INTRODUCTION:Virtual TBL is an online adaptation of the team-based learning (TBL) instructional strategy, emphasizing collaborative learning and problem-solving. The emergency shift to virtual TBL during the COVID-19 pandemic presented unique challenges. This study aims to 1) compare overall pharmacy students' perceptions and attitudes toward face-to-face (FTF) TBL vs. virtual TBL in the didactic curriculum and stratify their perceptions and attitudes by various students' characteristics; 2) evaluate students' perceptions of the strengths and weaknesses of virtual TBL.METHODS:This mixed-methods, pre-post, cross-sectional study utilized an anonymous survey to collect the data. Pharmacy students completed a survey to compare their perceptions and attitudes toward learning, class experience, learning outcomes achieved, and satisfaction with FTF TBL vs. virtual TBL using a 5-point Likert-type scale. Additionally, the survey included two open-ended questions to gather students' perceptions of the strengths and weaknesses of virtual TBL. Quantitative survey data were analyzed using the Wilcoxon matched-pairs signed rank exact test, while qualitative survey data were analyzed using thematic analysis.RESULTS:A total of 117 students (response rate of 59.4%) completed the study survey. Pharmacy students perceived FTF TBL to be superior to virtual TBL in their attitudes toward learning, class experience, learning outcomes achieved, and overall satisfaction across various students' characteristics. While the students identified some unique strengths of using virtual TBL, they also highlighted several weaknesses of using this learning modality compared to FTF TBL.CONCLUSIONS:Pharmacy students perceived FTF TBL to be superior to virtual TBL across various students' characteristics. These findings can be helpful to pharmacy programs considering the implementation of virtual TBL in their didactic curricula. Future research should explore whether a purposefully designed virtual TBL environment, as opposed to the pandemic-driven emergency TBL planning, can influence students' perceptions and attitudes toward virtual TBL.

PURPOSE:Utilization of rapid diagnostic testing alongside intensive antimicrobial stewardship interventions improves patient outcomes. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel in an established Antimicrobial Stewardship Program (ASP) with limited personnel resources.METHODS:A single center retrospective pre- and post-intervention cohort study was performed following the implementation of a BCID panel on patients admitted with at least 1 positive blood culture during the study period. The primary outcome was time to optimal therapy from blood culture collection. Secondary outcomes included days of therapy (DOT), length of stay, and 30-day mortality and readmission rates.RESULTS:277 patients were screened with 180 patients included, with 82 patients in the pre-BCID and 98 in the post-BCID arms. Median time to optimal therapy was 73.8 hours (IQR; 1.1-79.6) in the pre-BCID arm and 34.7 hours (IQR; 10.9-71.6) in the post-BCID arm (p ≤ 0.001). Median DOT for vancomycin was 4 and 3 days (p ≤ 0.001), and for piperacillin-tazobactam was 3.5 and 2 days (p ≤ 0.007), for the pre-BCID and post-BCID arms, respectively. Median length of hospitalization was decreased from 11 to 9 days (p = 0.031). No significant change in 30-day readmission rate was noted, with a trend toward lower mortality (12% vs 5%; p = 0.086).CONCLUSION:Introduction of BCID into the daily workflow resulted in a significant reduction in time to optimal therapy for bloodstream infections and DOT for select broad-spectrum antibiotics, highlighting the potential benefits of rapid diagnostics even in settings with limited personnel resources.

