A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies

Factors influencing Implementation of point-of-care testing for acute respiratory infectious diseases in community pharmacies: A scoping review using the Consolidated Framework for Implementation research

BACKGROUND

Emerging evidence suggests pharmacy-based point-of-care (POC) testing for acute respiratory infectious diseases is beneficial, but not widely implemented. A theory-informed review to understand the factors influencing service Implementation is lacking.

OBJECTIVE

To examine the extent, range, and nature of research available on enablers and barriers to POC testing Implementation for infectious respiratory diseases in community pharmacies and identify their underpinning theoretical constructs using the Consolidated Framework for Implementation Research (CFIR).

METHODS

Scoping review guided by the JBI Manual for Evidence Synthesis. A comprehensive search from inception to June 28th, 2022 was conducted using Medline, Embase, CINAHL, Cochrane Library, and ProQuest dissertations without date or language restriction. Eligible articles investigated barriers and/or facilitators to strep throat, influenza, C-reactive protein, and COVID-19 POC testing in community pharmacies. Two reviewers independently performed title & abstract screening, full-text screening, and data extraction. Content analysis was conducted according to a pre-established Framework and concepts were mapped to the CFIR.

RESULTS

Forty-three studies were included. Most originated from the USA (n = 24; 56%) and investigated strep throat. The majority were testing/initial Implementation projects (n = 23; 54%) conducted in urban centers (n = 17; 40%). Thirty-six (84%) studies used quantitative methodology, while 6 (14%) were qualitative. Only four studies (9%) used theory to guide their inquiry. The 124 identified Implementation factors mapped onto 21 CFIR constructs, covering all 5 domains. The domain "Outer setting" (n = 35/43; 81%) was most prevalent as were the constructs "Patient needs and resources," (n = 21/43; 49%) "External policy & incentives," (n = 17/43; 40%) and "Relative advantage" (n = 17/43; 40%).

CONCLUSION

A large volume of research explores factors influencing the Implementation of pharmacy-based respiratory infectious disease POC testing services, but few studies use qualitative or theory-informed methods. Knowledge of the wide range of facilitators and barriers identified can help pharmacy managers and researchers design strategies to support successful service Implementation.

Assessing Community Pharmacists' Perception on Readiness to Initiate Point-of-Care Testing for SARS-CoV-2 in New York State During the Pandemic

Introduction: Pursuant to the COVID-19 pandemic, an executive order issued by the New York State (NYS) governor allowed pharmacists to act as laboratory directors for a limited-service laboratory (LSL) to order and perform Food and Drug Administration (FDA) and Emergency Use Authorization (EUA) Clinical Laboratory Improvement Amendment (CLIA)-waived COVID-19 point-of-care testing (POCT). Objectives: To (i) assess the status of NYS community pharmacists with POCT in the early stages of the COVID-19 pandemic, (ii) assess the readiness and willingness of community pharmacists to incorporate COVID-19 POCT into their workflow during a pandemic, and (iii) assess community pharmacists' perception of the barrier to initiating COVID-19 POCT. Methods: This is a prospective cross-sectional study conducted from February 4 to February 21, 2021. An electronic survey consisting of 66 Likert-type questions, select all that apply, and fill-in-style questions were emailed to 250 Community Pharmacy Enhanced Service Network (CPESN) NY pharmacies, with a follow-up email sent halfway into the data collection period. The data were analyzed using descriptive statistics. Results: The result indicated that most participants (median = 5) demonstrated readiness and willingness to offer COVID-19 testing. Barriers to COVID-19 POCT were identified: impact on pharmacy workflow (59%), lack of payment mechanism (55%) and lack of sufficient training (21%). Most participants expressed interest in continuing POCT beyond the pandemic (86.1%). Conclusion: Community pharmacists in NYS reported willingness to initiate COVID-19 POCT. Addressing the identified barriers, such as workflow disruption and reimbursement challenges, will enable pharmacies to be better prepared to provide patient care, including POCT.

Point-of-care testing in private pharmacy and drug retail settings: a narrative review

BACKGROUND

Point-of-care testing (POCT) using rapid diagnostic tests for infectious disease can potentially guide appropriate use of antimicrobials, reduce antimicrobial resistance, and economise use of healthcare resources. POCT implementation in private retail settings such as pharmacies and drug shops could lessen the burden on public healthcare. We performed a narrative review on studies of POCTs in low- and middle-income countries (LMICs), and explored uptake, impact on treatment, and feasibility of implementation.

METHODS

We searched MEDLINE/PubMed for interventional studies on the implementation of POCT for infectious diseases performed by personnel in private retail settings. Data were extracted and analysed by two independent reviewers.

RESULTS

Of the 848 studies retrieved, 23 were included in the review. Studies were on malaria (19/23), malaria and pneumonia (3/23) or respiratory tract infection (1/23). Nine randomised controlled studies, four controlled, non-randomised studies, five uncontrolled interventions, one interventional pre-post study, one cross-over interventional study and three retrospective analyses of RCTs were included. Study quality was poor. Overall, studies showed that POCT can be implemented successfully, leading to improvements in appropriate treatment as measured by outcomes like adherence to treatment guidelines. Despite some concerns by health workers, customers and shop providers were welcoming of POCT implementation in private retail settings. Main themes that arose from the review included the need for well-structured training with post-training certification covering guidelines for test-negative patients, integrated waste management, community sensitization and demand generation activities, financial remuneration and pricing schemes for providers, and formal linkage to healthcare and support.

