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P Jewesson

Publications and source records attributed to P Jewesson.

17 recordsLinked to original sources
PubMed2000

Influence of the British Columbia reference drug program on hospital formularies: a survey of hospital pharmacy managers.

OBJECTIVES: To assess the impact of the British Columbia Reference Drug (RD) Program on the management of hospital formularies in the province. MATERIALS AND METHODS: A survey of pharmacy managers in British Columbia hospitals with more than 100 beds was conducted in November, 1997. The survey instrument contained questions regarding hospital characteristics, drugs listed on the formulary before and after implementation of RD policies for four drug classes, the hospitals' responses to RD policies and the respondents' opinions of the RD Program. RESULTS: Thirty-two (86%) hospitals returned the survey by the stated deadline. Before the RD Program was implemented, significantly more hospitals listed cimetidine (P=0.03), felodipine (P<0.001), quinapril (P<0.001) and ramipril (P<0.001) on the hospital drug formulary. The main reasons given for changes to hospital drug formularies were community prescribing patterns (25% to 38%) and the RD Program (23% to 44%) depending on the drug category. Twenty-seven (84%) hospitals did not automatically adopt RD policies; 22 (69%) hospitals reviewed the policies at Pharmacy and Therapeutics Committee meetings. Sixteen (50%) respondents thought that hospitals should change their drug formularies to match the policies. Median satisfaction with the RD Program on a 10-point rating scale (1 = unsatisfied, 10 = satisfied) was 7 (range 2 to 10). CONCLUSIONS: Respondents appeared to be neutral when asked their opinion of the RD initiative. The RD policies resulted in drug category-dependent changes in the hospital formulary listings. H2 receptor antagonists and antihypertensives were the most significantly influenced drug categories. RD status does not automatically confer formulary status of a drug; however, it does appear to be a criterion in most hospitals when considering a drug for inclusion in the formulary.

British Columbia↗
PubMed1999

Experience with ceftazidime parenteral-to-parenteral dosage stepdown in the empiric treatment of febrile neutropenia.

We assessed the clinical and economic impact of a new parenteral-toparenteral stepdown program involving ceftazidime for the treatment of febrile neutropenia. This was a two-phase (before and after), 12-month, single-center, prospective study with a historical control. Ninety-eight ceftazidime treatment courses (47 preintervention, 51 postintervention) were administered for management of febrile neutropenia in 85 adults with hematologic malignancies. Multidisciplinary creation and promotion of parenteral-to-parenteral ceftazidime stepdown criteria were applied at the discretion of the health care team. Patient demographics between phases were similar. Only 2 (4%) treatment courses before the intervention involved parenteral-to-parenteral dosage stepdown, compared with 34 (67%) after the intervention (p<0.00001). Mean number of total ceftazidime doses/treatment course and mean duration of therapy did not change between phases. Clinical cure or improvement was identified in 74% and 80% of treatment courses before and after the intervention, respectively. The two main reasons for discontinuing the drug before the intervention were recovery of neutrophil count (60%) and adverse reactions (19%). Neutrophil count recovery (59%) and hospital discharge (14%) were the two most common reasons for discontinuation after the intervention. Of 34 stepdown treatment courses after the intervention, 3 (9%) failed to meet established stepdown criteria, and 2 of these required stepdown reversal. Ancillary antibacterial drugs and treatment course outcomes were similar between phases. Total ceftazidime acquisition cost for 704 treatment days in the preintervention phase was $52,473 CAN compared with $54,778 CAN for 907 days of therapy in the postintervention phase. The mean acquisition cost/ceftazidime treatment course was $1100 CAN and did not differ between phases. The mean daily cost of ceftazidime therapy was lower after the intervention ($60.39 vs $74.54 CAN) as a result of a greater frequency of stepdown (p<0.001). Assuming an equivalent number of treatment days, the projected annual acquisition cost avoidance associated with this stepdown program was $19,900 CAN.

Adult↗
PubMed1998

Piperacillin/tazobactam versus imipenem: a double-blind, randomized formulary feasibility study at a major teaching hospital.

