Lavern Vercaigne - Academia.edu (original) (raw)

Papers by Lavern Vercaigne

Research paper thumbnail of Conversion from Epoetin Alfa to Darbepoetin Alfa: Effects on Patients’ Hemoglobin and Costs to Canadian Dialysis Centres

The Canadian Journal of Hospital Pharmacy, 2012

Background: The erythropoiesis-stimulating agents epoetin alfa (EPO) and darbepoetin alfa (DPO) e... more Background: The erythropoiesis-stimulating agents epoetin alfa (EPO) and darbepoetin alfa (DPO) effectively treat the anemia that occurs in most patients undergoing hemodialysis. Published studies indicate that these 2 agents have similar efficacy and safety outcomes, but their relative costs in actual practice in Canada have not been extensively studied. Objectives: To determine the relative utilization and cost of erythropoiesis-stimulating agents in Canadian practice. Secondary objectives were to examine various clinical parameters in patients receiving these drugs. Methods: In this retrospective, open-label, observational study, 3 hospital-based hemodialysis centres in Ontario, Canada, converted patients from EPO to DPO over the period July 2004 to April 2006. The starting dose-conversion ratio was 200:1. The dose of DPO was changed, as needed, to achieve the same target hemoglobin (Hb) as before the conversion (110-120 g/L). For 3 to 6 months before conversion, and for 6 to 12 months after, weekly dose of erythropoiesis-stimulating agent, dose-conversion ratio, serum Hb, ferritin, and transferrin saturation were recorded for each patient at all 3 sites. One site also documented medication administration errors before and after the conversion. Results: Data were collected for a total of 442 patients. Baseline patient characteristics were similar across the 3 sites. The median dose-conversion ratio for each hemodialysis centre ranged from 288:1 to 400:1, and the average annual per-patient savings varied between 2140and2140 and 2140and4711. No clinically meaningful differences between EPO and DPO were reported in terms of patients' serum hemoglobin levels, iron dose, or number of transfusions. With DPO, the relative risk of medication administration errors was reduced by 72% (p < 0.001) (based on data from one site). Conclusion: In this real-world evaluation of the clinical effectiveness and cost-efficiency of switching patients from EPO to DPO, patients' clinical outcomes were maintained while considerable reductions in cost were achieved.

Research paper thumbnail of Use of an alteplase algorithm for the management of hemodialysis catheter dysfunction

Hemodialysis International, 2011

Research paper thumbnail of An ethanol/sodium citrate locking solution compared to heparin to prevent hemodialysis catheter-related infections: a randomized pilot study

The journal of vascular access, Jan 7, 2015

The objective of this study was to compare the initial safety and efficacy of a novel 30% ethanol... more The objective of this study was to compare the initial safety and efficacy of a novel 30% ethanol/4% sodium citrate catheter-locking solution to heparin in a hemodialysis population. This was a prospective, randomized, pilot study of 40 hemodialysis patients randomized to a 30% ethanol/4% sodium citrate or heparin 1000 units/mL locking solution. The primary outcome was identification of any serious adverse events over the study duration. Secondary outcomes included the rate per 1000 catheter days for catheter-related bloodstream infections (CRBSI), alteplase use, catheter dysfunction, and catheter removal. Three serious adverse events were reported as possibly related to the catheter solutions. Only one CRBSI was observed during the study in the heparin arm. The rate of alteplase use was 1.5/1000 catheter days in the heparin arm compared to 2.8/1000 catheter days in the ethanol/citrate arm (rate ratio = 1.85, 90% CI 0.48, 7.07, p value = 0.45), while the rate of catheter dysfunction...

Research paper thumbnail of A critical review of the fluoroquinolones: Focus on respiratory tract infections

Drugs, 2002

The new fluoroquinolones (clinafloxacin, gatifloxacin, gemifloxacin, grepafloxacin, levofloxacin,... more The new fluoroquinolones (clinafloxacin, gatifloxacin, gemifloxacin, grepafloxacin, levofloxacin, moxifloxacin, sitafloxacin, sparfloxacin and trovafloxacin) offer excellent activity against Gram-negative bacilli and improved Gram-positive activity (e.g. against Streptococcus pneumoniae and Staphylococcus aureus) over ciprofloxacin. Ciprofloxacin still maintains the best in vitro activity against Pseudomonas aeruginosa. Clinafloxacin, gatifloxacin, moxifloxacin, sitafloxacin, sparfloxacin and trovafloxacin display improved activity against anaerobes (e.g. Bacteroides fragilis) versus ciprofloxacin. All of the new fluoroquinolones display excellent bioavailability and have longer serum half-lives than ciprofloxacin allowing for once daily dose administration. Clinical trials comparing the new fluoroquinolones to each other or to standard therapy have demonstrated good efficacy in a variety of community-acquired respiratory infections (e.g. pneumonia, acute exacerbations of chronic bronchitis and acute sinusitis). Limited data suggest that the new fluoroquinolones as a class may lead to better outcomes in community-acquired pneumonia and acute exacerbations of chronic bronchitis versus comparators. Several of these agents have either been withdrawn from the market, had their use severely restricted because of adverse effects (clinafloxacin because of phototoxicity and hypoglycaemia; grepafloxacin because of prolongation of the QTc and resultant torsades de pointes; sparfloxacin because of phototoxicity; and trovafloxacin because of hepatotoxicity), or were discontinued during developmental phases. The remaining fluoroquinolones such as gatifloxacin, gemifloxacin, levofloxacin and moxifloxacin have adverse effect profiles similar to ciprofloxacin. Extensive post-marketing safety surveillance data (as are available with ciprofloxacin and levofloxacin) are required for all new fluoroquinolones before safety can be definitively established. Drug interactions are limited; however, all fluoroquinolones interact with metal ion containing drugs (eg. antacids). The new fluoroquinolones (gatifloxacin, gemifloxacin, levofloxacin and moxifloxacin) offer several advantages over ciprofloxacin and are emerging as important therapeutic agents in the treatment of community-acquired respiratory infections. Their broad spectrum of activity which includes respiratory pathogens such as penicillin and macrolide resistant S. pneumoniae, favourable pharmacokinetic parameters, good bacteriological and clinical efficacy will lead to growing use of these agents in the treatment of community-acquired pneumonia, acute exacerbations of chronic bronchitis and acute sinusitis. These agents may result in cost savings especially in situations where, because of their potent broad-spectrum activity and excellent bioavailability, they may be used orally in place of intravenous antibacterials. Prudent use of the new fluoroquinolones will be required to minimise the development of resistance to these agents.

