Antibiotic streamlining: monitoring and compliance

The principles of antibiotic streamlining are discussed. At the University of Nebraska Medical Center, antibiotic streamlining is conducted through the coordination of decentralized pharmacists and a comprehensive drug-usage evaluation program. Streamlining is focused on reducing redundant antibiotic coverages and converting from i.v. to oral therapy whenever possible. Examples include switching from i.v. to oral ciprofloxacin and reducing the number of ampicillin-sulbactam, clindamycin combinations. Benefits and drawbacks of the program are discussed.     

Use of benchmarking techniques to justify the evolution of antibiotic management programs in healthcare systems.

OBJECTIVE: To apply basic benchmarking techniques to hospital antibiotic expenditures and clinical pharmacy personnel and their duties, to identify cost savings strategies for clinical pharmacy services. DESIGN: Prospective survey of 18 hospitals ranging in size from 201 to 942 beds. Each was asked to provide antibiotic expenditures, an overview of their clinical pharmacy services, and to describe the duties of clinical pharmacists involved in antibiotic management activities. Specific information was sought on the use of pharmacokinetic dosing services, antibiotic streamlining, and oral switch in each of the hospitals. RESULTS: Most smaller hospitals (< 300 beds) did not employ clinical pharmacists with the specific duties of antibiotic management or streamlining. At these institutions, antibiotic management services consisted of formulary enforcement and aminoglycoside and/or vancomycin dosing services. The larger hospitals we surveyed employed clinical pharmacists designated as antibiotic management specialists, but their usual activities were aminoglycoside and/or vancomycin dosing services and formulary enforcement. In virtually all hospitals, the yearly expenses for antibiotics exceeded those of Millard Fillmore Hospitals by $2,000-3,000 per occupied bed. In a 500-bed hospital, this difference in expenditures would exceed $1.5 million yearly. Millard Fillmore Health System has similar types of patients, but employs clinical pharmacists to perform streamlining and/or switch functions at days 2-4, when cultures come back from the laboratory. CONCLUSIONS: The antibiotic streamlining and oral switch duties of clinical pharmacy specialists are associated with the majority of cost savings in hospital antibiotic management programs. The savings are considerable to the extent that most hospitals with 200-300 beds could readily cost-justify a full-time clinical pharmacist to perform these activities on a daily basis. Expenses of the program would be offset entirely by the reduction in the actual pharmacy expenditures on antibiotics.     

Streamlining antimicrobial therapy through pharmacists' review of order sheets

The impact of a pharmacy-conducted intervention program designed to contain costs by "streamlining" antimicrobial therapy is described. Streamlining of antimicrobial therapy may involve simplifying routes of administration, decreasing the dose or frequency of antimicrobial administration, or converting from multiple-agent therapy to single-agent therapy. Beginning on December 1, 1987, pharmacists at this university-affiliated teaching hospital used the antimicrobial order sheet (AOS) filled out by all prescribers of anti-infective agents to identify orders that were potential candidates for streamlining. Interventions involved a discussion between the pharmacist and prescriber in which the pharmacist specified the reasoning behind the recommended change. For each recommendation that was accepted by the prescriber, the cost savings per day was determined by subtracting the daily cost of the recommended streamlined therapy from the daily cost of the original "problem" therapy. Data collection continued until May 1, 1988. During that five-month period, 162 out of 173 pharmacist-initiated streamlining recommendations were accepted by prescribers, resulting in a total cost savings of $19,864. The average cost savings per intervention was $122.62. The most frequent intervention involved decreasing the frequency of i.v. administration, decreasing the dose, or both. The intervention that resulted in the greatest average cost savings involved simplifying the route of administration or discontinuing antimicrobial therapy entirely. The projected annual cost savings of this program is $47,700. By using information from AOSs to identify problem antimicrobial orders, pharmacists were able to recommend streamlining of antimicrobial therapies that resulted in an average cost savings of about $122 per intervention.     

