Barriers to Medication Error Reporting in a federally qualified health center (Barriers to MEET in a FQHC)

Barriers to medication error reporting in inpatient settings and primary care clinics are well known and can be categorized as psychological, logistical, knowledge, and workplace. These barriers have not been explored well at Federally Qualified Health Centers (FQHC) where limited pharmacy services may exist.

METHODS

This prospective, cross-sectional study surveyed 161 medical professionals at a large FQHC clinic with a small pharmacy team to explore their understanding of medication error categories and the influence of barriers to medication error reporting on their decision to report.

RESULTS

Thirty-six (22.4%) respondents completed the survey. Nearly 40% of respondents would not report a near miss error and were influenced by workplace/environmental barriers significantly more than those who would report. Regardless of reporting experience or patient-care role, assessed barrier categories influence the decision to report similarly.

CONCLUSION

Near miss medication errors are inconsistently reported. Efforts to improve reporting should emphasize addressing workplace/environmental barriers.

Exploring strategies to increase college students' motivation to receive their annual influenza vaccine

OBJECTIVE

To evaluate college students' awareness of an educational initiative to increase campus influenza vaccination rates and strategies to improve it.

PARTICIPANTS

Students attending a large public comprehensive university.

METHODS

An investigator-developed, online survey evaluated awareness of the initiative, the students' perception of incentives, and other motivations to receive seasonal influenza vaccine.

RESULTS

The vaccination rate was 43%, despite low awareness of the initiative (28%). Awareness was significantly higher among vaccinated students (p = 0.0013). Having knowledge that appointments to receive vaccine were not needed increased the motivation of vaccinated students more than unvaccinated students (p = 0.0001). Personal influencers increased motivation of vaccinated students only when they were aware of the initiative (p = 0.04). Tangible incentives did not motivate students.

CONCLUSIONS

Campus vaccination rates increased despite low initiative awareness. Improvements to the initiative should include strategies to increase emphasis on vaccination program conveniences like accessibility and perhaps engage personal influencers more.

Future leaders in pharmacy (FLIP): Student perceptions of leadership development within pharmacy school

INTRODUCTION

This study evaluated the perceptions of student pharmacists in their final year regarding leadership development and feelings of preparedness to assume their first leadership role after graduation.

METHODS

This research was conducted using an anonymous, researcher developed, online instrument distributed to 21 institutions across the United States for students in their final semester. Data collected included demographics, the availability/benefit of leadership development activities, and perceptions of leadership skills a pharmacist needs. Student pharmacists' perceptions of their own leadership development and feelings of preparedness to be a leader upon graduation were also analyzed using descriptive statistics.

RESULTS

Seventy-two percent of respondents agreed or strongly agreed that they felt prepared to assume their first leadership role after graduation. Students agreed (91.4%) that their school/college of pharmacy (S/COP) offered enough leadership development opportunities; however, common opportunities were not always identified as the most beneficial. Those most beneficial to student pharmacists' growth were in extracurriculars and experiential learning. Least beneficial were advocacy related activities and self-reflection.

CONCLUSIONS

The majority of respondents felt they were prepared to be a leader in their first professional role. Student pharmacists did not perceive certain common activities related to advocacy and self-reflection as beneficial to their growth. S/COPs should explore strategies to improve such leadership development opportunities.

Pharmacists’ role in infectious pandemics: illustration with COVID-19

In 2020 pharmacists around the globe were faced with overwhelming challenges due to the global coronavirus pandemic. This chapter describes salient issues impacting pharmacists’ response to the COVID-19 infectious disease pandemic. The chapter emphasizes the response in the United States and within regions to inform the readers of principles related to the scope of practice and practice in the community, point-of-care testing, critical care and health systems, and long-term care. Pharmacy educators responded to graduate essential healthcare workers on time. The chapter ends following the lead of World Health Organization Director-General advising “first, prepare and be ready; second, detect, protect, and treat; third, reduce transmission; and fourth, innovate and learn.”

Development, implementation and perceived benefits of student pharmacist learning experiences in transitions of care

BACKGROUND

Experiential education designed around transitions of care (TOC) offers student pharmacists a variety of educational activities to build their skills and confidence related to direct patient care, communication, and practice management. The purpose of this paper is to describe the development, implementation, and student perceptions of introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) that emphasize TOC.

EDUCATIONAL ACTIVITY

Sixty students (22 IPPE and 38 APPE) completed the learning experience with the oversight of two faculty members in two, separate, large community hospitals providing pharmacy led TOC services. Each educational activity was mapped to the Pharmacists' Patient Care Process, which includes guided electronic medical record review, patient case discussions, and direct patient care (i.e. medication history collection, patient education). Other aspects of the learning experience include the use of layered learning, intention/reflection dialogues, and topic discussions. Evaluation of the learning experience occurred through review of student performance data and feedback.

CRITICAL ANALYSIS OF THE EDUCATIONAL ACTIVITY

Student performance data demonstrated an increase in the mean score between midpoint and final evaluation of all TOC specific competencies. Students expressed a positive learning experience as demonstrated by an approximately 3.8 overall rating of the learning experience on a 4-point scale for both IPPEs and APPEs. Analysis of open comments from students demonstrated the most beneficial aspects of the learning experience as interprofessional communication, patient communication, and a variety of patient care opportunities.

APPE Evaluations are Positively Associated with MMI, Pre-pharmacy GPA and Pharmacy GPA

Objective. To determine factors associated with advanced pharmacy practice experience (APPE) performance in the pre-pharmacy and Doctor of Pharmacy (PharmD) curriculum and establish whether performance on the multiple mini interview (MMI) independently predicts APPE evaluation scores. Methods. A multi-case MMI has been used in the admissions process since 2008. Students are scored anywhere from 1 to 7 (unsatisfactory to outstanding) on each interview. Traditional factors (GPA, PCAT, etc.) are also used in the admissions determination. Pearson product-moment correlation and ordinary least squares regression were used to explore the relationships between admissions data, pharmacy GPA, and APPE evaluation scores for the graduating classes of 2011-2014. These analyses identified which factors (pharmacy GPA, PCAT, MMI score, age, gender, rurality, resident status, degree, and underrepresented minority status) related to APPE performance. Results. Students (n=432) had a mean APPE score of 4.6; a mean MMI score of 5.5; mean pharmacy GPA, PCAT and age of 3.14, 73.2, 22.6 years, respectively. Pre-pharmacy GPA and pharmacy GPA positively correlated with mean APPE scores. MMI score demonstrated positive correlations with overall APPE score; including subcategories patient care, documentation, drug information/EBM, public health, and communication. MMI scores were positively related to overall APPE scores in the multivariable regression. Variables showing negative associations with APPE scores included a pre-pharmacy GPA of <3.0 (ref= GPA >3.5) and pharmacy school GPA of >3.0 - 3.5 and GPA 2.6 - 3.0 when compared to GPAs >3.5. Conclusion. GPA (pre-pharmacy and pharmacy) and MMI positively correlate with preceptor-rated performances in the APPE year.

