Journal of Pharmaceutical Care

Phage Therapy from Bench to Bedside: Collaborative Approaches to Personalized Treatment

Narges Torkashvand — 2025-12-31

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Impact of a Pharmacist-Led Urinary Tract Infection Treatment Protocol in a Psychiatric Hospital Without Infectious Disease Support: A Before-After Study

Mina Borran — 2025-12-31

Background: Urinary tract infections (UTIs) are often misdiagnosed and inappropriately treated in psychiatric
hospitals, largely due to challenges in patient communication, polypharmacy, and limited access to infectious
disease specialists. In a psychiatric hospital setting in Tehran, Iran, ciprofloxacin was frequently prescribed
despite guideline warnings, leading to a pharmacist-led intervention aimed at improving antimicrobial
stewardship. This study aimed to evaluate the effectiveness of implementing a standardized urinary tract
infection (UTI) treatment protocol, designed and supervised by a clinical pharmacist, on improving diagnostic
accuracy and antibiotic prescribing in a psychiatric hospital setting.
Methods: This before–after study was conducted at Roozbeh Hospital over a six-month period. In phase one,
urinary tract infection treatments were initiated without pharmacist consultation. In phase two, a mandatory
pharmacist-led protocol was implemented based on the Infectious Diseases Society of America (IDSA) and
Journal of the American Medical Association (JAMA) guidelines. Data on urine culture rates, antibiotic
selection, dosage accuracy, and treatment appropriateness were compared across both phases.
Results: A total of 94 patients were included — 34 in phase I and 60 in phase II. Urine culture request rates
improved from 26.5% to 95% (P < 0.001), reflecting adherence to the new protocol rather than case complexity.
Correct antibiotic selection increased significantly (P = 0.004), with fosfomycin replacing ciprofloxacin as the
preferred agent. High-dose errors decreased from 29.4% to 8.3% (P = 0.02), and unnecessary treatment of
asymptomatic bacteriuria declined from 23.5% to 2% (P < 0.01).
Conclusion: Pharmacist-led interventions improved diagnostic precision and antibiotic use in this psychiatric
setting, suggesting a critical role for clinical pharmacists in antimicrobial stewardship, particularly in resource-limited mental health facilities.

Rational Use of Tocilizumab in Critically Ill COVID-19 Patients: A Comprehensive Evaluation in the Intensive Care Unit

Atefeh Afzali — 2025-12-31

Objectives:

Tocilizumab (TCZ) is a key treatment for severe COVID-19 but poses risks due to immunosuppression and limited evidence. Concerns about misuse and limited supply necessitate a thorough assessment. This study investigates the utilization patterns and appropriateness of tocilizumab use in critically ill COVID-19 patients.

Materials and Methods:

Over nine months, this descriptive-analytical study evaluated TCZ use in adult COVID-19 ICU (intensive care unit) patients at two referral hospitals in Isfahan, Iran. Data on TCZ dosing, duration, concomitant treatments, and patient demographics, including APACHE scores, were collected. Clinical outcomes, inflammatory markers, and adverse effects were monitored on days 3 and 5 post-TCZ administration. Statistical analyses were set at p < 0.05.

Results:

Out of 118 patients enrolled, 108 were analyzed for TCZ use; the mean age was 64.3 years, with 58.3% males. Notably, 39.8% of patients did not meet TCZ indication criteria, and only 7.5% received TCZ according to rational clinical guidelines regarding indication, dose, and dosing intervals. CRP levels significantly decreased after TCZ treatment (p < 0.001). The rational prescription group had higher APACHE scores five days post-treatment (p = 0.05), and appropriate TCZ use was significantly more common among intubated patients (p = 0.02).

Conclusion:

While rational use correlated with higher APACHE scores, no significant differences in other outcomes were observed, possibly due to sample size. Tocilizumab’s mechanism in reducing inflammation and CRP is well-established. Still, limitations include incomplete data on out-of-hospital prescriptions and patients who needed but did not receive TCZ, which necessitate further investigations.

