Curr Infect Dis Rep (2015) 17: 19 DOI 10.1007/s11908-015-0475-8
TRANSPLANT AND ONCOLOGY (M ISON AND N THEODOROPOULOS, SECTION EDITORS)
Value of Solid Organ Transplant-Trained Pharmacists in Transplant Infectious Diseases Jennifer Trofe-Clark & Tiffany Kaiser & Nicole Pilch & David Taber
Published online: 14 April 2015 # Springer Science+Business Media New York 2015
Abstract Advances in organ transplantation have led to improved graft and patient survival. Transplant pharmacist’s education and training uniquely position them to contribute knowledge and skills to the management of these highly complex patients. In 2004, the United Network for Organ Sharing bylaws added requirements that all transplant programs identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients. These bylaws
also delineated the transplant pharmacist’s roles and responsibilities. To further support these efforts, in 2007 the Centers for Medicare and Medicaid Services accreditation standards for transplant centers also mandated that a center have a designated, qualified expert in transplant pharmacology as a multidisciplinary team member. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care.
This article is part of the Topical Collection on Transplant and Oncology
Keywords BK virus . Center for Medicare and Medicaid Services . Cytomegalovirus . Graft survival . Human immunodeficiency virus . Immunosuppression . Infectious prophylaxis . Opportunistic infections . Organ transplant . Patient survival . Pharmacists . United Network for Organ Sharing
J. Trofe-Clark (*) Renal Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA e-mail: [email protected] J. Trofe-Clark Department of Pharmacy Services, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA T. Kaiser Division of Digestive Disease, 231 Albert Sabin Way, ML 0595, Cincinnati, OH 45267, USA e-mail: [email protected] N. Pilch Department of Pharmacy and Clinical Sciences, South Carolina College of Pharmacy - MUSC Campus, Medical University of South Carolina, 150 Ashley Ave, Charleston, SC 29425, USA e-mail: [email protected] N. Pilch Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Ave, Charleston, SC 29425, USA D. Taber Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC 29425, USA e-mail: [email protected]
Introduction Advances in organ transplantation have led to improved graft and patient survival, especially in the short-term setting [1, 2]. Success is in large part due to progress in the intricate management of narrow therapeutic index immunosuppressive therapies [3]. Transplant pharmacist’s education and training uniquely position them to contribute knowledge and skills to the medical management of these complicated patients. As a result, they have been recognized as integral and respected members of the multidisciplinary transplant team for over three decades and are involved in all phases of transplant care. The expertise of transplant pharmacists have become coveted in industry, government, administrative, and academic positions as well. However, documentation of the value and
19 Page 2 of 7
justification of transplant pharmacy services continues to evolve, including in the area of transplant infectious diseases. In 1976, pharmacist John F. Mitchell published on his involvement as a member of the renal transplant team at The Ohio State University Hospitals [4]. His clinical activities consisted of daily rounds with the team, drug dosage monitoring, providing drug information to staff and patients, development of a transplant patient handbook, and providing patient medication education, including prior to hospital discharge. Almost four decades later, these same pharmacy services, in addition to others, are still considered essential to the function of a transplant team and patient outcomes. In the 1980s, transplant pharmacists continued this trajectory by providing guidance on complicated immunosuppressive pharmacokinetics and pharmacodynamics. For example, Gil Burckart and colleagues at the University of Pittsburgh developed a cyclosporine blood level monitoring program and eventually received funding from the National Institutes of Health to support these efforts [5]. Pharmacokinetic and pharmacodynamics monitoring of immunosuppression are still fundamental to today’s transplant practice, and many pharmacists continue to be involved in all phases of drugrelated research focused not only on immunosuppressants but also on anti-infective agents. Since the 2000s, transplant pharmacists dramatically expanded upon research in transplant-specific