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Purpose Prior to the 2020 release of a joint consensus guideline on monitoring of vancomycin therapy for serious methicillin-resistant Staphylococcus aureus (MRSA) infections, clinicians had escalated vancomycin doses for 2 decades while targeting trough concentrations of 15 to 20 µg/mL, leading to an increased frequency of nephrotoxicity. For MRSA infections, the 2020 guideline recommends adjusting doses to achieve a 24-hour area under the concentration-time curve (AUC) of 400 to 600 µg · h/mL; however, monitoring of trough concentrations has been entrenched for 3 decades. Calculating dose regimens based on AUC will require obtaining an increased number of vancomycin serum concentrations and, possibly, advanced software. The aim of this investigation was to determine the relationship between AUC and trough concentration and the influence of dosing regimen on goal achievement. Methods The relationship between trough concentration and AUC was explored through derivation of an equation based on a 1-compartment model and simulations. Results 24-hour AUC is related to dosing interval divided by half-life in a nonlinear fashion. The target trough concentration can be individualized to achieve a desired AUC range, and limiting use of large doses (>15-20 mg/kg) can protect against excessive 24-hour AUC with trough-only monitoring. Conclusion After initially determining pharmacokinetic parameters, subsequent monitoring of AUC can be accomplished using trough concentrations only. Trough concentration may be used as a surrogate for AUC, although the acceptable target trough concentration will vary depending on dosing interval and elimination rate constant. This work included development of an AUC-trough equation to establish a patient-specific target for steady-state trough concentration.

OBJECTIVES To identify opportunities to perform point-of-care (POC) testing and/or screening for infectious diseases in community pharmacies, provide an overview of such tests and how they are used in current practice, discuss how the Clinical Laboratory Improvement Amendments of 1988 (CLIA) affect pharmacists performing POC testing, and identify and discuss barriers and provide recommendations for those wanting to establish POC testing for infectious diseases services in community pharmacies. DATA SOURCES PubMed and Google Scholar were searched from November 2012 through May 2013 and encompassed the years 2000 and beyond for the narrative review section of this article using the search terms rapid diagnostic tests, POC testing and infectious diseases, pharmacy services, CLIA waiver, and collaborative drug therapy management. All state boards of pharmacy in the United States were contacted and their regulatory and legislative websites accessed in 2012 and January 2013 to review relevant pharmacy practice laws. DATA SYNTHESIS POC testing for infectious diseases represents a significant opportunity to expand services in community pharmacies. Pharmacist education and training are addressing knowledge deficits in good laboratory practices and test performance and interpretation. Federal regulations do not define the qualifications for those who perform CLIA-waived tests, yet few pharmacists perform such services. Fewer than 20% of states address POC testing in their statutes and regulations governing pharmacy. CONCLUSION POC testing for infectious diseases could benefit patients and society and represents an opportunity to expand pharmacy services in community pharmacies. Existing barriers to the implementation of such services in community pharmacies, including deficits in pharmacist training and education along with state regulatory and legislative variance and vagueness in statutes governing pharmacy, are not insurmountable.

Voichita Ianas1, Kathryn R Matthias2, Stephen A Klotz11Section of Infectious Diseases and Department of Medicine, 2School of Pharmacy, University of Arizona, Tucson, Arizona, USAAbstract: Posaconazole is the newest azole antifungal approved by the US Food and Drug Administration, and possesses a broad spectrum of activity against numerous yeasts and filamentous fungi. It is available as an oral suspension and is generally well tolerated by patients, but gastrointestinal absorption is sometimes inadequate and remains a clinical concern in treating deep-seated infections. It is used routinely and effectively for the prophylaxis of invasive fungal infections in immunosuppressed hosts and is an effective treatment of oropharyngeal candidiasis, including azole-resistant disease.Keywords: posaconazole, azole, yeasts, filamentous fungi

