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To evaluate recommendations of an antibiotic stewardship (ABS) team during routine weekly visits and to analyse their implementation and reasons for non-implementation by the ward physicians.Multiprofessional ABS Rounds (members: infectiology, microbiology, pharmacy and hospital epidemiology) were accompanied by an observer in nine intensive and peripheral wards of a university hospital (1451 beds) for eight weeks. The recommendations of the ABS team were prospectively analysed, and when these were not implemented, ward physicians in charge were asked to give reasons for non-implementation.A total of 262 patients were visited in the course of 359 ABS visits. A median of four physicians and one pharmacist (Q25/Q75: 4/6) participated in the ABS rounds. In 177/359 (49%) of visits, at least one recommendation for anti-infective therapy was given; the total number of recommendations made was 210. The most frequent (38%, 80/210) recommendations were related to the prescribed therapy duration. The more different the professional groups participating in the ABS rounds, the larger was the number of recommendations given (p=0.016; odds ratio=1.018 (1.003-1.033)). 62/210 (30%) of the ABS recommendations were not implemented by the ward physicians in charge. The most frequent reason (32%: 20/62) for this was the deliberate decision by the physicians to deviate from the recommended therapy.The high recommendation rate of 50% demonstrates the need for optimizing therapy by the ABS teams in routine practice. The larger the number of different specialists participating in single visits, the larger was the number of recommendations. Reasons for the lack of implementations need to be critically examined by both the ABS team and the ward physicians in charge.Ziel dieser Studie war es, die Empfehlungen eines etablierten ABS-Teams während der wöchentlichen Routinevisiten zu evaluieren sowie ihre Umsetzungsrate und die Gründe der Nichtumsetzung zu untersuchen.Die Visiten eines multiprofessionellen ABS-Teams (Infektiologie, Mikrobiologie, Apotheke und Krankenhaushygiene) wurden über 8 Wochen auf 9 intensivmedizinischen und peripheren Stationen eines Universitätsklinikums (1451 Betten) begleitet. Die Empfehlungen des ABS-Teams wurden prospektiv analysiert und bei fehlender Umsetzung Gründe standardisiert von den behandelnden Ärzten erfragt.Während des Beobachtungszeitraums fanden bei 262 Patienten 359 ABS-Visiten statt. Im Median nahmen 4 Ärzte und 1 Apotheker (Q25/Q75: 4/6) an den ABS-Visiten teil. Bei 177/359 (49%) ABS-Visiten erfolgte mindestens eine Empfehlung zur Antiinfektivatherapie. Insgesamt wurden 210 Empfehlungen ausgesprochen. Am häufigsten waren mit 38% (80/210) Empfehlungen zur Einhaltung der festgesetzten Therapiedauer. Je mehr unterschiedliche Berufsgruppen an der ABS-Visite teilnahmen, je eher wurde eine Empfehlung ausgesprochen (p=0,016; Odds Ratio=1,018 (1,003–1,033)). 62/210 (30%) der Empfehlungen des ABS-Teams wurden vom behandelnden Arzt nicht umgesetzt. Als häufigster Grund wurde mit 32% (20/62) eine bewusst von der Empfehlung abweichende Therapieentscheidung angegeben.Die hohe Empfehlungsrate von knapp 50% zeigt den Bedarf an Therapieoptimierung durch ABS-Teams in der Routine. Je multiprofessioneller diese besetzt sind, desto häufiger werden auch Empfehlungen ausgesprochen. Gründe für die fehlende Umsetzung von Empfehlungen sollten kritisch hinterfragt werden – sowohl seitens des ABS-Teams als auch seitens der behandelnden Ärzte auf Station.

