Effect of a pharmacist-led antimicrobial stewardship (AMS) program on outpatient fluoroquinolone prescribing in the elderly

Title: Effect of a pharmacist-led antimicrobial stewardship (AMS) program on outpatient fluoroquinolone prescribing in the elderly Authors: LaRue, Katie PharmD; Mannebach, Chelsea PharmD, BCPS, BCACP; Jiron, Bonnie, PharmD, BCACP Introduction: The Center for Disease Control and Prevention, the Society of Infectious Diseases Pharmacists, and American Pharmacists Association recognize the need for outpatient AMS programs and the important role pharmacists play in appropriate prescribing. Fluoroquinolones (FQ) pose many risks, highlighted by U.S Food and Drug Administration safety warnings, including aortic dissection, hypoglycemia, mental health side effects, and tendonitis, along with the risk of Clostridium difficile infections, particularly in the elderly. Outcomes: The primary outcome is to determine the change in the number of FQ prescriptions written for patients ≥65 years of age in the primary care setting between March 2018 and 2019, and March 2019 and 2020. Secondary objectives include determining the appropriateness of fluoroquinolone prescriptions before and after education intervention, and provider attitudes towards outpatient AMS. Methods: Education on fluoroquinolone antibiotic risks, safety warnings, and guideline-directed uses was provided to prescribers in February 2020. During education, prescribers were given a report of the number of fluoroquinolones prescribed to patients ≥65 years of age during March 2018 and March 2019 with comparison to other prescribers. Data was collected for March 2020 and a similar report was given to prescribers. Approximately 15% of fluoroquinolone prescriptions were reviewed for secondary outcomes. Changes in fluoroquinolone prescriptions will be analyzed by Bayesian inference and secondary outcomes will be reported with descriptive statistics. Results: There was a decrease in the total number of fluoroquinolone prescriptions in March 2020 (n=134) compared to March 2019 (n=200) and March 2018 (n=272). After secondary review of 15% of these prescriptions, there was an increase in appropriately prescribed fluoroquinolones from 2.4% in March 2018 (n=41) to 27.8% in March 2020 (n=18). Of 118 providers surveyed before and after the educational presentation, 6.8% correctly identified all risks associated with fluoroquinolone therapy prior to the education and 84.1% correctly identified all risks associated with fluoroquinolone therapy after receiving education. After the education, an increase in providers reported being very comfortable discussing the risks and benefits of FQ therapy with their patients, from 23% prior to the education to 65% after the education. Conclusions: Provider education on risks associated with fluoroquinolone use in the elderly and individualized provider reports was associated with a decrease in total fluoroquinolones prescribed to patients ≥65 years of age in the included primary care clinics. Additionally, a higher percentage of fluoroquinolones were prescribed appropriately based on evidence-based guidelines. Ongoing AMS efforts are needed to continually improve patient safety and reduce unnecessary antimicrobial exposure.https://digitalcommons.psjhealth.org/pharmacy_PGY2/1002/thumbnail.jp

Therapeutic approaches to slowing the progression of diabetic nephropathy – is less best?

Objective: Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors are known to reduce proteinuria and have been the first-line agents in the management of diabetic nephropathy for the past 20 years. This review covers recent studies that compare the benefit of additional blockage of the renin–angiotensin–aldosterone system through combination therapy with an ACE inhibitor and ARB, or a direct renin inhibitor (DRI), to monotherapy.Design: Primary and review articles that addressed the pathophysiology, diagnosis, and therapeutic options for attenuating the progression of diabetic nephropathy were retrieved through a MEDLINE search (January 1990 to December 2012) and the bibliographies of identified articles were reviewed. English language sources were searched using the following search terms: diabetes mellitus, nephropathy, proteinuria, ACE inhibitors, ARBs, and DRIs.Setting: Randomized, placebo-controlled, short- and long-term studies published in peer-reviewed journals that were determined to be methodologically sound, with appropriate statistical analysis of the results, were selected for inclusion in this review.Participants: Adult (≥18 years) patients with diabetic nephropathy.Measurements: Serum creatinine level was used to estimate glomerular filtration rate (GFR). GFR was calculated using the four-variable Modification of Diet in Renal Disease formula. The urine albumin-to-creatinine ratio was measured at baseline and at the conclusion of each study. A value between 3.4 mg/mmol and below 33.9 mg/mmol was defined as microalbuminuria. A value of 33.9 mg/mmol or more (approximately 300 mg/g creatinine) was defined as macroalbuminuria.Results: ACE inhibitors and ARBs are now the mainstay of treatment for diabetic nephropathy. However, combination therapy with an ACE inhibitor and an ARB, or DRI, has not been found to be more effective than monotherapy with an ACE inhibitor or ARB, and may increase the risk of hyperkalemia or acute kidney injury.Conclusion: Both ACE inhibitors and ARBs remain the first-line agents in attenuating the progression of diabetic nephropathy; however, recent studies suggest that combining an ACE inhibitor with an ARB, or combining a DRI with an ACE inhibitor or ARB, may increase adverse events without clinical benefits to offset them