pharmacoeconomics, medication education, and adherence improvement strategies [6–12]. Subsequently, the critical role of the transplant pharmacist became further formalized in 2004 when the United Network for Organ Sharing (UNOS) bylaws added requirements that all transplant programs should identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients, and these bylaws also delineated the transplant pharmacist’s roles and responsibilities [13]. In 2007, the Centers for Medicare and Medicaid Services (CMS) accreditation standards for transplant centers mandated that a transplant center have a designated, qualified expert in transplant pharmacology as a member of the multidisciplinary team [14]. CMS further described the transplant pharmacist’s role and responsibilities to state that the pharmacist must be involved in every phase of the transplant patient’s care. As a result of these changes, a joint American Society of Transplantation Transplant Pharmacy Community of Practice and the American College of Clinical Pharmacy Immunology/Transplantation Practice and Research Network White Paper was published which describes the education and training necessary for transplant pharmacists, as well as a guide to centers who wish to develop a designated transplant pharmacist position in the future [15••]. More recent reports published since 2008 have described the role of the transplant pharmacist in all phases of care, including involvement in activities such as acquisition of medications,
Curr Infect Dis Rep (2015) 17: 19
medication reconciliation, patient and staff education, assessment and tools for improving medication adherence, development of clinical protocols, drug selection, dosing and monitoring, avoidance of medication errors and adverse events, assisting in decreasing hospital readmissions and decreasing hospital lengths of stay, development of collaborative practice agreements, involvement in clinical research, assisting in establishing specialty pharmacy services, and billing for pharmacy services [16–31, 32••, 33–37]. Transplant pharmacists have also been active contributing members to inter-professional transplant-related organizations. For example, transplant pharmacists have had a long history of involvement in the American Society of Transplantation (AST). Members have presented peerreviewed transplant infectious disease-related abstracts at annual meetings as well as participated in the publication of guidelines like the AST Infectious Disease Guidelines 3rd Edition [38, 39]. Many pharmacists are also members of the Transplant Pharmacy Community of Practice (COP) within the AST, which was established in 2007. This group has allowed pharmacists to not only network in a collaborative fashion across the Transplant Pharmacy COP but to also integrate with other transplant disciplines such as the AST Infectious Diseases COP on topics including profession and patient education, public policy initiatives, meeting planning, establishing clinical guidelines, and collaborative publications. As a result of UNOS and CMS issuing mandates requiring transplant programs to document the participation of a pharmacist on multidisciplinary teams in order to meet accreditation standards, the number of transplant pharmacist practicing across the USA has grown substantially [13, 14]. Yet, to date, little has been published describing the transplant pharmacy workforce [11, 25, 29, 40]. As the demand for the transplant pharmacist to be involved in all phases of transplant care continues to increase, it will be important to develop standards of practice for transplant pharmacists [41••]. The transplant pharmacist is therefore in a unique position to understand and aid in alterations of immunosuppression and antimicrobials in the setting of infectious diseases. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care (Table 1). Evaluation Phase (Pre-transplant) Transplant pharmacists are mandated to be involved in the evaluation of patients being considered for organ donation and transplant [13, 14]. They play a critical role in the recognition and stratification of both pharmacologic and nonpharmacologic risk factors during the transplant evaluation process. When pertinent issues are identified, the pharmacist
Curr Infect Dis Rep (2015) 17: 19 Table 1
Page 3 of 7 19
Examples of transplant pharmacist activities related to transplant infectious diseases in each phase of transplant care Evaluation phase (pre-transplant)
Transplant phase (inpatient) and post-transplant phase (hospital readmissions)
