THE IMPACT OF THE DOCENT CLINICAL PHARMACIST
ON TREATMENT OF STREPTOCOCCAL PNEUMONIA
by Joel O. Covinsky, Stephen C. Hamburger, Kim L. Kelly, Bonnie Pastewski,
Nancy Robertson, Roger Eskridge, Glen Park, and Edward J. Twin
IN THE EARLY 1970s, the first doctoral level clinical phar-
macist was hired by the Kansas City General Hospital
(now called Truman Medical Center-West) to assist the
medical staff in developing sound therapeutic programs
for the management of disease. Dr. Edward J. Twin was
the executive medical director for the Kansas City
General Hospital and for the affiliate Jackson County
Hospital (now called Truman Medical Center-East). Ac-
cording to Twin, these doctors of pharmacy were as-
signed to various medical teams (called docent teams)
and were responsible for drug therapy on their respec-
tive units.' They were called docent clinical pharmacists
and were accountable for the selection of therapy ac-
cording to considerations of efficacy, safety, and cost.
Numerous programs were developed to evaluate the
quality of care provided by these multidisciplinary do-
cent teams. For example, under the direction of the
Department of Medicine, a multidisciplinary commit-
tee was charged with the responsibility of developing
audit criteria for the common diseases seen at the two
institutions. These audits provided the objective indices
for evaluating the quality of patient care on the in-
dividual units. Additionally, data were collected on a
monthly basis to evaluate the activities of the various
units by examining the efficiency with which hospital
personnel, facilities, and resources were utilized in
providing patient care. Inpatient costs, including
JOEL O. COVINSKY, Pharm.D., is Associate Professor and
Director of Clinical Pharmacology Program, Schools
of Medicine and Pharmacy, University of Missouri-
Kansas City, and Docent Clinical Pharmacist, Clinical
Pharmacology Section, Truman Medical Center;
STEPHEN C. HAMBURGER, M.D., is Associate Professor
and Vice-Chairman, Department of Medicine, School
of Medicine; KIM L. KELLY, Pharm.D., atthetimeofthis
study, was Associate Professor, Schools of Medicine
and Pharmacy, University of Missouri-Kansas City, and
Docent Clinical Pharmacist, Clinical Pharmacology Sec-
tion, Truman Medical Center; he is now Director of
Professional Education for Syva Company, and Clinical
Professor of Medicine at the University of Missouri
School of Medicine. BONNIE PASTEWSKI, Pharm.D., is
Assistant Professor of Clinical Pharmacy, Philadelphia
College of Pharmacy and Science; NANCY ROBERTSON,
Pharm.D., is Assistant Professor of Clinical Pharmacy,
College of Pharmacy, Medical University of South
Carolina; ROGER ESKRIDGE, Pharm.D., is Assistant
Director of Pharmacy Services, Trinity Lutheran
Hospital, Kansas City; GLEN PARK, Pharm.D., at the
time of this study, was Clinical Pharmacist, Department
of Pharmacy Services, University Hospitals of
Cleveland; he is now a faculty member at the Universi-
ty of Iowa; EDWARD J. TWIN, M.D., is Professor and
Senior Docent, School of Medicine, University of
Missouri-Kansas City, Kansas City, MO.
Drug Intelligence and Clinical Pharmacy VOL 16
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medication cost per day, and outpatient costs, including
outpatient medical cost, were among the kinds of in-
formation collected for these monthly reports. In an ef-
fort to identify the docent clinical pharmacist's specific
contribution to these cost figures in the inpatient area,
the following study was designed, using an infectious
disease model.
The purpose of this two-phase, retrospective study
was to determine the influence of the clinical phar-
macists on the management of streptococcal
(pneumococcal) pneumonia. Streptococcal pneumonia
was chosen as the model disease state for several
reasons: it has a 5-10 percent per year incidence of mor-
tality in the U.S.; there is a recognized problem with
inappropriate antibiotic utilization;' use of antibiotics
is associated with tremendous expense (often consum-
ing from Y4 to Y3 or more of the hospital pharmacy's
budget); and well-documented standards for ap-
propriate drug therapy for this disease have been
published in the medical literature. 3 Additionally, the
emergence of antibiotic-resistant bacteria has been
reported at numerous institutions.':" Finally, the Joint
Commission on Accreditation of Hospitals has required
the development of formal programs to review antibiotic
usage in hospitalized patients. For these reasons, the
review of an infectious disease provided an optimal
model for evaluating the contribution of the docent
clinical pharmacist to an area of patient care that re-
quired further study.
