Drug-induced thrombocytopenia is a rare but serious adverse event that has been associated with multiple drugs including β-lactams. Although it mostly occurs with prolonged medication use, some cases of rapid-onset thrombocytopenia have been reported. We describe the case of a 69-year-old man who developed severe and immediate thrombocytopenia following reexposure to piperacillin-tazobactam in the critical care setting. He received a 6-day course of piperacillin-tazobactam for a possible pneumonia immediately after cardiac surgery. During this course of therapy, his platelet count decreased (fluctuating between 69 × 10(3) /mm(3) and 104 × 10(3) /mm(3) ) and then progressively increased after completion of the antibiotic to 340 × 10(3) /mm(3) on postoperative day 15. Ten days after the antibiotic course was completed (postoperative day 16), the patient developed new signs of infection (fever and neutrophilia), and piperacillin-tazobactam was restarted. Eight hours after reintroducing the antibiotic, his platelet count dropped from 317 × 10(3) /mm(3) to 7 × 10(3) /mm(3) . After reviewing all the medications administered to the patient as well as other potential causes of thrombocytopenia, and given the chronology of events, piperacillin-tazobactam was suspected as the most likely offending agent and was therefore replaced by meropenem on postoperative day 17. The patient's platelet count began to rise 2 days after discontinuation of piperacillin-tazobactam and reached 245 × 10(3) /mm(3) by postoperative day 30. No spontaneous bleeding or thrombosis occurred while the patient was thrombocytopenic. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a probable relationship (score of 6) between the patient's development of thrombocytopenia and piperacillin-tazobactam therapy. This case highlights the severity and swiftness in which drug-induced thrombocytopenia may present in the context of cardiac surgery.

<p><strong>ABSTRACT</strong></p><p><strong>Background:</strong> Spontaneous reports of adverse drug reactions (ADRs) form an essential component of both drug safety monitoring and patient safety initiatives. Pharmacists are well positioned to report ADRs, but many barriers exist to their doing so. Over the past decade, substantial changes have occurred with regard to drug regulations and medication safety initiatives, and it is possible that knowledge-based interventions may be needed to enhance ADR reporting by pharmacists.</p><p><strong>Objective:</strong> To determine whether ADR reporting behaviours of pharmacists improved after release of a revised policy on the reporting of medication incidents.</p><p><strong>Methods:</strong> A telephone survey was administered to pharmacists practising in the Canadian Forces Health Services Group. Self-reported behaviours and perceived barriers related to ADR reporting were compared before and 3 months after the updated policy was released. Accuracy in participants’ self-assessed ADR reporting was evaluated using independently derived workload statistics.</p><p><strong>Results:</strong> During the second survey phase (after release of the revised policy), a greater proportion of respondents reported awareness of institutional policies on ADR reporting and declared that they were able to complete all necessary ADR reports during their assigned work hours. However, the number of ADR reports submitted did not increase. Participants’ recall of their ADR reporting behaviour was corroborated<br />by workload data. During the second survey phase, there was a noticeable reduction in the number of free-form comments mentioning lack of staff as a barrier to ADR reporting.</p><p><strong>Conclusions:</strong> Release of a more comprehensive policy was not associated with an increase in the number of ADR reports generated by pharmacists in the study setting. Interventions to strengthen the organization’s work processes for detection of ADRs and submission of individual ADR reports should be strongly considered, to reinforce and enhance existing ADR reporting behaviours among pharmacists.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte :</strong> Les déclarations spontanées des réactions indésirables aux médicaments (RIM) sont essentielles à la pharmacovigilance et aux initiatives au profit de la sécurité des patients. Les pharmaciens sont bien placés pour déclarer des RIM, mais divers éléments y font obstacle. Au cours de la dernière décennie, d’importants changements ont eu lieu en ce qui touche aux règlements sur les médicaments et aux initiatives en sécurité des médicaments, et il est possible que des interventions fondées sur le savoir soient nécessaires pour améliorer dans l’ensemble les déclarations des RIM par les pharmaciens.