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Wildenthal JA, Schwartz DJ, Nolan NS, Zhao L, Robinson JI, Jones E, Jawa R, Henderson JP, Marks LR. Everything but the Kitchen Sink: An Analysis of Bacterial and Chemical Contaminants Found in Syringe Residue From People Who Inject Drugs. Open Forum Infect Dis 2024; 11:ofad628. [PMID: 38179104 PMCID: PMC10766411 DOI: 10.1093/ofid/ofad628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024] Open
Abstract
Background People who inject drugs (PWID) are at high risk of severe wounds, invasive infections, and overdoses. To date, there are few data on the bacterial and chemical contaminants PWID are exposed to when using illicitly manufactured fentanyls and stimulants. Methods Previously used injection drug use equipment was recovered in St Louis, Missouri, by harm reduction organizations over a 12-month period. Syringe residue was analyzed for bacterial contaminants by routine culturing followed by whole genome sequencing of single bacterial isolates. Chemical adulterants in syringe residue were identified by liquid chromatography-mass spectrometry. Results Bacteria were cultured from 58.75% of 160 syringes analyzed. Polymicrobial growth was common and was observed in 23.75% of samples. Bacillus cereus was the most common pathogen present and was observed in 20.6% of syringe residues, followed closely by Staphylococcus aureus at 18.8%. One hundred syringes underwent mass spectrometry, which demonstrated that chemical adulterants were common and included caffeine, diphenhydramine, lidocaine, quinine, and xylazine. Conclusions Analysis of syringe residue from discarded drug use equipment demonstrates both chemical and biological contaminants, including medically important pathogens and adulterants.
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Affiliation(s)
- John A Wildenthal
- Medical Scientist Training Program, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Drew J Schwartz
- Department of Pediatrics, Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Division of Infectious Disease, Department of Internal Medicine, Veterans Affairs St Louis Health Care, St Louis, Missouri, USA
| | - Lingxia Zhao
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - John I Robinson
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Erin Jones
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Raagini Jawa
- Center for Research on Healthcare, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P Henderson
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Laura R Marks
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Khachigian LM, Liew G, Teo KYC, Wong TY, Mitchell P. Emerging therapeutic strategies for unmet need in neovascular age-related macular degeneration. J Transl Med 2023; 21:133. [PMID: 36810060 PMCID: PMC9942398 DOI: 10.1186/s12967-023-03937-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/27/2023] [Indexed: 02/23/2023] Open
Abstract
Neovascular age-related macular degeneration (nAMD) is a major cause of visual impairment and blindness. Anti-vascular endothelial growth factor (VEGF) agents, such as ranibizumab, bevacizumab, aflibercept, brolucizumab and faricimab have revolutionized the clinical management of nAMD. However, there remains an unmet clinical need for new and improved therapies for nAMD, since many patients do not respond optimally, may lose response over time or exhibit sub-optimal durability, impacting on real world effectiveness. Evidence is emerging that targeting VEGF-A alone, as most agents have done until recently, may be insufficient and agents that target multiple pathways (e.g., aflibercept, faricimab and others in development) may be more efficacious. This article reviews issues and limitations that have arisen from the use of existing anti-VEGF agents, and argues that the future may lie in multi-targeted therapies including alternative agents and modalities that target both the VEGF ligand/receptor system as well as other pathways.
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Affiliation(s)
- Levon M. Khachigian
- grid.1005.40000 0004 4902 0432Vascular Biology and Translational Research, Faculty of Medicine and Health, School of Medical Sciences, University of New South Wales, Sydney, NSW 2052 Australia
| | - Gerald Liew
- grid.476921.fCentre for Vision Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Australia
| | - Kelvin Y. C. Teo
- grid.419272.b0000 0000 9960 1711Singapore National Eye Centre and Singapore Eye Research Institute, Singapore, Singapore ,grid.4280.e0000 0001 2180 6431Duke-NUS Graduate Medical School, National University of Singapore, Singapore, Singapore
| | - Tien Y. Wong
- grid.419272.b0000 0000 9960 1711Singapore National Eye Centre and Singapore Eye Research Institute, Singapore, Singapore ,grid.4280.e0000 0001 2180 6431Duke-NUS Graduate Medical School, National University of Singapore, Singapore, Singapore ,grid.12527.330000 0001 0662 3178Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Paul Mitchell
- grid.476921.fCentre for Vision Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Australia
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Davis J, Ayars C. Retention of Sterile Compounding Knowledge Among Pharmacy Technicians. J Pharm Technol 2021; 37:219-224. [PMID: 34752565 DOI: 10.1177/87551225211032395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Patient safety is in jeopardy due to a rise in the preparation of adulterated parenteral products with poor technique identified as a significant contributing factor. Pharmacy technicians perform an overwhelming majority of aseptic compounding practices; however, this group's progressive loss of aseptic technique knowledge has not been documented. Objective: The purpose of this correlational research study was to investigate the association between sterile compounding knowledge and years in the field controlling for formal training in sterile compounding techniques. Methods: An assessment tool of fundamental sterile compounding content was electronically distributed to sterile compounding technician members of pharmacy organizations in the southeastern United States. A multiple regression was conducted to predict sterile compounding knowledge from number of years in the field and prior years of formal compounding training. Results: Sixty-eight assessments were returned complete. The overall model was significant (P < .0005), explaining 22% of the variance in knowledge retention. Years in the field was the only significant predictor (P < .001). Each additional year of work experience was associated with a 0.18 drop in the assessment score. Conclusions: The longer pharmacy technicians remain in the field, the more aseptic technique knowledge they will lose. Modeling of poor sterile compounding techniques in the workplace may promote loss of competency of the skill. As a result, a plan to address continuing education for pharmacy technician sterile compounders is necessary to ensure patient safety.
