Critically ill patients are more likely to acquire venous thromboembolism (VTE) due to various underlying factors, including severe illness, mechanical ventilation, sedative medications, and extended immobility. Thromboprophylaxis is a crucial component in critically ill patients’ management because of their high risk of VTE. However, there is uncertainty about the appropriate type of pharmacological VTE prophylaxis in critically ill patients admitted to the medical intensive care units (ICUs). Therefore, our study aims at evaluating the effectiveness and safety of standard dosing regimens (Enoxaparin vs. unfractionated heparin (UFH)) as a VTE prophylaxis in those populations. This is a retrospective cohort study included medical ICU patients aged ≥ 18 years with a normal body mass index (BMI) who received either Enoxaparin 40 mg daily or UFH 5000 Unit three times daily as a VTE prophylaxis between January 1, 2018 and December 31, 2018. The primary outcome was VTE and any case of thrombosis, and the secondary outcomes included complications during the ICU stay (i.e., major bleeding, minor bleeding, RBC transfusion during ICU stay, HAT, and HIT). A total of 1866 patients were screened; 311 patients were included in the study. The differences in VTE (OR 0.47; 95% CI 0.10–4.10; P = 0.49) and any case of thrombosis (OR 0.43;95%CI 0.14–1.32; P = 0.14) during ICU were similar between the two groups and not statistically significant. Conversely, patients who received enoxaparin have a higher incidence of major bleeding, specifically GI bleeding, compared with UFH (OR 3.30; 95% CI 0.85–12.61; P = 0.08); however, it is not statistically significant. Standard dosing of enoxaparin in critically ill medical patients was not associated with thrombosis benefit, but it is linked with higher odds of GI bleeding.

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The Saudi Society of Clinical Pharmacy (SSCP) is striving to enhance the concept of clinical pharmacy within Saudi Arabia (SA) at all levels. Given the differences that exist between clinical pharmacy education, training, and practice settings in SA and other countries, the SSCP believes that it can play a proactive role in highlighting and streamlining various aspects of clinical pharmacy in SA. By gaining new knowledge, skills, and values through entering clinical practice, clinical pharmacists should be equipped with certain competencies to meet the expectations of the SSCP clinical pharmacy definition. In 2019, the SSCP established an expert writing task force of clinical pharmacy specialists representing different private and governmental sectors to lead and write a series of position statements relating to clinical pharmacy within SA. This position statement seek to identify the core competencies of clinical pharmacists in SA. The SSCP is calling on all educational institutions, postgraduate training programs, and professional organizations to collaborate to guarantee that these competencies are adopted to ensure the professional growth of clinical pharmacists and that optimal individual and population health outcomes are achieved.

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Medication error is a preventable problem and different interventions can be used to prevent the occurrence of errors. The aims of this study were to describe interventions used to reduce prescribing, dispensing, and administration errors in hospitalized patients in Saudi Arabia, and to describe the impact of interventions used. Six databases were searched for articles published between 1985 and June 2021. Studies reporting impact of interventions on prescribing, dispensing, or administration errors were included. Interventions were summarized using the Template for Intervention Description and Replication (TIDieR) Checklist and Guide. Five studies met the inclusion criteria, all of them were before/after studies. Three studies used bundle interventions and two studies used a stand-alone intervention, which were education, training, standardized table, drug information service, counselling, unifying reorder days, and double-checking. One study described the intervention fairly well, the other four studies were of low quality. There is a limited number of studies that investigated interventions used to reduce errors in Saudi hospitals, the majority of which were with low quality. There is a need for higher-quality studies that explicitly state details such as how the intervention was chosen, how it was implemented, and the impact of the intervention on reducing errors.

