Evaluation of the Effectiveness of Clinical Pharmacists' Consultation in the Treatment of Infectious Diseases: A Single-Arm, Prospective Cohort Study

Development of a prediction model for antimicrobial stewardship pharmacy consultations to identify high-risk pediatric patients: a retrospective study across two centers

BACKGROUND

Antimicrobial Stewardship Pharmacy Consultation (ASPC) in China has been shown to reduce patients' length of stay (LOS). However, prolonged LOS remains a challenge, resulting in unnecessary psychological and financial burden for patients.

OBJECTIVE

This study aimed to develop a prediction model using ASPC parameters to identify high-risk pediatric patients with infectious diseases. These patients received ASPC interventions but still experienced prolonged LOS, which defined their high-risk status.

METHODS

Predictors for the ASPC model were selected using lasso regression, a nomogram was developed using multivariate logistic regression, and internal validation was performed using tenfold cross-validation. The data set consisted of 474 electronic medical records of pediatric patients with infectious diseases from two hospitals. LOS was dichotomized at the median, and patients with LOS greater than the median were considered to have achieved the outcome.

RESULTS

The proportion of outcome events was set at 50% by design. Five independent predictors were identified in the ASPC model: (1) the suggestions from the crucial consultation (OR: 1.74; 95% CI: 1.10 to 2.74), (2) weight (OR: 0.98; 95% CI: 0.97 to 1.00), (3) whether the patient received first aid (OR: 0.54; 95% CI: 0.3 to 1.00), (4) the aim of the crucial consultation (OR: 0.15; 95% CI: 0.03 to 0.66), and (5) whether the patient was critically ill (OR: 0.22; 95% CI: 0.12 to 0.41). The ASPC model showed good discrimination with a C-statistic of 0.772 (95% CI: 0.748 to 0.797) and good calibration performance with intercept and slope values of 0.00 (95% CI: -0.12 to 0.12) and 0.93 (95% CI: 0.82 to 1.04), respectively, under tenfold cross-validation.

CONCLUSIONS

The antimicrobial stewardship pharmacy consultation model has good discrimination and calibration, and effectively identifies patients at risk for prolonged length of stay.

Evaluation of interventions led by pharmacists in antimicrobial stewardship programs in low- and middle-income countries: a systematic literature review

Objective

We performed a systematic literature review to identify and describe pharmacist-led antimicrobial stewardship programs (ASPs) interventions in low- and middle-income countries (LMICs).

Design

Systematic literature review.

Methods

We searched PubMed for studies evaluating pharmacist-led ASP interventions in LMICs from January 1, 2012, to November 4, 2023. We evaluated the article's country of origin, described ASP interventions, and analyzed their reported outcomes.

Results

Twenty-four studies were included; ten were conducted in China, two in India, two in Thailand, five in Africa, three in Latin America, and two in the Middle East. The predominant interventions in the studies were education and training followed by audit and feedback. The outcomes reported included reduction in antimicrobial consumption, cost reduction, shortening of the duration of antimicrobial therapy, and de-escalation.

Conclusions

Our findings reinforce the importance of clinical pharmacists leading interventions related to antimicrobial stewardship in LMCIs and the global importance of investing in Infectious Disease training.

A Nomogram for Predicting the Effectiveness of Consultations on Multi-Drug Resistant Infections: An Exploration for Clinical Pharmacy Services

Purpose

The increasing multi-drug resistance (MDR) is a serious threat to human health. The appropriate use of antibiotics can control the progression of MDR and clinical pharmacists play an important role in the rational use of antibiotics. There are many factors that influence the effectiveness of multi-drug resistant organisms (MDRO) infection consultations. The study aimed to establish a model to predict the outcome of consultation and explore ways to improve clinical pharmacy services.

Patients and methods

Patients diagnosed with MDRO infection and consulted by clinical pharmacists were included. Univariate analysis and multivariate logistic regression analysis were used to identify independent risk factors for MDRO infection consultation effectiveness, and then a nomogram was constructed and validated.