Changes in drug therapy at intersectoral interfaces can lead to clinically relevant drug-related problems. This study aimed, therefore, at comparing the drug prescription continuity of patients with and without a medication plan at hospital admission. After ethical approval, patients of a health insurance company in 6 hospitals in Saxony were consecutively assigned to this study from November 2011 to January 2012 after written informed consent. We assessed the following drug-related data for patients with and without medication plan at hospital admission: (i) the medication prescribed by the hospital physician on the day of hospital admission and (ii) the medication of the hospital discharge letter. Patient-individual claims data were assigned to the inpatient data for a period of 6 months before and after inpatient treatment (data linkage). Of the 279 study participants, 173 (62 %) used a medication plan at hospital admission. Patients with a medication plan had a statistically significantly older age, higher numbers of drugs and diagnoses and fewer emergency admissions. At admission 53 % of the drugs were continued in patients with medication plan and 40 % in patients without a medication plan (p 0.001). At hospital discharge 66 % and 64 % were continued after discharge (n. s.). Medication plans were mostly written by their GP (38 %) and in 12 % by the patients themselves. Even before implementation of the national medication plan, nearly two third of the patients had a medication plan at hospital admission. However, in many cases it had been prepared by the patients themselves. The existence of a medication plan can have an impact on the continuity of the drug prescription during hospitalisation but not after discharge. Veränderungen der Arzneimitteltherapie an intersektoralen Schnittstellen können zu klinisch relevanten arzneimittelbezogenen Problemen führen. Ziel dieser Studie war ein Vergleich der Kontinuität in der Arzneimittelverordnung von Patienten mit und ohne Medikationsplan (MP) bei Krankenhausaufnahme. Nach Erhalt des Ethikvotums wurden in 6 Krankenhäusern in Sachsen von November 2011 bis Januar 2012 konsekutiv Patienten einer gesetzlichen Krankenversicherung (GKV) nach schriftlicher Einwilligung aufgenommen. Für Patienten mit und ohne MP bei Krankenhausaufnahme wurden diese Daten ausgewertet: (1) die am Tag der Krankenhausaufnahme vom Krankenhausarzt verordneten Arzneimittel aus der Patientenkurve, (2) die Arzneimittel des Krankenhausentlassungsbriefes. Diesen Daten wurden patientenbezogene ambulante Arzneimittelverordnungsdaten einer GKV für den Zeitraum 6 Monate vor und nach der stationären Therapie zugeordnet (Datenlinkage). Bei 173 (62 %) der 279 Studienteilnehmer lag ein MP bei Krankenhausaufnahme vor. Patienten mit MP hatten ein statistisch signifikant höheres Lebensalter, eine höhere Anzahl an Arzneimitteln und Diagnosen und wurden bei diesem Krankenhausaufenthalt seltener als Notfallbehandlung aufgenommen. Bei Krankenhausaufnahme weitergeführt wurden 53 % der Arzneimittel bei Patienten mit mitgebrachtem MP und 40 % bei Patienten ohne MP (p 0,001). Bei Krankenhausentlassung wurden 66 % bzw. 64 % der Medikation fortgesetzt (n. s.). Am häufigsten wurde der mitgebrachte MP vom Hausarzt erstellt (38 %) und in 12 % vom Patienten selbst. Noch vor der gesetzlich vorgesehenen Einführung des MP besaßen bei Krankenhausaufnahme fast zwei Drittel der Patienten einen MP. Dieser war allerdings in vielen Fällen vom Patienten selbst erstellt worden. Das Vorliegen eines MP kann einen Einfluss auf die Kontinuität der Arzneimittelverordnung im Krankenhaus nehmen, jedoch nicht auf die Weiterverordnung bei Krankenhausentlassung.

