Pharmacy News

Entries for December 2018

Update in the Management of Clostridium Difficile Infection

By Carly Burns, Pharm.D. candidate 2019 and Jamie George, Pharm.D. candidate 2019, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit

Clostridium difficile infection (CDI) has become the leading cause of nosocomial infection in the United States. Treatment of CDI is costly, and unfortunately, incidence is projected to increase in both the inpatient and outpatient care settings.1,2

C. difficile is transmitted via the fecal-oral route or direct exposure, often by the hands of healthcare workers. In vulnerable individuals, the bacteria can produce two exotoxins (A and B) and cause colitis.2,3 Individuals most at risk of developing infection include those with recent or current antibiotic use, hospital exposure and age greater than 65.3 Prevention of CDI is routed in antibiotic stewardship and appropriate hand hygiene in healthcare personnel. Hand washing with soap and water is preferred over alcohol rubs, as alcohol fails to eliminate spores.2

The gold standard to diagnose CDI involves laboratory fecal testing. These steps should be considered in patients with new-onset diarrhea for whom there is no alternative cause.4 CDI is categorized by the severity of illness. Severe CDI is classified as the presence of leukocytosis (white blood cell count of >15,000 cells/mL) or a serum creatinine level of greater than 1.5 mg/dL (with non-severe CDI failing to meet these criteria). Fulminant CDI is the presence of shock/hypotension, ileus or toxic megacolon.4

Historically, metronidazole was utilized as first-line treatment for CDI due to lower costs and concerns of vancomycin-resistant organisms. However, metronidazole is no longer recommended as initial single-agent therapy in the recent 2017 Infectious Diseases Society of America (IDSA) guideline. This change in practice is based upon numerous trials published since the early 2000s where oral vancomycin was found to be superior to metronidazole in terms of clinical cure and diarrhea resolution.4 One trial conducted by Zar et al. found clinical cure was achieved in only 76 percent of patients receiving metronidazole compared to 97 percent in those receiving vancomycin. A pooled analysis demonstrated increased recurrence of CDI with metronidazole 30 days following treatment completion.5 Increased rates of metronidazole resistance may be in part responsible for these findings. An additional theory takes into consideration the pharmacokinetic profile of the two antibiotics.6 Vancomycin is minimally absorbed into systemic circulation following oral administration and maintains consistently high concentrations in the feces, compared to metronidazole which achieves low fecal concentrations.6

Table 1 delineates the key points of the new CDI treatment recommendations according to the updated IDSA guidelines. Development of new CDI treatments continues to gain considerable interest. Several strategies, including the development of a C. difficile vaccine, are currently undergoing clinical trials due to the increasing incidence of disease and emerging resistance to standard of care.7

Table 1. Treatment for CDI in adult patients4.

Classification

Treatment Recommendation

Strength of Recommendation/ Quality of Evidence

Initial Presentation

 


Non-severe and Severe CDI

Fulminant CDI

  • Vancomycin PO 125mg four times daily x 10 days 

OR

  • Fidaxomicin PO 200mg twice daily x 10 days
  • Vancomycin PO 500mg four times daily +/- Parenteral metronidazole

o Rectal administration for patients with ileus

Strong/High

 


Strong/High

Strong/Moderate

 

Weak/Low

Recurrent CDI

 

Determined by initial antibiotic used

  • Metronidazole initially: Retreat with vancomycin
  • Vancomycin initially:

o Tapered and pulsed regimen of Vancomycin 

OR

o Fidaxomicin

 

Weak/Low

 

Weak/Low

 


Weak/Moderate

Multiple Recurrent CDI

Same as recurrent CDI in addition to:

  • Vancomycin PO x 10 days followed by a 20-day course of rifaximin
  • Fidaxomicin
  • Fecal transplantation

 

Weak/Low

Weak/Low

Strong/Moderate

 

References:

  1. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile Infection in the United States. N Engl J Med. 2015; 372:825-834.
  2. Centers for Disease Control and Prevention. Health Care Associated Infections. CDC website. https://www.cdc.gov/hai/organisms/cdiff/cdiff_clinicians.html. Updated Sept. 23, 2015. Accessed Aug. 12, 2018.
  3. Leffler DA, and Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015; 372:1539-1548.
  4. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1–e48.
  5. Zar FA, Bakkanagari SR, Moorthi K, et al. A Comparison of Vancomycin and Metronidazole for the Treatment of Clostridium difficile–Associated Diarrhea, Stratified by Disease Severity. Clin Infect Dis. 2007;45(3):302-307.
  6. Chahine EB. The Rise and Fall of Metronidazole for Clostridium difficile Infection. Ann Pharmacother. 2018;52(6):600–602.
  7. Peng Z, Ling L, Stratton CW, et al. Advances in the diagnosis and treatment of Clostridium difficile infections. Emerg Microbes Infect. 2018;7(1):15.
Posted in: Professional Practice
Regional Society Update: Southeastern Michigan Society of Health-System Pharmacists

By Neha Desai, Pharm.D., director of pharmacy, Beaumont Hospital, Dearborn and Michigan Society of Health-System Pharmacists southeast regional representative

The Southeastern Michigan Society of Health-System Pharmacists (SMSHP) meetings are held the second Wednesdays of the month from September through May, most of them providing live continuing education (CE). We started the new season off strong at the September meeting with a CE presentation by Alison Lobkovich, Pharm.D. She delivered her SMSHP Resident CE Award winning presentation entitled “Direct Acting Oral Anticoagulant Use in Special Patient Populations” to a packed audience at Burton Manor in Livonia. There was also a call for annual SMSHP award nominations at the meeting.

The focus of the October SMSHP meeting was around our Annual Residency Showcase. This year the showcase featured 30 residency programs from Michigan and other states! The student pharmacists, residents and preceptors had a chance to interact and learn about area programs and what they have to offer in terms of post-graduate training. General election ballots were presented at the Board meeting in October. The nominees for awards were presented to the Board by the Awards Committee chairs Renee Paxton and Jeff Hurren.

The CE program in November was delivered by Levi Hall, Pharm.D., BCPS in Southfield. The pain and palliative medicine specialist presented, “Michigan Public Acts: Changing All the Rules on Opioid Prescribing” which provided an update on the new state laws on opioids.

The newly elected officials of SMSHP as well as the winners of the annual SMSHP awards were announced. Please see our Facebook page for pictures of the event and our winners.

The new SMSHP officials are: Elizabeth Briscoe, president-elect; Carrie Nemerovski, secretary; Dmitriy Martirosov, executive director and Macey Williams, executive director.  

The deserving award winners are:

Exemplary Student Scholarships


Lauren Aschermann, University of Michigan (right) 
 
Benjamin August, Wayne State University (right)

Student Research Award

 
Ashley Blanchette, Wayne State University (right)


Committee Service Award


 Alicia Thorne, CE Committee (right)


Technician of the Year


Jean Schafer, CPhT, Beaumont Hospital, Dearborn (right) 


Resident of the Year


Sarah Adie, Michigan Medicine (right) 


Pharmacist of the Year

 
Raymond Yost, DMC Receiving Hospital (right)


Innovative Practice Award

 
The HATRIX Group (DMC and Wayne State University) Josh Raub, 
Sean McConachie, David Trupaino, Taylor Franckowiak, Ray Yost


Preceptor of the Year Award


Ryan Mynatt, DMC Detroit Receiving Hospital (right) 

As regional delegate to Michigan Society of Health-System Pharmacists, I have learned so much in the past year and had the pleasure of working with a great team of pharmacy leaders from across Michigan. I hope to apply much of those learning experiences as President of SMSHP in 2019 and continue the tradition of excellence and service to our members. Please visit our website at www.SMSHP.org

New Officers

   



 





Posted in: Member News
Tips for a Successful Fourth Year

By Serena Kelley, Pharm.D. candidate 2019, Ferris State University College of Pharmacy

 

Pharmacy school can be viewed as a marathon, and P4 year is the final sprint to the finish line. As I pass the halfway point in my last year, I find it important to stop and reflect on the journey so far and evaluate the steps that have led to success and ways to improve. During the didactic portion of pharmacy school students are faced with frequent examinations, countless assignments and objective structured clinical examinations (OSCE’s) that are all intended to prepare us for clinical rotations. These are great tools to gain knowledge and assess clinical understanding, but as you approach P4 year, it quickly becomes apparent to most students how much you have forgotten and have yet to learn in order to become a pharmacist.