Research paper thumbnail of Effectiveness of a 30% ethanol/4% trisodium citrate locking solution in preventing biofilm formation by organisms causing haemodialysis catheter-related infections

The Journal of Antimicrobial Chemotherapy, Jul 18, 2008

Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CR... more Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CRIs). This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate lock solution in preventing biofilm formation by the most common pathogens causing haemodialysis CRIs.

Research paper thumbnail of Stability of Trisodium Citrate and Gentamicin Solution for Catheter Locks after Storage in Plastic Syringes at Room Temperature

The Canadian Journal of Hospital Pharmacy, Jul 1, 2010

Research paper thumbnail of The ketolides: A critical review

Research paper thumbnail of Establishing and funding renal clinical pharmacy services

Nephrology news & issues, 2010

Research paper thumbnail of Long-term effect of an ethanol/sodium citrate locking solution on the mechanical properties of hemodialysis catheters

The journal of vascular access

To investigate the effect of a 30% ethanol/4% sodium citrate catheter locking solution on the mec... more To investigate the effect of a 30% ethanol/4% sodium citrate catheter locking solution on the mechanical properties of hemodialysis (HD) catheters over 36 weeks. Twenty-one HD catheters were used in this study. Three catheters, not exposed to locking solutions, underwent mechanical testing to determine baseline properties. Nine of the remaining 18 catheters were filled with normal saline and underwent mechanical testing in groups of three at 12, 24 and 36 weeks. Similarly, nine catheters were filled with the 30% ethanol/4% sodium citrate locking solution and tested in a similar manner. The average force required to break the catheter lumens tended to be smaller in the catheters exposed to 30% ethanol/4% sodium citrate compared to saline controls at 12 and 24 weeks; however, there were no statistically significant differences between the groups after 36 weeks of exposure. The forces required to break these HD catheters are magnitudes greater than forces generated during a typical HD ...

Research paper thumbnail of Conversion from epoetin alfa to darbepoetin alfa within the Manitoba Renal Program: evaluation of dose ratios

CANNT journal = Journal ACITN

We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patien... more We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patients with anemia of chronic kidney disease (CKD) in a large provincial renal program. Hemodialysis (HD), peritoneal dialysis (PD) and pre-dialysis patients with CKD were included. Laboratory parameters and darbepoetin alfa doses were compared to epoetin alfa doses (same route). In 2005, 857 patients received darbepoetin alfa and were compared to 746 patients who received epoetin alfa in 2003-2004. Mean dose conversion ratios were 12,939 IU, 53.1 microg, 244:1 for HD; 9,273 IU, 41.8 microg, 222:1 for PD; and 5,516 IU, 25.2 microg and 219:1 for CKD patients. The mean hemoglobin and iron parameters were within K/DOQI targets on both drugs. Conversion ratios in HD, PD and CKD patients using erythropoietic therapies was greater than 200:1 with both intravenous and subcutaneous dosing. Renal programs across Canada should consider dosage conversion ratios in addition to drug acquisition costs whe...

Research paper thumbnail of Effect of ethanol/trisodium citrate lock on microorganisms causing hemodialysis catheter-related infections

The journal of vascular access

This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate (TSC) lo... more This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate (TSC) lock solution against the most common pathogens causing hemodialysis catheter-related infections. Clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) (n = 4), methicillin-sensitive S. aureus (MSSA) (n = 8), methicillin-resistant Staphylococcus epidermidis (MRSE) (n = 8), Pseudomonas aeruginosa (n = 4) and Escherichia coli (n = 4) were tested in duplicate. Bacterial suspensions of each isolate were made in a control solution of normal saline and Mueller-Hinton broth (MHB), and in a lock solution of ethanol 30%, TSC 4% and MHB. Suspensions were incubated at 37 degrees C for 48 h. Colony counts were determined from samples collected at t = 0 h (before exposure to the ethanol/TSC lock), t = 1 h (one hour after exposure to the ethanol/TSC lock), t = 24 h and t = 48 h. To confirm the absence of viable organisms in the lock solution, the remaining volume at 48 h was filtered t...

