Journal of Pharmacy Technology

Includes bibliographical references.

Analysis of Community-Acquired Urinary Tract Infection Treatment in Pediatric Patients Requiring Hospitalization: Opportunity for Use of Narrower Spectrum Antibiotics -- AM Versus PM Postoperative Administration of Warfarin With a Mechanical Mitral Valve -- The Role of the Pharmacist in Inhaler Selection and Education in Chronic Obstructive Pulmonary Disease -- Thiamine Dosing for the Treatment of Alcohol-Induced Wernicke’s Encephalopathy: A Review of the Literature -- Antiepileptic Drugs–Induced Enuresis in Children: An Overview -- Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases -- Hypermanganesemia-Induced Cerebral Toxicity Mimicking an Acute Ischemic Stroke: A Case Report and Review of Overlapping Pathologies.

[Article Title: Analysis of Community-Acquired Urinary Tract Infection Treatment in Pediatric Patients Requiring Hospitalization: Opportunity for Use of Narrower Spectrum Antibiotics/ Jeremy S. Stultz, Natalie Francis, Samantha Ketron, Bindiya Bagga, Chasity M. Shelton, Kelley R. Lee and Sandra R. Arnold, p. 79–88]

Abstract:

Background: The most narrow-spectrum antibiotic possible should be used for empiric and definitive treatment of pediatric urinary tract infections (UTIs).

Objectives: The objectives of this study were to determine an appropriate narrow-spectrum antibiotic for empiric UTI treatment, factors differentiating empiric first-generation cephalosporin (FGC) versus third-generation cephalosporin (TGC) coverage, and factors associated with unnecessarily broad-spectrum definitive antibiotic treatment.

Methods: This was a retrospective chart review of children admitted from 2013 to 2015 who were diagnosed with a UTI and received treatment. Multivariable logistic regression assessed independent factors associated with our outcomes.

Results: Of 568 diagnosed UTIs, 88.6% received empiric TGC treatment. Empiric coverage among cultured organisms was only 5.4% lower in FGC versus TGC. Adolescent age group (odds ratio [OR] = 8.83, 95% confidence interval [CI] = 1.47-53.11), uncircumcised males (OR = 4.52, 95% CI = 1.27-16.08), Hispanic ethnicity (OR = 4.37, 95% CI = 1.14-16.82), and hospitalization within the preceding 3 months (OR = 4.73, 95% CI = 1.38-16.23) were associated with FGC nonsusceptibility among TGC susceptible Enterobacteriaceae pathogens. De-escalation occurred in 55.8% of diagnosed UTIs eligible for de-escalation at discharge. Urine white blood cell (WBC) count >5 (OR = 2.89, 95% CI = 1.14-7.21), serum WBC count (OR = 1.04, 95% CI = 1.01-1.07), and having only one narrow-spectrum treatment option (OR = 5.1, 95% CI = 2.43-10.66) were associated with unnecessarily broad-spectrum definitive treatment. Conclusion and Relevance: FGC would be an appropriate narrow-spectrum empiric agent for UTIs at our institution. The factors associated with FGC nonsusceptibility can further stratify empiric treatment decisions. The factors associated with unnecessarily broad-spectrum definitive treatment illustrate areas for educational efforts and future research regarding UTI treatment.

https://doi.org/10.1177/8755122520964435

[Article Title: AM Versus PM Postoperative Administration of Warfarin With a Mechanical Mitral Valve/ Justin R. Harris, Rachel Hatch, Prashanth Vallabhajosyula, Danielle Mowery and Neepa Patel, p. 9–94]

Abstract:

Background: Currently, there are no guidelines regarding the optimal daily timing of inpatient warfarin administration.

Objective: The purpose of this study was to determine whether dosing warfarin in the morning will have a significant impact on therapeutic international normalized ratio (INR) achievement compared with evening administration in mechanical mitral valve patients initiated on warfarin following cardiac surgery.

Methods: This was a single-center, pre- and post-retrospective cohort conducted between 2014 and 2018. One-hundred fifty-four adult patients who underwent a mechanical mitral valve replacement or alternative cardiac surgery with a history of a mechanical mitral valve were enrolled. The primary outcome was achievement of therapeutic INR at any time point after initiation of warfarin. Pre-intervention administration timing was 6 pm and post-intervention timing was 10 am.

Results: Baseline characteristics including age, sex, and race were similar between the 2 groups (P = NS for each characteristic). Therapeutic INR achievement was significantly improved at all time points following 10 am warfarin administration compared with 6 pm (hazard ratio = 1.69; P = .005). Mean time-to-therapeutic INR was 7.37 days in the post-intervention group and 8.39 days in the pre-intervention group (P = .073). There were no significant differences in INR >4, bleeding, or thrombotic complications between groups.