 

As daunting as clinical rotations appear, there are a few strategies and steps you can take to try and make the most out of each experience. First, it is important to remember that no one expects you to have all the answers, and it is okay to admit when you don’t know something. That being said, it is also important to try to answer every question thrown your way. Learn to trust your knowledge base and try to reason out what you think the answer might be before looking it up. You might just surprise yourself with how much you actually do know. Try to look at each unknown answer as an assignment, challenge yourself not just to find the answer, but to learn a little bit more about the disease state, medication or guidelines.

 

Secondly, make sure to challenge yourself and guide your own learning. Your preceptors are invaluable and want to see you succeed, but they do not know your current knowledge base. Make sure to discuss your strengths and weaknesses and set goals. Ask for topic discussions in areas you are unfamiliar with and challenge yourself to pick a final case report about a disease state you can learn the most from. Just remember, your preceptors have been in your shoes and serve as a valuable resource. Ask about their experiences as a student, resident and practicing pharmacist. Find out what they are passionate about and how they have developed into lifelong learners.

 

Thirdly, remember that you are not alone on each rotation. Reach out to your classmates and colleagues to ask about their experiences and strategies for success. You may discover a new area of pharmacy or learn about a new medication. As students, we are spread all over the state during our last year, but we can continue to work together. After all, in a few short months we will all be practicing pharmacists in the close-knit community of pharmacy.

 

Finally, keep in mind that rotations are meant to challenge you as a student, just like the didactic coursework in previous years. There will be some areas that come naturally while others remain a struggle. Try not to focus on your mistakes, but instead take time to appreciate how much you have learned since starting pharmacy school. As always, remember there is always something more to learn and another patient that you can help. Keep up the hard work, and the finish line will be in sight faster than you can imagine.

Posted in: Member News
Advocacy: Every Professional’s Responsibility

By Bridget Caito, specialty pharmacy 340B analyst, Ascension Michigan Pharmacy and Deb Sopo, R.Ph., MBA, FMPA, pharmacy manager, Ascension Michigan Pharmacy, Warren

 

Dozens of times a day, nuances come up in the pharmacy that make our job more difficult. Today, it may be another uninsured case that we lost hundreds of dollars on, or a needed drug that is not on formulary. As pharmacists and pharmacy technicians, our roles go beyond making sure our patients receive their medications when they are in our care. We have a responsibility to get involved in matters like: immunizations, medication therapy management (MTM), transparency within pharmacy benefit managers (PBM), MAC pricing, medication safety and patient access to pharmacy services that influence the safety and ease of taking care of patients. This is no easy task, but you are not alone in advocating for key issues with an organization like the Michigan Pharmacists Association (MPA) Political Action Council (PAC).

 

The MPA PAC was created in 1968 as a voluntary, nonpartisan committee of 527 pharmacy professionals. This group of professionals actively sought to promote good government and good public health policy. Contributions to Pharmacy PAC support legislators who support pharmacy, drive advocacy efforts and facilitate pharmacy participating in notable political events. Pharmacy PAC sponsors annual legislative events that encourage student pharmacists and pharmacy professionals to speak with key legislators and educate them and their staff on issues that are important to our profession. PAC also works to inform MPA members of legislative changes that impact our practice.

 

Proper funding the Michigan Pharmacy PAC elevates the status of MPA and pharmacy within the state. MPA, in collaboration with the practice sections, works on critical issues like provider status with Medicare, appropriate prescribing of opioids, reimbursement rates, technician product verification, direct and indirect remuneration fees and PBM transparency. Supporting Pharmacy PAC and MPA gives Michigan pharmacists and pharmacy technicians a voice, and of course, there is strength in numbers. In 2018 alone, MPA was involved in over 60 introduced bills. As our advocates, MPA ensures that the bills that effect the pharmacy profession and our patients are addressed.

 

Advocating on behalf of our profession and patients does not have to be an overwhelming task especially if you support the Michigan Pharmacy PAC and MPA’s Pharmacy Advocacy Response Team (PART). Our profession, by nature, is one that protects and serves, and advocating is an effective way to do just that. Consider following the mission of PART: participate, advocate, respect and teach. Become a member of PART by signing up today at www.MichiganPharmacists.org/advocacy/part.

