Improving Outpatient Antibiotic Prescribing

Over 250 millions antibiotic medications are prescribed each year and a large percentage of these prescriptions are unnecessary. Unneeded and extended antibiotic use can lead to adverse drug effects and antibacterial-resistant infections. There are regulatory agencies that require acute care hospitals to have stewardship programs to improve antibiotic use. Unfortunately, the majority of antibiotic use occurs in the outpatient setting where there are no steward programs.

A study over 18 months was completed to compare the effect of behavioral interventions that occurred after an antibiotic was prescribed for a respiratory tract infection. The interventions were suggested alternatives to antibiotic use, accountable justification for antibiotic treatment, and peer comparison by other providers. Inappropriate prescribing decreased from 22% to 6% with suggested alternatives, from 23% to 5% with accountable justification, and from 20% to 4% with peer comparison. The control group also had a decrease from 24% to 13%.

This study justifies further investigation to create interventions to decrease inappropriate antibiotic use. This includes specifying tactics toward each outpatient clinics and certain common antibiotics. A suggestion is to require clinicians to justify every prescription for antibiotics with indication documentation and comparison with peers.

This is very interesting. If all prescribers were required to justify their prescriptions, I believe that there would be less antibiotic use. Additionally, the prescribers could provide the pharmacists with test results if applicable, proving that an antibiotic is needed. This would greatly reduce antibiotic resistance and the related complications. Can you think of any cons to this solution?

JAMA. doi: 10.1001/jama.2016.0430. (accessed 11 Feb 2016). 

Pediatric Weight-based Dosing in Outpatient Pharmacies

A retrospective outpatient prescription record review was conducted for 6 months to determine the percentage of outpatient pediatric prescriptions with errors. Johns Hopkins Outpatient Pharmacy fills about 450 prescriptions daily with 30% for pediatric patients. Weight-based checking includes having 2 pharmacists complete a dosing calculation and cite an appropriate reference. The final verification pharmacist then double checks the calculation before dispensing to the patient. Any discrepancies are sent to the problem queue for further investigation.

For the 6 month study, 5,010 pediatric prescriptions were filled, 1,448 were sent to the problem queue and 156 required a pharmacist intervention. 50% of those prescriptions (78) were changed. The majority of prescribing errors included dose too high, incomplete or illegible prescription, inappropriate dosing interval, and dose too low.

There were several limitations to the study because pharmacists could call the physician directly and change the prescription without documenting it in the problem queue. Additionally, the majority of prescribers were from a teaching hospital where errors may have been higher.

Although the numbers seem small, I think that any reduction in error is significant. Since pediatric patients require very specific doses, it is so critical to check and double check the prescribed dosing. I wonder how many less errors are given to the patients due to weight-based dosing. This study showed that many errors were caught by pharmacists but did not compare it to other outpatient pharmacies. What other factors should the pharmacist consider when filling pediatric prescriptions?

J Am Pharm Assoc. 2016;56(1):54-57.