Prescribing Advice Research Articles

First-line treatment with ceftriaxone for Neisseria gonorrhoeae infection less likely to be prescribed to patients with a penicillin allergy label: a retrospective audit of medical records.

Background Gonorrhoea notifications have increased substantially in Australia over the past decade. Neisseria gonorrhoeae is already highly resistant to several antibiotics and so, alternatives to first-line treatment are generally strongly discouraged. The penicillin allergy label (AL) on patient medical records has previously been shown to influence prescribing practices, to the detriment of best-practice management and antimicrobial stewardship. This study aimed to understand how the penicillin AL influences antibiotic selection for gonorrhoea treatment at Canberra Sexual Health Centre. Methods A retrospective chart audit of gonorrhoea cases treated at Canberra Sexual Health Centre between January 2020 and October 2023 (n =619 patients, n =728 cases). Antibiotic selection was assessed according to penicillin AL status. Ceftriaxone selection was assessed according to penicillin allergy severity reported in the medical records and as determined using a validated antibiotic allergy assessment tool. Results Cases with a penicillin AL were more likely to receive antibiotics other than ceftriaxone (n =7/41, 17.1%) than cases without the label (n =8/687, 1.2%, P n =28/41, 68.3%) to apply the assessment tool. Those reported as low-severity in the records were more likely to receive ceftriaxone (n =21/22, 95.5%) than those reported as moderate-high (n =7/11, 63.6%) or unreported (n =6/8, 0.75%). Conclusions Treatment of gonorrhoea in outpatient settings requires an understanding of penicillin allergy, and the ability to quickly and accurately identify penicillin-AL patients who can safely tolerate ceftriaxone. Institutionally endorsed penicillin allergy de-labelling protocols and access to easy-to-navigate prescribing advice within national sexually transmitted infection management guidelines would support this.

Effect of directive laboratory comments on prescribing response to positive throat swab cultures.

In patients without ethnicity risk factors for acute rheumatic fever (ARF), our local guidelines recommend limiting antibiotic use following a positive throat swab culture (TSC). If symptoms are severe, a 5-7 day course is recommended. Despite this, most local patients with a positive TSC for group A Streptococcus (GAS) or Streptococcus dysgalactiae subsp. equisimilis (SDSE) were being prescribed 10 days of antibiotics. In response, we added comments to positive TSC reports recommending shorter treatment durations in those without ARF risk factors. No other antimicrobial stewardship initiatives were implemented. To assess the effect of these comments on antibiotic course duration after positive TSC. All community TSC results from 1 October 2021 to 31 March 2023 (1 year pre- to 6 months post-change) were matched to antibiotic dispensing data. Patients who had been empirically dispensed an antibiotic prior to the culture report were excluded. The outcome of interest was the antibiotic duration dispensed in the 5 day period after the TSC report. Following introduction of the comments, median course duration reduced from 10 (IQR 5-10) to 7 days (IQR 0-10; P < 0.01) and from 7 (IQR 0-10) to 0 days (IQR 0-5; P < 0.01) following GAS- and SDSE-positive TSC, respectively, in those without ARF risk factors. The percentage of people receiving 10 days of antibiotics decreased from 63.0% to 37.0% (P < 0.01) and 41.2% to 14.6% (P < 0.01) for GAS and SDSE, respectively. The introduction of comments providing direct prescribing advice to requestors appears to have been highly effective at improving guideline-compliant prescribing following positive TSC report.

Who is asking? Requests for antimicrobial prescribing advice received by hospital pharmacists