CONCLUSION

Our review found evidence that POCT can be implemented successfully in private retail settings in LMICs, but comprehensive protocols are needed. High-quality randomised studies are needed to understand POCTs for infectious diseases other than malaria.

Evaluation of Point-of-Care Testing in Pharmacy to Inform Policy Writing by the New Brunswick College of Pharmacists

Pharmacy practice continues to advance, allowing professionals to contribute further to patient care and the healthcare system. Pharmacists are authorized to perform point-of-care testing (POCT) in seven out of ten Canadian provinces. In considering the potential for enhanced clinical decision-making with the opportunity to gain patient data at the site of care, the New Brunswick College of Pharmacists (NBCP) proceeded to draft regulatory amendments and a policy to enable POCT scope in New Brunswick. Policy writing is a core function of Provincial Regulatory Authorities in Canada as the process determines principles that direct pharmacy practice. Each province has a differing scope of practice and method for developing documents. This paper highlights the approach, analysis, and findings of the NBCP pursuant to drafting a POCT policy. The policy development process included a literature search and environmental scan of the ten Canadian provincial regulatory authorities along with other countries. The findings highlighted in this paper describe the use of POCT, quality assurance, regulatory framework, educational opportunities, and the role of pharmacy technicians in relation to POCT in a pharmacy setting. The approach NBCP took to engage professionals and decisions on the direction of the policy are described. As point-of-care services continue to expand in pharmacies, the insights by the NBCP can be utilized by other regulatory bodies or pharmacy professionals who are implementing or enhancing POCT policies or procedures within their organizations.

Characteristics of the sore throat test and treat service in community pharmacies (STREP) in Wales: cross-sectional analysis of 11 304 consultations using anonymized electronic pharmacy records

BACKGROUND

An NHS-funded sore throat test and treat (STTT) service was introduced in selected community pharmacies in Wales. Service users were screened using FeverPAIN/Centor scores, offered rapid antigen detection testing (RADT) to detect group A Streptococcus if appropriate, and supplied with antibiotics (by the pharmacist) if indicated. Following an initial evaluation, the service was rolled out nationally.

OBJECTIVES

This study forms part of the long-term STTT evaluation. The aim was to describe characteristics of the service and service users, the delivery, service outcomes, patient safety and antibiotic prescribing.

METHODS

Cross-sectional descriptive study using anonymized individual-level data from electronic pharmacy records of all eligible STTT service users between November 2018 and February 2020.

RESULTS

We identified 11 304 pharmacy STTT consultations in service users aged 6 years and over, with a median age of 25 years (IQR: 12 to 44). RADT was undertaken in 8666 (76.7%) consultations with 2503 (28.9% of RADT) positive tests. In total, 2406 (21.3%) service users were supplied with antibiotics. Pharmacists managed 91% of consultations in the pharmacy and referred only 937 (9.3%) service users to a GP and 27 (0.2%) to the Emergency Department. Higher rates of antibiotic supply were observed in out-of-hours consultations when compared with in-hours (24.9% versus 20.9%).

CONCLUSIONS

This is the largest description of a pharmacy-led STTT service to date and suggests it can be delivered at scale to align with a pre-specified pathway that promotes appropriate use of RADT and antibiotics. The service could substantially reduce workload from a common illness in other heavily pressurized areas of primary and emergency care.

What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies

OBJECTIVE

Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings.

DESIGN

We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare.

SETTING AND PARTICIPANTS

The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies.

MAIN OUTCOME MEASURES

The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to.

RESULTS

In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%.

CONCLUSIONS

Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.

Rapid antigen detection and molecular tests for group A streptococcal infections for acute sore throat: systematic reviews and economic evaluation

BACKGROUND

Sore throat is a common condition caused by an infection of the airway. Most cases are of a viral nature; however, a number of these infections may be caused by the group A Streptococcus bacterium. Most viral and bacterial sore throat infections resolve spontaneously within a few weeks. Point-of-care testing in primary care has been recognised as an emerging technology for aiding targeted antibiotic prescribing for sore throat in cases that do not spontaneously resolve.

OBJECTIVE

Systematically review the evidence for 21 point-of-care tests for detecting group A Streptococcus bacteria and develop a de novo economic model to compare the cost-effectiveness of point-of-care tests alongside clinical scoring tools with the cost-effectiveness of clinical scoring tools alone for patients managed in primary care and hospital settings.

DATA SOURCES

Multiple electronic databases were searched from inception to March 2019. The following databases were searched in November and December 2018 and searches were updated in March 2019: MEDLINE [via OvidSP (Health First, Rockledge, FL, USA)], MEDLINE In-Process & Other Non-Indexed Citations (via OvidSP), MEDLINE Epub Ahead of Print (via OvidSP), MEDLINE Daily Update (via OvidSP), EMBASE (via OvidSP), Cochrane Database of Systematic Reviews [via Wiley Online Library (John Wiley & Sons, Inc., Hoboken, NJ, USA)], Cochrane Central Register of Controlled Trials (CENTRAL) (via Wiley Online Library), Database of Abstracts of Reviews of Effects (DARE) (via Centre for Reviews and Dissemination), Health Technology Assessment database (via the Centre for Reviews and Dissemination), Science Citation Index and Conference Proceedings [via the Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA)] and the PROSPERO International Prospective Register of Systematic Reviews (via the Centre for Reviews and Dissemination).