Potential for Pharmacy-Public Health Collaborations Using Pharmacy-Based Point-of-Care Testing Services for Infectious Diseases

CONTEXT

Health care professionals must continually identify collaborative ways to combat antibiotic resistance while improving community health and health care delivery. Clinical Laboratory Improvement Amendments of 1988 (CLIA)-waived point-of-care (POC) testing (POCT) services for infectious disease conducted in community pharmacies provide a means for pharmacists to collaborate with prescribers and/or public health officials combating antibiotic resistance while improving community health and health care delivery.

OBJECTIVE

To provide a comprehensive literature review that explores the potential for pharmacists to collaborate with public health professionals and prescribers using pharmacy-based CLIA-waived POCT services for infectious diseases.

DESIGN

Comprehensive literature review.

SETTING

PubMed and Google Scholar were searched for manuscripts and meeting abstracts for the following key words: infectious disease, community pharmacy, rapid diagnostic tests, rapid assay, and POC tests.

INTERVENTION

All relevant manuscripts and meeting abstracts utilizing POCT in community pharmacies for infectious disease were reviewed.

OUTCOME MEASURE

Information regarding the most contemporary evidence regarding CLIA-waived POC infectious diseases tests for infectious diseases and their use in community pharmacies was synthesized to highlight and identify opportunities to develop future collaborations using community pharmacy-based models for such services.

RESULTS

Evidence demonstrates that pharmacists in collaboration with other health care professionals can leverage their knowledge and accessibility to provide CLIA-waived POCT services for infectious diseases. Testing for influenza may augment health departments' surveillance efforts, help promote rationale antiviral use, and avoid unnecessary antimicrobial therapy. Services for human immunodeficiency virus infection raise infection status awareness, increase access to health care, and facilitate linkage to appropriate care. Testing for group A streptococcal pharyngitis may curb inappropriate outpatient antibiotic prescribing. However, variance in pharmacy practice statues and the application of CLIA across states stifle collaboration.

CONCLUSION

CLIA-waived POCT services for infectious diseases are a means for pharmacists, public health professionals, and prescribers to collaboratively combat antibiotic resistance and improve community health.

Assessing the Medication Adherence App Marketplace From the Health Professional and Consumer Vantage Points

Background

Nonadherence produces considerable health consequences and economic burden to patients and payers. One approach to improve medication nonadherence that has gained interest in recent years is the use of smartphone adherence apps. The development of smartphone adherence apps has increased rapidly since 2012; however, literature evaluating the clinical app and effectiveness of smartphone adherence apps to improve medication adherence is generally lacking.

Objective

The aims of this study were to (1) provide an updated evaluation and comparison of medication adherence apps in the marketplace by assessing the features, functionality, and health literacy (HL) of the highest-ranking adherence apps and (2) indirectly measure the validity of our rating methodology by determining the relationship between our app evaluations and Web-based consumer ratings.

Methods

Two independent reviewers assessed the features and functionality using a 4-domain rating tool of all adherence apps identified based on developer claims. The same reviewers downloaded and tested the 100 highest-ranking apps including an additional domain for assessment of HL. Pearson product correlations were estimated between the consumer ratings and our domain and total scores.

Results

A total of 824 adherence apps were identified; of these, 645 unique apps were evaluated after applying exclusion criteria. The median initial score based on descriptions was 14 (max of 68; range 0-60). As a result, 100 of the highest-scoring unique apps underwent user testing. The median overall user-tested score was 31.5 (max of 73; range 0-60). The majority of the user tested the adherence apps that underwent user testing reported a consumer rating score in their respective online marketplace. The mean consumer rating was 3.93 (SD 0.84). The total user-tested score was positively correlated with consumer ratings (r=.1969, P=.04).

Conclusions

More adherence apps are available in the Web-based marketplace, and the quality of these apps varies considerably. Consumer ratings are positively but weakly correlated with user-testing scores suggesting that our rating tool has some validity but that consumers and clinicians may assess adherence app quality differently.

Assessment of medication adherence app features, functionality, and health literacy level and the creation of a searchable Web-based adherence app resource for health care professionals and patients

OBJECTIVES

To assess the features and level of health literacy (HL) of available medication adherence apps and to create a searchable website to assist health care providers (HCP) and patients identify quality adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence continues to be a significant problem and leads to poor health outcomes and avoidable health care expense. The average adherence rate for chronic medications, regardless of disease state, is approximately 50% leaving significant room for improvement.

PRACTICE INNOVATION

Smartphone adherence apps are a novel resource to address medication nonadherence. With widespread smartphone use and the growing number of adherence apps, both HCP and patients should be able to identify quality adherence apps to maximize potential benefits.

INTERVENTIONS

Assess the features, functionality and level of HL of available adherence apps and create a searchable website to help both HCP and patients identify quality adherence apps.

EVALUATION

Online marketplaces (iTunes, Google Play, Blackberry) were searched in June of 2014 to identify available adherence apps. Online descriptions were recorded and scored based on 28 author-identified features across 4 domains. The 100 highest-scoring apps were user-tested with a standardized regimen to evaluate their functionality and level of HL.

RESULTS

461 adherence apps were identified. 367 unique apps were evaluated after removing "Lite/Trial" versions. The median initial score based on descriptions was 15 (max of 68; range: 3 to 47). Only 77 apps of the top 100 highest-scoring apps completed user-testing and HL evaluations. The median overall user-testing score was 30 (max of 73; range: 16 to 55).

CONCLUSION

App design, functionality, and level of HL varies widely among adherence apps. While no app is perfect, several apps scored highly across all domains. The website www.medappfinder.com is a searchable tool that helps HCP and patients identify quality apps in a crowded marketplace.

