Pharmacists and physicians get smart about antibiotics: A prescription for change

Antibiotic resistance has been growing nationally and it is of definite concern to not only us, as healthcare professionals, but to our communities. Every time someone is dosed an antibiotic they have increased chance of developing a antibiotic resistant infection, and put those around them at the same risk. Approximately 258 million antibiotic prescriptions were written from an outpatient setting in 2010, while about 50% of those prescriptions were thought to be inappropriate. Not only was the number of written prescriptions outrageous but the price to pay was even more for these prescriptions, 10.7 billion to estimate.

This article pulls from multiple studies and highlights one particularly about collaborative care agreements. This study focused on pharmacist physician collaborative care agreements in the prescribing of antibiotics from an outpatient setting. Pharmacists were able to ask questions and challenge the antibiotic course that the physicians were recommending. Patients in the collaborative care were prescribed more “narrow spectrum”, first-line antibiotic regimens. The cost of their antibiotic also decreased by a third. Not only can pharmacists help to cut costs or input on the prescribed medication, but they can also counsel patients to provide optimal outcomes.

I think that it is important to become aware of the role of pharmacists in a collaborative health care agreements. Not only are pharmacists useful for the over-prescribing and inappropriate prescribing of antibiotics, but we are the best resource for medication information and are known to be cost effective. Overall, pharmacists have a huge impact on collaborative care agreements and can impact prescribing challenges.

Link to Article

 

Goode A, Roberts R. Pharmacists and physicians get smart about antibiotics: A prescription for change. JAPhA. 2015

Macrolide antibiotics and the risk of ventricular arrhythmia in older adults

Macrolides are a kind of antibiotic often prescribed to combat respiratory tract infections.  In the past the FDA has included a warning with these medications suggesting increased risk of arrhythmia development, especially in older adults.  This warning was based on a previous observational study.  This journal article includes a study that contradicts previous results and could lead to a change in warnings listed on the medication label.

This study, a population-based retrospective cohort study, looked at records of adults over 65 who had been prescribed a macrolide to determine incidence of hospitalization within the following 30 days for a ventricular arrhythmia.  They also looked for any mortality within those 30 days as a secondary parameter.  Patients taking macrolides were compared on a 1:1 ratio with patients taking nonmacrolide medications.  The results were analyzed and particular attention was payed to four subgroups including patients with CKD, CHF, CAD, and concurrent use of a QT prolonging drug.

After comparing charts of 260 patients, the study determined that readmission for ventricular arrhythmia was not statistically different between macrolides and nonmacrolides, and use of macrolides was actually associated with lower rates of mortality within the 30-day period.

These results demonstrate that the previous observational study and associated warnings may not be the best information to guide prescribing of antibiotics.  As this study showed, macrolides may actually be safer in general.  This demonstrates why new research looking at old questions is essential to understanding medications.  We would miss out on a lot of medical opportunities if we remained certain of preliminary drug studies.  Do you agree that it is important to re-examine potential adverse effects and efficacy of medications?

 

Trac MH, McArthur E, Jandoc R, et al. Macrolide antibiotics and the risk of ventricular arrhythmia in older adults. Can Med Assoc Jdoi:10.1503/cmaj.150901 (published 22 February 2016).

http://www.cmaj.ca/content/early/2016/02/22/cmaj.150901

New Societal Approaches to Empowering Antibiotic Stewardship

All over the world, antibiotic resistance is a constant issue.  The CDC has issued statements about antibiotic stewardship, and now event the US Government wants to implement programs in hospitals to cut down on overuse of antibiotics.  Antibiotic “stewardship” is the description of these programs that will optimize the antibiotic selection process.

The first step is making sure hospitals are transparent and public about the frequency of health-care related infections along with making them commit to establishing these programs.  A lot of medical professionals need to be reminded that they are the only pharmacological entity that loses efficacy over extended use, so the the criteria for prescribing them should also be put under scrutiny.  If a well-defined system is put in place, with regulations on things like time frames of use or prior authorization for specific antibiotics before use, maybe they can crack down on the complication that is antibiotic resistance.

The article uses the example of fluroquinolones, the only antibiotic that is used to treat gram-negative bacilli.  Oftentimes, prescribers just resort to the antibiotic, where there are other treatment options readily available.  The more we prescribe antibiotics over other treatments, the more susceptible we make the patient and society in general to infections.  Here’s a situation where a guideline could be put in place.  Maybe if a diagnosis is reached, there could be a chart with potential action plans that prioritize antibiotics as a last option.

 

Spellberg B, Srinivasn A, Chambers H. New societal approaches to empowering antibiotic stewardship. JAMA. doi:10.1001/jama.2016.1346 (published 25 February 2016).

Ceftolozane–tazobactam: A new-generation cephalosporin

Bacterial resistance to current antibiotics is a major concern today. Some people do not take their medications properly, leading to the development of antibiotic resistant bacteria. In response to this, scientists are trying to develop new antibiotics that can kill these resistant bacteria. One new antibiotic is ceftolozane-tazobactam. Ceftolozane-tazobactam, a cephalosporin, is a beta-lactam and beta-lactamase inhibitor that can be used to treat urinary tract and intraabdominal infections. Its suggested use is to treat multi-drug-resistant bacterial infections.