Hospital Pharmacists’ Awareness of a New Antibiotic Guideline in the UK: Implications for Practice

Objectives: Pharmacists play an important role in the review of local hospital guidelines. British Thoracic Society (BTS) guidelines for the management of patients with community-acquired pneumonia (CAP) were updated in 2001, and it is important that individual hospital recommendations are based upon this national guidance. The aim of this study was to identify UK Chief Pharmacists’ awareness of these updated guidelines one year after their publication. Secondary aims were to identify whether pharmacists had subsequently initiated revision of institutional CAP guidelines, and what roles different professional staff had performed in this process. Method: A self-completion postal questionnaire was sent to the Chief Pharmacist (or their nominated staff) in 253 UK NHS hospitals in November 2002. This aimed to identify issues relating to their awareness of the 2001 BTS guidelines and subsequent revision of their hospital’s guidelines. Results:188 questionnaires were returned (a response rate of 74%), of which 164 hospitals had local antibiotic prescribing guidelines. Respondents in 29% of these hospitals were unaware of the 2001 BTS publication and institutional guidelines had been revised in only 51% of hospitals where the Chief Pharmacist was purportedly aware of the new BTS guidance. Generally, more staff types were involved in revising guidelines than initiating revision. Conclusions:Variability existed in both Chief Pharmacists’ awareness of new national guidance and subsequent review processes operating in individual hospitals. A lack of proactive reaction to new national guidance was identified in some hospitals, and it is hoped that the establishment of specialist “infectious diseases pharmacists” will facilitate the review of institutional antibiotic prescribing guidelines in the future.     

Impact of an institution-specific hospital-acquired pneumonia protocol on the appropriateness of antibiotic therapy and patient outcomes

STUDY OBJECTIVE: To evaluate the impact of a hospital-acquired pneumonia (HAP) protocol on appropriateness of empiric antibiotic therapy, antibiotic deescalation, antibiotic duration, patient mortality, and length of stay. DESIGN: Before- and after-study of protocol implementation. SETTING: A 450-bed, academic medical center. PATIENTS: One hundred consecutive patients with proven or suspected HAP. INTERVENTION: Implementation of an HAP protocol that was based on the 2005 American Thoracic Society-Infectious Diseases Society of America guidelines and included extensive education of clinicians and monitoring by pharmacists. MEASUREMENTS AND MAIN RESULTS: Before protocol implementation, 50 patients with HAP were evaluated against protocol criteria. After protocol implementation, a second cohort of 50 patients with HAP was evaluated. Compared with the preprotocol group, implementation of the protocol led to an increase in both the proportion of patients who received appropriate empiric antibiotic coverage (17 [34%] vs 31 [62%] patients, p=0.005) and appropriate antibiotic deescalation (21 [42%] vs 36 [72%] patients, p=0.002) according to protocol recommendations but did not affect the appropriateness of empiric antibiotic therapy based on final lung culture data (34 [68%] vs 41 [82%] patients, p=0.11). Compared with the preprotocol group, use of the protocol decreased the duration of intravenous antibiotic therapy (median [range] 9 [2-21] vs 7 [1-16] days, p=0.024), was associated with a trend for a shorter duration of stay in the intensive care unit (median [range] 19 [2-57] vs 11 [3-76] days, p=0.065), and did not significantly affect mortality (5 [10%] vs 8 [16%] patients, p=0.37). Pharmacists performed 59 interventions to support the protocol in 29 patients in the postprotocol group, of which 48% were accepted. CONCLUSIONS: Implementation of an HAP protocol improved appropriate empiric antibiotic use and decreased the duration of antibiotic therapy without adversely affecting patient outcomes.     

西安市医疗机构医务人员药品不良反应报告的质量分析

目的评价2008年至2010年西安市医疗机构上报的药品不良反应(adverse drug reaction,ADR)报告表的质量。方法根据《"药品不良反应/事件报告表"规范分级标准》和《WHO药品不良反应病例报告分级标准》对报告表的完整性进行评价;对报告表的基本信息缺项进行统计;评估新的和严重的ADR病例报告比例以及报告表提交的时效性等。结果护士填报的报告表完整性3或4级的占72.29%,显著低于医生和药师(分别为95.01%和98.52%);报告表基本信息的缺失主要存在于患者病历号/门诊号(30.55%)、联系方式(23.55%)以及药品商品名(8.19%);药师报告的新的和严重的ADR病例构成比显著高于医生和护士;护士在ADR发生后超过3个月才上报的比例最低(2.29%),其次是医生和药师(分别为4.16%和8.30%)。结论不同专业医务人员对ADR的关注角度以及对报告过程的掌握程度并不一致,应该采取各种措施有针对性地提高药品不良反应报告表的质量。     

Improved pharmacy services through pharmacist participation in medical rounds.