Multiple Mini-Interview Performance Predicts Academic Difficulty in the PharmD Curriculum

Objective. To identify admissions variable prognostics for academic difficulty in the PharmD curriculum to use for admissions determinations and early identification of at-risk students. Methods. Retrospective multivariate analysis of 2008-2012 admission data were linked with academic records to identify students with academic difficulty (ie, those with Ds, Fs, delayed progression). The influence of prepharmacy grade point average (GPA), composite Pharmacy College Admission Test (PCAT) score, multiple-mini interview (MMI) score, age, credit hours, state residence, and prior degree on academic difficulty was estimated using multivariate logistic regression. Results. Students' (n=587) prepharmacy GPA, composite PCAT score, mean MMI score, and age were 3.6, 72.0, 5.5, 22.8 (SD=4.14 years), respectively. Students having a GPA <3.25, PCAT score <60th percentile, or MMI score <4.5, were approximately 12-, 7-, and 3-times more likely, respectively, to experience academic difficulty than those with a GPA ≥ 3.75, PCAT score >90, or MMI score of 5-6. Conclusion. Using GPA, PCAT, and MMI performance can predict academic difficulty and assist in the early identification of academically at-risk PharmD students.

Exploration of Methods Used by Pharmacy Professional Programs to Contract with Experiential Practice Sites

Objective. To explore methods used by pharmacy programs to attract and sustain relationships with preceptors and experiential practice sites. Methods. Interviews with eight focus groups of pharmacy experiential education experts (n=35) were conducted at two national pharmacy meetings. A semi-structured interview guide was used. Focus group interviews were recorded, transcribed verbatim, and categorically coded independently by two researchers. Codes were compared, consensus was reached through discussion, and two experiential education experts assisted with interpretation of the coded data. Results. Six themes emerged consistently across focus groups: a perceived increase in preceptor compensation, intended vs actual use of payments by sites, concern over renegotiation of established compensation, costs and benefits of experiential students, territorialism, and motives. Conclusion. Fostering a culture of collaboration may counteract potentially competitive strategies to gain sites. Participants shared a common interest in providing high-quality experiential learning where sites and preceptors participated for altruistic reasons, rather than compensation.

The Influence of Influenza and Pneumococcal Vaccines on Community-Acquired Pneumonia (CAP) Outcomes Among Elderly Patients

Elderly are at high risk for hospitalization for community-acquired pneumonia (CAP), especially due to Streptococcus pneumoniae, and seasonal influenza viruses. Data suggest PPV23's influence on various CAP-related outcomes among the elderly may depend upon how many years have elapsed since they received this vaccine. PPV23's protection against invasive pneumococcal disease and CAP hospitalizations are often limited to moderately ill elderly, who are less than 75 years old, or female. PCV13 demonstrates broad protection against a variety of CAPs, but ultimately, its influence on their outcomes among the elderly may be limited by herd immunity from PCV7 use. Influenza vaccine's indirect protective effect against all-cause and non-invasive pneumococcal CAP in the elderly is difficult to ascertain. The use of both PPV23 and influenza vaccine shortens length of stay in hospitalized elderly with CAP, but whether that benefit would be realized in the presence of herd immunity is unknown.

Prior pneumococcal and influenza vaccinations and in-hospital outcomes for community-acquired pneumonia in elderly veterans

BACKGROUND

Studies of adults hospitalized for community-acquired pneumonia (CAP) reported better outcomes associated with prior pneumococcal vaccination (PV), suggesting potential additional benefits of PV in hospitalized CAP patients. Influenza (flu) vaccination (FV) could independently/additively improve CAP outcomes in hospitalized patients.

OBJECTIVE

To examine the effect of prior PV and FV on in-hospital outcomes in elderly veterans hospitalized for CAP.

DESIGN

Retrospective cohort study.

SETTING AND PATIENTS

A total of 6,723 elderly veterans who were admitted to Veterans Affairs hospitals for CAP between October 1, 2002 and September 30, 2003.

INTERVENTION

PV in the 5 years and FV in the 1 year before admission.

MEASUREMENTS

The association of prior PV and/or FV with inpatient mortality and length of stay (LOS) (primary) and risk of any bacteremia and respiratory complications (secondary) were assessed using logistic regressions and generalized linear model, controlling for patient demographic and clinical characteristics.

RESULTS

Prior PV alone was not associated with shortened LOS, or reduced risk of inpatient mortality or respiratory complications. Lower risk of bacteremia was associated with prior PV (odds ratio: 0.66; 95% confidence interval [CI]: 0.48-0.90). After adjusting for patients' characteristics, risk of inpatient mortality was not statistically significantly different across the vaccination groups, but having had both PV and FV before CAP admission was associated with a 10% reduction in LOS (95% CI: 0.86-0.95) compared to having had neither vaccinations.

CONCLUSION

Significant survival benefit and improved in-hospital outcomes may not be expected among CAP-hospitalized elderly patients with prior PV alone. However, having both PV and FV before CAP admission may reduce LOS.

Point-of-care testing for infectious diseases: opportunities, barriers, and considerations in community pharmacy

OBJECTIVES To identify opportunities to perform point-of-care (POC) testing and/or screening for infectious diseases in community pharmacies, provide an overview of such tests and how they are used in current practice, discuss how the Clinical Laboratory Improvement Amendments of 1988 (CLIA) affect pharmacists performing POC testing, and identify and discuss barriers and provide recommendations for those wanting to establish POC testing for infectious diseases services in community pharmacies. DATA SOURCES PubMed and Google Scholar were searched from November 2012 through May 2013 and encompassed the years 2000 and beyond for the narrative review section of this article using the search terms rapid diagnostic tests, POC testing and infectious diseases, pharmacy services, CLIA waiver, and collaborative drug therapy management. All state boards of pharmacy in the United States were contacted and their regulatory and legislative websites accessed in 2012 and January 2013 to review relevant pharmacy practice laws. DATA SYNTHESIS POC testing for infectious diseases represents a significant opportunity to expand services in community pharmacies. Pharmacist education and training are addressing knowledge deficits in good laboratory practices and test performance and interpretation. Federal regulations do not define the qualifications for those who perform CLIA-waived tests, yet few pharmacists perform such services. Fewer than 20% of states address POC testing in their statutes and regulations governing pharmacy. CONCLUSION POC testing for infectious diseases could benefit patients and society and represents an opportunity to expand pharmacy services in community pharmacies. Existing barriers to the implementation of such services in community pharmacies, including deficits in pharmacist training and education along with state regulatory and legislative variance and vagueness in statutes governing pharmacy, are not insurmountable.

