Pharmacy News

Entries for June 2017

Gonococcal Infections: Reduced Susceptibility to Antimicrobial Therapy

By Amy Montague, Pharm.D., PGY1 resident, Sparrow Hospital, Lansing

 

Sexually transmitted infections from Neisseria (N.) gonorrhoeae are the second most commonly reported infectious disease with an estimated 820,000 new infections reported each year.1 If inadequately treated, N. gonorrhoeae can lead to serious and permanent complications in women, such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy and chronic pelvic pain.2 Appropriate and adequate treatment with antibiotics is essential in preventing complications as well as transmission to sexual partners.

                                                                                              

Over the past few decades, treatment of N. gonorrhoeae has been complicated by resistance to antibiotic therapy. In the late 1990s, resistance to fluoroquinolones was detected, and in 2007, the Centers for Disease Control and Prevention (CDC) stopped recommending fluoroquinolones as empiric treatment of N. gonorrhoeae infections, leaving cephalosporins as the only remaining recommended treatment option. As a measure to prevent resistance and reserve cephalosporins, the CDC later recommended dual therapy for treatment of N. gonorrhoeae with ceftriaxone injection and oral azithromycin.3 However, recent data published by the Morbidity and Mortality Weekly Report (MMWR), suggests resistance may be on the horizon for the current recommended treatment therapy with azithromycin.4

 

Resistance of N. gonorrhoeae to antibiotic therapy is monitored by the Gonococcal Isolate Surveillance Project (GISP), which has recently reported increased rates of resistance to azithromycin as well as recommended alternative treatment regimens. The most recent published data from 2014 isolates indicated 25.3 percent of isolates were resistant to tetracyclines, 19.2 percent to ciprofloxacin and 16.2 percent to penicillin. Fortunately, rates of cephalosporin susceptibility from 2013 to 2014 were relatively unchanged and likely a result of the CDC’s recommendation of dual therapy for treatment of N. gonorrhoeae infections. Although susceptibility rates to cephalosporins were fairly stable, azithromycin did not fare as well. Reduced susceptibility to azithromycin was detected in 2.5 percent of isolates, compared to 0.6 percent just one year prior. This increase in reduced susceptibility to azithromycin was seen among all people across the entire United States.4

 

The current CDC recommended therapy for gonococcal infections is a single dose of ceftriaxone 250 mg intramuscularly plus a single dose of azithromycin 1000 mg orally. Orally administered cefixime 400 mg is available as an alternative to ceftriaxone but should be reserved for use only when ceftriaxone is unavailable as it has lower rates of efficacy. Healthcare providers should educate patients to refrain from unprotected sexual intercourse for seven days following completion of therapy to prevent reinfection. All patients treated for gonorrhea should be retested three months after treatment to ensure reinfection did not occur, regardless if they believe their partner has been appropriately treated.1

 

Screening for N. gonorrhoeae should be done on an annual basis for sexually active women younger than 25 years of age or for older women who are at high risk of infection. Persons are considered high risk for infection if they have another sexually transmitted infection (STI), exchange sex for money or drugs, have a new sex partner, have more than one sex partner or their sex partner has more than one sex partner. Additional at risk groups include men who have sex with men (MSM) and HIV positive patients; they should be tested at minimum annually and as often as every three to six months in some populations.5

 

Treatment of sexual partners is essential in reducing the rates of N. gonorrhoeae reinfection but is often a difficult task due to the reluctance of partners to seek treatment for various reasons. One way healthcare providers may address this issue is through expedited partner therapy (EPT), a treatment approach that enables the sex partner of a patient who has tested positive for gonorrhea to be provided treatment without a medical evaluation. The CDC has recommended the use of EPT for heterosexual partners of patients diagnosed with gonorrhea in instances where the partner is unlikely to otherwise seek treatment. The recommended EPT regimen consists of cefixime 400 mg orally in a single dose plus azithromycin 1 g orally in a single dose. It is important for caregivers to note that EPT is not recommended for MSM persons due to the high risk of other sexually transmitted infections and the need for further evaluation in this patient population.6

 

Failure of infections to respond to treatment recommendations from the CDC should be reported to the Surveillance & Data Management Branch, Division of STD Prevention, at the CDC or to our local STD Epidemiologist, Jim Kent, at (517) 284-4926 or kentj3@michigan.gov.

 

References:

1. Centers for Disease Control and Prevention (CDC). Gonococcal Infections (2015). http://www.cdc.gov/std/tg2015/gonorrhea.htm. Accessed 2016, Jul 31.