Research paper thumbnail of The glycylcyclines: a comparative review with the tetracyclines

Drugs, 2004

The tetracycline class of antimicrobials exhibit a broad-spectrum of activity against numerous pa... more The tetracycline class of antimicrobials exhibit a broad-spectrum of activity against numerous pathogens, including Gram-positive and Gram-negative bacteria, as well as atypical organisms. These compounds are bacteriostatic, and act by binding to the bacterial 30S ribosomal subunit and inhibiting protein synthesis. The tetracyclines have been used successfully for the treatment of a variety of infectious diseases including community-acquired respiratory tract infections and sexually transmitted diseases, as well in the management of acne. The use of tetracyclines for treating bacterial infections has been limited in recent years because of the emergence of resistant organisms with efflux and ribosomal protection mechanisms of resistance. Research to find tetracycline analogues that circumvented these resistance mechanisms has lead to the development of the glycylcyclines. The most developed glycylcycline is the 9-tert-butyl-glycylamido derivative of minocycline, otherwise known as t...

Research paper thumbnail of A patient-focused approach to thrombolytic use in the management of catheter malfunction

Seminars in dialysis

Thrombus-related catheter malfunction is a significant problem for catheter-dependent dialysis pa... more Thrombus-related catheter malfunction is a significant problem for catheter-dependent dialysis patients. The primary medical intervention is the local luminal installation of thrombolytic agents (TLAs). There are three major TLA installation methodologies: locking, push, and infusion protocols. A systematic literature review of existing TLA protocols for treating dialysis catheter malfunction was performed using the PubMed and EMBASE (Drugs and Pharmacology) databases from the time of each database's inception to August 2005. Thrombolytic administration was then categorized according to the patient's clinical need: (1) an acute/immediate requirement, such as when malfunction prohibits dialysis initiation, and (2) rescue therapy, such as when the thrombus threatens to significantly impair current or subsequent dialysis clearance. Published TLA protocols are discussed in the context of their clinical requirement (acute or rescue therapy). A unifying clinically relevant managem...

Research paper thumbnail of Using Curriculum Mapping to Engage Faculty Members in the Analysis of a Pharmacy Program

American Journal of Pharmaceutical Education, 2014

To develop a curriculum mapping process that supports continuous analysis and evidence-based deci... more To develop a curriculum mapping process that supports continuous analysis and evidence-based decisions in a pharmacy program. A curriculum map based on the national educational outcomes for pharmacy programs was created using conceptual frameworks grounded in cognitive learning and skill acquisition. The curriculum map was used to align the intended curriculum with the national educational outcomes and licensing examination blueprint. The leveling and sequencing of content showed longitudinal progression of student learning and performance. There was good concordance between the intended and learned curricula as validated by survey responses from employers and graduating students. The curriculum mapping process was efficient and effective in providing an evidence-based approach to the continuous quality improvement of a pharmacy program.

Research paper thumbnail of Erythropoietin-Alpha Dosage Requirements in a Provincial Hemodialysis Population: Effect of Switching from Subcutaneous to Intravenous Administration

Nephron Clinical Practice, 2006

The purpose of this initiative was to compare erythropoietin-alpha doses in hemodialysis patients... more The purpose of this initiative was to compare erythropoietin-alpha doses in hemodialysis patients who changed from subcutaneous to intravenous administration. The Manitoba Renal Program switched routes due to concern about erythropoietin-associated pure red cell aplasia. We compared the erythropoietin-alpha dosage requirements during subcutaneous administration (3 months pre-switch) and intravenous administration (months 4-6 post-switch). We also compared: hemoglobin, transferrin saturation (Tsat%), ferritin, and percent of patients receiving intravenous iron. The same erythropoietin-alpha regimen was initially used when patients were switched. Of the 628 patients receiving erythropoietin-alpha, the data were complete for 400. The dose increased 26% (mean +/- SD, 10,425 +/- 7,330 vs. 13,125 +/- 8,638 IU/week; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), despite similar hemoglobin, (mean +/- SD, 11.5 +/- 1.1g/dl (114.9 +/- 11.2 g/l) vs. 11.3 +/- 1.0 g/dl (113.5 +/- 10.4 g/l); p = 0.0450) and iron parameters (Tsat 30.9%, ferritin 464 ng/ml (microg/l) vs. Tsat 28.7%, ferritin 538 ng/ml (microg/l)). For the subgroup of 84 patients who maintained target hemoglobin (10-11 g/dl or 110-120 g/l) for both periods, the dose increased 26% (mean +/- SD, 8,393 +/- 6,242 vs. 10,589 +/- 7,049 IU/week; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) without a change in hemoglobin, (mean +/- SD, 11.5 +/- 0.3 g/dl (115.2 +/- 3.0 g/l) vs. 11.5 +/- 0.3 g/dl (114.9 +/- 3.3 g/l); p = 0.5789). When stratified by subcutaneous dose, patients with the lowest dose (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;5,000 IU/week) demonstrated the greatest increase (89%), and those with the highest dose (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;20,000 IU/week) experienced no increase (-3%). Overall, erythropoietin-alpha doses increased by 26% when patients were converted from subcutaneous to intravenous administration.