Post-transplant phase (ambulatory)
Evaluation of pharmacologic and non-pharmacologic contraindications to transplant Allergy and medication reconciliation
X X
X
X
Review of immunization records and recommendations Patient medication education and adherence assessments Drug selection/dose/monitoring recommendations including druginteraction management Assist with prior authorizations and medication assistance programs Protocol development and adherence Involvement with quality improvement/drug utilization evaluations/ research
X X X
X X X
X X X
X
X X
X X X
can collaborate with other disciplines to develop a mitigation strategy. Additionally, since the pharmacist is involved in all phases of care, they can also assist with the communication of the plan to the inpatient team during the transplant admission, such as decisions regarding infectious prophylaxis and management of medication allergies and drug-drug interactions. They can also be involved in the follow-through of the plan in the post-transplant ambulatory setting or during hospital readmissions. Pharmacists are well positioned to assist with care continuity including issues related to infectious diseases. A manuscript authored by practicing transplant pharmacists described evidence from the literature for management of common pharmacologic and non-pharmacologic risk factors pharmacists may encounter while evaluating patients being listed for kidney transplantation [42]. Examples of concerns related to transplant infectious diseases in this manuscript include the following: assessment of medication allergies, colonization with resistant organisms, immunization records, anti-infective and immunosuppressive drug-drug interactions, medication adherence, barriers to communication, issues with education/literacy, and lack of adequate finances and/or insurance coverage. Drug-drug interactions of anti-infective agents with anticipated post-transplant medications can be pharmacodynamic or pharmacologic interactions [39]. One category of important interactions to consider in candidates prior to transplantation is for those patients with human immunodeficiency virus (HIV) who are on antiretroviral agents. Many of these agents can either induce or inhibit cytochrome P450 3A and/or p-glycoprotein, leading to substantial drug-drug interactions with immunosuppressive agents, such as the calcineurin inhibitors (cyclosporine and tacrolimus) or the mammalian targets of rapamycin inhibitors (sirolimus and everolimus) [38, 43, 44]. The most potent of these interactions is with the antiretroviral protease inhibitors. When identified pre-transplant, the pharmacist can work with the transplant infectious disease
X
specialist to determine if the interacting agent(s) may be altered prior to transplant or will become part of the posttransplant medication regimen. The transplant pharmacist can then work with the transplant team to devise the most appropriate drug and dosing regimen for initiation and monitoring of the interacting immunosuppressive agents posttransplantation and communicate this to the inpatient team at the time of transplant [45, 46]. Another example of the transplant pharmacist’s involvement is in assessment of anti-infective medication allergies and intolerances. The transplant pharmacist can obtain as much information as possible about these reactions and assist in creating, in conjunction with the multidisciplinary team, an appropriate immunosuppressive and post-transplant anti-infective prophylaxis regimen. Additionally, many pharmacists also review eligibility for medication assistance programs, in association with transplant social work and finance, or recommend alternative therapies and management of anti-infective prophylaxis when the patient is anticipated to have exorbitant copays or limited coverage for particular medications [12, 34]. The transplant pharmacist can also be involved in review of pre-transplant vaccination strategies and implementation of post-transplant vaccine regimens [47]. A number of these pre-transplant activities may be captured on the Medicare cost report and can offset a portion of a transplant pharmacist’s salary [32••]. Transplant Phase (Inpatient) and Post-transplant Phase (Hospital Readmissions) During the transplant (inpatient) and post-transplant phase (hospital readmissions), transplant pharmacists are typically involved in many facets of the patient’s care [15••, 19, 24, 26]. The transplant pharmacist usually rounds with the inpatient transplant team; performs medication reconciliation and education and adherence assessments from the outpatient
