A Continuing Education Activity Durably Addressed Knowledge Gaps Related to Penicillin Allergies Among Pharmacists and Pharmacy Technicians

Background: Penicillin allergy is one of the most frequent self-reported allergies; however, only about 10% of reported allergies are accurate. Objectives: Through the creation of a continuing pharmacy education (CPE) activity, we sought to assess knowledge gaps and comfort levels in the management of penicillin allergies. Methods: A 1-hour enduring-content CPE activity was offered as an interactive course from September 20, 2019, to September 20, 2020. Participants completed 3 surveys (pre-survey, post-survey, and follow-up survey). Participants were pharmacists and pharmacy technicians who completed, at a minimum, the activity and both pre- and post-surveys. The primary outcome was the percentage of participants scoring >80% on knowledge-based questions on the post-survey compared with the pre-survey. Secondary outcomes included pre-post comparisons on knowledge-based questions, participants’ self-report of an allergy, and comfort levels dispensing cephalosporins in a patient with a self-reported penicillin allergy. Results: A total of 389 participants completed the CPE activity, with 176 included for analysis. Significantly more participants scored >80% on knowledge-based questions on the post-survey compared with the pre-survey (71.6% vs 22.7%, P < .001). There was no significant difference between the percentage of participants scoring >80% on the post-survey and the follow-up survey (71.6% vs 65%, P = .119). The majority of participants (74%) felt comfortable dispensing a cephalosporin in a patient with a penicillin allergy on the pre-survey, with similar percentages on the post- and follow-up surveys (77% and 90%, respectively). Conclusion: A targeted continuing education program improved overall knowledge, which was sustained for up to 2 months.

Tebipenem pivoxil hydrobromide-No PICC, no problem!

Tebipenem pivoxil hydrobromide is a novel orally bioavailable prodrug of tebipenem, a carbapenem antimicrobial, that binds to penicillin-binding proteins, inhibiting the synthesis of the bacterial cell wall. This results in weakening of peptidoglycan, leading to lysis of bacterial cells. Tebipenem displays a broad spectrum of activity against anaerobic, gram-positive, and gram-negative pathogens, including extended-spectrum β-lactamase producing Enterobacterales. In a large phase 3 clinical trial (ADAPT-PO), oral tebipenem pivoxil hydrobromide 600 mg every 8 h was shown to be non-inferior to intravenous ertapenem 1 g every 24 h. Overall response at test of cure was 58.8% [264/449] in the tebipenem pivoxil hydrobromide group compared to 61.6% [258/419] in the ertapenem group for the treatment of complicated urinary tract infections, including acute pyelonephritis. At the test of cure, clinical cure rates were 93.1% and 93.6% and microbiological eradication was 59.5% and 63.5% with tebipenem pivoxil hydrobromide and ertapenem, respectively. The most common adverse reactions associated with tebipenem pivoxil hydrobromide are diarrhea, headache, and nausea. As with other carbapenems, tebipenem pivoxil hydrobromide is expected to have the potential to decrease the seizure threshold and will likely require renal dosage adjustment for patients with altered renal function due to high renal clearance. If approved in the United States, tebipenem pivoxil hydrobromide can serve as a potential oral antimicrobial option to decrease hospital length of stay and prevent hospital admissions due to resistant pathogens.

Acute Care Pharmacy Practice: A Perspective for Pharmacy Students, Residents, and Other Health-Care Providers

Purpose:

To describe the acute care setting with a specific focus on acute care pharmacy practices.

Summary

Acute care is the sector of health care where time-sensitive episodes of illness are managed. Acute care pharmacy practice includes both hospital and clinical pharmacists serving, in a variety of domains, as medication experts and authority on patient-centered medication therapy. Pharmacists serving in this area can have a beneficial impact on patient care and the health-care system.

Conclusion:

The demand for acute care services is likely to grow as the population continues to grow and age. Pharmacists are key members of interdisciplinary teams in the acute care setting.

Pharmacy faculty and students' perceptions of standardized patients for objective structured clinical examinations

BACKGROUND AND PURPOSE

Objective structured clinical examinations (OSCEs) are one method of assessing clinical competency and communication in doctor of pharmacy programs. The purpose of this study was to capture student and faculty perceptions regarding the use of standardized patients (SPs) in administering OSCEs.

EDUCATIONAL ACTIVITY AND SETTING

Pharmacy students in our program initially participated in OSCEs using internal-SPs (I-SPs) that consisted of faculty and staff acting as patients. One year later, we piloted use of trained actor-based SPs and surveyed students and faculty about the experience.

FINDINGS

Fifty-four (80.6%) students and 12 (92.3%) faculty members completed the survey. When asked about their interactions with SPs, 42 (77.8%) students either agreed or strongly agreed that SPs portrayed patients more realistically and 41 (75.9%) students perceived SPs created a more comfortable environment for patient communication than I-SPs. Thirty-six (66.7%) students either agreed or strongly agreed to feeling more confident when communicating with patients, and 33 (61.1%) felt more confident making recommendations. Ten (83.3%) faculty members either agreed or strongly agreed that SPs portrayed patient interactions more realistically, and 7 (58.3%) felt SPs were more consistent in their simulated patient portrayal for the duration of the OSCE.

SUMMARY

Pharmacy students felt more confident in their ability to communicate and interact with the patient during their OSCEs when actor-based SPs were used. Both students and faculty members perceived this SP portrayal of patient interactions as more realistic than I-SPs and recommended the continued use of actor-based SPs for OSCEs.