REVIEW METHODS

Eligible studies included those of people aged ≥ 5 years presenting with sore throat symptoms, studies comparing point-of-care testing with antibiotic-prescribing decisions, studies of test accuracy and studies of cost-effectiveness. Quality assessment of eligible studies was undertaken. Meta-analysis of sensitivity and specificity was carried out for tests with sufficient data. A decision tree model estimated costs and quality-adjusted life-years from an NHS and Personal Social Services perspective.

RESULTS

The searches identified 38 studies of clinical effectiveness and three studies of cost-effectiveness. Twenty-six full-text articles and abstracts reported on the test accuracy of point-of-care tests and/or clinical scores with biological culture as a reference standard. In the population of interest (patients with Centor/McIsaac scores of ≥ 3 points or FeverPAIN scores of ≥ 4 points), point estimates were 0.829 to 0.946 for sensitivity and 0.849 to 0.991 for specificity. There was considerable heterogeneity, even for studies using the same point-of-care test, suggesting that is unlikely that any single study will have accurately captured a test's true performance. There is some randomised controlled trial evidence to suggest that the use of rapid antigen detection tests may help to reduce antibiotic-prescribing rates. Sensitivity and specificity estimates for each test in each age group and care setting combination were obtained using meta-analyses where appropriate. Any apparent differences in test accuracy may not be attributable to the tests, and may have been caused by known differences in the studies, latent characteristics or chance. Fourteen of the 21 tests reviewed were included in the economic modelling, and these tests were not cost-effective within the current National Institute for Health and Care Excellence's cost-effectiveness thresholds. Uncertainties in the cost-effectiveness estimates included model parameter inputs and assumptions that increase the cost of testing, and the penalty for antibiotic overprescriptions.

LIMITATIONS

No information was identified for the elderly population or pharmacy setting. It was not possible to identify which test is the most accurate owing to the paucity of evidence.

CONCLUSIONS

The systematic review and the cost-effectiveness models identified uncertainties around the adoption of point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care test. Further research is needed to understand the test accuracy of point-of-care tests in the proposed NHS pathway and in comparable settings and patient groups.

STUDY REGISTRATION

The protocol of the review is registered as PROSPERO CRD42018118653.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 31. See the NIHR Journals Library website for further project information.

Structured review of primary interventions to reduce group A streptococcal infections, acute rheumatic fever and rheumatic heart disease

Rheumatic heart disease (RHD) is a large, preventable, global public health burden. In New Zealand (NZ), acute rheumatic fever (ARF) and RHD rates are highest for Māori and Pacific children. This structured review explores the evidence for primary prevention interventions to diagnose and effectively treat group A Streptococcus (GAS) pharyngitis and skin infections to reduce rates of ARF and RHD. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 50 publications from 1980 onwards. This review has identified that there is little available evidence for effective primary prevention strategies to reduce ARF rates in NZ. However, two primary intervention strategies that should be considered by communities at high-risk of ARF are: the use of school-based clinics to identify and treat GAS pharyngitis and GAS skin infections; and intramuscular benzathine penicillin G with lignocaine analgesia in children who present with a GAS positive throat.

A Pragmatic Study to Evaluate the Use of a Rapid Diagnostic Test to Detect Group A Streptococcal Pharyngitis in Children With the Aim of Reducing Antibiotic Use in a UK Emergency Department

OBJECTIVE

Sore throat is a common presentation to the children's emergency department (ED), and many patients are likely prescribed antibiotics unnecessarily. We aimed to reduce antibiotic prescribing for sore throat in our UK ED through use of an established scoring system combined with a rapid diagnostic test (RDT) to detect group A streptococcal (GAS) pharyngitis.

METHODS

AB single-subject and diagnostic accuracy studies were used to measure both antibiotic prescribing rates over time and the performance of the McIsaac clinical score combined with RDT to screen for and treat GAS pharyngitis. All children between the age of 6 months and 16 years with symptoms of sore throat were eligible for inclusion. The study adhered to SQUIRE guidelines.

RESULTS

During 2014 and 2016, antibiotic prescribing rates for 210 children at baseline (median age, 3 years) and 395 children during the intervention (median age, 2 years) were assessed. The baseline prescribing rate was 79%, whereas rates after intervention were 24% and 27%, respectively. The RDT had an acceptable false-negative rate of 7.9%, poor sensitivity of 64.3%, and a negative predictive value of 92.1% when compared with conventional throat culture. A McIsaac score of 3 or more had good sensitivity (92.11%) but very low specificity (12.62%) for predicting GAS infection.

CONCLUSIONS

Despite poor RDT sensitivity and the McIsaac score's poor specificity in children, their use in combination decreased antibiotic prescribing rates in a children's ED setting.

Community pharmacist prescribing of antimicrobials: A systematic review from an antimicrobial stewardship perspective

Background:

Pharmacist prescribing authority is expanding, while antimicrobial resistance is an increasing global concern. We sought to synthesize the evidence for antimicrobial prescribing by community pharmacists to identify opportunities to advance antimicrobial stewardship in this setting.

Methods:

We conducted a systematic review to characterize the existing literature on community pharmacist prescribing of systemic antimicrobials. We searched MEDLINE, EMBASE and International Pharmaceutical Abstracts for English-language articles published between 1999 and June 20, 2019, as well as hand-searched reference lists of included articles and incorporated expert suggestions.