Purpose Over the past two decades, the minimum inhibitory concentrations (MICs) of ciprofloxacin have been steadily increasing for gram-negative bacteria. One major reason cited for this “MIC creep” is underdosing of ciprofloxacin due to a lack of understanding of its pharmacodynamic properties. The primary objective of this study was to evaluate the frequency of underdosing of ciprofloxacin in a tertiary acute care medical center based on a population pharmacokinetic model. Secondary objectives included evaluation of appropriateness of dosing based on renal function and approved product labeling. Methods Seventy-six patients were included in this single-center, retrospective study. Data collection included demographic, laboratory, and microbiology data along with details on antibiotic administration. Patient-specific predicted 24-hour area under the curve/MIC (AUC24/MIC) values were estimated using a population pharmacokinetic model with a goal predicted AUC24/MIC of at least 100 and a preferred target value of 250. Results Only 8% of the subjects obtained a predicted AUC24/MIC higher than 250, while 34% of the subjects achieved a predicted AUC24/MIC of 100 or less. The majority of patients (79%) received a total daily intravenous-equivalent dose of 800 mg, whereas only 8% of subjects received an initial total daily intravenous-equivalent dose of 1,200 mg, which is the recommended dose for most severe infections. Overall 26% of subjects were prescribed an appropriate initial dose for their estimated renal function based on infection type and severity. Conclusion Ciprofloxacin for acute infection treatment was frequently underdosed based on US Food and Drug Administration–approved labeling and estimated predicted AUC24/MIC at a tertiary acute care medical center.

Purpose The level of nurses' satisfaction regarding pharmacy services provided at a rural medical center was evaluated and compared to data collected in a previous study at the same institution. Information obtained was used to determine potential areas for pharmacy service improvements. Methods This project employed a survey research design that acquired demographic and descriptive data. The updated survey contained 43 items including 34 scaled, seven demographic, and two open-ended items. Aspects assessed by this instrument included accessibility of pharmacists, accuracy of medication delivery, quality of drug information services, and perceptions of pharmacists' value by nursing staff. All inpatient nurse practitioners, licensed practical nurses, and registered nurses who were employed at the Medical Center in the winter of 2004 were eligible to participate in this study. The a priori level of significance for all analyses was two-tailed at 0.05. Results A total of 199 surveys were returned for a response rate of 43.9%. The overall level of nurses' satisfaction with pharmacy services at the Medical Center had not significantly changed between the years of 2000 and 2004; however, satisfaction with several specific aspects of pharmaceutical services changed over time. Increased levels of satisfaction were related to medication accuracy and inpatient pharmacy hours; decreased levels of satisfaction were reported for medication availability in automated medication dispensing machines and pharmacy telephone services. The level of nurses' satisfaction with pharmacy services was increased in relation to the communication between pharmacists and nurses and decreased in relation to technology associated pharmacy services. Conclusion The data gleaned from the survey were evaluated in order to make recommendations to the Medical Center's Director of Pharmacy. An instrument was developed and validated to discern nurses' level of satisfaction with pharmacy services. This methodology may also be used at other institutions.

The effect of protein binding on the antimicrobial activity of ertapenem was evaluated using the bacterial kill rate and concentration-response studies. Various proportions of human serum were utilized to determine the total and free-drug concentrations using a validated high-performance liquid chromatography assay. The MICs and kill curves were determined for test isolates of Enterobacter cloacae and Staphylococcus aureus at various percentages of human serum. The killing of bacteria was analyzed in relation to the free and total concentrations of ertapenem at various proportions of human serum. It was determined that unbound ertapenem was responsible for the antimicrobial activity against the test isolates.

Purpose. The adequacy of end-of-procedure free cefazolin concentrations after administration for the prevention of surgical-site infection (SSI) and compliance with national guidelines for antimicrobial prophylaxis for SSI were assessed. Methods. Patients undergoing elective surgery and receiving cefazolin for perioperative antimicrobial prophylaxis were prospectively enrolled. Antibiotic administration was controlled by the surgeon and usage was recorded. For each patient, a single blood sample for cefazolin serum free and total concentrations was obtained within 15 minutes of wound closure. A free serum concentration threshold of 4 μg/mL was arbitrarily chosen based on the minimum inhibitory concentration required to inhibit 90% of strains of methicillin-susceptible Staphylococcus aureus and Escherichia coli . Results. Fifty-seven subjects were enrolled, and noncompliance with published guidelines was observed for 26% of patients. Forty-six subjects had serum samples available for assay, 21.7% of whom had end-of-procedure free cefazolin concentrations of

We read with interest the recent article by Leong et al.[1][1] concerning the use of adjusted body weight (AdjBW) for determining clearance (CL) of vancomycin in overweight and obese patients. Several previous publications involving the pharmacokinetics of vancomycin in this population have