The need for PGY2-trained clinical pharmacy specialists

The American College of Clinical Pharmacy and other stakeholder organizations seek to advance clinical pharmacist practitioners, educators, and researchers. Unfortunately, there remains an inadequate supply of residency-trained clinical specialists to meet the needs of our health care system, and nonspecialists often are called on to fill open specialist positions. The impact of clinical pharmacy specialists on pharmacotherapy outcomes in both acute care and primary care settings demonstrates the value of these specialists. This commentary articulates the need for postgraduate year two (PGY2)-trained clinical specialists within the health care system by discussing various clinical and policy rationales, interprofessional support, economic justifications, and their impact on quality of care and drug safety. The integrated practice model that has grown out of the American Society of Health-System Pharmacists Pharmacy Practice Model Initiative (PPMI) could threaten the growth and development of future clinical specialists. Therefore, the ways in which PGY2-trained clinical pharmacist specialists are deployed in the PPMI require further consideration. PGY2 residencies provide education and training opportunities that cannot be achieved in traditional professional degree programs or postgraduate year one residencies. These specialists are needed to provide direct patient care to complex patient populations and to educate and train pharmacy students and postgraduate residents. Limitations to training and hiring PGY2-trained clinical pharmacy specialists include site capacity limitations and lack of funding. A gap analysis is needed to define the extent of the mismatch between the demand for specialists by health care systems and educational institutions versus the capacity to train clinical pharmacists at the specialty level.

Factors associated with health-related quality of life of student pharmacists

OBJECTIVE

To assess the health-related quality of life (HRQoL) of student pharmacists and explore factors related to HRQoL outcomes of student pharmacists in a doctor of pharmacy (PharmD) program at a public university.

METHODS

A survey instrument was administered to all student pharmacists in a PharmD program at a public university to evaluate differences and factors related to the HRQoL outcomes of first-year (P1), second-year (P2), third-year (P3), and fourth-year (P4) student pharmacists in the college. The survey instrument included attitudes and academic-related self-perception, a 12-item short form health survey, and personal information components.

RESULTS

There were 304 students (68.6%) who completed the survey instrument. The average health state classification measure and mental health component scale (MCS-12) scores were significantly higher for P4 students when compared with the P1through P3 students. There was no difference observed in the physical component scale (PCS-12) scores among each of the 4 class years. Significant negative impact on HRQoL outcomes was observed in students with higher levels of confusion about how they should study (scale lack of regulation) and concern about not being negatively perceived by others (self-defeating ego orientation), while school satisfaction increased HRQoL outcomes (SF-6D, p<0.001; MCS-12, p=0.013). A greater desire to be judged capable (self-enhancing ego-orientation) and career satisfaction were positively associated with the PCS-12 scores (p<0.05).

CONCLUSION

Factors associated with the HRQoL of student pharmacists were confusion regarding how to study, ego orientation, satisfaction with the chosen college of pharmacy, and career satisfaction. First-year through third-year student pharmacists had lower HRQoL as compared with P4 students and the US general population. Support programs may be helpful for students to maintain or improve their mental and overall health.

Smartphone medication adherence apps: potential benefits to patients and providers

OBJECTIVES

To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful.

PRACTICE INNOVATION

Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior.

MAIN OUTCOME MEASURES

Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. RESULTS 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality.

CONCLUSION

Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.

Academic help-seeking behavior among student pharmacists

Objectives. To identify factors associated with academic help-seeking behavior among student pharmacists at a public university.Methods. Semi-structured focus group interviews were conducted to explore in depth perceptions of facilitators of and barriers to the help-seeking behavior and academic achievement of student pharmacists who had received a D or F grade in any year. A 4-part survey instrument was developed and administered to all student pharmacists and included sections for (1) attitudes and academic help-seeking behavior, (2) health status, (3) demographics, and (4) open comments. A structural equation modeling approach was used to assess relationships among domains of interest.Results. Three student focus groups noted that helpfulness of faculty members and school administrators were 2 prominent facilitators of help-seeking behavior and academic achievement. Diminished quality of life caused by stress and depression was the primary barrier to help-seeking and achievement. Three hundred four (68.6%) student pharmacists completed the survey instrument. Academic help-seeking behavior was influenced mostly by perceived academic competence and perceived faculty helpfulness. In contrast, ambivalence and perception of help-seeking as threatening were 2 factors that were negatively associated with academic help-seeking behavior.Conclusions. Academic help-seeking behavior was positively related to greater perceived academic competence and positive relationships among student pharmacists and faculty members.

Benchmarking in academic pharmacy departments

Benchmarking in academic pharmacy, and recommendations for the potential uses of benchmarking in academic pharmacy departments are discussed in this paper. Benchmarking is the process by which practices, procedures, and performance metrics are compared to an established standard or best practice. Many businesses and industries use benchmarking to compare processes and outcomes, and ultimately plan for improvement. Institutions of higher learning have embraced benchmarking practices to facilitate measuring the quality of their educational and research programs. Benchmarking is used internally as well to justify the allocation of institutional resources or to mediate among competing demands for additional program staff or space. Surveying all chairs of academic pharmacy departments to explore benchmarking issues such as department size and composition, as well as faculty teaching, scholarly, and service productivity, could provide valuable information. To date, attempts to gather this data have had limited success. We believe this information is potentially important, urge that efforts to gather it should be continued, and offer suggestions to achieve full participation.

Population mobility, globalization, and antimicrobial drug resistance

Human travel contributes to antimicrobial drug resistance around the world.

Population mobility, globalization, and antimicrobial drug resistance

Population mobility is a main factor in globalization of public health threats and risks, specifically distribution of antimicrobial drug-resistant organisms. Drug resistance is a major risk in healthcare settings and is emerging as a problem in community-acquired infections. Traditional health policy approaches have focused on diseases of global public health significance such as tuberculosis, yellow fever, and cholera; however, new diseases and resistant organisms challenge existing approaches. Clinical implications and health policy challenges associated with movement of persons across barriers permeable to products, pathogens, and toxins (e.g., geopolitical borders, patient care environments) are complex. Outcomes are complicated by high numbers of persons who move across disparate and diverse settings of disease threat and risk. Existing policies and processes lack design and capacity to prevent or mitigate adverse health outcomes. We propose an approach to global public health risk management that integrates population factors with effective and timely application of policies and processes.

Drug-drug interactions of antifungal agents and implications for patient care

Drug interactions in the gastrointestinal tract, liver and kidneys result from alterations in pH, ionic complexation, and interference with membrane transport proteins and enzymatic processes involved in intestinal absorption, enteric and hepatic metabolism, renal filtration and excretion. Azole antifungals can be involved in drug interactions at all the sites, by one or more of the above mechanisms. Consequently, azoles interact with a vast array of compounds. Drug-drug interactions associated with amphotericin B formulations are predictable and result from the renal toxicity and electrolyte disturbances associated with these compounds. The echinocandins are unknown cytochrome P450 substrates and to date are relatively devoid of significant drug-drug interactions. This article reviews drug interactions involving antifungal agents that affect other agents and implications for patient care are highlighted.