Impact of Clinical Decision Support Software on the Prevalence of Drug-Drug Interactions in an Emergency Ward: A Quasi-Experimental Before-and-After Study

Mehrshad Ebrahimpour — 2025-12-31

Background: Drug interactions present significant challenges in emergency departments due to the diverse patient population and the complexity of medical conditions. These interactions threaten patient safety and increase healthcare costs. Strategies such as Clinical Decision Support Systems (CDSS) and audit-and-feedback mechanisms are essential for alerting physicians to potential medication risks.
Methods: A quasi-experimental before-and-after study was conducted in the emergency department of Ghaem Hospital in Mashhad. Phase 1 (June–August 2024) retrospectively analyzed drug interactions for 482 patients using Lexidrug 2024. To ensure comparability and minimize ascertainment bias, the Phase 1 analysis was restricted to interactions involving the 150 most commonly used medications in the emergency ward, which were included in the Phase 2 software. Phase 2 (October–December 2024) assessed 482 patients using a locally developed software (Idea Pardazan Asr Hoshmand Etminan) combined with a weekly audit-and-feedback intervention sent to physicians. Major interactions, classified as Category X (life-threatening) and Category D (clinically significant), were compared using the Chi-square test in SPSS version 12.
Results: Phase 1 recorded 42 Category X interactions (8.7%) and 118 Category D interactions (24.5%). In Phase 2, Category X interactions decreased to 32 (6.6%), but this reduction was not statistically significant (P = 0.276). However, Category D interactions significantly decreased to 45 (9.3%) in Phase 2 (P < 0.01). There were no significant differences in interaction rates between academic and non-academic specialists.
Conclusion: The implementation of the software, combined with weekly feedback reports, significantly reduced clinically significant (Category D) interactions. However, the lack of a statistically significant reduction in life-threatening (Category X) interactions suggests that weekly feedback may be insufficient for critical alerts requiring immediate action. Future iterations should focus on real-time integration into clinical workflows to address urgent patient safety threats.

Drug Utilization Evaluation of Intravenous Pantoprazole with Focus on Appropriateness, Route Switching, and Economic Impact in a Pediatric Tertiary Hospital

Maryam Shahrokhi — 2025-12-31

Background: Proton pump inhibitors (PPIs), including intravenous (IV) pantoprazole, are frequently prescribed in hospital settings. Although effective, IV formulations are often used inappropriately, leading to unnecessary risks and increased financial burden. Data on IV pantoprazole use in pediatric populations remain limited.
Methods: This study was designed as a retrospective, descriptive, cross-sectional Drug Utilization Evaluation (DUE) conducted in a tertiary pediatric teaching hospital. All inpatients aged ≥3 months who received at least one dose of IV pantoprazole during hospitalization were included. Prescribing appropriateness was evaluated according to international guidelines with respect to indication, dose, route, and duration. Opportunities for intravenous-to-oral (IV-to-PO) conversion and direct medication costs were also assessed.
Results: A total of 260 pediatric patients were analyzed. Overall, 42% of IV pantoprazole prescriptions were classified as appropriate, reflecting the composite appropriateness score across all evaluated domains (indication, dose, route, and duration). The majority of prescribing errors were related to unjustified indications and prolonged duration of therapy. Nearly 81% of eligible patients did not undergo IV-to-PO conversion. Dosing deviations were uncommon. Economic analysis showed that 76.6% of total pantoprazole expenditures were attributable to inappropriate use, corresponding to approximately 1.57 billion Iranian Rials (IRR) [≈8,300 United States dollars (USD)]. The Internal Medicine II ward accounted for the highest absolute excess cost, while the Surgery ward demonstrated 92.3% inappropriate prescribing.
Conclusion: PInappropriate use of IV pantoprazole is prevalent among pediatric inpatients, primarily driven by unjustified indications and missed opportunities for IV-to-PO conversion. These practices impose substantial economic costs and raise safety concerns. Implementation of pharmacist-led DUE and stewardship interventions may improve prescribing practices, reduce unnecessary expenditures, and enhance the quality of pediatric patient care.