A Comprehensive Survey of Infectious Diseases Curriculum Among US Pharmacy Schools

Objective. To describe what and how infectious diseases (ID) topics are taught in US schools of pharmacy and summarize pharmacy faculty members' and students' perceived successes and challenges in teaching and learning about ID. Methods. A 23-item survey instrument was distributed electronically to ID faculty members at 137 US pharmacy schools. Data collected included curricular hours and format, topics covered, active-learning strategies, and curricular successes and concerns. Results. Surveys were collected from 106 schools (77% response rate). Infectious diseases curricula were allotted a median of 60 (IQR=40) hours of classroom time. Respondents dedicated 33% of curriculum hours to ID fundamentals and 66% to disease states. Greater than 94% of schools taught all tier one ID topics from the 2016 American College of Clinical Pharmacy Pharmacotherapy Didactic Curriculum Toolkit. Curricula were primarily delivered through traditional lectures rather than active learning (75% vs 25% of classroom time, respectively). The median number of active-learning strategies used was four (IQR=3). The most common active-learning modalities used either consistently or frequently were patient case application (98%) and audience response systems (76%). The most common successes cited by faculty members were implementation of active learning, the "real-world" applicability of the ID topics, and the breadth of topics and topic exposure covered in the curriculum. The most common concerns were a lack of time to cover material and the amount of material covered. Conclusion. Increased communication and collaboration between ID educators is warranted to increase consistency of ID education and distribution of educational innovations.

2539. Characterization of Infectious Diseases Advanced Pharmacy Practice Experiences at United States Colleges of Pharmacy

Background

Antimicrobial resistance is a public health crisis. Experiential education about the appropriate use of antimicrobials is necessary to prevent the post-antibiotic era. The purpose of this study was to describe the learning experiences during infectious diseases (ID) advanced pharmacy practice experiences (APPEs) offered by ID pharmacy faculty.

Methods

A 18-item, cross-sectional, multi-center, electronic survey was distributed via e-mail to ID pharmacy faculty at 124 schools and colleges of pharmacy in the United States. Programs were identified via the Accreditation Council for Pharmacy Education directory. Data related to student learning experiences, preceptor credentials, and teaching opportunities offered to pharmacy students were collected.

Results

Seventy-two (58%) ID faculty responded to the survey and 64 (89%) offered an ID APPE. Forty-three (67%) preceptors completed a PGY-2 ID pharmacy residency and 17 (27%) completed an ID pharmacy fellowship. ID physicians served as co-preceptors for 52% of rotations but only 34% had other ID pharmacists as co-preceptors. Of the 64 APPEs offered, 45% were at an academic medical center. The majority of students participated in antimicrobial stewardship activities (84%) and ID consults (80%) in adults. Greater than 90% of APPEs included learning experiences related to bone and joint, cardiovascular, central nervous system, Clostridioides difficile, fungal, intra-abdominal, lower respiratory, skin and soft-tissue, and urologic infections. Viral hepatitis (39%), travel medicine (13%), ophthalmologic (39%), parasitic (33%), and rickettsial (31%) infections were less commonly offered. Most students were required to present patient cases (92%), lead topic discussions (91%), present journal clubs (89%), conduct medication use evaluations (56%) and work on research projects (53%).

Conclusion

Pharmacy ID APPEs provide students with a broad range of experiences, particularly in adult populations. Students commonly participated in the management of core infectious syndromes. ID APPEs provide students additional training on the appropriate use of antimicrobials.

Disclosures

All authors: No reported disclosures.

Antimicrobial stewardship education in US colleges and schools of pharmacy

Background

Pharmacists are key members of antimicrobial stewardship (AS) teams. It is unknown if and how US colleges and schools of pharmacy incorporate AS into their Doctor of Pharmacy (PharmD) curricula.

Methods

This study was a cross-sectional, multicentre, electronic survey distributed to infectious diseases faculty or department chairs of 137 accredited and candidate-status PharmD programmes.

Results

One hundred and sixteen programmes participated, representing an 84.7% response rate. AS education was integrated into the required didactic, elective didactic and experiential education components of the curricula in 79 (68.1%), 43 (37.1%) and 97 (83.6%) PharmD programmes, respectively. The most common AS topics in required and elective didactic curricula were AS definitions, principles and purpose (98.7% and 86.0%) and the pharmacist's role in AS (93.7% and 83.7%). In the required and elective didactic curricula, lecture (93.7% and 86.0%) and case-based instruction (57.0% and 83.7%) were the most common instructional methods. For experiential education, the pharmacist's role in AS (96.9%), de-escalation of antimicrobials (96.9%) and antimicrobial dose optimization (95.9%) were the most common AS topics. PharmD programmes employing a faculty member who specializes in AS were more likely to offer AS experiential education than programmes without AS faculty (88.1% versus 71.9%, P = 0.049).

Conclusions

Integration of AS education in US PharmD curricula is variable and there are considerable differences in the AS activities and topics delivered. PharmD programmes should attempt to expose students to AS education to prepare future pharmacists for AS practice. Efforts should be made to incorporate interprofessional collaboration into AS education.

Learning Experiences Within Infectious Diseases Pharmacy Residency Programs in the United States: A Cross-Sectional Survey

Background

Pharmacists with residency training in infectious diseases (ID) optimize antimicrobial therapy outcomes in patients and support antimicrobial stewardship (AS) programs. Although most ID residencies are accredited and assessed by certain standards, the degree to which these programs are similar is not known.

Methods

A 19-item, cross-sectional, multicentered, electronic survey was distributed via e-mail to pharmacy residency program directors (RPDs) of all 101 second-year postgraduate (PGY-2) ID residency programs in the United States.

Results

Survey responses were collected from 71 RPDs (70.3%); 64.8% were associated with an academic medical center and 97.2% focused primarily in adult ID. Rotations in the microbiology laboratory, adult AS, and adult ID consult were required in 98.6% of residency programs. Only 28.2% of responding programs required pediatric AS and pediatric ID consult rotations. Programs at academic medical centers were more likely to offer immunocompromised host ID consult (P = .003), pediatric ID consult (P = .006), and hospital epidemiology (P = .047) rotations but less frequently offered outpatient AS (P = .003), viral hepatitis clinics (P = .001), and travel medicine clinics (P = .007) rotations compared to programs at nonacademic medical centers. Residents were frequently involved in AS committees (97.2%), pharmacokinetic dosing of antimicrobials (83.1%), precepting pharmacy trainees (80.3%), and performing research projects (91.5%).