Research paper thumbnail of Review: Does Warfarin Safely Prevent Clotting of Hemodialysis Catheters?

Seminars in Dialysis, 2007

This article reviews the efficacy and safety of warfarin to prevent tunneled cuffed catheter (TCC... more This article reviews the efficacy and safety of warfarin to prevent tunneled cuffed catheter (TCC) thrombosis in the hemodialysis population. Literature searches of PubMed, EMBASE,

Research paper thumbnail of Antibiotic-Heparin Lock: In Vitro Antibiotic Stability Combined with Heparin in a Central Venous Catheter

Pharmacotherapy, 2000

Long-term hemodialysis frequently requires vascular access through central venous catheters (CVCs... more Long-term hemodialysis frequently requires vascular access through central venous catheters (CVCs). Infection related to these catheters is a significant complication. The use of an antibiotic-heparin lock could decrease the risks associated with infected permanent catheters. As an initial step in developing an antibiotic-heparin lock, we investigated the in vitro stability of antibioticheparin combinations in CVCs. Initially, cefazolin, vancomycin, ceftazidime, ciprofloxacin 10 mg/ml each, and gentamicin 5 mg/ml were incubated separately in glass test tubes in the dark at 37ºC for 72 hours. Samples were analyzed spectrophotometrically for stability at 24-hour intervals. The procedure was repeated with the addition of heparin (final concentration 5000 U/ml in glass test tubes), and the combination was also examined in CVCs. High-performance liquid chromatography analysis was conducted on the antibiotic-heparin combinations at 72 hours to confirm the spectrophotometric results. Ciprofloxacin produced an immediate precipitate with the addition of heparin and was not analyzed further. Absorbance values decreased for all antibiotics, with the greatest decreases at 72 hours for cefazolin (27.4%), vancomycin (29.7%), ceftazidime (40.2%), and gentamicin (8%) when combined with heparin. These decreases were postulated to be secondary to adsorption of the antibiotics to the luminal surface of the catheters because submitting the catheters to ultrasound with 1% sodium bicarbonate and analyzing the resulting solution for absorbance revealed that some of the drug was recovered. Although free antibiotic in CVC solution was reduced, the concentration should be sufficient (approximately 5 mg/ml) to decrease the frequency of infections associated with CVCs. We conclude that the concentrations of vancomycin, ceftazidime, cefazolin, or gentamicin used in our study should be sufficient for an antibiotic-heparin lock.

Research paper thumbnail of Conversion From Subcutaneous to Intravenous Erythropoietin in a Hemodialysis Population

The Journal of Clinical Pharmacology, 2005

The purpose of this study was to compare erythropoietin dosage requirements during subcutaneous v... more The purpose of this study was to compare erythropoietin dosage requirements during subcutaneous versus intravenous administration in a hemodialysis population. Hemodialysis patients receiving subcutaneous epoetin alfa were switched to the intravenous route using a prospective, crossover design. Baseline anemia parameters were measured at months -2, -1, and 0 when patients were receiving subcutaneous dosing and compared to months 4, 5, and 6 after the switch to intravenous dosing. Ninety-eight patients were enrolled into the study with an average age of 54.8 years. Over the course of the study, 34 patients were excluded from analysis, leaving 64 patients with complete hemoglobin and erythropoietin dosing data throughout the subcutaneous and intravenous evaluation periods. In these patients, the dose of erythropoietin increased significantly from the subcutaneous to the intravenous period (7567.7 to 10229.2 IU/wk). The conversion of hemodialysis patients from the subcutaneous to the intravenous route of administration significantly increased epoetin alfa dosage requirements.

Research paper thumbnail of Effectiveness of a 30% ethanol/4% trisodium citrate locking solution in preventing biofilm formation by organisms causing haemodialysis catheter-related infections

Journal of Antimicrobial Chemotherapy, 2008

Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CR... more Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CRIs). This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate lock solution in preventing biofilm formation by the most common pathogens causing haemodialysis CRIs.

Research paper thumbnail of An in vitro evaluation of the antibiotic/heparin lock to sterilize central venous haemodialysis catheters

Journal of Antimicrobial Chemotherapy, 2002

This in vitro study investigated the ability of antibiotic/heparin locks to sterilize central ven... more This in vitro study investigated the ability of antibiotic/heparin locks to sterilize central venous haemodialysis catheters (CVCs) inoculated with methicillin-resistant Staphylococcus epidermidis (MRSE). Isolates of MRSE were incubated in broth inside CVCs. The catheters were then drained and filled with either vancomycin/gentamicin/heparin (VGH), cefazolin/gentamicin/ heparin (CGH) or control locks for 48 h. The catheters were drained, filled with fresh broth and again incubated. The final catheter solutions were sampled and the remaining volumes filtered. The samples, filters and catheter segments were examined for growth. For two isolates, both the VGH and CGH locks sterilized the catheters. Bacterial counts of the remaining two isolates were significantly reduced by &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;99%, but the catheters were not sterilized after the instillation of a single-antibiotic/heparin lock.