This medication could be very beneficial to people who have an infection that can not be treated by other antibiotics, but the cost is very expensive. The wholesale acquisition cost for seven days of treatment with ceftolozane-tazobactam is $1700, and the article states that there are alternative antibiotics that are have a similar efficacy and are much less expensive. Due to this, I’m not sure how much this new antibiotic will actually be used in practice, but I think it is good that there are people still working to find better antibiotics.

David Cluck, Paul Lewis, Brooke Stayer, Justin Spivey, and Jonathan Moorman. “Ceftolozane–tazobactam: A new-generation cephalosporin” American Journal of Health-System Pharmacy. 72.24 (2015): 2135-2146

<http://www.ajhp.org.pitt.idm.oclc.org/content/72/24/2135.full>

Oritavancin: A Novel Lipoglycopeptide

The article goes into details about the use of Oritavancin in relation to other glycopeptides. Noted positives include a broad spectrum of activity against gram positive bacteria and a prolonged half life (245 hours) for one time administration. In addition, the medication is not known to cause significant side effects other than gastrointestinal problems consistent with many other antibiotics. Perhaps the best qualities of Oritavancin are the reduced monitoring requirements, which can make it easier for the patient involved as well as the care provider. Detailed information about the pharmacokinetics and drug interactions were also included in the article.

The point of this article is to take a comprehensive look at Oritavancin and how it compares to other antibiotics in the same class.

Do you think the market for drugs like Oritavancin will expand in the coming years despite the growing epidemic of resistant bacteria?

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

Inappropriate antibiotic prescribing is a prevalent issue in the healthcare world as over prescribing can lead to antibiotic resistance which means at at a later point when an antibiotic can actually have an affect in reducing symptoms of a disease state it may not be effective. In addition according to the CDC, as of 2013, there has been no new antibiotics made for over 10 years 1. This mean that antibiotics are a precious resources in combating bacterial infections and diseases and if there’s nothing done to prevent over prescribing then antibiotic resistance becomes a more likely and a bigger issue for everyone.

A clinical trial included 248 clinicians among 47 primary care practices in Boston and LA were randomized to receive 0-3 interventions for a period of 18 months from November 2011 to October 2012. Upon enrollment into the study all the clinicians received education on antibiotic prescribing guidelines, and follow up for the trial ended April 2014.  The three interventions were as follow: “suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justificationprompted clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of “top performers” (those with the lowest inappropriate prescribing rates)”. The interventions were given either alone or in combination.

In total there were 31,712 visits (14,753 during baseline period and 16,959 during intervention period) that qualified for evaluation. The mean prescribing rates decreased from 24.1% at the start of the interventions to 13.1% at the end for controlled practice (-11.0% absolute difference). For suggestive alternatives the percentage went from 22.1% to 6.1% (-16.0% absolute difference); for accountable justification, percentages went from 23.3% to 5.2% (-18.1% absolute difference); and for peer comparison percentages dropped from 19.9% to 3.7% (16.3% absolute difference).  The researchers concluded that  with primary care practices, accountable justification and peer comparison as interventions results in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. What would have made any of the interventions more effective? Is there a better way to prevent inappropriate antibiotic prescribing? Why do you think there has not been any new antibiotics invented in so long?

(1)  “Combating Resistance: Getting Smart About Antibiotics.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 26 Nov. 2013. Web.

Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275.

http://jama.jamanetwork.com/article.aspx?articleid=2488307

Problems and Advice Regarding Appropriate Antibiotic Use for Acute Respiratory Tract Infections in Adults

The most common reason for antibiotic prescription in adults is acute respiratory tract infection (ARTI) and they are often inappropriately prescribed to these patients. This article examines the best practices for antibiotic use and prescription in otherwise health adults showing signs of ARTI.

ARTI includes pharyngitis, uncomplicated bronchitis, and the common cold. The common cold is the most common reason for outpatient physicians to prescribe antibiotics. Antibiotics are prescribed more than 100 million times per year. The innaccurate use of these antibiotics is contributing to antibiotic resistance, which is a very urgent health threat. Antibiotics are responsible for the largest number of adverse effects related to medication use. This article provides evidence for the appropriate prescribing of antibiotics for adults with ARTI to prevent these issues from arising.

This study showed the best guidelines for antibiotic prescription among physicians who see patients for ARTI. Clinicians should not test patients or prescribe antibiotics for patients with bronchitis unless the clinician also suspects pneumonia. It is, in fact, appropriate for clinicians to prescribe antibiotics if streptococcal pharyngitis has been confirmed. Finally, antibiotics should not be prescribed for patients who have a common cold. By following these guidelines, antibiotic overprescribing can be reduced to make for a healthier population. How do you think pharmacists could aid in reducing antibiotic overprescription?