Conclusions

The PGY-2 ID pharmacy residency programs demonstrated consistency in required adult ID consult, antimicrobial management activities, committee service, and teaching and research opportunities. Pediatric experiences were less common. The PGY-2 ID residency programs prepare pharmacists to become antimicrobial stewards for adult patients.

Aminoglycoside Allergic Reactions

Aminoglycosides are antimicrobial agents that are primarily used for infections caused by Gram-negative pathogens. The purpose of this article is to review the allergic reactions reported in the published literature to aminoglycoside antibiotics. A thorough PubMed search was conducted and excluded non-allergic adverse reactions to aminoglycosides. Allergic reactions to aminoglycosides occur infrequently, but can include cutaneous reactions as well as systemic reactions, including anaphylaxis. Of the evaluated aminoglycosides, gentamicin had the most reported allergic reactions, including the most reports of anaphylaxis, followed by tobramycin, and then amikacin. Most reports of allergic reactions occurred in patients who had a prior exposure to some dosage form of an aminoglycoside. Cross-reactivity among aminoglycosides is common and occurs due to the similarities in their chemical structures. Desensitization protocols to tobramycin have been described in the literature.

Baloxavir marboxil: a novel cap-dependent endonuclease (CEN) inhibitor for the treatment of acute uncomplicated influenza

Baloxavir marboxil is a newly approved antiviral agent with activity against influenza via a novel mechanism of action of inhibition of cap-dependent endonuclease (CEN). The novel agent was approved in October of 2018 in the United States for the treatment of acute uncomplicated influenza A and B in patients aged 12 years or older. Baloxavir is given as a single weight-based dose of 40 mg orally once for patients weighing less than 80 kg and 80 mg orally once for those weighing 80 kg or more within 48 hours of symptom onset. In comparison with current therapy, baloxavir is as effective in decreasing time to symptom alleviation as the drug of choice, oseltamivir, and significantly reduces viral load 1 day after treatment compared with placebo and oseltamivir. In safety analyses baloxavir was well tolerated with only mild adverse events reported (nausea, headache, diarrhea, bronchitis, nasopharyngitis), thus providing a safe and reliable alternative option to current therapy for acute uncomplicated influenza. Further studies are being conducted to evaluate the use of baloxavir in additional patient populations including pediatric patients less than 12 years of age and patients who are at high risk of complications related to influenza.

Preparing pharmacy students for postgraduate training through a residency preparedness elective course

OBJECTIVE

To determine the benefit of a residency preparedness elective course and assess the ability of the course to provide students with the knowledge and experiences needed to competitively apply for residency programmes.

METHODS

A pre-/postsurvey study on a 2-credit hour elective course for third-year pharmacy students. This course was designed to provide them with the knowledge and experiences needed to competitively apply for pharmacy residency programmes.

KEY FINDINGS

Students' perceptions of the elective course were captured through pre- and postcourse evaluations utilizing a 15-item survey. The main reasons students participated in this course was to gain a better understanding of the residency application process (median Likert score = 5; 1 = strongly disagree and 5 = strongly agree), develop interviewing techniques (5) and enhance clinical competency (5). By the end of the course, students felt more confident with their understanding of pharmacy residency programmes (4 versus 5, P = 0.002) and of the residency application process (2 versus 5, P = 0.001).

CONCLUSION

Upon completion of a pharmacy residency preparedness elective course, students felt more confident in their understanding and ability to apply for a residency programme.

Plazomicin: A Next-Generation Aminoglycoside

Plazomicin is a novel aminoglycoside antibiotic that binds to the bacterial 30S ribosomal subunit, thus inhibiting protein synthesis in a concentration-dependent manner. Plazomicin displays a broad spectrum of activity against aerobic gram-negative bacteria including extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and organisms with aminoglycoside-modifying enzymes. In a large phase III clinical trial, plazomicin was shown to be noninferior to meropenem in the treatment of complicated urinary tract infections (cUTIs) with respect to the coprimary efficacy end points of the microbiologically modified intent-to-treat composite cure rate at day 5 (plazomicin 88% [168/191 subjects] vs meropenem 91.4% [180/197]) and at the test-of-cure visit (plazomicin 81.7% [156/191] vs meropenem 70.1% [138/197]). In a small phase III clinical trial, plazomicin was shown to be effective in the treatment of infections caused by carbapenem-resistant Enterobacteriaceae. It was associated with a lower all-cause mortality or significant disease-related complication rate (23.5% [4/17]) compared with colistin (50% [10/20]). The most common adverse reactions associated with plazomicin are decreased renal function, diarrhea, hypertension, headache, nausea, vomiting, and hypotension. As with other aminoglycosides, plazomicin may cause neuromuscular blockade, ototoxicity, and fetal harm in pregnant women. Due to limited efficacy and safety data, plazomicin is indicated for the treatment of cUTIs in adults with limited or no alternative treatment options, using a dosage regimen of 15 mg/kg intravenously every 24 hours for 4-7 days. Dosage reductions and therapeutic drug monitoring are warranted in patients with moderate or severe renal impairment. Plazomicin is not recommended in patients with severe renal impairment including those receiving renal replacement therapy. With the approval of plazomicin, clinicians now have an additional option for the treatment of adults with cUTIs, particularly those caused by multidrug-resistant gram-negative rods.

Ridinilazole: a novel antimicrobial for Clostridium difficile infection

Clostridium difficile (C. difficile) infection remains a global healthcare threat worldwide and the limited options available for its treatment are of particular concern. Ridinilazole is one potential future agent, as it demonstrates rapid bactericidal activity against C. difficile. Current studies show that ridinilazole has a lower propensity for collateral damage to the gut microbiome and appears to diminish the production of C. difficile toxins. Results from phase II studies demonstrate that patients receiving ridinilazole had a higher sustained clinical response compared with patients receiving vancomycin (66.7% vs. 42.4%; P=0.0004). Adverse reactions were similar between ridinilazole and vancomycin (40% vs. 56%, respectively), with most being gastrointestinal-related. Nausea (20%) and abdominal pain (12%) were the most commonly reported adverse reactions associated with ridinilazole. Phase II study results are promising and future availability of phase III trial results will help further delineate the role and value of ridinilazole.