Research paper thumbnail of Conversion from Epoetin Alfa to Darbepoetin Alfa: Effects on Patients’ Hemoglobin and Costs to Canadian Dialysis Centres

The Canadian Journal of Hospital Pharmacy, 2012

Background: The erythropoiesis-stimulating agents epoetin alfa (EPO) and darbepoetin alfa (DPO) e... more Background: The erythropoiesis-stimulating agents epoetin alfa (EPO) and darbepoetin alfa (DPO) effectively treat the anemia that occurs in most patients undergoing hemodialysis. Published studies indicate that these 2 agents have similar efficacy and safety outcomes, but their relative costs in actual practice in Canada have not been extensively studied. Objectives: To determine the relative utilization and cost of erythropoiesis-stimulating agents in Canadian practice. Secondary objectives were to examine various clinical parameters in patients receiving these drugs. Methods: In this retrospective, open-label, observational study, 3 hospital-based hemodialysis centres in Ontario, Canada, converted patients from EPO to DPO over the period July 2004 to April 2006. The starting dose-conversion ratio was 200:1. The dose of DPO was changed, as needed, to achieve the same target hemoglobin (Hb) as before the conversion (110-120 g/L). For 3 to 6 months before conversion, and for 6 to 12 months after, weekly dose of erythropoiesis-stimulating agent, dose-conversion ratio, serum Hb, ferritin, and transferrin saturation were recorded for each patient at all 3 sites. One site also documented medication administration errors before and after the conversion. Results: Data were collected for a total of 442 patients. Baseline patient characteristics were similar across the 3 sites. The median dose-conversion ratio for each hemodialysis centre ranged from 288:1 to 400:1, and the average annual per-patient savings varied between 2140and2140 and 2140and4711. No clinically meaningful differences between EPO and DPO were reported in terms of patients' serum hemoglobin levels, iron dose, or number of transfusions. With DPO, the relative risk of medication administration errors was reduced by 72% (p < 0.001) (based on data from one site). Conclusion: In this real-world evaluation of the clinical effectiveness and cost-efficiency of switching patients from EPO to DPO, patients' clinical outcomes were maintained while considerable reductions in cost were achieved.

Research paper thumbnail of Use of an alteplase algorithm for the management of hemodialysis catheter dysfunction

Hemodialysis International, 2011

Research paper thumbnail of An ethanol/sodium citrate locking solution compared to heparin to prevent hemodialysis catheter-related infections: a randomized pilot study

The journal of vascular access, Jan 7, 2015

The objective of this study was to compare the initial safety and efficacy of a novel 30% ethanol... more The objective of this study was to compare the initial safety and efficacy of a novel 30% ethanol/4% sodium citrate catheter-locking solution to heparin in a hemodialysis population. This was a prospective, randomized, pilot study of 40 hemodialysis patients randomized to a 30% ethanol/4% sodium citrate or heparin 1000 units/mL locking solution. The primary outcome was identification of any serious adverse events over the study duration. Secondary outcomes included the rate per 1000 catheter days for catheter-related bloodstream infections (CRBSI), alteplase use, catheter dysfunction, and catheter removal. Three serious adverse events were reported as possibly related to the catheter solutions. Only one CRBSI was observed during the study in the heparin arm. The rate of alteplase use was 1.5/1000 catheter days in the heparin arm compared to 2.8/1000 catheter days in the ethanol/citrate arm (rate ratio = 1.85, 90% CI 0.48, 7.07, p value = 0.45), while the rate of catheter dysfunction...

Research paper thumbnail of A critical review of the fluoroquinolones: Focus on respiratory tract infections

Drugs, 2002

The new fluoroquinolones (clinafloxacin, gatifloxacin, gemifloxacin, grepafloxacin, levofloxacin,... more The new fluoroquinolones (clinafloxacin, gatifloxacin, gemifloxacin, grepafloxacin, levofloxacin, moxifloxacin, sitafloxacin, sparfloxacin and trovafloxacin) offer excellent activity against Gram-negative bacilli and improved Gram-positive activity (e.g. against Streptococcus pneumoniae and Staphylococcus aureus) over ciprofloxacin. Ciprofloxacin still maintains the best in vitro activity against Pseudomonas aeruginosa. Clinafloxacin, gatifloxacin, moxifloxacin, sitafloxacin, sparfloxacin and trovafloxacin display improved activity against anaerobes (e.g. Bacteroides fragilis) versus ciprofloxacin. All of the new fluoroquinolones display excellent bioavailability and have longer serum half-lives than ciprofloxacin allowing for once daily dose administration. Clinical trials comparing the new fluoroquinolones to each other or to standard therapy have demonstrated good efficacy in a variety of community-acquired respiratory infections (e.g. pneumonia, acute exacerbations of chronic bronchitis and acute sinusitis). Limited data suggest that the new fluoroquinolones as a class may lead to better outcomes in community-acquired pneumonia and acute exacerbations of chronic bronchitis versus comparators. Several of these agents have either been withdrawn from the market, had their use severely restricted because of adverse effects (clinafloxacin because of phototoxicity and hypoglycaemia; grepafloxacin because of prolongation of the QTc and resultant torsades de pointes; sparfloxacin because of phototoxicity; and trovafloxacin because of hepatotoxicity), or were discontinued during developmental phases. The remaining fluoroquinolones such as gatifloxacin, gemifloxacin, levofloxacin and moxifloxacin have adverse effect profiles similar to ciprofloxacin. Extensive post-marketing safety surveillance data (as are available with ciprofloxacin and levofloxacin) are required for all new fluoroquinolones before safety can be definitively established. Drug interactions are limited; however, all fluoroquinolones interact with metal ion containing drugs (eg. antacids). The new fluoroquinolones (gatifloxacin, gemifloxacin, levofloxacin and moxifloxacin) offer several advantages over ciprofloxacin and are emerging as important therapeutic agents in the treatment of community-acquired respiratory infections. Their broad spectrum of activity which includes respiratory pathogens such as penicillin and macrolide resistant S. pneumoniae, favourable pharmacokinetic parameters, good bacteriological and clinical efficacy will lead to growing use of these agents in the treatment of community-acquired pneumonia, acute exacerbations of chronic bronchitis and acute sinusitis. These agents may result in cost savings especially in situations where, because of their potent broad-spectrum activity and excellent bioavailability, they may be used orally in place of intravenous antibacterials. Prudent use of the new fluoroquinolones will be required to minimise the development of resistance to these agents.

