In 2016, the Japanese Society of Chemotherapy and Japanese Society for Surgical Infection jointly issued the “Japanese Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery” (hereinafter referred to as guidelines). The Infection Control Committee of the Gifu Prefectural Society of Hospital Pharmacists conducted a survey to clarify the current status of the perioperative clinical pathway (CP) and the intervention of antimicrobial stewardship team (AST) at various medical institutions in Gifu Prefecture. Furthermore, the said survey aimed to promote the appropriate use of antimicrobial prophylaxis during surgery. Of the 23 hospitals surveyed, 22 hospitals created CP (average 408 licensed beds), and the total number of CPs was 378. The rates of compliance with the CP guidelines were 76.2％ for antibiotic selection, 50.0％ for administration duration, and 42.1％ for both antibiotic selection and administration duration. Lower rates of compliance were observed for the treatment duration rather than for the choice of antimicrobials. Moreover, the AST intervention rate for CP was 36.4％. In addition, we evaluated the effects of antimicrobial stewardship (AS) on guideline compliance. In the univariate analysis, 604 or more beds, AST intervention, AS of pharmacists of more than 23 hours/week, and 4.8 or more pharmacists/100 beds were significant factors for compliance with the CP guideline. Additionally, multivariate analysis showed that AST intervention and AS of pharmacists of more than 23 hours/week were independent factors affecting CP guideline compliance. In conclusion, playing an active role for improvement of CP by AST pharmacists can promote the optimization of antimicrobial prophylaxis in surgery.
At Hiroshima City Hospital, the Antimicrobial Stewardship Team and ward pharmacists monitor cases where the administration of carbapenem antibiotics has been started, and make proposals to the doctor regarding the dose and selection of the antimicrobial agent, and so forth. In the present study, we verified the effectiveness of this approach. As a result, it is suggested that the de-escalation rate and the proposed prescription rate increased significantly, the antimicrobial agent use density / days of therapy value improved, and that this approach had certain utility. In contrast, there was no change in the administration days until de-escalation and the total administration period, and it was considered that the approach should be reviewed and further appropriate use of an antimicrobial agent should be promoted.
In cancer chemotherapy, oral anticancer drugs are used as monotherapy or combination therapy of multiple regimens for various cancer types. In recent years, apart from the conventional cytotoxic anticancer drugs, the number of molecular targeted drugs that target specific factors related to cancer growth and proliferation has been increasing. Despite their benefits, these drugs have characteristic adverse effects, and management becomes more complicated over the long term. On the other hand, the involvement of pharmacists in cancer chemotherapy is also expanding. Some facilities have an adverse effect countermeasure team for each drug. In our hospital, a pharmacist outpatient service for lenvatinib (LEN Outpatient) is being implemented. In this study, we investigated the status of LEN Outpatient and the usefulness of this service. Thirteen patients who utilized LEN Outpatient (intervention group), and 9 patients who did not utilize LEN Outpatient (non-intervention group) were studied. A significantly larger number of patients in the intervention group started first stage dose reduction. The incidence of adverse effects tended to be higher in the intervention group; especially, the incidence of hypertension was significantly higher. The duration of LEN administration tended to be longer in the intervention group. The entry of information about adverse effects in medical records was better in the intervention group. The adoption rate of prescription proposed by pharmacists was 77.5％, with the highest rate for supportive care proposals. These results suggest that pharmacist intervention might have led to earlier detection of adverse effects and earlier implementation of countermeasures.
To evaluate changes in the efficacy and safety of antimicrobial therapy through de-escalation improved by the antimicrobial stewardship (AS) activities, which started from 2013 in Kagawa University Hospital, we analyzed changes in the de-escalation rate and the patient outcomes. The number of carbapenem-treated cases evaluated as ‘improper use’ had decreased from 2013 to 2017. In most of these cases, improper use of blood culture was indicated. The AS team directed the proper use of carbapenem through weekly rounds, focusing on “intervention and feedback” according to the guideline. This activity was performed with emphasis on the appropriate use of blood culture results and the process of target therapy. As a result, it was shown that the number of blood culture orders and the rates of hospitalized cases, for which multiple sets of blood cultures were ordered, were increased. Also, the de-escalation rate of blood culture-positive cases treated with carbapenem was improved from 13.1％ in 2011 to 29.9％ in 2017. Furthermore, as a patient outcome, the 90-day mortality rate was decreased from 24.3％ in 2011 to 15.6％ in 2017. Similarly, the recurrent bloodstream infections rate was decreased from 5.6％ to 0％. On the other hand, in 2011 vs 2017, there was no significant difference in the detection rate of resistant bacteria. Taken together, most of the changes in the indicators related to patient outcome analyzed in the present study suggest that AS activities improved the de-escalation rate, and that the de-escalation contributed to the efficacy and safety of antimicrobial therapy.
One of the adverse effects of benzodiazepine receptor agonists is the high risk of falls. In particular, in elderly people, physiological functions are decreased, so that excessive sedation, muscle relaxation, and carry-over effects often occur; thus, the risk of fall accidents increases. In recent years, sleeping medications with new mechanisms of action, ramelteon and suvorexant, have been launched. The impact of these medicines on fall accidents has not been clarified. Between 2015 and 2018, in-hospital prescriptions for sleeping pills were switched from benzodiazepine receptor agonists to drugs with the new mechanisms of action in our hospital. Subsequently, we evaluated the fall risk by drug mechanism. The number of fall accidents followed an upward trend in 2015, 2016 and 2017 shortly after the switching process started, and followed a downward trend in 2018, when the prescription of benzodiazepine receptor agonists decreased. In contrast, it was shown that the risk of falling with suvorexant was equivalent to that with benzodiazepine receptor agonists. Because confounding factors were not excluded, clear evidence was not obtained, but it is suggested that for patients administered suvorexant, similar to benzodiazepine receptor agonists, the risk of falls should be considered.
Recent studies on nivolumab, an anti-programmed death 1 antibody, demonstrate dramatic improved outcomes for patients with non-small-cell lung cancer (NSCLC). However, serious immune-related adverse events (irAEs) can occur because of nivolumab. The efficacy of the pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as predictive factors for serious irAEs was examined in a retrospective review of 37 outpatients with NSCLC treated with nivolumab at Osaka-fu Saiseikai Noe hospital from December 2015 to June 2018. NLR and PLR were calculated by dividing the number of neutrophils and platelets by that of lymphocytes measured in the peripheral blood. No risk factors in patient characteristics or laboratory data were seen in patients with or without irAEs. ROC curve analysis found the cut-off values of NLR and PLR were 2.95 and 191, respectively, and AUC of NLR and PLR were 0.61 and 0.68, respectively. The irAE incidence at NLR ≧ 2.95 or PLR ≧ 191 was higher than those at NLR < 2.95 or PLR < 191. The incidence of irAEs at NLR ≧ 2.95 and/or PLR ≧ 191 was also higher than that at NLR < 2.95 and PLR < 191. All Grade 3 or higher irAEs were detected at NLR ≧ 2.95 and/or PLR ≧ 191. The combined biomarker, NLR and PLR, is suggested to be useful as a predictive marker for the occurrence and severity of irAEs in patients with NSCLC.