Objective: The objective of this study was to investigate the attitudes regarding student consumerism and academic entitlement among pharmacy students and faculty and the association of student consumerism with professionalism in the classroom. Methods: The authors surveyed students and faculty at a college of pharmacy to measure attitudes for 'student as the consumer' and 'student as the product' of pharmacy education. The authors assessed the face validity, factor analysis, and Cronbach's alpha value to examine the validity and reliability of their newly developed scales. Further, they used ordinal logistic regressions to analyse the association of student consumerism with professionalism in the classroom among pharmacy students. Results: The majority of student participants were female, had bachelor degrees, and were employed as pharmacy technicians or interns. The student survey scales exhibited high validity and reliability. Amongst pharmacy students, the authors found high levels of attitudes for students as both the consumers and the products of pharmacy education. However, most of the faculty believed that students are the products and not the consumers of pharmacy education. Further, the students who believed that they are the consumers of pharmacy education were more likely to be unprofessional in the classroom. Conclusion: Although students had high levels of attitude regarding student consumerism, they still believed that the goal of their education is professional competence. It is important to curb student consumerism to curtail unprofessional behaviour in the classroom. Education and support should be provided to the faculty in their efforts to check consumerism among pharmacy students.

In 2010, the Clinical and Laboratory Standards Institute (CLSI) lowered carbapenem breakpoints to reduce the proportion of 'susceptible' organisms that produced carbapenemases. Few studies have evaluated the effect of this change on clinical outcomes. This systematic review aimed to evaluate the effect of carbapenem MICs on 30-day mortality from pooled patient-level data from studies of patients treated with carbapenems across a range of meropenem MICs. PubMed was searched to March 2019 with the terms 'carbapenem', 'meropenem', 'imipenem', 'doripenem', 'ertapenem', 'susceptibility' and 'outcomes'. Studies were included in the analysis if patients had Enterobacteriaceae bacteraemia treated with a carbapenem for >= 48 h and mortality was reported. Studies were excluded if all isolates were either susceptible or resistant to meropenem based on CLSI 2010 breakpoints or if only carbapenemase-producing isolates were included. Authors were contacted for patient-level data. The primary outcome was 30-day mortality, with planned subset analyses of patients treated with meropenem, receiving active combination therapy, treated in the ICU or infected with Klebsiella pneumoniae. Of 157 articles identified, 4 met the inclusion criteria (115 eligible patients). The odds of mortality increased with each increasing meropenem MIC dilution (OR = 1.51, 95% CI 1.06-2.15) as a continuous variable. A similar increase in odds was observed in patients treated with meropenem, treated in the ICU, infected with K. pneumoniae or receiving no other active antimicrobials. Increasing meropenem MICs in Enterobacteriaceae were associated with increased mortality; however, more work is needed to define optimal clinical decision rules for infections within the susceptible range. (C) 2019 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.

In late 2011, a shortage of IV acyclovir led to the need to empirically substitute high-dose oral valacyclovir (HDVA) to conserve IV acyclovir for patients with confirmed herpes simplex virus (HSV) meningitis or encephalitis. This report describes the management of the most recent national IV acyclovir shortage by the Antimicrobial Stewardship Program (ASP) at Northwestern Memorial Hospital (NMH), Chicago, IL, USA, and the use of HDVA. Secondarily, we assessed the safety and tolerability of HDVA as an alternate to IV acyclovir during this shortage.

To the Editor,Drug shortages may lead to less prescribing of medications due to needed restrictions or reduced inventory. We read with interest a report in the present journal on an antimicrobial s...