19 Page 4 of 7
setting, particularly during readmission periods and daily medication review; provides drug selection recommendations, dosing, and monitoring recommendations to the inpatient team; is involved with approval of restricted medications; assists with prior authorizations and coordination of discharge medications; and verifies additional medication reconciliations often performed by non-transplant trained providers. They are closely involved in anti-infective pharmacotherapy management through reviewing allergies and immunizations; providing recommendations regarding drug selection, dosing, and monitoring; assessing and managing drug-drug interactions; and evaluating the appropriateness of the choice and dose over the course of treatment. Additionally, the transplant pharmacist may serve as a preceptor to pharmacy students, residents, and fellows and provide education to staff, including promoting organ donation [15••, 48–50]. The transplant pharmacist is also involved in transplant-related anti-infective drug institutional selections, order set development, monitoring guidelines (i.e., pre-emptive viral monitoring) medication use evaluations and participates in pharmacy and therapeutics committee. Many transplant centers also have their pharmacists develop anti-infective prophylaxis protocols in conjunction with the transplant infectious disease specialists and surgical and medical transplant clinicians [26]. The transplant pharmacist may then serve as the lead to ensure appropriate implementation, monitoring, and dose adjustments, evaluation of outcomes, and updating of these protocols as transplant center practices and the literature evolve. Involvement in these quality assurance and process improvement (QAPI) metrics may provide valuable data to the transplant center and may generate research ideas that also result in literature contributions that benefit the entire transplant community [32••]. An example of this is a recently published study that performed a post hoc analysis of a single-center randomized controlled trial of valganciclovir dosing, renal function, and development of cytomegalovirus (CMV) in 187 kidney transplant recipients [51]. The results strongly suggested that current recommended dose adjustments for valganciclovir (based on estimated renal function using ideal body weight) may indirectly result in underexposure of valganciclovir in obese patients. An additional example is that of a transplant center which changed its CMV prophylaxis in CMV D+/R- patients from 900 mg/day to 450 mg/day (renally adjusted) in an effort to decrease the cost to the patient but found that this change resulted in an increased occurrence of breakthrough CMV infection [52]. Due to concern for increased risk of breakthrough infection and ganciclovir resistance, the institutional protocol was revised back to 900 mg/day (renally adjusted) for all CMV D+/ R-kidney transplant recipients. Another important published study performed a post hoc analysis of a prospective trial of 200 kidney transplant patients evaluating medication errors and adverse drug related events [31]. The authors demonstrated that patients that developed a clinically significant
Curr Infect Dis Rep (2015) 17: 19
medication error (defined as a significant medication error that contributed to a hospital admission) were more likely to be prescribed a triazole antifungal (30 versus 9 %; p
TRANSPLANT AND ONCOLOGY (M ISON AND N THEODOROPOULOS, SECTION EDITORS)
Value of Solid Organ Transplant-Trained Pharmacists in Transplant Infectious Diseases Jennifer Trofe-Clark & Tiffany Kaiser & Nicole Pilch & David Taber
Published online: 14 April 2015 # Springer Science+Business Media New York 2015
Abstract Advances in organ transplantation have led to improved graft and patient survival. Transplant pharmacist’s education and training uniquely position them to contribute knowledge and skills to the management of these highly complex patients. In 2004, the United Network for Organ Sharing bylaws added requirements that all transplant programs identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients. These bylaws
also delineated the transplant pharmacist’s roles and responsibilities. To further support these efforts, in 2007 the Centers for Medicare and Medicaid Services accreditation standards for transplant centers also mandated that a center have a designated, qualified expert in transplant pharmacology as a multidisciplinary team member. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care.