Results

198 patients were finally included. The number of underlying diseases (OR=1.720, 95% CI: 1.260-2.348), whether surgery was performed prior to infection (OR=8.853, 95% CI: 2.668-29.373), ALB level (OR=0.885, 95% CI: 0.805~0.974), pharmacist title (OR=3.463, 95% CI: 1.277~9.396) and whether the recommendation was taken up (OR=0.117, 95% CI: 0.030~0.462) were identified as independent influences on the effectiveness of the consultation. The nomogram prediction model was successfully constructed and the AUC of the training set and the verification set were 0.849 (95% CI: 0.780-0.917) and 0.761 (95% CI: 0.616-0.907) respectively. The calibration curves exhibited good overlap between the data predicted by the model and the actual data.

Conclusion

A nomogram model was developed to predict the risk of consultation failure and was shown to be good accuracy and good prediction efficiency, which can provide proactive interventions to improve outcomes for potentially treatment ineffective patients.

The impact of pharmacist early active consultation (PEAC) on multidrug resistance organism treatment outcomes: A prospective historically controlled study

Background and aim: Infectious disease (ID) consultation can improve multidrug-resistant organism (MDRO) treatment outcomes. However, the impact of clinical pharmacists' ID consultation on MDRO therapy, especially early initiation, has not been reported. In this study, we try to explore the impact of the pharmacist early active consultation (PEAC) on MDRO patient management. Methods: We conducted a prospective historical controlled study based on PEAC in MDRO patients. The retrospective control group was patients hospitalized 18 months before the PEAC initiation, and the prospective PEAC group was patients hospitalized 18 months after the PEAC initiation. Primary endpoint was 30-day all-cause mortality. Secondary outcomes were MDRO clinical outcome, duration of antibiotic use, length of stay, antibiotic consumption and antibiotic costs. Further subgroup analysis of secondary outcomes was performed by the condition at admission, MDRO pathogenicity and MDRO clinical outcome. Results: 188 MDRO patients were included. After adjusting for potential predictors, PEAC reduced the 30-day all-cause mortality by 70% (HR 0.30, 95% CI 0.09-0.96, p = 0.042). PEAC group had clinical improvement than control group (89.47% vs. 65.59%, p < 0.001), especially in patients with non-severe clinical conditions at admission (98.41% vs. 70.18%, p < 0.001). However, no significant differences were found between groups in length of stay, antibiotics consumption, and antibiotics costs. Conclusion: Early active pharmacy ID consultation can reduce 30-day all-cause mortality and improve clinical outcomes in MDRO patients.

Infection and the evaluation of biomarkers in obstetrics and gynecology patients with infectious disease: a retrospective observational study from clinical pharmacists’ consultation experience

Background

The use of empirical anti-infective medication calls for the identification of common pathogens and accurate infectious biomarkers. However, clinical pharmacists’ anti-infective experience in the field of obstetrics and gynaecology is rare in the literature. This study aimed to retrospectively analyze the correlation between the anti-infective effectiveness after 7 days of antibiotic treatment and infectious biomarkers, according to clinical pharmacists’ consultation cases of gynecological and obstetric infections.

Methods

In this retrospective study, clinical pharmacists’ anti-infective consultation experiences applied by physicians from January 1, 2018, to December 31, 2020, were included. The exclusion criteria were as follows: (1) the patient died or left the hospital before undergoing an effectiveness evaluation after the consultation; (2) treatment was discontinued due to adverse reactions related to antibiotics; (3) the patient did not undergo an effectiveness evaluation within 3 or 7 days after application of the clinical pharmacist’s treatment plan; and (4) the physician did not adopt the clinical pharmacist’s suggestions. The registered information included patient characteristics, pathological bacteria, anti-infective medication and changes in infection indices before and after treatment. Statistical analysis of temperature, white blood cells (WBCs), C-reactive protein (CRP), procalcitonin (PCT) and WBCs in urine after 3 days and 7 days of anti-infective treatment, compared with before anti-infective treatment, was performed by the chi-square test. A t test was conducted to further study WBC count and CRP. A receiver operating characteristic curve verified the sensitivity and specificity of WBC count, CRP and PCT.

