• Evaluation of Combination Therapy for Clostridium Difficile Infections at an Academic Hospital

      Matthias, Kathryn; Nix, David; Wolk, Donna; Stehmer, Theresa; Campbell, Jackie; Matthias, Kathryn; Nix, David; Wolk, Donna; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: The incidence of non-response, recurrence, relapse, and rate of complications of Clostridium difficile infections treated with combination of metronidazole and vancomycin versus vancomycin or metronidazole alone over a one-year period by treatment and strain type (i.e. NAP1/BI/027) were evaluated. The incidence of mortality in patients with moderate to severe Clostridium difficile associated diarrhea prescribed metronidazole, vancomycin, or combination metronidazole plus vancomycin as initial therapy was also determined. Additionally, significant factors associated with the use of combination vancomycin-metronidazole as initial therapy for moderate to severe CDAD were characterized. Methods: T This retrospective medical record review has been approved by the Institutional Review Board. Adult patients with stool specimens tested for detection of Clostridium difficile toxin B by PCR between April 2010 and March 2011 at a tertiary care, academic medical center were evaluated. Patients were included in the study if diagnosed with moderate to severe disease and received either monotherapy with metronidazole, monotherapy with oral vancomycin, or combination therapy with metronidazole and oral vancomycin for at least 80% of the first 10 days of treatment. Patients who are discharged alive within 72 hours of admission or who received therapy for less than 48 hours were excluded. Main Results: All patients (N=411) with laboratory evidence of Clostridium difficile during the study time period were evaluated. A total of 26 subjects who received oral vancomycin monotherapy and 56 subjects who received oral vancomycin along with metronidazole for at least 80% of the first 10 days of treatment were identified. Of the subjects who received oral vancomycin monotherapy during the first ten days of therapy, 5 (19%) were classified has a treatment failure or died within the first 21 days of therapy and 5 (19%) had either a recurrence or reappearance of Clostridium difficile associated diarrhea between 22 and 65 days post start of therapy. Of the subjects who received a combination of oral vancomycin and metronidazole during the first 10 days of therapy, 14 (25%) were classified has a treatment failure or died within the first 21 days of therapy and 22 (39%) had either a recurrence or reappearance of Clostridium difficile associated diarrhea between 22 and 65 days post start of therapy. In the combination therapy group, 5 (9%) were reported to have an ileus, toxic megacolon, or necrotic bowel during the first 10 days of therapy. Conclusions: In this study, the subjects who received a combination of oral vancomycin and metronidazole had higher rates of clinical failure, death, and recurrence than subjects who received monotherapy. Current guideline statements recommend combination therapy only in patients with an ileus with Clostridium difficile-associated diarrhea.
    • Evaluation of Implementation of Extended-Infusion Piperacillin-Tazobactam at an Academic Medical Center

      Matthias, Kathryn; Radosevich, John; Brunelle, Adam; DiPede, Michael; College of Pharmacy, The University of Arizona (The University of Arizona., 2011)
      OBJECTIVES: The objective of this study was to compare patient clinical outcomes, vascular access line administration complications, and piperacillin-tazobactam costs before and after implementation of an extended infusion piperacillin-tazobactam protocol in adult patients at an academic medical center. METHODS: In this IRB-approved retrospective project, the effect of the implementation of a piperacillin- tazobactam extended infusion protocol at a tertiary care, academic medical center was accessed. The use of piperacillin-tazobactam was accessed during 3 one-month time periods in 2010: Time Period 1 (pre-education and implementation of protocol), Time Period 2 (post-education of pharmacists and infectious disease physicians), and Time Period 3 (post-education of healthcare professionals and implementation of extended-infusion piperacillin- tazobactam protocol). Patients were excluded if piperacillin-tazobactam therapy was prescribed for less than 72 hours. Data collected in each one-month period included demographic data, culture results, number of piperacillin-tazobactam grams prescribed per day, percentage of patients who received extended-infusion piperacillin-tazobactam, other antimicrobial therapy prescribed, medications prescribed with intravenous incompatibilities with piperacillin-tazobactam, number of intravenous line lumens before and after start of piperacillin-tazobactam therapy, length of stay, and all-cause 30 day mortality. RESULTS: During a three step process, the use of extended infusion piperacillin-tazobactam was implemented at an academic medical center after administration approval, education of healthcare professionals, and development of an electronic piperacillin-tazobactam order set. Use of extended-infusion piperacillin-tazobactam protocol significantly decreased the average daily piperacillin-tazobactam dose per patient. CONCLUSION: Implementation of extended-infusion piperacillin-tazobactam protocol for adult patients did significantly decrease the average daily dose of piperacillin-tazobactam per patient (reduced drug cost) but increased vascular access requirements.
    • Evaluation of Prescribed Empiric Cellulitis Therapy at an Academic Medical Center Emergency Department

      Matthias, Kathryn R.; Patanwala, Asad; Bissing, Joe; Ito, Satoru; Erwin, Lam; Matthias, Kathryn R.; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi-square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost-effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.
    • Medication Reconciliation at an Academic Medical Center: Perceptions from Medical Professionals

      Warholak, Terri; Candlish, Karol; Young, Genevieve; Warholak, Terri; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: The goal of this project was to assess perceptions of medication reconciliation from medical professionals who perform them. Specific areas of interest included the perceived: amount of time spent on medication reconciliation; process complexity; and effectiveness of the current process. Opinions concerning the use of alternative processes were also solicited. Methods: This prospective qualitative study involved four focus group sessions at one tertiary referral teaching hospital in Tucson, Arizona. Nurses involved in admissions medication reconciliation in the emergency department were invited to participate, and their perceptions were categorized and summarized. Main Results: Participants reported a range of times to complete the medication reconciliation from zero to greater than 20 minutes. According to the participants, the time spent on each patient depended on patients’ medication knowledge and the complexity of their regimens. Participants wanted the medication list entry screen to be easier to use, and they also suggested patients’ medication lists from previous visits and from outpatient clinics associated with the medical center be easily accessible. Participants felt that emergency triage may not be the most ideal time in which to perform medication reconciliation, and they expressed concerns about accuracy of these medication lists. While some were interested in the possibility of using a patient medication database and expected that it would improve accuracy and save time, others were less open to a perceived additional step. Concusions: Participants provided suggestions for changes in the current medication reconciliation process that they feel could improve patient satisfaction and increase efficiency.