In 2019, the American Society of Health-System Pharmacists (ASHP) released its second edition of its Long-Range Vision for the Pharmacy Workforce in Hospitals and Health Systems. The report highlighted the agility and potential for growth in pharmacy, while affirming the rapidly evolving healthcare delivery models that drive practice. The report focused on drivers of change that would challenge and nurture pharmacy innovation. It predicted care transformation, technology advancements, and marketplace and organizational shifts influenced by global trends, as well as financial and health policy changes.1 A few months after its release, the coronavirus disease 2019 (COVID-19) pandemic took hold of the world, fundamentally changing the trajectory of healthcare. The pandemic fueled an already evolving healthcare landscape for pharmacy by influencing workforce, educational, and practice trends. The ASHP Section of Pharmacy Educators (SPE), abiding by its mission to support pharmacy educators in preparing, engaging, and advancing the pharmacy workforce to optimize health, sought forecasting among key pharmacy education leaders and influencers who shape the landscape for future practitioners. SPE's Crystal Ball project aimed to generate productive debate exploring disruption in pharmacy, the pharmacy workforce, and academia in the next 5 years. The SPE surveyed 4,232 SPE practitioner members and received 389 responses (9.2% response rate). Participants were asked to provide their opinions regarding key trends that influence the pharmacy workforce. Results are depicted in Figures 1 through 4. This commentary describes key observations based on the findings of this survey and provides recommendations to stimulate challenging conversations that influence pharmacy's scope, environment, and impact.

Teaching the next generation of pharmacy practitioners is a rewarding aspect of practice that must be juggled with the responsibility of ensuring that residency graduates meet program requirements and minimize patient-safety concerns. Preceptors need to be able to successfully navigate difficult learning situations that may be encountered in residency training. There is no consensus on the terminology describing challenging learning situations in the health professions, and such terms have been used carefully to avoid stigmatizing learners.1,2 Vaughn et al.3 defined a problem learner in medical training as a “learner with academic performance that is significantly below performance potential because of special affective, cognitive, structural, or interpersonal difficulty.” The American Board of Internal Medicine interprets a problem resident as a “trainee who demonstrates a significant enough problem that requires intervention by someone in authority, usually the program director or chief resident.” 4 In the pharmacy literature, Davis et al.1 use the term challenging trainee to describe a learner “who is performing below preceptor expectations with regard to knowledge, attitude, or skill set.”

Background: Food and Drug Administration–approved daptomycin dosing uses actual body weight, despite limited dosing information for obese patients. Studies report alterations in daptomycin pharmacokinetics and creatine phosphokinase elevations associated with higher weight-based doses required for obese patients. Limited information regarding clinical outcomes with alternative daptomycin dosing strategies in obesity exists. Objective: This study evaluates equivalency of clinical and safety outcomes in obese patients with daptomycin dosed on adjusted body weight versus a historical cohort using actual body weight. Methods: This retrospective, single center study compared equivalency of outcomes with two one-sided tests in patients with body mass index ⩾30 kg/m 2 who received daptomycin dosed on actual body weight versus adjusted body weight. The primary outcome was clinical failure. Secondary outcomes included 90-day readmission and 90-day mortality. A combined safety endpoint included creatine phosphokinase elevation, patient-reported myopathy, and rhabdomyolysis. Results: A total of 667 patients were screened for inclusion; 101 patients were analyzed with 50 in the actual body weight cohort and 51 in the adjusted body weight cohort. The two regimens were statistically equivalent for clinical failure (2% actual body weight versus 4% adjusted body weight; p < 0.001 for equivalency). The two regimens were also statistically equivalent for 90-day mortality (6% actual body weight versus 4% adjusted body weight; p = 0.0014 for equivalency). Limitations include single center, retrospective design, and sample size. Daptomycin dosing intensified throughout the study period. Conclusion: The two daptomycin dosing cohorts were statistically equivalent for both clinical failure and 90-day mortality. More data are needed to assess outcomes with higher (⩾8 mg/kg/day) daptomycin doses in this patient population.

