Background: Approximately 30% of antimicrobials prescribed in the outpatient setting are unnecessary and up to 50% are inappropriate. Despite this, antimicrobial stewardship (AS) efforts mostly focus on the inpatient setting, and limited data describe AS interventions at hospital discharge. Acknowledging the potential value of discharge AS, we used our existing resources to review discharge oral antimicrobial prescriptions. Objective: The primary objective of this retrospective, single-center study was to evaluate the impact of an AS program on discharge oral antimicrobial prescriptions. Methods Discharge oral antimicrobial prescriptions sent to our hospital-operated outpatient pharmacy, reviewed by an infectious diseases (ID) pharmacist, and recorded into our data collection tool from September 1, 2020, to February 28, 2021, were evaluated retrospectively. The primary outcome was to identify the frequency a drug-related problem (DRP) was identified by an ID pharmacist. Secondary outcomes included DRP characterization, percentage of prescriptions with interventions, intervention acceptance rate, and reduction in antimicrobial days dispensed at discharge when interventions to limit treatment duration were accepted. Results: Of the 803 discharge oral antimicrobial prescriptions reviewed, at least 1 DRP was identified in 43.1% (346/803). The most frequently identified DRPs pertained to treatment duration, drug selection, and dose selection. At least 1 intervention was recommended in 42.8% (344/803) of prescriptions. In total, 438 interventions were made and the acceptance rate was 75.6% (331/438). The most common types of interventions included recommendations for a different duration, a different dose or frequency, and antimicrobial discontinuation. When interventions to reduce treatment duration were accepted, the median (interquartile range) number of antimicrobial days decreased from 8 (5-10) days to 4 (0-5.5) days ( P < 0.001). Conclusion and Relevance: An ID pharmacist’s review of discharge oral antimicrobial prescriptions sent to our hospital-operated outpatient pharmacy resulted in identification of DRPs and subsequent interventions in a substantial number of prescriptions.

Purpose: The purpose of the article is to describe the successful use of parenteral olanzapine intravenously (IV) in a critically ill patient with severe agitated delirium. Summary: A 70-year-old man was admitted to the medical intensive care unit requiring plasmapheresis with platelet counts consistently below 20 000/µL secondary to thrombotic thrombocytopenic purpura (TTP). The patient had experienced agitated delirium requiring treatment, which was complicated by electrocardiogram (EKG) findings of a prolonged QTc interval. The antipsychotics the patient was receiving were believed to be responsible and, as such, the team desired an option that would have a lesser chance of worsening QTc (baseline-corrected QT) interval. Olanzapine was chosen and given IV versus the U.S. Food and Drug Administration (FDA)–approved parenteral route of intramuscular (IM) due to concern of bleeding. The patient’s delirious state responded to treatment to varying degrees and showed no increase in EKG abnormalities. To our knowledge, there is a paucity of published literature regarding this route of administration. Conclusion: Intramuscular olanzapine used IV may be a safe and effective option for the treatment of acutely agitated, delirious, critically ill patient.

Background: Dinutuximab, an immune-mediated therapy indicated for high-risk neuroblastoma, targets the protein disialoganglioside (GD2) on neuroblastoma cells, neurons, and peripheral nerve fibers. Off-target effects lead to severe nerve pain. Pain regimens including continuous infusion opioids are required during treatment courses.Our institution utilizes a combination of intravenous (i.v.) lidocaine infusions and morphine for the treatment of dinutuximab-associated neuropathic pain. Objective:The primary outcome of this study was to compare morphine equivalents for cycle 1 of dinutuximab at an institution that uses i.v. lidocaine (primary) versus those that do not (comparison). Secondary outcomes included both dinutuximab infusion time and safety of i.v. lidocaine. Methods:A retrospective, multicentered, electronic chart review was performed at three tertiary academic medical centers. Patients between 0 and 18 years of age during their first course of dinutuximab were included to evaluate the primary outcome of adjuvant morphine equivalents needed.Results: Twenty-one patients were identified for inclusion. Total morphine equivalents at the primary institution were 1.87 mg/kg versus 1.79 mg/kg at the comparison institutions (P = 0.413). Dinutuximab infusion time was statistically significantly less at the primary institution: 610.5 minutes versus 676.23 minutes (P = 0.046). Only one patient at the primary institution experienced nausea, vomiting, and paresthesias.Conclusions: This study did not find a statistically significant difference in morphine equivalents between patients receiving i.v. lidocaine and those who did not. Lidocaine use resulted in a statistically significant lower dinutuximab infusion time. Our data suggest it is a safe adjuvant medication, for use outside of the pediatric intensive care unit, in the treatment of dinutuximab-associated neuropathic pain.