Methods
Truman Medical Center consists of two hospitals,
Truman Medical Center-West (TMC-W) and Truman
Medical Center-East (TMC-E). Since 1971, there have
been full-time docent clinical pharmacists at TMC-W.
TMC-E did not have a clinical pharmacist until 1974.
Thus, this study was divided into two parts: a two-year
study of the treatment of streptococcal pneumonia at
TMC-W and TMC-E prior to 1974, and a two-year
study of the treatment of streptococcal pneumonia at
TMC-E after a clinical pharmacist was hired.
The Medical Records Department retrieved the
records of all patients admitted at either TMC-W or
TMC-E between June 1972 and June 1974 who had a
primary diagnosis of streptococcal pneumonia. In ad-
dition, the Medical Records Department at TMC-E
retrieved the charts of all patients admitted with a
primary diagnosis of streptococcal pneumonia between
June 1975 and June 1977. To be included in this study,
all patients had to meet the Department of Medicine
audit criteria for the diagnosis of streptococcal
pneumonia. They could not have (1) postoperative
JULY/AUG 82 587
pneumonias, (2) pneumonia diagnosed after hospital formed on an IBM (360-60) computer with the assistance
day 3, (3) allergic pneumonitis, (4) other occurrences of the statistical analysis system package. An estimated
that superceded the treatment of pneumonia and became hospital stay was derived from the patient's total
the primary diagnosis (e.g., acute myocardial infarc- number of hospital days.
tion), (5) white blood cell counts < 1500, (6) antibiotic The chi-square test was done to compare, statistical-
therapy less than one week before hospitalization, nor ly, the drug regimens utilized for streptococcal
(7) pneumonia with concurrent infection elsewhere. Pa- pneumonia at TMC-W and TMC-E with the standard
tients younger than 16 years were also excluded from recommended regimen.
the study.
Information gathered from each medical record Results
included:
Tables 1-5 contain comparative information on the
1. the diagnostic criteria-vital signs, chest X-ray, length of stay, raw cost of antibiotics, raw cost of in-
complete blood count with white blood cell dif- travenous additives, total raw costs of antibiotic ad-
ferential, Gram stain of the sputum or trans- ministration, raw cost of antibiotics on a daily basis,
tracheal aspiration, or culture and sensitivity total raw cost of antibiotic per day including intravenous
tests of the sputum or transtracheal aspirate; additives when appropriate, and finally, the patient
2. drug utilization (choice of antibiotic, dosage, charge based on the procedure utilized at these hospitals
number of total doses, and route of adminis- today.
tration); Table 1 shows a cross-group comparison of the out-
3. duration of hospital stay (total days of hos- come data obtained at TMC-W and TMC-E, with and
pitalization); and without the docent clinical pharmacist. The first column
4. readmission rate. shows the results obtained at TMC-W with the docent
clinical pharmacist. The second column shows the
No attempt was made to match the patient populations
results obtained in the group of patients at TMC-E
of the two institutions, although it is believed that they
treated by physicians with no previous exposure to the
are similar in many respects. Both hospitals, for exam-
ple, provide care to patients in the lower socioeconomic docent clinical pharmacist. Column 3 shows the results
class; however, TMC-W cares for more black patients obtained in a small group of patients who were treated
than does TMC-E. by physicians who had previous exposure to the docent
clinical pharmacist, and column 4 shows the results ob-
The standard accepted treatment for streptococcal
tained in a group of patients at TMC-E after the addi-
pneumonia was obtained from The Medical Letter
"Antimicrobial Therapy."> The drug regimen of choice tion of the clinical pharmacist. Statistically significant
is a 10- to 14-day course of penicillin: procaine penicillin differences in cost of raw antibiotics, total cost for an-
600000 U im q12h for 1-4 days followed by penicillin tibiotic administration, daily raw cost for antibiotics,
VK 250 mg po q6h to complete the 10- to 14-day course. total raw cost for antibiotic administration, and patient
charges were apparent.