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Watson CJ, Whitledge JD, Siani AM, Burns MM. Pharmaceutical Compounding: a History, Regulatory Overview, and Systematic Review of Compounding Errors. J Med Toxicol 2021; 17:197-217. [PMID: 33140232 PMCID: PMC7605468 DOI: 10.1007/s13181-020-00814-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Medications are compounded when a formulation of a medication is needed but not commercially available. Regulatory oversight of compounding is piecemeal and compounding errors have resulted in patient harm. We review compounding in the United States (US), including a history of compounding, a critique of current regulatory oversight, and a systematic review of compounding errors recorded in the literature. METHODS We gathered reports of compounding errors occurring in the US from 1990 to 2020 from PubMed, Embase, several relevant conference abstracts, and the US Food and Drug Administration "Drug Alerts and Statements" repository. We categorized reports into errors of "contamination," suprapotency," and "subpotency." Errors were also subdivided by whether they resulted in morbidity and mortality. We reported demographic, medication, and outcome data where available. RESULTS We screened 2155 reports and identified 63 errors. Twenty-one of 63 were errors of concentration, harming 36 patients. Twenty-seven of 63 were contamination errors, harming 1119 patients. Fifteen errors did not result in any identified harm. DISCUSSION Compounding errors are attributed to contamination or concentration. Concentration errors predominantly result from compounding a prescription for a single patient, and disproportionately affect children. Contamination errors largely occur during bulk distribution of compounded medications for parenteral use, and affect more patients. The burden falls on the government, pharmacy industry, and medical providers to reduce the risk of patient harm caused by compounding errors. CONCLUSION In the US, drug compounding is important in ensuring access to vital medications, but has the potential to cause patient harm without adequate safeguards.
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Affiliation(s)
- C James Watson
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA.
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - James D Whitledge
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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Fersing C, Deshayes E, Langlet S, Calas L, Lisowski V, Kotzki PO. Implementation and validation of an in-house combined fluorescein/media-fill test to qualify radiopharmacy operators. EJNMMI Radiopharm Chem 2021; 6:2. [PMID: 33411035 PMCID: PMC7790972 DOI: 10.1186/s41181-020-00117-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this work was to design, validate and implement a media-fill test combined with fluorescein (MFT-F) for the specific qualification and training of radiopharmacy operators, in accordance with United States Pharmacopeia General Chapter 797 and European Good Manufacturing Practices. MFT-F was embedded in the quality management system of our radiopharmacy unit. Its validation involved fluorescein concentration choice, media growth promotion test and evaluation protocol controls (with or without intentional aseptic mistakes). Each operator was evaluated following a three-part evaluation form. Evaluation criteria related to garbing and hygiene, fluorescent contamination and bacteriological contamination (pre- and post-evaluation environment controls and MFT-F samples). Combined MFT-F allowed the assessment of aseptic compounding skills and non-contamination of the working area through a single evaluation. It was also designed to fit the constraints of radiopharmacy common practice related to radiation protection equipment and to the small volumes handled. Results A 0.01% fluorescein concentration was chosen to prepare MFT-F. Addition of fluorescein in the culture medium did not jeopardize its growth properties according to growth promotion test. Eleven operators were evaluated and carried out 3 MFT-F over 3 successive days. Pre- and post-evaluation bacteriological controls of every session showed no CFU of microbiological contaminant above 5. All operators validated the garbing and hygiene evaluation, with an average score of 92.7%. All operators validated the fluorescent contamination evaluation, with an average score of 29.4 out of 30. None of the MFT-F samples showed any visible bacterial growth after incubation. Conclusions Combined MFT-F, as a part of a comprehensive sterile compounding training program, appeared as a convenient and promising tool to increase both the sterile compounding safety and awareness of radioactive contamination in radiopharmacy. Supplementary Information The online version contains supplementary material available at 10.1186/s41181-020-00117-6.
