Activating pharmacists to reduce the frequency of medication-related problems (ACTMed): a stepped wedge cluster randomised trial.

BACKGROUND: Medicines are the most frequent health care intervention type; their safe use provides significant benefits, but inappropriate use can cause harm. Systemic primary care approaches can manage serious medication-related problems in a timely manner. OBJECTIVES: ACTMed (ACTivating primary care for MEDicine safety) uses information technology and financial incentives to encourage pharmacists to work more closely with general practitioners to reduce the risk of harm, improve patients' experience of care, streamline workflows, and increase the efficiency of medical care. METHODS AND ANALYSIS: The stepped wedge cluster randomised trial in 42 Queensland primary care practices will assess the effectiveness of the ACTMed intervention. The primary outcome will be the proportion of people at risk of serious medication-related problems - patients with atrial fibrillation, heart failure, cardiovascular disease, type 2 diabetes, or asthma or chronic obstructive pulmonary disease - who experience such problems. We will also estimate the cost per averted serious medication-related problem and the cost per averted potentially preventable medication-related hospitalisation. ETHICS APPROVAL: The University of Queensland Human Research Ethics Committee approved the pilot (2021/HE002189) and trial phases of the ACTMed study (2022/HE002136). Access to Patron data was granted by the Patron Data Governance Committee (PAT052ACTMed). Access to linked hospitalisations and deaths data are subject to Public Health Act approval (pending). DISSEMINATION OF FINDINGS: A comprehensive dissemination plan will be co-developed by the researchers, the ACTMed steering committee and consumer advisory group, project partners, and trial site representatives. Aboriginal and Torres Strait Islander communities will be supported in leading community-level dissemination. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (pilot: ACTRN12622000595718; 21 April 2022; full trial: ACTRN12622000574741; 14 April 2022).

Pharmacist role in vaccination: Evidence and challenges.

Vaccines prevent an estimated 2.5 million deaths worldwide each year and are amongst the most cost-effective preventive measures against infectious diseases. Despite the effectiveness and availability of vaccines in many parts of the world, vaccination rates and service uptake remains suboptimal among both healthcare providers and the public. Pharmacists as established advocates, educators as well as qualified providers of vaccinations have a significant role to play in promoting and supporting the uptake of vaccination. Challenges and barriers to pharmacist vaccination are multifactorial, which needs effective strategies to address. Overcoming these barriers will increase the role of pharmacists as vaccinators that ultimately increases public access to vaccination and accurate and reliable information about vaccines.

"There's No Touching in Pharmacy": Training Pharmacists for Australia's First Pharmacist Immunization Pilot.

BACKGROUND: Vaccination is a safe, efficient, and cost-effective means of preventing, controlling, and eradicating many life-threatening infections and diseases. Globally, the World Health Organization estimates that vaccination saves between 2 million and 3 million lives annually. However, low immunization rates are a significant public health concern. Individual factors, along with the vaccination process and system, have been reported as perceived barriers and challenges to immunization. Lack of time, on the part of both health care professionals and patients, has also been reported as a key factor influencing patterns of immunization. Despite the accessibility of pharmacists in community pharmacies in Australia, and initiatives by other countries to introduce pharmacist vaccination services, pharmacists in Australia had not previously delivered this service. The Queensland Pharmacist Immunisation Pilot (QPIP), initially implemented for the 2014 influenza season and later expanded, as QPIP2, to include other vaccines, allowed Australian pharmacists to vaccinate for the first time. OBJECTIVES: To develop, implement, and evaluate a training program for pharmacists undertaking vaccination services in community pharmacies in Australia. METHODS: Background content was developed and delivered through 2 online modules. Pharmacists were required to successfully answer a series of multiple-choice questions related to the background reading before attending a face-to-face workshop. The workshop provided practical training in injection skills and anaphylaxis management. Participants were also asked to evaluate the training program. RESULTS: Of the 339 pharmacists who completed the training program, 286 (84%) provided an evaluation. Participants were satisfied with the training, as indicated by consistently high scores on the "overall satisfaction" question (mean 4.65/5 for the QPIP and QPIP2 training combined). Participants described the background reading as relevant to their practice and stated that it met their expectations. They also valued the opportunity to practise injections on each other during the face-to-face workshop, and this aspect was noted as a key component of the training. CONCLUSIONS: QPIP demonstrated that a pharmacist-specific training program could produce competent and confident immunizers and could be used to "retrofit" the profession, to facilitate delivery of vaccination services in Australia.