Pharmacokinetics and safety of oral posaconazole in neutropenic stem cell transplant recipients

The pharmacokinetics of posaconazole oral suspension in neutropenic patients undergoing high-dose chemotherapy and stem cell transplantation were evaluated, and the association of plasma posaconazole exposure with the presence and severity of oral mucositis was explored in this nonrandomized, open-label, parallel-group, multiple-dose pharmacokinetic study. Thirty patients were enrolled and received one of three regimens (group I, 200 mg once daily; group II, 400 mg once daily; group III, 200 mg four times daily) for the duration of neutropenia. The mean total exposure for day 1, as shown by the area under the concentration-time curve from 0 to 24 h (AUC(0-24)), was 1.96 mg . h/liter in group I and was 51% higher in group II and in group III. Increases in AUC(0-24) and maximum plasma concentration (C(max)) in groups II and III were dose related. The AUC(0-24) and C(max) values on day 1 were similar between groups II and III. There was interpatient variability of up to 68% in the pharmacokinetic values for our study population. Steady state was attained by days 5 to 6. Average steady-state plasma posaconazole trough values were 192, 219, and 414 ng/ml in groups I, II, and III, respectively. The AUC(0-24) and apparent oral clearance increased by increasing dose and dosing frequency. Mucositis appeared to reduce exposure but did not significantly affect mean total posaconazole exposure (AUC and C(max)) at steady state (P = 0.1483). Moreover, this reduction could be overcome by increasing the total dose and dosing frequency. Posaconazole was safe and well tolerated.

Renal interaction between itraconazole and cimetidine

Renal drug interactions can result from competitive inhibition between drugs that undergo extensive renal tubular secretion by transporters such as P-glycoprotein (P-gp). The purpose of this study was to evaluate the effect of itraconazole, a known P-gp inhibitor, on the renal tubular secretion of cimetidine in healthy volunteers who received intravenous cimetidine alone and following 3 days of oral itraconazole (400 mg/day) administration. Glomerular filtration rate (GFR) was measured continuously during each study visit using iothalamate clearance. Iothalamate, cimetidine, and itraconazole concentrations in plasma and urine were determined using high-performance liquid chromatography/ultraviolet (HPLC/UV) methods. Renal tubular secretion (CL(sec)) of cimetidine was calculated as the difference between renal clearance (CL(r)) and GFR (CL(ioth)) on days 1 and 5. Cimetidine pharmacokinetic estimates were obtained for total clearance (CL(T)), volume of distribution (Vd), elimination rate constant (K(el)), area under the plasma concentration-time curve (AUC(0-240 min)), and average plasma concentration (Cp(ave)) before and after itraconazole administration. Plasma itraconazole concentrations following oral dosing ranged from 0.41 to 0.92 microg/mL. The cimetidine AUC(0-240 min) increased by 25% (p < 0.01) following itraconazole administration. The GFR and Vd remained unchanged, but significant reductions in CL(T) (655 vs. 486 mL/min, p < 0.001) and CL(sec) (410 vs. 311 mL/min, p = 0.001) were observed. The increased systemic exposure of cimetidine during coadministration with itraconazole was likely due to inhibition of P-gp-mediated renal tubular secretion. Further evaluation of renal P-gp-modulating drugs such as itraconazole that may alter the renal excretion of coadministered drugs is warranted.

Tick-Borne Bacterial, Rickettsial, Spirochetal, and Protozoal Infectious Diseases in the United States: A Comprehensive Review

Approximately 900 tick species exist worldwide, and they parasitize a variety of mammals, including humans; thus, ticks play a significant role in the transmission of infectious diseases. In the United States, tick-borne diseases are seasonally and geographically distributed; they typically occur during spring and summer but can occur throughout the year. Tick-borne diseases are endemic to a variety of geographic regions of the United States, depending on the species of tick commonly found in a specific locale. Specific tick-borne diseases are difficult to diagnose. Most patients have vague constitutional symptoms and nonspecific laboratory findings. Initially, serologic methods are of little benefit because they lack sensitivity early in the disease course. Therefore, a thorough history and physical examination are necessary for establishing a diagnosis. Antimicrobial regimens for tick-borne infections are poorly studied but well established. Tetracyclines and rifampin form the cornerstones of therapy for most tick-borne infections, but these agents may not be suitable for all patient populations. Therefore, no single agent can be chosen empirically to treat all tick-borne diseases. Because pharmacists are the most accessible health care providers, they are often asked how to treat tick-borne diseases. Thus, practitioners should be familiar with the ticks that inhabit their locale.

Are Antimicrobial-Impregnated Catheters Effective? Replace the Water and Grab Your Washcloth, Because We Have a Baby to Wash

Significant controversy surrounds the usefulness of central venous catheters (CVCs) impregnated with antimicrobial agents (A-CVCs) for the prevention of catheter-related bloodstream infections (CRBSIs). In a recent issue of Clinical Infectious Diseases, we reviewed 11 published trials of A-CVCs versus uncoated CVCs, and we concluded that there is a lack of solid evidence to support a benefit of A-CVCs in reducing the rate of CRBSIs. A response to our review was recently published in Clinical Infectious Diseases. In this response, our colleagues assert that there is a large body of evidence that demonstrates a powerful decrease in the risk of infection, and they conclude that we should not waste precious resources while we perform additional research to confirm what we have already found to be true. Although these authors agree with us on the significant shortcomings of the studies used to support the use of A-CVCs, they dismiss the need for additional trials to demonstrate that the use of A-CVCs does reduce infections. This dismissal, however, cannot be justified, because of the existence of an ongoing, federally supported, multicenter, prospective, placebo-controlled trial, led by our colleagues, that compares the rate of CRBSIs among patients randomized to receive either an A-CVC or a "placebo" uncoated CVC. That our colleagues are leading a trial that assesses the efficacy of A-CVCs versus placebo uncoated CVCs supports our viewpoint that the truth regarding the protective role of A-CVCs has yet to be determined. Because of the significant cost, potential toxicity, and risk of increased antimicrobial resistance associated with the use of A-CVCs, and until the results of the important trial conducted by our colleagues convincingly demonstrate that A-CVCs reduce the rate of clinically significant events (not just catheter colonization), we recommend that the use of A-CVCs be limited to investigational settings.

