Individual Prescription Research Articles

Antibiotic Economies: The Economisation of Antibiotic Use in Australia and Implications for the Mitigation of Antimicrobial Resistance.

This paper examines how economic rationalities shape antibiotic usage with the aim of expanding options for the reduction of antimicrobial resistance (AMR). Antibiotic usage is typically attributed to the individual behaviours of patients, pet owners and prescribers, an emphasis that has neglected sociological explanations, particularly the economic rationalities that are transforming healthcare. We used sociological theory of pharmaceutical capitalisation and economisation to explore in-depth interviews on antibiotic usage with scientists, policymakers, prescribers, patients and pet owners in Australia. Antibiotics attracted values in terms of cost to the patient and pet owner, profit for the clinic, how the drugs saved time away from work and childcare, and how they eased the pressures of self-care, parenting and pet ownership. Economic transactions that are only partially under individual patient and prescriber control shape antibiotic use. In these circumstances, antibiotic use is influenced by other social agents-for example, business managers and clinic owners-decentring prescriber authority. Adoption of socio-economic values of antibiotic usage and inclusion of its other economic agents is needed to improve AMR intervention effectiveness.

STANDARDIZED ADAPTED CARDIAC REHABILITATION AT AN INPATIENT REHABILITATION FACILITY

https://youtu.be/hXlMMThneUU INTRODUCTION Inpatient rehabilitation facilities (IRFs) serve as an interim level of care for many patients with cardiac dysfunction but are not included among the three phases of cardiac rehabilitation (CR). The education on modifiable risk factors, cardiovascular exercise, and flexibility training given to patients with cardiac diseases are delivered in the acute hospital (phase I) and the outpatient setting (phase II). Our hypothesis was that adapting phase II components to this interim setting would improve outcomes and bridge the gap between phases. In this study, the feasibility of a standardized adapted CR protocol for IRFs and effect on functional outcomes was assessed. METHODS This prospective cohort study screened 60 patients over a 6-month period. Patients with primary cardiac diagnoses were screened for inclusion. Both surgical and non-surgical candidates were included. Exclusion criteria were based on the phase II CR criteria of the American College of Sports Medicine (ACSM). Patients received continuous ECG monitoring and physician clearance prior to participation. The standardized adapted CR protocol included individual prescription for cardiopulmonary endurance exercise consistent with ACSM Phase II CR guidelines, flexibility training, and education on modifiable risk factors. Standardized outcome measures included the 6-minute walk test, Borg rating of perceived exertion scale (6-20), EQ-5D-5L quality of life measure, and Section GG (mobility) scores of the Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument. A one-month follow-up evaluated attendance to phase II CR, and quality of life (including maintenance of functional gains). Physical therapy staff were surveyed to identify limitations. RESULTS Forty-one patients were deemed eligible to participate. Thirty-two patients participated in at least one endurance session with an average of 3 (+ 1) 20-minute sessions completed. Borg scores (14 + 1) reached the recommended range (somewhat hard to hard) during sessions. Participants demonstrated a statistically significant improvement in their GG mobility scores. Sixty-nine percent reached the 6-minute walk minimal clinically important difference (MCID), and 59% met the quality-of-life MCID, despite their short length of stay in the IRF setting (11 + 4 days). Survey results indicated short length of stay, the need to address functional goals over exercise, inability to tolerate 20 minutes of cumulative aerobic exercise, and compliance of protocol amongst therapists were limiting factors to endurance protocol adherence. CONCLUSIONS A standardized adapted CR protocol was feasible within an IRF setting, providing targeted education, increased awareness of phase II CR options, and clear and specific guidelines for creation of individualized exercise programs. Patients demonstrated improvements in functional mobility, cardiovascular endurance, and quality of life.

Perceived organizational support for the treatment of opioid use disorder and its association with primary care provider treatment willingness and medication prescribing.

