Pharmacist-driven antimicrobial optimization in the emergency department

This article reviewed the influence of a pharmacist-driven antimicrobial stewardship/ optimization service in a non-trauma emergency department of a hospital. The impact of a nurse-driven chart review was compared with a pharmacist-driven chart review. Impact was based on the number of clinical interventions made, along with resistance patterns identified from wound and urine cultures. The nurses assessed 499 patients with positive cultures, and intervened on 50% of the cultures which indicated the need for an intervention. The pharmacists assess 473 patients with positive cultures, and intervened on 80% of those that needed intervention. Interventions were based on inappropriate therapy. Also, E. coli, the most frequently isolated urinary organism, displayed a fluoroquinolone resistance rate of 38%.

This antimicrobial stewardship program showed 30% more pharmacist interventions compared to nurse interventions for “bug-drug” mismatches. Proper prescribing of antibiotics is an essential part of offsetting antibiotic resistance. This program shows that pharmacists are a key part of modifying antimicrobial therapies when needed. The high fluoroquinolone resistance rate suggests that alternative therapies may be better for some urinary tract infections, such as nitrofurantoin.

I thought this was an interesting article, because of the increase in antibiotic resistance and various efforts to offset this increase. It seems that the pharmacists are in a better position to assess and address proper prescribing of antibiotics than the nurses, because ultimately they are the medication experts. With this in mind, do you think it is beneficial for pharmacists to be able to prescribe antibiotics to patients?

Davis, L., Covey, R., Weston, J., et al. Pharmacist-driven antimicrobial optimization in the emergency department. Am J Health Pharm. 2016; 73:49-56. Doi: 10.2146/sp150036.

 

Pharmacist-led feedback workshops increase appropriate prescribing of antimicrobials

Inappropriate antimicrobial prescribing is a common occurrence in hospitals, and may lead to increased patient morbidity. Not only does this produce deleterious effects for individual patients, but it also contributes to the growing global health problem of anti-microbial resistance. Research has indicated that most inappropriate antimicrobial prescriptions are written by junior doctors in their first 2 years of practice. Therefore, initiatives targeting these junior doctors and educating them on proper antimicrobial use may increase individual health outcomes and help alleviate the problem of antimicrobial resistance.

A European study aimed to reduce inappropriate antimicrobial prescriptions by targeting junior doctors with intervention provided by pharmacists. This was done via data collection on junior doctors’ prescribing habits, followed by feedback workshops aimed at addressing knowledge gaps, discussing social and behavioral aspects of prescribing, and encouraging reflection. 29 doctors were recruited for the study, 14 were randomized to the intervention group and 15 were randomized to the control group. The normalized rate of suboptimal prescribing was significantly lower for the intervention group than the control group. Analysis showed that pharmacist intervention increased junior doctors’ awareness of their prescribing behavior.

This article was a prime example of how pharmacist intervention in drug therapy can improve health outcomes, both on an individual and public health scale. Often, I feel doctors hesitate to consult pharmacists about drug therapy unless the drug being provided is a particularly complex or new drug (such as chemotherapy or psychiatric drugs). Something as commonplace as antimicrobials is not typically seen as being a serious enough drug to warrant pharmacist opinion. However, it is clear that by including pharmacists in the decision-making process on antimicrobial prescriptions and allowing them to educate prescribers, better health outcomes can be achieved. How do you think pharmacists can become more involved in the decision-making process and education for prescribing more commonplace medications, such as antibiotics, antivirals, etc.? Especially in an outpatient setting where pharmacists are often not on-site?

McLellan L, Dornan T, Newton P, et al. Pharmacist-led feedback workshops increase appropriate prescribing of antimicrobials. J Antimicrob Chemother. pii: dkv482. [published 2016 Feb 24]

End of Life Infection Care

A lot of patients in the final stages of life face complicated decisions on their medical care and what should be treated. Infections are one of the most prevalent complications that these patients experience. A lot of clinicians prescribe antimicrobials in the weeks leading up to death. According to the article, 90% of cancer patients are prescribed these medications during the week prior to death. There are risks and benefits associated with prescribing antimicrobials to these patients when they are so close to death. Risks include drug reactions and interactions, the burden of treating more symptoms when the patient is terminally ill, and contributing to drug resistance. However, these medications can contribute to prolonged survival and symptom relief.

I think pharmacists can have a huge impact in these type of situations. Pharmacists, in my opinion, may be the best suited for these decisions and can help physicians make an informed decision. Will this drug be effective enough in relieving symptoms compared to the risks it poses to the patient? Do these medications interact with any treatment the patient is currently on? Pharmacists can weigh the risks and benefits of all of these questions and help other clinicians make informed decisions. This is an excellent article in showing how pharmacists need to be part of the health care team.

JAMA. 2015;314(19):2017-2018