Results:

Of 3793 articles identified, 14 met inclusion criteria. Pharmacists are most often prescribing for uncomplicated urinary tract infection (UTI), acute pharyngitis and cold sores using independent and supplementary prescribing models. This was associated with high rates of clinical improvement (4 studies), low rates of retreatment and adverse effects (3 studies) and decreased health care utilization (7 studies). Patients were highly satisfied (8 studies) and accessed care sooner or more easily (7 studies). Seven studies incorporated antimicrobial stewardship into study design, and there was overlap between study outcomes and those relevant to outpatient antimicrobial stewardship. Pharmacist intervention reduced unnecessary prescribing for acute pharyngitis (2 studies) and increased the appropriateness of prescribing for UTI (3 studies).

Conclusion:

There is growing evidence to support the role of community pharmacists in antimicrobial prescribing. Future research should explore additional opportunities for pharmacist antimicrobial prescribing and ways to further integrate advanced antimicrobial stewardship strategies in the community setting. Can Pharm J (Ott) 2021;154:xx-xx.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

OBJECTIVE

While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.

SETTINGS

English primary care.

INTERVENTIONS

AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections.

METHODS

We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.

RESULTS

We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.

CONCLUSIONS

Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.

Point-of-care testing in pharmacies-An evaluation of the service from the lens of resource-based theory of competitive advantage

BACKGROUND

Point-of-care tests (POCTs) are innovative services that are increasingly offered in community pharmacies. Assessments of these services should consider their financial sustainability in addition to their effectiveness if they are to be successful over time in a competitive environment.

OBJECTIVES

The aim of this research was to review and evaluate the POCT practice innovations literature through the lens of the resource-based theory (RBT) of competitive advantage.

DATA SOURCES

Articles describing POCT services were identified systematically through PubMed, exclusively.

STUDY SELECTION

All POCT articles in the review met the following inclusion criteria: (1) articles were published after 1999; (2) interventions were pharmacist-led innovations within a community pharmacy; (3) articles described research studies with results; and (4) articles were published in English, Spanish, or Portuguese.

DATA EXTRACTION

The RBT was operationalized using a strengths, weaknesses, opportunities, threats matrix and a business model canvas, which were employed to extract and analyze data. Articles were assessed according to the degree to which they articulated elements that the RBT needed to assess their financial sustainability in targeted markets.

RESULTS

A total of 36 articles describing POCTs and associated services were included in this review. Most of the studies reported aspects pertaining to the contextual environment of the innovation, value proposition, key activities, partners, and channels of distribution. However, the competitive dimension of the environment, as well as the cost structure and revenue streams, were often neglected in the studies.

CONCLUSIONS

The RBT is a widely tested framework that can be used for planning and reporting POCT practice innovations. On the basis of this framework, pharmacists seem to do a good job in describing how to provide POCT but fall short in explaining how these services are sustainable over time.

Impact of a pilot NHS-funded sore throat test and treat service in community pharmacies on provision and quality of patient care

Objective

A National Health Service (NHS)-funded sore throat test and treat (STTT) service was introduced in selected pharmacies in two local health boards in Wales, as an extension to the national pharmacy common ailment scheme. The aim of this study was to evaluate the impact of STTT on provision and quality of patient care, namely antibiotic use, patient safety and general practitioner (GP) consultation rates.

Methods

Secondary analyses of STTT consultation data to describe service outcomes, and routine data to explore changes in antibiotic prescribing and the prevalence of complications. Data were also collected from one GP practice to explore the feasibility of measuring changes in sore throat consultation rates in general practice.

Results

Less than 20% of 1725 consultations resulted in antibiotic supply. The availability of STTT was associated with greater reductions in prescriptions for phenoxymethylpenicillin than in areas where STTT was not available (−3.8% and −3.4%, difference 0.4%). When pharmacy supplies were included, the reductions in the supply of the antibiotic were similar. No increase in the monthly number of incidents of quinsy was detected, and patients were appropriately referred to other healthcare professionals during pharmacy consultations. GP consultation rates since introduction of STTT were found to be lower than the equivalent monthly average since 2014.

Conclusions

Data from the first 5 months of the STTT service suggest that it may have a role in safely rebalancing uncomplicated sore throat management from general practice to community pharmacies while continuing to promote antibiotic stewardship.

Point-of-Care Testing for Pharyngitis in the Pharmacy

Pharyngitis (also known as sore throat) is a common, predominately viral, self-limiting condition which can be symptomatically managed without antibiotic treatment. Inappropriate antibiotic use for pharyngitis contributes to the development and spread of antibiotic resistance. However, a small proportion of sore throats caused by group A streptococcal (GAS) infection may benefit from the provision of antibiotics. Establishing the cause of infection is therefore an important step in effective antibiotic stewardship. Point-of-care (POC) tests, where results are available within minutes, can distinguish between viral and GAS pharyngitis and can therefore guide treatment in primary healthcare settings such as community pharmacies, which are often the first point of contact with the healthcare system. In this opinion article, the evidence for the use of POC testing in the community pharmacy has been discussed. Evidence suggests that pharmacy POC testing can promote appropriate antibiotic use and reduce the need for general practitioner consultations. Challenges to implementation include cost, training and 'who prescribes', with country and regional differences presenting a particular issue. Despite these challenges, POC testing for pharyngitis has become widely available in pharmacies in some countries and may represent a strategy to contain antibiotic resistance and contribute to antimicrobial stewardship.

Understanding the impact of a new pharmacy sore throat test and treat service on patient experience: A survey study

BACKGROUND

A pilot of the first NHS funded Sore Throat Test and Treat (STTT) service in the United Kingdom began in selected community pharmacies in Wales in November 2018. The aim of this research was to explore whether a pharmacist delivering consultation for sore throat that included clinical scoring and point-of-care testing was acceptable to patients and how this might influence future health-seeking behaviour.