Evaluation of the Rational Use of Intravenous Clindamycin at an Academic Medical Center in Iran

Mahila Monajati — 2025-12-31

Background: The inappropriate use of antibiotics is prevalent in low- and middle-income countries, which can lead to serious complications such as Clostridium difficile infections and antimicrobial resistance. This study aimed to evaluate the rational use of intravenous clindamycin in hospitalized patients.
Methods: A retrospective observational study was conducted to analyze the medical records of patients over 18 years old who received intravenous clindamycin. Patient characteristics, clindamycin indications, dosage, and treatment duration were recorded. Additionally, the initial diagnosis and infection type for each patient were reviewed using available information. The rational use of clindamycin was evaluated using the UpToDate® Lexidrug™ database and relevant guidelines. Data were analyzed using SPSS software.
Results: Of the 208 patients, 56% were female. The most prevalent initial diagnosis was sepsis (16.8%). More than half of the prescriptions were made by internists. Confirmed infections primarily included aspiration pneumonia (24.5%), diabetic foot infections (11.1%), and prophylaxis for gynecological surgery (10.6%). After reviewing the patients’ records, it was found that 49.5% of clindamycin indications, 98.6% of dosages, and 48.6% of treatment durations were appropriate. Considering all three factors—and excluding cases involving unnecessary duplicate therapy for anaerobes or methicillin-resistant Staphylococcus aureus (MRSA), as well as those lacking adequate evidence for clindamycin use—only 25.5% of the clindamycin regimens were deemed appropriate. Mild adverse effects were reported in four patients.
Conclusion: The study revealed that only one-fourth of clindamycin use was entirely appropriate. These findings underscore the need to implement anti-anaerobic stewardship programs that consider the type of infection, standard antibiotic regimens, prophylaxis duration, and concurrent antibiotic use to promote rational antibiotic prescribing.

Carbapenem Utilization in a Tertiary Referral Teaching Hospital Over 8 Years: A Quasi-Experimental Study

Maryam Taghizadeh-Ghehi — 2025-12-31

Background: The high prevalence of resistance to broad-spectrum antibiotics in the hospital setting is a challenge worldwide. Inappropriate use of carbapenems has led to growing antimicrobial resistance, specifically in gram-negative pathogens. Evidence suggested that interventions might improve the appropriate use of carbapenems in hospitals. Therefore, we aimed to compare the appropriate use of carbapenems before and after guideline implementation and to investigate consumption trends over 8 years, following restriction policies.

Methods: This quasi-experimental study was conducted in a tertiary referral teaching hospital. Before and after the implementation of the carbapenem use guideline in the hospital, utilization of imipenem and meropenem was evaluated with respect to the appropriateness of indication, initial dose, maintenance dose, and obtaining cultures. Annual consumption of carbapenems in terms of Defined Daily Doses (DDDs) per 100 Occupied Bed-Days (OBDs) was estimated in the hospital from 2014 to 2021.

Results: The frequency of generally appropriate orders increased from 31.6% at baseline to 38% after the primary intervention (P=0.057). The number of cases with carbapenem use for more than 5 days without obtaining cultures decreased significantly in the second evaluation phase (from 15.8% to 8.1%, P=0.001). Despite fluctuations and a non-steady trend, carbapenem consumption increased from 39.30 to 71.37 DDDs/100 OBDs over 8 years with a statistically significant trend (p < 0.001, R² = 0.93).

Conclusion: The rising carbapenem consumption rate was slowed down following the interventions. Additionally, our study demonstrated that guideline implementation improved the appropriate choice of carbapenem and the timely obtaining of cultures. However, the practice change was temporary and limited before the commencement of the restriction policy and ASP. Prospective audit and feedback might be necessary to achieve sustainable changes in the appropriate use of carbapenem in hospitals.

Antioxidant Drugs in the Prevention of Postoperative Atrial Fibrillation: A Literature Review

Zahra Jahani — 2025-12-31

Background: Post-operative atrial fibrillation (POAF) is a prevalent complication after cardiac surgery, affecting 20-50% of patients and linked to increased morbidity and healthcare costs. Given the central role of oxidative stress in POAF pathogenesis, this review evaluates the efficacy and evidence base of antioxidant drugs for POAF prevention.

