Pharmacist-managed antimicrobial stewardship program for patients discharged from the emergency department

Positive outcomes of antimicrobial stewardship programs in the inpatient setting are well documented, but the benefits for patients not admitted to the hospital remain less clear. This report describes a retrospective case-control study of patients discharged from the emergency department (ED) with subsequent positive cultures conducted to determine whether integrating antimicrobial stewardship responsibilities into practice of the emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of antimicrobial therapy. Pre- and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Positive cultures were identified in 177 patients, 104 and 73 in pre- and post-implementation groups, respectively. Median time to culture review in the pre-implementation group was 3 days (range 1-15) and 2 days (range 0-4) in the post-implementation group (P = .0001). There were 74 (71.2%) and 36 (49.3%) positive cultures that required notification in the pre- and post-implementation groups, respectively, and the median time to patient or PCP notification was 3 days (range 1-9) and 2 days (range 0-4) in the 2 groups (P = .01). No difference was seen in the appropriateness of therapy. In conclusion, EPh involvement reduced time to positive culture review and time to patient or PCP notification when indicated.     

Antibiotic prescribing for lower respiratory tract infections within secondary care

□ A systematic content analysis of the treatment guidelines for lower respiratory tract infection was performed on antibiotic formularies and policies obtained from hospital management units within the West Midlands and university hospitals from the rest of the United Kingdom □ Analysis of antibiotic formularies and policies demonstrated considerable variation between prescribing guidelines with regard both to the agents and dosages used □ A proportion of hospitals in the West Midlands and university hospitals from the rest of the UK gave no guidance regarding drug dosages, which may result in wide variations in therapy □ These findings have important consequences for quality of patient care, drug budget management and antibiotic resistance     

Impact of clinical decision support on oritavancin prescribing in the emergency department

BackgroundEmergency department (ED) visits and hospitalizations from skin and soft tissue infections (SSTIs) have been on the rise and have led to an increased clinical and economic burden. Owing to their single-dose regimen, recently approved lipoglycopeptides such as oritavancin have the potential to shift the management of SSTIs from an inpatient to outpatient setting. Limited data exist regarding the use of these drugs in the ED setting.ObjectivesThe purpose of this study was to describe the impact that clinical decision support (CDS) incorporation into the computerized physician order entry (CPOE) system had on oritavancin use and to assess compliance with appropriate use guidelines in the ED.MethodsThis was a retrospective cohort study evaluating patients who received oritavancin from September 2016 to May 2018. The patients were assigned to the pre-CDS–implementation group if oritavancin was used between September 13, 2016, and June 28, 2017 and to the post-CDS–implementation group if oritavancin was used between August 28, 2017, and May 25, 2018. There was a 2-month transition period between the 2 study time periods. Patients were excluded if the administration occurred outside of the ED or during the transition period. The primary endpoints were oritavancin use and compliance with the appropriate use guidelines after the implementation.ResultsThere were 169 oritavancin orders in total, of which 119 met the inclusion criteria. There was a marked decrease in use post-CDS implementation (9.2 orders/mo vs. 3 orders/mo). Among those who were prescribed oritavancin, compliance with the appropriate use guidelines increased; however, this did not reach statistical significance.ConclusionThe implementation of the appropriate use guidelines with CDS integration into the CPOE system decreased overall oritavancin use but did not have an impact on compliance with the appropriate use guidelines.     

Prevalence of inappropriate prescribing in primary care

Objective To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. Setting A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen. Method Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients’ own GPs. The GPs were asked to provide baseline information regarding the patients’ medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded. Results 212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as ‘not indicated’, 6% were rated as ‘ineffective’, 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug–drug interactions, 8.6% had clinically significant drug–disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics. Conclusion The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.     

Optimising antibiotic prescribing in primary care.

Prudent antimicrobial prescribing in the community may help to prevent the relentless increase in resistance, highlighted worldwide by numerous parliamentary documents. Antibiotic guidance, developed by primary care professionals and disseminated locally with outreach workshops, helps to reduce the use of broad-spectrum antimicrobials. Computerised guidance, audit of antibiotic use and restricted laboratory sensitivity reporting moves the prescriber towards the selection of recommended drugs. Educational campaigns and patient leaflets given at the consultation help to modify patients' expectations. Primary care physicians need to consider how much pharmaceutical representatives and free samples influence their prescribing. This multi-faceted approach needs to be backed up with a research programme developing the evidence base for management guidance of antimicrobial use in primary care.     

Laxative prescribing during pregnancy in primary care

□ Hormonal changes, mechanical pressure and concurrent medication all contribute to altered bowel habit during pregnancy □ It has been suggested that pregnant women are more likely to receive laxatives than the baseline population □ A retrospective case control study using a primary care prescribing database was undertaken to compare laxative prescribing before and during pregnancy with that in matched controls □ Prescribing rate of laxatives increased during pregnancy compared with before becoming pregnant but this was not different to controls □ Pregnant women were more likely to receive a laxative if they were using antibacterials, preparations for haemorrhoids or drugs for nausea and vertigo.     

Repeat prescribing processes in primary care: a qualitative study

Objective To investigate the characteristics, local agreements and changes regarding repeat prescribing processes in primary health care in Finland. Setting Twenty‐eight municipal health centres nationwide. Method Twenty‐eight physicians and 28 medical receptionists were given semi‐structured telephone interviews about repeat prescribing practices. The repeat prescribing process of each health centre was displayed as a flow chart and the processes were classified according to the quality of the practical flow and the medication review. Key findings There are various ways of carrying out repeat prescribing in different health centres. In some centres, a review of the medications is recognised as part of the repeat prescribing process, but in others there is no systematic review of the patients' medication. Repeat prescribing is often performed in a busy atmosphere. Repeat prescribing systems have evolved over time without proper management, and few local guidelines exist. Conclusions There is a need to reorganise the repeat prescribing systems in primary health care. A regular review of long‐term medications, in particular, needs to become a part of the repeat prescribing process. There is a need for both local and national guidelines.     

An evaluation of a collaborative pharmacist prescribing model compared to the usual medical prescribing model in the emergency department

BackgroundWorkforce reform has placed a significant focus on the role of non-medical prescribers in the healthcare system. Pharmacists are trained in pharmacology and therapeutics, and therefore well placed to act as non-medical prescribers.ObjectivesTo assess the safety and accuracy of inpatient medication charts within a pharmacist collaborative prescribing model (intervention), compared to the usual medical model (control) in the emergency department (ED). Another objective compared venous thromboembolism (VTE) risk assessment and prescribing, between intervention and control groups.MethodsAdult patients in ED referred for hospital admission were randomised into control or intervention by a block randomisation method, until the required sample size was reached. Medication charts were audited retrospectively by an independent auditor, using validated audit forms.ResultsIntervention group medication charts contained significantly fewer prescribing errors, omissions and discrepancies compared to the control group, and improved documentation of adverse drug reactions. VTE risk assessment and prescribing had higher guideline concordance in the intervention group compared to the control group.ConclusionsThis collaborative prescribing trial showed excellent results in safety and accuracy of pharmacist prescribing when compared to the usual medical model of prescribing. The admitting medical practitioner and extended scope pharmacist prescriber worked as a collaborative team in emergency, which improved Australian national prescribing safety indicators.