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The purpose of this paper was to review the literature regarding the clinical and economic impact of pharmacist interventions (PIs) related to antimicrobials in the hospital setting. A PubMed literature search from January 2003 to March 2016 was conducted using the terms pharmacist* or clinical pharmacist* combined with antimicrobial* or antibiotic* or anti-infective*. Comparative studies that assessed the clinical and/or economic impact of PIs on antimicrobials in the hospital setting were reviewed. Outcomes were classified as: treatment-related outcomes (TROs), clinical outcomes (COs), cost and microbiological outcomes (MOs). Acceptance of pharmacist recommendations by physicians was collected. PIs were grouped into patient-specific recommendations (PSRs), policy, and education. Studies' risk of bias was analyzed using Cochrane's tool. Twenty-three studies were evaluated. All of them had high risk of bias. The design in most cases was uncontrolled before and after. PSRs were included in every study; five also included policy and four education. Significant impact of PI was found in 14 of the 18 studies (77.8%) that evaluated costs, 15 of the 20 studies (75.0%) that assessed TROs, 12 of the 22 studies (54.5%) that analyzed COs, and one of the two studies (50.0%) that evaluated MOs. None of the studies found significant negative impact of PIs. It could not be concluded that adding other strategies to PSRs would improve results. Acceptance of recommendations varied from 70 to 97.5%. Pharmacists improve TROs and COs, and decrease costs. Additional research with a lower risk of bias is unlikely to change this conclusion. Future research should focus on identifying the most efficient interventions.

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OBJETIVO: La conciliación de la medicación se considera un elemento clave en la seguridad del paciente, no existiendo apenas datos sobre cómo afecta al paciente crítico. En este estudio, se evalúa un programa de conciliación en el paciente crítico liderado por el farmacéutico adscrito a la Unidad de Cuidados Intensivos (UCI).DISEÑO: Estudio prospectivo sobre los errores de conciliación en 50 pacientes. Ámbito: UCI médico-quirúrgica. PACIENTES: Se incluyó a todos los pacientes con estancia en UCI, excluyendo a los pacientes sin tratamiento habitual. INTERVENCIONES: La conciliación de la medicación se realizó en las primeras 24 h tras el ingreso en UCI. En caso de encontrar discrepancias, se contactó con el médico responsable. Variables principales: Se analizó la incidencia, tipo y gravedad de los errores, sus características, las intervenciones realizadas y su aceptación por el médico responsable. RESULTADOS: El 48% de los pacientes presentó algún error de conciliación. La omisión de fármacos supuso el 74% de los mismos, afectando principalmente a fármacos antihipertensivos (33%). El58% de los errores de conciliación corresponden a la categoría D de gravedad. Se realizaron sugerencias al prescriptor en el 98% de los pacientes con discrepancias, aceptándose el 81% de las intervenciones. CONCLUSIONES: Los errores de conciliación en UCI tienen una incidencia y características similares a los referenciados en pacientes no críticos, afectando a grupos terapéuticos de gran significación clínica. Nuestros datos apoyan la incorporación de los procesos de conciliación al cuidado habitual del paciente crítico. El farmacéutico adscrito a la unidad puede llevar a cabo el proceso adecuadamente. (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. CONCLUSIONS: The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately

OBJECTIVE: Medicines reconciliation plays a key role in patient safety. However, there is limited data available on how this process affects critically ill patients. In this study, we evaluate a program of reconciliation in critically ill patients conducted by the Intensive Care Unit's (ICU)pharmacist. DESIGN: Prospective study about reconciliation medication errors observed in 50 patients. Scope: ICU. PATIENTS: All ICU patients, excluding patients without regular treatment. INTERVENTIONS: Reconciliation process was carried out in the first 24 h after ICU admission. Discrepancies were clarified with the doctor in charge of the patient. Main variable: We analyzed the incidence of reconciliation errors, their characteristics and gravity, the interventions made by the pharmacist and their acceptance by physicians. RESULTS: A total of 48% of patients showed at least one reconciliation error. Omission of drugs accounted for 74% of the reconciliation errors, mainly involving antihypertensive drugs (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. CONCLUSIONS: The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately

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OBJECTIVE: Medicines reconciliation plays a key role in patient safety. However, there is limited data available on how this process affects critically ill patients. In this study, we evaluate a program of reconciliation in critically ill patients conducted by the Intensive Care Unit's (ICU) pharmacist. DESIGN: Prospective study about reconciliation medication errors observed in 50 patients. SCOPE ICU PATIENTS: All ICU patients, excluding patients without regular treatment. INTERVENTIONS: Reconciliation process was carried out in the first 24h after ICU admission. Discrepancies were clarified with the doctor in charge of the patient. MAIN VARIABLE: We analyzed the incidence of reconciliation errors, their characteristics and gravity, the interventions made by the pharmacist and their acceptance by physicians. RESULTS: A total of 48% of patients showed at least one reconciliation error. Omission of drugs accounted for 74% of the reconciliation errors, mainly involving antihypertensive drugs (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. CONCLUSIONS: The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately.