Introduction: Excess body mass index (BMI) is associated with a higher risk of death in many disease states, yet less is known about the impact of higher BMIs on clinical outcomes of serious bacterial infections. We sought to quantify the risk of all-cause mortality and/or organ failure following Gram negative bacteria bloodstream infections (GNBSI) according to BMI.Materials and methods: We retrospectively reviewed the charts of patients with confirmed GNBSI who received >= 48 h of active antimicrobial therapy. Composite and component patient outcomes, including hospital mortality and organ failure, were assessed as a function of BMI. Organ failure was defined using modified consensus Surviving Sepsis Campaign definitions. Multi-variate methods were used to control for baseline confounders.Results: Seventy-six patients met our inclusion criteria, of whom 8 died (10.5%). The majority of GNBSI were Escherichia (41.6%) or Klebsiella species (23.3%). Patients with higher BMI more frequently developed cardiovascular failure (P = 0.032), respiratory failure (P < 0.001), renal failure (P = 0.003), and died (P = 0.009). Multivariate analyses demonstrated that higher BMIs were associated with a greater risk of death and/or organ failure (aOR 1.07, 95% CI 1.01-1.14), respiratory failure (aOR 1.10, 95% CI 1.03-1.17), and renal failure (aOR 1.08, 95% CI 1.01-1.14) after adjusting for relevant covariates.Conclusion: Higher BM's in patients with GNBSIs were associated with a greater risk of a composite of all-cause mortality and organ failure. (C) 2016 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

PURPOSE:A methodology for predicting how long the on-hand inventory of a given medication will last during a supply shortage is described; a practical example of application of the methodology is provided.METHODS:Single-site data on consumption of i.v. tobramycin over an eight-month evaluation period were collected using commercial software that tabulates barcode-assisted medication administration (BCMA) events; administered doses were standardized as 1200-mg "vial-equivalents" and summed over the review period. The total number of vial-equivalents consumed was divided by the number of "non-zero weeks of consumption" (i.e., weeks during which any tobramycin use occurred) to obtain a mean ± S.D. weekly consumption rate; this rate was multiplied by the total i.v. tobramycin on-hand supply (in vial-equivalents) to determine the mean number of potentially sustainable weeks of therapy in the event a shortage were to restrict the future supply of the drug.RESULTS:Overall, 99.6 vial-equivalents of i.v. tobramycin were used during the evaluation period. The mean ± S.D. number of vial-equivalents used per non-zero week of consumption was 3.11 ± 1.26. A manual count of pharmacy inventory revealed that 102.9 vial-equivalents were available at the time of analysis. The mean predicted duration of supply was 33 weeks (95% confidence interval, -126 to 192 weeks).CONCLUSION:Available BCMA data on tobramycin consumption over eight months were used to calculate the mean number of weeks the on-hand supply of the drug could be expected to last during a persistent drug shortage.

ABSTRACT Increasingly, infectious disease studies employ tree-based approaches, e.g., classification and regression tree modeling, to identify clinical thresholds. We present tree-based-model-derived thresholds along with their measures of uncertainty. We explored individual and pooled clinical cohorts of bacteremic patients to identify modified acute physiology and chronic health evaluation (II) (m-APACHE-II) score mortality thresholds using a tree-based approach. Predictive performance measures for each candidate threshold were calculated. Candidate thresholds were examined according to binary logistic regression probabilities of the primary outcome, correct classification predictive matrices, and receiver operating characteristic curves. Three individual cohorts comprising a total of 235 patients were studied. Within the pooled cohort, the mean (± standard deviation) m-APACHE-II score was 13.6 ± 5.3, with an in-hospital mortality of 16.6%. The probability of death was greater at higher m-APACHE II scores in only one of three cohorts (odds ratio for cohort 1 [OR 1 ] = 1.15, 95% confidence interval [CI] = 0.99 to 1.34; OR 2 = 1.04, 95% CI = 0.94 to 1.16; OR 3 = 1.18, 95% CI = 1.02 to 1.38) and was greater at higher scores within the pooled cohort (OR 4 = 1.11, 95% CI = 1.04 to 1.19). In contrast, tree-based models overcame power constraints and identified m-APACHE-II thresholds for mortality in two of three cohorts ( P = 0.02, 0.1, and 0.008) and the pooled cohort ( P = 0.001). Predictive performance at each threshold was highly variable among cohorts. The selection of any one predictive threshold value resulted in fixed sensitivity and specificity. Tree-based models increased power and identified threshold values from continuous predictor variables; however, sample size and data distributions influenced the identified thresholds. The provision of predictive matrices or graphical displays of predicted probabilities within infectious disease studies can improve the interpretation of tree-based model-derived thresholds.

