Search

Objective Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting. The absence of a clinical decision support system (CDSS) from direct clinician workflows such as computerized provider order entry (CPOE) hinders the uptake of CDSS. This study implemented CDSS in an environment independent of CPOE, introduced to prescribers via academic detailing, to address the dosing of renally cleared drugs. Design GFR+ was designed to automatically calculate and update renal function, doses of key drugs adjusted for renal function, and highlight clinically significant decreases in renal function. Prescribers were made aware of GFR+, its navigation, and surrounding clinical issues, using academic detailing. Measurement The rate of dosing conformity and management for key renally cleared drugs in hospitalized patients, before and after GFR+ implementation. Results Improvements were seen in dosing conformity for enoxaparin (from 68% to 86%, p¼0.03), gentamicin (63e87%, p¼0.01), and vancomycin (47e77%, p¼0.07), as well as the appropriate use of gentamicin therapeutic drug monitoring (70e90%, p¼0.02). During episodes of acute renal impairment, renally cleared drugs were held on 38% of instances in the pre-intervention period compared with 62% post-intervention (p¼0.01). Conclusion Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalized population. Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that cannot be placed directly into the clinician workflow.

Lepidopteran larvae were sampled in the field to determine levels of infection by the gypsy moth, Lymantria dispar (L.), fungal pathogen, Entomophaga maimaiga Humber, Shimazu & Soper. Lepidopteran larvae were reared from 7 plots in Virginia in which moderate density gypsy moth populations simultaneously exhibited from 40.8 to 97.5% E. maimaiga infection. From a total of 1,511 larvae from 52 species belonging to 7 lepidopteran families in 4 superfamilies, only 2 individuals, 1 of 318 forest tent caterpillars, Malacosoma disstria Hiibner (0.3% infection), and 1 of 96 Catocala ilia (Cramer) (1.0% infection), became infected by entomophthoralean pathogens. Results from genomic DNA probes and bioassays confirmed that E. maimaiga had caused these infections. Laboratory studies yielded infection over a greater diversity of species, and percentages of infection from laboratory studies were higher than findings from the field for the 1 species infected in both the laboratory and field. At all sites, the gypsy moth nuclear polyhedrosis virus also was found, occasionally causing epizootics, but viral occlusion bodies were never found in nontarget Lepidoptera that died. In addition, 279 nontarget Lepidoptera belonging to 34 species in 8 families were collected and reared from areas with low density native gypsy moth populations, and E. maimaiga infections were not found in these nontarget hosts, although E. maimaiga was active in gypsy moth populations. A survey of lepidopteran cadavers collected from 1989 to 1995 containing entomophthoralean spores documented E. maimaiga infections in 3 species of lymantriids. The Lepidoptera-specific North American endemic entomopathogen Entomophaga aulicae (Reichardt in Bail) Humber, which is morphologically identical to E. maimaiga, was found in 1 geometrid species, 1 notodontid, 2 species of arctiids, and 1 introduced lymantriid, but in none of the gypsy moth larvae tested. Our results demonstrate that data from laboratory bioassays are poor estimates for predicting nontarget impact.