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The need for healthcare reform in Saudi Arabia (SA) is mostly related to inadequate primary care services, the inconsistent quality of services, and the high demand for workforce capacity and capabilities. Therefore, the proposed healthcare transformation plan is part of the country’s overall transformation plan of Saudi Vision 2030, which aims to prevent morbidity and mortality associated with non-communicable diseases (NCD), communicable diseases, and avoidable injuries. Clinical pharmacists in internal medicine (IM) play an integral role in managing and preventing NCDs and communicable diseases. Most of the leading causes of mortality in SA can be prevented or managed with medications, and highly skilled pharmacist in medication therapy management. To improve the quality of health and well-being of the Saudi population, there is a need for a much larger number of well-trained IM clinical pharmacists in the public and private sectors. This opinion paper by the IM Pharmacy Specialty Network (PSN) of the Saudi Society of Clinical Pharmacy (SCCP) presents the current status of the IM pharmacy workforce in SA and provide initial phase recommendations to help develop the IM pharmacy workforce to serve the needs of the Saudi people. However, to meet the goals of Saudi Vision 2030, all healthcare systems need to work collaboratively with other stakeholders such as MOH, Ministry of Human Resources and Social Development, and SCFHS to prepare a highly skilled and effective Saudi healthcare workforce to meet the high demands of reforming the healthcare system.

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Clinical pharmacy services in Saudi Arabia are expanding steadily, particularly with notable developments in critical care pharmacy services and training programs, including four critical care residency programs localized in Riyadh and one program in Jeddah. The Scientific Council of Pharmacy leads extensive efforts to advance clinical pharmacy practice and training under the Saudi Commission for Health Specialties (SCFHS), the accrediting body for critical care training programs and all other specialties. Despite launching critical care pharmacy programs in 2013, currently available accreditation standards and competency assessments for specialized residency programs in critical care were established in 2020. These accreditation standards and competency assessment modalities have been found to have significant areas of improvement based on the feedback of practicing critical care pharmacy residency program directors and trainees over the past few years. This is an opinion paper based on a consensus of critical care and emergency medicine pharmacy experts which recommends updating the current accreditation standards framework and competency assessment blueprint for specialized critical care pharmacy programs. Additionally, it highlights the need to modify the accreditation standards framework for critical care pharmacy programs. Further evaluation of these modalities can be revised as deemed reasonable by governmental authorities by recruiting practicing critical care clinical pharmacy experts.

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Background: Hepatorenal syndrome (HRS) is a functional form of acute kidney injury (AKI) that develops in patients with advanced liver disease. The use of octreotide (OCT) and midodrine (MID) along with albumin is commonly used in practice despite lack of strong evidence. Objective: The purpose of the study is to evaluate the efficacy of combining octreotide and midodrine in HRS patients. Materials and Methods: This is a retrospective, single center study. All patients who received both OCT/MID from January 2005 to April 2013 were identified from the electronic pharmacy system at a major tertiary care center in Riyadh, Saudi Arabia. The aim of the study is to evaluate the safety and efficacy and predictors to response of the combination of OCT/MID in patients with decompensated liver cirrhosis with type I HRS receiving standard of care therapy. The primary endpoint was the change in estimated glomerular filtration rate (eGFR) within 30 days of starting therapy compared to baseline. Results: There was no significant improvement in eGFR using Cockcroft-Gault (CG) from baseline until the end of treatment (P = 0.311). Conclusion: Combination therapy of octreotide and midodrine along with albumin did not improve the eGFR in patients with type 1 HRS.

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Objectives: Respiratory tract infections (RTIs) are a significant cause of hospitalization due to morbidity and mortality. The unwise use of antimicrobial agents in RTI management may contribute to the emergence of bacterial resistance. Therefore, we aimed to assess prescription patterns and antibiotic resistance among hospitalized patients with RTIs. Materials and Methods: This retrospective study included patients with any RTI who were hospitalized between 2016 and 2017. Antibiotics prescribed and changes in antibiotic resistance over time were evaluated. Results: The 405 included patients ranged in age from a few months old to over 65 years old. The most common clinical manifestations were fever (98% of patients) and sore throat (57.5%), followed by cough (46.7%) and dyspnea (27.2%). C-reactive protein was elevated in 43%. The most common diagnoses among all the patients were tonsillitis (43.2%), pharyngitis (36%), and pneumonia (23%). The most commonly isolated organisms were Haemophilus influenza (93.2%), Streptococcus pneumoniae (90.9%), Pseudomonas aeruginosa (84.1%), and Klebsiella pneumoniae (84.1%). Amoxicillin/clavulanate was mostly prescribed for upper RTIs, whereas levofloxacin was mostly prescribed for lower RTIs. Amoxicillin/clavulanate was the major antibiotic prescribed for pediatric patients, whereas geriatric patients (≥65 years) were mostly prescribed levofloxacin. No major changes in resistance rates were observed for amoxicillin/clavulanate, levofloxacin, or ciprofloxacin before (in 2015), during the study period (2016–2017), and after the study (2018). Conclusion: Amoxicillin/clavulanate and levofloxacin were the most commonly prescribed antibiotics, but resistance to these antibiotics did not increase over time. However, clinicians should make every attempt to collect cultures from patients with severe RTIs to rule out bacterial involvement.