2. Walker CK, Sweet RL. Gonorrhea infection in women: prevalence, effects, screening, and management. Int J Womens Health. 2011;3:197-206.

3. Centers for Disease Control and Prevention (CDC). Antibiotic-resistant gonorrhea basic information. http://www.cdc.gov/std/gonorrhea/arg/basic.htm. Accessed 2016, Jul 31.

4. Centers for Disease Control and Prevention (CDC). Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance –The Gonococcal Isolate Surveillance Project, 27 sites, United States, 2014. MMWR Morb Mortal Wkly Surveillance Summaries. 2016;65(7):1–19.

5. Centers for Disease Control and Prevention (CDC). Screening recommendations referenced in treatment guidelines and original recommendation sources (2015). http://www.cdc.gov/std/tg2015/screening-recommendations.htm. Accessed 2016, Jul 31.

6. Centers for Disease Control and Prevention (CDC). Guidance on the use of expedited partner therapy in the treatment of gonorrhea (2013). http://

www.cdc.gov/std/ept/gc-guidance.htm. Accessed 2016, Jul 31.

Posted in: Professional Practice
Capital Area Pharmacist Association Regional Update
By Cathleen Edick, Pharm.D., CDE, pharmacy program coordinator, McLaren Greater Lansing, central regional representative

The Capital Area Pharmacists Association (CAPA) was busy in March with a very informative continuing education (CE) program and a Poison Prevention event at the Impression 5 Science Center in Lansing. On March 15, Sarah Kelling, Pharm.D., clinical assistant professor at the University of Michigan, delivered a CE titled “NOITACINUMMOC: Strategies to Improve Effectiveness.”  She gave some very helpful tips and tricks on ways to more effectively communicate with patients that may have lower health literacy and also showed how the use of motivational interviewing can help promote behavioral change.  On March 25, some CAPA members interacted with the community at the Impression 5 Science Center as they showcased the “medication or candy?” display board and passed out other pharmacy related materials.  Not only did parents see how easy it is for a child or an adult to mistake a medication for candy, but they also were given the number for poison control (1-800-222-1222) in case a poisoning does occur.    

April and May were not quiet months either.  In April, like all months with a 5th Saturday, CAPA provided a warm meal to people in the Lansing area at the Advent House.  Everyone helping at these events is sure to have fun and fellowship with their colleagues; July 29, Sept. 30 and Dec. 30 are the next Advent House dates.  On May 16, Joy Wahawisan, Pharm.D., clinical pharmacist from Physicians Health Plan in Lansing, delivered a CE titled “COPD Therapy Updates: It’ll Leave you Breathless!”  Dr. Wahawisan reviewed the various devices used for COPD and showed where they all fit into therapy using the most recent COPD guidelines.  

Save the date for July 30, as CAPA will be partnering with Michigan Pharmacists Association for their new practitioner event at the Lansing Lugnuts game.  CAPA will host a pre-game get-together at a local downtown vendor. Reserve your tickets here!  

Last, but not least, if you know  a pharmacy student in at least their first year of pharmacy school who is a resident of Ingham, Eaton, Clinton or Shiawassee County, tell them to check out the CAPA pharmacy webpage for information about the $500 scholarships that are available.  Scholarship applications are due Sept. 15 and can be found under the awards tab on www.CAPAPharm.org

Posted in: Member News
Gearing Up Locally
By Angela Green, Pharm.D., BCPS, ambulatory pharmacy services manager, Mercy Health Muskegon

Update on the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592 and S. 109)
Currently the House has 188 co-sponsors, including four representatives from Michigan, and the Senate has 42 co-sponsors, including both senators from Michigan.1 Thank you to all Michigan Society of Health-System Pharmacists (MSHP) members who have contacted their representatives to support this bill. If you are not sure if your representative is a co-sponsor, check out www.Congress.gov and then search for the bill. If you do not find them as a co-sponsor, contact them. There are great resources through Michigan Pharmacists Association (MPA) and the American Society of Health-System Pharmacists (ASHP) with talking points and letters to send to representatives. Find MPA talking points documents here, and feel free to visit ASHP’s resources at this link.   


With pharmacists currently co-managing patients in an underserved area within my organization, I have been thinking about what we can do now to prepare for provider status. In previous articles, MSHP President, Dana Staat, and MSHP Immediate Past-President, Jesse Hogue, wrote about bringing health-system leaders up to speed on pharmacy services and aligning quality initiatives. In the April MSHP Monitor, Board of Directors member, Shawna Kraft, described some great resources and best practices to help get prepared and explored what other states with provider status have done. 