AbstractDoctors are perceived as the primary decision makers in antimicrobial therapy, but prescribing decisions are influenced by the multidisciplinary team. Antimicrobial stewardship (AMS) programs formalise interprofessional advice‐giving. No studies capture the advice provided by pharmacists. This study aimed to describe the volume and nature of antimicrobial prescribing advice that healthcare professionals seek from hospital pharmacists. A prospective audit of antimicrobial‐related advice requests received by pharmacists (n = 18) at an Australian public hospital was undertaken in July 2020. Antimicrobial advice was sought from 11 pharmacists on 300 occasions. Most requests (80%) were received by the AMS pharmacist. A mean (range) of 30 (17–40) requests per day was recorded and the AMS pharmacist received 24 (16–31) requests daily. Most requests came from the intensive care unit (22.1%), pharmacy (21.4%), and infectious diseases (17.1%). The AMS pharmacist was mostly contacted by consultants and pharmacists, and other pharmacists were contacted by registrars and junior medical officers. Despite COVID‐19 adaptations, face‐to‐face interaction was most common. This audit demonstrates the value of an AMS pharmacist, and indicates the importance of face‐to‐face interactions and the formalisation of pharmacists' role in prescribing decision‐making. Pharmacists provided antimicrobial advice daily to other healthcare professionals. Further research is required to provide insights into the barriers and enablers to effective advice‐giving interactions.

Influence of drug safety advisories on drug utilisation: an international interrupted time series and meta-analysis

ObjectiveTo evaluate the association between regulatory drug safety advisories and changes in drug utilisation.DesignWe conducted controlled, interrupted times series analyses with administrative prescription claims data to estimate changes in drug...

Pharmacists providing prescribing advice and education to healthcare professionals in community, primary care and outpatient settings

Pharmacists providing prescribing advice and education to healthcare professionals in community, primary care and outpatient settings

Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care

BackgroundPrescribing for patients taking multiple medicines (i.e. polypharmacy) is challenging for general practitioners (GPs). Limited evidence suggests that the integration of pharmacists into the general practice team could improve the management of these patients. The aim of this study is to develop and test an intervention involving pharmacists, working within GP practices, to optimise prescribing in Ireland, which has a mixed public and private primary healthcare system.MethodsThis non-randomised pilot study will use a mixed-methods approach. Four general practices will be purposively sampled and recruited. A pharmacist will join the practice team for 6 months. They will participate in the management of repeat prescribing and undertake medication reviews (which will address high-risk prescribing and potentially inappropriate prescribing, deprescribing and cost-effective and generic prescribing) with adult patients. Pharmacists will also provide prescribing advice regarding the use of preferred drugs, undertake clinical audits, join practice team meetings and facilitate practice-based education. Throughout the 6-month intervention period, anonymised practice-level medication (e.g. medication changes) and cost data will be collected. A nested Patient Reported Outcome Measure (PROM) study will be undertaken during months 4 and 5 of the 6-month intervention period to explore the impact of the intervention in older adults (aged ≥ 65 years). For this, a sub-set of 50 patients aged ≥ 65 years with significant polypharmacy (≥ 10 repeat medicines) will be recruited from each practice and invited to a medication review with the pharmacist. PROMs and healthcare utilisation data will be collected using patient questionnaires, and a 6-week follow-up review conducted. Acceptability of the intervention will be explored using pre- and post-intervention semi-structured interviews with key stakeholders. Quantitative and qualitative data analysis will be undertaken and an economic evaluation conducted.DiscussionThis non-randomised pilot study will provide evidence regarding the feasibility and potential effectiveness of general practice-based pharmacists in Ireland and provide data on whether a randomised controlled trial of this intervention is indicated. It will also provide a deeper understanding as to how a pharmacist working as part of the general practice team will affect organisational processes and professional relationships in a mixed public and private primary healthcare system.

Thai clinicians' attitudes toward antimicrobial stewardship programs

Effective hospital-wide antimicrobial stewardship (AMS) programs need multidisciplinary engagement; however, clinicians' attitudes have not been investigated in Thailand where AMS is in early development. The aim of this study was to explore Thai clinicians' (doctors, nurses, and pharmacists) perceptions and attitudes toward AMS. A paper-based survey was distributed in a 1,000-bed university hospital in Bangkok, Thailand, between November 9, 2015, and December 21, 2015. A total of 1,087 clinicians participated: 392 doctors, 613 nurses, and 82 pharmacists. Most participants agreed that improving antimicrobial prescribing would decrease antimicrobial resistance (AMR) and should be a priority of hospital policy. Doctors were less likely to agree with policies that limit antimicrobial prescribing (P < .001) than nurses or pharmacists, and were less likely to be interested in participating in AMS education than other clinicians (P < .001). Pharmacists indicated higher agreement with the statement, recommending that a specialist team provide individualized antimicrobial prescribing advice (P < .01) and that feedback improves antimicrobial selection (P < .001). Nurses were less likely to agree that community antibiotic use (P < .001) or patient pressure for antibiotics contribute to AMR (P < .001). AMS programs are vital to improving antimicrobial use by clinicians. Understanding clinicians' attitudes and perceptions related to AMS is important to ensure that AMS programs developed address areas relevant to local clinical needs.