Heplisav-B vaccination for the prevention of hepatitis B virus infection in adults in the United States

The prevalence of hepatitis B virus (HBV) infections is a worldwide issue that can lead to both acute and chronic complications with increased morbidity and mortality in affected individuals. Current methods of preventing HBV infections primarily include building patient immunity through administration of hepatitis B vaccinations starting at birth. Certain at-risk individuals, including those with occupational exposure to pathogenic bodily fluids, those who are sexually active or intravenous drug users, are recommended to receive some form of hepatitis B vaccination. The current standard of hepatitis B vaccination in the United States is the Engerix-B vaccine, which consists of a three-dose regimen over a 6-month time period. A new hepatitis B vaccine, Heplisav-B, has been approved for adults in the United States and requires only two doses over 1 month. The unique dosing schedule of Heplisav-B provides the potential for increasing patient compliance and therefore can aid in the effort toward protecting individuals from developing an HBV infection. Results from clinical trials showed that Heplisav-B compared favorably with Engerix-B in safety and efficacy profiles. This paper provides a review of the pharmacology, safety, clinical trials and indications for use for the Heplisav-B vaccine in the United States.

Impact of the use of local fidaxomicin treatment algorithms for managing Clostridium difficile infection in hospitalized patients in southeastern United States

Background

Clostridium difficile-associated diarrhea (CDAD) is a major public health threat that results in increased length of stay, hospital readmissions, deaths, and economic burden. CDAD treatment is often guided by severity of disease. Although various tools exist to determine CDAD severity, real-world data evaluating the use of such tools in treatment algorithms are sparse.

Methods

A local CDAD treatment pathway was developed independently to guide fidaxomicin prescribing at wellStar Health System (WellStar) and at Lee Health (LH) and Sarasota Memorial Hospital (SMH). Each algorithm was designed locally by the stewardship pharmacist and was utilized to identify patients at high risk for C. difficile recurrence. Patient and clinical data was retrospectively gathered to evaluate the utility and outcomes of the treatment pathway.

Results

There were 262 patients that received fidaxomicin at these three hospitals during the study time period. Only 30% at WellStar and 20% at LH or SMH met the study criteria and adhered to the pathway requirements. After completion of fidaxomicin, 30-day recurrence rates at WellStar was 0 and at LH and SMH 7%. Clinical cure rates were 83% in WellStar and 93% in LH and SMH.

Conclusions

The results from these two pathways show positive outcomes for the use of fidaxomicin in patients at high risk for CDAD recurrence. This data supports the potential utility of fidaxomicin against CDAD.

Letermovir for prophylaxis of cytomegalovirus in allogeneic hematopoietic stem cell recipients

Letermovir is a new antiviral agent with activity against human cytomegalovirus (CMV). Letermovir works as an inhibitor of the CMV DNA terminase complex which further inhibits viral DNA processing and packaging. Letermovir is available both orally and intravenously in 480-mg and 240-mg dosage forms, and is approved for use in the prophylaxis of CMV infection and disease in CMV-seropositive recipients of allogeneic hematopoietic stem cell transplant (HSCT) over the age of 18. The recommended dose is 480 mg p.o./i.v. once daily initiated between day 0 through day 28 post-allogeneic HSCT and continued through day 100 post-transplantation; the dose should be reduced to 240 mg daily if coadministered with cyclosporine. Letermovir is metabolized primarily by hepatic OATP1B1/3 and is not recommended for patients with severe hepatic impairment (Child-Pugh class C). Renal dosage adjustments are not warranted until a creatinine clearance (CrCl) of less than 10 mL/min; however, serum creatinine should be monitored when administered to patients with a CrCl of less than 50 mL/min. Cross-resistance with other useful antiviral agents in the treatment of CMV has not been observed. Additionally, letermovir is active against DNA polymerase inhibitor-resistant viral strains. Letermovir has shown promising clinical efficacy and is generally well tolerated, thus providing a favorable new option in the prophylaxis of CMV infection and disease.

Selecting candidates for pharmacy residencies: A national survey of residency program directors

WHAT IS KNOWN AND OBJECTIVE

Due to advances in healthcare and treatment options, there is a need for pharmacists with additional post-graduate residency training. With the growing need for residency-trained pharmacists, obtaining a post-graduate pharmacy residency has become more competitive. The objective of this study was to capture the perspectives of post-graduate year 1 residency programme directors (RPDs) in the United States (US) regarding aspects of a candidate's application and interview they found most important when selecting future residents.

METHODS

A cross-sectional, electronic survey was distributed via e-mail to PGY-1 pharmacy RPDs in the USA. RPDs were identified via the American Society of Health-System Pharmacists' pharmacy residency directory. Data related to programme demographics, candidate applications and interview evaluations were collected. RPDs' perceptions were captured via a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree).

RESULTS AND DISCUSSION

A total of 327 (26.6%) RPDs completed the survey. RPDs highly considered overall compatibility (mean Likert score: 4.9), letters of recommendation (4.6) and letter of interest (4.5) when inviting candidates for on-site interviews. Residency programmes focusing in acute care valued hospital pharmacy work experience more compared to non-acute care-focused residency programmes (4.2 vs 2.9). During the interview, critical thinking ability (4.8), verbal communication (4.8) and overall compatibility (4.9) were viewed as highly important when considering ranking of candidates.

WHAT IS NEW AND CONCLUSION

Due to the competitive nature of obtaining a residency programme, insight from RPDs on factors they consider significant when assessing prospective residents is valuable. The results from this study show that a strong letter of intent, letters of recommendations and overall compatibility are considered important by RPDs and should be used by candidates to better prepare themselves for residency applications. Additionally, the candidate should remain knowledgeable about the residency programme and be able to respond to questions asked during the residency interview process.

Meropenem/Vaborbactam, the First Carbapenem/β-Lactamase Inhibitor Combination

OBJECTIVE

To review the pharmacology, spectrum of activity, pharmacokinetics, pharmacodynamics, safety, efficacy, administration, and considerations for clinical use of meropenem/vaborbactam (M/V).