METHODS

A non-experimental design was employed using a survey research tool including a mix of closed and open questions. The patient experience survey was distributed to all patients who had completed a consultation between November 2018 and May 2019. Data from completed surveys were entered in Jisc Online Surveys® and exported to Excel® for descriptive statistics. Free-text comments were analysed using content and inductive thematic analysis.

RESULTS

A total of 510 surveys were received (n = 2,839 total consultations, response rate 18%). Overall, 501 patients (98%) were satisfied with the service. Patients' confidence in managing their condition and service satisfaction was not dependent on having been supplied antibiotics. After the service, 504 patients (99%) stated that they would return to the pharmacy for subsequent sore throat symptoms. Three themes were constructed after inductive analysis of free-text comments (n = 242): convenience and accessibility; professionalism of pharmacy team; and perceived value of the service.

CONCLUSIONS

Results confirmed high levels of patient satisfaction with the new service, its delivery and the choice of options offered for sore throat symptom management. Whilst this research can only discuss patients' reported future behaviour, the patient-reported stated intentions signify a potential shift in health-seeking behaviour towards a pharmacist-led service. This has important implications in supporting the long-term plan of the governments in Wales and England to redirect management of uncomplicated conditions from GPs to pharmacies.

Impact of point-of-care tests in community pharmacies: a systematic review and meta-analysis

OBJECTIVES

To summarise the literature regarding the use of point-of-care test (POCT) in pharmacies versus control/usual care.

DESIGN AND SETTING

Systematic review and random-effects meta-analysis in community pharmacy.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Embase, ClinicalTrial.gov and Web of Science databases were searched.

ELIGIBILITY CRITERIA

Articles were included if they: involved a POCT conducted by a community pharmacist, member of pharmacy staff or local equivalent; measured a clinically relevant outcome for example, clinical parameter monitoring. No clinical condition or language limits were set.

PATIENT AND PUBLIC INVOLVEMENT

No patient involvement.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted by two members of the review team to capture changes in clinical care that resulted from the use of the POCTs. The methodological quality of included studies was assessed, using the Cochrane Risk of Bias tool and Newcastle-Ottawa scale.

RESULTS

Thirteen of the 1584 articles found were included in the meta-analyses. Studies covered four therapeutic areas: targeted anti-malarial therapy (n=3 studies), glycated haemoglobin (HbA1c) in diabetes (n=2 studies), lipid control (n=3 studies) and international normalised ratio (INR) control in patients taking warfarin (n=5 studies). POCT in pharmacies reduced the risk of receiving antimalarial treatment when not clinically indicated (risk ratio 0.34, 95% CI 0.31 to 0.37). Lipid and HbA1c control appeared largely unaffected by pharmacy POCTs, and the impact on INR time-in-therapeutic-range was inconclusive.

CONCLUSIONS

Only 4 out of 13 included studies used a gold-standard randomised controlled trial (RCT) design, limiting our ability to conclusively determine the clinical utility of POCT conducted in pharmacies. Further RCTs are needed, particularly in areas such as upper respiratory tract infections, which have gathered momentum among service commissioners in recent years.

PROSPERO REGISTRATION NUMBER

CRD42017048578.

Pharmacy-Based Infectious Disease Management Programs Incorporating CLIA-Waived Point-of-Care Tests

There are roughly 48,000 deaths caused by influenza annually and an estimated 200,000 people who have undiagnosed human immunodeficiency virus (HIV). These are examples of acute and chronic illnesses that can be identified by employing a CLIA-waived test. Pharmacies across the country have been incorporating CLIA-waived point-of-care tests (POCT) into disease screening and management programs offered in the pharmacy. The rationale behind these programs is discussed. Additionally, a summary of clinical data for some of these programs in the infectious disease arena is provided. Finally, we discuss the future potential for CLIA-waived POCT-based programs in community pharmacies.

Improving Management of Respiratory Tract Infections in Community Pharmacies and Promoting Antimicrobial Stewardship: A Cluster Randomised Control Trial with a Self-Report Behavioural Questionnaire and Process Evaluation

In England, 81% of all antibiotic prescriptions originate in primary care/community settings, of which up to 20% are thought to be inappropriate. Community pharmacies are often the first point of community contact for patients with suspected infections; providing an opportunity for community pharmacy teams to promote antimicrobial stewardship (AMS). The objective of the study was to improve the management of infections and antimicrobial stewardship in community pharmacies. The study methodology included a non-blinded cluster randomised control trial with pharmacy staff in 272 community pharmacies in England. The intervention arm received an AMS webinar and a patient facing respiratory tract infection (RTI) leaflet (TARGET TYI-RTI) for use in everyday practice for four weeks. The control arm received a webinar on how to participate in the study. The primary outcome was self-reported referrals to general practitioners (GPs). The secondary outcomes were; provision of self-care advice/ written information to patients, referrals to pharmacists, sign-posting to non-prescription medicines and common barriers and facilitators to advice-giving in community pharmacies. Ethics approval was granted by the Public Health England Research Ethics and Governance Group. 66.91% (182 of 272) of pharmacies provided 3649 patient consultation data reports across both arms. Use of the leaflet was associated with a lower likelihood of referrals to GPs for certain RTIs (p < 0.05) and a more frequent provision of self-care advice than the control (p = 0.06). Opportunities to deliver self-care advice were limited due to lack of time. Pharmacy staff had good motivation and capability for managing self-limiting infections but the opportunity to do so was a perceived barrier. Use of the TARGET leaflet facilitated pharmacy staff to give more self-care advice and decreased referrals to GPs.

