Journal of Pharmaceutical Care
Volume:7 Issue: 3, Winter 2019

Stenotrophomonas maltophilia, a multidrug-resistant gram-negative bacillus is an opportunistic organism. Infections caused by this pathogens needs to be treated promptly and is life-threatening in neonates (1,2). The most common clinical presentations are pneumonia and bacteremia. Treatment includes limited number of antimicrobials with defined MIC cutoffs by US Clinical and Laboratory Standards Institute (CSLI). These include trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin, ticarcillin-clavulanate, minocycline, ceftazidime and chloramphenicol (1). Treatment of choice is TMP-SMX based on reliable in-vitro activity and favorable clinical outcomes (1, 2). Levofloxacin is a potential alternative to TMP-SMX (1). Usually we encounter high resistant rates to ceftazidime (3). Ticarcillin-clavulanate is not readily available in Iran. Also it is shown to be less active than TMP-SMX in vivo (2). One of the concerns with sulfa antibiotics in neonates is the potential risk of hyperbilirubinemia and kernicterus (2,4-6). The landmark study was in 1956 in which Andersen et al elucidated that premature infants receiving a penicillin/sulfisoxazole combination had a significantly higher rate of mortality and kernicterus compared with oxytetracycline (4). In the study by Thyagarajan et al, suggested that the concept of kernicterus and TMP-SMX remains a theory and needs to be further illuminated in trials. Based on their experience, who prescribed TMP-SMX for treatment of sepsis and pneumonia in newborns and infants in rural and tribal areas in India in a home-based neonatal care setting, no adverse effects, including any signs of central nervous system (CNS) toxicity was noted (6). There are also no dosing recommendations for TMP-SMX in neonates (2) and if used when facing stenotrophomonas maltophilia infection, it is used in an off-label manner. So when we encounter stenotrophomonas maltophilia infection in neonates (term and preterm) with TMP-SMX being the first treatment choice, how could the risk-benefit assessment be judged? When reviewing the literature there are case reports of treatment of neonatal stenotrophomonas maltophilia pneumonia with TMP-SMX with no report of kernicterus (2,7). One of the concerns with fluoroquinolones in children is the risk of arthropathy (8,9). Bradley et al demonstrated that musculoskeletal toxicity 5 years after therapy with levofloxacin appear to be uncommon, clinically undetectable or are reversible in children (10). So the challenge is selecting between TMP-SMX with risk of kernicterus and levofloxacin with risk of arthropathy when treating stenotrophomonas maltophilia pneumonia or sepsis in neonates when it is susceptible to both agents. Since the concern on kernicterus still remains, one conservative approach may be selecting levofloxacin over TMP-SMX in neonates. A recent systematic review and meta-analysis has shown comparable efficacy of fluoroquinolones on mortality to TMP-SMX (11). Other approach may use combination therapy of TMP-SMX with levofloxacin because of high morbidity and mortality associated with this pathogen (2,7). Studies reporting experience regarding successful treatment of this pathogen in meningitis, sepsis, pneumonia or urinary tract infections in neonates are highly needed.

Albumin is generally used in hypovolemic conditions and due to its high cost and complicated manufacturing process, its appropriate use is a vital issue to be considered.

The aim of this study is to evaluate the pattern of Albumin prescription in Imam Khomeini teaching hospital in Urmia-Iran Methods This study was carried out between December 2014- December 2015 in the Imam Khomeini hospital, affiliated to Urmia University of Medical Sciences, Iran using pre-designed forms covering demographic data and clinical and laboratory information that was completed by the educated pharmacist on a daily observational basis.

A total of 202 patients were selected with the mean age of 55.91±20.5 years including 53 % male patients. The highest prescription percentages were for patients with the diagnosis of Gastrointestinal Cancers (10.9%) while most of the patients were admitted in burn ward (16.3 %). Overall 2755 Albumin 20% vials equal to almost 3030 million Rials were used while only 79 (39.1%) of prescriptions were appropriate among which, hypoalbuminemia with 5% had the highest number of inappropriate indications.

Our results showed a significantly low percentage of justifiable prescriptions which highlights the necessity for reviewing and supervising the utilization of Albumin in the hospital.

Oral medication administration through enteral feeding tubes is a challenging issue in critically ill patients, which can lead to medication error. Patients admitted to the intensive care unit may not have the ability to swallow oral medications for various reasons such as lack of consciousness, or the need for mechanical ventilation. Improving the quality of drug administration through enteral feeding tubes is essential.

The present study aimed at evaluation of the prevalence of medication errors that occur during the administration of oral medications through enteral feeding tubes in mechanically ventilated critically ill patients.

This study was a cross-sectional observational study conducted in Golestan Educational Hospital, Ahvaz, Iran. Oral medication administration was evaluated in 50 patients within three months; information about each patient was examined. The errors were measured according to the Handbook of Drugs Administration via enteral feeding tubes.