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OBJECTIVE: To quantify the impact of the incorporation of a hospital pharmacy resident into a healthcare team. To describe the work schedule followed. METHOD: The resident was integrated for 8 months in Medical Oncology, Intensive Care Unit, and Oncology Day Hospital. Interventions were recorded and evaluated using Atefarm software. Problem characteristics, type, and severity were recorded, as were acceptance, and costs avoided by interventions. RESULTS: In all, 2,415 drug-related problems were detected (10 per day, and 3.6 per patient), and 2,545 interventions for 672 patients were carried out. Most common problems were inadequate treatment duration, and conversion to oral route. Sixty-one percent of errors were prevented. Sixty-five percent of interventions influenced safety, 35% efficiency, and 25% effectiveness. Ninety-four percent of interventions were accepted. Costs avoided by the pharmacist amounted to 3,133 euro per month. CONCLUSIONS: The integration of a pharmacist in the healthcare teams optimizes therapy, reduces costs, prevents adverse events, and offers healthcare education.

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Objetivo: Cuantificar el impacto de la integración de un residentede Farmacia Hospitalaria en el equipo asistencial. Describirla sistemática de trabajo seguida.Método: El residente se integró durante 8 meses en oncologíamédica, unidad de cuidados intensivos y hospital de día de oncología.Las intervenciones se registraron y evaluaron mediante elprograma informático Atefarm®. Se registraron las características,tipo y gravedad de los problemas y la aceptación y coste evitadode las intervenciones.Resultados: Se detectaron 2.415 problemas relacionadoscon los medicamentos (10 por día y 3,6 por paciente) y se realizaron2.545 intervenciones sobre 672 pacientes. Los más frecuentesfueron la inadecuada duración de los tratamientos y la conversióna vía oral. El 61% de los errores fueron prevenidos. Un 65%de las intervenciones tuvo impacto sobre seguridad, 35% sobreeficiencia y 25% sobre efectividad. El 94% de las intervencionesfueron aceptadas. El coste evitado por farmacéutico/mes ascendióa 3.133 €.Conclusiones: El farmacéutico integrado en los equipos asistencialesoptimiza la terapia, reduce costes, previene efectosadversos y ofrece educación sanitaria

Objective: To quantify the impact of the incorporation of ahospital pharmacy resident into a healthcare team. To describethe work schedule followed.Method: The resident was integrated for 8 months in MedicalOncology, Intensive Care Unit, and Oncology Day Hospital. Interventionswere recorded and evaluated using Atefarm®‚ software.Problem characteristics, type, and severity were recorded, as wereacceptance, and costs avoided by interventions.Results: In all, 2,415 drug-related problems were detected(10 per day, and 3.6 per patient), and 2,545 interventions for672 patients were carried out. Most common problems wereinadequate treatment duration, and conversion to oral route. Sixty-one percent of errors were prevented. Sixty-five percent ofinterventions influenced safety, 35% efficiency, and 25% effectiveness.Ninety-four percent of interventions were accepted.Costs avoided by the pharmacist amounted to 3,133 per month.Conclusions: The integration of a pharmacist in the healthcareteams optimizes therapy, reduces costs, prevents adverseevents, and offers healthcare education

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OBJECTIVE: To report a case of delayed elimination of high-dose methotrexate (MTX) associated with concomitant omeprazole administration. CASE SUMMARY: Delayed MTX elimination was observed in an 11-year-old white boy who concomitantly received high-dose MTX and omeprazole. The patient's serum creatinine and liver function tests were normal during treatment and follow-up. The only medication we suspected of inhibiting MTX elimination was omeprazole 20 mg every 12 hours. Twenty-four hours after the first high-dose MTX cycle (15 g), omeprazole was discontinued. Thereafter, the patient received one high-dose MTX cycle without omeprazole every month for five months; MTX elimination was normal throughout MTX cycles 2 to 5. DISCUSSION: MTX is actively secreted in the distal tubules. The renal hydrogen/potassium adenosine triphosphatase (H+/K(+)-ATPase) pump makes the urine more acidic, by secreting hydrogen ions into the renal tubule and reabsorbing potassium ions. Active tubular secretion of MTX requires the activity of this pump because MTX is excreted with hydrogen ions. Omeprazole can inhibit renal elimination of the hydrogen ion and block the active tubular secretion of MTX. Therefore, the elimination half-life of MTX increases, which may result in potentially toxic concentrations of MTX. At a pH of approximately 5, as found in the renal tubules, pantoprazole is more slowly activated than omeprazole, reducing the incidence of unwanted reactions with sulfhydryl groups and adverse effects occurring outside of the gastric hydrogen pump. CONCLUSIONS: Based on the Naranjo probability scale, a probable drug interaction was observed. Omeprazole may delay MTX elimination; therefore, when prescribing MTX, an alternative to omeprazole should be considered.

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