The participation by pharmacists in medical rounds in a 250-bed pediatric hospital with centralized unit dose drug distribution and i.v. admixture programs is discussed. A redistribution of responsibilities enabled pharmacists to attend physician work rounds on each medical service. Nursing-pharmacy rounds were set up for services which had no scheduled physician work rounds. As a result, the amount of medication waste due to late order changes, which had previously been a problem, was reduced by 0.54 cents per patient day. Pharmacist participation in medical rounds increased his clinical expertise and supplied him with the clinical data necessary to make more informed recommendations to physicians.     

Pharmacist involvement in antimicrobial use at rural community hospitals in four Western states.

PURPOSE: Pharmacist involvement in antimicrobial use at small rural hospitals in four Western states was studied. METHODS: Surveys were mailed in July 2000 to hospitals with a daily patient census of <150 in Idaho, Nevada, Utah, and eastern Washington. RESULTS: Seventy-seven (77%) of 100 hospitals returned completed surveys. Only 5% of the hospitals had onsite pharmacists 24 hours per day. An onsite pharmacist was present for a median of 26 hours per week in hospitals without 24-hour pharmacist coverage (range, 0-116 hr/wk). Many hospitals (71%) had policies for monitoring or controlling antimicrobial use, but only 28% had a system capable of monitoring compliance with such policies. Few hospitals had systems for recommending changes in antimicrobial selection on the basis of susceptibility test results (27%) or for monitoring physician compliance with dosage recommendations by pharmacists (21%). Onsite pharmacist hours were significantly associated with pharmacists being involved in the initial ordering of antibiotics and providing active oversight of antimicrobial use. There was a negative correlation between onsite pharmacist hours and use of third-generation cephalosporins and carbapenems. CONCLUSION: A survey showed that rural hospital pharmacists in four Western states spent relatively little time monitoring and influencing antimicrobial prescribing.     

Antimicrobial Stewardship Programs: Comparison of a Program with Infectious Diseases Pharmacist Support to a Program with a Geographic Pharmacist Staffing Model

Background:

Stewardship of antimicrobial agents is an essential function of hospital pharmacies. The ideal pharmacist staffing model for antimicrobial stewardship programs is not known.

Objective:

To inform staffing decisions for antimicrobial stewardship teams, we aimed to compare an antimicrobial stewardship program with a dedicated Infectious Diseases (ID) pharmacist (Dedicated ID Pharmacist Hospital) to a program relying on ward pharmacists for stewardship activities (Geographic Model Hospital).

Methods:

We reviewed a randomly selected sample of 290 cases of inpatient parenteral antibiotic use. The electronic medical record was reviewed for compliance with indicators of appropriate antimicrobial stewardship.

Results:

At the hospital staffed by a dedicated ID pharmacist, 96.8% of patients received initial antimicrobial therapy that adhered to local treatment guidelines compared to 87% of patients at the hospital that assigned antimicrobial stewardship duties to ward pharmacists (P < .002). Therapy was modified within 24 hours of availability of laboratory data in 86.7% of cases at the Dedicated ID Pharmacist Hospital versus 72.6% of cases at the Geographic Model Hospital (P < .03). When a patient’s illness was determined not to be caused by a bacterial infection, antibiotics were discontinued in 78.0% of cases at the Dedicated ID Pharmacist Hospital and in 33.3% of cases at the Geographic Model Hospital (P < .0002).

Conclusion:

An antimicrobial stewardship program with a dedicated ID pharmacist was associated with greater adherence to recommended antimicrobial therapy practices when compared to a stewardship program that relied on ward pharmacists.     

Comité de l'Antibiogramme de la Société Française de Microbiologie report 2003

Following the recommendations of the WHO Expert Committee for Biological Standardization (Technical reports No. 610, 1977), the French Society for Microbiology created an Antibiogram Committee (CA-SFM), with the aim of proposing the standards which define the clinical categories of antibiotic susceptibility (formerly therapeutic categories). The MIC and zone diameter interpretive standards, as well as the specific recommendations for certain species or certain antibiotic groups, are published in a yearly report.     

