The oral azole drugs--ketoconazole, fluconazole, and itraconazole--represent a major advance in systemic antifungal therapy. Among the three, fluconazole has the most attractive pharmacologic profile, including the capacity to produce high concentrations of active drug in cerebrospinal fluid and urine. Ketoconazole, the first oral azole to be introduced, is less well tolerated than either fluconazole or itraconazole and is associated with more clinically important toxic effects, including hepatitis and inhibition of steroid hormone synthesis. However, ketoconazole is less expensive than fluconazole and itraconazole--an especially important consideration for patients receiving long-term therapy. All three drugs are effective alternatives to amphotericin B and flucytosine as therapy for selected systemic mycoses. Ketoconazole and itraconazole are effective in patients with the chronic, indolent forms of the endemic mycoses, including blastomycosis, coccidioidomycosis, and histoplasmosis; itraconazole is also effective in patients with sporotrichosis. Fluconazole is useful in the common forms of fungal meningitis--namely, coccidioidal and cryptococcal meningitis. In addition, fluconazole is effective for selected patients with serious candida syndromes such as candidemia, and itraconazole is the most effective of the azoles for the treatment of aspergillosis.

These results suggest a need for ensuring that prescribers review each patient's allergy profile before order entry.

Although the long-term implications of drug-induced lipoprotein changes are still undefined, physicians need to consider these effects in clinical practice.

This continuing feature highlights the experiences of various health care organizations regarding the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Medication Management Standards and National Patient Safety Goals implementation. Practical information on what worked and how organizations have been surveyed regarding the standards and goals will be provided along with updates on revisions and recommendations being established by JCAHO. To share your success stories, contact Sondra K. May, PharmD, Department of Pharmacy Services, University of Colorado Hospital, 4200 East Ninth Avenue, Box A-027, Denver, CO 80262. E-mail: sondra.may@uch.edu. Purpose Changes in the JCAHO survey process and in the scope of the standards governing medication management (MM) make it no longer possible to have the Pharmacy Department as the sole contact point for JCAHO questions pertaining to medication use. In an effort to raise awareness of MM standards to the institutional level, we conducted an exhaustive review of individual standards and communicated shared points of responsibility to persons outside the Pharmacy Department. Methods Organizational changes were implemented to direct our efforts. These included instituting an ad hoc Pharmacy Department Committee and creating a Coordinator for MM standards position. Hospital organizational structure changed, so the Pharmacy Director now reports directly to the Chief Operating Officer. A spreadsheet outlined each MM standard including existing policies, those requiring revision, and departmental or interdisciplinary actions needed. Other disciplines were involved as indicated in policy revisions and improvements in medication-use systems. A new process for holding other departments accountable for medications purchased and stored outside of Pharmacy was implemented. Staff education focused on key issues and standards. Mock surveys were regularly conducted. Results Policies were revised in collaboration with the Pharmacy and Therapeutics Committee and other interdisciplinary teams. Departments purchasing their own medications routinely inspect their stock. Pharmacy staff education became routine. Conclusions Through focused interdisciplinary efforts, our institution addressed potential deficiencies, improved medication safety and was better prepared for the JCAHO survey. The first unannounced survey was just completed. There were no Recommendations for Improvement (RFIs) regarding the MM standards.

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