Interventions to mitigate the effects of poverty and inequality on mental health.

To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health. Systematic reviews, controlled trials and realist evaluations of the last 10years are reviewed, without age or geographical restrictions. Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted. The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate a cross-sectoral approach, and to form partnerships between different government departments, civic society organisations and other stakeholders. This approach is referred to as Mental Health in All Policies and it can be applied to all public policy levels from local policies to supranational.

Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use.

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n=20), those 'EQUiPPED' with the interventions (n=10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n=10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n=11) were asked about 'usability'. Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.

Implementing antimicrobial stewardship in the Australian private hospital system: a qualitative study.

To explore organisational factors and barriers contributing to limited uptake of antimicrobial stewardship (AMS) in Australian private hospitals and to determine solutions for AMS implementation. A qualitative study using a series of focus group discussions was conducted in a large private hospital making use of a semistructured interview guide to facilitate discussion among clinical and non-clinical stakeholders. A thematic analysis using five sequential components that mapped and interpreted emergent themes surrounding AMS implementation was undertaken by a multidisciplinary team of researchers. Analysis revealed that autonomy of consultant specialists was perceived as being of greater significance in private hospitals compared with public hospitals. Use of an expert team providing antimicrobial prescribing advice and education without intruding on existing patient-specialist relationships was proposed by participants as an acceptable method of introducing AMS in private hospitals. There was more opportunity for nursing and pharmacist involvement, as well as empowering patients. Opportunities were identified for the hospital executive to market an AMS service as a feature that promoted excellence in patient care. Provision of advice from experts, championing by clinical leaders, marketing by hospital executives and involving nurses, pharmacists and patients should be considered during implementation of AMS in private hospitals.

Reflective and Automatic Processes in Health Care Professional Behaviour: a Dual Process Model Tested Across Multiple Behaviours

Clinicians' behaviours require deliberate decision-making in complex contexts and may involve both impulsive (automatic) and reflective (motivational and volitional) processes. The purpose of this study was to test a dual process model applied to clinician behaviours in their management of type 2 diabetes. The design used six nested prospective correlational studies. Questionnaires were sent to general practitioners and nurses in 99 UK primary care practices, measuring reflective (intention, action planning and coping planning) and impulsive (automaticity) predictors for six guideline-recommended behaviours: blood pressure prescribing (N = 335), prescribing for glycemic control (N = 288), providing diabetes-related education (N = 346), providing weight advice (N = 417), providing self-management advice (N = 332) and examining the feet (N = 218). Respondent retention was high. A dual process model was supported for prescribing behaviours, weight advice, and examining the feet. A sequential reflective process was supported for blood pressure prescribing, self-management and weight advice, and diabetes-related education. Reflective and impulsive processes predict behaviour. Quality improvement interventions should consider both reflective and impulsive approaches to behaviour change.

Antimicrobial stewardship auditing of patients reviewed by infectious diseases physicians in a tertiary university hospital

BackgroundThe optimal way for antimicrobial stewardship programs (ASPs) to interact with existing infectious disease physician (IDP) services within the same institution is unknown. In our institution, IDPs and our prospective audit and feedback ASP operate independently, with occasionally differing recommendations offered for the same inpatient. We performed a retrospective audit on inpatients that had been reviewed by both IDPs and ASP within a 7-day period, focusing on cases where different therapy-modifying recommendations had been offered. We analyzed the outcomes in inpatients where the ASP recommendations were accepted and compared these with the inpatients where the IDP recommendations were accepted instead. Outcomes assessed were 30-day mortality post-ASP review, unplanned re-admission within 30 days post-discharge from hospital, and clinical deterioration at 7 days post-ASP review.FindingsThere were 143 (18.9%) patients where differing recommendations had been offered, with primary physicians accepting 69.9% of ASP recommendations. No significant differences in terms of demographics, clinical characteristics, 30-day mortality, and re-admission rates were observed, although clinical deterioration rates were lower in patients where the ASP recommendation was accepted (8.0% vs. 27.9%; p = 0.002). On multivariate analysis, hematology-oncology inpatients were associated with unplanned readmission. Increasing age and hematology-oncology inpatients were associated with clinical deterioration 7 days post-recommendation, whereas acceptance of ASP recommendations was protective. No characteristic was independently associated with 30-day mortality.ConclusionIn conclusion, independent reviews by both IDPs and ASPs can be compatible within large tertiary hospitals, providing primary physicians even in situations of conflicting recommendations viable alternative antimicrobial prescribing advice.

