• Fondaparinux was the most cost-effective agent for suspected HIT, prevailing over both argatroban and bivalirudin.• Our data suggest potential cost savings with fondaparinux and underscore the need for larger clinical studies of fondaparinux in this area.Despite the availability of multiple nonheparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT), few data are available comparing the costeffectiveness of these agents. This analysis is particularly important when considering differences in the risk of adverse effects, routes of administration, requirements for phlebotomy and laboratory monitoring, and overall drug costs. We conducted a costeffectiveness analysis of argatroban, bivalirudin, and fondaparinux for the treatment of suspected HIT from the institutional perspective. A 3-arm decision-tree model was developed that employs standard practices for anticoagulation monitoring. We incorporated published data on drug efficacy and probability of HIT-related thromboembolism and major bleeding. We considered both institutional costs and average wholesale price (AWP) and performed probabilistic sensitivity analyses (PSA) to address any uncertainty in model parameters. Using institutional costs, fondaparinux prevailed over both argatroban and bivalirudin in terms of cost ($151 vs $1250 and $1466, respectively) and adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). Results were consistent when AWP was used, with fondaparinux being less expensive ($555 vs $3081 and $2187, respectively) and more effective in terms of adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). The PSA confirmed our findings using both institutional costs and AWP. In conclusion, fondaparinux subcutaneous injection afforded significant advantages in terms of cost savings and adverse events averted compared with IV argatroban or bivalirudin infusions. Our data strongly suggest potential cost savings with fondaparinux and underscore the critical need for larger clinical studies of fondaparinux in the treatment of suspected HIT. (Blood. 2016;128(26):3043-3051)

BackgroundBoth typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a β-lactam) to a regimen without atypical antibiotic coverage (β-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints).MethodsWe searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I 2) was observed.ResultsFive RCTs with a total of 2011 patients were retained. A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732–0.99; P = 0.037]; I 2 = 0%). The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259–1.165, P = 0.118], I 2 = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523–1.272, P = 0.369], I 2 = 0%), diarrhea (RR = 0.746 [95% CI, 0.311–1.790, P = 0.512], I 2 = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542–1.270, P = 0.39], I 2 = 0%).ConclusionsEmpiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP. Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage. Our findings provide support for the current guidelines recommendations to include empiric atypical coverage.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-017-2495-5) contains supplementary material, which is available to authorized users.

BackgroundDextrose is commonly administered with insulin during the management of hyperkalaemia to avoid hypoglycaemia. Previous research has evaluated the incidence of hypoglycaemia; however, none have reported the extent of blood glucose reduction after this regimen. The aim of this study was to better characterise the changes in blood glucose and to identify patients who may have an increased response to insulin.MethodsThis was a multicentre retrospective study evaluating adult patients who received a regimen of 10 units of intravenous regular insulin plus 25 g of intravenous dextrose to manage hyperkalaemia between January 2014 and September 2016. The primary outcome was to evaluate the extent of blood glucose reduction (milligram per decilitre) up to 6 hours following the above regimen. Secondary outcomes included incidence of hypoglycaemia (blood glucose <70 mg/dL) and severe hypoglycaemia (blood glucose <40 mg/dL), and predictors of the extent of blood glucose reduction.ResultsA total of 90 patients were included. The median blood glucose change over 6 hours was −24 mg/dL (IQR −53 to 6 mg/dL). Hypoglycaemia developed in 20 patients (22.2%, 95% CI 14.1% to 32.2%) and five patients (5.6%, 95% CI 1.8% to 12.5%) had severe hypoglycaemia. Patients who developed hypoglycaemia had a median baseline blood glucose of 110 mg/dL (IQR 80 to 127 mg/dL), which decreased to a median value of 52 mg/dL (IQR 40 to 60 mg/dL). Higher baseline blood glucose was significantly associated with greater blood glucose reduction (coefficient −0.36, 95% CI −0.55 to −0.18, p<0.001).ConclusionsThe extent of blood glucose reduction is variable and hypoglycaemia is common. The high incidence of hypoglycaemia highlights the importance of frequent blood glucose monitoring.

Background The number of students enrolled in the colleges of pharmacy in Saudi Arabia is high, and the number of pharmacy graduates expected to join the workforce in the coming years is expected to grow. There are limited number of studies that assess factors influencing pharmacy students’ career choices in Saudi Arabia in the literature. The aim of this study was to assess the factors that influence career goals and to investigate students’ perceptions about their career goals. Methods This study was a prospective cross-sectional survey targeting PharmD students in their last year (i.e. interns) in the academic year of 2018 – 2019. A questionnaire containing four parts and total questions of 32 was completed by interns. Data collected and analyzed using Qualtrics. This study was reviewed and approved by the Unit of Biomedical Ethics Research Committee at King Abdulaziz University. Results 93 were reachable via email and all of them attended the interview and completed the survey (100% response rate). The most important job considerations were: work environment (67.7%), advancement opportunities (55.9%), salary (52.7%), benefits (40.9%), flexible work schedule (34%), and finally geographic region (29%). The top ranked career goal upon graduation were in industry and drug company (35.5%), clinical pharmacy (26.9%), (14%) academics/research and hospital pharmacy setting (inpatient/outpatient) (14%) each, and regulatory and community pharmacy (3.2% and 4.3%, respectively) Conclusion This study showed that work environment, advancement opportunities, and salary were the most important job consideration for pharmacy interns. The top ranked career goals were industry and drug company followed by clinical pharmacy. Further studies across Saudi Arabia are needed to confirm our results.

