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Background: Medication nonadherence leads to an increase in morbidity and mortality. In the United States, it results in an annual estimated cost of $290 billion in patients with chronic diseases. Several adherence screening tools are available for use, but none have been adopted for widespread use. Objective: Examine the impact of using a novel 3-item adherence tool (The Adherence Estimator) and individualized patient counseling on medication adherence, as determined by rate of initial prescription fill. Methods: This prospective, descriptive study enrolled patients discharged home from an inpatient adult family medicine service who received a prescription for at least one new chronic medication. Patients completed the Adherence Estimator survey for each new medication prescribed. All patients received counseling from a pharmacist or student pharmacist. Date of initial fill was determined by contacting the dispensing pharmacy. Results: The survey was completed for 79 medications. The rate of first fill for medications identified as low, medium, and high risk for nonadherence was 76.5% (n = 28), 71.4% (n = 20), and 94% (n = 17), respectively. Conclusions: The brevity of The Adherence Estimator and the ease of scoring allow the possibility of adoption for widespread clinical use. The survey permits immediate results that allow the clinician to tailor medication counseling toward the 3 most common predictors of nonadherence. The rate of first fill for medications classified as high risk was improved following administration of the tool and targeted medication counseling, 94% in our population compared to predicted probability of adherence of <32%. Several factors, including targeted counseling or study/tool limitations, could account for these results. Consideration should be given to revising the statements in the tool to a lower reading level. This screening tool provides significant advantages over available tools; however, further research is needed to determine the most appropriate population and setting for use of this tool.

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BACKGROUND: Diabetes treatment cost increased 41% from 2007 to 2011. Pharmacists have provided collaborative diabetes management for decades with improvement in disease-related end points. Few have reported economic benefits of pharmacist management of type 2 diabetes. OBJECTIVE: The purpose was to determine if cost savings associated with hemoglobin A1c (A1C) and systolic blood pressure (SBP) change outweighed programmatic pharmacist-physician collaborative care model costs. METHODS: This cost analysis of a 12 month, prospective, multicenter, observational study included English-speaking adults, 18 years or older, with type 2 diabetes mellitus, a life expectancy >1 year, and either a A1C >7%, SBP >130 mm Hg, diastolic blood pressure >80 mm Hg, or low-density lipoprotein concentration >100 mg/dL. Pregnant patients were excluded. Primary analysis outcome was average cost per outcome, ratio of net cost (numerator) and percentage achieving outcomes (denominator). Assessment outcomes included A1C reduction by at least 1% and SBP reduction by at least 5.6 mm Hg. RESULTS: 206 patients were seen by pharmacists during 1612 encounters (mean = 7.8 encounters/patient). Pharmacists spent 983 hours caring for type 2 diabetes patients (mean 3.8 hours/patient). Base case net labor and program costs per patient were -$66.77 and $106.81, respectively. Improvement in A1C and SBP yielded $421.01 in cost savings per patient. Labor and program average costs per patient for each outcome achieved were -$100.40 and $160.61, respectively. CONCLUSIONS: This multisite pharmacist-physician collaboration in diabetes management showed cost savings when assessing pharmacist labor costs alone. Total program costs, including overhead, slightly increased cost of care.

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OBJECTIVES: To assess pharmacy residents' perceptions regarding the incorporation of health literacy in pharmacy school and pharmacy residency training and to assess confidence while interacting with patients of limited health literacy. DESIGN: Prospective cross-sectional study. SETTING: United States from March to May 2012. PARTICIPANTS: Postgraduate year (PGY)1 and -2 pharmacy residents and pharmacy residency program directors. INTERVENTION: Online survey. MAIN OUTCOME MEASURE: PGY1 and -2 resident perceptions of health literacy incorporation into pharmacy school and residency training. RESULTS: 939 surveys were completed. Residents agreed that their pharmacy school training encouraged the development of health literacy skills ( P < 0.001) and made efforts to improve health literacy awareness ( P < 0.001) significantly more than their PGY1 programs. In addition, they felt significantly more confident in their ability to communicate with patients with limited health literacy after their pharmacy school training compared with during or following PGY1 residency training ( P < 0.001); however, no difference was found regarding confidence in identifying patients of limited health literacy. CONCLUSION: PGY1 residency programs lag behind the efforts of schools of pharmacy to incorporate the health literacy training essential to encountering patients of limited health literacy. Future studies should assess whether these perceptions reflect true health literacy awareness and management among pharmacy residents.