Research paper thumbnail of Effectiveness of a 30% ethanol/4% trisodium citrate locking solution in preventing biofilm formation by organisms causing haemodialysis catheter-related infections

The Journal of Antimicrobial Chemotherapy, Jul 18, 2008

Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CR... more Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CRIs). This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate lock solution in preventing biofilm formation by the most common pathogens causing haemodialysis CRIs.

Research paper thumbnail of Stability of Trisodium Citrate and Gentamicin Solution for Catheter Locks after Storage in Plastic Syringes at Room Temperature

The Canadian Journal of Hospital Pharmacy, Jul 1, 2010

Research paper thumbnail of The ketolides: A critical review

Research paper thumbnail of Establishing and funding renal clinical pharmacy services

Nephrology news & issues, 2010

Research paper thumbnail of Long-term effect of an ethanol/sodium citrate locking solution on the mechanical properties of hemodialysis catheters

The journal of vascular access

To investigate the effect of a 30% ethanol/4% sodium citrate catheter locking solution on the mec... more To investigate the effect of a 30% ethanol/4% sodium citrate catheter locking solution on the mechanical properties of hemodialysis (HD) catheters over 36 weeks. Twenty-one HD catheters were used in this study. Three catheters, not exposed to locking solutions, underwent mechanical testing to determine baseline properties. Nine of the remaining 18 catheters were filled with normal saline and underwent mechanical testing in groups of three at 12, 24 and 36 weeks. Similarly, nine catheters were filled with the 30% ethanol/4% sodium citrate locking solution and tested in a similar manner. The average force required to break the catheter lumens tended to be smaller in the catheters exposed to 30% ethanol/4% sodium citrate compared to saline controls at 12 and 24 weeks; however, there were no statistically significant differences between the groups after 36 weeks of exposure. The forces required to break these HD catheters are magnitudes greater than forces generated during a typical HD ...

Research paper thumbnail of Conversion from epoetin alfa to darbepoetin alfa within the Manitoba Renal Program: evaluation of dose ratios

CANNT journal = Journal ACITN

We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patien... more We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patients with anemia of chronic kidney disease (CKD) in a large provincial renal program. Hemodialysis (HD), peritoneal dialysis (PD) and pre-dialysis patients with CKD were included. Laboratory parameters and darbepoetin alfa doses were compared to epoetin alfa doses (same route). In 2005, 857 patients received darbepoetin alfa and were compared to 746 patients who received epoetin alfa in 2003-2004. Mean dose conversion ratios were 12,939 IU, 53.1 microg, 244:1 for HD; 9,273 IU, 41.8 microg, 222:1 for PD; and 5,516 IU, 25.2 microg and 219:1 for CKD patients. The mean hemoglobin and iron parameters were within K/DOQI targets on both drugs. Conversion ratios in HD, PD and CKD patients using erythropoietic therapies was greater than 200:1 with both intravenous and subcutaneous dosing. Renal programs across Canada should consider dosage conversion ratios in addition to drug acquisition costs whe...

Research paper thumbnail of Effect of ethanol/trisodium citrate lock on microorganisms causing hemodialysis catheter-related infections

The journal of vascular access

This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate (TSC) lo... more This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate (TSC) lock solution against the most common pathogens causing hemodialysis catheter-related infections. Clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) (n = 4), methicillin-sensitive S. aureus (MSSA) (n = 8), methicillin-resistant Staphylococcus epidermidis (MRSE) (n = 8), Pseudomonas aeruginosa (n = 4) and Escherichia coli (n = 4) were tested in duplicate. Bacterial suspensions of each isolate were made in a control solution of normal saline and Mueller-Hinton broth (MHB), and in a lock solution of ethanol 30%, TSC 4% and MHB. Suspensions were incubated at 37 degrees C for 48 h. Colony counts were determined from samples collected at t = 0 h (before exposure to the ethanol/TSC lock), t = 1 h (one hour after exposure to the ethanol/TSC lock), t = 24 h and t = 48 h. To confirm the absence of viable organisms in the lock solution, the remaining volume at 48 h was filtered t...