With the introduction of piperacillin/tazobactam to the North American market, hospitals have been faced with the task of making a decision regarding its formulary role. In view of its broad spectrum of activity, piperacillin/tazobactam could be considered as a formulary alternative to imipenem. To evaluate the formulary feasibility of substituting piperacillin/tazobactam for imipenem, a comparative assessment of these agents in the empiric treatment of serious bacterial infections was undertaken at this tertiary care hospital. This trial was conducted as a randomized, double-blind, single-center study. Consenting adult patients (>16 years of age) who were prescribed imipenem were randomized to receive either 4 g of i.v. piperacillin/tazobactam or imipenem 500 mg of i.v. Q6H with or without concurrent antibiotics. Doses were adjusted according to renal function. There were no restrictions regarding the use of nonstudy antibiotics before and during the study period. Patients with beta-lactam allergies or meningitis or who had received greater than 72 h of previous imipenem therapy were excluded. Patients were evaluated at the end of treatment, at discharge, and at 30 days postdischarge. Endpoints included both clinical and microbiologic efficacy as well as drug toxicity. Over the 433-day study period, 360 imipenem treatment courses were initiated. Of these, 150 treatment courses (75 piperacillin/tazobactam courses and 75 imipenem courses) met study criteria and were subsequently randomized. The distribution of prescriber services for enrolled patients was similar to that for all patients receiving imipenem during the study period (p = 0.15). Also, there were no statistically significant differences in demographic parameters between enrolled and excluded patients. For those patients enrolled in the study, demographic characteristics, treatment course indication(s), and accompanying antibiotics were similar across treatment arms. The mean duration of study drug therapy was 7.7 days (SD, 6.2) for imipenem and 7.5 days (SD, 6.7)for piperacillin/tazobactam (p = 0.84). In the majority of cases, treatment discontinuation occurred as a result of a favorable treatment course outcome, stepdown to a narrower spectrum parenteral agent, or stepdown to an oral agent and did not differ between study drugs (p = 0.73). Clinical and microbiologic treatment course outcomes were also similar across treatment arms. Clinical outcome was deemed successful or improved for 68% of imipenem and 70% of the piperacillin/tazobactam treatment courses (p = 0.54). Fifty-three percent of treatment courses were microbiologically confirmed. Of the 58 courses that were assessed for microbiological outcome, 93% demonstrated successful eradication of the causative pathogens. There was no difference between study drugs (96% imipenem; 90% piperacillin/tazobactam; p = 0.61). The proportion of treatment courses with at least one adverse event was similar between the study drugs (p = 1.0). Nausea and/or vomiting were/was observed more commonly in the imipenem arm (p = 0.03). Discontinuation of therapy due to drug toxicity occurred in 16% of imipenem and 5% of piperacillin/tazobactam treatment courses (p = 0.06). There was no statistically significant difference between the mean treatment course cost for imipenem ($762; range, $55-$3192) versus piperacillin/tazobactam ($696; range, $79-$2967; p = 0.59). In summary, piperacillin/tazobactam seems to represent a suitable alternative to imipenem for several clinical indications including intraabdominal infections, pneumonia, febrile neutropenia, and skin/soft tissue infections in which the causative pathogens are susceptible. However, in view of the prevalence of multiresistant Gram-negative aerobic pathogens at this institution, we do not believe that imipenem can be removed from the drug formulary. In addition, at the currently studied dosing regimen, there seems to be no evidence of a direct cost advantage associated with

Adolescent↗
PubMed1997

A double-blind, randomized study of three antimicrobial regimens in the prevention of infections after elective colorectal surgery.

