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      Evaluation of the occurrence and type of antiretroviral and opportunistic infection medication errors within the inpatient setting Translated title: Evaluación de la aparición y tipo de errores de medicación de antirretrovirales y medicamentos para infección oportunistas en el entorno hospitalario

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          Background: Previous data reports inpatient antiretroviral (ARV) and opportunistic infection (OI) medication errors in as many as 86% of patients, with averages ranging from 1.16-2.7 errors/patient. Objective: To determine the occurrence and type of inpatient ARV and OI medication errors at our institution. Methods: A retrospective, observational, electronic medical chart review of patients with HIV/AIDS admitted between February 15, 2011- May 22, 2012 was conducted to assess the occurrence and type of ARV and OI medication errors. Secondary outcomes included assessing each medication with an error and evaluating its potential for a medication error, calculating a medication error rate per patient, evaluating whether a non-formulary (NF) medication impacted the error potential, determining whether a clinical pharmacist on service decreased the medication error rate, and assessing whether patients who experienced an error were more likely to have a longer length of stay (LOS). Analysis included descriptive statistics, averages, and Spearmen rank correlation. Results: There were 344 patients included in this analysis, 132 (38%) experienced 190 medication errors (1.44 errors/patient). An omitted order was the most frequent ARV error and accounted for 30% (n=57) of total errors. There were 166 patients requiring OI medications, 37 patients experienced 39 medication errors. Omitting OI prophylaxis accounted for 31 errors. Only 45 of 190 (24%) errors were corrected prior to discharge. Being prescribed at least 1 NF medication was correlated with increased errors (n=193 patients "on NF medication", p<0.025, r=0.12). Coverage of a service by a clinical pharmacist did not affect the number of errors. Patients experiencing an error had a longer LOS (p=0.02). Conclusions: Errors relating to ARV and OI medications are frequent in HIV-infected inpatients. More errors occurred in patients receiving NF medications. Suggested interventions include formulary revision, education, and training. Dedicated HIV clinicians with adequate training and credentialing may improve the management of this specialized disease state.

          Translated abstract

          Antecedentes: Datos existentes confirman que los errores de medicación en pacientes hospitalizados con antiretrovirales (ARV) e infecciones oportunistas (IO) aparecen en tantos como el 86% de los pacientes, con medias que oscilan entre 1,16 y 2,7 erroers por paciente. Objetivo: Determinar la aparición y el tipo de errores de medicación ARV y de IO en nuestra institución. Métodos: Se realizó una revisión retrospectiva y observacional de las historias clínicas electrónicas de los pacientes con VIH/SIDA ingresados entre el 15 de febrero de 2011 y el 22 de mayo de 2012, para evaluar la aparición y el tipo de errores de medicación ARV y de IO. Los resultados secundarios incluían evaluar las medicaciones con error y evaluar su posibilidad de error de medicación, calculando una tasa de erro de medicación por paciente, evaluando si una medicación de fuera del formulario impactaba en el potencial de error, determinando si un farmacéutico clínico disminuía la tasas de error de medicación, y evaluando si los pacientes que sufrían errores de medicación tenían más probabilidad de tener un tiempo de internamiento (LOS) mayor. Los análisis incluyeron estadística descriptiva, medias y correlaciones de Spearmen Rank. Resultados: Hubo 344 pacientes incluidos en este estudio, 132 (38%) sufrieron 190 errores de medicación (1,44 errores/paciente). Una dosis omitida fue el error de ARV más frecuente y alcanzó un 30% (n=55) del total de errores. Hubo 166 pacientes que necesitaron medicación para IO, 37 de ellos sufrieron 39 errores de medicación. Omitir la profilaxis de IO contabilizó 31 errores. Sólo 45 de los 190 errores (24%) fueron corregidos antes del alta. La prescripción de al menos 1 medicamento fuera del formulario estaba correlacionado con aumento de errores (n=193 pacientes con medicamentos fuera de formulario, p<0,025, r=0,12). La actuación de un farmacéutico clínico no afectó al número de errores. Los pacientes que sufrieron un error tuvieron una LOS mayor (p=0,02). Conclusiones: Los errores asociados a medicaciones ARV y para IO son frecuentes en pacientes infectados con VIH. Aparecen más errores en pacientes que reciben medicamentos fuera del formulario. Las intervenciones recomendadas incluyen la revisión del formulario, educación, y entrenamiento. Clínicos dedicados al VIH con entrenamiento adecuado y acreditados puede mejorar la gestión de esta enfermedad.