Harris, Aaron M. “Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults.” Ann Intern Med. 2016: M15-1840. http://annals.org/article.aspx?articleid=2481815

 

 

 

Antibiotic Effectiveness in Treating Pediatric Appendicitis

When most people think of Appendicitis, they think of a surgical procedure to remove the appendix, one that includes both pre and postoperative pain. In fact, this procedure is fairly common considering 11.4% of child hospitalizations are due to acute uncomplicated appendicitis. This disease is defined as a form of appendicitis in which the appendix has not yet rupture and there are not yet impacted feces, but there is a relatively low white blood cell count and there is still abdominal pain associated with it. Previous to this study, the only way to treat this form of appendicitis was to remove the appendix in an invasive surgery. This surgery is associated with children missing 2 to 3 weeks of school and activities after, complications occurring in 5 to 10% of procedures, and serious complications occurring in 1 to 7% of patients.

 

A recent study suggested treating these pediatric patients with antibiotics instead of choosing the surgery option. The study took place over a six-month period in which 102 patients between the age of 7 and 17 were enrolled. This unique study allowed the patients and their families to choose which form of treatment they were to receive, either the antibiotic treatment or the operative treatment. 37 of these patients chose to take short-term antibiotics in order to avoid some of the complications associated with the surgery. This antibiotic treatment includes receiving an intravenous antibiotic for approximately 24 hours or until symptoms have improved. Following this inpatient treatment, the patient is then given a 10-day oral antibiotic treatment that they can receive at home while they continue on with their day-to-day lives. After just 30 days of treatment 89.2% patients had success and were cured. The nonoperative group also showed a lower incidence of the appendicitis turning complicated. 2.7% of the nonoperative group developed complicated appendicitis while 12.3% of patients in the operative group developed complicated appendicitis. Furthermore, after 1 year the antibiotic group was associated with lower health care costs and experienced fewer disability days.

 

After analyzing this article I think that it is extremely interesting and advanced that we are looking to treatment options other than operations. With the increasing cost of health care I think that it is extremely important to consider these cheaper and less invasive options. The only question I had that the article did not answer was the potential of antibiotic resistance, which I think would be something to consider in the future. I believe that if this antibiotic treatment method is further studied and the results continue to show its effectiveness that this could become the most important and best option for treating acute uncomplicated appendicitis.

 

Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. JAMA Surg. 2015: 1-8

 

Pharmacists Help Encourage Short Term Antibiotic Regimines

This study aimed to reduce the duration of antibiotics prescribed to children with uncomplicated skin and skin structure infections. Uncomplicated skin and skin structure infections, or uSSTIs, usually are treated with antibiotic therapy and include simple abscesses, cellulitis, impetiginous lesions, and furuncles. Complicated skin structure and skin structure infections (cSSTIs) affect deeper skin or are considered complicated in an immune-deficient patient. These include major abscesses, infected burns and ulcers, other infected wounds, and diabetic foot infections. The guidelines from Infectious Diseases Society of America for the management of SSTIS suggest a 5 day course of antibiotic treatment for uSSTIs, and can be extended if improvement is not made. The short antibiotic courses can help prevent antibiotic resistant bacteria from forming, lower costs, and reduce adverse effects. This study took place at the Cincinnati Children’s Hospital Medical Center, and aimed to increase short course antibiotic treatment (less than 7 days) in patients who came in with uSSTIs, compared to the previously used long-course therapy which lasts 7 to 14 days. At the beginning of this study 23% of patients with uSSTIs were prescribed short course antibiotic treatment.

To accomplish the study’s goal, they used a few methods. First, they had two 15-minute information sessions with residents and attendants. They also attached information cards about optimal antibiotic regimens for SSTIs to medical personnel’s identification badges. Pharmacists identified the third intervention as part of a multidisciplinary team, who noted that the order set default for uSSTIs was a 14-day course of therapy. The last intervention method was having a team member from the study contacting the physicians attending to SSTI patients and reiterating that short term antibiotic therapies can be used for uSSTIs, and to contact them with any questions. 5 months after the project began, 74% of patients with uSSTIs were discharged with the short term antibiotic therapies, and there was no significant difference in the amount of readmissions or recurrence for those who received the short term antibiotic treatment.

I really thought that this article showed the importance of pharmacists as part of a healthcare team, and how pharmacists can contribute innovative practices to medication changes. While changing the automatic duration of therapy in the prescribing system may seem simple, it can remind and alert the physician about the benefits of short term antibiotics and lead to less human error and increased savings. Also, this was the first time I had heard about short-term antibiotic regimens. While at first it seemed a little strange to me since I’ve been taught a lot about the importance of finishing antibiotic treatments to avoid resistance, it makes sense that shorter term antibiotic regimens would lead to increased patient adherence. Do you think that any of these methods could be implemented into a community pharmacy setting? Could pharmacists have played a more important role in this study, perhaps by educating pharmacists as well so that they can perform interventions when filling out prescriptions?

 

Citation: Schuler CL, Courter JD, Conneely SE, et al. Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections. Pediatrics. doi: 10.1542/peds.2015-1223 (published 18 January 2016).

 

Link: http://pediatrics.aappublications.org/content/early/2016/01/15/peds.2015-1223