The objective of this study was to assess the prophylactic efficacy of cefoxitin, ceftizoxime, and metronidazole-gentamicin in colorectal surgery. A double-blind, randomized prospective clinical trial design was used in a Canadian tertiary care teaching hospital. Patients were randomized to one of three treatment groups and received three doses of a study drug (30 min preoperative and 2 postoperative doses at 12 and 24 h). Cefoxitin and ceftizoxime were given as 1000-mg doses. Metronidazole-gentamicin was given as 500 mg of metronidazole plus 120 mg of gentamicin in a minibag. High-risk patients (bowel ischemia, diabetic, current steroid use, etc.) received 10 postoperative doses. Patients with infections, prior antibiotics, or study drug allergies were excluded. Over 30 months, 153 patients were enrolled. Thirty-one patients were excluded for protocol violations. Of the 122 evaluable patients (38 ceftizoxime, 45 metronidazole-gentamicin, 39 cefoxitin), there was no difference across groups regarding sex, age, weight, preoperative Apache II score, and prior history of bowel surgery. Groups were equivalent regarding surgeon, nursing unit, high-risk status (six ceftizoxime, seven metronidazole-gentamicin, seven cefoxitin), bowel preparation, and procedure (including blood loss, drains, organ injury, intraoperative complications). Clinically significant infection requiring systemic antibiotics (7-day hospital and 30-day follow-up) was identified in 0% of ceftizoxime, 15% of metronidazole-gentamicin, and 26% of cefoxitin receiving patients (p = 0.005). Mean ASEPSIS scores for each group were 2.3 (range 0-15) for ceftizoxime, 9.2 (range 0-45) for metronidazole-gentamicin, and 10.4 (range 0-75) for cefoxitin (p = 0.01). Ceftizoxime patients tended to have a shorter total hospital stay (12.2 days versus 19.7 days for cefoxitin versus 13.9 days for metronidazole-gentamicin; p = 0.04), although the procedure to discharge interval was not significantly different (p = 0.09). There was no difference in clinical outcome according to risk status. Anaerobic bacteria were observed more commonly in the ceftizoxime and cefoxitin groups, whereas enteric Gram-negative aerobes were observed most often in the metronidazole-gentamicin group. The study regimens were generally well tolerated. Drug costs were equivalent between ceftizoxime and cefoxitin and lowest with the metronidazole-gentamicin regimen. Ceftizoxime appears to be more effective for the prevention of infection in colorectal surgery than either cefoxitin or metronidazole-gentamicin in the dosage regimens studied.

Adult↗
PubMed1996

Aminoglycoside administration as a single daily dose. An improvement to current practice or a repeat of previous errors?

Despite the availability of newer and safer antibacterials, aminoglycosides continue to play a major role in the management of infections in hospitalised patients. The concept of single daily dose (SDD) regimens was introduced many years ago and is now receiving much attention as an alternative regimen for this class of drugs. To evaluate the rationale and clinical support for SDD schemes, we conducted a 'MEDLINE' search to locate relevant preclinical and clinical literature pertaining to this issue. The results of animal model and noncomparative clinical data tended to be variable and inconclusive. We were able to identify 28 prospective comparative clinical trials; however, only one was randomised, double-blind and of sufficient sample size to detect differences in efficacy between treatment arms, should any exist. Despite these flaws, our review suggests that SDD schemes appear to be no more efficacious and no less toxic, but may be less costly, than traditional multiple daily dose schemes. We also assessed the predicted disposition of tobramycin/gentamicin in 415 patients with known pharmacokinetic parameters. With doses of 7 mg/kg at intervals of between 24 and 60 hours (depending upon renal function), the maximum serum concentration at steady-state (Cmaxss) varied from 8.5 to 55.6 mg/L, while the Cminss was < 2.0 mg/L in the majority of patients. Mid-interval serum aminoglycoside concentrations were < 0.5 mg/L in up to 23% of patients, suggesting possible underdosage in certain patients with this scheme. More conclusive clinical evidence is necessary before SDD schemes should be adopted as standard clinical practice. Empirical weight-based dosage schemes appear to yield widely variable serum aminoglycoside concentrations which could be considered therapeutically inadequate or toxic.

Aminoglycosides↗
PubMed1995

Antibiotic therapeutic interchange program: six years of experience.