Influence of grapefruit juice on the systemic availability of itraconazole oral solution in healthy adult volunteers

STUDY OBJECTIVE

To evaluate the effect of repeated ingestion of grapefruit juice on the systemic availability of itraconazole (ITZ) and hydroxyitraconazole (OHITZ) serum concentrations in subjects administered hydroxypropyl-beta-cyclodextrin-ITZ (HP-beta-CD ITZ) oral solution.

DESIGN

Randomized, two-period, crossover study.

SETTING

College of pharmacy research unit.

SUBJECTS

Twenty healthy, adult volunteers (10 men, 10 women).

INTERVENTION

Subjects received 240 ml of regular-strength grapefruit juice from frozen concentrate or bottled purified water 3 times/day for 2 days. On the third day they received a single dose of HP-beta-CD ITZ oral solution 200 mg (20 ml) with 240 ml of the beverage. Two hours after dosing they received another 240 ml of the beverage.

MEASUREMENTS AND MAIN RESULTS

Repeated blood samples were drawn for 72 hours after dosing. After a 14-day washout period, subjects were crossed over to the beverage they had not received previously and the above procedure was repeated. There was no difference in peak ITZ concentration (Cmax) or time to Cmax (Tmax). Coadministration of grapefruit juice reduced OHITZ Cmax nearly 10%, but this difference was not statistically significant. It produced a statistically significant increase in ITZ area under the concentration-time curves from 0-48 hours (AUC(0-48)) (17%) and from time zero extrapolated to infinity (AUC(0-infinity)) (19.5%). Apparent oral clearance of ITZ was significantly reduced (14%). Significant changes in OHITZ exposure were not observed; however, grapefruit juice coadministration produced statistically significant decreased mean OHITZ:ITZ AUC(0-48) and AUC(0-infinity) ratios. Grapefruit juice also decreased the mean OHITZ:ITZ Cmax ratio, but the difference was not statistically significant.

CONCLUSION

Repeated grapefruit juice consumption moderately affects ITZ systemic availability in subjects administered HP-beta-CD ITZ oral solution. Unlike previous findings with ITZ capsules, changes in the disposition of ITZ and OHITZ after repeated grapefruit juice consumption are consistent with grapefruit juice inhibition of intestinal cytochrome P450 3A4.

Do antimicrobial-impregnated central venous catheters prevent catheter-related bloodstream infection?

Controversy surrounds the role of central venous catheters (CVCs) impregnated with antimicrobial agents in the prevention of catheter-related bloodstream infection (CRBSI). We reviewed the current literature to evaluate the efficacy of antimicrobial-impregnated CVCs for preventing CRBSI. Eleven randomized studies published in article form were identified that included a control group that received nonimpregnated CVCs. We evaluated study methodologies, inclusion of key patient characteristics, use of clinically relevant end points, and molecular-relatedness studies. Review of these 11 trials revealed several methodological flaws, including inconsistent definitions of CRBSI, failure to account for confounding variables, suboptimal statistical and epidemiological methods, and rare use of clinically relevant end points. This review also failed to demonstrate any significant clinical benefit associated with the use of antimicrobial-impregnated CVCs for the purpose of reducing CRBSI or improving patient outcomes. More rigorous studies are required to support or refute the hypothesis that antimicrobial-impregnated CVCs reduce the rate of or prevent CRBSI.

Effect of interleukin 6 on the hepatic metabolism of itraconazole and its metabolite hydroxyitraconazole using primary human hepatocytes

A potential cytokine-drug interaction between interleukin 6 (IL-6) and itraconazole (ITZ) was studied using human hepatocytes in primary culture. Cultures from 5 adult males (mean age 42 +/- 15 years) who had not received any medicines known to interact with CYP3A4 were studied. Cultures were exposed to ITZ 500 ng/ml, and the effects of 120 microg/ml cimetidine, 50 ng/ml human IL-6, or IL-6 plus IL-6 receptor antagonist were analyzed for 2, 4, 8, and 12 h. Intracellular ITZ and hydroxyitraconazole concentrations were measured using HPLC and normalized to total cellular protein. Mean intracellular concentrations between groups were compared using one-way Anova (f test; p < 0.10) and corresponding Bonferroni versus control test for multiple comparisons (p < 0.02). Mean intracellular ITZ concentrations between the groups were similar at all time points. Human hepatocytes in primary culture can metabolize ITZ. However, IL-6 did not inhibit hydroxyitraconazole formation, but it may inhibit its subsequent metabolism.

Evaluation of P-glycoprotein-mediated renal drug interactions in an MDR1-MDCK model

STUDY OBJECTIVE

To evaluate P-glycoprotein (P-gp)-mediated renal drug interactions in an in vitro model of tubular secretion.

DESIGN

In vitro experiment.

SETTING

University-affiliated pharmacokinetics laboratory. CELL LINES: Madin-Darby canine kidney (MDCK), multidrug-resistant-1 (MDR1)-MDCK, and human colon carcinoma (Caco-2) cells.

INTERVENTION

Transepithelial transport (basolateral-to-apical and apical-to-basolateral) of cimetidine was assessed in the absence and presence of various concentrations of the P-gp inhibitors itraconazole and PSC-833 in a renal P-gp cell culture model (MDR1-MDCK).

MEASUREMENTS AND MAIN RESULTS

Apparent permeability of cimetidine was characterized, and level of P-gp expression was determined by Western blot analysis, in MDCK (wild type), MDR1-MDCK, and Caco-2 cells (for relative comparison). In the presence of PSC-833, cimetidine's apparent permeability value for basolateral-to-apical transport decreased from 2.96 to 1.15 x 10(-6) cm/second, coupled with a decrease in efflux ratio from 2.36 to 1.80. The effect of itraconazole was concentration dependent, with cimetidine's apparent permeability value for basolateral-to-apical transport decreasing from 3.96 to 1.92 x 10(-6) cm/second (p < 0.05), resulting in a 50% decrease in efflux ratio. Expression of P-gp was negligible in MDCK (wild-type) cells, but high-level expression was confirmed in both MDR1-MDCK and Caco-2 cells.

CONCLUSION

P-glycoprotein plays a significant role in the renal tubular secretion of organic cations such as cimetidine, and the high level of P-gp expression in MDR1-MDCK cells makes this a well-suited model for evaluating mechanisms of renal drug interactions.