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Chronic obstructive pulmonary disease (COPD) is the third most common cause of death in the USA. In 2010, the cost of COPD in the USA was projected to be approximately US$50 billion, which includes $20 billion in indirect costs and $30 billion in direct health care expenditures. These costs can be expected to continue to rise with this progressive disease. Costs increase with increasing severity of disease, and hospital stays account for the majority of these costs. Patients are diagnosed with COPD following a multifactorial assessment that includes spirometry, clinical presentation, symptomatology, and risk factors. Smoking cessation interventions are the most influential factor in COPD management. The primary goal of chronic COPD management is stabilization of chronic disease and prevention of acute exacerbations. Bronchodilators are the mainstay of COPD therapy. Patients with few symptoms and low exacerbation risk should be treated with a short-acting bronchodilator as needed for breathlessness. Progression of symptoms, as well as possible decline in forced expiratory volume in the first second of expiration (FEV1), warrant the use of long-acting bronchodilators. For patients with frequent exacerbations with or without consistent symptoms, inhaled corticosteroids should be considered in addition to a long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA) and may even consist of "triple therapy" with all three agents with more severe disease. Phosphodiesterase-4 inhibitors may be an option in patients with frequent exacerbations and symptoms of chronic bronchitis. In addition to a variety of novel ultra-LABAs, LAMAs and combination bronchodilator and inhaled corticosteroid (ICS) therapies, other bronchodilators with a variety of mechanisms are also being considered, to expand therapeutic options for the treatment of COPD. With more than 50 new medications in the pipeline for the treatment of COPD, optimal management will continue to evolve and grow more complex as benefits of therapy are balanced with the limitations and needs of each patient.

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BACKGROUND: ß-Adrenergic antagonist (ß-blocker) use in patients with chronic obstructive pulmonary disease (COPD) has been avoided as a result of potential risk of pulmonary adverse effects. However, recent studies indicate that ß-blocker use in patients with COPD can decrease outpatient visits and either decrease or have no effect on the number of hospitalizations. Long-term treatment with ß-blockers has been shown to increase survival and decrease exacerbations in patients with COPD. OBJECTIVE: To assess the impact of ß-blocker use on the incidence of exacerbations in patients with COPD. METHODS: In a retrospective cohort study of patients with COPD from 2 academic primary care practice sites who were seen in 2010, patients were identified using International Classification of Diseases, 9th revision, Clinical Modification codes for COPD and reviewing active medication lists for COPD-specific medications (tiotropium). Patients were classified as either a ß-blocker user or a nonuser. Primary outcomes were incidence and severity of COPD exacerbations. Secondary outcomes included COPD exacerbations distinguished by ß-blocker cardioselectivity and all-cause hospitalizations. RESULTS: The study enrolled 412 patients. Of those, 166 patients were ß-blocker users and 246 were ß-blocker nonusers. ß-Blocker users were less likely to have a COPD exacerbation (OR 0.61, 95% CI 0.40-0.93) and had fewer mild exacerbations (OR 0.56; 95% CI 0.34-0.89). There was no significant difference in COPD exacerbations based on ß-blocker cardioselectivity (OR 0.84, 95% CI 0.38-1.83). When controlled for, using a backwards stepwise logistic regression, ß-blocker use was a variable in the model that predicted exacerbations but alone was not statistically significant (adjusted OR 0.62, 95% CI 0.39-1.01). CONCLUSIONS: Patients with COPD prescribed a ß-blocker were significantly less likely to have a COPD exacerbation and had fewer mild COPD exacerbations.

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BACKGROUND AND OBJECTIVES: Although typically symptomatic, chronic obstructive pulmonary disease (COPD) is undertreated as compared to many asymptomatic conditions such as hypertension. Unfortunately, many patients lack basic information about their major disease states, including COPD. The purpose of this study was to assess the clinical utility of the valid and reliable COPD Questionnaire (COPD-Q) in a sample of underserved patients carrying a diagnosis of COPD. METHODS: This prospective, descriptive study enrolled COPD patients at a family medicine residency teaching clinic. Patients were administered a telephone survey assessing COPD knowledge, demographic data, and health literacy. Data regarding COPD clinical outcomes were gathered through the electronic medical record. RESULTS: Average total COPD-Q score was 7.6 plus or minus 2.1 (total possible score=13). Total COPD-Q scores were significantly related to health literacy and educational attainment. CONCLUSIONS: The COPD-Q is a valid, reliable tool used to assess COPD knowledge in a setting that includes patients with limited health literacy. It is useful in identifying key knowledge deficits that will allow the clinician to offer focused, individualized patient education and counseling.