Background: Organism detection by 16S ribosomal RNA (rRNA) PCR followed by amplicon sequencing identification may help guide antimicrobial treatment in culture-negative patients. The objectives of this study were to assess the effect of a positive versus negative 16S rRNA PCR on antibiotic length of therapy (LOT) and rate of antibiotic discontinuation.Methods: Patients with a sterile site, direct-specimen 16S rRNA PCR negative, and suspected active infection were matched 1:1 with 16S rRNA PCR positive patients based on specimen site and retrospectively evaluated.Results: Ninety patients were included (n = 45 positive and negative). 16S rRNA PCR negative patients had shorter median LOT (33 days [IQR 8-46] versus 43 days [IQR 29-51], P = 0.02). Antibiotics were discontinued more frequently in 16S rRNA PCR negative patients (38% versus 4%, P < 0.01).Conclusions: For culture-negative patients with suspected sterile site infection, a negative, direct-specimen 165 rRNA PCR may help discontinue antibiotics and decrease LOT. (C) 2017 Elsevier Inc. All rights reserved.

Pharmacists are key partners in antimicrobial stewardship efforts, yet their degree of education on and attitudes toward this topic during training are not well documented. An electronic survey measuring knowledge and attitudes regarding antimicrobial use and resistance was administered to graduating pharmacy students at 12 US schools of pharmacy. Of 1445 pharmacy students, 579 (40%) completed the survey. The vast majority (94%) believed that strong knowledge of antimicrobials was important for their pharmacy careers, and 89% desired more education on appropriate antimicrobial use. Most students (84%) considered their pharmacy education regarding antimicrobials useful or very useful, but there was significant variability on perceptions of preparation for most antimicrobial stewardship activities according to the students' school. The mean number of correct answers on a section of 11 knowledge questions was 5.8 (standard deviation 2.0; P value for score between schools <.001). On multivariable linear regression analysis, significant predictors of a higher knowledge score were pharmacy school attended, planned postgraduate training, completion of a clinical rotation in infectious diseases, perception of pharmacy school education as useful, use of resources to answer the knowledge questions, and use of Infectious Diseases Society of America guidelines and smartphone applications as frequent resources for learning about antimicrobials. Pharmacy students perceive antimicrobial stewardship to be an important healthcare issue and desire more education on the subject. Student perceptions of antimicrobial coursework and actual antimicrobial knowledge scores significantly varied by the school of pharmacy attended. Sharing of best practices among institutions may enhance the preparation of future pharmacists to contribute to effective antimicrobial stewardship.

Clinical studies have suggested that blaOXA-40-positive Acinetobacter baumannii isolates are associated with poor patient outcomes; however, reasons for unfavorable outcomes are difficult to discern in clinical studies. The objective of this study was to assess the virulence of carbapenem-resistant A. baumannii according to blaOXA-40 and epidemiological outbreak status in a Galleria mellonella model. Eight isolates of A. baumannii were studied. Nonoutbreak isolates and blaOXA-40-negative isolates more rapidly killed infected G. mellonella (P < 0.01).

OBJECTIVES Warfarin, a frequently prescribed anticoagulant with a narrow therapeutic index, is susceptible to drug-drug interactions with antiretroviral therapy (ART). This study compared the warfarin maintenance dose (WMD) between patients receiving and not receiving ART and evaluated predictors of warfarin dosage among those on ART. METHODS This was a case-control (1:2) study. Cases were HIV-infected patients receiving warfarin and protease inhibitor (PI)- and/or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART. Controls were randomly selected HIV-uninfected patients receiving warfarin. The WMD was compared between cases and controls and between cases on varying ART regimens. Bivariate comparisons were performed and a linear regression model was developed to identify predictors of WMD. RESULTS We identified 18 case and 36 control patients eligible for inclusion. Cases were younger than controls (mean age: 45.8 versus 63.1 years, P < 0.01), more often male (72.2% versus 36.1%, P=0.02) and more likely to be African American (50.0% versus 22.2%, P=0.04). ART was classified as PI-based (n=9), NNRTI-based (n=7) and PI + NNRTI-based (n=2). The WMD (mean ± SD) differed between cases and controls (8.6  ±  3.4 mg versus 5.1 ± 1.5 mg, P < 0.01), but not ART regimens (PI: 8.8  ±  4.5 mg; NNRTI: 8.6   ± 1.8 mg; PI + NNRTI: 7.3  ±  3.3 mg; P = 0.86). Race and ritonavir dose were independent predictors of WMD, predicting an increase of 3.9 mg (95% CI: 0.88-6.98, P = 0.02) if a patient was African American or 3.7 mg (95% CI: 0.53-6.89, P = 0.03) if the total daily ritonavir dose was 200 mg. CONCLUSIONS The required WMD was significantly higher in patients receiving ART. Prompt dose titration to achieve a higher WMD with vigilant monitoring may be required due to these drug-drug interactions.