Background: The aging process makes geriatric populations more prone to various chronic diseases. Such diseases require older patients to be on more medications than any other age group and make them more susceptible to adverse drug events related to potentially inappropriate medications (PIMs). Aim: To identify the prevalence of potentially inappropriate medications among older people and explore the most commonly prescribed PIMs in hospitalized patients. Design and Setting: A retrospective study conducted in a large tertiary hospital among patients hospitalized in a 4 year period from January 2015 to December 2018. Methods: The 2019 Beers Criteria were used to assess PIMs in all inpatient prescribed medications focusing on the first class (i.e., drug/drug class to be avoided in older adults). Results: The mean age was 75.17 ± 7.66 years. A total of 684 (80.6%) patients were prescribed at least one medication listed in the first-class category of the 2019 Beers Criteria. Top five drugs were proton pump inhibitors (40.3%), nonsteroidal anti-inflammatory drugs (10.2%), metoclopramide (9.3%), benzodiazepines (8.4%), and insulin (5.4%). Conclusions: The prevalence of PIMs is high among older patients admitted to the hospital. More efforts are needed to investigate the potential reasons and develop action plans to improve concordance to Beers Criteria among healthcare providers.

(1) Background: Outpatient parenteral antibiotic therapy (OPAT) is a well-established and cost-effective measure that improves the efficient use of healthcare resources and increases bed availability. Only limited published data is available to illustrate OPAT implementation and outcomes in Saudi Arabia. The main objective of this study was to evaluate the effectiveness of OPAT in a tertiary center in Saudi Arabia. (2) Methods: In this retrospective study, clinical charts of enrolled patients were reviewed in a tertiary care center from the initial month of November 2017 to March 2020. All admitted patients with a central line and who enrolled in the OPAT of the hospital during this study period were included. The primary outcome was the 30-days readmission rate of OPAT patients. Secondary outcomes were factors associated with OPAT failure. Descriptive analysis of the data was used to express the results. (3) Results: We enrolled 90 patients; 54 (60%) were male; the mean age was 55.16 (±17.7) years old. The mean duration of the antimicrobial treatment was 21.9 (+24.6) days. All patients completed the intended course of therapy. Ertapenem was the most frequently used antimicrobial (43%), followed by vancomycin (11.2%). Urinary tract infections (UTIs) are some of the most common bacterial infections in 25 patients (26.9%), followed by osteomyelitis in 16 patients (17.2%). Extended-spectrum beta-lactamase E.coli was the highest common isolated microorganism (44.9%), followed by methicillin-resistant Staphylococcus aureus MRSA (16.9%). The readmission to the hospital during therapy was required for 12 patients (13.3%). Shifting from hospital care to OPAT care resulted in cost savings of 18 million SAR in the overall assessment period and avoided a total of 1984 patient days of hospitalization. (4) Conclusion: The findings have shown that OPAT therapy was effective with minimum hospital readmissions and therapy complications. OPAT programs can reduce healthcare costs and should be integrated into practice.

Background: Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. Methods: We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. Results: A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Conclusion: Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes. Contexte : La thromboembolie veineuse (TEV) est une complication grave et fréquente chez les patients vus en traumatologie. Les lignes directrices recommandent l'utilisation systématique d'une prophylaxie pharmacologique; par contre, les taux de conformité aux lignes directrices varient beaucoup. Le but de cette étude était de décrire la pratique clinique en matière de thromboprophylaxie dans notre centre de traumatologie canadien de niveau 1 au cours des 24 premières heures suivant un traumatisme et l'impact d'un service de prévention des thromboses.

Carbapenem-resistant Klebsiella pneumoniae (CRKP)-associated infections have become a major concern and life-threatening worldwide. Understanding the epidemiology of CRKP using a reliable molecular technology can help to develop an effective infection control policies. In the western region of Saudi Arabia, there are no sufficient data on the prevalence of CRKP and its carbapenem-resistant determinants. Therefore, this study aimed to determine the molecular epidemiology of CRKP and identify the most common carbapenemase genes. In the current study, a total of 191 CRKP isolates were collected and obtained from clinical specimens of patients at King Fahad Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia. All isolates that were resistant or intermediately susceptible to either of the carbapenem antimicrobials (imipenem, meropenem, or ertapenem) were included. All CRKP showed resistance to ceftazidime, cefepime, and piperacillin/tazobactam, whereas low (14%) and moderate (37.7%) levels of resistance were reported against tigecycline and colistin, respectively. The most common carbapenemase genes identified were blaOXA-48 (n = 157 [82.2%]), followed by blaNDM in 27 (14%) isolates. The blaVIM and blaKPC were reported in only one isolate each and no blaIMP producers were detected among all tested isolates. The high prevalence of OXA-48 among K. pneumoniae isolates reported in the current study may reflect that OXA-48 has become an endemic in Saudi Arabian hospitals. The second major finding was that the identification of CRKP co-harbors both blaNDM and blaOXA-48, and such isolates can be threating for healthcare societies (patients and healthcare workers) due to their high level of resistance to carbapenems. These results suggest that the use of molecular diagnostic methods and proper surveillance programs are required to monitor and control the spread of all multidrug-resistant (MDR) bacteria, including CRKP. Therefore, further research is recommended to expand the study and further analyze the genotyping of the most common clones of CRKP in other hospitals in the western regions of Saudi Arabia.