Evaluation of a community pharmacy-led test-and-treat service for women with uncomplicated lower urinary tract infection in England

Background

Uncomplicated lower urinary tract infections (UTIs) are common in women consulting primary healthcare, taking up GP resources. Delayed consultation can increase the risk of serious infections such as pyelonephritis or bacteraemia.

Objectives

To evaluate the effectiveness and uptake of a lower UTI test-and-treat service for women presenting with urinary symptoms within a community pharmacy in supporting self-care and appropriate use of antibiotics and reducing demand on other NHS resources.

Methods

The service was aligned to national guidelines to diagnose and treat lower UTI in women aged 16–64 years and used national resources to provide safety-netting and self-care advice. Consultation included clinical assessment and a urine dipstick test alongside a novel smartphone app, with diagnosis informed by test results. Women were provided with safety-netting advice and either advised on self-care, supplied with antibiotics or referred to their GP.

Results

Data were analysed for 764 women who presented to 23 pharmacies during December 2018 to April 2019. Lower UTI was found to be likely in 372/496 (75.0%) women, most of whom purchased antibiotics on the same day. Had the service not been available, approximately three-quarters of women who had completed the service and responded to the question would have visited their GP (214/301) and more than one-third would have used self-care with or without going to see their GP (116/301).

Conclusions

A community pharmacy-led UTI test-and-treat service for women aged 16–64 years presenting with urinary symptoms provided accessible and timely care aligned to national guidance, with 75.0% of consultations requiring antibiotic treatment.

Community Pharmacist Views On The Early Stages Of Implementation Of A Pathfinder Sore Throat Test And Treat Service In Wales: An Exploratory Study

Objectives

To explore the views and opinions of community pharmacists regarding their initial experience of and levels of preparedness for the pathfinder sore throat test and treat (STTT) service in Wales.

Methods

A phenomenological qualitative approach with constructivist paradigm was adopted as the first cycle of ongoing action research. Semi-structured interviews with community pharmacists who had completed at least three consultations within the first 3 weeks of the service were conducted, with informed consent and audio recorded. Interviews were transcribed ad verbatim and data were thematically analysed both inductively and deductively.

Results

A total of seven interviews with pharmacists who had conducted more than three consultations identified three main themes: 1) perceived impact of the service on patient care, including the value of the structure and technology infrastructure, the role of STTT towards antimicrobial stewardship, and its potential role in rebalancing primary care resources so that workload is distributed appropriately among healthcare professionals; 2) factors that empower pharmacists to deliver the service, in particular quality and consistency of training, appropriate staffing resource and internally motivated willingness to engage; 3) interface with GP surgeries such as nature of existing relationships before implementing the service, role of GP staff and GP perceived value of STTT.

Conclusion

The pathfinder STTT service has been well received by pharmacists who recognised the service’s role in providing patient education and contributing to principles of antimicrobial stewardship and described factors that would empower them to deliver the service confidently. Results have been fed back to the service implementation team to inform future developments.

Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies

PURPOSE OF REVIEW

Overutilization of antimicrobials is a known contributor to the development of antimicrobial resistance, which is a threat to global health. The goal of antimicrobial stewardship programs (ASPs) is to implement targeted interventions to reduce inappropriate antimicrobial prescribing and prevent development of antimicrobial resistance. We aim to review recently published literature focused on five categories of ASP interventions that have demonstrated success in optimizing appropriate antimicrobial use, improving patient outcomes, and fighting antimicrobial resistance.

RECENT FINDINGS

In the past year, ASP interventions in the published literature have focused on minimizing duration of antimicrobial therapy for infectious syndromes, implementing novel methods for performing prospective audit and feedback, utilizing microbiology laboratory or rapid diagnostic tests to expedite diagnosis, leveraging clinical decision support and electronic medical record tools, and performing penicillin allergy assessment. While the majority of studies assessing ASP interventions do not assess changes in antimicrobial resistance, outcomes demonstrating improved appropriate antibiotic use have been used as a surrogate. Successful ASPs should seek to implement and evaluate novel interventions targeting improvement in antimicrobial prescribing. Such interventions are of critical importance to prevent further growth of antimicrobial resistance.

Evaluation of a community pharmacy-based influenza and group A streptococcal pharyngitis disease management program using polymerase chain reaction point-of-care testing

OBJECTIVES

The purpose of this study was to demonstrate the feasibility of implementing a Clinical Laboratory Improvement Amendments-waived real-time polymerase chain reaction (PCR) molecular test into a community pharmacy setting as part of a collaborative influenza and group A Streptococcus (GAS) disease management program.

SETTING AND PARTICIPANTS

Two community pharmacy sites in Tennessee.

PRACTICE DESCRIPTION

Patients presenting to the pharmacy with symptoms consistent with influenza or GAS from November 1, 2016, to April 30, 2018.

PRACTICE INNOVATION

Influenza and GAS management programs based on previously developed protocols occurred at 2 community pharmacies in Tennessee. Pharmacies used the Cobas Liat testing system (Roche Diagnostics). Based on test results and under a collaborative practice agreement, pharmacists dispensed prescription medications for patients with a positive test: oseltamivir for influenza and amoxicillin for GAS. Patients with negative tests were treated with over-the-counter (OTC) medications or referred. Patients testing negative for GAS were asked to consent to having a second throat swab sent for culture.