Results

A total of 265 cases were included. The CRP levels of patients 3 d and 7 d after antibiotic treatment were significantly lower than before antibiotic treatment (P < 0.05, P < 0.01), while the WBC count showed a downward trend after 3 days and a significant decrease after 7 days (P < 0.01). The areas under the curve (AUCs) for prognosis on the 7th day for WBC count, CRP and PCT were 0.90, 0.75 and 0.522, respectively. The AUC for WBC count combined with CRP was 0.90, which was higher than that for the biomarkers tested separately, especially compared to PCT. The most common gynecological infections were surgical site infection (SSI), urinary tract infection and fever of unknown origin, and the most common pathogens were E. coli and E. faecalis in Gram-negative and Gram-positive samples, respectively. Pharmacists’ recommended treatment plans included carbapenems and β-lactam antibiotics.

Conclusions

Our dual-center study indicates that the combination of WBC count and CRP can improve diagnostic accuracy and treatment efficiency, and PCT alone is insensitive to gynecological infections, according to clinical pharmacists’ experience.

The Impacts of Clinical Pharmacists' Interventions on Clinical Significance and Cost Avoidance in a Tertiary Care University Hospital in Oman: A Retrospective Analysis

Objectives: Pharmaceutical interventions are implicit components of the enhanced role that clinical pharmacists provide in clinical settings. We aimed to study the clinical significance and analyze the presumed cost avoidance achieved by clinical pharmacists’ interventions. Methods: A retrospective study of documented clinical pharmacists’ interventions at a tertiary care hospital in Oman was conducted between January and March 2022. The interventions were electronically recorded in the patients’ medical records as routine practice by clinical pharmacists. Data on clinical outcomes were extracted and analyzed. Cost implications were cross checked by another clinical pharmacist, and then, cost avoidance was calculated using the Rx Medi-Trend system values. Results: A total of 2032 interventions were analyzed, and 97% of them were accepted by the treating physicians. Around 30% of the accepted interventions were for antimicrobials, and the most common type was dosage adjustment (30%). Treatment efficacy was enhanced in 60% and toxicity was avoided in 22% of the interventions. The presumed cost avoided during the study period was USD 110,000 with a projected annual cost avoidance of approximately USD 440,000. Conclusion: There was an overall positive clinical and financial impact of clinical pharmacists’ interventions. Most interventions have prevented moderate or major harm with a high physician acceptance rate. Optimal documentation of the interventions is crucial for emphasizing clinical pharmacists’ value in multi-specialty hospitals.

Integrating Multidisciplinary Individualized Medication Recommendations Into the Traditional Pharmacists' Consultation Method: A Retrospective Study Using Propensity Score Matching Analysis

Chinese clinical pharmacists consider improving the quantity and quality of consultations to be an important task in providing better pharmaceutical care. To achieve this goal, we developed a clinical pharmacist consultation method using multidisciplinary individualized medication recommendations (MIMRs) and studied the effects of its implementation. A retrospective study of 812 clinical pharmacist-led consultations was conducted. In the pre-intervention group, medication advice was given based on the purpose of the consultation. In the post-intervention group, a consultation method using MIMRs was implemented, in which clinical pharmacists with specialties in anticoagulation, gastroenterology, and nutrition were asked to give individualized medication recommendations. Outcomes, including the effectiveness rate of consultations (ERC) and acceptance rate of consultations (ARC), were compared between the two groups using propensity score matching method. Patterns and numbers of consultations and individualized medication recommendations were also compared. The results showed that the ERC in the post-intervention group compared with the ERC in the pre-intervention group was 83.3% vs 74.0%, respectively (P < .05). Significant difference was also shown between the two groups in ARC (98.4% vs 92.2%, P < .05). The total number of consultations increased, as did the number of general consultations, multidisciplinary/difficult consultations, anti-infection consultations, and non-anti-infection consultations specifically. As a result, we proposed that the implementation of MIMRs can improve the effects of treatment and increase the number of consultations by pharmacists, which is worthy of further promotion to better serve physicians and patients.