To assess the long-term impact of a therapeutic interchange program on the use of target antimicrobial drugs, we conducted a retrospective study of target drug utilization at our institution--a 1,000-bed Canadian tertiary care teaching hospital. Data were assessed to determine target drug utilization, incidence of therapeutic interchanges, and patient-target drug exposures. Results showed that the incidence of therapeutic interchanges per patient-target drug exposure decreased from a mean of 23% to 2%, resulting in a total net savings for the target drugs of approximately $1.07 million (Canadian) over 6 years. Prescriber acceptance and low manpower requirements combine to make this a useful method of altering prescribing patterns and reducing drug and drug delivery costs.

Anti-Bacterial Agents↗
PubMed1995

A prospective survey of knowledge and perceptions of ondansetron: what do health care workers know about this drug?

Ondansetron is a relatively new drug whose optimal use is dependent on an understanding of its characteristics and role relative to traditional antiemetics. To assess perceptions and knowledge regarding ondansetron, we conducted a prospective written survey involving 56 physicians, pharmacists, and nurses at this hospital. Pharmacists claimed to be exposed to ondansetron promotion by industry more than the other groups. Apart from industry, pharmacists were considered to be the most common source of drug information. Nurses were less aware of dosage form equivalence than the other groups (p = 0.042). Physicians were more aware of twice daily dosing efficacy than other respondents (p = 0.0006). Nurses were able to better identify the relative duration of antiemetic benefit over metoclopramide (p = 0.008); however, most participants tended to be misinformed on this issue. Pharmacists were more familiar with the side effect profile while physicians were more cognizant of oral (p = 0.001) and parenteral (p = 0.018) drug costs than other groups. Overall, survey scores for physicians and pharmacists were higher than those for nurses (p = 0.007). There is an apparent difference across health care profession disciplines in the perceptions and knowledge about ondansetron. Specific misconceptions could lead to suboptimal drug use and warrant efforts to ensure a good understanding of the attributes and relative role of this agent.

Antiemetics↗
PubMed1995

Streptomycin-loaded bone cement in the treatment of tuberculous osteomyelitis: an adjunct to conventional therapy.

Streptomycin-loaded bone-cement (7 g of streptomycin in 40 g of bone cement) beads were used in the treatment of tuberculous bursitis and osteomyelitis of the greater trochanter in a 76-year-old woman. Wound drainage, serum and urine concentrations of streptomycin were measured. For the first 96 hours, the streptomycin levels in the wound drainage ranged from 2932 mg/L to 414.4 mg/L, and in the serum, streptomycin levels ranged from 1.7 mg/L to 13.7 mg/L. The patient recovered without complication and at follow-up 2 years later was free of infection and walking without pain. The authors conclude that the use of streptomycin-loaded bone cement can safely and effectively eradicate mycobacterial tuberculosis osteomyelitis.

Aged↗
PubMed1994

Cost-effectiveness and value of an IV switch.

A few antibiotics (i.e. metronidazole, clindamycin and ciprofloxacin) are available in both parenteral and oral formulations, and have good bioavailability, ensuring equivalent systemic drug concentrations. During a 4-year period subsequent to the initiation of a parenteral to oral (IV-PO) stepdown programme for metronidazole and clindamycin, Vancouver General Hospital saved approximately $C85 000. However, many parenteral antibacterials lack an oral formulation, requiring oral stepdown to a different antibacterial with a similar spectrum of activity. Alternatively, the oral formulation of a parenteral antibacterial may have poor bioavailability (i.e. cefuroxime axetil, ampicillin, cloxacillin, erythromycin, and tetracycline) and it is not possible to maintain equivalent systemic drug concentrations. While rigid criteria are not applicable to all clinical scenarios, the general criteria for oral stepdown include the following: the patient 1) continues to need an antibiotic; 2) is clinically stable; 3) is capable of tolerating the oral dosage form; and 4) has no factors present (e.g. gastrointestinal abnormalities or drug interactions) that would adversely affect oral bioavailability. A review of subsequent IV-PO stepdown programmes at Vancouver General Hospital revealed that 1) not all patients receiving parenteral therapy are candidates for oral stepdown; 2) oral stepdown is delayed in a large proportion of treatment courses; 3) oral stepdown is not occurring in many patients for whom it is deemed appropriate; and 4) in a very few treatment courses stepdown may occur prematurely and may contribute to clinical deterioration.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1993

Computer-Assisted Retrospective Clinical Activities Statistics (CARCAS) Program.