INTRODUCTION:Methicillin-resistant Staphylococcus aureus (MRSA)is a common pathogen in acute bacterial skin and soft tissue infections (ABSSSIs), nosocomial pneumonia, bacteremia, endocarditis, as well as diabetic foot, bone, and joint infections. Areas covered: This review summarizes the randomized controlled trials that evaluated the clinical efficacy of tedizolid in ABSSSIs, which is currently the only United States Food and Drug Administration-labeled indication for tedizolid. Expert opinion: Tedizolid has several potential advantages over linezolid including once-daily dosing, shorter duration of therapy, and increased tolerability. However, its cost will likely limit its adoption for ABSSSIs with MRSA because other oxazolidinone antibiotics are available in less costly generic versions. Tedizolid is also currently being investigated for its use in other MRSA infections including nosocomial pneumonia as well as diabetic foot, bone, and joint infections and tedizolid's use in these disease states appears more promising. Potential indications for future clinical investigation of tedizolid's efficacy and safety include bacteremia and meningitis.

Ceftazidime-avibactam is a novel combination antimicrobial agent consisting of a broad-spectrum cephalosporin, ceftazidime, and a non-beta-lactam beta-lactamase inhibitor, avibactam. This agent has demonstrated activity against resistant gram-negative bacteria, including Klebsiella pneumoniae carbapenemase-producing organisms; however, it is US Food and Drug Administration approved for use in urinary tract and intra-abdominal infections only. We present a case of successful treatment of K. pneumoniae carbapenemase-producing K. pneumoniae bacteremia with a combination of meropenem and colistin followed by ceftazidime-avibactam and colistin.

BACKGROUND:Clostridium difficile infection treatment guidelines exist for immunocompetent patients; however, there is a paucity of data evaluating clinical outcomes and time to C. difficile-associated diarrhea resolution in neutropenic patients.OBJECTIVE:To assess clinical outcomes in neutropenic patients treated with metronidazole, oral vancomycin, the combination of metronidazole plus oral vancomycin, and switch of metronidazole to oral vancomycin.METHODS:This retrospective, observational cohort study assessed adult neutropenic inpatients with C. difficile-associated diarrhea treated with metronidazole, oral vancomycin, combination (metronidazole and oral vancomycin), or switch therapy (metronidazole to oral vancomycin). The primary outcome was time to diarrhea resolution based on treatment regimen. Secondary outcomes included C. difficile-associated diarrhea resolution of diarrhea by day 14, recurrence, and occurrence of major complications.RESULTS:Overall, 44 patients met full inclusion criteria (52.2% metronidazole monotherapy, 22.7% combination, and 25.0% switch therapy). Two patients on oral vancomycin monotherapy were excluded due to insufficient sample size. Overall time to C. difficile-associated diarrhea resolution was 9.1 ± 10.7 days. The Cox regression results suggested both switch and combination therapy were associated with 65.5% (p = 0.002) and 65.9% (p = 0.046) longer time to C. difficile-associated diarrhea resolution compared to metronidazole monotherapy, respectively. An increasing absolute neutrophil count was associated with an increase in C. difficile-associated diarrhea resolution (p = 0.007).CONCLUSION:Switch or combination therapy was associated with a prolonged time to C. difficile-associated diarrhea resolution. The decision to use switch or combination therapy may represent a surrogate marker for more severe disease and need for therapy escalation. It is unknown if initial therapy with oral vancomycin would provide better outcomes as this could not be assessed.

Background Fluconazole is the drug of choice for candiduria requiring treatment; however, it may not be optimal in some cases because of resistance, drug interactions, or adverse effects. Case reports and retrospective analyses suggest that echinocandins may be effective in treating candiduria and Candida urinary tract infections, despite low urinary concentrations. The purpose of this investigation was to evaluate the effectiveness of echinocandins for the treatment of Candida urinary tract infections in hospitalized patients. Methods This was a 5-year, retrospective evaluation of patients treated with micafungin for Candida urinary tract infections (symptomatic) or asymptomatic candiduria with qualifying conditions (pregnancy, neutropenia, recent urologic procedure). The primary outcome was clinical success, defined as symptom resolution (symptomatic patients) or urine sterilization (asymptomatic patients) by the end of treatment. Secondary outcomes included urine sterilization in all patients and time to symptom resolution. Results A total of 302 patients with candiduria received micafungin during the study period. Of these, 97 met the inclusion criteria; however, 83 were excluded. Fourteen patients were included in the case series. Twelve patients (85.7%) were symptomatic, and 2 (14.3%) were asymptomatic with neutropenia. Ten patients (71.4%) achieved the primary outcome of symptom resolution or urine sterilization by the end of treatment. Six patients (42.9%) had urine sterilization by the end of therapy; however, a follow-up urine culture was not performed in the remaining 8 patients. Median time to symptom resolution was 4 days. Conclusions In some clinical settings, micafungin may be an effective therapy for Candida urinary tract infections in hospitalized patients.