In patients allergic to penicillin, the drug regimen of
choice for streptococcal pneumonia is a 10- to 14-day Table 2 compares TMC-W with the total population
course of erythromycin ethylsuccinate 500 mg po q6h. of patients treated at TMC-E prior to the hiring of the
clinical pharmacists. In combining the populations
Each chart was examined by clinical pharmacy
previously listed separately in columns 2 and 3 in Table
students, a resident or faculty member, and one of the
physician coinvestigators. (The two coinvestigators 1, the contamination of the study population by
previous exposure to the docent clinical pharmacist is
were, at the time of the study, medical directors for the
respective institutions and practicing internists.)
The cost for all pharmaceutical products was ob- Table 1. Comparison of TMC-W and TMC-E
tained from the 1974 TMC hospital bid prices. Daily with and without the Docent Clinical Pharmacist
inpatient costs for antibiotics and intravenous solutions,
with or without piggy-back infusion sets, were TMC-E No Pharm 0
calculated. At the beginning of the study, the pharmacy Pharm 0 Pharm 0 C Pharm 0 Education
TMC-W TMC-E Education TMC-E
had no centralized intravenous additive service; all in-
n 12 7 4 8
travenous solutions were prepared by the nurse direct-
length of Stay 8.33 5.86 3.25 12.25
lyon the unit. Subsequently, the pharmacy initiated an S.D. 4.54 5.0.2.12 S.D. 1.84 S.D. 9.96
intravenous additive program, charging a fee of $15 for Raw Dru9 Cost 9.23 7.29 4.91 116.43
all intravenous solutions, $2 for all intramuscular in- S.D. 9.60 5.0.3.27 S.D. 5.95 S.D. 149.53 •

jections or medications administered by intravenous Raw Cost of 7.83 6.80 2.13 28.26
Additive S.D. 9.39 5.0.5.29 S.D. 4.25 S.D. 36.12
push, and $0.60 for all oral medications. The results of
this study reflect the system currently used to determine Total Raw Cost 17.0 14.11 37.41 408.69
S.D. 17.71 5.0.7.73 5.0.65.80 S.D. 592.94 •
patient medication charges. Raw Cost of 1.24 1.46 1.06 8.11
Statistical comparisons were made between TMC- Drug Per Day S.D. 1.03 5.0.0.99 S.D. 0.87 S.D. 7.51 •
E, both with and without physician exposure to a clinical
pharmacist, and TMC-W.
Total Raw Cost
Per Day S.D.
2.38
2.11
280
5.0.2.13
6.47
5.0.11.64 5.0
32.63
3961
.
Patient 149.60 112.69 41.50 520.35
The Mann-Whitney U test and the Kruskal- Wallis Charge S.D. 159.81 5.0.94.36 5.0.72.70 S.D. 600.13 •
test were utilized to compare, statistically, the costs
calculated in this study. The calculations were per- • Statistically significant with P < 0.05 (Kruskal Wallis test)

588

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 DOCENT CLINICAL PHARMACIST

Table 2. Comparison of TMC-W with TMC-E Table 3. Comparison of TMC-W with Subgroup
before Hiring a Clinical Pharmacist at TMC-E with No Exposure to the
Docent Clinical Pharmacist
TMC-W TMC-East
Pharm.D No Pharm 0 TMC-E with
TMC-W No Pharm D
Pharm 0 Education
n 12 12
12 8
length of Stay 8.33 9.25
5.0.4.54 5.0.9.16 length of Stay 8.33 12.25
S.D. 4.54 S.D. 9.96
Raw Drug Cost 9.23 79.26
5.0.9.60 S.D. 131.55
Raw Drug Cost 9.23 116.43
Raw Cost for 7.83 19.55 S.D. 9.60 5.0.149.53*
Additive 5.0.9.39 5.0.31.63
Raw Cost for 7.83 28.26
Additive S.D. 9.39 S.D. 36.12
Total Raw Cost 17.02 284.10
S.D. 17.71 5.0.505.84
Total Raw Cost 17.02 408.69
Raw Cost of 1.24 5.76 5.0.17.71 S.D. 592.94 *
Drug Per Day S.D. 1.03 S.D. 6.94 *
Raw Cost of 1.24 8.11
Drug Per Day S.D. 1.03 S.D. 7.51 *
Total Raw Cost 2.38 23.91
Per Day 5.0 2.11 S.D. 34.66
Total Raw Cost 2.38 32.63
Per Day S.D. 2.11 S.D. 39.61 *
Patient Charge 149.60 361.57
S.D. 159.81 5.0.577.84
Patient Charge 149.60 520.35
5.0.159.81 5.0.600.13 *
• Statistically significant with Pe 0.05 (Mann Whitney U test)
..