Clinical pharmacy services have been demonstrated to have a positive impact on patient care in the hospital setting. Accurate and complete documentation of interventions aimed at improving drug use is essential to assess workload characteristics, determine the impact of pharmacist activities, justify current programs and predict future clinical staffing requirements. The need for an improved system of collecting and analyzing clinical workload statistics led to the development of a Computer-Assisted Retrospective Clinical Activities Statistics (CARCAS) Program in our department. Using a pre-defined clinical activity coding system, pharmacist activities were efficiently documented on a daily basis using an existing distributional computer system. Training requirements and data entry time were minimal. The CARCAS Program appeared to capture more clinical pharmacist activities than the earlier manual system. The flexibility of the CARCAS Program should permit adaptation to other hospitals with similar computer systems regardless of the nature of their clinical programs.

British Columbia↗
PubMed1991

Outcome of a ceftriaxone/cefotaxime interchange programme in a major teaching hospital.

A two-stage intervention programme was performed to enable the effective substitution of ceftriaxone for cefotaxime in a teaching hospital with large numbers of transient prescribers. One hundred and sixteen patients with a variety of bacterial infections were randomized to an open, historical control comparative study to determine if ceftriaxone was an acceptable replacement for cefotaxime. For 6 months prior to the intervention, both cephalosporins were available on formulary. Following an initial informational stage, a therapeutic interchange programme was implemented to convert prescriptions for cefotaxime to ceftriaxone. Ceftriaxone and cefotaxime were equivalent in terms of microbiological and clinical efficacy and patient tolerance in 77 evaluable patients. No changes in prescriber service occurred after the changeover. Post-intervention treatment courses required a ceftriaxone/cefotaxime interchange in 28% of the cases. Ceftriaxone appeared to be a suitable and cost-effective alternative to cefotaxime in this hospital. The intervention programme successfully invoked the formulary change with minimal expense and prescriber opposition.

Adult↗
PubMed1991

Rifampin and ansamycin interactions with cyclosporine after renal transplantation.

Cyclosporine whole blood concentrations are routinely monitored to help ensure optimal therapy. Several drugs have been shown to alter cyclosporine disposition by altering hepatic metabolism. Rifampin, a potent enzyme inducer, has been demonstrated to increase cyclosporine clearance. The effects of ansamycin, a chemically related investigational antibiotic, on cyclosporine disposition, have not been previously published. We report a renal transplant patient receiving cyclosporine and consecutive therapy with rifampin and ansamycin. When compared to rifampin, ansamycin's effect on cyclosporine disposition appeared to be delayed and of less magnitude. Further characterization of this interaction is required. Until this issue is resolved, we would advise careful monitoring of cyclosporine blood levels in patients receiving either rifampin or ansamycin in concert with cyclosporine.

Anti-Bacterial Agents↗
PubMed1990

Nonvalue of antigen detection immunoassays for diagnosis of candidemia.

We evaluated the Cand-Tec (Ramco Laboratories Inc., Houston, Tex.) and LA-Candida antigen detection system (Immuno-Mycologics Inc., Norman, Okla.) tests as possible rapid alternatives to blood cultures for the identification of patients with candidemia. Tests were performed on sera from (i) 33 patients with candidemia, (ii) 82 patients with fever and risk factors for invasive candidiasis, and (iii) 13 healthy controls. A total of 21 patients had no evidence of invasive candidiasis, as determined by clinical course, blood culture, and/or autopsy; results for 61 patients were indeterminate regarding the presence of invasive candidiasis, or else the patients had invasive candidiasis with organ involvement. By using a threshold positive Cand-Tec titer of greater than or equal to 1:4, the sensitivity in candidemic patients was 49%; the specificity was 43% (patients with true-negative results had neither candidemia nor other evidence of invasive candidiasis). Coexistent disseminated candidiasis in some candidemic patients may have accounted for some positive Cand-Tec tests and possible overestimation of the sensitivity of the test for candidemia. Cand-Tec test results were negative for healthy controls. All test results obtained by the LA-Candida antigen detection system assay were negative. Our findings indicate that neither of these assays reliably identifies patients with candidemia.