Conclusion and Relevance: This retrospective analysis suggests that there may be a postoperative benefit in therapeutic INR achievement in mechanical valve patients when dosing warfarin in the morning compared with evening administration. Large-scale studies should be conducted to further elucidate the potential benefit across more heterogeneous populations.

https://doi.org/10.1177/8755122520973613

[Article Title: The Role of the Pharmacist in Inhaler Selection and Education in Chronic Obstructive Pulmonary Disease/ Sarah E. Petite, Michael W. Hess and Herbert Wachtel, p. 95–106]

Abstract:

Objective: To review the role of pharmacists in educating and monitoring patients with chronic obstructive pulmonary disease (COPD) on inhalation technique.

Data Sources: A PubMed search (January 2000 to May 2020) was performed using the following keywords and associated medical subject headings: adherence, chronic obstructive pulmonary disease/COPD, education, inhaler, pharmacist, and technique.

Study Selection and Data Extraction: The search was conducted to identify English language articles highlighting the importance of correct inhaler technique in COPD management and benefits of pharmacist inhaler training such as improved adherence, quality of life (QoL), and disease control. Randomized controlled trials, retrospective studies, observational studies, systematic reviews, and meta-analysis reporting pharmacist training were included.

Data Synthesis: This review summarizes that incorrect inhaler use negatively affects treatment outcomes, prognosis, and QoL. Pharmacists are in a unique position to educate and monitor patients with COPD on optimal inhaler technique and an individualized, multifactorial approach to COPD management involving pharmacists could provide cost-effective patient care and improve adherence and minimize inhaler misuse. Several strategies used by pharmacists can optimize patient inhaler use, such as face-to-face technique demonstrations, the “teach-back” method, telemonitoring, instructional videos, or informational leaflets. An individualized action plan involving education and regular monitoring of inhaler use further enhances optimal adherence and disease management.

Conclusions: As pharmacists are easily accessible to both patients and health care providers, they are ideally placed to play an important role in the enhancement of education on, and continuous assessment of, optimal inhaler technique, thereby improving adherence, disease control, and QoL.

https://doi.org/10.1177/8755122520937649

[Article Title: Thiamine Dosing for the Treatment of Alcohol-Induced Wernicke’s Encephalopathy: A Review of the Literature/ Haleigh Smith, Morgan McCoy, Kevin Varughese and Justin P. Reinert, p. 107–113]

Abstract:

Objective: To determine the most appropriate thiamine replacement regimen by evaluating safety and efficacy of the drug specific to alcohol-induced Wernicke’s encephalopathy (WE).

Data Sources: A comprehensive literature search was conducted using PubMed, MEDLINE, Scopus, and ProQuest between January and August 2020 using the following keyword and Boolean search terminology: “thiamine” AND “alcohol” AND (encephalopathy OR korsakoff).

Study Selection and Data Extraction: Randomized control trials; prospective, observational, and retrospective cohort analyses; and case reports and series were included in this evaluation. A confirmed diagnosis of alcohol-induced WE and treatment with parenteral or intramuscular (IM) thiamine were required for inclusion.

Data Synthesis: Six publications composed of 138 patients were evaluated in this review, in which a wide variety of thiamine supplementation strategies were employed. Clinical diagnostic criteria varied significantly between publications. Doses ranged from 100 to 1500 mg intravenous thiamine and up to 300 mg IM thiamine, with no apparent difference in patient outcomes. All patients who received thiamine experienced symptom improvement, and adverse drug events were minimal.

Conclusions: Despite the clinical controversy regarding the appropriate thiamine supplementation regimen, the heterogeneity of published works combined with symptom resolution across the gamut of dosing strategies makes a definitive consensus elusive. Clinicians should continue to provide parenteral or IM thiamine in doses of ≥100 mg to patients with confirmed alcohol-induced WE.

https://doi.org/10.1177/8755122520962859

[Article Title: Antiepileptic Drugs–Induced Enuresis in Children: An Overview/ Arya Sathyan, Reshma Scaria, Pavithra Arunachalam, Mohanapriya Ramasamy, Dithu Thekkekkara and Shalini Sivadasan, p. 114–119]

Abstract:

Objective: To evaluate enuresis-induced antiepileptic drugs in children.

Data Sources: A PubMed search (1917 to July 2020) was performed using the following keywords and associated medical subject headings: antiepileptic drugs, enuresis, pediatric population, drug-induced enuresis, and epilepsy.

