Farida Hanim Islahudin

Faculty of Pharmacy, Universiti Kebangsaan Malaysia, 50300 Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia

Beware of Triple Whammy

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    Abstract

    The term “triple whammy” refers to a drug interaction following the concurrent use of angiotensin-converting enzyme inhibitors or angiotensin-II receptor blockers, diuretics and non-steroidal anti-inflammatory drugs, the combination of which greatly increases the odds of acute kidney injury. Here, we report a case of a 66-year-old gentleman who was admitted into a tertiary care hospital for elective orthopaedic intervention. He had previously been prescribed sacubitril/valsartan and frusemide and had newly been started on celecoxib during hospitalisation. Upon the initiation of celecoxib, a mild increase in his serum creatinine was immediately observed, and this occurrence is believed to be due to the “triple whammy” combination. The combination of perindopril, frusemide and celecoxib continued to be overlooked throughout his hospitalisation. He was subsequently planned to be discharged with celecoxib on top of his existing chronic medications. However, upon discharge, the dispensing pharmacist took notice of the drug interaction and successfully intervened to withhold celecoxib.

    Impact of an Antibiotic Stewardship Program on the Use of Carbapenem in a Malaysian Tertiary Hospital (ACTION)

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      Abstract

      Introduction: The Antimicrobial Stewardship (AMS) program had been advocated to promote the rational use of antibiotic prescribing. However, the outcome of AMS in promoting the judicious use of carbapenem, and thus, minimising resistance, has not been widely studied in Malaysia. Objective: To investigate the types of interventions made by the AMS team, their acceptance, and the impact of such interventions on carbapenem consumption as well as the resistance pattern of carbapenem-resistant Enterobacterales (CRE). Method: This was a retrospective study conducted in adult medical wards of the Kuala Lumpur General Hospital (HKL), whereby data was extracted from the AMS forms of patients and subsequently reviewed by the AMS team from January to December 2016. Result and Discussion: The mean (SD) age of 169 patients included in this study was 59.2 (10.6) years. Ertapenem was the most prescribed carbapenem (44.4%), followed by meropenem (34.3%) and imipenem/cilastatin (21.3%). The study demonstrated that only 32% of carbapenem therapy had been empirically initiated, while, 68 cases (40.2%) were classified as unjustified use. Out of these cases, 39 cases (57%) were recommended to be discontinued, 25 cases (37%) were to be de-escalated and 4 cases (6%) were set for changing/escalation. The acceptance rate was reported to be around 73.5% (50 out of 68 cases). After one year of AMS implementation, carbapenem consumption (as shown by the defined daily dose/1000 inpatient bed-days) reduced by 33.7%. Similarly, a notable decrease in CRE cases (33.3%) was observed following a year of AMS initiation. Conclusion: AMS-guided interventions were able to demonstrate a reduction in carbapenem consumption as well as CRE rates in the medical wards.