Adolescent↗
PubMed1990

Metronidazole cost containment: a two-stage intervention.

A two-stage intervention was undertaken to extend the dosing interval of metronidazole--from the typically prescribed q6h or q8h regimen to a q12h dosing interval. Following an 2-week informational period, all prescriptions for parenteral metronidazole specifying a dosage interval of 8 hours or less were modified to 12-hour dosage intervals, unless overridden by the prescriber. Prescriptions for the 6-month periods prior to and following the intervention were reviewed to assess its impact on prescribing patterns and cost containment. The incidence of regimens involving 12-hour intervals increased from 5 to 95% following the intervention. A 2-year general hospital/drug utilization health record screen found no drug substitution effect, nor any change in postoperative infection rate or death among metronidazole recipients. Overall, the two-stage intervention was a well-accepted and effective means of cost containment, resulting in an estimated yearly cost savings of $28,000.

British Columbia↗
PubMed1989

Impact of a practical two-stage intervention on aminoglycoside usage.

To control aminoglycoside usage and costs, a two-stage intervention was implemented at this 1,000-bed, major Canadian teaching hospital. An informational stage, reviewing the therapeutic equivalence of netilmicin, gentamicin, and tobramycin in various internal publications, was followed by an automatic therapeutic interchange program. The intervention involved removing netilmicin from the formulary and substituting gentamicin for tobramycin. Comparing the 8-week pre-implementation period with the 24-week, post-implementation period, new orders for netilmicin declined from 42% to less than 1% of the total new aminoglycoside courses initiated. During the same time frame, new orders for gentamicin increased from 50% to 90%, orders for tobramycin remained stable at approximately 5.5%, and orders for amikacin remained unchanged at 1%. A retrospective health record review revealed a low incidence of microbiologically inappropriate interchanges. Pharmacy manpower requirements were minimal and prescriber acceptance was high. A +27,000 cost savings per year was estimated.

Aminoglycosides↗
PubMedDate not supplied

Development and implementation of simplified aminoglycoside empiric dosing guidelines.

Poor empiric dosing of aminoglycosides continues to be a problem in many hospitals. Consequently, a two-phase study was undertaken to evaluate gentamicin and tobramycin (G-T) dosing in our institution and to develop practical guidelines to achieve optimum initial G-T serum concentrations. In the pre-intervention phase (phase 1), approximately one-third of 232 G-T treatment courses were initiated with regimens that resulted in low initial serum concentrations. Empiric dosing guidelines were subsequently developed using Pharmacy Pharmacokinetic Service data and literature recommendations. They were validated with patients in phase 1. Compared with earlier dosing methods, the guidelines resulted in initial serum G-T concentrations within the therapeutic range in an equivalent proportion of patients. To simplify the procedure, recommended dosages were based on age, total weight, and serum creatinine only. The guidelines were tabular in format, and prescriber calculations were not required. Pocket and wall chart guidelines were distributed and promoted. During the post-intervention phase (phase 2), the impact of the guidelines was assessed. A review of 232 phase 1 and 203 phase 2 treatment courses revealed an increase in the initial mean dose per interval prescribed after the intervention (p < 0.01). No change in the mean interval was noted. When guidelines were followed, a higher proportion of treatment courses achieved early therapeutic serum concentrations (Cpmax 5-10 mg/L, 80% vs 54%; p < 0.005). The new empiric guidelines appear to be a practical alternative to existing methods of dosing aminoglycosides.

Adult↗