</p><p><strong>Objectif :</strong> Déterminer si les habitudes des pharmaciens relatives à la déclaration des RIM se sont améliorées après la mise à jour d’une politique portant sur la déclaration des incidents liés aux médicaments.</p><p><strong>Méthodes :</strong> Les pharmaciens qui exerçaient dans le Groupe des Services de santé des Forces canadiennes ont été sondés par téléphone. On a comparé les réponses des pharmaciens quant à leurs propres habitudes de déclaration et aux éléments perçus comme des obstacles à la déclaration des RIM, avant la mise à jour de la politique et trois mois après sa mise à jour. L’exactitude des réponses des participants à propos de leurs propres habitudes de déclaration des RIM a été vérifiée à l’aide de statistiques sur la charge de travail obtenues indépendamment.</p><p><strong>Résultats :</strong> Pendant la deuxième phase de l’enquête (après la mise à jour de la politique), une plus grande proportion de répondants ont indiqué être conscients des politiques institutionnelles sur la déclaration des RIM<br />et ils ont soutenu qu’ils étaient en mesure de remplir tous les rapports de déclaration des RIM nécessaires pendant leurs heures normales de travail. Cependant, le nombre de déclarations de RIM soumises n’a pas crû. Les<br />habitudes de déclaration de RIM que les participants ont affirmé avoir ont été corroborées par les données sur la charge de travail. Dans la deuxième phase de l’enquête, il y a eu une baisse notable du nombre de<br />commentaires libres indiquant le manque de personnel comme obstacle à la déclaration des RIM.</p><p><strong>Conclusions :</strong> La mise en place d’une politique plus détaillée n’a pas été associée à une augmentation du nombre de déclarations de RIM produites par des pharmaciens dans le contexte de cette étude. Des interventions visant à améliorer, au sein de l’organisme, les méthodes de travail pour la détection des RIM et le dépôt de déclarations de RIM individuelles doivent être fortement envisagées afin de consolider et d’améliorer les habitudes de déclaration des RIM chez les pharmaciens.</p><p> </p><p> </p>

BackgroundAppropriate antibiotic (AB) therapy is crucial in sepsis and septic shock. Two central factors govern patient survival: adequate empiric coverage and rapid initiation of therapy. The administration of broad-spectrum antibiotics in sepsis and septic shock play an important role diminishing patient morbidity and mortality.1 The sequence of antibiotic administration has been suggested to affect patient outcomes.2MethodsThis is a retrospective study to assess the impact of a pictogram (Figure 1) in the emergency department medication rooms on nurses’ antibiotic administration order in the septic patient. The study population included patients prescribed at least two concomitant AB between January 2017 and January 2018. Each patient’s AB regimen, indication and administration sequence were reviewed using a standardized form. Sequence of administration was deemed appropriate if the sequence followed the pictogram: broad to narrower spectrum AB, and was deemed inappropriate if the sequence differed from the pictogram. Ethics approval was obtained before starting the chart review.ResultsA total of 120 patients were identified pre-/postintervention. 20% (10/51) had received AB in an incorrect sequence prior to the pictogram implementation compared with 11% (8/70) postintervention. AB prescribed were piperacillin/tazobactam (24%), azithromycin (24%) and vancomycin (18%), ceftriaxone (15%) for sepsis arising from pneumonia, urinary tract, and intra-abdominal infections.ConclusionThe availability of a pictogram to guide the sequence of antibiotic administration in the septic patient can assure its correct administration sequence and potentially affect patient outcomes. An improvement (45%,P = 0.2) was seen post implementation suggesting the pictogram to be a helpful visual aid for nurses. Although not statistically significant, the difference implies a tendency that may be explored in a larger sample size to search for a potential effect.References1. Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Crit Care Med 2017(45)486–552.2. Roberts R, et al. Impact of Antibiotic Initiation Sequence on Outcomes in Patients with Septic Shock. Poster 652. Crit Care Med 2016(44) Suppl. Disclosures All authors: No reported disclosures.