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

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]

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).