Effect of pharmacists' clinical interventions on nonformulary drug use

The effect on drug costs of pharmacists' interventions in reducing the use of nonformulary medications was studied in a private teaching hospital. During a four-month period, nonformulary medication request forms and pharmacist consultation logs were reviewed to determine physicians' actions taken on requests for nonformulary medications. Cost avoidance of interventions (nonformulary medication cost) and the cost of pharmacist cost) and the cost of pharmacist time for the interventions were determined. The pharmacist was able to contact The pharmacist was able to contact the physician in 388 of 394 instances in which the use of a nonformulary medication was considered. Of 230 recommendations by pharmacists to change a nonformulary drug order to one for a formulary alternative, 64.8% (149) were accepted by physicians. Of pharmacists' recommendations that were accepted, 75.8% (113/149) were from decentralized areas, which was a significantly higher acceptance rate than that for the centralized areas (24.7% or 36/149). Cost avoidance resulting from acceptance of pharmacists' recommendations during the four-month study was $2,645, or $13,573 per year; this was more than the cost of pharmacist time required to perform interventions. Pharmacist interventions to decrease use of nonformulary drugs can be cost-effective and appear to be more successful in decentralized pharmacy service areas than in areas served by a central pharmacy.     

Adverse drug reaction reporting by general medical practitioners and retail pharmacists in Harare--a pilot study

OBJECTIVE: The pilot study was undertaken to investigate whether doctors and pharmacists in the private sector are willing to undertake Adverse Drug Reaction (ADR) reporting, to analyse their perceptions with regard to ADR reporting and to determine whether the concept of sentinel reporters could be of value in Zimbabwe. DESIGN: An open, prospective study where a selected group of private general medical practitioners and community pharmacists were asked to report any suspected ADRs over a six month period and to complete a structured self administered questionnaire. SETTING: Private medical and pharmacy practices in Harare. SUBJECTS: General medical practitioners and community pharmacists. MAIN OUTCOME MEASURES: Number of ADR reports received at Medicines Control Authority (MCA) and questionnaire responses. RESULTS: 19 reports were received from participants (eight pharmacists and five doctors) accounting for 79.2% of ADR reports to the MCA, during the study period. Seventeen (89.5%) of the reports generated from the study came from doctors. The 19 reports involved 15 different drugs, three (20%) of which had been registered in the last three years. Twelve questionnaires were completed. Serious and unexpected reactions were more likely to be reported. Most respondents knew what was expected and were willing to report, although five (41.7%) felt they were too busy. Seventy five percent of the doctors had not known that a reporting scheme existed in Zimbabwe and none of the participants had ever sent in a report prior to the study. Medical journals and the drug manufacturers were the most important sources of information about ADRs. CONCLUSION: Simply having interested pharmacists and doctors on the look out for ADRs and increased reporting of ADRs to the MCA. There are willing health care personnel but there is a need for larger studies to see if sentinel reporting of ADRs is applicable on a country wide basis.     

Pharmacist job turnover, length of service, and reasons for leaving, 1983-1997.

Pharmacist job turnover from 1983 to 1997 was studied. Data were collected from a randomized 1997 mail survey of 1600 licensed pharmacists in four states (Ohio, Massachusetts, Oregon, and Alabama). The survey instrument included questions on pharmacist demographics, work schedules, salary, and work history. A total of 541 pharmacists responded, yielding an adjusted response rate of 34.5%. Information was provided on a total of 1697 jobs with start dates from 1931 to 1997. Pharmacist job turnover was fairly steady across the 1983-1997 period, averaging 11% annually. The average median tenure of pharmacists who left jobs was 32 months. The percentage of pharmacists leaving jobs and ranking stress as the reason for leaving increased, and the percentage of leavers ranking salary as the reason decreased. Women had a significantly higher annual turnover rate (15%) than men (9.7%), and they stayed in jobs for significantly less time (25.2 months) than men (56.5 months). There were no differences in turnover rates across practice settings. A larger percentage of pharmacists leaving jobs in large chain and institutional settings ranked stress as a reason for leaving than pharmacists leaving independent or small chain pharmacies. A larger percentage of pharmacists leaving independent or small chain pharmacies ranked salary as a reason than pharmacists in the other two settings. Pharmacist job turnover averaged 11% per year between 1983 and 1997. Pharmacists who left jobs typically stayed less than three years. The percentage citing stress as a reason for leaving increased, and the percentage citing salary decreased.     