Anti-infective shortages pose significant logistical and clinical challenges to hospitals and may be considered a public health emergency. Anti-infectives often represent irreplaceable life-saving treatments. Furthermore, few new agents are available to treat increasingly prevalent multidrug-resistant pathogens. Frequent anti-infective shortages have substantially altered patient care and may lead to inferior patient outcomes. Because many of the shortages stem from problems with manufacturing and distribution, federal legislation has been introduced but not yet enacted to provide oversight for the adequate supply of critical medications. At the local level, hospitals should develop strategies to anticipate the impact and extent of shortages, to identify therapeutic alternatives, and to mitigate potential adverse outcomes. Here we describe the scope of recent anti-infective shortages in the United States and explore the reasons for inadequate drug supply.

Predictive modeling suggests that actual carbapenem MIC results are more predictive of clinical patient outcomes than categorical classification of the MIC as susceptible, intermediate, or resistant. Some have speculated that current CLSI guidelines' suggested thresholds are too high and that clinical success is more likely if the MIC value is ≤1 mg/liter for certain organisms. Patients treated with carbapenems and with positive blood cultures for Pseudomonas aeruginosa, Acinetobacter baumannii, or extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria were considered for evaluation in this clinical retrospective cohort study. Relevant patient demographics and microbiologic variables were collected, including carbapenem MIC. The primary objective was to define a risk-adjusted all-cause hospital mortality breakpoint for carbapenem MICs. Secondarily, we sought to determine if a similar breakpoint existed for indirect outcomes (e.g., time to mortality and length of stay [LOS] postinfection for survivors). Seventy-one patients met the criteria for study inclusion. Overall, 52 patients survived, and 19 died. Classification and regression tree (CART) analysis determined a split of organism MIC between 2 and 4 mg/liter and predicted differences in mortality (16.1% versus 76.9%; P < 0.01). Logistic regression controlling for confounders identified each imipenem MIC doubling dilution as increasing the probability of death 2-fold (adjusted odds ratio [aOR] 2.0; 95% confidence interval [CI], 1.3 to 3.2). Secondary outcomes were similar between groups. This study revealed that patients with organisms that had a MIC of ≥4 mg/liter had worse outcomes than patients whose isolates had a MIC of ≤2 mg/liter, even after adjustment for confounding variables. We recommend additional clinical studies to better understand the susceptibility breakpoint for carbapenems.

Journal Article Effective use of a clinical decision-support system to advance antimicrobial stewardship Get access Jean Patel, Pharm.D., Jean Patel, Pharm.D. Clinical Coordinator/Clinical Pharmacist—Infectious Diseases jpatel@nmh.org Search for other works by this author on: Oxford Academic Google Scholar John S. Esterly, Pharm.D., John S. Esterly, Pharm.D. Clinical Pharmacist—Infectious Diseases Search for other works by this author on: Oxford Academic Google Scholar Marc H. Scheetz, Pharm.D., M.Sc., Marc H. Scheetz, Pharm.D., M.Sc. Clinical Pharmacist—Infectious Diseases Department of Medicine Division of Infectious Diseases Feinberg School of Medicine Northwestern University Chicago, IL Search for other works by this author on: Oxford Academic Google Scholar Maureen K. Bolon, M.D., M.S., Maureen K. Bolon, M.D., M.S. Associate Professor Department of Pharmacy Northwestern Memorial Hospital Feinberg LC-700 251 East Huron Chicago, IL 60611 Search for other works by this author on: Oxford Academic Google Scholar Michael J. Postelnick, B.S.Pharm. Michael J. Postelnick, B.S.Pharm. Senior Infectious Diseases Pharmacist and Manager Department of Pharmacy Northwestern Memorial Hospital Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 69, Issue 18, 15 September 2012, Pages 1543–1544, https://doi.org/10.2146/ajhp110729 Published: 15 September 2012

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