Buprenorphine is a highly effective medication for opioid use disorder (MOUD; OUD), which can be prescribed alongside naloxone in the primary care setting as part of a harm reduction approach to OUD. Despite this potential, implementation challenges have limited adoption of MOUD. To address barriers at the organizational level, we need better tools to measure perceived organizational support for the treatment of OUD and use of MOUD in the primary care setting. In this study, we developed an OUDSUPPORT measure to assess the relationship between organizational culture and critical treatment attitudes and behaviors in primary care. We conducted a statewide survey of 404 primary care-aligned health professionals (PCPs) in Ohio. We analyzed the survey data using descriptive and bivariate statistics. Additionally, three stepwise multivariable regression models assess the relationship between organizational support and three primary outcomes: willingness to treat OUD; receipt of the X-waiver, which was previously required to prescribe buprenorphine; and naloxone prescribing, independent of individual and county-level predictors. The OUDSUPPORT measure demonstrated satisfactory psychometric properties, and was associated with meaningful treatment outcomes. PCPs perceived the strongest organizational support for a shared mission of providing care to people with OUD. The least commonly endorsed form of organizational support was for prescribing buprenorphine. Perceived organizational support was associated with increased willingness to treat OUD (b = 0.26; 95 % CI: 0.17, 0.35); higher odds of having received the X-waiver (OR = 1.63; 95 % CI: 1.26, 2.12); and higher odds of naloxone prescribing (OR = 1.71; 95 % CI: 1.30, 2.25). OUDSUPPORT is a multidimensional measure of perceived organizational support for the treatment of OUD, which was associated with treatment willingness, receipt of buprenorphine prescribing training, and naloxone prescribing among PCPs. Implementation strategies to increase buprenorphine prescribing in the primary care setting must include efforts to decrease stigma, and address hesitance related to MOUD and harm reduction at the administrative level, in addition to addressing well known barriers at the individual prescriber level.

Antibiotic consumption and utilization at a large tertiary care level hospital in Uganda: A point prevalence survey.

Effective antimicrobial stewardship programs require data on antimicrobial consumption (AMC) and utilization (AMU) to guide interventions. However, such data is often scarce in low-resource settings. We describe the consumption and utilization of antibiotics at a large tertiary-level hospital in Uganda. In this cross-sectional study at Kiruddu National Referral Hospital, we analyzed medicine delivery records for the period July 2021 to June 2022, accessed on 12/08/2022, to extract AMC data expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID). We used the WHO point prevalence survey (PPS) to analyze AMU data with a systematic sampling of outpatient department (OPD) for a period between June and August 2022 and selected all inpatient department (IPD) patients admitted before 8:00 AM on 27/11/2022. AMU data was analyzed as the proportion of individual antibiotic prescriptions, indications for prescriptions, and compliance with the national treatment guidelines. Both AMC and AMU data were categorized by the WHO AWaRe (access, watch, and reserve) criteria. In the year 2021-2022, a total of 6.05 DID of antibiotics were consumed comprising 3.61 DID (59.6%) access, 2.44 DID (40.3%) watch, and 0.003 (0.1%) reserve antibiotics. The most consumed antibiotics comprised penicillin (1.61 DID, 26.7%), cephalosporins (1.51, 25%), and imidazole (1.10 DID, 18.1%). A total of 119/211 (56%) patients in the OPD and 99/172 (57.5%) patients in the IPD were prescribed antibiotics. Of the 158 OPD antibiotic prescriptions, 73 (46.2%) were access, 72 (45.6%) were watch, 0 (0%) were reserve, and 13 (8.2%) were unclassified antibiotics. Of the 162 IPD antibiotic prescriptions, 62 (38.3%) were access, 88 (54.3%) were watch, 01 (0.6%) was reserve, and 11 (6.8%) were unclassified antibiotics. Indications for antibiotic prescriptions in the OPD comprised respiratory tract infections (53, 38.1%), urinary tract infections (34, 26.6%), gastrointestinal infections (20, 14.4%), sepsis (17, 12.2%), and medical prophylaxis (12, 8.7%). The indications for antibiotic prescriptions in the IPD comprised sepsis (28.2%), respiratory tract infections (18.3%), burn wounds (14.1%), and gastrointestinal infections (14.1%). Prescription of watch antibiotics in both OPD and IPD hospital settings was high. Establishment of robust antimicrobial stewardship measures could help improve the rational prescription of antibiotics.

