Pharmacists may be tasked to lead antibiotic stewardship programmes (ASP) implementation in small hospitals in absence of infectious diseases (ID) physicians. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a hospital without ID physician support, with special focus on indicators of the hospital use of antimicrobial agents based on consumption and asess the potential clinical and economic impact of pharmacist interventions (PIs) through the CLEO tool. A prospective quasi-experimental study to implement an ASP in a 194-bed hospital. We evaluated changes in antimicrobial use measured as mean defined daily doses per 1000 patient-days (AUD) for intervention versus preintervention period. A total of 847 antimicrobial PIs were proposed, being 88.3% accepted. Discontinuation due to excessive duration was the most frequently performed PI (23.4%). Most of PIs was classified as major or moderate clinical impact, 41.7% and 37.8% respectively. The global consumption of antimicrobial was reduced from 907.1 to 693.8 AUD, with a signifcant drop in carbapenems and quinolones. Direct expenditure of antibiotics decreased significantly. Pharmacist-led ASP has being effective in reducing consumption of antibiotics. In the absence of ID physician´s support and oversight, pharmacists could lead the improvement of the use of antimicrobials.

Pulmonary arterial hypertension is an infrequent but nevertheless serious life-threatening severe complication of HIV infection. It can be treated with bosentan and oral anticoagulants. Bosentan could induce the acenocoumarol metabolism and it increases the INR values. Until now, no study of interaction between bosentan and oral anticoagulants in HIV patients has reported. So we present a case of this interaction between these drugs and we reviewed MEDLINE to identify all the papers published so far. In our case, several weeks after increasing dose of bosentan acenocoumarol dose had to be progressively increased to 70 mg/week (+33%) without obtaining an adequate INR level (2.0–3.0). Forty-nine days later, we achieved a therapeutic INR with 90 mg/week of warfarin. The use of bosentan and oral anticoagulants together in these patients require a closer monitoring during first weeks of treatment, after increasing the bosentan dose and even during longer periods of time.

Antimicrobials are the most frequently prescribed drugs in long-term care facilities (LTCF). Antibiotic stewardship programs (ASP) are coordinated interventions promoting the responsible use of antibiotics to improve patient outcomes and reduce antibiotic resistant bacterias. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a LTCF, to characterise antibiotic therapy and assess the appropriateness of antibiotic prescriptions. A prospective quasi-experimental study to implement an ASP in a LTCF. Antibiotic prescriptions for suspected infections initiated in any setting for LTCF residents were included. We assessed appropriateness and prospective audits and feedback of each inappropriate antimicrobial prescription were carried out. Associations of variables with appropriate antibiotic prescribing were estimated using logistic regression. A total of 416 antibiotic prescriptions were included. The mean consumption of antibiotics was reduced from 63.2 defined daily doses per 1000 residents-days (DRD) in the preintervention period to 22.8 in the intervention period (− 63.8%), with a signifcant drop in fluoroquinolones (81.4%). Overall, 46.6% of antibiotic prescriptions were judged inappropriate, mainly because of a use not recommended in treatment guidelines (63.2%). Multivariable analysis showed that empirical therapy, some classes of antibiotics (cephalosporins, fluoroquinolones, fosfomycin calcium, macrolides) and prescription initiation in the emergency department were independent predictors of antimicrobial inappropriateness. Pharmacist-led ASP in a LTCF has being effective in reducing consumption of antibiotics by improving appropriateness of treatment decisions. However, ASP should include interventions in the emergency department because of the high inappropriate use in this setting.