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PURPOSE: Pharmacists' use of mobile technology (MT) to verify medication orders placed during their participation in medical rounds is investigated. METHODS: A retrospective observational study was conducted at a large academic medical center to assess the impact of MT on the average time to pharmacist verification of medication orders written by general medicine staff during pharmacist participation in patient rounds. A total of 260 medication orders for 129 patients were evaluated: 146 orders processed over a one-month period during which rounding pharmacists verified orders using stationary computer terminals on patient care units and 114 orders processed using an MT device. The primary endpoint was the average time to pharmacist verification for all medication orders; average verification times for orders for specific medication classes (analgesics, antibiotics, antidiabetes drugs, and antihypertensives) were also evaluated. RESULTS: Overall, the average time to order verification was significantly lower with the use of the MT device compared with non-MT-assisted order verification (7.5 minutes versus 38.9 minutes, p < 0.001), with significant (p < 0.001) time benefits favoring MT-assisted verification for all order subsets within the evaluated medication classes. Challenges posed by the use of MT-assisted order verification included the selected device's relatively small keyboard and the frequent loss of network connections as the pharmacist moved from floor to floor within the hospital. CONCLUSION: Clinical pharmacists' use of an MT device to verify medication orders written during patient care rounds can significantly decrease the average time required for order verification relative to the use of stationary computer terminals.

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Postgraduate year one (PGY1) and postgraduate year two (PGY2) residencies serve to develop pharmacists into skillful clinicians who provide advanced patient-centered care in various general and specialized areas of pharmacy practice. Pharmacy residencies are a minimum requirement for many clinical pharmacy positions, as well as for positions in academia. The role of clinical pharmacists typically includes teaching, regardless of whether they pursue an academic appointment. Common teaching duties of pharmacist-clinicians include giving continuing education or other invited presentations, providing education to colleagues regarding clinical initiatives, precepting pharmacy students (early and advanced experiences) and residents, and educating other health care professionals. Although ASHP provides accreditation standards for PGY1 and PGY2 residencies, the standards pertaining to teaching or education training are vague. Through the years, teaching certificate programs that develop residents' teaching skills and better prepare residents for a diverse pharmacy job market have increased in popularity; moreover, teaching certificate programs serve as an attractive recruitment tool. However, the consistency of requirements for teaching certificate programs is lacking, and standardization is needed. The Task Force on Residencies developed two sets of guidelines to define teaching experiences within residencies. The first guideline defines the minimum standards for teaching experiences in any residency-training program. The second guideline is for programs offering a teaching certificate program to provide standardization, ensuring similar outcomes and quality on program completion. One of the main differences between the guidelines is the recommendation that residency programs offering a teaching certificate program be affiliated with an academic institution to provide the pedagogy and variety of teaching experiences for the resident. Residency program directors should consider adopting these guidelines to offer consistent teaching experiences. In addition, residents should inquire about the elements of teaching in a program as an aid to selecting the training best suited to their needs.

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OBJECTIVE: To determine pharmacy students' knowledge retention from and comfort level with a patient-case simulation compared with a written patient case. DESIGN: Pharmacy students were randomly assigned to participate in either a written patient case or a simulated patient case in which a high-fidelity mannequin was used to portray a patient experiencing a narcotic and acetaminophen overdose. ASSESSMENT: Participants' responses on a multiple-choice test and a survey instrument administered before the case, immediately after the case, and 25 days later indicated that participation in the simulated patient case did not result in greater knowledge retention or comfort level than participation in the written patient case. Students' knowledge improved post-intervention regardless of which teaching method was used. CONCLUSIONS: Although further research is needed to determine whether the use of simulation in the PharmD curriculum is equivalent or superior to other teaching methods, students' enthusiasm for learning in a simulated environment where they can safely apply patient care skills make this technology worth exploring.