• StatIstIcally SIgnifIcant wIth peO.05 (Mann WhItney U test)

evident. Table 2 shows a consistent pattern with the

previous comparison; however, only the raw cost of
drug per day was significantly different, statistically. Table 4. Apparent Sustained Influence of Teaching
Table 3 compares TMC-W with the subgroup of pa- Program by the Docent Clinical Pharmacist
tients at TMC-E treated by physicians not previously
exposed to the docent clinical pharmacist. Thus, Table TMC-E TMC-E
3 clarifies the source of significant differences shown No Prior
in the cross-group comparison. There was a statistical- Pharm 0 Pharm 0
ly significant difference in the raw cost of antibiotics, Education Education
the total raw cost for administering the antibiotics, the Number of Patients 8 4
raw cost for the antibiotics given daily, the total raw
length of Stay 12.25 3.25
cost per day for antibiotic administration, and the pa- S.D. 9.96 S.D. 1.84
tient charge.
Table 4 shows the apparent sustained influence of a Raw Drug Cost 116.43 4.91 *
teaching program, provided by the docent clinical phar- 5.0.149.79 S.D. 5.95
macist, in a small population sample. At TMC-E, when
Raw Cost for 28.26 2.13
comparisons were made between data for patients Additive S.D. 36.12 S.D. 4.25
treated by physicians with previous exposure to the do-
cent clinical pharmacist and patients treated by physi- 37.41
Total Raw Cost 408.69 *
cians with no prior exposure, the difference in the raw 5.0.592.94 S.D. 70.80
cost of antibiotics, the total raw cost for administering
the antibiotics, the raw cost for the antibiotics on a daily Raw Cost of Drug 8.11 1.06 *
basis, the total raw cost per day for antibiotic ad- Per Day S.D. 7.51 S.D. 0.87
ministration, and the patient charge was statistically
significant. Total Raw Cost 32.63 6.47 *
Table 5 shows a comparison of TMC-E, prior to hir- Per Day S.D. 39.61 S.D. 11.64
ing the docent clinical pharmacist, with TMC-E after
Patient Charge 520.35 41.50 *
the clinical pharmacist was added to the Department of 5.0.600.13 S.D. 72.35
Medicine staff. There was a statistically significant dif-
ference in the raw cost of antibiotics, the total raw cost • Statistically significant with P eO.05 (Mann Whitney U test)

Drug Intelligence and Clinical Pharmacy VOL 16 JULY/AUG 82 589

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 Table 5. Comparison of TMC-E before and after
Hiring a Docent Clinical Pharmacist
Prior to Pharm 0 Post Pharm 0
TMC-E
n 72
length of Stay 9.25
S.D. 9.16 S.D.
Raw Drug Cost 79.26
S.D. 131.55 S.D.
Raw Cost for 19.55
Additive S.D. 31.63 S.D.
Total Raw Cost 284.10
5.0.505.84 S.D.
Raw Cost of 5.76
Drug Per Day S.D. 6.94 S.D.
Total Raw Cost 23.91
Per Day S.D. 34.66 S.D.
Patient 361.57 112.69
Charge 5.0.577.84 S.D. 94.36
• Statistically significant with peO.OS (Mann Whitney U test)
for antibiotic administration, the raw cost for antibiotics
on a daily basis, the total raw cost per day for antibiotic
administration, and the patient charge.
Table 6 compares drug selection for the treatment of
streptococcal pneumonia at: TMC-W with the docent
clinical pharmacist, TMC-E with physicians previously
exposed to the docent clinical pharmacist, TMC-E with
physicians not previously exposed to the docent clinical
pharmacist, and TMC-E after the addition of the do-
cent clinical pharmacist. It is important to realize that
none of the patients reviewed in this study had a history
of penicillin allergy. There was a statistically significant
difference in drug choice between physicians without
prior exposure to the docent clinical pharmacist and
physicians practicing with or previously exposed to the
docent clinical pharmacist.