HRT prescribing post WHI and MWS: What did you do? Would you do it again?

As we write the editorial for this edition, a very public row has broken out over the principal findings of the Million Women Study (MWS). It was this study, in combination with the principal findings of the Women’s Health Initiative (WHI), that completely transformed the opinion of professionals and patients worldwide with regard to almost any hormone therapy. Various estimates of the quantitative effect on hormone-replacement therapy (HRT) prescribing exist depending on the markets examined but it is clear that the overall effect is a halving in the use of HRT globally. It is highly likely that most HRT prescribers reduced the numbers of prescriptions immediately after the publication of these studies. Thus, was what many of us did right? Before we changed our prescribing habits or advice to patients, did we look at the data with the same level of scrutiny we would apply were we personally to be the ones about to start or continue therapy? Did we follow the investigators’ conclusions, or worse the conclusions from the media to influence our actions? Most of us recall the frenzy of sensationalism that accompanied these publications. Newspaper front pages screamed about the dangers of HRT and interviews with lead investigators promulgated their conclusions further. It was all too easy to take the path of least resistance and accept the indirect recommendations from investigators and press and the more direct guidance from some regulatory authorities. What we all should have done right from the start is to make our own minds up, either sit down, read the papers in detail or discuss them in a practice or multiprofessional meeting. Following the herd may have been the safest thing to do from a purely professional point of view but did we do the right thing for our patients? Without a doubt there may have been patients taking HRT who were not being regularly assessed and having their risk profiles assessed yearly who should have considered stopping. The worrying thing is the number of patients who had their treatment stopped suddenly without an option to discuss things further. With this probably well-intentioned risk-reducing manoeuvre, many women were plunged suddenly into a hormone-free hell. Many women suffered a significant and sudden reduction in quality of life, seeking out alternatives such as phytoestrogens and other drugs that are largely less well researched than HRT. It was easy to see the immediate effects on quality of life but other unwanted effects of cessation such as bone loss, vulvovaginal atrophy and short-term cognitive effects would take longer to present. Thus, what should we do with the reawakened debate about the validity of the MWS? Firstly, it should be considered that the recent publication does not actually provide new factual challenge to the MWS, it provides challenges to the methodological processes that lead to the main conclusion that HRT causes breast cancer. This conclusion has been challenged in several publications since the MWS was published and now adds further concern that the validity of the data and subsequent recommendations from regulatory authorities may need urgent review. Professionals new to the area of menopause are right to be confused. Have we been practising proper evidencebased medicine? Has there been a formal revision of the advice that arose from the main conclusions of the WHI and MWS? Whether a revision is needed or not we should all be practising an individualized approach to HRT prescribing, known risks and benefits should be carefully discussed prior to the decision to prescribe with effectiveness, tolerance and both shortand long-term effects monitored to facilitate continued prescription. What is urgently required is a formal expert group reappraisal resulting in a balanced assessment of whether women can feel safer on HRT and whether prescribers can have a greater degree of professional support from a regulatory body. In the meantime, please encourage colleagues to be aware of the debate, keep their professional ears to the ground and remain open to the possibility that HRT administration to the right woman at the right time in her life might actually be good for her.

A systematic review of the safety information contained within the Summaries of Product Characteristics of medications licensed in the United Kingdom for Attention Deficit Hyperactivity Disorder. how does the safety prescribing advice compare with national guidance?

