How do pharmacists select antimicrobials? A model of pharmacists’ therapeutic reasoning processes

INTRODUCTIONClinicians engage in clinical reasoning, comprised of both diagnostic and therapeutic components, when caring for patients. While diagnostic reasoning has been extensively investigated, relatively few studies have examined how clinicians make treatment decisions. Recent work has explored how physicians engage in therapeutic reasoning while selecting antimicrobials. However, understanding pharmacists’ antimicrobial reasoning is equally important due to their role in ensuring appropriate antimicrobial use. Therefore, we aimed to further our understanding of antimicrobial reasoning in pharmacists and compare their reasoning processes to physicians.METHODSWith a postpositivist orientation and using a general qualitative approach, we conducted semi‐structured interviews with hospital‐based pharmacists specializing in infectious diseases or other hospital‐based specialties. Participants narrated their thought processes while selecting antimicrobials for three case vignettes. We analyzed transcripts iteratively using a code book from a prior study of antimicrobial reasoning in physicians as a sensitizing framework.RESULTSParticipants included 11 pharmacists (5 infectious diseases and 6 noninfectious diseases pharmacists). Overall, participants’ responses reflected a three‐step reasoning process: Naming the Syndrome, Delineating Pathogens, and Selecting the Antimicrobial. Patient‐, syndrome‐, and system‐based factors interacted with drug characteristics to influence the selection of specific antimicrobial regimens.CONCLUSIONWe identified a framework for pharmacists’ antimicrobial therapeutic reasoning similar to physicians’ reasoning, with some nuances that may be attributable to the pharmacists’ role in medication review and antimicrobial stewardship. Application of this framework has the potential to aid in teaching, improve multidisciplinary care, and provide a framework for interprofessional communication.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/172005/1/jac51580.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/172005/2/jac51580_am.pd

Identification of Sex Differences in Tumor-Specific T Cell Infiltration in Bladder Tumor-Bearing Mice Treated with BCG Immunotherapy

International audienceBACKGROUND:Bladder cancer is the fourth most common cancer for men. However, women are often diagnosed with later stage disease and have poorer outcomes. Whether immune-based sex differences contribute to this discrepancy is unclear. In addition, models to investigate tumor-specific immunity in bladder cancer, in the context of tumor development or response to therapy, are lacking.OBJECTIVE:To address this specific unmet need, we incorporated a commonly used model antigen, ovalbumin, into two well-established models of bladder cancer; the orthotopic MB49 cell line model and the carcinogenic BBN bladder cancer model.CONCLUSIONS:We propose our modified BBN model will contribute to our understanding of how tumor-specific immunity arises in bladder cancer. Additionally, the BBN bladder cancer model may help to uncover sex differences in tumor-specific immunity, which would provide valuable information for the development of new treatments or combination therapies for bladder cancer in women and men.METHOD:We tested the utility of these models to investigate tumor-specific immunity in the context of immunotherapy in both sexes.RESULTS:We found that BCG vaccination, prior to weekly BCG instillation does not impart an immune-specific benefit to tumor-bearing mice in the context of multiple BCG instillations. Furthermore, tumors developed in the testes in male mice, precluding the use of the MB49 model to directly investigate sex-based immune differences. In the BBN model, we observed that more tumor antigen-specific CD8+ T cells infiltrated male bladders compared to female bladders in the context of BCG immunotherapy whereas regulatory T cells had higher levels of the exhaustion marker PD-1 in female mice