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Bronchodilator drugs are the foundation for the treatment of chronic obstructive pulmonary disease. The principal inhaled bronchodilator treatments used are ß(2) -agonists and anticholinergics, either alone or in combination. Currently available ß(2) -agonists are of either short duration and used multiple times/day, or of long duration, which requires twice-daily administration. Indacaterol is considered an ultra-long-acting ß(2) -agonist and was recently approved for use in the United States. Its duration of action is approximately 24 hours, allowing for once-daily administration. Cough was the most commonly reported adverse effect with use of indacaterol. Cough usually occurred within 15 seconds of inhalation of the drug, lasted around 6 seconds, was not associated with bronchospasm, and did not cause discontinuation of the drug. Otherwise, the drug's safety profile was similar to that of other bronchodilators. Based on similar improvement in spirometric measurements compared with other bronchodilator drugs and the convenience of its once-daily dosing, indacaterol may be beneficial in the management of mild-to-moderate chronic obstructive pulmonary disease, either alone or in combination with anticholinergic drugs administered once/day.

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BACKGROUND AND OBJECTIVES: Smoking cessation interventions should be individualized based on patient history and readiness for change. The objective of this study was to assess stages of change and key components of smoking and cessation history among a sample of primary care patients. METHODS: A telephone survey of current or recent smokers identified smoking status, stage of change, motivation, concerns, relapse history, pharmacotherapy, and social support. RESULTS: Of 150 participants, most were within precontemplation (22.7 percent) or contemplation (44.0 percent) stages of change; 14.0 percent were in preparation, 4.7 percent in action, and 14.7 percent in maintenance. The primary motivation for quitting was to improve general health (42.3 percent). The most common cessation-related concerns were: breaking the habit, stress, and weight gain. Pharmacotherapy was discontinued due to adverse events in 31.5 percent of users. Intratreatment social support was reported by 17.5 percent. The most common reasons for relapse were falling back into the habit (36 percent), stressful situations (27 percent), and being around other smokers (25 percent). CONCLUSIONS: Targeted interventions are needed for patients in either precontemplation or contemplation stages. Counseling should focus on helping patients resolve barriers to cessation and reasons for relapse, particularly stress and weight management. Pharmacotherapy should be utilized when patients are ready to quit. Increased intratreatment social support and counseling appear warranted to support behavior change and appropriate medication use.

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The increasing number of patients affected by chronic obstructive pulmonary disease (COPD) and associated exacerbations has led to both rising hospital admissions and significant economic impact. Evidence-based guidelines have been formulated for COPD management recommending the use of low dose, oral corticosteroid therapy in the treatment of exacerbations. However, fewer than 50% of physicians' prescribing practices appropriately reflect the published clinical guidelines on the use of systemic corticosteroids in these patients. Objective: The purpose of this study was to evaluate the impact of a pharmacist-led educational intervention on prescribing practices and patient outcomes when using systemic corticosteroids in patients with COPD exacerbations. Methods: This retrospective case-control study included patients admitted to an inpatient family medicine service with a COPD exacerbation who received systemic corticosteroids. Two pharmacist-led educational interventions were delivered to prescribers to review current guidelines for managing COPD exacerbations with systemic corticosteroids. Patients were retrospectively identified over a three month span prior to and following the educational intervention. Data was collected via chart review to evaluate prescribing practices prior to and following the educational sessions. In addition, data was collected to evaluate the effects of an educational intervention on length of stay, adverse events, and cost of treatment. Results: A total of 23 pre-intervention patients and 18 post-intervention patients met inclusion criteria. After pharmacist-led interventions, guidelines were not more likely to be adhered to by prescribers when compared to guideline adherence in the pre-intervention patients. Because no statistically significant change in guideline adherence was observed, there was no impact on secondary outcomes. Conclusion: Pharmacist-led didactic educational interventions and guideline dissemination do not improve guideline adherence and prescribing practices with respect to systemic corticosteroids in COPD exacerbations (AU)