Efficient use of non-steroidal anti-inflammatory drugs for treatment of joint pain in the practice of physicians and pharmacists

Background. Due to the prevalence of dystrophic degenerative diseases, the annual increase in the number of visits from young and middle-aged patients leading an active lifestyle, and the growing frequency of traumatic injuries of various origins, the problem of joint pain is particularly relevant. Aim. To investigate the main factors influencing the effective and safe use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in the treatment of joint pain syndrome. Materials & Methods. Using the developed questionnaire, patients with articular pain syndrome were interviewed about the safety and rational use of NSAIDs. Results & Conclusions. It was found that most often, people of working age with moderate intensity of pain syndrome sought medical care for joint pain. In one third of respondents, pain was accompanied by impaired motor activity in the joint. The largest proportion of respondents used oral systemic NSAIDs to reduce pain (46.7%), mainly non-selective сyclooxygenase inhi­bitors. A small proportion of patients (13.3%) who used NSAIDs topically preferred diclofenac, ibuprofen, and ketoprofen in the form of ointments and gels. 16.7% of respondents increased the dose of the drug on their own to achieve the desired therapeutic effect. 26.7% of patients simultaneously used several drugs from the NSAID group. However, the majority of the surveyed patients (63.3%) were not informed about the possibility of side effects associated with these drugs. A wide range of modern NSAIDs, a variety of dosage forms, high frequency and duration of use, and the potential risk of side effects require individual prescribing of drugs in this group. Prescribing timely and adequate treatment with a fast, effective and safe pain reliever remains an urgent issue in the daily practice of physicians and pharmacists. Keywords: dosage form, side effects, gastropathy, selectivity.

Consensus Radiation Treatment Planning Guidelines Utilizing (68)Ga-DOTATATE PET/CT for Resected Meningiomas.

Meningiomas are the most common primary intracranial tumor. Somatostatin receptor 2 (SSTR 2) is almost universally expressed in meningioma tissue. For patients who require adjuvant radiation, SSTR based (68)Ga-DOTATATE positron emission tomography (PET) imaging can detect additional or residual disease not discernible on magnetic resonance imaging (MRI). PET-guided radiation treatments may improve local control, minimize toxicity by allowing for more precise radiotherapy plans, and allow for more precise dose escalation to maximize local control. The aim of this study was to develop consensus PET-guided treatment planning guidelines for common meningioma presentations. Five post-operative clinically relevant meningioma cases were selected from a prospective single-institutional registry of patients. Each patient had a preoperative and post-operative contrast enhanced T1-weighted volumetric MRI, and a post-operative (68)Ga-DOTATATE PET/CT, to assist with target delineation. The full treatment scenario including clinical history, histology, surgical history, and imaging were provided for each patient. Nineteen international experts who have published on the treatment and management of meningiomas, and who utilize (68)Ga-DOTATATE PET/CT in their practice, evaluated each case. Individual prescription recommendations were created, pooled, and discussed to create consensus recommendations. Consensus recommendations were created for each case. In most cases, PET-based contouring allowed for more precise-dose escalation to 66-70Gy targeting residual disease. When compared to RTOG 0539 and modern clinical trial contouring guidelines, a smaller CTV expansion from the surgical cavity was recommended using PET-guided radiation plans in the absence of radiographic or pathologic evidence of brain or bone invasion. This report provides consensus target volume delineation guidelines for meningiomas receiving postoperative radiation in common clinical situations. Integration of these guidelines into clinical practice may allow for more precise biomarker-guided radiation treatments and standardize radiotherapy on future meningioma clinical trials.

Prescription drug use in Danish children and adolescents 2005-2023.

Continuous monitoring of pediatric drug utilization is important for ensuring rational use and prioritizing research. This study provides an overview of pediatric prescription drug use among Danish children and adolescents from 2005-2023. Using Danish nationwide individual-level dispensing data, we identified all redeemed prescriptions for individuals < 18years from January 2005-December 2023. We computed overall annual prevalence proportions of users and mean number of prescriptions per child. For all non-antibiotic drugs, we further determined the quantity of drug use measured in defined daily doses (DDDs) and stratified all analyses by age and Anatomical Therapeutic Chemical classification first and forth level. During the study period, the overall yearly prevalence of prescription drug use decreased due to reductions in antibiotic prescribing. When antibiotic prescriptions were disregarded, the prevalence of children with at least one prescription increased from 38% in 2005 to 42% in 2023, while the mean number of prescriptions and DDDs increased from 1.2 prescriptions per child and 51.2 million DDDs in 2005 to 1.5 prescriptions per child and 76.5 million DDDs in 2023. This increase was primarily driven by prescribing of central nervous system drugs to adolescents 12-17years, with a substantial increase in centrally acting sympathomimetics and melatonin use. Overall pediatric drug prescribing is decreasing due to reduced antibiotic use. Non-antibiotic drug use is, however, rising, especially among adolescents and notably for psychotropic drugs. These findings underscore the importance of ongoing monitoring and call for further research into underlying causes and prescription practices for psychotropics.