I currently practice in ambulatory care, and our pharmacists are currently co-managing chronic diseases in physician office practices amongst other activities. We have had many successes shared anecdotally; however, we did not have data that aligned with organizational quality initiatives, and they were not transparent to pharmacy or senior leadership. To remedy this, the first thing we did was to analyze organizational goals and set supporting departmental goals and measurements. We made this data transparent and accessible to leadership and pharmacy staff. Now all of our pharmacists know how many patients they are interacting with and how ambulatory pharmacists are improving quality measures. Having this data makes it easier to have a conversation with senior leadership to explain the impact pharmacists are having with our patients. 

I encourage you to invite leaders to meet with pharmacists and the healthcare providers they interact with to continue spreading knowledge of what services pharmacists can provide. No matter what setting, pharmacists and pharmacy technicians are doing great work to serve patients. Determine what matters to your organization and develop programs and metrics to support and share these in a meaningful way.

Another consideration is credentialing and privileging. It is not clear what the requirements will be for pharmacists to be recognized as providers, but as MSHP President, Dana Staat, said in January, "the time is now to brainstorm." This may look different for each organization, so get familiar with your organizational requirements. Having conversations with your credentialing body in your organization will help you understand how to get pharmacists prepared and what barriers you may encounter.  

Finally, one of the best ways to be prepared is to get involved. MSHP has created meaningful committee charges to prepare for provider status. Participating in MSHP Committee Day is a great way to meet other pharmacists and technicians to share ideas and challenges. Get inspired by all the good work happening within our state to provide the best care for our patients. Learn more about MSHP and our Committees here. 

References:
1. H.R. 592 – Pharmacy and Medically Underserved Areas Enhancement Act. Congress.gov. https://www.congress.gov/bill/115th-congress/house-bill/592/cosponsors?q=%7B%22search%22%3A%5B%22hr+592%22%5D%7D&r=1. 



 

Posted in: Member News
SAVE THE DATE - Pharmacy Day at the Capitol and Medication Disposal Event

Every year in September, Michigan Pharmacists Association (MPA) holds a Medication Disposal Event @ the Capitol on the south Capitol lawn in Lansing. This year, the event will be held Tuesday, Sept. 12 from 10:30 a.m. to 1 p.m. This event helps the general public safely and responsibly dispose of medications, including controlled substances and narcotics. Those dropping of medications will learn about proper disposal and the valuable role the pharmacist plays in patient safety.

Medications can be dropped off from 10:30 a.m. to 1 p.m. Medications should be kept in their original containers as the labels provide safety information. Scratch out or cover with tape to make the personal information unreadable. There will be a tent available at Captiol Ave. and Michigan Ave. to conveniently drop these medications off.

Items Accepted:

·            Controlled substance medications/narcotics

·            Eye drops

·            Inhalers

·            Insulin

·            Medicated ointments/lotions

·            Medication samples

·            Medications from individuals/households

·            Over-the-counter medications

·            Pet medications

·            Prescription medications

·            Vitamins/supplements

 

Items Not Accepted:

·            Hazardous pharmaceuticals

·            Hazardous materials

·            Injectables

·            Medical/infectious waste

·            Medications from hospitals/health facilities

·            Needles/syringes

 

This event is also held in conjunction with Michigan Pharmacists Association, Pharmacy Day at the Capitol, an event that educates legislators and their staff about the vital role pharmacists play on the healthcare team. Volunteer pharmacists, student pharmacists and pharmacy technicians will have one-on-one time to provide wellness demonstrates and tests and discuss the important issues. Volunteers will work to educate the legislators on the following areas:

  • Blood glucose monitoring
  • Blood pressure monitoring
  • Collaborative practice
  • Compounding
  • Emergency preparedness
  • Healthy lifestyle practices
  • Immunizations
  • Pharmacist and pharmacy technician education and training
  • Point-of-care testing

A press conference will also be held at the event, typically occurring around 11 a.m. In previous years, speakers have touched on the opioid epidemic in the state and efforts to ensure patients receive the best care possible while preventing tragic and avoidable deaths.