DATA SOURCES

A literature search using PubMed and clinicaltrials.gov (June 2013 to December 2017) was conducted using the search terms meropenem, vaborbactam, RPX7009, biapenem, RPX2003, and carbavance. References from relevant articles and conference abstracts were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

Preclinical, phase I studies, and phase III studies written in the English language were evaluated.

DATA SYNTHESIS

M/V is a novel carbapenem/β-lactamase inhibitor antimicrobial with in vitro activity against nearly 99% of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. M/V is approved for the treatment of adults with complicated urinary tract infections (cUTIs), including pyelonephritis. In a phase III cUTI trial (TANGO I), 98.4% of patients treated with M/V experienced overall clinical success compared with 94% of patients treated with piperacillin/tazobactam (95% CI = 0.7 to 9.1). When compared with best available therapy for carbapenem-resistant Enterobacteriaceae (CRE) infections in TANGO II, patients receiving M/V were more likely to achieve clinical cure at both the end of therapy (64.3% vs 33.3%, P = 0.04) as well as at the test of cure (57.1% vs 26.7%, P = 0.04). The most common adverse effects associated with M/V were headache, infusion-site reactions, and diarrhea.

CONCLUSION

M/V has a valuable role in the treatment of CRE and should be used judiciously to preserve its use for resistant infections.

What Is Old Is New Again: Delafloxacin, a Modern Fluoroquinolone

Delafloxacin is a new fluoroquinolone antimicrobial approved for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) in adults using dosage regimens of 300 mg intravenously every 12 hours, 450 mg orally every 12 hours, or switching from intravenous to oral regimens for a 5- to 14-day treatment duration. Dosage adjustments in patients with severe renal dysfunction (estimated glomerular filtration rate [eGFR] = 15-29 ml/min/1.73 m² ) are not required for oral doses but should be decreased to 200 mg intravenously every 12 hours in patients requiring parenteral therapy. Due to insufficient data, use of delafloxacin is not recommended for patients on hemodialysis or with end-stage renal disease (eGFR < 15 ml/min/1.73 m² ). Delafloxacin works through inhibition of DNA gyrase (topoisomerase II) and topoisomerase IV, which are essential enzymes for bacterial DNA transcription, replication, repair, and recombination and exhibits bactericidal activity against gram-positive and gram-negative organisms through a concentration-dependent matter. Delafloxacin has a very broad spectrum of activity against atypical, anaerobic, and resistant gram-negative and gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. During phase 3 trials, the most common side effects associated with delafloxacin were gastrointestinal (nausea, diarrhea). Unlike other fluoroquinolones, there does not seem to be a risk of QTc prolongation or phototoxicity with delafloxacin. The availability of both parenteral and oral formulations for delafloxacin distinguishes it from many of the currently available agents approved for ABSSSIs. Phase 3 studies for the treatment of respiratory infections are currently under way, and future results of these studies will further help delineate the role of delafloxacin.

National Survey Regarding the Importance of Leadership in PGY1 Pharmacy Practice Residency Training

BACKGROUND

Leadership is considered a professional obligation for all pharmacists. It is important to integrate leadership training in residency programs to meet the leadership needs and requirements of the profession.

OBJECTIVE

To evaluate the importance of leadership development during postgraduate year 1 (PGY1) pharmacy practice residency training as perceived by new practitioners.

METHODS

A 15-question online survey was distributed to residency-trained new practitioners to assess (1) amount of time dedicated to leadership training during residency training, (2) different leadership tools utilized, (3) residents' participation in various committees or councils, (4) perceived benefit of increased leadership training, (5) importance of having a mentor, (6) understanding of the residency organization's strategic objectives, (7) discussion of Pharmacy Practice Model Initiative (PPMI) during residency training, and (8) adequacy of leadership training in preparation to become a pharmacy practice leader.

RESULTS

Although the majority of resident respondents had less than 20% of their residency devoted to leadership, nearly all survey participants acknowledged that leadership is an important component of PGY1 residency training. Residents agreed that their residency experience would have benefited from increased leadership opportunities. Most residents were knowledgeable about their organization's strategic objectives but did not have a full understanding of pharmacy initiatives such as the PPMI.

CONCLUSION

Feedback from residents indicates that an optimal dedication to leadership training would range between 20% and 30% of the residency year. Increased focus on PPMI, mentorship, and expanded use of leadership tools can serve as a way to help meet the future leadership needs of the pharmacy profession and help to better prepare residents to become pharmacy practice leaders.

Treatment of methicillin-sensitive Staphylococcus aureus bacteremia secondary to septic phlebitis using dalbavancin

WHAT IS KNOWN AND OBJECTIVE

Treatment of bacteremia due to Staphylococcus aureus often requires prolonged therapy leading to increased hospital lengths of stay and associated costs. For certain patients, referral to an outpatient parenteral antimicrobial therapy (OPAT) programme serves as an alternative to increased inpatient length of stay. We report an alternative to OPAT using dalbavancin for the treatment of methicillin-sensitive Staphylococcus aureus (MSSA).

CASE SUMMARY

A 54-year-old Caucasian man was brought to the emergency department from a rehabilitation centre with altered mental status and possible seizure. A peripheral intravenous catheter was placed in the left forearm, and the patient was transferred to the intensive care unit (ICU) for management of his acute psychosis, possible seizure and hyponatremia. Seven days into admission, the patient became febrile thought to be secondary to septic phlebitis of the forearm. Blood cultures were taken and organism identification using Nanosphere Verigene^® BC-GP rapid diagnostic testing resulted in MSSA. The patient received treatment with cefazolin with a planned treatment duration of 14 days but because of the patient's history of alcohol abuse, psychosis requiring hospitalization via the Baker Act, and history of non-compliance to follow-up appointments, the patient was deemed ineligible for OPAT. Due to the limited treatment options, therapy for MSSA bacteremia was changed on day 6 of cefazolin therapy to dalbavancin to complete the 14-day treatment duration. Blood cultures were negative at the end of treatment and no relapse of infection occurred.