Prescriber perceptions of the safety and efficacy of unfractionated heparin versus low molecular weight heparin in the acute treatment phase: a qualitative study.

Intravenous unfractionated heparin (IVUFH) and low molecular weight heparins (LMWH) are first line anticoagulants for the management of acutely unwell patients. The decision to prescribe either IVUFH or an LMWH is complex with minimal direction from clinical guidelines. The aim of this study was to explore individual prescribers' perceptions on prescribing IVUFH or LMWH in patients' acute management. Semi-structured interviews were conducted with purposively selected senior medical officers who were from specialities including cardiology, cardiothoracic surgery, respiratory, emergency, vascular surgery, nephrology, neurology and general medicine, identified as those that routinely prescribe IVUFH or LMWH. An interview tool with seven questions and four hypothetical case scenarios guided interview discussions. Interviews were audio recorded, transcribed and inductively coded for thematic analysis. Twelve doctors participated in interviews between February and October 2022. Mean interview duration was 24 min; data saturation was achieved. Most were senior doctors: one was a registrar and others were staff specialists. Three key themes emerged: (1) rationale for the choice of heparinoid, (2) patient safety considerations and (3) resources required. The themes and subthemes identified the complexity of issues to consider when choosing between IVUFH and LMWH. Multiple factors were considered by participants which were based on previous experiences and institutional capabilities rather than evidence-based medicine. Future interventions should focus on highlighting LMWH as the preferred heparinoid in most clinical scenarios. The use of IVUFH should be reserved for specific patient cohorts where the benefit of IVUFH outweighs the additional risks.

Prescriber Phenotypes: Variability in Topical Rosacea Treatment Patterns among United States Dermatologists

Background/Objectives: Aggregate prescribing behavior for inflammatory lesions of rosacea has been described, but individual physician behavior has not been characterized. This study aims to assess the modern state of topical rosacea drug selection by analyzing prescribing patterns among individual dermatologists. Methods: We assessed utilization patterns of four topical papulopustular rosacea agents in 2021 Medicare Part-D data. K-means cluster analysis identified prescriber phenotypes based on the proportion of claims for each drug by physician. Results: Cluster analysis identified four prescriber phenotypes for topical rosacea agents, with the majority favoring metronidazole. In each of the other clusters, metronidazole was co-prescribed alongside the primary agent. Significant predictors of phenotype included patient ages, patient risk scores, and a group practice setting. Conclusions: The study reveals nonuniform prescribing patterns for topical papulopustular rosacea treatments among U.S. dermatologists. While aggregate data indicate diverse drug utilization, cluster analysis suggests that individual prescribers tend to use a limited selection of agents.

Effects of a Sorghum Beverage with Lacticaseibacillus paracasei on Body Composition, Lipid Profiles, and Intestinal Health in Overweight and Obese Adults: A Randomized Single-Blind Pilot Study.

(1) Background: This study aimed to evaluate the effect of an extruded whole-grain sorghum beverage containing L. paracasei on body composition, lipid profiles, and intestinal health in overweight and obese adults. (2) Methods: A chronic, single-blind randomized controlled pilot study was conducted with 30 volunteers allocated to three groups (n = 10/group): extruded sorghum beverage (ESB), extruded sorghum beverage with L. paracasei (ESPB), and control beverage (CB) (waxy maize starch). The chemical composition of the beverages was analyzed. Volunteers consumed the beverages for ten weeks at breakfast, along with individual dietary prescriptions. Body composition, biochemical markers, gastrointestinal symptoms, stool consistency, intestinal permeability, short-chain fatty acids, fecal pH, and stool L. paracasei DNA concentration were analyzed at the beginning and end of the intervention period. (3) Results: The ESB showed better composition than the CB, particularly in terms of resistant starch content, total phenolic compounds, condensed tannins, and antioxidant capacity. Both the ESB and the ESPB had an effect on body composition (estimated total visceral fat and waist volume), biochemical markers (Castelli index I), and intestinal health (Bristol scale, diarrhea score, valeric acid, and L. paracasei DNA concentration). No changes were observed in the CB group after the intervention. (4) Conclusions: Whole-grain sorghum beverages demonstrated good nutritional value, and consumption of these beverages, with or without L. paracasei, provided health benefits, including improvements in body composition, Castelli index I scores, and intestinal health, in overweight and obese adults.