Effectiveness of Pharmacist-Physician Collaborative Management for Patients With Idiopathic Pulmonary Fibrosis Receiving Pirfenidone

Background: Pirfenidone is an anti-fibrotic agent used to treat patients with idiopathic pulmonary fibrosis (IPF). Managing adverse drug events and ensuring compliance with pirfenidone treatment for a prolonged period are important to reduce the rate of disease progression. To maximize the benefits of pirfenidone treatment, we established and evaluated an ambulatory care pharmacy practice, a model of pharmacist-physician collaborative management, for patients receiving pirfenidone. Methods: We conducted a retrospective chart review of 76 consecutive patients treated with pirfenidone in the Kobe City Medical Center General Hospital, Japan, between January 2012 and January 2019. The first group (61 patients) received pirfenidone treatment as conventional management, whereas the second group (15 patients) started pirfenidone based on collaborative pharmacist-physician management. The drug discontinuation rate and time to drug discontinuation were compared between the groups. To analyze factors associated with pirfenidone discontinuation, we used a multivariate Cox regression analysis to evaluate the baseline characteristics of patients, including those receiving the collaborative management. Clinical outcomes were compared using a propensity score matched analysis. Results: In the collaborative management group, pharmacists made 56 suggestions, including suggestions for supportive care (51 suggestions), to the physicians. Among these suggestions, 52 were accepted by the physicians. The discontinuation rates at 3 [6.7% (1/15) vs. 26.2% (16/61)] and 6 [9.1% (1/11) vs. 36.1% (22/61)] months were lower in the collaborative management group than in the conventional management group. Multivariate analysis revealed that collaborative management [hazard ratio (HR) 0.34, 95% CI 0.08-0.96, p = 0.041] and predicted baseline forced vital capacity <60% (HR 2.13, 95% CI 1.17-3.85, p = 0.015) were significantly associated with pirfenidone discontinuation. The time to drug discontinuation was also significantly longer in the collaborative management group than in the conventional management group (p = 0.034, log-rank test). Propensity score matched analysis confirmed a significant correlation between collaborative management and drug discontinuation time (HR 0.20, 95% CI 0.03-0.84, p = 0.027). Conclusions: We established an ambulatory care pharmacy practice for out-patients with IPF receiving pirfenidone. The results suggest that collaborative management may help prevent pirfenidone discontinuation compared with conventional management.

The Effectiveness of Clinical Pharmacist-Led Consultation in the Treatment of Infectious Diseases: A Prospective, Multicenter, Cohort Study

Background

Antimicrobial resistance (AMR) is a serious global health threat and leads to a huge challenge to infectious diseases (ID) treatment. To tackle AMR, regional ‘Antimicrobial Stewardship Programs’ (ASP) have been implemented in many countries. Due to insufficient clinical pharmacy resources, a major intervention mode of ASP in China is through clinical pharmacist-led consultation (CPC). The current study aims to prospectively evaluate this intervention and compare the effectiveness of CPC served by ID and non-ID clinical pharmacists.

Methods

We conducted a prospective and multicenter cohort study based on a regional registry database in 17 hospitals in Western China, including consecutive patients with ID between April 2017 and December 2019. Baseline characteristics including sex, age, liver and kidney function, comorbidity, infection severity were prospectively collected and recorded. The main exposure of interest was whether the attending physician adopted recommendations of the clinical pharmacist in the therapeutic scheme. The outcome was the infection effective response, assessed during day 3–7 after completing CPC. Multivariate analyses were performed by generalized linear mixed models.

Results

A total of 2,663 ID patients were included in the final analysis according to the predesigned inclusion and exclusion criteria. The number of patients whose treatment followed and did not follow the pharmacists’ suggestion was 2,529 and 134, respectively. CPC intervention could improve the ID patient prognosis in the context of other confounders controlled (Adjusted Odds ratio(AOR)=1.838, 95%Confidence Interval(CI)=[1.212, 2.786]), and the effectiveness of CPC served by ID and non-ID clinical pharmacists might be equivalent (AOR=0.958, 95%CI[0.740, 1.240]). Special consultation (AOR=1.832, 95%CI[1.106, 3.035]) and surgical treatment of infectious sites (AOR=1.380, 95%CI[1.039, 1.834]) had positive influences on the patient prognosis, while hypoalbuminemia (AOR=0.694, 95%CI[0.523, 0.921]), liver dysfunction (AOR=0.705, 95%CI[0.559, 0.889]), presence of high-risk factors (AOR=0.775, 95%CI[0.613, 0.980]), and increased infection severity (AOR=0.631, 95%CI[0.529, 0.753])were associated with a decrease in effective response rate, independently.