Expertise in a variety of fields is required for the diagnostic process of epilepsies in children and adolescents as well as for their treatment with anticonvulsants. Patients benefit in the process from the cooperation of different health care professionals. It is of critical importance for risks to be minimised and for the efficacy shown in controlled clinical trials to be maintained in routine conditions. In the first instance, drug prescription procedures, including the choice of anticonvulsants and combinations of drugs and dosing, have to be considered. The administration of drugs has, of course, also to be taken into account. Only if patients are given their anticonvulsants appropriately, the intended success of the therapy can be accomplished. Strategies aimed at improving drug administration have to be directed not only at nurses but also at parents, children and adolescents themselves, as well as caregivers in schools and children's day-care facilities. By providing theoretical teaching, practical training, and routinely including pharmacists in the therapeutic team, drug-related problems that may result in limited effectiveness and increased risks are prevented. As a result, drug (therapy) safety is not only qualitatively improved, but the degree of participation and quality of life of patients and families is improved as well.Für die Diagnostik von Epilepsien im Kindes- und Jugendalter und deren Behandlung mit Antikonvulsiva ist Expertise in unterschiedlichen Bereichen nötig. Der Patient profitiert dabei vom Zusammenwirken verschiedener Berufsgruppen. Risiken müssen reduziert und die in klinischen Studien gezeigte Wirksamkeit auch in eine möglichst gute Effektivität unter Routinebedingungen umgesetzt werden. Dabei sollten zunächst Aspekte der Arzneimittelverschreibung durch den Arzt berücksichtigt werden, wie etwa die Auswahl, Kombination und Dosierung der Antikonvulsiva. Dabei sollte die Arzneimittelanwendung nicht vergessen werden. Erst, wenn ein Antikonvulsivum richtig angewendet wird, kann der vom verordnenden Arzt gewünschte Therapieerfolg auch erreicht werden. Dabei sollten sich Maßnahmen nicht nur auf den Pflegedienst, sondern auch auf die Eltern, die Kinder und Jugendlichen selbst sowie Betreuer in Schulen und Kindertageseinrichtungen erstrecken. Durch theoretische Schulungen, praktische Übungen und regelmäßige Einbindung von Apothekern ins interdisziplinäre Behandlungsteam wird vermeidbaren arzneimittelbezogenen Problemen, die zu mangelnder Effektivität und dem Auftreten erhöhter Risiken führen können, vorgebeugt. Auf diese Weise wird nicht nur die Arzneimittel(therapie)sicherheit qualitativ verbessert, sondern auch die Teilhabe und Lebensqualität der Patienten und deren Familien positiv beeinflusst.

Intensive pharmaceutical and medical care can lead to fewer drug-related problems (DRPs) in hospitals. Currently available methods to track drug changes after transition from inpatient to outpatient care are susceptible to systemic bias. Therefore we analysed the feasibility of a data linkage between prescription data extracted from hospital medical records and claims data from a health insurance company.At six Saxonian hospitals, patients with a written informed consent were consecutively assigned to a control (CG) or intervention group (IG) depending on the time of admission. Clinical pharmacists documented predetermined DRPs and prescribed medication on the day of hospital admission and in the discharge letter. In case of DRP (IG) or potentially life-threatening DRPs (CG), drug changes were recommended to the hospital physician. These data were patient-individually linked to claims data from a health insurance company comprising a period of six months before and six months after hospitalisation (data linkage). We analysed data consistency within the data linkage and the post-hospital prevalence of DRPs identified in the hospital setting.We enrolled 532 patients (CG/IG 280/252). The data linkage was feasible for 97.0% (CG) and 96.6% (IG) of the patients, respectively. A total of 318 DRPs (CG/IG 176/142) was detected. Because of restrictions in the reimbursement of drugs in the outpatient setting, 22 (12.5%, CG) and 13 (9.2%, IG) DRPs were not analysable. Insurance claims data during a 6-month follow-up showed no statistically significant difference between the CG (without intervention) and in the IG (with intervention) with respect to DRPs (43.4% vs 38.1%; p = 0.472).The linkage of inpatient and outpatient data was feasible for the majority of enrolled patients. Compared to similar studies, the risk for systemic bias decreased because fewer patients were lost to follow-up. Within this feasibility study the expected difference between IG and CG could not be demonstrated statistically.

In tertiary care, computerized physician order entries may improve performance, cross-linking, and documentation when prescribing drugs. A clinical decision support integrated in these systems is discussed to prevent additional medication errors. For an optimal performance, the implementation into the clinical information systems is required to gain access to patient data (e. g. from laboratory). In routine care, the question rises whether a benefit of the systems can be proven in clinical studies and whether there is a difference between the systems. To achieve optimal results, these systems should also consider specific requirements, i. e. the patient groups and prescribed drugs in the local setting. We performed a systematic literature evaluation searching for published data in the topic electronic prescribing to assess them in a structured analysis considering medical-pharmaceutical aspects. Additionally, we assessed three databases in German language and one in English language taking drug-drug-interactions as an example to compare the identification of drug-related problems. Medication data from our own patients in a paediatric intensive care unit of a university hospital were analysed by the systems. Our results revealed strengths but also limitations of electronic prescribing.