Real-World Prescription Data for Intrathecal Drug Delivery: A Retrospective Analysis in 32,784 Patients

ObjectivesCurrently, there are three monotherapy drugs approved by the United States Food and Drug Administration (FDA) for use in intrathecal drug delivery systems (IDDS): morphine, ziconotide, and baclofen. In practice, use includes alternate drugs, drug combinations, and drug concentrations. There is a paucity of real-world data examining prescription patterns for IDDS. Our analysis explores a one-year sample of prescription intrathecal (IT) medications from a large pharmaceutical data base to characterize medication usage in IDDS. Materials and MethodsData were provided by an accredited pharmacy as a deidentified data base of IT drug prescriptions. Statistical analyses included rates of monotherapy vs combination therapies, frequencies of various IT prescriptions, use of on- vs off-label medications, and opioid vs nonopioid formulations. ResultsData were extracted from February 1, 2021 to February 14, 2022. No patients were excluded. The initial sample comprised 49,917 individual IT prescriptions for 32,784 patients. Monotherapies constituted 55.0% of all prescriptions (27,475/49,917). Of these, 23,257 prescriptions (84.6%) were opioid based, with the most common medications being morphine (46.5%), hydromorphone (39.4%), and fentanyl (13.5%). Although 29.3% of all prescriptions were for one of the FDA-approved medications, only 7.9% used FDA-approved concentrations; 9865 patients underwent ≥one prescription change in the study period—16.7% of whom were initially prescribed medications that met the approved, on-label indications for the pump before being switched to off-label concentrations or combinations to address clinical needs. ConclusionsDespite the prevalence of IDDS for managing chronic, intractable pain, minimal data exist on real-world prescription practices. Our study found that FDA-approved IT formulations accounted for the minority of prescriptions, indicating significant practice variation, with off-label prescriptions being common.

Quality improvement initiative to reduce URI-associated antibiotic prescriptions among adult primary care providers

ImportanceDespite evidence that most upper respiratory infections (URIs) are due to viruses, antibiotics are frequently prescribed for this indication in the outpatient setting. Antibiotic stewardship strategies are needed to reduce...

Individualized pleasure-oriented exercise sessions, exercise frequency, and affective outcomes: a pragmatic randomized controlled trial

BackgroundAffective responses are increasingly recognized as potentially effective intervention targets that may facilitate exercise and physical activity behavior change. While emerging correlational evidence suggests that more pleasant affective responses are associated with higher participation and adherence, experimental evidence remains scarce. In light of this, we conducted a preregistered, pragmatic, single-blinded, superiority randomized controlled trial with two parallel groups, with the goal of determining the impact of an individualized exercise-intensity prescription targeting pleasure on exercise frequency.MethodsForty-seven non-regular exercisers were randomized into two groups. For both groups, the intervention consisted of three exercise sessions based on the Frequency-Intensity-Time-Type (FITT) principle. However, the experimental group also received an individualized intensity prescription based on prior assessment of preference for and tolerance of exercise intensity, as well as instructions emphasizing the promotion of pleasure as a basis for self-regulating exercise intensity. The primary outcome was gymnasium attendance over an eight-week follow-up period. Secondary outcomes were affective valence and arousal, post-exercise enjoyment, core affective exercise experiences, and anticipated and remembered affect.ResultsForty-six participants were retained for analysis (Mage = 32.00; SD = 8.62 years; 56.5% female). Compared to the control group, the experimental group exhibited 77% higher session attendance (14.35 vs. 8.13 sessions) over the eight-week follow-up period (group main effect p = 0.018, η2p = 0.120; Cohen’s d ranged from 0.28 to 0.91 during follow-up). Also, the experimental group reported higher levels of pleasure during the intervention sessions (for all group main effects, p < 0.001, η2p from 0.33 to 0.37) and higher levels of remembered pleasure (group main effect p = 0.021, η2p = 0.116) and anticipated pleasure (group main effect p = 0.022, η2p = 0.114). No harm was detected.ConclusionsThese results demonstrate the practicality and effectiveness of an intervention aimed at enhancing affective responses to exercise in improving short-term session attendance.Trial registrationClinicalTrial.gov NCT05416593.