WHAT IS NEW AND CONCLUSION

To our knowledge, this is the first case report using dalbavancin in clinical practice for the treatment of MSSA bacteremia secondary to septic phlebitis. This report highlights the potential role of the newer lipoglycopeptides, such as dalbavancin, in treating patients who require long-term parenteral antimicrobial therapy and are ineligible for treatment via OPAT.

Neisseria gonorrhoeae and fosfomycin: Past, present and future

Drug-resistant Neisseria gonorrhoeae has become a global health concern that requires immediate attention. Due to increasing resistance to cephalosporins, pursuing novel alternatives for treating N. gonorrhoeae infections is paramount. Whilst new drug development is often cumbersome, reviving antiquated antibiotic agents for treatment of modern infections has become prevalent in clinical practice. Fosfomycin exhibits bactericidal activity through a unique mechanism of action, and a variety of organisms including N. gonorrhoeae are susceptible. In vitro studies have demonstrated that fosfomycin can retain activity against ceftriaxone-resistant N. gonorrhoeae; however, it remains unclear whether there is synergy between fosfomycin and other antibiotics. Clinical investigations evaluating fosfomycin for the treatment of N. gonorrhoeae infections are confounded by methodological limitations, none the less they do provide some perspective on its potential role in therapy. Future studies are needed to establish a safe, convenient and effective fosfomycin regimen for treating N. gonorrhoeae infections.

Analysis of electrical property changes of skin by oil-in-water emulsion components

ObjectivesAs the ‘Dry Skin Cycle’ produces continuous deterioration, cosmetic xerosis (flaky, dry skin) is one of the major concerns to most consumers. The purpose of this study was to investigate the moisturizing effect of oil-in-water (O/W) emulsion components. There are numerous types of oils, waxes, polyols and surfactants used as ingredients in skincare products. However, the moisturizing effect of each ingredient and understanding each use to make an effective moisturizing products are still not well understood.

Methods To provide answers to these questions, we investigated the moisturizing effect of widely used 41 components (four different classes) in a simple O/W emulsion using capacitance methods. 106 different single oils, and combinations of oil with oil, wax, humectants, and surfactant were formulated and tested.

Results In this study, we found that most of the O/W emulsion components had hydration effects on the skin. (i) The average relative water content increase (RWCI) rate of a single oil-based emulsion was 11.8 ± 5.2% (SE) and 7.9 ± 6.0% (SE) at 3 and 6 h, respectively. (ii) An oil combination emulsion showed an average RWCI rate similar to that of a single oil-based emulsion, 12.6 ± 6.0% (SE) and 12.1 ± 6.4% (SE) at 3 and 6 h, respectively (iii) A combination of waxes with oil showed an average RWCI rate of 16 ± 5.6% (SE) and 12.4 ± 4.5% (SE) at 3 and 6 h, respectively. (iv) Humectant combinations showed the highest average RWCI rate 28 ± 7.3% (SE) and 22.2 ± 7.5% (SE) at 3 and 6 h, respectively (v) Surfactant combinations had an average RWCI of 10.8 ± 4.5% (SE) and 6.0 ± 4.0% (SE) at 3 and 6 h, respectively.

Conclusion Interestingly, it was difficult to find moisturizing power differences among samples in the same group. Only the humectants group showed significant differences among samples. Glycerine and urea showed significant skin hydration effects compared with other humectants. We also found a significant moisturizing effect by analysing the chemical functional groups; amide class had a higher hydration effect than betaines and disaccharides in humectants combination.

Résumé

Objectif Puisque le «cycle de la peau sèche” produit une détérioration continue, la xérose cosmétique (squameuse, peau sèche) est l’une des préoccupations majeures pour la plupart des consommateurs. Le but de cette étude était d’étudier l’effet hydratant des composants d’émulsions H / E. Il existe de nombreux types d’huiles, des cires, de polyols, et des tensioactifs utilisés comme ingrédients dans les produits de soins de la peau. Cependant, l’effet hydratant de chaque ingrédient et de leur utilisation dans des produits hydratants efficaces ne sont pas encore bien compris.

MethodesPour apporter des réponses à ces questions, nous avons étudié l’effet hydratant des 41 éléments (4 classes différentes) largement utilisés dans une émulsion simple O/W en utilisant des méthodes de capacitance. 106 huiles individuelles différentes et des combinaisons d’huile avec de l’huile, de la cire, des humectants, et de tensioactifs ont été formulées et testées.

ResultatsDans cette étude, nous avons constaté que la plupart des composants des émulsions huile-dans-eau (H/E) possédaient des effets d’hydratation de la peau. (i) Le taux moyen d’augmentation d’eau (RWCI = relative water content increase) d’une émulsion à base d’une seule huile était de 11,8 ± 5,2% (SE) et de 7,9 ± 6,0% (SE) à 3 et 6 h, respectivement. (ii) Une émulsion de combinaison d’huile montrait une RWCI similaire à celle d’une émulsion à base d’huile unique, 12,6 ± 6,0% (SE) et 12,1 ± 6,4% (SE) à 3 et 6 h, respectivement. (iii) Une combinaison des cires avec de l’huile présentait une RWCI de 16 ± 5,6% (SE) et 12,4 ± 4,5% (SE) à 3 et 6 h, respectivement. (iv) Les combinaisons d’humectant ont montré la plus forte augmentation avec +28 ± 7,3% (SE) et 22,2 ± 7,5% (SE) à 3 et 6 h, respectivement. (v) Les combinaisons de tensioactifs ont une RWCI moyenne de 10,8 ± 4,5% (SE) et de 6,0 ± 4,0% (SE) à 3 et 6 h, respectivement.

ConclusionFait intéressant, il était difficile de trouver des différences de pouvoir d’hydratation entre les échantillons dans le même groupe. Seul le groupe des humectants a montré des différences significatives entre les échantillons. La glycérine et l’urée ont montré des effets significatifs sur l’hydratation de la peau par rapport aux autres humectants. Nous avons également constaté un effet hydratant important en analysant les groupes fonctionnels chimiques; la classe “amide” a eu un effet d’hydratation plus élevé que les bétaînes et disaccharides dans les combinaisons des humectants.