This article is part of the Topical Collection on Transplant and Oncology
Keywords BK virus . Center for Medicare and Medicaid Services . Cytomegalovirus . Graft survival . Human immunodeficiency virus . Immunosuppression . Infectious prophylaxis . Opportunistic infections . Organ transplant . Patient survival . Pharmacists . United Network for Organ Sharing
J. Trofe-Clark (*) Renal Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA e-mail: [email protected] J. Trofe-Clark Department of Pharmacy Services, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA T. Kaiser Division of Digestive Disease, 231 Albert Sabin Way, ML 0595, Cincinnati, OH 45267, USA e-mail: [email protected] N. Pilch Department of Pharmacy and Clinical Sciences, South Carolina College of Pharmacy - MUSC Campus, Medical University of South Carolina, 150 Ashley Ave, Charleston, SC 29425, USA e-mail: [email protected] N. Pilch Department of Pharmacy Services, Medical University of South Carolina, 150 Ashley Ave, Charleston, SC 29425, USA D. Taber Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC 29425, USA e-mail: [email protected]
Introduction Advances in organ transplantation have led to improved graft and patient survival, especially in the short-term setting [1, 2]. Success is in large part due to progress in the intricate management of narrow therapeutic index immunosuppressive therapies [3]. Transplant pharmacist’s education and training uniquely position them to contribute knowledge and skills to the medical management of these complicated patients. As a result, they have been recognized as integral and respected members of the multidisciplinary transplant team for over three decades and are involved in all phases of transplant care. The expertise of transplant pharmacists have become coveted in industry, government, administrative, and academic positions as well. However, documentation of the value and
19 Page 2 of 7
justification of transplant pharmacy services continues to evolve, including in the area of transplant infectious diseases. In 1976, pharmacist John F. Mitchell published on his involvement as a member of the renal transplant team at The Ohio State University Hospitals [4]. His clinical activities consisted of daily rounds with the team, drug dosage monitoring, providing drug information to staff and patients, development of a transplant patient handbook, and providing patient medication education, including prior to hospital discharge. Almost four decades later, these same pharmacy services, in addition to others, are still considered essential to the function of a transplant team and patient outcomes. In the 1980s, transplant pharmacists continued this trajectory by providing guidance on complicated immunosuppressive pharmacokinetics and pharmacodynamics. For example, Gil Burckart and colleagues at the University of Pittsburgh developed a cyclosporine blood level monitoring program and eventually received funding from the National Institutes of Health to support these efforts [5]. Pharmacokinetic and pharmacodynamics monitoring of immunosuppression are still fundamental to today’s transplant practice, and many pharmacists continue to be involved in all phases of drugrelated research focused not only on immunosuppressants but also on anti-infective agents. Since the 2000s, transplant pharmacists dramatically expanded upon research in transplant-specific pharmacoeconomics, medication education, and adherence improvement strategies [6–12]. Subsequently, the critical role of the transplant pharmacist became further formalized in 2004 when the United Network for Organ Sharing (UNOS) bylaws added requirements that all transplant programs should identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients, and these bylaws also delineated the transplant pharmacist’s roles and responsibilities [13]. In 2007, the Centers for Medicare and Medicaid Services (CMS) accreditation standards for transplant centers mandated that a transplant center have a designated, qualified expert in transplant pharmacology as a member of the multidisciplinary team [14]. CMS further described the transplant pharmacist’s role and responsibilities to state that the pharmacist must be involved in every phase of the transplant patient’s care. As a result of these changes, a joint American Society of Transplantation Transplant Pharmacy Community of Practice and the American College of Clinical Pharmacy Immunology/Transplantation Practice and Research Network White Paper was published which describes the education and training necessary for transplant pharmacists, as well as a guide to centers who wish to develop a designated transplant pharmacist position in the future [15••]. More recent reports published since 2008 have described the role of the transplant pharmacist in all phases of care, including involvement in activities such as acquisition of medications,
Curr Infect Dis Rep (2015) 17: 19
