Trending Topics in Health-System Pharmacy
Inappropriate medications at discharge could lead to adverse effects
While admission to hospital provides an opportunity for a comprehensive medication review, the safety of drug regimens after discharge is unclear. In a study published online in the June 2020 issue of the Journal of the American Geriatric Society, researchers at McGill University used a prospective cohort study to estimate the number of potentially inappropriate medications prescribed to patients at hospital discharge and its association with the risk of adverse events 30 days after discharge. Study participants were patients from internal medicine and cardiac and thoracic surgery, who were aged 65 years and older, 57% male (median of 76 years), and admitted between October 2014 and November 2016.
Of the 2,402 patients in the study, 66% were prescribed at least one potentially inappropriate medication at discharge, 49% continued a potentially inappropriate medication from prior to admission, and 31% were prescribed at least one new potentially inappropriate medication. In the 30 days after discharge, 9% of patients experienced an adverse drug event, and 36% visited the emergency department, were rehospitalized, or died.
The authors concluded that increasing numbers of potentially inappropriate medications prescribed at discharge were associated with an increased risk of adverse drug events and all‐cause adverse events. Improving hospital prescribing practices could potentially reduce the frequency of potentially inappropriate medication prescribing and associated adverse events.
CDC warns of ciprofloxacin-resistant meningococcal isolates
Meningococcal disease, which typically presents as meningitis or meningococcemia, requires antibiotic treatment for patients and antibiotic prophylaxis for their close contacts. Resistance to the antibiotics used for meningococcal treatment and prophylaxis, including penicillin and ciprofloxacin, has been rare in the United States.
Recently, however, after antibiotic-resistant Neisseria meningitidis serogroup Y (NmY) isolates were detected in the United States, CDC issued recommendations that health care providers perform antimicrobial susceptibility testing to determine susceptibility of all meningococcal isolates to penicillin before changing from empirical treatment with cefotaxime or ceftriaxone to penicillin or ampicillin.
In addition, in states that have experienced meningococcal disease cases caused by ciprofloxacin-resistant strains within the past 1–2 years, clinicians and public health staff should consider antimicrobial susceptibility testing on meningococcal isolates to inform prophylaxis decisions. This testing should not delay the initiation of prophylaxis with ciprofloxacin, rifampin, or ceftriaxone.
Assessing antibiotic appropriateness in the ICU
Use of the CDC tool for Assessment of Appropriateness of Inpatient Antibiotics provides an opportunity to assess antibiotic appropriateness in ICUs and identify opportunities for local improvement in antibiotic stewardship. Members of the Partnership for Quality Care Inpatient Antimicrobial Stewardship Working Group collected data from 47 ICUs, with most hospitals identified as teaching hospitals with a median of 70 ICU beds.
The study, published online in Critical Care Medicine on April 17, showed that on March 1, 2017, 362 (54%) of 667 ICU patients were on antibiotics. Of these cases, 112 were identified as inappropriate. Reasons for inappropriate use included using an unnecessarily broad-spectrum medication (29%), no infection or nonbacterial syndrome (22%), and longer than necessary treatment duration (21%).
The authors noted that prophylactic regimens were often inappropriate across different ICU types, particularly in surgical ICUs.
The group concluded that their study underscores the value of standardized assessment tools and benchmarking to be shared with local leaders for targeted antibiotic stewardship program interventions.
Machine learning predicts adverse drug reactions based on drugs’ in vitro pharmacology
In an effort to minimize adverse drug reactions, researchers at Harvard Medical School, The Jackson Laboratory, the Massachusetts Institute of Technology, the University of Massachusetts, Northeastern University, Oracle Health Sciences, and the Novartis Institutes for Biomedical Research studied adverse drug reaction events from post-marketing identification surveys and target-based in vitro pharmacology of more than 2,000 marketed drugs.
Through machine learning, they were able to systematically predict the drug effects on human patient populations from their target-based preclinical profiles. The work was published online in EBioMedicine on June 17.
The team validated the machine learning predictions based on chronological event reporting, comparison with drug labels, and systematic text mining of scientific literature. Using a target-centric approach, they identified 221 statistical associations between protein targets and adverse reactions, providing novel insight into the molecular components underlying physiological adverse reactions.
The machine learning algorithms, which can be downloaded online, are scalable and adaptable to similar datasets.
Documentation of penicillin allergy leads to less effective antibiotic treatment
Half of all hospitalized patients receive antibiotics, and more than 10% of these patients have a penicillin allergy documented in their medical record. Yet few of these allergies are confirmed when evaluated with skin testing.
In a study published online in JAMA Internal Medicine on June 29, researchers from Massachusetts General Hospital and Harvard Medical School found that patients with a documented penicillin allergy were more likely to receive broader-spectrum, sometimes less effective, and more harmful antibiotics than those without the allergy documentation.
The research team, led by Kimberly G. Blumenthal, MD, MSc, reviewed data on 11,000 inpatients who received antibiotics at 106 U.S. hospitals in 2019. They found that among the roughly 16% of patients who reported penicillin allergies, 64% received non–beta-lactam antibiotics such as vancomycin, fluoroquinolones, macrolides, sulfonamides, tetracyclines, clindamycin, aminoglycosides, and linezolid, compared with 48% of nonallergic patients. Only 13% of patients with reported allergies received narrow-spectrum beta-lactam antibiotics, compared with 30% of nonallergic patients.
Those with penicillin allergies were 5 times more likely to receive clindamycin and 18 times more likely to receive aztreonam than nonallergic patients. Patients with allergies who required surgical prophylaxis were seven times more likely to receive broader-spectrum non–beta-lactam antibiotics than nonallergic patients.
The authors noted that their results highlight a need for penicillin allergy evaluations as part of antibiotic stewardship programs.