3D printing for drug manufacturing: A perspective on the future of pharmaceuticals

Since a three-dimensional (3D) printed drug was first approved by the Food and Drug Administration in 2015, there has been a growing interest in 3D printing for drug manufacturing. There are multiple 3D printing methods &amp;ndash; including selective laser sintering, binder deposition, stereolithography, inkjet printing, extrusion-based printing, and fused deposition modeling &amp;ndash; which are compatible with printing drug products, in addition to both polymer filaments and hydrogels as materials for drug carriers. We see the adaptability of 3D printing as a revolutionary force in the pharmaceutical industry. Release characteristics of drugs may be controlled by complex 3D printed geometries and architectures. Precise and unique doses can be engineered and fabricated via 3D printing according to individual prescriptions. On-demand printing of drug products can be implemented for drugs with limited shelf life or for patient-specific medications, offering an alternative to traditional compounding pharmacies. For these reasons, 3D printing for drug manufacturing is the future of pharmaceuticals, making personalized medicine possible while also transforming pharmacies.

Online-delivered resistance exercise intervention among racially diverse breast cancer survivors: Feasibility, acceptability, and exploratory outcomes of B-REP.

The aims are to determine the feasibility of an online-delivered resistance exercise program among racially diverse breast cancer survivors and to conduct an exploratory analysis of the intervention on muscular strength, physical activity levels, health-related quality of life, and self-efficacy. A 2-arm randomized controlled trial study design with assessments at pre- and post-intervention was used. Participants (n = 52) were recruited from clinics at the host institution and randomized to either intervention (n = 28) or minimal contact control (MCC) conditions (n = 24). All participants received a 12-week individualized resistance exercise prescription based on their baseline functional strength assessment. Intervention participants exercised one-on-one once per week over Zoom with an exercise trainer. MCC participants received no supervision. Descriptive statistics were used to determine feasibility and acceptability (primary outcomes). Repeated measures ANOVAs were used to examine exploratory outcomes. The intervention demonstrated high rates for feasibility outcomes of enrollment (80.0%) and post-intervention assessment completion (92.9%). Acceptability outcomes were high for session attendance (98.0%) and satisfaction (Mscore = 4.87 out of 5, SD = .18). The intervention group increased upper- (p < .01) and lower- (p < .02) body strength compared to MCC condition. The intervention was feasible, acceptable, and demonstrated increases in muscular strength. Limitations include a small sample recruited from one cancer center. Future research is needed to determine longitudinal impacts of resistance exercise on survivorship outcomes. Online-delivered resistance exercise shows promising efficacy among racially diverse breast cancer survivors. gov registration: NCT04562233 on September 18, 2020.

DOSage of Exercise for chronic low back pain disorders (DOSE): protocol for a systematic review with dose-response network meta-analysis

Chronic low back disorders are the leading cause of direct and indirect healthcare burden globally. Exercise training improves pain intensity, mental health and physical function. However, the optimal prescription variables...

A Systematic Overview of Contraindications and Special Warnings for Biologic and Targeted Synthetic Disease Modifying Antirheumatic Drugs: Establishing a Framework to Create a "Safety Checklist".

The purpose of this review is to provide an overview of the contraindications, special warnings, and boxed warnings with the aim to establish a framework to create a prescription safety checklist for a class of drugs or disease indication. This study covers biologic disease modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs). We identified contraindications, boxed warnings, and special warnings provided by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA). The study included b/tsDMARDs approved for treating rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (SpA), and juvenile idiopathic arthritis (JIA) within the drug-classes anti-CD20, tumor necrosis factor inhibitors (TNFi), interleukin-1 inhibitors (IL-1i), cytotoxic T-lymphocyte-associated protein (CTLA) 4, interleukin-12/23 inhibitors (IL-12/23i), interleukin 6 receptor inhibitors (IL-6Ri), Janus kinase inhibitors (JAKi), phosphodiesterase 4 inhibitors (PDE4i), interleukin-17 inhibitors (IL-17i), and interleukin-23 inhibitors (IL-23i). All drug classes, except PDE4i, had contraindications and/or warnings related to infections, including tuberculosis. A warning about herpes zoster was listed for anti-CD20, IL-1i, IL-6Ri, and JAKi, while a warning about hepatitis reactivation was listed for anti-CD20, TNFi, IL-1i, CTLA4-Ig, IL-6Ri, and JAKi. Malignancy risk was mentioned for all drug classes except PDE4i, IL-17i, and IL-23i. Other warnings included demyelinating disease (TNFi, CTLA4-Ig, and IL-6Ri), heart failure (anti-CD20 and TNFi), major adverse cardiac events (JAKi and IL-12/23) and venous thromboembolism (JAKi), hyperlipidemia (IL-6Ri and JAKi), liver impairment (TNFi, IL-1i, IL-6Ri, and JAKi), kidney impairment (IL-1i, JAKi, and PDE4i), inflammatory bowel disease (IL-17i), gastrointestinal perforation (IL-6Ri, JAKi), cytopenia (anti-CD20, TNFi, IL-1i, IL-6Ri, JAKi), and depression (PDE4i). Contraindications and warnings appeared to increase with the passage of time since the drug's approval. This review provides an overview to establish the framework to create an easily accessible and actionable prescription safety checklist from individual medical product prescription information provided by regulatory medical authorities.