El creciente número de pacientes afectados por enfermedad obstructiva pulmonar crónica (EPOC) y las exacerbaciones asociadas han conducido a una elevación de los ingresos hospitalarios y un significativo impacto económico. Se crearon guías basadas en la evidencia fueron creadas para EPOC recomendando el uso de corticoides orales en baja dosis para el tratamiento de las exacerbaciones. Sin embargo, menos del 50% de los actos de prescripción reflejan lo publicado en las guías sobre el uso sistémico de corticoides en estos pacientes. Objetivo: El propósito de este estudio fue evaluar el impacto de una intervención educativa de un farmacéutico sobre la práctica de prescripción y los pacientes ambulatorios cuando se usaban corticoides sistémicos en pacientes con exacerbaciones de EPOC. Métodos: Este estudio retrospectivo caso-control incluyó pacientes ingresados en un servicio de medicina familiar con exacerbación de EPOC que recibieron corticoides sistémicos. Se desarrollaron dos realizaron intervenciones educativas de farmacéuticos a los prescriptores para revisar las guías actuales de manejo de las exacerbaciones de EPOC con corticoides sistémicos. Los pacientes fueron identificados retrospectivamente durante los tres meses previos y posteriores a la intervención. Los datos se recogieron mediante revisión del historial para evaluar las prácticas de prescripción anterior y posterior a las sesiones educativas. Además, se recogieron datos para evaluar los efectos de la intervención educativa en la duración de la estancia, eventos adversos, y coste del tratamiento. Resultados: Un total e 23 pacientes pre-intervención y 18 post-intervención cumplieron los criterios de inclusión. Después de las intervenciones del farmacéutico, las guías no eran seguidas con más probabilidad por los prescriptores cuando se comparaba el cumplimiento de guías con los pacientes pre-intervención. Como no hubo cambios estadísticamente significativos en el cumplimiento de las guías, no hubo impacto en el resultado secundario. Conclusión: Las intervenciones educativas farmacéuticas y la diseminación de guías no mejoraron el cumplimiento de las guías y las practicas de prescripción en relación al uso de corticoides sistémicos en exacerbaciones de EPOC (AU)

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OBJECTIVE: This study evaluated the prevalence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) nasal carriage, risk factors for nasal carriage, and antibiotic susceptibility patterns in college student athletes. DESIGN: Cross-sectional study. SETTING: Methicillin-resistant Staphylococcus aureus nasal samples and data collection forms were obtained at athletic team training rooms at 2 colleges. PARTICIPANTS: : The study population included 277 college student athletes older than 18 years. INTERVENTIONS: A nasal swab was obtained from each athlete after completion of a data collection form. Variables collected on the data collection form included age, sex, race/ethnicity, athletic team, recent health care exposure(s), history of CA-MRSA exposure, recent antibiotic treatment(s), sharing towels, razors or soap, nose picking, and on-campus or off-campus living. MAIN OUTCOME MEASURES: Prevalence of CA-MRSA nasal carriage and antibiotic susceptibility patterns was analyzed. Risk factors for nasal carriage were also evaluated. RESULTS: Five positive CA-MRSA nasal carriers (4 men and 1 woman) were identified of 277 sampled; a prevalence of 1.8%. Two institutions were involved in the study. Institution 1 had 4 positive CA-MRSA nasal carriers of 124 sampled (3.2%). Institution 2 had 1 positive CA-MRSA nasal carrier of 153 sampled (0.65%). No risk factors were found to be significantly associated with positive CA-MRSA nasal carriage. CONCLUSIONS: The prevalence of CA-MRSA nasal carriage in college student athletes in East Tennessee (1.8%) seems similar to what has been reported in the general population (1.5%).

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UNLABELLED: The increasing number of patients affected by chronic obstructive pulmonary disease (COPD) and associated exacerbations has led to both rising hospital admissions and significant economic impact. Evidence-based guidelines have been formulated for COPD management recommending the use of low dose, oral corticosteroid therapy in the treatment of exacerbations. However, fewer than 50% of physicians' prescribing practices appropriately reflect the published clinical guidelines on the use of systemic corticosteroids in these patients. OBJECTIVE: The purpose of this study was to evaluate the impact of a pharmacist-led educational intervention on prescribing practices and patient outcomes when using systemic corticosteroids in patients with COPD exacerbations. METHODS: This retrospective case-control study included patients admitted to an inpatient family medicine service with a COPD exacerbation who received systemic corticosteroids. Two pharmacist-led educational interventions were delivered to prescribers to review current guidelines for managing COPD exacerbations with systemic corticosteroids. Patients were retrospectively identified over a three month span prior to and following the educational intervention. Data was collected via chart review to evaluate prescribing practices prior to and following the educational sessions. In addition, data was collected to evaluate the effects of an educational intervention on length of stay, adverse events, and cost of treatment. RESULTS: A total of 23 pre-intervention patients and 18 post-intervention patients met inclusion criteria. After pharmacist-led interventions, guidelines were not more likely to be adhered to by prescribers when compared to guideline adherence in the pre-intervention patients. Because no statistically significant change in guideline adherence was observed, there was no impact on secondary outcomes. CONCLUSION: Pharmacist-led didactic educational interventions and guideline dissemination do not improve guideline adherence and prescribing practices with respect to systemic corticosteroids in COPD exacerbations.