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Background: Hajj pilgrimage is the largest mass gathering worldwide. The Saudi Ministry of Health (MOH) provides free medical services for all pilgrimages. In 2022, MOH incorporated clinical pharmacy services in intensive care units (ICUs) of the sacred rituals hospitals. In addition to their role in ICUs settings, they were involved in other activities related to emergency department admissions as well as conducting several educational services at the hospital level. This study aimed to describe the impact of clinical pharmacy services implementation during the Hajj season and to explore the clinical interventions delivered to ICU patients. Materials and Methods: A multicenter-retrospective, chart-review study including adult critically ill patients (>14 years old) admitted to ICUs of seven sacred rituals hospitals between June 30 and July 14, 2022. Patients were excluded if they were not admitted to the ICU or admitted to an area with no assigned clinical pharmacist. Clinical interventions were categorized based on a modified version of the American Society of Health-System Pharmacists (ASHP) categorization. The study was approved by MOH Central Institutional Review Board (IRB) on September 18, 2022 (Ref. 22-41 E). Results: Clinical pharmacists performed 269 interventions for 82 patients admitted to the ICUs of participating hospitals. Each patient had a median of three interventions (interquartile range 2–5). The most common intervention was the untreated indication (n = 93; 34.5%), followed by dose adjustment (n = 60; 22.3%) and improper drug selection (n = 42; 15.6%). The ICU teams ultimately accepted all interventions. Conclusion: Incorporating clinical pharmacy services into ICU settings during Hajj season optimized patient care. The variety of provided clinical interventions shows the impact of clinical pharmacists’ presence among multidisciplinary teams. Further studies are needed to explore the economic implication of clinical pharmacist services during Hajj.

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Case Report: In this paper we discuss the clinical course of a 25-week gestational age preterm neonate who suffered with multiple comorbidities atop of an E. meningoseptica infection causing meningitis and hydrocephalus. A multitude of antibiotics were administered to the child, such as vancomycin, ciprofloxacin, trimethoprim-sulfamethoxazole, and rifampicin. However, the pathogen either had prior resistance to the agents or newly developed resistance along the disease course. After many trials of antibiotics, the usage of ceftazidime/avibactam and moxifloxacin dual therapy induced clinical and microbiological eradication of the pathogen. Objective: This case report aims to discuss the multidrug approach used to treat a preterm neonates Elizabethkingia Meningoseptica infection in a Tertiary Care Hospital in Saudi Arabia. Conclusion: E. meningoseptica is an uncommon infectious agent which can cause meningitis and even sepsis that is difficult to treat due to its multidrug resistance phenotype. Continuous reviews of new case reports on successful attempts of treating E. meningoseptica are paramount to maintaining updated therapy options for newly encountered cases in day-to-day practice in the neonatal intensive care unit (NICU).

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Stewardship programs aiming at optimizing medication use are a core element of healthcare organizations. It allows for strategic interventions to improve both financial and therapeutic outcomes. The antibiotic and opioid stewardship programs have already been successfully established in several healthcare organizations. In addition to the financial aspect, they have also improved clinical outcomes and minimized harm by reducing antibiotic resistance, opioid use disorders, morbidity, and mortality. Steroids, also known as corticosteroids, are anti-inflammatory medications used to treat a range of conditions. If used inappropriately, they can result in serious and undesirable adverse effects. Steroid stewardship is a rather novel concept that aims to reduce inappropriate prescribing and improve clinical outcomes by creating a careful balance between therapeutic doses vs. doses that may cause adverse effects. The article’s objective is to highlight the need for a comprehensive approach to implement steroid stewardship programs as a multicomponent program involving multidisciplinary teams to identify potential treatment gaps and establish cognitive and practical approaches to overcome them.