 

For those who are planning on attending and volunteering for the event, there are several activities planned for your involvement:

  • Advocacy (in the tent and legislative visits)
  • Speak with legislators about your work as a pharmacist and the impact that current bills may have on your practice. Find talking points at www.ThatsMyPharmacist.com
  • Pharmacy Services
  • Provide basic testing to legislators attending the event including blood pressure monitoring, blood glucose monitoring as well as other point-of-care testing
  • Greeting event attendees
  • Help MPA greet and direct attendees to Pharmacy Day activities.
  • Help with the Medication Take-Back, or prepare attendees for the press conference
  • Medication Take Back
  • Work with other pharmacists, student pharmacists and technicians to collect unused or unneeded medications for the proper disposal.

For more information, including sponsorship opportunities, visit www.MichiganPharmacists.org/2017pdac.  Please keep in mind that we ask all volunteers to register for the event, so we have an idea of the number attending. If you have any other questions, feel free to get in touch with Eric Liu at EricL@MichiganPharmacists.org. We look forward to seeing you there!

Posted in: Member News
Updated Vaccination Schedule Recommendations 2017

The Centers for Disease Control and Prevention (CDC) has released several updated vaccination schedules for 2017 for both adolescents and adults from the Advisory Committee on Immunization Practices. See recommendation summaries below, or visit the CDC for more complete information.

 

Children and Adolescents Aged 18 and Younger Updates:

·         Hepatitis B vaccine

o   Monovalent Hepatitis B vaccine should be administered within 24-hours of birth for medically stable infants weighing ≥2,000 grams born to hepatitis B surface antigen (HBsAg)-negative mothers. The recommendations for vaccination of infants <2,000 grams (as well as infants bron to HBsAg-positive mother or mother whose hepatitis B status is unknown) remain unchanged

o   Preterm infants weighing <2,000 grams born to HBsAg-negative mothers should receive the first dose of vaccine one month after birth or at hospital discharge

o   Additional detail regarding Hepatitis B vaccination of infants born to HBsAg-positive mothers or mothers whose hepatitis B status is unknown can be found in the ACIP Hepatitis B recommendations.

·         Polio Vaccine

o   The Jan. 13 and Feb. 17, 2017, MMWRs provide additional guidance regarding assessment of poliovirus vaccination status and vaccination of children who have received poliovirus vaccine outside the United States. View that information here.

o   The guidance offers additional clarifications and changes impacting the IPV footnote in the 2017 catch-up schedule

§  If both OPV and IPV were administered as part of a series, the total number of doses needed to complete the series is the same as that recommendations for the U.S. IPV schedule. A minimum interval of four weeks should separate doses in the series, with the final dose administered on or after the fourth birthday and at least six months after previous dose.

§  If only OPV was administered, and all doses were given before age four years, one dose of IPV should be given at four years or older and at least six months after the last OPV dose. This six-month period is a change from the current footnote which indicates the period is four weeks after the last OPV dose.

§  Only trivalent OPV (tOPV) counts toward the U.S. vaccination requirements (tOPV was used for routine poliovirus vaccination in all OPV-using countries until April 1, 2016). See more guidance here.

·         Additional Vaccine Updates Included:

o   Medical Conditions – information over what indications may be for adolescents based on medical conditions.

o   Diphtheria and tetanus toxoids and acellular pertussis vaccine

o   Haemophilus influenza type B vaccine

o   Human papilloma virus vaccine

o   Influenza vaccine

o   Meningococcal vaccine

o   Pneumococal vaccine

·         Click here for Birth-18 Years and Catch-Up Vaccination Schedules for 2017

·         Click here for full schedule changes in the Morbidity and Mortality Weekly Report (MMWR)

 

Adults aged 19 years or older

·         Influenza

o   LAIV should not be used during the 2016-2017 influenza season

·         Hep B

o   Adults with chronic liver disease, including but not limited to, hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level greater than twice the upper limit of normal should receive a HepB series.

·         HPV

o   Adult females through age 26 and adult males through age 21 who have not received any HPV vaccine should receive a three-dose series of HPV vaccine at zero, one to two, and six months. Males aged 22 through 26 may be vaccinated with a three-dose series of HPV vaccine at zero, one to two and six months.

·         Meningococcal Disease

o   Adults with anatomical or functional asplenia or persistent complement component deficiencies should receive a two-dose primary series of MenACWY, with doses administered at least two months apart, and revaccinate every five years. They should also receive a series of MenB with either MenB-4C (two doses administered at least one month apart) or MenB-FHbp (three doses administered at 0, 1-2 and six months).

·         Click here for the Adult Immunization Schedule

·         Click here for full schedule changes in the Morbidity and Mortality Weekly Report (MMWR)

Posted in: Professional Practice
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