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BACKGROUND: Medication samples are commonly dispensed by prescribers. Written consumer medication information (CMI) provided with sample packaging is an important source of patient information. Although one-third of Americans have health literacy deficiencies, previous studies have found that CMI is often too complex for many patients to understand. This may prevent patients from using these medications appropriately. OBJECTIVE: To evaluate readability and formatting characteristics of CMI included with nonsolid (ie, topical cream/lotion, inhalation, transdermal) drug samples. METHODS: We collected a convenience sample of nonsolid dosage sample medications (N = 55) from several different private and university-affiliated primary care and specialty physician practices at a large academic medical center in the southeastern US. We noted whether CMI was present and, if it was, we assessed it for instruction presentation, reading level, text size, format/layout, and comprehensibility. RESULTS: Most (43 of 55) products included CMI, either as a separate leaflet or directly on the packaging. Reading level of CMI leaflets ranged from the 6th- to 14th-grade level, with just 4 (16.0%) written at the recommended 6th-grade level. Text font point size was 9.48 +/- 2.14 (mean +/- SD; range 5-12). Text printed directly on sample packaging averaged 6.61 point +/- 2.62 (4-11) font size. Ninety-two percent of CMI leaflets included a combination of text and pictures; only 11.1% of CMI printed directly on the packaging used pictorial aids. CONCLUSIONS: Most CMI accompanying nonsolid medication samples is written at a reading level that exceeds that of many consumers and does not meet recommended standards for readability and comprehensibility of patient education material.

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OBJECTIVE: To report a case of tobramycin-induced hepatotoxicity. CASE SUMMARY: A 20-year-old female was hospitalized for treatment of Pseudomonas aeruginosa bacteremia and osteomyelitis. Empiric intravenous antibiotic therapy with piperacillin/tazobactam, vancomycin, and ciprofloxacin was started, and based on the results of culture and sensitivity testing, was changed to intravenous ceftazidime and tobramycin 70 mg every 8 hours on hospital day 3. Liver enzyme levels then increased over days 3-6. Tests for hepatitis A, B, and C were all nonreactive, and HIV testing was negative. On day 8, therapy was changed from ceftazidime to piperacillin/tazobactam and the tobramycin dose was increased to 100 mg every 8 hours. Due to a continued increase in total bilirubin, aspartate aminotransferase, and alanine aminotransferase, piperacillin/tazobactam was discontinued and aztreonam was started on day 10. All antibiotics were stopped on day 12 and the elevated liver parameters began to decrease. Aztreonam and ciprofloxacin were restarted on day 16, and most laboratory test results returned to baseline levels by day 19; total bilirubin and alkaline phosphatase decreased to lower than baseline values. DISCUSSION: This case illustrates a possible occurrence of tobramycin-induced hepatotoxicity. Liver enzymes rose when tobramycin therapy was initiated, markedly increased when the tobramycin dose was increased, then resolved upon discontinuation of therapy. Other medication-related causes were ruled out by temporal relationship or rechallenge (aztreonam). Use of the Naranjo probability scale indicated a possible relationship between hepatotoxicity and tobramycin therapy. Other adverse reaction scales specific for evaluation of drug-induced liver disease were also used. Both the Council for International Organizations of Medical Sciences and Maria and Victorino scales indicated a probable likelihood of tobramycin-induced hepatotoxicity. This patient was not rechallenged with tobramycin due to the highly suggestive timeline present, lack of specific symptoms, and unnecessary risk to the patient. CONCLUSIONS: Although no other case reports on this interaction have been published through October 9, 2007, historical data from tertiary sources reveal the possibility of aminoglycoside-induced hepatotoxicity; therefore, tobramycin-induced hepatotoxicity cannot be ruled out in this patient. Clinicians should be aware of this adverse event.

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