients discharged from the ED with a positive culture. Patients discharged from the ED from February 1, 2015 to October 31, 2015 were managed by ED providers (pre-ASP), and those discharged from February 1, 2016 to October 31, 2016 were managed by a pharmacist-driven ASP (post-ASP implementation). The primary outcome was median time to change of antibiotic(s) in patients with inadequate antimicrobial therapy based on culture results. Secondary outcomes included time to culture evaluation, appropriateness of antimicrobials, and 30-day readmissions.

Results: A total of 790 patients were included in the analysis (398 in pre-ASP group vs 392 in post-ASP implementation group). Median time to modification of inadequate antibiotic therapy decreased from 6.79 days in the pre-ASP group to 1.99 days in the post-ASP implementation group (P < .0001). Median time to culture review decreased in the post-ASP implementation group from 9.83 to 0.32 days (P < .0001). Appropriateness of culture-guided therapy increased in the post-ASP implementation group from 85.7 to 91.8% (P = .047). The rate of combined ED revisits and hospital readmissions was similar between groups (P = .367).

Conclusion: ASP pharmacist evaluation of positive cultures in the ED was associated with a significant decrease in the time to appropriate therapy in patients discharged with inadequate therapy and higher rates of appropriate antimicrobial therapy.

https://doi.org/10.1177/0018578719844171

[Article Title: Fidaxomicin Compared With Oral Vancomycin for the Treatment of Severe Clostridium difficile–Associated Diarrhea: A Retrospective Review / Bryant B. Summers, Mary Yates, Kerry O. Cleveland, Michael S. Gelfand and Justin Usery, p. 268-272]

Abstract:

Purpose: The most recent published guidelines on Clostridium difficile–associated diarrhea (CDAD) developed by the Infectious Diseases Society of America (IDSA) were released in 2017 and outline its treatment based on severity of the disease and recurrence; however, a clear first-line agent has not been recommended specifically for severe CDAD.

Methods: This retrospective chart review was approved by the institutional review board and consisted of three community hospitals and one academic medical center. To be included, patients need to meet criteria for severe CDAD and receive at least 72 hours of therapy. Patients received either oral vancomycin or fidaxomicin, in addition to other therapies for CDAD, and differences in outcomes such as cost obtained from a common charge center, rates of recurrence, time to recurrence as measured at time of positive to negative polymerase chain reaction (PCR) test, and mortality were assessed.

Results: Of the 147 patients, 74 patients received fidaxomicin and 73 patients received oral vancomycin. The average hospitalization cost for patients receiving fidaxomicin was $129,338.69 and for patients receiving vancomycin was $153,563.81 (P = .26). Recurrence rates were lower with fidaxomicin compared with vancomycin (6.8% vs 17.6%; P = .047), and time to recurrence was longer with fidaxomicin versus vancomycin, but not statistically significant (96.8 ± 45.9 days vs 63.2 ± 66.9 days; P = .321). Mortality, length of stay in the intensive care unit, and overall length of stay were similar between the two therapies.

Conclusions: In the treatment of severe CDAD, recurrence rates were lower and time to recurrence was higher with fidaxomicin compared with oral vancomycin. A clear financial benefit has yet to translate from these known findings.

https://doi.org/10.1177/0018578719844165

[Article Title: Evaluation of Intraoperative, Local Site Injections of Liposomal Bupivacaine as an Alternative to Standard Local Anesthetics in Patients Undergoing Total Hip Arthroplasty / Edward C. Rainville, Carl Asche, Jinma Ren, MinChul Kim, Lucas Walker, B. Ted Maurer, Daniel R. Knolhoff and Kyle M. Shick, p. 273-278]

Abstract:

Background: Achieving postsurgical pain control after total hip arthroplasty (THA) is a critical factor for successful recovery because inadequately treated pain may lead to a delay in ambulation and hospital discharge and have an adverse impact on a patient’s quality of life.

Objective: This study compares the effectiveness of immediate-release local anesthetics for pain control in THA vs liposomal bupivacaine (LB) related to patient outcomes and costs of care.

Methods: This is a retrospective cohort study of consecutive patients undergoing THA at 3 hospitals from January 2013 to July 2016. The control group received plain bupivacaine or ropivacaine while the study group received LB. Generalized linear models were used controlling for several patient factors. Primary measures included length of stay (LOS), hospitalization costs, pain relief, opioid use, and mobility. Secondary outcomes were discharge disposition and 30-, 60-, and 90-day readmissions.

Results: One hundred and ninety-six patients were identified, with 103 as controls, 70 receiving LB, and 23 excluded. The LB group showed a decrease in LOS of 0.5 days (2.5 ± 2.6 vs 3.0 ± 2.1 days, P = .010), increased mobility on the day of surgery (27.6 ± 49.3 vs 12.5 ± 48.5 feet, P = .001) and the first day after surgery (186.8 ± 133.8 vs 155.2 ± 135.6, P = .039), and decreased hospital costs ($10 670 vs $11 351, P = .022). There were no significant differences in pain scores, opioid use, adverse events, discharge disposition, or readmissions. Study limitations include retrospective analysis, unblinded participants, and generalizability of results.

Conclusions: LB provides an effective alternative to standard local anesthetics in patients undergoing THA based on improvements of inpatient parameters, LOS, and cost measures.

https://doi.org/10.1177/0018578719844702