Two Novel Antibiotic Use Metrics for Facilities and Individual Prescribers in Post-Acute and Long-Term Care Settings

Background: Measuring and reporting antibiotic use are essential to antimicrobial stewardship activities. The most common metric to assess facility-level use is days of antibiotic therapy per 1000 days of care (DOT/1000 DOC). This metric may be difficult to calculate, not be readily comparable, or not provide actionable data to individual prescribers, particularly those that work in post-acute and long-term care (PALTC) settings. Here we use data from a centralized dispensing pharmacy to develop antibiotic use metrics suitable for offering individualized feedback to prescribers working in PALTC settings. Methods: We obtained medication dispensing data and resident census data for 13 PALTC settings within the same network. After omitting non-pharmacologic items and limiting the data to medications dispensed from 1/2020 – 12/2022, we determined the following metrics by month: days of antibiotic therapy (DOT), number of medications prescribed, number of antibiotic courses prescribed (antibiotic starts), and the number of individual residents issued a prescription for any medication (unique residents). These metrics were assessed for each facility (2020 – 2022) and for prescribers responsible for &gt; 1% of prescriptions within that facility (2022 only). Prescriber-level unique residents was the number of residents issued a prescription by the given provider. We obtained facility-level census data to calculate antibiotic DOT/1000 resident days of care (DOC) as a standard to which we compared novel metrics. Results: During the 3-year study period, 1718 prescribers at 13 PALTC settings wrote for 672256 medications, including 31087 antibiotic courses. At the facility level, the correlation between monthly antibiotic starts (courses)/unique residents and antibiotic DOT/1000 DOC was 0.83 (p &lt; 0 .0001). The correlation between monthly antibiotic DOT/unique residents and antibiotic DOT/1000 DOC was 0.98 (p &lt; 0 .0001). Trends in monthly values of both novel metrics and DOT/1000 DOC were consistent across the examined period (Figure 1). For individual prescribers, both novel metrics permit assessment and comparison of antibiotic prescription rates over time (Figure 2). Conclusions: Pharmacy dispensing data can be used to determine antibiotic DOT/unique residents and antibiotic starts/unique residents at the facility level and for individual providers. The novel metric antibiotic DOT/unique residents demonstrated strong correlation with antibiotic DOT/1000 DOC at the facility level. In addition to supporting tracking and reporting of antibiotic use among PALTC settings, these new metrics permit visualization of the antibiotic prescribing rates of individuals prescribers, as well as peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC.

Greenhouse Gas Emissions Due to Unnecessary Antibiotic Prescriptions for Respiratory Diagnoses