medication reconciliation, patient and staff education, assessment and tools for improving medication adherence, development of clinical protocols, drug selection, dosing and monitoring, avoidance of medication errors and adverse events, assisting in decreasing hospital readmissions and decreasing hospital lengths of stay, development of collaborative practice agreements, involvement in clinical research, assisting in establishing specialty pharmacy services, and billing for pharmacy services [16–31, 32••, 33–37]. Transplant pharmacists have also been active contributing members to inter-professional transplant-related organizations. For example, transplant pharmacists have had a long history of involvement in the American Society of Transplantation (AST). Members have presented peerreviewed transplant infectious disease-related abstracts at annual meetings as well as participated in the publication of guidelines like the AST Infectious Disease Guidelines 3rd Edition [38, 39]. Many pharmacists are also members of the Transplant Pharmacy Community of Practice (COP) within the AST, which was established in 2007. This group has allowed pharmacists to not only network in a collaborative fashion across the Transplant Pharmacy COP but to also integrate with other transplant disciplines such as the AST Infectious Diseases COP on topics including profession and patient education, public policy initiatives, meeting planning, establishing clinical guidelines, and collaborative publications. As a result of UNOS and CMS issuing mandates requiring transplant programs to document the participation of a pharmacist on multidisciplinary teams in order to meet accreditation standards, the number of transplant pharmacist practicing across the USA has grown substantially [13, 14]. Yet, to date, little has been published describing the transplant pharmacy workforce [11, 25, 29, 40]. As the demand for the transplant pharmacist to be involved in all phases of transplant care continues to increase, it will be important to develop standards of practice for transplant pharmacists [41••]. The transplant pharmacist is therefore in a unique position to understand and aid in alterations of immunosuppression and antimicrobials in the setting of infectious diseases. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care (Table 1). Evaluation Phase (Pre-transplant) Transplant pharmacists are mandated to be involved in the evaluation of patients being considered for organ donation and transplant [13, 14]. They play a critical role in the recognition and stratification of both pharmacologic and nonpharmacologic risk factors during the transplant evaluation process. When pertinent issues are identified, the pharmacist
Curr Infect Dis Rep (2015) 17: 19 Table 1
Page 3 of 7 19
Examples of transplant pharmacist activities related to transplant infectious diseases in each phase of transplant care Evaluation phase (pre-transplant)
Transplant phase (inpatient) and post-transplant phase (hospital readmissions)
Post-transplant phase (ambulatory)
Evaluation of pharmacologic and non-pharmacologic contraindications to transplant Allergy and medication reconciliation
X X
X
X
Review of immunization records and recommendations Patient medication education and adherence assessments Drug selection/dose/monitoring recommendations including druginteraction management Assist with prior authorizations and medication assistance programs Protocol development and adherence Involvement with quality improvement/drug utilization evaluations/ research
X X X
X X X
X X X
X
X X
X X X
can collaborate with other disciplines to develop a mitigation strategy. Additionally, since the pharmacist is involved in all phases of care, they can also assist with the communication of the plan to the inpatient team during the transplant admission, such as decisions regarding infectious prophylaxis and management of medication allergies and drug-drug interactions. They can also be involved in the follow-through of the plan in the post-transplant ambulatory setting or during hospital readmissions. Pharmacists are well positioned to assist with care continuity including issues related to infectious diseases. A manuscript authored by practicing transplant pharmacists described evidence from the literature for management of common pharmacologic and non-pharmacologic risk factors pharmacists may encounter while evaluating patients being listed for kidney transplantation [42]. Examples of concerns related to transplant infectious diseases in this manuscript include the following: assessment of medication allergies, colonization with resistant organisms, immunization records, anti-infective and immunosuppressive drug-drug interactions, medication adherence, barriers to communication, issues with education/literacy, and lack of adequate finances and/or insurance coverage. Drug-drug interactions of anti-infective agents with anticipated post-transplant medications can be pharmacodynamic or pharmacologic interactions [39]. One category of important interactions to consider in candidates prior to transplantation is for those patients with human immunodeficiency virus (HIV) who are on antiretroviral agents. Many of these agents can either induce or inhibit cytochrome P450 3A and/or p-glycoprotein, leading to substantial drug-drug interactions with immunosuppressive agents, such as the calcineurin inhibitors (cyclosporine and tacrolimus) or the mammalian targets of rapamycin inhibitors (sirolimus and everolimus) [38, 43, 44]. The most potent of these interactions is with the antiretroviral protease inhibitors. When identified pre-transplant, the pharmacist can work with the transplant infectious disease
X