Characterizing and predicting amphotericin B-associated nephrotoxicity in bone marrow or peripheral blood stem cell transplant recipients

STUDY OBJECTIVE

To characterize amphotericin B-associated nephrotoxicity and to determine the variables associated with it that can be used to identify, a priori, at-risk patients.

DESIGN

Retrospective analysis.

SETTING

University hospital.

PATIENTS

A homogeneous population of 69 recipients of a bone marrow (BMT) or peripheral blood stem cell transplant (PBSCT) with multiple myeloma and who received at least two doses of amphotericin B deoxycholate from January 1, 1992-January 1, 1995.

INTERVENTION

Data on demographics, prior and concomitant nephrotoxic drug therapy, daily laboratory values, and amphotericin B dosing were collected serially from medical and pharmacy records.

MEASUREMENTS AND MAIN RESULTS

Forward stepwise logistic regression analysis was performed on the data from the first day of therapy to characterize and determine variables related to amphotericin B-associated nephrotoxicity. Nephrotoxicity occurred in 30 patients (43%) and developed rapidly Patients who developed nephrotoxicity were similar to those who did not in many aspects associated with their treatment. However, baseline estimated creatinine clearance, cyclosporine therapy, nephrotoxic drug therapy within 30 days of starting amphotericin B, and the number of concomitant nephrotoxic drugs were significant predictors of amphotericin B-associated nephrotoxicity.

CONCLUSION

Recipients of a BMT or PBSCT who have multiple myeloma and are receiving cyclosporine or multiple nephrotoxic drugs at the start of amphotericin B therapy should be considered at high risk for developing amphotericin B-associated nephrotoxicity. Also, because amphotericin B-associated nephrotoxicity develops rapidly, clinicians should be aware of the rapid changes in serum creatinine and electrolyte levels that can occur.

Rapid and sensitive high-performance liquid chromatographic method for the determination of ritonavir in human plasma

Ritonavir is an HIV-1 protease inhibitor that is often used to improve the systemic availability of concurrently administered protease inhibitors by impairing their metabolism through cytochrome P450 (CYP) 3A4. Pharmacodynamic relationships between plasma ritonavir concentrations and efficacy and toxicity have also been described. To date, published high-performance liquid chromatographic (HPLC) methods for the determination of ritonavir in human plasma are often complex, requiring the use of a buffered mobile phase that contains amine-modifiers (i.e. diethylamine, triethylamine). In the method herein, ritonavir was precipitated with acetonitrile plus barium hydroxide and zinc sulphate. Chromatographic separation was accomplished using a C-18 base-deactivated (250 x 4.6 mm I.D., 5 atm particle size) analytic column with a mobile phase composed of acetonitrile:water (52:48, v/v). Quantification was performed at 239 nm. Calibration curves were linear from 0.5-25 microg/ml (R2 > 0.999); percent errors, as a measure of accuracy, were < 12.7%. Intra- and inter-assay relative standard deviations (RSD) were below 12.8%. This method provides a rapid and simple means for the accurate and precise analysis of ritonavir in human plasma. Furthermore, the assay requires neither the use of a buffered mobile phase adjusted to a specific pH, nor the addition of amine modifiers. This method has been successfully used to determine plasma ritonavir concentrations in drug interaction studies.

Incidence of imipenem hypersensitivity reactions in febrile neutropenic bone marrow transplant patients with a history of penicillin allergy

The purpose of this retrospective study was to assess cross-hypersensitivity between imipenem/cilastatin and penicillin in patients with reported penicillin allergies. Medical records of febrile neutropenic, penicillin-allergic bone marrow transplant recipients who received imipenem/cilastatin treatment were retrospectively reviewed. The findings of this study indicate the incidence of cross-reactivity between imipenem/cilastatin and penicillin among patients with a history of penicillin allergy may be lower than previously reported.

Investigation of an outbreak of gram-negative bacteremia among hematology-oncology outpatients

OBJECTIVE

To identify risk factors associated with an outbreak of gram-negative bacteremia (GNB).

SETTING

A university hospital.

PATIENTS

Hematology-oncology outpatients.

DESIGN

Retrospective case-control study.

RESULTS

Thirty-eight patients developed GNB; 13 patients experienced more than one episode, and eight blood cultures grew more than one gram-negative organism. The most frequently isolated organisms were Stenotrophomonas maltophilia, Klebsiella pneumoniae, Acinetobacter baumannii, and Acinetobacter johnsonii. When the GNB patients (cases) were compared with randomly selected hematology-oncology patients (controls), central venous catheter (CVC) self-care (71% vs 39%; P=.02), and duration of recent hospital stay (median, 15 vs 4 days; P=.01) were identified as risk factors. In a logistic regression model, duration of recent hospital stay was the only risk factor significantly associated with GNB (odds ratio, 1.05; 95% confidence interval, 1.01-1.08; P<.02).

CONCLUSIONS

Hematology-oncology patients providing their own CVC care who have recently been hospitalized for more than 2 weeks may be at increased risk of GNB. CVCs should be protected from possible environmental contamination in hematologyoncology patients. Patients providing their own CVC care should undergo continued rigorous education regarding proper CVC care.

Current management of funguria

Recent findings on the epidemiology and treatment of funguria are reviewed. Funguria, or candiduria, is a common nosocomial condition and may develop as early as the first two weeks of hospitalization. Risk factors include antibacterial therapy, an indwelling urinary catheter, urologic procedures, female sex, diabetes, and immunosuppressive therapy. Candida albicans is the species most commonly isolated from the urine of infected patients. Spontaneous resolution of funguria is relatively infrequent. Furthermore, although nonpharmacologic measures, such as removing unnecessary antibacterials and changing or removing indwelling urinary catheters, may be beneficial, they are often inadequate without additional, pharmacologic therapy. The most serious complication of untreated asymptomatic funguria is candidemia. Bladder irrigations with amphotericin B have been the standard of therapy for many years; recently, the optimal concentration and method of irrigation (continuous versus intermittent) have been debated. Studies indicate that intravesical amphotericin B and oral fluconazole therapy are each effective in clearing funguria. Intravesical amphotericin B appears to act more rapidly; however, the effect of systemic fluconazole therapy often persists longer than that of amphotericin B irrigation, and oral therapy is more convenient and less expensive. Oral fluconazole appears to have a more delayed but more lasting effect on funguria than amphotericin B bladder irrigation. Studies are needed to determine whether intravesical amphotericin B still has a role in the treatment of funguria and to refine strategies involving fluconazole.