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          Most cited references 33

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          Lower Pill Burden and Once-Daily Antiretroviral Treatment Regimens for HIV Infection: A Meta-Analysis of Randomized Controlled Trials

          Among human immunodeficiency virus (HIV)–infected patients, adherence to antiretroviral therapy (ART) is a primary determinant of virological suppression, disease progression, and death [1–3]. ART regimens are now simpler than they were in the past, with lower pill burden and dosing frequency; they have also become less toxic and better tolerated [4]. In 2006, tenofovir–emtricitabine–efavirenz became the first approved branded, fixed-dose, single-tablet regimen (STR) [5, 6]. Two other STRs were subsequently approved by the US Food and Drug Administration: tenofovir–emtricitabine–rilpivirine and tenofovir–emtricitabine–elvitegravir–cobicistat [7, 8], both of which are currently recommended by the US Department of Health and Human Services [9]. Little is known about the impact of once- vs twice-daily ART and pill burden on adherence and virological outcomes. Indeed, in some patients with suboptimal adherence and/or virological failure, reducing the pill burden may be more important than switching from a twice-daily regimen to a once-daily regimen. Furthermore, governments, third-party payers, and HIV programs may prefer the use of non-coformulated ART generics because they are less expensive than brand name STRs. Therefore, as more generics become available, there is the potential for a paradoxical “desimplification,” with movement away from STR regimens [10, 11]. A 2009 meta-analysis by Parienti and colleagues of 11 randomized trials reported that ART adherence rates were significantly better with once-daily than with twice-daily regimens [12], with a modest effect that was more pronounced at the time of treatment initiation and was not observed in ART-experienced patients. However, that study did not find a significant effect of once-daily vs twice-daily regimens on virological outcome, possibly because of insufficient statistical power [13]. Since 2009, more randomized clinical trials comparing once- vs twice-daily regimens have been published, allowing a pooled meta-analysis with greater power to reinvestigate this question as well as the impact of pill burden [14–26]. Also, these more recent trials investigated better-tolerated, more contemporary regimens that are currently in wide clinical use. Thus, we conducted an updated meta-analysis to evaluate the impact of pill burden and once- vs twice-daily ART on adherence as well as virological outcomes in both ART-naive and -experienced HIV-infected adults. METHODS Protocol and Registration The study background, rationale, and methods were specified in advance and documented in a protocol that was published in the PROSPERO register (CRD42012002515). Inclusion Criteria We included only randomized controlled trials (RCTs) that compared once-daily vs twice-daily regimens in either ART-naive or -experienced patients with objective measures of adherence and measures of virological outcomes. Search Strategy We systematically searched the following databases from their inception until 31 March 2013 (including those years searched by the Parienti meta-analysis): Cochrane CENTRAL, PubMed, Google scholar, and Web of Science. Our search terms included the following: “HIV,” “treatment simplification,” “co-formulation,” “fixed-dose combination,” “QD,” “twice-daily,” “once-daily,” “adherence,” “HAART,” “ART,” “cART,” and “patient preference.” We also searched abstracts from major HIV/AIDS and infectious diseases conferences (from 2008 onward) including Conference on Retrovirus and Opportunistic Infections, International AIDS Conference, International AIDS Society Conference on HIV Treatment, Pathogenesis and Prevention, International Conference on Antimicrobial Agents and Chemotherapy, and Infectious Diseases Society of America Conference. In addition, the bibliographies of relevant review articles, metaanalyses, and selected articles were examined for pertinent studies. Study Selection We evaluated each identified study using the following predetermined selection criteria: open-label RCTs of HIV-infected subjects either ART naive or ART experienced that compared once-daily ART regimens with any twice-daily antiretroviral regimens and assessed both adherence (using objective measures, such as pill count or medication event monitoring system [MEMS]) and viral suppression (percentage of subjects with HIV-1 RNA levels 50%). Also, by focusing on once-daily vs twice-daily dosing, our analysis may have masked regimen-specific effects (eg, differences in toxicity) that have little to do with the frequency of dosing. Finally, the impact of regimen frequency and pill burden on adherence and virological outcomes in RCTs may not necessarily generalize to desimplification, in which patients may perceive that their regimen has been reduced in quality. Such a change could adversely affect adherence and/or treatment outcome, and, as noted above, specific studies to investigate this question are needed. In this meta-analysis of 19 RCTs, we confirmed that once-daily ART regimens increased adherence when compared with twice-daily regimens, but the difference was modest and not associated with a difference in virological suppression. Importantly, we found that higher pill burden was associated with lower rates of virological suppression regardless of dosing frequency. The nonlinear correlation between pill burden and adherence or virological suppression suggests that, while ART desimplification from once-daily STRs to once-daily multitablet regimens may have adverse effects on virological outcomes, separating out STRs and/or fixed-dose combinations into their constituents is not likely to have a major detrimental impact on virological outcomes (provided that the overall pill burden does not increase dramatically). Nevertheless, further research is needed to directly investigate the impact of such a switch, in particular among patients who are virologically suppressed at baseline. In the meantime, our results suggest that pill burden should be a consideration in the selection of an antiretroviral regimen, independent of dosing frequency. Supplementary Data Supplementary materials are available at Clinical Infectious Diseases online ( Supplementary materials consist of data provided by the author that are published to benefit the reader. The posted materials are not copyedited. The contents of all supplementary data are the sole responsibility of the authors. Questions or messages regarding errors should be addressed to the author. Supplementary Data
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            Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