Research paper thumbnail of The glycylcyclines: a comparative review with the tetracyclines

Drugs, 2004

The tetracycline class of antimicrobials exhibit a broad-spectrum of activity against numerous pa... more The tetracycline class of antimicrobials exhibit a broad-spectrum of activity against numerous pathogens, including Gram-positive and Gram-negative bacteria, as well as atypical organisms. These compounds are bacteriostatic, and act by binding to the bacterial 30S ribosomal subunit and inhibiting protein synthesis. The tetracyclines have been used successfully for the treatment of a variety of infectious diseases including community-acquired respiratory tract infections and sexually transmitted diseases, as well in the management of acne. The use of tetracyclines for treating bacterial infections has been limited in recent years because of the emergence of resistant organisms with efflux and ribosomal protection mechanisms of resistance. Research to find tetracycline analogues that circumvented these resistance mechanisms has lead to the development of the glycylcyclines. The most developed glycylcycline is the 9-tert-butyl-glycylamido derivative of minocycline, otherwise known as t...

Research paper thumbnail of A patient-focused approach to thrombolytic use in the management of catheter malfunction

Seminars in dialysis

Thrombus-related catheter malfunction is a significant problem for catheter-dependent dialysis pa... more Thrombus-related catheter malfunction is a significant problem for catheter-dependent dialysis patients. The primary medical intervention is the local luminal installation of thrombolytic agents (TLAs). There are three major TLA installation methodologies: locking, push, and infusion protocols. A systematic literature review of existing TLA protocols for treating dialysis catheter malfunction was performed using the PubMed and EMBASE (Drugs and Pharmacology) databases from the time of each database's inception to August 2005. Thrombolytic administration was then categorized according to the patient's clinical need: (1) an acute/immediate requirement, such as when malfunction prohibits dialysis initiation, and (2) rescue therapy, such as when the thrombus threatens to significantly impair current or subsequent dialysis clearance. Published TLA protocols are discussed in the context of their clinical requirement (acute or rescue therapy). A unifying clinically relevant managem...

Research paper thumbnail of Using Curriculum Mapping to Engage Faculty Members in the Analysis of a Pharmacy Program

American Journal of Pharmaceutical Education, 2014

To develop a curriculum mapping process that supports continuous analysis and evidence-based deci... more To develop a curriculum mapping process that supports continuous analysis and evidence-based decisions in a pharmacy program. A curriculum map based on the national educational outcomes for pharmacy programs was created using conceptual frameworks grounded in cognitive learning and skill acquisition. The curriculum map was used to align the intended curriculum with the national educational outcomes and licensing examination blueprint. The leveling and sequencing of content showed longitudinal progression of student learning and performance. There was good concordance between the intended and learned curricula as validated by survey responses from employers and graduating students. The curriculum mapping process was efficient and effective in providing an evidence-based approach to the continuous quality improvement of a pharmacy program.

Research paper thumbnail of Erythropoietin-Alpha Dosage Requirements in a Provincial Hemodialysis Population: Effect of Switching from Subcutaneous to Intravenous Administration

Nephron Clinical Practice, 2006

The purpose of this initiative was to compare erythropoietin-alpha doses in hemodialysis patients... more The purpose of this initiative was to compare erythropoietin-alpha doses in hemodialysis patients who changed from subcutaneous to intravenous administration. The Manitoba Renal Program switched routes due to concern about erythropoietin-associated pure red cell aplasia. We compared the erythropoietin-alpha dosage requirements during subcutaneous administration (3 months pre-switch) and intravenous administration (months 4-6 post-switch). We also compared: hemoglobin, transferrin saturation (Tsat%), ferritin, and percent of patients receiving intravenous iron. The same erythropoietin-alpha regimen was initially used when patients were switched. Of the 628 patients receiving erythropoietin-alpha, the data were complete for 400. The dose increased 26% (mean +/- SD, 10,425 +/- 7,330 vs. 13,125 +/- 8,638 IU/week; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), despite similar hemoglobin, (mean +/- SD, 11.5 +/- 1.1g/dl (114.9 +/- 11.2 g/l) vs. 11.3 +/- 1.0 g/dl (113.5 +/- 10.4 g/l); p = 0.0450) and iron parameters (Tsat 30.9%, ferritin 464 ng/ml (microg/l) vs. Tsat 28.7%, ferritin 538 ng/ml (microg/l)). For the subgroup of 84 patients who maintained target hemoglobin (10-11 g/dl or 110-120 g/l) for both periods, the dose increased 26% (mean +/- SD, 8,393 +/- 6,242 vs. 10,589 +/- 7,049 IU/week; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) without a change in hemoglobin, (mean +/- SD, 11.5 +/- 0.3 g/dl (115.2 +/- 3.0 g/l) vs. 11.5 +/- 0.3 g/dl (114.9 +/- 3.3 g/l); p = 0.5789). When stratified by subcutaneous dose, patients with the lowest dose (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;5,000 IU/week) demonstrated the greatest increase (89%), and those with the highest dose (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;20,000 IU/week) experienced no increase (-3%). Overall, erythropoietin-alpha doses increased by 26% when patients were converted from subcutaneous to intravenous administration.