Discussion
After all the criteria were met, the final sample size
of this study was relatively small. Additionally, in com-
paring two institutions with affiliation agreements, one
might anticipate cross-over contamination to influence
the outcome. This contamination may have been a fac-
tor in the antibiotic selection process at the two institu-
tions. For some, it may be difficult to perceive a cause
and effect relationship between the presence of the do-
cent clinical pharmacist and the prescribing practices
utilized in these two institutions without first recogniz-
ing that the docent clinical pharmacists in these institu-
tions function as part of the attending staff. Examina-
tion of the various data subsets consistently indicates
significant differences between the prescribing practices
of those physicians exposed to the clinical pharmacist
and those who are not. Antibiotic costs are influenced
not only by the selection of the specific antibiotic but
also by the method of administration. In this institu-
tion, the method by which the antibiotics were ad-
ministered contributed significantly to the overall pa-
tient charge. Inasmuch as oral or intramuscular
590
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penicillin therapy is considerably cheaper than in-
travenous infusion, the clinical pharmacist recommend-
ed oral penicillin as soon as the patient was able to take
medications by mouth. This one factor dramatically in-
TMC-E fluenced the cost of antibiotic therapy.
7 Drug-drug, drug-disease, and drug-laboratory in-
5.86 teractions can significantly influence patient manage-
2.12
ment and hospital stay. In this study, the only signifi-
7.29 * cant drug-drug and drug-disease interactions were found
3.27
at TMC-E prior to the hiring of the clinical pharmacist.
6.80 For example, one patient was placed initially on am-
5.29 picillin for the treatment of streptococcal pneumonia
14.11 * and developed a rash. The patient was hyperuricemic
7.73 at the time of admission, which may have contributed
1.46 * to what was interpreted as an allergic reaction to
0.99 penicillin. Consequently, a more expensive antibiotic
was substituted. None of the patients admitted to this
2.80 *
2.13 study was noted to have a penicillin allergy; however,
second-line antibiotics were frequently employed in the
* initial phase of this study at TMC-E, where there was
no clinical pharmacist. In one case, combination therapy
with a cephalosporin and aminoglycoside was initiated.
This combination may have been responsible for the pa-
tient's subsequent development of renal problems.v'
although the significance of this interaction is
questionable.v" If one compares the length of hospital-
ization at TMC-W with TMC-E prior to and after the
hiring of the docent clinical pharmacist, a trend toward
.a shorter hospital stay is noted for those patients in the
institution at which a clinical pharmacist was present.
While it is impossible to substantiate a cause and effect
relationship between the hospital stay and the contribu-
tion of the clinical pharmacist, drug-related complica-
tions may have influenced the length of stay of those
patients treated at TMC-E prior to the hiring of the
clinical pharmacist.
The docent clinical pharmacist does have significant
educational responsibilities for the basic and clinical
pharmacology instruction provided at TMC-W. This has
been described elsewhere.10 Despite the small sample size
for this four-year study, the data in Table 1 indicate that
those physicians who received a portion of their educa-
tion or training with the docent clinical pharmacist
tended to prescribe drugs in a more cost-effective man-
Table 6. Comparison of Drug Selection for Treatment
of Streptococcal Pneumonia in TMC-W and TMC-E
Number Non
o( Penicillin Penicillin
Patients
TMC-W
with Pharm 0 12 12 0
TMC-E
No Pharm 0 8 0 8
TMC-E
trained with 4 4 0
Pharm 0
TMC-E 7 7 0
with Pharm 0
Note: None of the patients had history of penicillin allergy
Statistically significant PeO.OOl (Ch. Square test X'= 38.83)
ner. However, it obviously would be inappropriate to Revised & Updated, July 1981
overstate the significance of this finding, based on such
a small sample.
Although it is impossible to control all the indepen- PSYCHOTROPIC
dent variables that may have contributed to the dif-
ferences in this study (e.g., the immunocompetence of DRUG HANDBOOK
the patient or the patient's condition on admission to Third Edition
the hospital), one significant variable needs to be con-
sidered: the attending physician staff. During the initial Paul J. Perry, Ph.D. Bruce Alexander, Pharm.D.
phase of study at TMC-E, the attending staff included Associate Professor Clinical Assistant Professor
physicians who currently hold academic appointments The University of Iowa The University of Iowa
College of Pharmacy College of Pharmacy
at this medical center. and and
During these two study periods, no patient was re- Clinical Pharmacist Clinical Pharmacist
admitted to either institution for pneumonia during the Psychiatric Hospital Psychiatry Service
Iowa City. Iowa Iowa City VA Medical Center
six months following the study period. Thus, the more Iowa City, Iowa
economical approach to the treatment of pneumonia ap-
peared to be successful. Barry I. Liskow, M.D.
