SAN FRANCISCO – Medication reviews by an antimicrobial stewardship team often led inpatient physicians to adjust antiretroviral regimens or opportunistic infection drugs in hospitalized patients with HIV, according to a recent study at the University of Michigan, Ann Arbor.
The team, consisting of two physicians and three pharmacists specializing in infectious diseases, assessed medications for 69 HIV-infected patients during 114 hospitalizations from March to December 2011.
Jerod L. Nagel, Pharm.D.
"Errors were present both at the time of admission and throughout hospitalization," Jerod L. Nagel, Pharm.D., said in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
Some previous studies have suggested that prescribing errors can be reduced if clinical pharmacists review antiretroviral medications when a patient is admitted, but this may be the first study to integrate daily assessments of antiretroviral therapy and opportunistic infection prophylaxis into the work of a hospital antimicrobial stewardship team, said Dr. Nagel.
Hospitalizations averaged 4 days in duration. The antimicrobial stewardship team identified errors in antiretroviral therapy or opportunistic infection prophylaxis at a mean of 2 days after admission (range, 1-5 days after admission), and made recommendations to the inpatient physician in charge of the patient. All inpatient physicians accepted all of the team’s recommendations reported Dr. Nagel of the University of Michigan, Ann Arbor, and his associates.
As the management of HIV disease has shifted to a chronic-disease model that mainly utilizes outpatient care, hospital providers may be less knowledgeable about the complexities of antiretroviral regimens. The risk of medication errors also is influenced by drug-drug interactions and the need to adjust antiretroviral therapy for acute organ dysfunction that may go undetected throughout hospitalization, he said at the meeting, which was sponsored by the American Society for Microbiology.
Patients in the study ranged in age from 14 to 82 years. They were admitted through the Medicine service in 63% of cases, Surgery in 16%, Hematology/Oncology in 15%, and Pediatrics in 2%; and the rest were admitted through other services.
The antimicrobial stewardship team incorporated into its work flow daily evaluations of the appropriateness of antiretroviral therapy and the dosage regimen (including renal and hepatic adjustments), the appropriateness of regimens and dosages for prophylaxis against opportunistic infections, and clinically significant drug-drug interactions. They evaluated only patients who were on antiretroviral therapy, and so could not assess potential errors in which antiretroviral therapy was omitted completely.
The team identified a total of 26 errors. Of these, 2 involved the omission of at least one antiretroviral agent (8%). Twelve errors involved the antiretroviral dosage regimen incorrectly adjusted for renal impairment or a dose frequency error independent of organ dysfunction (46%). Prophylaxis against opportunistic infection was missing in two patients (8%). The team identified errors in the dose frequency for opportunistic prophylaxis in five patients (19%). Five patients (19%) had clinically significant drug-drug interactions that were not being addressed, involving atazanavir and ranitidine, darunavir and vincristine, or phenytoin and lopinavir/ritonavir.
Enlisting an antimicrobial stewardship team to help manage hospitalized patients with HIV, who are at "a considerable risk of medication errors," might help detect the errors, shorten the duration of their effects, and improve patient care, Dr. Nagel suggested. Computerized systems to reconcile medications and assist clinical decision-making might help prevent these errors, he added.
A tradition of collaboration supports the stewardship team’s work. "We are fortunate to have an excellent working relationship between our hospitalists and clinical pharmacy staff," Dr. Nagel said. "So, implementing an initiative to improve the management of HIV patients by our antibiotic stewardship group wasn’t a major change of culture at our institution. Overall, I think physicians appreciate pharmacy input and don’t view it as ‘correcting’ errors."
The study did not include a historical control group for comparison or analyze clinical and virological outcomes associated with the team’s involvement, but the investigators may pursue these, as well as a cost analysis, in future studies, Dr. Nagel said in an interview.
In general, hospital antimicrobial stewardship teams have started to expand their roles beyond limited functions such as making sure a patient is on the right drug. "We’re trying to focus on a high-risk group and see if we can improve some outcomes," he said.
Dr. Nagel reported having no financial disclosures.