Conclusion

This study suggests that CPC is a promising pharmacist-led intervention to improve ID treatment, and it can achieve standardization among clinical pharmacists with different backgrounds by some measures. Policy/decision-makers should promote this intervention mode in developing countries or regions where there is an insufficient number of clinical pharmacists.

A survey of Chinese pharmacists participating in anti-infective therapy and its related information technology support

WHAT IS KNOWN AND OBJECTIVE

Anti-infective therapy is the major daily work for most clinical pharmacists in China, and information technology (IT) support for them is very important. However, the current situation of pharmacists' roles in anti-infective therapy and related IT support are seldom reported. The aim of the study was to investigate the current situation of pharmacists participating in anti-infective therapy and the corresponding hospital IT support, which may help identify and solve related problems and facilitate pharmacists to play better roles.

METHODS

A 15-item questionnaire was distributed online to clinical pharmacists from Chinese hospitals. Pharmacists answered the questions on the WeChat platform. Data were analysed using descriptive statistics.

RESULTS AND DISCUSSION

A total of 272 valid questionnaires were returned, and the respondents were from 27 provinces (or autonomous regions or municipalities) of China covering over 15 specialties. Most of the respondents (76.1%) were from tertiary hospitals and 72.4% of all the respondents participated in anti-infective therapy. They mainly performed drug selection (95.4%), dose adjustment (88.8%) and adverse drug reaction monitoring (84.8%) for anti-infective therapy, in ways such as consultation (71.1%), drug consult (86.3%) and prescription evaluation (88.8%). Most pharmacists (93.0%) thought that the modules of anti-infective therapy in hospital IT system needed to be advanced, in the aspects of doctor-pharmacist interaction, convenience for pharmacists to control drug expenses and integration of multi-functions for anti-infective therapy.

WHAT IS NEW AND CONCLUSION

The roles of Chinese clinical pharmacists in anti-infective therapy are becoming increasingly clear, and establishing smart, pharmacist-friendly and highly-integrated electronic interfaces will facilitate the establishment of pharmacist-driven anti-infective therapy team, thus improving work efficiency and user experience.

The Clinical Pharmacist-Led Consultation for Infectious Diseases in Guizhou Province, China: A Survey Among Hospital Pharmacies

BACKGROUND

As antimicrobial resistance became an increasing threat to global public health, Clinical Pharmacist-led Consultation (CPC) for Infectious Diseases (ID) was developed in China. We conducted a survey among hospital pharmacies to investigate the present situation and potential determinants of CPC for ID in China's Guizhou Province.

METHODS

The study was conducted by sending the questionnaire to the directors of hospital pharmacy who were members of Guizhou Province Pharmaceutical Administration Collaboration Network (GPPACN) from April to May 2019. We implemented the Firth's logistic regression model to analyze the factors that influence the implementation of CPC. The acceptance rate of consultation suggestions (ARCS) and effective response rate after acceptance of pharmacists' suggestions (ERRAPS) were pooled by meta-analysis using a random effect model, respectively. A pairwise meta-analysis was performed to compare the effective response rate between patients whose treatment followed the pharmacists' suggestions and those whose treatment did not.

RESULTS

A total of 83 hospitals covering 9 regions in Guizhou Province were included in this survey. The results showed that 50 hospitals (60.24%) developed the CPC for ID. Staffing ID, respiratory, or general clinical pharmacist had a significantly positive effect on the implementation of CPC [adjusted odds ratios = 7.298, 95% CI (confidence interval): 2.232 to 23.858]. The pooled ARCS and ERRAPS for secondary hospitals were 97.59% (95% CI: 94.27 to 100.00%) and 88.36% (95% CI: 84.71 to 92.17%), respectively. Importantly, CPC improved the prognosis of ID patients [risk ratio (RR) = 6.49, 95% CI: 2.84 to 14.82] in these hospitals.

CONCLUSION

CPC adoption is gradually increasing among hospitals and will be a promising intervention for ID treatment at grassroots medical institutions in Guizhou Province. Training more clinical pharmacists to specialize in ID, respiratory, or general diseases might be the most practical measure to promote the development of CPC for ID.