Study Selection and Data Extraction: The search was conducted to find the role of antiepileptic drugs–induced enuresis in children in studies published in English.

Data Synthesis: Enuresis or bedwetting is an underreported adverse drug reaction of antiepileptic drugs. Owing to that fact, it is a condition that is outgrown with age and also could cause embarrassment. As antiepileptic drugs sometimes need to be taken for a long duration until epilepsy relapses, the occurrence of enuresis in this situation can be troublesome for both the child and the caretaker. Even though enuresis is proposed to have a significant effect on the child’s psychology, it is still considered to be a condition that is outgrown with age. This article includes a review of antiepileptic drugs reported to have caused enuresis in children.

Conclusions: If a child develops enuresis as an adverse drug reaction, this adds further challenges to their life. A better understanding of this potential adverse effect may help prevent unwanted stress. Though the exact mechanisms are not known, the hypothesis generated is from the occurred cases, most of which relapsed when the drug was withdrawn. Considering the gravity of epilepsy in children, more detailed studies need to be conducted on this adverse effect to ensure a safe and effective treatment in children.

https://doi.org/10.1177/8755122520964047

[Article Title: Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases/ Grace Huynh and Justin P. Reinert, p. 120–126]

Abstract:

Objective: To review the efficacy and safety of medications used in the management of steroid-induced psychosis.

Data Sources: A comprehensive literature search was conducted using PubMed, MEDLINE, ProQuest, and Scopus between May and October 2020 using the following search terminology: “steroid-induced psychosis” OR “corticosteroid-induced psychosis.”

Study Selection and Data Extraction: Definitive cases, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, were included in this review. Geriatric patients >65 years of age, those with a confounding neurological condition such as a traumatic brain or spinal cord injury, or those with active malignancy were excluded.

Data Synthesis: A total of 13 patient cases were included in this review, representing 8 male patients and 5 female patients. The mean age at symptom presentation was 42.5 years. Six patients presented with delusions, 5 presented with hallucinations, and 2 presented with both manifestations; 12 patients were managed with an antipsychotic, with haloperidol being the most commonly prescribed, followed by risperidone. One patient was managed with lithium and clonazepam alone. All patients returned to their psychological baseline upon the discontinuation or decreased dose of steroids in combination with Pharmacological intervention, though the time to resolution of symptoms varied significantly. No notable adverse drug events associated with treatments were reported.

Conclusions: Steroid-induced psychosis is a serious adverse effect of corticosteroid therapy; however, management strategies that combine a dose reduction or elimination of steroids, in combination with an antipsychotic medication, are effective in resolving this syndrome.

https://doi.org/10.1177/8755122520978534

[Article Title: Hypermanganesemia-Induced Cerebral Toxicity Mimicking an Acute Ischemic Stroke: A Case Report and Review of Overlapping Pathologies/ Justin P. Reinert, Michael Garner and Laramie Forbes, p. 127–132]

Abstract:

Objective: To review and consider risk factors associated with the accumulation of and toxicity from manganese in patients receiving total parenteral nutrition (TPN).

Case Summary: A 66-year-old female presented to the emergency department with right facial and arm weakness that initiated 1 hour prior to admission. Past medical history includes oral cancer with chronic aspiration and gastroparesis secondary to chemotherapy, TPN for 9 months, and a previous episode of right facial and arm parasthesias due to hypertensive emergency 4 years prior. The patient was assigned a National Institutes of Health Stroke Scale score of 6, cleared of an intracranial hemorrhage on imaging, and was administered tPA (tissue plasminogen activator) for an acute ischemic stroke after managing her hypertension to <185/110 mm Hg. Resolution of symptoms occurred within 24 hours. A magnetic resonance imaging of the patient’s brain 24-hours post-tPA indicated an increased signal density in the globus pallidus, which in turn is linked with encephalopathy and has been described as a marker for hypermanganesemia.

Discussion: Manganese is an essential trace element with a critical role in numerous physiologic functions. Though readily obtained from dietary sources and rarely causing issue, manganese provided to patients via TPN may result in toxicities. Though the presentation of neurotoxicities associated with TPN-delivered manganese has been previously documented, the clinical presentation of toxicity has never mimicked an acute ischemic stroke

Conclusion: Though an evaluation of overlapping pathologies is warranted, this patient’s clinical presentation of manganese toxicity mimicked an acute ischemic stroke and resulted in the administration of a fibrinolytic. A more comprehensive appreciation of the implications of trace elements is demanded of clinicians.

https://doi.org/10.1177/8755122520976418