Which effects has the interdisciplinary collaboration including pharmacists and psychologists in depressive patients?In a 3-arm (each N = 10) randomized pilot study, we compared SC (standard care by specialized physicians in a tertiary care center) with SC + pharmaceutical medication management and SC + psychological counselling in respect to the number of drug-drug interactions, guideline conformity, patient knowledge, and medication adherence (according to MARS).The number of drug-drug interactions decreased by the MM up to 67 % (p 0.05). Guideline conformity was fulfilled in all groups before and after intervention. Patient knowledge and medication adherence were not influenced by additional medication management or psychological counselling.In a greater patient group, these explorative results should now be verified.

Nowadays multiple pharmacotherapeutic options are available to treat pain. The diverse analgesics differ not only in their mechanism, potency, and efficacy but vary also in adverse drug reactions and drug interactions. Knowledge about the clinically relevant aspects in this field is essential to fit pain therapy to the individual patient. Non-opioids such as acetaminophen are hepatotoxic at high doses or may induce agranolcytosis such as dipyrone. Non-steroidal anti-inflammatory drugs (e.g. diclofenac) have a high risk of toxic effects particularly affecting stomach and kidneys. Especially the reasonable combination with other drugs that were frequently used in pain therapy, such as glucocorticoids, can induce gastrointestinal toxicity and bleeding. Also the use of WHO-II opioids (e.g. tramadol) should be carefully monitored for drug-related problems because of their individual drug metabolism and multiple drug-drug interactions. WHO-II as well as WHO-III opioids (e.g. morphine) provoke constipation, nausea, vomiting, and flush as adverse drug reactions of particular clinical relevance. An appropriate supportive therapy is mandatory, particularly regarding laxatives.

In Germany, about one fourth of all tablets are split before ingestion. Since April 2007, by German law, pharmacists are legally obligated to substitute a prescribed drug for a generic drug, provided the patients' health insurance company has made corresponding contracts with pharmaceutical companies (discount contracts). However, generic drugs may differ substantially in their splitting properties. Until now it is unknown how generic substitutions due to discount contracts will influence the prescribing quality with regard to tablet splitting.The prescription data of 425 ambulatory patients with polymedication insured at the Allgemeine Ortskrankenkasse (AOK) were analyzed and their drugs switched according to current discount contracts.Altogether 24% of all tablets were split before ingestion. For 54% of these split tablets (182 of 335) existing discount contracts mandated generic substitution. In about 10% of the substitutions there was a chance of substituting a scored tablet for a dosage form not suitable for splitting (unscored tablet or capsule).Therefore, current legislation should not only aim at reducing medication cost but also safeguard both effectiveness of the drugs and handling by the patients.

Drug therapy should be individualized according to criteria of efficacy, adverse effects, and treatment adherence. This is particularly important at the interface of inpatient and ambulatory care. Aspects of drug approval (labeling) and individual refunding by health care insurance should also be taken into account.A patient (male, 61 years, painter) showed elevated transaminases after treatment with phenprocoumon because of a deep vein thrombosis in 1999. Transaminases normalized completely after discontinuation of phenprocoumon. Other reasons for the elevated transaminases could be excluded. After a recurrent thrombosis in 2003 phenprocoumon was prescribed again followed by recurrent elevation of transaminases and subsequent cholestatic hepatitis progressing to fulminant hepatic failure that required liver transplantation. After transplantation the patient's general state of health was good and liver function nearly normal. Anticoagulation was indicated beyond the postoperative phase because of recurrent deep vein thrombosis and atrial fibrillation. A low-molecular-weight heparin was chosen for long-term treatment.A low-molecular-weight heparin appears to be the most appropriate way to maintain effective and safe anticoagulation in this patient. Coumarins carry a residual risk of an extrahepatic, immunologically mediated cross-sensitization. Long-term use of ximelagatran may also cause liver damage. For heparinoids, hirudins, and other drugs affecting coagulation like platelet aggregation inhibitors, therapeutic evidence is not sufficient. Though subcutaneous application of heparin is a disadvantage for the patient, therapeutic alternatives do not have better documented efficacy or less hepatotoxic potential. The low-molecular-weight heparin fulfills the criteria for refunding set by federal jurisdiction.