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              Antiretroviral medication errors among hospitalized patients with HIV infection.

              Highly active antiretroviral therapy (HAART) has improved survival for persons living with human immunodeficiency virus (HIV) infection. However, effective therapy requires high levels of adherence over extended periods of time. Previous studies suggest that patients receiving long-term medication are at risk for unintended medication discrepancies at the time of hospital admission. We retrospectively identified every HIV-infected patient admitted to our hospital over a 1-year period who received an antiretroviral agent. We collected information on medications and renal function from the hospital computerized provider order entry system. We reviewed the medical records for those admissions for which a potential error was identified. We defined errors using Department of Health and Human Services guidelines and included only those errors that were not corrected within 24 h after initial entry. There were a total of 209 admissions during a 1-year period in which an HIV-infected patient received antiretroviral therapy. After review of the medical records for 77 admissions with a potential error, 61 uncorrected errors from 54 admissions were identified (percentage of total admissions, 25.8%; 95% confidence interval, 20.1%-32.3%). The most common type of error was an error with respect to the amount or frequency of dosage, which occurred in 34 (16.3%) of the admissions; 18 of these errors were attributable to failure to appropriately adjust dosage for renal insufficiency. The next most common error was combining antiretroviral drugs with a contraindicated medication; this occurred in 12 (5.2%) of the admissions. Patients erroneously received

                Author and article information

                [1 ] University of Illinois at Chicago United States
                [2 ] University of Illinois at Chicago United States
                Role: ND
                Role: ND
                Role: ND
                Pharmacy Practice (Granada)
                Pharmacy Pract (Granada)
                Centro de Investigaciones y Publicaciones Farmacéuticas (Redondela )
                March 2015
                : 13
                : 1
                : 0


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