Detection of mega plasmid from polycyclic aromatic hydrocarbon-degrading Sphingomonas sp. strain KS14

Polycyclic aromatic hydrocarbon (PAH) degrading Sphingomonas sp. strain KS14 was isolated from soil. Strain KS14 was able to utilize phenanthrene and naphthalene as sole source of carbon and energy, and mineralize phenanthrene to carbon dioxide. Strain KS14 cometabolically degraded pyrene using phenanthrene as secondary growth substrate. A large degradative plasmid (>500 kb) was detected from the strain KS14. This study suggests that this mega plasmid could be responsible for the degradation of PAH by strain KS14.

Bacterial species determination from DNA-DNA hybridization by using genome fragments and DNA microarrays

Whole genomic DNA-DNA hybridization has been a cornerstone of bacterial species determination but is not widely used because it is not easily implemented. We have developed a method based on random genome fragments and DNA microarray technology that overcomes the disadvantages of whole-genome DNA-DNA hybridization. Reference genomes of four fluorescent Pseudomonas species were fragmented, and 60 to 96 genome fragments of approximately 1 kb from each strain were spotted on microarrays. Genomes from 12 well-characterized fluorescent Pseudomonas strains were labeled with Cy dyes and hybridized to the arrays. Cluster analysis of the hybridization profiles revealed taxonomic relationships between bacterial strains tested at species to strain level resolution, suggesting that this approach is useful for the identification of bacteria as well as determining the genetic distance among bacteria. Since arrays can contain thousands of DNA spots, a single array has the potential for broad identification capacity. In addition, the method does not require laborious cross-hybridizations and can provide an open database of hybridization profiles, avoiding the limitations of traditional DNA-DNA hybridization.

Preparation and characterization of poly(3-hydroxybutyrate-co-3-hydroxyvalerate) microspheres for the sustained release of 5-fluorouracil

Biodegradable microspheres were prepared with poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV, 85:15 by mole ratio of hydroxybutyrate to hydroxyvalerate) by an water-in-oil-in-water (W/O/W), oil-in-water (O/W) and oil-in-oil (O/O) solvent evaporation method for the sustained release of anti-cancer drug, 5-fluorouracil (5-FU) with controlling the fabrication conditions. The shape of microspheres prepared was relatively rough due to highly crystalline property of PHBV and spherical. The efficiency of 5-FU loading into the PHBV microsphere with O/O method was over 80% compared to that 7% for microspheres by O/W method and below 1% for microspheres by a conventional W/O/W method. However, the most desirable release pattern can be achieved from the O/W method due to the cosolvent effect. The effects of preparation conditions such as the type and amount of surfactant, initial amount of loaded drug, the temperature of solvent evaporation, and etc. on the morphology for W/O/W method were investigated. Possible mechanisms of the desirable sustained release pattern for O/W system have been proposed.

Biogeography and degree of endemicity of fluorescent Pseudomonas strains in soil

Fluorescent Pseudomonas strains were isolated from 38 undisturbed pristine soil samples from 10 sites on four continents. A total of 248 isolates were confirmed as Pseudomonas sensu stricto by fluorescent pigment production and group-specific 16S ribosomal DNA (rDNA) primers. These isolates were analyzed by three molecular typing methods with different levels of resolution: 16S rDNA restriction analysis (ARDRA), 16S-23S rDNA intergenic spacer-restriction fragment length polymorphism (ITS-RFLP) analysis, and repetitive extragenic palindromic PCR genomic fingerprinting with a BOX primer set (BOX-PCR). All isolates showed very similar ARDRA patterns, as expected. Some ITS-RFLP types were also found at every geographic scale, although some ITS-RFLP types were unique to the site of origin, indicating weak endemicity at this level of resolution. Using a similarity value of 0.8 or more after cluster analysis of BOX-PCR fingerprinting patterns to define the same genotypes, we identified 85 unique fluorescent Pseudomonas genotypes in our collection. There were no overlapping genotypes between sites as well as continental regions, indicating strict site endemism. The genetic distance between isolates as determined by degree of dissimilarity in BOX-PCR patterns was meaningfully correlated to the geographic distance between the isolates' sites of origin. Also, a significant positive spatial autocorrelation of the distribution of the genotypes was observed among distances of <197 km, and significant negative autocorrelation was observed between regions. Hence, strong endemicity of fluorescent Pseudomonas genotypes was observed, suggesting that these heterotrophic soil bacteria are not globally mixed.

Heavy contamination of a subsurface aquifer and a stream by livestock wastewater in a stock farming area, Wonju, Korea

A survey of groundwater and stream water quality was undertaken in a stock farming area where livestock wastewater infiltrates into sandy unsaturated zones and saturated bedrock aquifers containing fractures. To determine the degree of contamination and track the effect of livestock wastewater on groundwater and stream water quality, the population of indicator bacteria (total coliforms, fecal coliforms, fecal streptococci, Staphylococcus spp., and sulfite-reducing clostridia) together with relevant physicochemical parameters were monitored along the wastewater flow-pathways over a 19-month period. The stream water was severely contaminated with livestock wastewater. Nearly all physicochemical and bacteriological parameters in the stream water were much greater than those in the groundwater. Nitrate-N concentrations ranged from 10.0 to 20.0 mg l(-1) in boreholes located downstream (site C) from the livestock waste disposal site, while those in the background borehole (W2) were below 1.0 mg l(-1). Densities of indicator bacteria in boreholes at site C were two or three orders of magnitude higher than those in W2 borehole. In boreholes located downstream from the livestock waste disposal site, the concentration of ammonium-N, nitrate-N, and pollution indicator bacteria increased as groundwater level rose due to infiltration of rainwater. In W2 borehole, however, physicochemical parameters and the number of pollution indicator bacteria had no correlation with the groundwater level. Collectively, these results suggest that the deep aquifers were heavily contaminated with infiltrated livestock wastewater, which consequently must be adequately treated to minimize groundwater pollution.