Chief. Alcohol Dependency Treatment Unit
This study is one of many internal reviews that have Kansas City VA Medical Center
been conducted over the past ten years to evaluate the Kansas City, Missouri
impact of the docent clinical pharmacist on patient care and
Associate Professor
in this institution. Results to date have been encourag- Department of Psychiatry
ing. Plans for the future include comparison of the University of Kansas
results of this study with studies at other similar institu- Kansas City, Kansas
tions in this region of the country. ~ A quick reference gUide on drugs used for treating psychiatric
patients. Includes cost comparisons. drug Interaction tables.
patient Instruction section. rational prescribing principles. and
KEY WORDS: docent clinical pharmacists.
other practical Information and clinical data.

TABLE OF CONTENTS
ABSTRACT I. General Principles - Therapeutic Use
This two-phase retrospective study was designed to evaluate 2. General Principles - Adverse Effects
the impact of the clinical pharmacist on prescribing practice 3. Antipsychotics
of physicians in an internal medicine service. Streptococcal 4. Antidepressants
(pneumococcal) pneumonia was chosen as the model disease 5. lithium
state. The drug of choice was used more frequently and 6. Antianxiety Agents
there was a statistically significant difference in raw cost 7. Hypnotics
of antibiotic, total cost for antibiotic administration, daily 8. Analgesics
raw cost for antibiotics; total raw cost for antibiotic adminis- 9. Agents for Treating Extrapyramidal Side Effects
tration, and patient charges when physicians were exposed to 10. Disulfiram
the clinical pharmacists' influence. I I. Drug Interactions
j 2. Management and Treatment of Drug Overdosage
13. Management of Withdrawal
References 14. Amy tal interview
15. Electroconvulsive Therapy
I. Dimond EG. The academic plan for the school of medicine.
16. Patient Instructions
Kansas City: University of Missouri-Kansas City, 1977.
2. Counts GW. Review and control of antimicrobial usage in 204 pages, soft cover, 41f2 x 6 3k inches.
hospitalized patients. A recommended collaborative approach. JAMA Send check, money order or credit card number
1977;238:2170-4. (MasterCard or Visa) to:
3. Simmons HE, Stolly PD. This is medical progress? Trends and
consequences of antibiotic use in the United States. JAMA HARVEY WHITNEY BOOKS PRICE $9.50
1974;227: 1023-8. . (plushandling and postage
P.O. BOX 42442 If not prepaid)
4. Sherris JC, The epidemiologyof drug resistance. In: Brachman Prepayment IS required
PS, Eickhoff TC, eds. Proceedings of the International Conference CINCINNATI, OH 45242 for individual orders.
of Nosocomial Infections. Baltimore: WaverlyPress, Inc., 1971: 50-60.
5. The medical letter on drugs and therapeutics. Handbook on
antimicrobial therapy. New Rochelle,NY: MedicalLetter, Inc. Revised Send _ _ copies at $9.S0 each of PSYCHOTROPIC DRUG
edition, 1976. HANDBOOK to:
6. Borrows SN. Anuria and acute tubular necrosis associated with Name
gentamicin and cephalothin. JAMA 1972;222:1546-7.
7. Fillastre lP, Laumonier R, et al. Acute renal failure associated Address _
with combined gentamicin and cephalothin therapy. Br Med J
1973;2:396.
8. Fanning WL, Gump 0, lick H. Gentamicin and cephalothin
associated rises in blood urea nitrogen. Antimicrob Agents Chemother City
1976;10:80-3. State/Country Z,p _
9. Luft FC, Patel V, Yum MN, Kleit SA. Nephrotoxicity of
cephalosporin-gentamicin combinations in rats. Antimicrob Agents o payment enclosed: 0 please bill 0 VISA D MasterCard
Chemother 1976;9:831-9. Exp. date Signature
10. Covinsky 10. The role of the clinical pharmacist in medical Acct.
education. J Clin Pharmacol 1981;21:198-200. No.

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