BackgroundThe safety of paediatric medications is paramount and contraindications provide clear pragmatic advice. Further advice may be accessed through Summaries of Product Characteristics (SPCs) and relevant national guidelines. The SPC can be considered the ultimate independent guideline and is regularly updated. In 2008, the authors undertook a systematic review of the SPC contraindications of medications licensed in the United Kingdom (UK) for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). At that time, there were fewer contraindications reported in the SPC for atomoxetine than methylphenidate and the specific contraindications varied considerably amongst methylphenidate formulations. In 2009, the European Medicines Agency (EMA) mandated harmonisation of methylphenidate SPCs. Between September and November 2011, there were three changes to the atomoxetine SPC that resulted in revised prescribing information. In addition, Clinical Guidance has also been produced by the National Institute for Health and Clinical Excellence (NICE) (2008), the Scottish Intercollegiate Guidelines Network (SIGN) (2009) and the British National Formulary for Children (BNFC).MethodsAn updated systematic review of the Contraindications sections of the SPCs of all medications currently licensed for treatment of ADHD in the UK was undertaken and independent statements regarding contraindications and relevant warnings and precautions were then compared with UK national guidance with the aim of assessing any disparity and potential areas of confusion for prescribers.ResultsAs of November 2011, there were seven medications available in the UK for the treatment of ADHD. There are 15 contraindications for most formulations of methylphenidate, 14 for dexamfetamine and 5 for atomoxetine. Significant differences exist between the SPCs and national guidance part due to the ongoing reactive process of amending the former as new information becomes known. In addition, recommendations are made outside UK SPC licensed indications and a significant contraindication for methylphenidate (suicidal behaviours) is missing from both the NICE and SIGN guidelines. Particular disparity exists relating to monitoring for suicidal and psychiatric side effects. The BNFC has not yet been updated in line with the European Union (EU) Directive on methylphenidate; it does not include any contraindications for atomoxetine but describes contraindications for methylphenidate that are no longer in the SPC.ConclusionClinicians seeking prescribing advice from critical independent sources of data, such as SPCs and national guidelines, may be confused by the disparity that exists. There are major differences between guidelines and SPCs and neither should be referred to in isolation. The SPC represents the most relevant source of safety data to aid prescribing of medications for ADHD as they present the most current safety data in line with increased exposure. National guidelines may need more regular updates.

Is There a Role for Herpes Zoster Vaccine in Chronic Pain Management?

Is There a Role for Herpes Zoster Vaccine in Chronic Pain Management?

The use of antibacterials in children: a report of the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) Paediatric Subgroup

The Paediatric Subgroup of SACAR has identified major changes in antibacterial use for children. The number of prescriptions for antibacterials for children in primary care in 2000 was half that in 1996, with amoxicillin still accounting for around 50% of all antibacterial prescribing. There is a marked regional variation in prescribing rates. The UK now has paediatric antibacterial prescribing rates lower than many other European countries at around 700 prescriptions/1000 children/year. The group has been using the General Practice Research Database and Hospital Episode Statistics data to identify trends in clinical disease patterns associated with this change in prescribing practice. Data are also now available from the Health Protection Agency for all paediatric bacteraemias reported over the last decade. In 1992, around 50% of bacteraemias were due to Gram-positive bacteria, but this has increased to over 75% in 2003 with Staphylococcus aureus now becoming the leading significant bacteraemia reported in children. It may now be possible to link existing childhood data sets to develop collaborative prospective antimicrobial surveillance networks, monitoring antimicrobial prescribing, bacterial isolates and clinical outcome data, and to provide updated evidence-based prescribing advice to all prescribers. Adherence to national guidelines and clinical outcome data can then be monitored in turn to provide a continuous audit process aimed at improving prescribing advice and reducing antimicrobial resistance.

Contraception

Contraception

The community pharmacy contract

In the seventh in our series of prescribing articles, independent prescribing adviser Angus Thompson highlights key features of the new community pharmacy contract that may be of relevance to nurse prescribers

Over-the-counter medicines

In the final article in our prescribing series, independent prescribing adviser Angus Thompson discusses developments in over-the-counter medicines

Reporting adverse drug reactions

In the sixth article in our prescribing series, independent prescribing adviser Angus Thompson discusses the important contribution to patient safety made by the reporting of adverse drug reactions