Background: To date, there are no recommendations regarding the timing of removal of peripherally inserted central catheters (PICC) in the presence of confirmed upper extremity deep vein thrombosis (UEDVT).Objective: We aimed to determine the incidence of symptomatic pulmonary embolism (PE) post line removal in patients with PICC-associated UEDVT according to treatment strategy.Patients/Methods: We conducted a retrospective study in adult patients who received a PICC with documented UEDVT or superficial thrombosis (UESVT) by vascular ultrasound. Patients’ demographic characteristics, co-morbid diseases, medications, ultrasound findings, treatment strategy for UEDVT/SVT and occurrence of symptomatic PE after PICC removal was documented.Results: 124 patients had PICC-associated UEDVT or UESVT; 69 males and 55 females with mean age 52.2 years. Of 81 patients meeting study criteria, 57 patients had UEDVT and 24 patients UESVT. No episodes of symptomatic PE after PICC removal were documented. Regarding timing of removal, 20 patients had their PICC removed within 24 hours after UEDVT diagnosis, 15 within 1 week, 7 within 2 weeks, 11 within 1 month and 4 at more than a month after diagnosis of UEDVT. No patients had objectively confirmed PE during the follow up period.Conclusion: This retrospective analysis revealed no symptomatic PE with removal of PICC in the presence of UEDVT or UESVT if performed within 24 hours, and an overall low rate of PE events regardless of treatment strategy and duration of PICC insertion. These findings are hypothesis generating and should be confirmed in a prospective trial.

Purpose: Clinical studies comparing vancomycin with alternative therapy for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are limited. The objective of this study was to compare outcomes of early daptomycin versus vancomycin treatment for MRSA bacteremia with high vancomycin MICs in a geographically diverse multicenter evaluation.Methods: This nationwide, retrospective, multicenter (N = 11), matched, cohort study compared outcomes of early daptomycin with vancomycin for MRSA bloodstream infection (BSI) with vancomycin MICs 1.5 to 2 mu g/mL. Matching variables, based on propensity regression analysis, included age, intensive care unit (ICU), and type of BSI. Outcomes were as follows: (1) composite failure (60-day all-cause mortality, 7-day clinical or microbiologic failure, 30-day BSI relapse, or end-of-treatment failure (EOT; discontinue/change daptomycin or vancomycin because of treatment failure or adverse event]); (2) nephrotoxicity; and (2) day 4 BSI clearance.Findings: A total of 170 patients were included. The median (interquartile range) age was 60 years (50-74); the median (range) Acute Physiology and Chronic Health Evaluation II score was 15 (10-18); 31% were in an ICU; and 92% had an infectious disease consultation. BSI types included endocarditis/endovascular (39%), extravascular (55%), and central catheter (6%). The median daptomycin dose was 6 mg/kg, and the vancomycin trough level was 17 mg/L. Overall composite failure was 35% (59 of 170): 15% due to 60-day all-cause mortality, 14% for lack of clinical or microbiologic response by 7 days, and 17% due to failure at end of therapy (discontinue/change because of treatment failure or adverse event). Predictors of composite failure according to multivariate analysis were age >60 years (odds ratio, 3.7; P < 0.01) and ICU stay (odds ratio, 2.64; P = 0.03). Notable differences between treatment groups were seen with: (1) end of therapy failure rates (11% vs 24% for daptomycin vs vancomycin; P = 0.025); (2) acute kidney injury rates (9% vs 23% for daptomycin vs vancomycin; P = 0.043); and (3) day 4 bacteremia clearance rates for immunocompromised patients (n = 26) (94% vs 56% for daptomycin vs vancomycin; P = 0.035).Implications: Results from this multicenter study provide, for the first time, a geographically diverse evaluation of daptomycin versus vancomycin for patients with vancomycin-susceptible MRSA bacteremia with vancomycin MIC values > 1 ug/mL. Although the overall composite failure rates did not differ between the vancomycin and daptomycin groups when intensively matched according to risks for failure, the rates of acute kidney injury were significantly lower in the daptomycin group. These findings suggest that daptomycin is a useful therapy for clinicians treating patients who have MRSA bacteremia. Prospective, randomized trials should be conducted to better assess the potential significance of elevated vancomycin MIC. (C) 2016 Elsevier HS Journals, Inc. All rights reserved.