EVALUATION

Number of patients tested, point-of-care test results, and treatment received.

RESULTS

Two hundred and two patients received care at the 2 pharmacies (116 for influenza, 46 for GAS, and 43 for both). Sixty (38%) tested positive for influenza, with 51 receiving an antiviral prescription, and 16 (18%) tested positive and were treated for GAS. No patient testing negative for either or positive for influenza was dispensed an antibiotic. For patients consenting to a follow-up culture, all GAS cultures sent for confirmatory testing were negative.

CONCLUSION

A protocol-driven community pharmacy-based disease management program using real-time PCR testing for influenza and GAS was able to offer appropriate treatment to patients without overuse of antibiotics.

Evaluation of a new patient consultation initiative in community pharmacy for ear, nose and throat and eye conditions

Background

Community pharmacy Common Ailments Services can ease the considerable workload pressures on primary and secondary care services. However, evidence is needed to determine whether there are benefits of extending such services beyond their typically limited scope. This study therefore aimed to evaluate a new community pharmacy model of a service for patients with ear, nose and throat (ENT) and eye conditions who would otherwise have had to seek primary care appointments or emergency care.

Methods

People with specified ENT or eye conditions registered with General Practitioners in Staffordshire or Shropshire who presented at participating community pharmacies were offered a consultation with a pharmacist trained to provide the service. The service included provision of relevant self-care advice and, where clinically appropriate, supply of non-prescription medicines or specified prescription-only medicines (POMs), including antibiotics, under Patient Group Directions. Patients received a follow up telephone call from the pharmacist five days later. Data were collected on the characteristics of patients accessing the service, the proportion of those who were treated by the pharmacist without subsequently seeing another health professional about the same condition, and patient reported satisfaction from a questionnaire survey.

Results

A total of 408 patients accessed the service, of whom 61% received a POM, 15% received advice and medicine supplied under the common ailments service, 9% received advice and purchased a medicine, 10% received advice only and 5% were referred onwards. Sore throat accounted for 45% of diagnoses where a POM was supplied, 32% were diagnosed with acute otitis media and 15% were diagnosed with acute bacterial conjunctivitis. The number of patients successfully followed up was 309 (76%), of whom 264 (85%) had not seen another health professional for the same symptoms, whilst 45 (15%) had seen another health professional, usually their GP. The questionnaire was completed by 259 patients (response rate 63%) of whom 96% reported being very satisfied or satisfied with the service.

Conclusions

The study demonstrates that pharmacists can effectively diagnose and treat these conditions, with a high degree of patient satisfaction. Wider adoption of such service models could substantially benefit primary care and emergency care services.

Exploring views of pharmacists on antibacterial prescribing: a Maltese perspective

OBJECTIVES

To investigate the perception of Maltese pharmacists to prescribe a selected number of antibiotics.

METHODS

A self-administered questionnaire entitled 'Antibiotic Prescribing by Pharmacists' was developed to study pharmacist perception to prescribing a selected number of antibacterial agents. The questionnaire was validated by a two-round Delphi technique and disseminated to all practising pharmacists (N = 930) during a 3-month period.

KEY FINDINGS

Two hundred and nine pharmacists answered the questionnaire. The majority of pharmacists (77%) were in agreement with pharmacists prescribing a selected number of antibacterials. Reasons given are that pharmacist prescribing would increase recognition of the participation of pharmacists within patient care and as members of the healthcare team. Protocol-based prescribing was the preferred model for prescribing by 60% of pharmacists. Half of the respondents (50%) feel competent to prescribe, 34% have no opinion and 16% do not feel competent at all. Co-amoxiclav for an uncomplicated upper respiratory tract infection was the antibacterial that most pharmacists (51%) feel confident prescribing. When pharmacists were asked whether they feel comfortable prescribing other medications rather than antibacterials, 93% answered positively, with 83% feeling mostly comfortable prescribing lactulose solution.

CONCLUSION

Pharmacists in Malta are in agreement with prescribing selected antibiotics for minor ailments. A collaborative approach between medical practitioners and pharmacists should be evaluated as a possible national structure towards achieving better antibiotic prescribing whilst giving patient access to the use of antibacterials as necessary.

Role of the Pharmacist in Antimicrobial Stewardship

The goals of antimicrobial stewardship are to optimize antimicrobial use to improve patient outcomes and minimize adverse consequences. A successful antimicrobial stewardship program is one that is multidisciplinary. Pharmacists are core members of antimicrobial stewardship and undertake multiple roles to accomplish the goals of the program. As antimicrobial stewardship continues to expand across the patient care continuum, pharmacists will serve a vital role in preserving the armamentarium of antimicrobials and improving quality of patient care.

Pharmacist-Provided Pharmacogenetic Point-of-Care Testing Consultation Service: A Time and Motion Study

Background: With recent advances in pharmacogenomics (PGx) comes the potential to customize medication use based on genetic data. Support for PGx has found practical limitations in terms of workflow and turnaround time of a test. However, with the expansion of point-of-care testing (POCT) in pharmacy practice models comes opportunity for PGx testing in the pharmacy setting. Objective: The purpose of this study is to quantify the amount of time spent during each step of a PGx POCT encounter in a community pharmacy setting. Methods: A time and motion study was conducted using a mock community pharmacy space for a simulated PGx-focused encounter to manage antiplatelet therapy following hospital discharge. PGx POCT was conducted using the Spartan RX instrument. Simulated patient encounters were divided into 7 categories. Time spent in each step, as well as total time spent, was tracked. Results: A total of 54 simulated PGx POCT encounters took place with an average time of 9.49 minutes (SD ± 1.38 minutes). Instrument run time adds 60 minutes to the total time required to obtain a result. Duties that could be performed by an appropriately trained pharmacy technician totaled 6.86 minutes. Conclusions: PGx POCT would require 9.49 minutes of pharmacy staff hands-on time for the encounter, which could be reduced to 2.64 minutes of pharmacist time with appropriate pharmacy technician involvement. Time requirements for PGx POCT are similar to that of community pharmacy-based immunizations. Future studies could explore how practice could change if PGx testing were routinely performed in the pharmacy.

