2023 Research Manuscript Publications


Antifungal Prophylaxis in Adults Receiving Parenteral Nutrition

Denise Truong, PharmD

Background: Candidemia is a serious infection associated with high mortality and prolonged hospital length of stay. Antifungal prophylaxis is warranted in patients with composite risk factors including but not limited to recent intra-abdominal surgery, immunocompromised status, receiving total parenteral nutrition (TPN), having a central venous catheter, and prolonged antibiotic therapies. With a low overall reported incidence of candidemia of approximately 3% in high-risk populations, prophylaxis in general hospitalized patients is likely to be unnecessary. Inappropriate antifungal therapy is associated with higher healthcare cost and unwanted adverse events. The goal of this project is to compare the incidence rates of candidemia in non-abdominal surgical patients receiving parenteral nutrition with and without antifungal prophylaxis to determine if therapy is warranted in this patient population.

Evaluation of optimal care provided to a patient with third- or fourth-degree frostbite presenting to a level II trauma center emergency department

Sabrina Curtis, PharmD 

Background: Frostbite is a cold injury that occurs when patients are exposed to cold temperatures for a prolonged period of time. The Wilderness Medical Society has published clinical practice guidelines for the prevention and treatment of frostbite. Severe frostbite is uncommon and requires prompt attention. The purpose of this study was to evaluate the incidence of guideline concordant care of third- and fourth-degree frostbite presenting within 48 hours to an emergency department.

Evaluation of a pediatric ceftriaxone dose rounding protocol on time to administration in an emergency department

Ricardo Aguirre-escobar, PharmD

Background: Pediatric doses utilize weight-based dosing, which results in doses not available in commercially available products. Dose rounding can round doses to commercially available products, which may be stored in patient care areas and thereby expedite acquisition time. These commercially available products may then be prepared in a patient care area and prepared for administration. In the emergency department (ED), antibiotics are regularly administered empirically. At the Renown Regional Medical Center (RRMC) ED, ceftriaxone is used as a broad-spectrum cephalosporin for the empiric coverage of various infections. Doses of ceftriaxone were prepared at bedside if the dose was available commercially. Otherwise, doses were prepared in the pharmacy IV room and given as an infusion. Workflow is more intense for doses prepared in the IV room, as this utilizes pharmacy technician hours, a double-pharmacist check on the compounded product, and then delivery of the patient specific dose to the patient care area

The impact of a pharmacist on conversion of intravenous to subcutaneous insulin in cardiac surgery patients

Megan Farrell, PharmD

Background: In 2009 the Society of Thoracic Surgeons (STS) published guidelines for perioperative glucose management in cardiac surgery.1 Per STS, continuous insulin infusion is recommended for perioperative glucose control; it is additionally recommended that infusion be initiated intra-operatively and continued for ≥ 24 hours postoperatively in diabetic patients. Perioperative hyperglycemia is an independent predictor of mortality in adults undergoing cardiac surgery, regardless of diabetic status.2,3,4 Maintaining blood glucose levels ≤ 180 mg/dL perioperatively decreases overall mortality and reduces length of hospital stay in both diabetic and non-diabetic patients. Once past the initial 24-48 hours postoperatively patients may be transitioned to subcutaneous insulin. In order to standardize the transition from intravenous to subcutaneous insulin and increase the amount of time in goal glucose range in cardiac surgery patients at Dignity Health - St. Rose Dominican Hospital, a pharmacy-driven protocol was created. This protocol allowed pharmacists to transition adult cardiac surgery patients from intravenous insulin to subcutaneous insulin once blood glucose has stabilized in the post-operative period.

The Impact of a Hospital Protocol in Neonates at Risk for Neonatal Abstinence Syndrome

Victoria Pang, PharmD, MBA

Background: In the midst of the opioid epidemic, neonatal abstinence syndrome (NAS) has become one of the leading causes of extended-stay admissions among neonates nationwide1. Within the last 2 decades, the use of controlled substances in adults, including pregnant women, have nearly quadrupled2. Patients diagnosed with NAS typically stay an average of 22 days in the hospital3. The “Eat, Sleep, Console” (ESC) protocol was designed to maximize non-pharmacological measures to reduce symptoms of NAS, as well as dependence on one or more substances. If pharmacologic treatments are deemed necessary despite non-pharmacological therapy, ESC utilizes a daily morphine taper to slowly reduce dependence on these controlled substances4. Although not well understood, it is hypothesized that implementing protocols such as ESC can decrease length of hospital stay, as well as reduce the usage of morphine and other rescue treatments by nearly 50 percent according to a paper published by Grossman et al. With that in mind, this protocol was implemented at St. Rose Hospital – Siena Campus in September of 2021 to establish a standard of care within the facility, as well as to understand the impact the ESC protocol has on neonatal patients.