Errors occurred in percentage of total prescriptions as follows: Drug-drug interaction 26%, wrong preparation 22.28%, wrong form 12.09%, wrong time 11.57%, drug-food interaction 6.73%, wrong dose 5.53%, wrong route 3.8%, extra dose 0.86%, omission 0.18%, deteriorated drug 0.18%, and unordered drug 0.0%. In our study, it was found that most of the drugs were administered in solid dosage forms, and almost 33% of them could be substituted for injection or oral liquid formulations.

Our study indicated the high frequency of drug administration and preparation errors in mechanically ventilated critically ill patients. Close teamwork between pharmacists or pharmacotherapists, physicians, and nurses can result in the appropriate administration of medications by an enteral feeding tube.

Caspofungin is prescribed for systemic treatment of fungal infections and correct prescription pattern is an issue of importance. Hence in this study the Caspofungin utilization and the frequency rate of medication errors were investigated at a training hospital in a developing country.

In this cross-sectional descriptive comparative study 43 consecutive patients receiving Caspofungin in Firoozgar Hospital, Tehran, Iran from March to September 2017 were enrolled. The prescription frequency of the drug was compared with the national data and the suggested rates by World Health Organization.

The prescription rate was higher in Intensive Care Unit with 72.1% rate. Infectious disease specialists were responsible for Caspofungin prescription only in 11 cases (25.5%). The cause of Caspofungin prescription was unknown in 18.6% of cases; but experimental treatment for febrile neutropenia and ICU patients with Candida Score > 2.5 were the most known causes. The drug administration in 11 cases (25.6%) occurred in less than one hour. The indication of treatment was incorrect in 12 out of 43 cases (28%). On the first day of the treatment a dose of both 70 mg and 50 mg was prescribed, which was higher than the appropriate dose and also it was lower than the optimal dose in five cases (83.7%). The mean treatment duration was 10.88 ± 5.35 days ranging from 2 to 24 days. The duration of treatment was correct in 20 cases (46.5%) and incorrect in 23 patients (53.5%).

 According to the obtained results, it may be concluded that in comparison with the international guidelines there are multiple discordance in our setting including inappropriate duration, continuation, and indications. Hence these should be announced to the physicians for further cautions in this area, and it is better to consult with infectious diseases specialists for the administration of anti-fungal drugs.

Effects of different doses of vancomycin on the renal biomarkers (Cys-C and KIM-1) of acute kidney injury were compared in patients with severe bacterial infections.

Serum levels of Cys-C, KIM-1 and creatinine and urine level of Cys-C were measured at baseline and every other day in patients receiving different doses (15 mg/kg every 8 or 12h) of vancomycin.

  Level of serum Cys-C demonstrated significant increased during vancomycin treatment in both groups. However, there was no significant difference between the groups regarding serum Cys-C level. Urine Cys-C level neither changed significantly within nor between groups during vancomycin treatment. The same results were detected for serum KIM-concentrations.

Different doses of vancomycin showed comparable effects on the serum and urine biomarkers of acute kidney injury.

Antimicrobial resistance among uropathogens causing community-acquired urinary tract infections (UTIs) is a worldwide concern. It has been suggested that diabetes could be a possible cause of antibiotic resistance. This study was undertaken to identify the responsible microbial culprits for UTI in patients with different range of glycosylated hemoglobin (HbA1C)  and evaluate their corresponding resistance pattern. In a prospective study between 2013 to 2018, data related to the urine culture and sensitivity of patients who had bacteriuria were gathered. For patients with positive urine culture, HbA1C was requested and correlations between HbA1C level with microorganism and its susceptibility were evaluated. In total, 121 patients were recruited. All study participants were female.The mean age of the patients was 50.2 ± 22.5 (range 19-96) . All study participants were of the same race. Fifteen (12.4%) out of 121 patients were diabetics. There were no difference between bacteriology of UTIs in diabetic and nondiabetic patients with the preponderance being caused by E. coli and other gram-negative organisms but, there were positive association between HbA1C and resistance to Nalidixic acid and Gentamicin. Our study supports the findings that  diabetes in itself could be a possible cause of antibiotic resistance to some antimicrobial agents.

Relatively few medications are available for the management of obesity and all are indicated as adjuncts to increased physical activity, caloric restriction and lifestyle modification. Among different weight-loss drugs, the most intriguing and controversial class is the one of anorexic amphetamines, due to their high efficiency but also relevant side-effects. Several previously approved anorexic amphetamines like fenfluramine, phenylpropanolamine, phenmetrazine and sibutramine have been withdrawn from the market due to unanticipated adverse effects. Nowadays only four amphetamine derivatives are approved for short-term treatment of obesity: amfepramone, benzphetamine, phendimetrazine and phentermine. The article provides an overview of both the history, and the current status, of the use of amphetamine derivatives in the obesity pharmacotherapy.