Analytical quality and effectiveness of point-of-care testing in community pharmacies: A systematic literature review

BACKGROUND

Point-of-care tests are characterised through the ability of conducting them near the patient's side without the necessity of a laboratory. They can be applied in different healthcare settings to improve patients' access to testing.

OBJECTIVE

To evaluate the effectiveness and analytical quality of point-of-care tests performed in the community pharmacy.

METHODS

Six electronic databases were systematically searched using a predefined search strategy. Interventional studies that reported on the effectiveness of the point-of-care tests and accuracy studies that investigated their analytical quality were included. The literature search, study selection, and data extraction were performed independently by two researchers.

RESULTS

In total, eleven studies were identified focusing on blood glucose, cholesterol, creatinine, uric acid, liver enzymes, international normalized ratio for anticoagulation therapy, bone mineral density for osteoporosis, forced expiratory volume for chronic obstructive pulmonary disease, and infection with human immunodeficiency virus. The included studies showed that point-of-care tests that were conducted and analysed in community pharmacies had satisfactory analytical quality and that the interventions applying these tests were effective overall.

CONCLUSIONS

Community pharmacies are well suited to deliver a wide range of point-of-care tests. In the future this will allow easier access to various screening and diagnostic tests for patients.

The essential role of pharmacists in antibiotic stewardship in outpatient care: An official position statement of the Society of Infectious Diseases Pharmacists

OBJECTIVES

The objective of this position statement is to describe the essential role of pharmacists in antimicrobial stewardship in outpatient care.

DATA SOURCES

N/A.

SUMMARY

The majority of antibiotic prescribing occurs in outpatient care settings highlighting the need for antibiotic stewardship in the community. Given their expertise on medication management, pharmacists are essential to any antibiotic stewardship effort.

CONCLUSION

As the regulations for antibiotic stewardship in outpatient settings continue to evolve and optimal stewardship strategies are defined, pharmacists must be leaders in the implementation of these programs.

Rapid antigen test use for the management of group A streptococcal pharyngitis in community pharmacies

Despite group A streptococci being an infrequent cause of pharyngitis in adult outpatients, sore throat remains a common indication for antibiotic prescription. This prospective multicentre non-randomised study describes a community pharmacy-based antimicrobial stewardship intervention consisting in the implementation of rapid antigen testing (RAT) for the management of adults with sore throat. Trained pharmacists triaged patients presenting with symptoms of pharyngitis using the modified Centor score. Those at risk for streptococcal infection were tested with RAT. Patients with a positive RAT were invited to consult a physician, whereas others were offered a symptomatic treatment. All patients received educational leaflets and were asked to fill in a follow-up form 7 days later. Ninety-eight pharmacies in one French region participated, and 559 patients were included over 6 months. RAT was proposed in 367 (65.7%) cases, and it was positive in 28 (8.3%). The follow-up form was returned by 140 (38.5%) participants. Of these, 10/10 patients with positive RAT further consulted a physician and were prescribed an antibiotic treatment, whereas 96.5% (110/114) of patients with negative results and not having any other reason to seek for doctor's advice did not consult. All participants found the intervention useful. Pharmacists spent 6-15 min to perform the intervention, and 98.6% (73/74) of pharmacists giving a feedback declared to be ready to implement this intervention in daily practice, if endorsed and reimbursed. Our results suggest that a pharmacy-based programme for the management of sore throat is feasible and could increase adherence to guidelines.

Utilization of influenza and streptococcal pharyngitis point-of-care testing in the community pharmacy practice setting

BACKGROUND

One way to reduce the complications and costs of influenza like illness and pharyngitis is to improve access to testing and treatment in early stages of infection. Pharmacy-based screening and treatment of group A streptococcus (GAS) infection and influenza has the potential to improve patient care and population health.

OBJECTIVE

To improve patient care and population health, the objective of this retrospective study was to assess if a previously validated service model could be implemented by pharmacy chains without mandated standardization.

METHODS

Researchers utilized a certificate program to provide initial training to pharmacists and shared templates from previous validated models. Pharmacy companies were responsible for navigation of all implementation within their company. Researchers analyzed the de-identified data from patients seeking point-of-care testing from the participating pharmacies.

RESULTS

Participating pharmacies reported 661 visits for adult (age 18 and over) patients tested for influenza for GAS pharyngitis. For the GAS patients, 91 (16.9%) tested positive. For the Influenza patients, 22.9% tested positive and 64 (77.1%) testing negative. Access to care was improved as patients presented to the visit outside normal clinic hours for 38% of the pharmacy visits, and 53.7% did not have a primary care provider.

CONCLUSION

A collaborative care model for managing patients with symptoms consistent with influenza or group A streptococcus can be successfully implemented, and improve access to care outside of normal clinic hours and for those without a regular primary care provider.