Research paper thumbnail of Review: Does Warfarin Safely Prevent Clotting of Hemodialysis Catheters?

Seminars in Dialysis, 2007

This article reviews the efficacy and safety of warfarin to prevent tunneled cuffed catheter (TCC... more This article reviews the efficacy and safety of warfarin to prevent tunneled cuffed catheter (TCC) thrombosis in the hemodialysis population. Literature searches of PubMed, EMBASE,

Research paper thumbnail of Antibiotic-Heparin Lock: In Vitro Antibiotic Stability Combined with Heparin in a Central Venous Catheter

Pharmacotherapy, 2000

Long-term hemodialysis frequently requires vascular access through central venous catheters (CVCs... more Long-term hemodialysis frequently requires vascular access through central venous catheters (CVCs). Infection related to these catheters is a significant complication. The use of an antibiotic-heparin lock could decrease the risks associated with infected permanent catheters. As an initial step in developing an antibiotic-heparin lock, we investigated the in vitro stability of antibioticheparin combinations in CVCs. Initially, cefazolin, vancomycin, ceftazidime, ciprofloxacin 10 mg/ml each, and gentamicin 5 mg/ml were incubated separately in glass test tubes in the dark at 37ºC for 72 hours. Samples were analyzed spectrophotometrically for stability at 24-hour intervals. The procedure was repeated with the addition of heparin (final concentration 5000 U/ml in glass test tubes), and the combination was also examined in CVCs. High-performance liquid chromatography analysis was conducted on the antibiotic-heparin combinations at 72 hours to confirm the spectrophotometric results. Ciprofloxacin produced an immediate precipitate with the addition of heparin and was not analyzed further. Absorbance values decreased for all antibiotics, with the greatest decreases at 72 hours for cefazolin (27.4%), vancomycin (29.7%), ceftazidime (40.2%), and gentamicin (8%) when combined with heparin. These decreases were postulated to be secondary to adsorption of the antibiotics to the luminal surface of the catheters because submitting the catheters to ultrasound with 1% sodium bicarbonate and analyzing the resulting solution for absorbance revealed that some of the drug was recovered. Although free antibiotic in CVC solution was reduced, the concentration should be sufficient (approximately 5 mg/ml) to decrease the frequency of infections associated with CVCs. We conclude that the concentrations of vancomycin, ceftazidime, cefazolin, or gentamicin used in our study should be sufficient for an antibiotic-heparin lock.

Research paper thumbnail of Conversion From Subcutaneous to Intravenous Erythropoietin in a Hemodialysis Population

The Journal of Clinical Pharmacology, 2005

The purpose of this study was to compare erythropoietin dosage requirements during subcutaneous v... more The purpose of this study was to compare erythropoietin dosage requirements during subcutaneous versus intravenous administration in a hemodialysis population. Hemodialysis patients receiving subcutaneous epoetin alfa were switched to the intravenous route using a prospective, crossover design. Baseline anemia parameters were measured at months -2, -1, and 0 when patients were receiving subcutaneous dosing and compared to months 4, 5, and 6 after the switch to intravenous dosing. Ninety-eight patients were enrolled into the study with an average age of 54.8 years. Over the course of the study, 34 patients were excluded from analysis, leaving 64 patients with complete hemoglobin and erythropoietin dosing data throughout the subcutaneous and intravenous evaluation periods. In these patients, the dose of erythropoietin increased significantly from the subcutaneous to the intravenous period (7567.7 to 10229.2 IU/wk). The conversion of hemodialysis patients from the subcutaneous to the intravenous route of administration significantly increased epoetin alfa dosage requirements.

Research paper thumbnail of Effectiveness of a 30% ethanol/4% trisodium citrate locking solution in preventing biofilm formation by organisms causing haemodialysis catheter-related infections

Journal of Antimicrobial Chemotherapy, 2008

Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CR... more Objectives: Antibiotic locks may be used to prevent haemodialysis catheter-related infections (CRIs). This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate lock solution in preventing biofilm formation by the most common pathogens causing haemodialysis CRIs.

Research paper thumbnail of An in vitro evaluation of the antibiotic/heparin lock to sterilize central venous haemodialysis catheters

Journal of Antimicrobial Chemotherapy, 2002

This in vitro study investigated the ability of antibiotic/heparin locks to sterilize central ven... more This in vitro study investigated the ability of antibiotic/heparin locks to sterilize central venous haemodialysis catheters (CVCs) inoculated with methicillin-resistant Staphylococcus epidermidis (MRSE). Isolates of MRSE were incubated in broth inside CVCs. The catheters were then drained and filled with either vancomycin/gentamicin/heparin (VGH), cefazolin/gentamicin/ heparin (CGH) or control locks for 48 h. The catheters were drained, filled with fresh broth and again incubated. The final catheter solutions were sampled and the remaining volumes filtered. The samples, filters and catheter segments were examined for growth. For two isolates, both the VGH and CGH locks sterilized the catheters. Bacterial counts of the remaining two isolates were significantly reduced by &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;99%, but the catheters were not sterilized after the instillation of a single-antibiotic/heparin lock.