Detection of adenoviruses and enteroviruses in tap water and river water by reverse transcription multiplex PCR

A reverse transcription (RT) multiplex polymerase chain reaction (PCR) assay was developed to simultaneously detect adenoviruses and enteroviruses, both of which have attracted much attention as molecular indices of viral pollution in environmental samples. The method involves a reverse transcription step, followed by a multiplex nested PCR in which the combination of primers amplifies cDNA from enteroviruses and adenoviruses. The sensitivity of this assay was found to be similar to that of each monoplex PCR or RT-PCR assay, and to be consistent regardless of relative concentrations of adenoviruses and enteroviruses. To assess suitability and environmental application of the RT multiplex PCR assay, a total of 12 river water samples and 4 tap water samples were analyzed by RT multiplex PCR, each monoplex PCR or RT-PCR, and cell culture assay on the Buffalo Green Monkey kidney cell line. The sensitivity of the RT multiplex PCR was also found to be similar to that of each monoplex PCR in environmental samples. This suggests the RT multiplex PCR assay could be applied to the routine monitoring of viral pollution in environmental waters.

Increase in bacterial community diversity in subsurface aquifers receiving livestock wastewater input

Despite intensive studies of microbial-community diversity, the questions of which kinds of microbial populations are associated with changes in community diversity have not yet been fully solved by molecular approaches. In this study, to investigate the impact of livestock wastewater on changes in the bacterial communities in groundwater, bacterial communities in subsurface aquifers were analyzed by characterizing their 16S rDNA sequences. The similarity coefficients of restriction fragment length polymorphism (RFLP) patterns of the cloned 16S ribosomal DNAs showed that the bacterial communities in livestock wastewater samples were more closely related to those in contaminated aquifer samples. In addition, calculations of community diversity clearly showed that bacterial communities in the livestock wastewater and the contaminated aquifer were much more diverse than those in the uncontaminated aquifer. Thus, the increase in bacterial-community diversity in the contaminated aquifer was assumed to be due to the infiltration of livestock wastewater, containing high concentrations of diverse microbial flora, into the aquifer. Phylogenetic analysis of the sequences from a subset of the RFLP patterns showed that the Cytophaga-Flexibacter-Bacteroides and low-G+C gram-positive groups originating from livestock wastewater were responsible for the change in the bacterial community in groundwater. This was evidenced by the occurrence of rumen-related sequences not only in the livestock wastewater samples but also in the contaminated-groundwater samples. Rumen-related sequences, therefore, can be used as indicator sequences for fecal contamination of groundwater, particularly from livestock.

Preparation and characterization of Japanese encephalitis virus vaccine loaded poly(L-lactide-co-glycolide) microspheres for oral immunization

Japanese encephalitis virus (JEV) vaccine loaded biodegradable poly(L-lactide-co-glycolide) (PLGA) microspheres (MSs) were prepared by W/O/W solvent evaporation method to study the possibility for oral vaccination. The influence of several preparation parameters as stirring rate, types and concentration of emulsifier, PLGA concentration, etc. has been observed on size, size distribution and biodegradation. The mean MSs size decreased when the agitation speed and the concentration of emulsifier were increased, and when the PLGA concentration was decreased. The surface morphology of porous and nonporous JEV vaccine loaded PLGA MSs was prepared from polyvinylalcohol and sodium dodecyl sulfate as used emulsifiers, respectively. From the assay of lactic acid and scanning electron microscope observation, it can be suggested that the rate of biodegradation of nonporous MSs was slower than that of porous surface morphology due to lower the surface area. Mechanisms of the formation of porous and nonporous surface by different types of emulsifier, and the biodegradation of MSs have been proposed. Also, the size and size distribution of JEV vaccine loaded PLGA MSs were discussed to apply oral vaccination through the Peyer's patches across the gastrointestinal tract.

Green fluorescent protein-based direct viable count to verify a viable but non-culturable state of Salmonella typhi in environmental samples

The gfp-tagging method and lux-tagging method were compared to select a better method for verifying a viable but nonculturable (VBNC) state of bacteria in the environment. An environmental isolate of Salmonella typhi was chromosomally marked with a gfp gene encoding green fluorescent protein (GFP). The hybrid transposon mini-Tn5 gfp was transconjugated from E. coli to S. typhi. Using the same method, S. typhi was chromosomally marked with luxAB genes encoding luciferase. The survival of gfp-tagged S. typhi introduced into groundwater microcosms was examined by GFP-based plate count, total cell count, and a direct viable count method. In microcosms containing lux-tagged S. typhi, luminescence-based plate count and the measurement of bioluminescence of each microcosm sample were performed. In microcosms containing lux-tagged S. typhi, viable but nonculturable cells could not be detected by using luminometry. As no distinguishable luminescence signals from the background signals were found in samples containing no culturable cells, a VBNC state of S. typhi could not be verified in lux-based systems. However, comparison between GFP-based direct viable counts and plate counts was a good method for verifying the VBNC state of S. typhi. Because GFP-based direct viable count method provided a direct and precise estimation of viable cells of introduced bacteria into natural environments, it can be used for verifying the VBNC state of bacteria in environmental samples.

Viable, but non-culturable, state of a green fluorescence protein-tagged environmental isolate of Salmonella typhi in groundwater and pond water

An environmental isolate of Salmonella typhi was chromosomally marked with a gfp gene encoding green fluorescence protein (GFP) isolated from Aequorea victoria. The hybrid transposon mini Tn5 gfp was transconjugated from E. coli to S. typhi, resulting in constitutive GFP production. The survival of S. typhi GFP155 introduced into groundwater and pond water microcosms was examined by GFP-based plate counts, total cell counts, and direct viable counts. A comparison between GFP-based direct viable counts and plate counts was a good method for verifying the viable, but non-culturable (VBNC), state of S. typhi. The entry into a VBNC state of S. typhi was shown in all microcosms. S. typhi survived longer in groundwater than in pond water as both a culturable and a VBNC state.