Disposal of hazardous pharmaceuticals

The literature contains very little information regarding the disposal of pharmaceuticals. This article examines this topic from the viewpoint of hospital pharmacists. Environmental, safety and legal factors are discussed. Of the three most common disposal methods available (i.e. sewer, landfill, and incineration), incineration is the preferred method of destruction. If this method is unavailable, discriminate disposal via the sewer or garbage (landfill) systems is acceptable. Special disposal precautions are discussed for biologicals (autoclaving and then incineration), antineoplastics (incineration or neutralization before disposal via sewer or landfill systems), and radiopharmaceuticals (disposal according to the recommendations of the Atomic Energy Control Board).     

1例慢性肾炎并发尿路感染患者的抗菌药物用药分析与药学监护

目的:为慢性肾炎并发尿路感染患者的抗菌药物合理应用提供参考。方法:分析1例慢性肾炎并发尿路感染患者的抗菌药物选择、用法用量、更换及降阶治疗情况,从患者肾功能状况、尿路感染的常见致病菌及耐药情况分析抗菌药物应用是否合理,并优化用药方案。结果:患者以氨曲南经验性治疗尿路感染存在一定的理论基础,但用药浓度偏大;后更换为抗菌药物哌拉西林/他唑巴坦,药师建议进一步优化,选择头孢哌酮/舒巴坦更佳;降阶治疗的时机把握欠合理。结论:肾功能低下的患者感染时要尽量选择肾毒性小的抗菌药物,药物剂量过大或浓度偏高可能会引发不良反应;经验性用药要结合感染类型和常见致病菌的耐药情况,尽量选择广谱抗菌药物;降阶治疗需及时,且要结合致病菌种类和药敏结果尽量选择相对窄谱、针对性强的抗菌药物。     

Evaluation of community pharmacy service mix: evidence from the 2004 National Pharmacist Workforce Study.

OBJECTIVES: To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services. DESIGN: Cross-sectional study. SETTING: Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies). PARTICIPANTS: Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey. INTERVENTION: Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists. MAIN OUTCOME MEASURES: Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services). RESULTS: Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index. CONCLUSION: Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.     

Predictors of receipt of a fluoroquinolone versus trimethoprim-sulfamethoxazole for treatment of acute pyelonephritis in women in Manitoba, Canada

PURPOSE: The increasing and comparatively high proportion of uropathogens in Canada resistant to trimethoprim-sulfamethoxazole (TMP-SMX) may be partially responsible for the increasing use of fluoroquinolones. A number of patient-specific variables have been identified as risk factors for infections caused by antibiotic-resistant pathogens. However, variables unrelated to need, have also been associated with receipt of broad-spectrum antibiotics. We identified patient variables associated with receipt of a fluoroquinolone versus TMP-SMX for treatment of acute pyelonephritis. METHODS: Healthcare claims from the province of Manitoba, Canada for the period February 1996 to March 1999 were examined to identify episodes of pyelonephritis in non-pregnant females between 18 and 65 years of age treated with TMP-SMX or a fluoroquinolone. Patient variables were identified based on healthcare claims review and data from Statistics Canada. Logistic regression was used to model the probability of receipt of a fluoroquinolone. RESULTS: A total of 1084 women met inclusion criteria; 653 treated with TMP-SMX and 431 treated with a fluoroquinolone. Age, income, rural residence, recent antibiotic use, recent hospitalization and presentation to an emergency room (ER) were positively associated with receipt of a fluoroquinolone. CONCLUSIONS: Patient variables reportedly associated with an increased probability of resistant organisms (e.g., age, recent antibiotic use and recent hospitalization) were significantly associated with an increased probability of receipt of fluoroquinolones. However, variables unrelated to antibiotic resistance (e.g., income, rural residence and presentation to an ER) were also significantly associated with receipt of a fluoroquinolone.     