The antimicrobial agent fosfomycin was discovered in 1969, at a time when bacteria had not yet developed extended‐spectrum β‐lactamases or carbapenemases. Decades later, it is not uncommon for gram‐negative organisms to be multidrug‐resistant and even pan‐resistant to available antibiotic regimens, leaving clinicians with few therapeutic alternatives. Because fosfomycin has been shown to retain activity against these virulent pathogens, there is renewed interest in its use as a therapeutic agent. Fosfomycin formulations including fosfomycin disodium and the newer tromethamine salt are less toxic than other alternatives and are attractive options for resistant gram‐negative and gram‐positive infections. Oral fosfomycin tromethamine is approved for urinary tract infections in the United States, and an intravenous formulation is also available outside of the United States for systemic disease. The bactericidal action of fosfomycin occurs at an earlier step in cell wall synthesis than that of β‐lactam antibiotics. From an in vitro standpoint, fosfomycin generally has high activity against ESBL ‐ and carbapenemase‐producing Enterobacteriaceae; multidrug‐resistant Pseudomonas aeruginosa susceptibility appears to be more dependent on the local antibiogram. Fosfomycin formulations have a large volume of distribution, penetrate biofilms, and concentrate in the urine. Both oral and intravenous fosfomycin formulations are effective for a wide range of gram‐negative infections and disease severities; however, clinical studies are limited. Fosfomycin formulations are well‐tolerated, and mild gastrointestinal distress is the most common adverse effect. The primary limitations of fosfomycin are the lack of established regimens for complicated infections and the lack of availability of the intravenous formulation in the United States. Further study of this promising agent seems warranted in the current climate of antibiotic resistance.

MRSA Bacteremia with Vancomycin MIC >1 mg/L: A Multicenter Evaluation Pamela Moise, PharmD; Darren Culshaw, PharmD; Annie Wong-Beringer, PharmD; Joyce Bensman, PharmD; Kenneth Lamp, PharmD; Winter J. Smith, PharmD; Karri Bauer, PharmD; Debra Goff, PharmD; Robert Adamson, PharmD; Kimberly Leuthner, PharmD; Michael Virata, MD; James A. Mckinnell, MD; Saira B. Chaudhry, PharmD, MPH; Romic Eskandarian, PharmD; Thomas Lodise, PharmD; Katherine Reyes, MD; Marcus Zervos, MD; Cubist Pharmaceuticals, Lexington, MA; Huntington Hospital, Los Angeles, CA; University of Southern California, Los Angeles, CA; University of Oklahoma Health Sciences Center, Oklahoma City, OK; Ohio State University Medical Center, Columbus, OH; St. Barnabas Health Care System, Livingston, NJ; University Medical Center of Southern Nevada, Las Vegas, NV; Hospital of Saint Raphael, New Haven, CT; Torrance Memorial Medical Center, Torrance, CA; Infectious Disease Clinical Outcomes Research Unit (ID-CORE) at Los Angeles Biomedical Research Institute, Torrance, CA; Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Piscataway, NJ; Glendale Adventist Medical Center, Glendale, CA; Albany College of Pharmacy, Albany, NY; Henry Ford Hospital, Detroit, MI