 Continuation of Atypical Antipsychotics Initiated in the Trauma ICU at Hospital Discharge

Sarah Forrest, PharmD

Background: The risks associated with transitions of care are well documented. Poor transitions of care have been known to cause delays in appropriate treatment, additional primary care and emergency department visits, increased adverse events, and emotional and physical pain and suffering experienced by patients and family members. Atypical antipsychotics have been identified as medications often continued unnecessarily at transitions of care. The purpose of this study is to determine if patients at University Medical Center of Southern Nevada are being discharged on atypical antipsychotics that were initiated in the ICU.

Pharmacy-led Continuous Sedation Stop Procedure Affect on Ventilation Days

Steven Burgos, PharmD

Background: The use of sedation medications in intensive care units (ICUs) has been common practice to alleviate patient stress and prevent agitation-related harm. Current guidelines prioritize pain management before sedation and recommend light sedation levels, spontaneous awakening trials (SATs), and limited use of benzodiazepines for better outcomes. This study aims to assess the impact of reinforcing SATs and utilizing a multifaceted approach involving analgesic and anxiolytic medications on mechanical ventilation duration in the ICU.


2022 Research Manuscript Publications

The impact of a pharmacist on inpatient urinary tract infections

Aspen Bryant, PharmD
About 150 million urinary tract infections (UTIs) occur globally every year. High prevalence of infection correlates with high antibiotic prescribing and the potential for antibiotic overuse. Inappropriate antibiotic use may approach up to 50%. The rapid, worldwide occurrence of antimicrobial resistance is endangering the efficacy of antibiotics and antibiotic overuse is a major cause. Pharmacists have the potential to play a role in reducing antimicrobial resistance by monitoring for appropriate antibiotic usage. There are different types of UTIs: pyelonephritis (involving the upper urinary tract) and cystitis (only involving the lower urinary tract). These types can be further broken down into uncomplicated (occurring in females, cystitis and lower urinary tract symptoms only) and complicated (occurring in males, pyelonephritis, and/or cystitis with one or more complicating factors). The recommended treatment for an uncomplicated UTI is 3 to 7 days of antibiotics. The recommended treatment for a complicated UTI is typically 5 to 14 days of antibiotics.

Dose effectiveness of piperacillin/tazobactam in prophylaxis of type III open fractures
Justin N. Fernando, PharmD
Open-fractures are commonly classified using the Gustilo-Anderson classification system. A type III fracture is defined as an open segmental fracture, open fracture with extensive soft tissue damage, or a traumatic amputation. Patients with type III fractures have up to a 40% chance of developing an infection at the site of injury. Piperacillin/tazobactam is sometimes used for post-operative prophylaxis in this patient population, however optimal dosing strategies are unknown. This study explored the safety and efficacy of different doses of piperacillin/tazobactam in the prevention of surgical site infections in contaminated type-III open fractures.

Rates of vancomycin associated nephrotoxicity when converting to AUC in a community hospital
Vivian Lee, PharmD
Vancomycin is the mainstay treatment for methicillin-resistant Staphylococcus aureus (MRSA) infections. Efficacious treatment is typically associated with an AUC:MIC between 400-600 mcg*h/mL. Recent studies have suggested that using a trough of 15 mg/L as a surrogate marker inaccurately estimates AUC and correlates with increased risk of nephrotoxicity. Vancomycin induced nephrotoxicity (VIN) is the development of acute kidney injury (AKI) on vancomycin therapy with no other apparent cause. The 2020 revised consensus guideline on therapeutic monitoring of vancomycin for serious MRSA infections now recommend AUC-guided dosing and monitoring as the most accurate and optimal way to manage therapy. The objective of this study aims to evaluate the safety of AUC-guided dosing as compared to trough-based dosing in relation to the rates of VIN in a community hospital setting.