Assessing pharmacists’ readiness to prescribe oral antibiotics for limited infections using a case-vignette technique

Background Pharmacist’s skills are underutilized whilst they are directly involved with antibiotic supply to the community. Addressing this issue could lead to better use of antibiotics and hence decreased resistance. Objective Explore how pharmacists can prescribe oral antibiotics to treat a limited range of infections whilst focusing on their confidence and appropriateness of prescribing. Setting Community pharmacies, Western Australia. Method Data were collected using a self-administered questionnaire also containing case vignettes. These were distributed to a random sample of metropolitan and rural community pharmacies in Western Australia. A Generalised Estimating Equation was used to compare respondents’ level of confidence in treating various infections and to assess appropriateness of prescribing. Main outcome measure Appropriateness and confidence of antibiotic prescribing. Results A response rate of 34.2% (i.e. 425 responses to case vignettes) was achieved from 240 pharmacies. There were high levels of confidence to treat simple infections such as uncomplicated UTIs (n = 73; 89.0%), impetigo (n = 65; 79.3%), mild bacterial skin infections (n = 62; 75.6%) and moderate acne (n = 61; 72.4%). Over 80% of respondents were confident to prescribe amoxicillin (n = 73; 89%), trimethoprim (n = 72; 87.8%), amoxicillin and clavulanic acid (n = 70; 85.4%), flucloxacillin (n = 70; 85.4%) and cephalexin (n = 68; 82.9%). High levels of appropriate antibiotic prescribing were shown for uncomplicated UTI (97.2%), cellulitis (98.2%) and adolescent acne (100.0%). Conclusion This study identified key limited infections and antibiotics for which pharmacists were supportive and confident to prescribe. This role could lead to better use of antibiotics in the community and minimisation of resistance.     

Evaluating a Pharmacy-Driven 72-Hour Antibiotic Monitoring Program Implemented in a Community Hospital

Background: Antimicrobial stewardship programs commonly utilize infectious diseases pharmacists to guide appropriate utilization of broad-spectrum antimicrobials. Strategies should be developed to increase staff pharmacist’s participation in decreasing broad-spectrum antibiotic use. Objective: The purpose of this study was to determine the effectiveness of a pharmacy-driven 72-hour antimicrobial stewardship initiative. Methods: A pharmacy-driven 72-hour antibiotic review policy was implemented at a community hospital. Targeted antibiotics included ertapenem, meropenem, and daptomycin. The hospital’s infectious diseases pharmacist provided policy education to staff pharmacists. All pharmacists provided prospective audit and feedback to physicians. Preimplementation and postimplementation data were collected through a retrospective chart review to analyze the impact of the initiative. Results: There were a total of 570 targeted antibiotic orders for review, of which 155 antibiotic orders met criteria for inclusion; 97 in the preimplementation group and 58 in the postimplementation group. Targeted antibiotic orders decreased postimplementation during the study period. Days of therapy per 1000 patient days decreased between the 2 groups, although this was statistically significant neither for the pooled targeted antibiotics nor for each individual antibiotic. There was a statistically significant increase in the number of appropriately prescribed targeted antibiotics from preimplementation compared to postimplementation (from 35% to 64%, P < .01). Pharmacist interventions documented for patients receiving the targeted antibiotics increased significantly during the intervention period (P < .01). In addition, there was a total of $28 795.96 in cost avoidance based on the difference in antibiotic use between the 2 groups. Conclusion: Implementation of a pharmacy-driven 72-hour broad-spectrum antibiotic review in a large community-based hospital resulted in a reduction in utilization and hospital spending and a significant increase in appropriate use of targeted antibiotics, while also increasing pharmacist engagement with antimicrobial stewardship.     

Ado-Trastuzumab Emtansine and Radium 223 Dichloride

The complexity of cancer chemotherapy requires pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparation, dispensing, and administration of antineoplastic therapy, and the agents, both commercially available and investigational, used to treat malignant diseases. Questions or suggestions for topics should be addressed to Dominic A. Solimando, Jr., President, Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203, email: ten.tsacmoc@cvSxRcnO; or J. Aubrey Waddell, Professor, University of Tennessee College of Pharmacy; Oncology Pharmacist, Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804, e -mail: ten.retrahc@ruofddaw.Name: Ado-trastuzumab emtansineSynonyms: Trastuzumab emtansine, Trastuzumab-DM1, T-DM1, Kadcyla