 

If you want to see pharmacy friendly legislation, what are you willing to do to make it happen? Changes will not happen without our active participation and advocacy. Call or write your local legislators. Find out what your local legislators stand for, and how they vote on the topics that matter to us. Share with them what needs to change and why. If you want a guide on what to cover and how to phrase it, check the MPA’s website Advocacy page at www.MichiganPharmacists.org/advocacy. It contains talking points for a fair number of current issues.

 

Advocate with our patients. Cultivate a respectful atmosphere where you can educate and communicate to them what is important in terms of good public health policy and what is good for their care. How many times have we helped patients understand because they were unaware of their own insurance policies? Chances are they are also unaware of legislation that impacts pharmacy, and ultimately themselves.

 

Spreading knowledge will create a momentum to get issues noticed. Voice your opinions. Be heard! Amplify your voice by supporting Michigan Pharmacy PAC. MPA will make the connections for you, provide resources and inform you of legislative events and educational opportunities. Advocacy can take shape in many different forms and many times without ever leaving the pharmacy. We can create change if we all do our small PART.

Posted in: Laws and Regulations
You Are Valuable

By Nancy MacDonald, Pharm.D., BCPS, FASHP, transition of care coordinator, Henry Ford Hospital, Detroit and MSHP president

 

The Michigan Society of Health-System Pharmacists (MSHP) president’s role is to move the organization forward in a strategic direction to help members consider or gain new perspectives. Having dedicated volunteers and Michigan Pharmacists Association staff to accomplish goals and objectives is critical to the success of MSHP. While some may say that as the MSHP president I deserve the credit for achieving the Society’s goals in 2018, the credit truly belongs to each of you.

 

As I started to write this article, I looked back at previous Monitor issues through the year to ensure I would not duplicate information that had already been published. I wanted to make my final article as President meaningful and unique. As I read each article written by Board members, committee chairs and various MSHP leaders, an overwhelming sense of pride came over me. I believe each one of those articles helped highlight the importance of continually demonstrating our value. The work we accomplished in 2018 took determination and persistence from many people. Some of the year’s highlights include the development of a formal Strategic Plan, the Michigan Residency Dashboard, the Ambulatory Care Workshop, the Ambulatory Care Antimicrobial Stewardship Survey and the list could go on for several paragraphs. While I heard about all the accomplishments throughout the year, I didn’t really appreciate just how much a group of committed leaders could accomplish in just 12 months. And if I didn’t tell you at some point during this year, I want to be sure to say the words in my last article as the 2018 MSHP president: you are valuable! Thank you for your contributions and for continuing to demonstrate our value as pharmacy professionals. But our work isn’t done. We need to be resilient to continue reaching higher goals.

 

Dr. Rebecca Finley, the 2018 ASHP Harvey A.K. Whitney Award winner, is quoted as saying, “We need to regularly reinforce that our careers are not a sprint, but rather a decade-long marathon.”1 In her speech, she highlights reflection, resilience, relationships and gratitude. Although her speech motivates me on an individual level, I also found it applicable to my MSHP role this year. I hope you take the time to read or listen to her speech and apply it to your own career. Try to envision how the concepts of reflection, resilience, relationships and gratitude also apply to the work you have done this past year for MSHP. Reflect on your committee’s accomplishments and what will take additional time to complete. Work on your resilience by taking the next couple of months to relax and focus on yourself, taking note of what role you would like to play on a 2019 committee. If you are an MSHP leader, mentor young MSHP leaders while they begin the first leg of their marathon. Think of the relationships you have formed and what they may look like at various stages of your marathon. Be grateful for the opportunity to advance our profession and influence young leaders by your service to MSHP.

 

Thank you for the honor of serving as your president. Thank you for your dedication and hard work that made MSHP so successful this year. Have a wonderful holiday season! See you in 2019!

 

References

1.       Finely RS. ASHP Research and Education Foundation. Harvey A.K. Whitney Award Lectures. Reflection, resilience, relationships, and gratitude. Harvey Whitney website. https://www.harveywhitney.org/lectures/rebecca-s-finley/.

Posted in: Member News
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