Methods: A narrative literature review was conducted. We searched PubMed, Scopus, and Web of Science up to April 2025 for studies on antioxidants and POAF prevention. The focus was on randomized controlled trials (RCTs), their meta-analyses, and key mechanistic studies.

Results: Twenty-eight relevant studies were included. Antioxidants, including N-acetylcysteine (NAC), ascorbic acid (vitamin C), L-carnitine, crocin, alpha-lipoic acid, coenzyme Q10, vitamin E, berberine, selenium and melatonin, were evaluated. NAC and vitamin C showed the most consistent benefit, with meta-analyses reporting significant reductions in POAF risk (e.g., pooled RR 0.69, 95% CI 0.52–0.91 for NAC; OR 0.44, 95% CI 0.32–0.61 for vitamin C). Evidence for other agents was less robust, often based on single-center trials or showing contradictory results (e.g., selenium, melatonin). Mechanisms involve ROS scavenging, anti-inflammatory effects, and improved mitochondrial function.

Conclusion: Current evidence supports a potential preventive role for specific antioxidants in POAF, particularly NAC and vitamin C. However, significant heterogeneity, contradictory findings for several agents, and a lack of large multicenter RCTs preclude firm clinical recommendations. Antioxidant therapy should currently be considered investigational. Future high-quality trials are needed to establish optimal agents and dosing for clinical practice.

A Case Report of Complete Heart Block in a 58-Year-Old Woman with Multiple Myeloma Treated with Carfilzomib: Implications for Risk Stratification in High-Risk Populations

Mehrshad Ebrahimpour — 2025-12-31

Carfilzomib, a proteasome inhibitor used to treat relapsed multiple myeloma, is linked to rare cardiac
complications. Complete heart block (CHB), though seldom reported, poses critical risks in patients with
multiple comorbidities. This case report illustrates the development of CHB in a patient with multiple myeloma
and high cardiovascular risk, underscoring the importance of risk-based monitoring rather than proposing a
new mechanism. A 58-year-old Iranian woman with relapsed multiple myeloma, acute coronary syndrome,
hypertension, dyslipidemia, type 2 diabetes, and hemodialysis-dependent chronic kidney disease (CKD)
developed CHB 48 hours after carfilzomib initiation. The Naranjo Adverse Drug Reaction Probability Scale
yielded a score of 3 (indicating a “possible” adverse drug reaction). Discontinuation of carfilzomib and
temporary pacemaker implantation restored hemodynamic stability. Although the patient’s hemodynamics
improved following pacing, she ultimately died due to septic complications unrelated to the arrhythmia. This
case demonstrates the complexity of attributing CHB to carfilzomib in a multimorbid patient. It highlights the
necessity of comprehensive cardiac evaluation and risk stratification in patients receiving proteasome inhibitors,
especially those with concurrent CKD, coronary artery disease (CAD), and polypharmacy.

Virological Failure Associated with the Concomitant Use of Red Yeast Rice and Dolutegravir/Abacavir/Lamivudine in an HIV-1 Patient: A Case Report

Ignacio Patier Ruiz — 2025-12-31

Red yeast rice (RYR) is increasingly used for cholesterol management but contains monacolin K, which is
chemically identical to lovastatin, and may interact with antiretroviral therapy via CYP3A4 and P-glycoprotein
pathways. We report the case of a 47-year-old man with well-controlled HIV-1 infection receiving dolutegravir/
abacavir/lamivudine who experienced virological rebound after self-initiating RYR supplementation. Eight
weeks after starting RYR (77.7 mg daily, with a labeled monacolin K content of 3 mg), the patient developed
virological rebound (897 copies/mL) despite confirmed adherence and absence of resistance mutations. Following pharmacist-led discontinuation of RYR, viral suppression (<50 copies/mL) was restored within eight weeks without modification of antiretroviral therapy. This represents the first documented case of RYR-associated virological failure in HIV treatment. Hospital pharmacists should routinely screen for herbal supplements and provide patient education regarding potential interactions with antiretroviral medications.