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Background: Middle East respiratory syndrome (MERS) is associated with significant mortality with no approved antiviral therapy. Objectives: The aim of this study was to compare the efficacy and safety of the combination of ribavirin and PEG-interferon α-2a (RIF), oseltamivir, and supportive care (SC) alone in MERS patients. Materials and Methods: Retrospective cohort for all patients admitted to the intensive care unit with severe symptomatic laboratory-confirmed MERS infection between September 2013 and February 2017. Patients were divided into two pairwise comparisons: RIF and oseltamivir combined (antivirals) vs. SC; and RIF vs. oseltamivir. The primary endpoint was 60-day mortality. Secondary endpoints were the requirement for mechanical ventilation (MV) and renal replacement therapy (RRT), and laboratory changes. Results: A total of 113 patients met the study inclusion criteria; 77 received antivirals (47 received RIF and 30 oseltamivir), and 36 SC. The 60-day mortality rate was 36% with antivirals vs. 50% with SC (P = 0.136), and 45% with RIF vs. 23% with oseltamivir (P = 0.092). The MV requirement was 42% with antivirals vs. 65% with SC (P = 0.083), and 54% with RIF vs. 27% with oseltamivir (P = 0.067). The RRT requirement was 29% with antivirals vs. 31% with SC (P = 0.943), and 40% with RIF vs. 14% with oseltamivir (P = 0.019). The median hemoglobin decrease with RIF was 4 g/dL vs. 1 with oseltamivir (P < 0.001); the WBC decrease with RIF was 1.3 vs. 0.2 with oseltamivir (P = 0.007); the blood glucose increase with RIF was 143 mg/dL vs. 89 with oseltamivir (P = 0.036), and the indirect bilirubin increase with RIF was 0.4 mg/dL vs. 0.3 with oseltamivir (P = 0.023). Conclusions: In this study, the use of RIF or oseltamivir in severe MERS infections did not significantly reduce 60-day mortality, nor the requirement for MV or RRT. Furthermore, the subgroup that received oseltamivir had more favorable renal, hepatic, and hematological outcomes than RIF. Larger, prospective, well-designed studies are warranted to confirm these findings.

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Objective: Self-medication prevalence and characteristics during the ongoing pandemic have been assessed and documented in some countries for COVID-19 treatment; little is known of this practice among pharmacy students who are estimated to have higher knowledge of medications and their use. This study aims to assess self-medication prevalence and pattern during COVID-19 pandemic in this population. Materials and Methods: following IRB approval, a descriptive, cross-sectional study was implemented, and a survey link was distributed among pharmacy students enrolled at King Abdulaziz University, from 1/1/2021 to 17/2/2021. Questionnaire items included (1) students’ demographic, (2) self-medication prevalence during the pandemic, (3) medications, vitamins and supplements used (pre and post infection), (4) source of information, and (5) how long they used the medication for. Results: A total of 270 students completed the survey (39.9% response rate). Majority were between 21–23 years of age (63.7%), female (70%), and single (97%). A total of 149 (55.2%) students practiced self-medication during COVID-19 pandemic. Most used supplements were vitamin C (38.9%), followed by multivitamins (22.2%) and vitamin D (18.1%). Most used OTC medication was paracetamol (26.3%) whereas, most prescription medication used was anxiolytics (4.8%), and antibiotics (3.3%). Most relied on personal knowledge for their practice (77.18%) and continued taking the supplement for less than a month (56%). Moreover, 9.3% (n = 25) were tested positive for COVID-19 and self-medicated with: vitamin C 44% (n = 11), zinc 24% (n = 6), and aspirin 12% (n = 3). Conclusion: Although most used supplements and OTC medications during the pandemic; there was a minority who did use prescription medications, such as anxiolytics, antibiotics and antidepressants which raise concerns over their unattended use and mandate awareness of risks associated with these medications.