The antimicrobial agent fosfomycin was discovered in 1969, at a time when bacteria had not yet developed extended-spectrum beta-lactamases or carbapenemases. Decades later, it is not uncommon for gram-negative organisms to be multidrug-resistant and even pan-resistant to available antibiotic regimens, leaving clinicians with few therapeutic alternatives. Because fosfomycin has been shown to retain activity against these virulent pathogens, there is renewed interest in its use as a therapeutic agent. Fosfomycin formulations including fosfomycin disodium and the newer tromethamine salt are less toxic than other alternatives and are attractive options for resistant gram-negative and gram-positive infections. Oral fosfomycin tromethamine is approved for urinary tract infections in the United States, and an intravenous formulation is also available outside of the United States for systemic disease. The bactericidal action of fosfomycin occurs at an earlier step in cell wall synthesis than that of beta-lactam antibiotics. From an in vitro standpoint, fosfomycin generally has high activity against ESBL- and carbapenemase-producing Enterobacteriaceae; multidrug-resistant Pseudomonas aeruginosa susceptibility appears to be more dependent on the local antibiogram. Fosfomycin formulations have a large volume of distribution, penetrate biofilms, and concentrate in the urine. Both oral and intravenous fosfomycin formulations are effective for a wide range of gram-negative infections and disease severities; however, clinical studies are limited. Fosfomycin formulations are well-tolerated, and mild gastrointestinal distress is the most common adverse effect. The primary limitations of fosfomycin are the lack of established regimens for complicated infections and the lack of availability of the intravenous formulation in the United States. Further study of this promising agent seems warranted in the current climate of antibiotic resistance.

Interprofessional learning is a key component of today's health sciences education. Within a two-course series in dental pharmacology and therapeutics, a dental curriculum was revised to provide an interprofessional activity to expose dental students to a community pharmacy setting. The objectives of this activity were to augment students' learning about drug laws and prescription writing, as well as to foster interprofessional relationships and collaboration between pharmacists and dentists. Dental students were scheduled for one-hour observations at community pharmacies on campus. Learning objectives to guide this activity focused on demonstrating community pharmacy operating procedures, identifying ways to minimize prescribing and dosing errors, and understanding how pharmacists can assist dentists in prescribing. Following the observation, students were required to submit a written assignment, which accounted for 14 percent of their course grade. All 119 dental students (100 percent) enrolled in the course for the summers of 2012 and 2013 completed the activity. The average grade on the written assignment was 96.2 out of 100. At the end of the course, students were asked to participate in an online course evaluation survey, for which response rates were 37 percent and 43 percent for 2012 and 2013, respectively. The students rated the pharmacy observation activity favorably on this course evaluation. The pharmacy observation activity provided a successful interprofessional component to the didactic pharmacy course and was well received by the dental students as well as the community pharmacists.

OBJECTIVE:To describe the development, implementation, and assessment of an internal medicine introductory pharmacy practice experience (IPPE) that was integrated with an existing advanced pharmacy practice experience (APPE) in internal medicine.DESIGN:A structured IPPE was designed for first-, second-, and third-year pharmacy (P1, P2, and P3) students. Activities for the IPPE were based on the established APPE and the individual learner's educational level.ASSESSMENT:Students reported a greater understanding of clinical pharmacists' roles, increased confidence in their clinical skills, and better preparation for APPEs. Peers viewed the approach as innovative and transferable to other practice settings. Participating faculty members provided a greater number of contact hours compared to traditional one-time site visits.CONCLUSIONS:Integrating an IPPE with an existing APPE is an effective and efficient way to provide patient care experiences for students in the P1-P3 years in accordance with accreditation standards.