Background: Healthcare accounts for 8.5% of total US greenhouse gas emissions (GHGE), with US healthcare the main contributor. Yet little effort has been made to measure healthcare related GHGE. Specifically, GHGE related to unnecessary antibiotic prescriptions is unclear, and to our knowledge, no one has used estimates of GHGE of unnecessary antibiotics as an antibiotic stewardship tool. We aimed to measure GHGE from solid waste associated with unnecessary antibiotic prescriptions for respiratory conditions. Methods: We calculated emissions for an outpatient prescription including the plastic bottle, paper leaflet, and paper bag (photos) based on the weight of each item multiplied by US Environmental Protection Agency (EPA) GHGE factors. Emission factors depend on waste type and treatment method which we assumed to be landfilled. To estimate unnecessary antibiotic prescriptions for respiratory infections, visits from nine University of Utah Health Urgent Care Centers from 2019-2022 were electronically identified and included if they had an ICD-10-CM code for a respiratory diagnosis where antibiotics are not indicated. Waste emissions of the paper and plastic in an individual prescription were then multiplied by the number of unnecessary respiratory antibiotic prescriptions for designated time periods to arrive at total landfilled waste emissions. We used similar methods applied to published 2014 data from CDC to estimate national waste emissions due to unnecessary antibiotic prescriptions for respiratory infections. Finally, we used the EPA’s GHG Equivalencies Calculator to convert emissions into tangible GHGE for providers and patients. Results: A prescription has 32g of paper and 15g of plastic waste. Among 124,461 urgent care visits (Table 1) in 2019-2022, 18,531 (14.9%) received an antibiotic. This equates to 593 kg of paper waste and 278 kg of plastic waste leading to a total landfilled waste emissions of 0.479 MT CO2e/ton. Using the EPA GHG Equivalencies Calculator, this equates to driving an average gasoline-powered car 1,228 miles. There were 14,482,976 unnecessary antibiotic prescriptions (Table 2) in the US for respiratory infections in 2014. Our estimates suggest these prescriptions led to 375.109 CO2e/ton of GHGE, the same as driving 961,610 miles by an average gasoline-powered vehicle. Conclusion: Unnecessary antibiotic prescriptions are associated with substantial GHGE. This estimate demands further evaluation across diagnoses and care delivery sites, and most importantly action. Additionally, the large GHG contribution of unnecessary antibiotics should be used as a stewardship tool to highlight low-value care that is likely contributing to global climate change.

Prescribing patterns of statins and associated factors among type 2 diabetes mellitus patients in Africa: A systematic review and meta-analysis

BackgroundIn sub-Saharan African nations, there's a documented shortfall in the utilization of statins, despite established clinical guidelines advocating their use for reducing cardiovascular risks and overall mortality among Type 2 diabetes patients aged 40–75 years old. Most clinical guidelines recommend prescribing statins to individuals with type 2 diabetes to reduce the chances of cardiovascular disease. There is currently a lack of extensive research on statin utilization specifically for primary prevention of cardiovascular disease in Africa. Thus, this study aimed to assess the prescription patterns of statins for preventing cardiovascular disease in type 2 diabetes patients. MethodsThe findings of the review were presented following the guidelines outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-2020) checklist. We conducted searches on electronic databases including PubMed, EMBASE, Cochrane Library, Science Direct, African Journal Online, and Google Scholar. This systematic review and meta-analysis included articles that met specific inclusion criteria: observational studies such as cross-sectional, cohort, and case-control studies focusing on determinants, risk factors, or correlates associated with statin prescription within Africa. Only published articles up to June 2, 2024, published in English, and conducted in either community or healthcare facility settings were considered. Data import was initially conducted using Microsoft Excel, and statistical analysis was performed using STATA software. Cochran's Q test was employed to assess whether there was a significant variance in prevalence among the studies. Additionally, the I2 statistic was utilized to quantify the extent of heterogeneity. A funnel plot, a visual tool, was utilized to evaluate publication bias. ResultsThe search strategy resulted in 7695 published original articles. The full texts of the 89 papers were assessed for eligibility and quality. Moreover, some articles were rejected due to inaccuracies in the outcome variable. Ultimately, only ten studies focusing on the prevalence of statin prescription were examined. The research suggests that the pooled prevalence of statin prescription among Type 2 diabetic individuals in Africa is found to be 48.82% (95% CI: 35.41–63.24). Age greater than 65 years (AOR = 3.56, 95% CI: 1.70–7.45; I2 = 54.7%), comorbidity (AOR = 1.13, 95% CI: 0.27–4.63, I2 = 96.4%), dyslipidemia (AOR = 3.15, 95% CI: 1.54–6.44, I2 = 61.7%), DM duration greater than ten years (AOR = 1.36, 95% CI: 0.81–2.28, I2 = 77.3%), and government insurance (AOR = 8.85, 95% CI: 2.72–28.76, I2 = 81.5%) were factors associated with statin prescription among type 2 diabetic patients. ConclusionsIn general, the extent of statin prescriptions for individuals with type 2 diabetes who are eligible for statin therapy was below the target outlined by clinical practice guidelines. Being over 65 years old, having comorbidities, experiencing dyslipidemia, having type 2 diabetes for more than ten years, and having government insurance were all identified as independent factors predicting the prescription of statins. This finding is concerning and underscores the urgent need to enhance adherence to clinical practice guidelines for the well-being of this vulnerable population at high risk.