Trending Topics in Health-System Pharmacy
Preventing the spread of S. aureus in the NICU
Researchers at Johns Hopkins Uni-versity have investigated a potential strategy for preventing the spread of Staphylococcus aureus colonization to babies in the neonatal intensive care unit (NICU). S. aureus is a leading cause of health care–associated infections in the NICU, and parents may expose neonates to S. aureus colonization, a well-established predisposing factor to invasive S. aureus disease.
In a randomized clinical trial that included 190 neonates with parents colonized with S. aureus, Milstone and colleagues demonstrated that treating parents with I.N. mupirocin and chlorhexidine-impregnated cloths compared with placebo significantly reduced the hazard of the infants acquiring colonization with a parental S. aureus strain.
Some of the mothers and fathers were treated with short-course I.N. mupirocin and 2% chlorhexidine-saturated cloths, while those in the placebo group were treated with petrolatum I.N. ointment and nonmedicated soap cloths.
In all, 74 of the 190 neonates acquired S. aureus colonization, with 42 (14.6% of babies in the intervention group vs. 28.7% of the placebo group) presenting strains concordant with a parent.
The results suggest that I.N. mupirocin and chlorhexidine bathing in parents cut the risk of transmitting S. aureus strain to their infants being treated in the NICU by about one-half.
The researchers emphasized that these findings, published in the December 30, 2019, issue of JAMA, are preliminary and require further research for replication and to assess generalizability.
Review of penicillin allergies finds safe, less-expensive treatment options
More than one-half of patients with reported penicillin allergies were able to take antibiotics from the same medication class rather than other antibiotics that may be more expensive and have more adverse effects, according to research presented at the American Society of Health-System Pharmacists’ 54th Midyear Clinical Meeting and Exhibition.
Pharmacists at Baptist Hospital of Miami interviewed patients with reported allergies and then carefully reviewed their medication history prior to verifying orders for substitute antibiotics.
In reviewing patient histories during the 3-month study, Rita Chamoun, PharmD, and colleagues found that 68% of patients with reported penicillin allergies had successfully used other beta-lactams, most often cephalosporins. Pharmacists recommended switching these patients to a beta-lactam antibiotic to save more broad-spectrum antibiotics, such as aztreonam and levofloxacin, for situations in which standard treatments are not effective.
The authors noted that the study does not suggest that every patient with a penicillin allergy can take cephalosporins but recommends a thorough examination of medication history before dispensing non–beta-lactam antibiotics to patients with reported penicillin allergies.
Penicillin allergies, reported by up to 10% of the population, are the most common drug allergy, but researchers estimate that true penicillin allergies occur in less than 1% of patients.
Improving treatment for MRSA blood infections
Researchers from the University of Melbourne attempting to improve treatment for methicillin-resistant S. aureus (MRSA) blood infections have discovered that the combination of two antibiotics was no better than one and led to more adverse effects.
The CAMERA2 randomized clinical study trial involved adults with MRSA bacteremia from 27 hospitals in four countries, with one-half of the participants receiving standard therapy (I.V. vancomycin or daptomycin) plus an antistaphylococcal beta-lactam (I.V. flucloxacillin, cloxacillin, or cefazolin) or standard therapy alone.
The results, published in JAMA, showed that among patients with MRSA bacteremia, addition of an antistaphylococcal beta-lactam to standard antibiotic therapy with vancomycin or daptomycin did not result in significant improvement in mortality, persistent bacteremia, relapse, or treatment failure.
Although the MRSA was killed more quickly by a combination of vancomycin and a penicillin-class antibiotic, combination treatment led to more episodes of kidney injury.
The researchers stressed that further study is needed to ensure effective treatment of MRSA infections.
Hospitals penalized over patient injury rates
CMS has identified almost 800 hospitals nationwide that will receive lower payments for a year as a result of higher rates of infections and patient injuries than other facilities.
The lower payments, known as HAC penalties, are part of the Affordable Care Act and are designed to encourage better care without expelling the hospital from the Medicare and Medicaid programs.
According to Kaiser Health News, the penalties have received criticism from all sides. Hospitals believe they are arbitrary and unfair, while some patient advocates believe they are too small to make a difference.
Under the law, Medicare must cut payments by 1% for the quarter of general care hospitals that have the highest rates of infections, blood clots, sepsis cases, bedsores, hip fractures, and other complications that occur in hospitals and might have been prevented.
Hospitals that solely served children, veterans, or psychiatric patients have special status as a “critical access hospital” and are excluded from the program.
Kaiser’s analysis showed that 145 hospitals received their first penalty in 2020, while 16 that had been penalized every year since the start of the program avoided punishment. Medicare included 7 of the 21 hospitals on the U.S. News & World Report Best Hospitals Honor Roll.
Preventing oral methotrexate errors
Oral use of methotrexate has grown rapidly, with the number of people exposed to methotrexate nearly doubling between 2013 and 2017, to approximately 1 million patients per year. This rapid increase in use has come with more errors in administration of the drug, according to the Institute for Safe Medication Practices (ISMP). In the 18 months ending on June 30, 2019, 14 cases of mistaken daily administration of methotrexate in patients aged 65 years or older were reported to FDA. In five cases, the patients died; the other nine patients required hospitalization.
In the December 2019 QuarterWatch, ISMP reported that in six of these cases, the error was made by the patient, while in the other eight cases, the oral methotrexate was ordered, labeled, or dispensed incorrectly. In one case, a community pharmacy dispensed a 3-month supply of methotrexate with instructions to take six 2.5-mg tablets daily instead of weekly. The patient survived after a long hospitalization.
Initially approved as a cancer treatment, the drug is now used primarily as a treatment for rheumatoid arthritis and psoriasis. The high-alert medication has a narrow therapeutic index and a wide range of doses and duration of treatment. A boxed warning lists 11 different risks, including bone marrow suppression, renal impairment, hepatotoxicity, tumor lysis syndrome, opportunistic infections, and severe toxic reactions.
For nononcologic uses, it is essential that methotrexate be taken weekly rather than daily. To prevent oral methotrexate errors, ISMP recommends
- Requesting that FDA require manufacturers of oral methotrexate used for nononcologic indications to provide oral methotrexate tablets for nononcologic use in calendar packaging to discourage daily use
- Including a warning on the package that emphasizes weekly use only
- Simplifying dosing schedules to take methotrexate once a week rather than in several divided doses 12 hours apart
- Improving the patient information section of the prescribing information to prominently state the importance of the weekly dose regimen and the consequences of nonadherence.
In addition, community pharmacies should dispense no more than a 30-day supply.