Grapefruit juice decreases the systemic availability of itraconazole capsules in healthy volunteers

The systemic availability of itraconazole capsules may be reduced secondary to elevated gastric pH and possibly by presystemic intestinal metabolism via CYP3A4. Grapefruit juice is acidic and an inhibitor of intestinal CYP3A4. To determine the effect of grapefruit juice on the systemic availability of itraconazole capsules, serum itraconazole and hydroxy-itraconazole concentrations were determined in eleven healthy volunteers studied in a randomized, two-way crossover design. Concurrent grapefruit juice resulted in a 43% decrease in the mean itraconazole AUC0-48 (2507 ng x hr/mL versus 1434 ng x hr/mL, p = 0.046) and a 47% decrease in the mean hydroxy-itraconazole AUC0-72 (7264 ng x hr/mL versus 3880 ng x hr/mL, p = 0.025). Grapefruit juice also significantly increased the mean itraconazole Tmax (5.5 versus 4 hours). We conclude that concomitant grapefruit juice does not enhance the systemic availability of itraconazole capsules, but rather appears to impair itraconazole absorption. Therefore, concomitant grapefruit juice will not likely be useful in improving the oral availability of itraconazole capsules.

Therapeutic drug monitoring of vancomycin in a morbidly obese patient

The authors describe the therapeutic drug monitoring of vancomycin in a man who is morbidly obese. Because serum vancomycin concentration (SVC) monitoring continues to be deemphasized, nomogram use will likely increase. However, vancomycin dosing nomograms have not been studied in patients who are morbidly obese. Furthermore, in nomograms that incorporate body weight, it is unclear whether ideal or total body weight (IBW and TBW, respectively) should be used to dose the morbidly obese. Therefore, the authors retrospectively evaluated four nomograms (Moellering, Matzke, Lake-Peterson, and Rodvold) and an individualized method in the simulated vancomycin dosing of their patient. Total body weight was more accurate than IBW in selecting a vancomycin dose when using the individualized method and in all nomograms except the Matzke nomogram. The Rodvold nomogram and the individualized method yielded the most appropriate doses. All nomograms suggested dosing intervals that were unacceptably short; the individualized method suggested an appropriately longer interval. Thus, if nomograms or the individualized method are used to empirically dose vancomycin, TBW--not IBW--should be used. Because these nomograms yielded inappropriately short dosing intervals in the patient, it is likely that patients who are morbidly obese represent a unique population in which at least one set of SVCs are necessary to select an appropriate dosing regimen.

Antifungal prophylaxis to prevent invasive mycoses among bone marrow transplantation recipients

We reviewed the effect of systemic, intranasal, and lipid formulations of amphotericin B, fluconazole, itraconazole for antifungal prophylaxis. Specifically we reviewed the effect of antifungal prophylaxis on the development of fungal colonization, frequency of superficial and invasive mycosis, and overall mortality and that due to invasive mycoses in bone marrow transplantation recipients. A MEDLINE search was conducted to identify literature describing the risk factors, epidemiology, and chemoprophylaxis of invasive mycosis in these patients. Preliminary data published as abstracts at national infectious diseases and hematology conferences within the last 5 years were included. Antifungal prophylaxis reduces fungal colonization and superficial infection. The ability of antifungal prophylaxis to prevent systemic infection or reduce the need for empiric amphotericin B depends on specific variables. Ultimately, antifungal prophylaxis has no affect on overall mortality, and very little impact on mortality attributed to fungi.

The association between cryptococcal variety and immunocompetent and immunocompromised hosts

The varieties of Cryptococcus neoformans serotypes are neoformans and gattii. Data suggest an association between cryptococcal variety and host immune status. In addition, the two varieties differ in their epidemiology and pathogenicity. Furthermore, symptoms, outcome, and response of cryptococcosis to antifungal therapy may vary. The two varieties also differ in immune-modulating effects. Sparse clinical data suggest var. gattii is more virulent and may be more recalcitrant to antifungal therapy. Also, its infections produce more sequelae. A better understanding of how cryptococcal variety influences the clinical course and response to the treatment of cryptococcosis is needed. Clinicians should be aware of the association, especially in patients with refractory disease. It may be useful to type the isolate to the variety level and administer prolonged antifungal therapy.

Rapid and sensitive high performance liquid chromatographic method for the determination of itraconazole and its hydroxy-metabolite in human serum

Published high performance liquid chromatographic (HPLC) methods for the determination of itraconazole (ITZ) in biological matrices are labor intensive, extraction-based procedures which operate at a pH approaching the limit of column tolerance, and unless modified, cannot measure its hydroxy-metabolite (OH-ITZ). A protein precipitation-based method requiring no solvent extraction and utilizing a base-deactivated C18 analytical column to minimize peak tailing is described herein. Calibration curves for OH-ITZ and ITZ were linear from 25-1500 ng ml-1 (r2 > or = 0.999). Intra-assay relative standard deviations (R.S.D.) were below 12%. Inter-assay R.S.D. were below 14%. This method provides a rapid means for the accurate and precise determination of both OH-ITZ and ITZ concentrations in human serum.

Relative bioavailability of itraconazole from an extemporaneously prepared suspension and from the marketed capsules

The bioavailability of itraconazole from an extemporaneously prepared suspension was compared with its bioavailability from the commercially available capsules. Ten healthy volunteers were fed breakfast and were then randomly assigned to receive either 400 mg of itraconazole 40-mg/mL oral suspension or four 100-mg itraconazole capsules with 240 mL of water. They were not allowed to rest in a supine position for six hours, eat for four hours, or take any beverages for two hours post-dose. Blood samples were taken immediately after the subjects had eaten and at intervals up to 72 hours post-dose. Serum was separated and stored at -70 degrees C. Serum itraconazole and hydroxyitraconazole concentrations were measured by high-performance liquid chromatography. After 14 days, each subject was given the dosage form that he or she did not previously receive, and testing was repeated. Maximum concentration (Cmax) and time to reach maximum concentration (tmax) were determined, and the area under the serum concentration-versus-time curve from 0 to 72 hours (AUC0-72) was estimated. The suspension:capsule ratios of least-squares means for Cmax, tmax, and AUC0-72 for itraconazole were 0.15 (90% confidence interval [CI], 0.11-0.21), 0.95 (90% CI, 0.75-1.20), and 0.12 (9% CI, 0.06-0.23), respectively. The results for hydroxyitraconazole were similar: 0.19 (0.13-0.28), 0.95 (0.81-1.12), and 0.13 (0.07-0.23), respectively. The bioavailability of itraconazole from the extemporaneously prepared suspension is much lower than that from capsules.