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Affiliation(s)
- Cyril Fersing
- Department of Nuclear Medicine, Montpellier Cancer Institute (ICM), University of Montpellier, 208 avenue des apothicaires, 34298, Montpellier Cedex 5, France. .,Institut des Biomolécules Max Mousseron, UMR 5247, CNRS, Université de Montpellier, ENSCM, UFR des Sciences Pharmaceutiques et Biologiques, Montpellier Cedex, France.
| | - Emmanuel Deshayes
- Department of Nuclear Medicine, Montpellier Cancer Institute (ICM), University of Montpellier, 208 avenue des apothicaires, 34298, Montpellier Cedex 5, France.,University of Montpellier, Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier Cancer Institute (ICM), Montpellier, France
| | - Sarah Langlet
- Department of Nuclear Medicine, Saint-Jean Hospital, Perpignan, France
| | - Laurence Calas
- Department of Nuclear Medicine, Montpellier Cancer Institute (ICM), University of Montpellier, 208 avenue des apothicaires, 34298, Montpellier Cedex 5, France
| | - Vincent Lisowski
- Institut des Biomolécules Max Mousseron, UMR 5247, CNRS, Université de Montpellier, ENSCM, UFR des Sciences Pharmaceutiques et Biologiques, Montpellier Cedex, France.,Quality Control Laboratory, University Hospital of Montpellier, Montpellier, France
| | - Pierre Olivier Kotzki
- Department of Nuclear Medicine, Montpellier Cancer Institute (ICM), University of Montpellier, 208 avenue des apothicaires, 34298, Montpellier Cedex 5, France.,University of Montpellier, Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier Cancer Institute (ICM), Montpellier, France
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de Lima Farah J, Sano R, Maugéri IML, Teixeira D, Ishimura ME, Martins G, Mimica LMJ, da Silva CB, Meyer CH, de Oliveira Dias JR, de Andrade GC, Farah ME. Evaluation of aflibercept and ziv-aflibercept binding affinity to vascular endothelial growth factor, stability and sterility after compounding. Int J Retina Vitreous 2018; 4:39. [PMID: 30386633 PMCID: PMC6199727 DOI: 10.1186/s40942-018-0143-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/13/2018] [Indexed: 12/27/2022] Open
Abstract
Purpose To investigate the binding affinity, stability, and sterility of aflibercept and ziv-aflibercept to vascular endothelial growth factor (Holash et al. in Proc Natl Acad Sci USA 99(17):11393–11398, 2002. 10.1073/pnas.172398299) after compounding and storage for up to 28 days at 4 °C and − 8 °C. Methods Tuberculin-type 1-mL syringes were prepared containing aflibercept (40 mg/mL) and ziv-aflibercept (25 mg/mL). Samples were stored at 4 °C and − 8 °C for 0, 14, and 28 days and evaluated for the binding affinity of anti-VEGF to VEGF and stability using enzyme-linked immunosorbent assays. The evaluation of sample sterility was performed. Results Laboratory trials with aflibercept and ziv-aflibercept showed preservation of the drug-binding capability to recombinant VEGF when stored in plastic syringes for up to 28 days at 4 °C and − 8 °C. No significant decrease in mass or concentration were observed. Microbiologic evaluations did not detect contamination in the syringes. Conclusions The current study corroborates that compounded anti-VEGF drugs aflibercept and ziv-aflibercept do not loose stability or binding affinity and do not become contaminated if prepared under sterile conditions and stored at 4 °C or − 8 °C for 14 or 28 days.
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Affiliation(s)
- Julia de Lima Farah
- 1Department of Ophthalmology, Santa Casa de Misericórdia of São Paulo, Rua Dr. Cesario Mota Junior 112, São Paulo, SP 01221-020 Brazil
| | - Ronaldo Sano
- 1Department of Ophthalmology, Santa Casa de Misericórdia of São Paulo, Rua Dr. Cesario Mota Junior 112, São Paulo, SP 01221-020 Brazil
| | - Ieda Maria Longo Maugéri
- 2Department of Microbiology, Immunology and Parasitology, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP Brazil
| | - Daniela Teixeira
- 2Department of Microbiology, Immunology and Parasitology, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP Brazil
| | - Mayari Eika Ishimura
- 2Department of Microbiology, Immunology and Parasitology, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP Brazil
| | - Gabriela Martins
- 2Department of Microbiology, Immunology and Parasitology, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP Brazil
| | - Lycia M J Mimica
- 3Department of Microbiology, Santa Casa de Misericórdia of São Paulo, São Paulo, SP Brazil
| | - Cely Barreto da Silva
- 3Department of Microbiology, Santa Casa de Misericórdia of São Paulo, São Paulo, SP Brazil
| | - Carsten H Meyer
- 4Vision Institute, Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP Brazil
| | | | - Gabriel Costa de Andrade
- 4Vision Institute, Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP Brazil
| | - Michel Eid Farah
- 4Vision Institute, Department of Ophthalmology, Federal University of São Paulo, São Paulo, SP Brazil
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Dubaut JP, Dong F, Tjaden BL, Grainger DA, Duong J, Tatpati LL. Prescribing Bioidentical Menopausal Hormone Therapy: A Survey of Physician Views and Practices. J Womens Health (Larchmt) 2018; 27:859-866. [DOI: 10.1089/jwh.2017.6637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jamie P. Dubaut
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Fanglong Dong
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, California
| | - Bruce L. Tjaden
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - David A. Grainger
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Jennifer Duong
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Laura L. Tatpati
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine–Wichita, Wichita, Kansas
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