specialist to determine if the interacting agent(s) may be altered prior to transplant or will become part of the posttransplant medication regimen. The transplant pharmacist can then work with the transplant team to devise the most appropriate drug and dosing regimen for initiation and monitoring of the interacting immunosuppressive agents posttransplantation and communicate this to the inpatient team at the time of transplant [45, 46]. Another example of the transplant pharmacist’s involvement is in assessment of anti-infective medication allergies and intolerances. The transplant pharmacist can obtain as much information as possible about these reactions and assist in creating, in conjunction with the multidisciplinary team, an appropriate immunosuppressive and post-transplant anti-infective prophylaxis regimen. Additionally, many pharmacists also review eligibility for medication assistance programs, in association with transplant social work and finance, or recommend alternative therapies and management of anti-infective prophylaxis when the patient is anticipated to have exorbitant copays or limited coverage for particular medications [12, 34]. The transplant pharmacist can also be involved in review of pre-transplant vaccination strategies and implementation of post-transplant vaccine regimens [47]. A number of these pre-transplant activities may be captured on the Medicare cost report and can offset a portion of a transplant pharmacist’s salary [32••]. Transplant Phase (Inpatient) and Post-transplant Phase (Hospital Readmissions) During the transplant (inpatient) and post-transplant phase (hospital readmissions), transplant pharmacists are typically involved in many facets of the patient’s care [15••, 19, 24, 26]. The transplant pharmacist usually rounds with the inpatient transplant team; performs medication reconciliation and education and adherence assessments from the outpatient
19 Page 4 of 7
setting, particularly during readmission periods and daily medication review; provides drug selection recommendations, dosing, and monitoring recommendations to the inpatient team; is involved with approval of restricted medications; assists with prior authorizations and coordination of discharge medications; and verifies additional medication reconciliations often performed by non-transplant trained providers. They are closely involved in anti-infective pharmacotherapy management through reviewing allergies and immunizations; providing recommendations regarding drug selection, dosing, and monitoring; assessing and managing drug-drug interactions; and evaluating the appropriateness of the choice and dose over the course of treatment. Additionally, the transplant pharmacist may serve as a preceptor to pharmacy students, residents, and fellows and provide education to staff, including promoting organ donation [15••, 48–50]. The transplant pharmacist is also involved in transplant-related anti-infective drug institutional selections, order set development, monitoring guidelines (i.e., pre-emptive viral monitoring) medication use evaluations and participates in pharmacy and therapeutics committee. Many transplant centers also have their pharmacists develop anti-infective prophylaxis protocols in conjunction with the transplant infectious disease specialists and surgical and medical transplant clinicians [26]. The transplant pharmacist may then serve as the lead to ensure appropriate implementation, monitoring, and dose adjustments, evaluation of outcomes, and updating of these protocols as transplant center practices and the literature evolve. Involvement in these quality assurance and process improvement (QAPI) metrics may provide valuable data to the transplant center and may generate research ideas that also result in literature contributions that benefit the entire transplant community [32••]. An example of this is a recently published study that performed a post hoc analysis of a single-center randomized controlled trial of valganciclovir dosing, renal function, and development of cytomegalovirus (CMV) in 187 kidney transplant recipients [51]. The results strongly suggested that current recommended dose adjustments for valganciclovir (based on estimated renal function using ideal body weight) may indirectly result in underexposure of valganciclovir in obese patients. An additional example is that of a transplant center which changed its CMV prophylaxis in CMV D+/R- patients from 900 mg/day to 450 mg/day (renally adjusted) in an effort to decrease the cost to the patient but found that this change resulted in an increased occurrence of breakthrough CMV infection [52]. Due to concern for increased risk of breakthrough infection and ganciclovir resistance, the institutional protocol was revised back to 900 mg/day (renally adjusted) for all CMV D+/ R-kidney transplant recipients. Another important published study performed a post hoc analysis of a prospective trial of 200 kidney transplant patients evaluating medication errors and adverse drug related events [31]. The authors demonstrated that patients that developed a clinically significant
Curr Infect Dis Rep (2015) 17: 19
medication error (defined as a significant medication error that contributed to a hospital admission) were more likely to be prescribed a triazole antifungal (30 versus 9 %; p