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Introduction: Acute acalculous cholecystitis is an acute gallbladder inflammation in the absence of cholelithiasis associated with high morbidity and mortality rates. Fungal organisms are an infrequent cause of gallbladder infections. Although many coronavirus disease-19 (COVID-19) patients reported gastrointestinal symptoms, there is little evidence of gallbladder and biliary tract involvement. we report a case of fungal acute acalculous cholecystitis secondary to COVID-19. Case Presentation: A 71-year-old man with a past medical history of benign prostatic hyperplasia, essential hypertension, and hyperlipidemia was admitted for COVID-19 and received appropriate treatment with dexamethasone, remdesivir, and convalescent plasma. The patient continued to be lethargic, weak, and had elevated inflammatory markers. He was transferred to the intensive care unit (ICU) for intubation and mechanical ventilation. The total bilirubin started to increase over the following days and reached 8 mg/dL (136.8 μmol/L). The ultrasound did not show cholelithiasis and the bile culture grew Candida albicans, indicating acalculous Candida cholecystitis. The patient had a significant deterioration in clinical status and passed away after being transferred to comfort care. Conclusion: Our case represents acute acalculous cholecystitis possibly secondary to COVID-19 infection that was resulted in an invasive fungal infection involving the gallbladder Future research could help facilitate a better pathophysiological understanding of gallbladder complications and provide a more precise explanation of the long-term effects of COVID-19.

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Background: In Saudi Arabia, asthma is one of the most common chronic respiratory diseases. Previous studies have identified that asthma management can be influenced by patients’ cultural beliefs and levels of asthma education. Therefore, community pharmacists should have good knowledge of both asthma and Saudi cultural beliefs to be able to effectively educate Saudi patients. Objective: The purpose of this study was to explore Saudi community pharmacists’ knowledge, experiences, and perspectives on providing care for Saudi patients with asthma. Materials and Methods: A qualitative method was employed to conduct semistructured interviews in the Eastern Province of Saudi Arabia. Community pharmacists were interviewed on the phone using an interview guide, and participants were recruited purposively. Verbatim transcripts of interviews were then thematically analyzed. Results: Analysis of 22 interviews resulted in five emergent themes: (1) lack of asthma knowledge among community pharmacists; (2) cultural and religious issues; (3) counseling issues; (4) patient medication issues and navigating the healthcare system; and (5) the need for asthma recourse and training. The findings indicate that community pharmacists have unsatisfactory levels of asthma knowledge and lack access to asthma guidelines in Saudi Arabia. It was also evident that the asthma management of Saudi patients was influenced by patients’ cultural and religious beliefs, which pharmacists needed to consider during patient counseling. Conclusions: Due to the lack of knowledge about asthma among our participants, there is an urgent need for asthma training. Furthermore, pharmacists should consider the impact of cultural issues on Saudi asthma patients to achieve better clinical outcomes.

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Background: Rheumatic heart disease (RHD) is a leading cause of heart disease in children and young adults in developing countries and is considered a significant cause of cardiovascular diseases. Antimicrobial prophylaxis is recommended as secondary prevention for heart complications caused by recurrent acute rheumatic fever. Objective: Our study aims to describe the prescribing patterns of RHD antibiotic secondary prophylaxis among eligible patients and highlight the frequency of valvular heart disease complications requiring intervention. Materials and Methods: A single-center retrospective study was conducted at a tertiary hospital in Saudi Arabia. The study included all patients 5 years old and above diagnosed with rheumatic heart fever and/or RHD and eligible for secondary prevention between January 2009 and December 2018. The primary outcome is the frequency of RHD secondary prophylaxis prescribed for eligible patients. Results: Among 806 patients who were screened, 272 patients were eligible for inclusion. A total of 194 (71.3%) were female, and 146 (53.67%) were older than 40. RHD secondary prophylaxis prescribing adherence was found in only 14 of 272 (5.14%). A total of 185 of 272 (68%) patients had at least one cardiac-related intervention during the follow-up period. Valvular heart disease progression was found in 72 of 185 (38.9%) after a primary intervention. Overall mortality was 30 (11%). Conclusion: Our study found low prescribing adherence to RHD secondary prevention among eligible patients in an area with a high disease prevalence. A larger sample size is needed to confirm these findings.

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