CONTEXTE: La vaccination est un moyen sécuritaire et efficient de prévenir, d'endiguer et d'éradiquer bon nombre d'infections et de maladies potentiellement mortelles. L'Organisation mondiale de la santé estime que, dans le monde, la vaccination permet de sauver entre 2 millions et 3 millions de vies par année. Cependant, les faibles taux d'immunisation représentent un enjeu de santé publique important. On a noté que des facteurs individuels ainsi que le processus et le système de vaccination sont perçus comme des obstacles à l'immunisation. Le manque de temps, tant de la part des professionnels de la santé que des patients, a aussi été présenté comme un facteur clé influençant les schémas d'immunisation. Malgré la disponibilité de pharmaciens dans les pharmacies communautaires en Australie et les initiatives lancées par d'autres pays pour mettre en place des services de vaccination offerts par les pharmaciens, les pharmaciens en Australie n'avaient pas prodigué ce service auparavant. L'étude Queensland Pharmacist Immunisation Pilot (QPIP), d'abord mise en place pour la saison de la grippe de 2014, puis reconduite en une version bonifiée nommée QPIP2 afin d'inclure d'autres vaccins, a permis aux pharmaciens australiens de vacciner pour la première fois. OBJECTIFS: Élaborer, mettre en place et évaluer un programme de formation pour les pharmaciens qui offrent des services de vaccination dans les pharmacies communautaires en Australie. MÉTHODES: La matière du programme a été élaborée et offerte sous forme de deux modules en ligne. Les pharmaciens devaient répondre adéquatement à une série de questions à choix multiples portant sur les lectures préparatoires à un atelier en personne. L'atelier offrait une formation pratique sur les techniques d'injection et sur la prise en charge de l'anaphylaxie. On a aussi demandé aux participants d'évaluer le programme de formation. RÉSULTATS: Des 339 pharmaciens ayant terminé le programme de formation, 286 (84 %) ont fourni une évaluation. Les participants étaient satisfaits de la formation, comme l'indiquaient des cotes systématiquement élevées à la question concernant la satisfaction globale (moyenne de 4,65 sur 5 pour la formation des études QPIP et QPIP2 prises ensemble). Les participants ont indiqué que les lectures préparatoires étaient pertinentes pour leur pratique et qu'elles répondaient à leurs attentes. Ils ont aussi apprécié l'occasion de s'exercer à faire des injections les uns sur les autres au cours de l'atelier en personne; on a d'ailleurs noté que cet aspect représentait un élément clé de la formation. CONCLUSIONS: L'étude QPIP a permis de constater qu'un programme de formation destiné aux pharmaciens pouvait produire des vaccinateurs compétents et sûrs d'eux et qu'il pouvait servir à « moderniser ¼ la profession afin de faciliter la prestation de services de vaccination en Australie.

Population pharmacokinetics of fluconazole in critically ill patients receiving continuous venovenous hemodiafiltration: using Monte Carlo simulations to predict doses for specified pharmacodynamic targets.

Fluconazole is a widely used antifungal agent that is extensively reabsorbed in patients with normal renal function. However, its reabsorption can be compromised in patients with acute kidney injury, thereby leading to altered fluconazole clearance and total systemic exposure. Here, we explore the pharmacokinetics of fluconazole in 10 critically ill anuric patients receiving continuous venovenous hemodiafiltration (CVVHDF). We performed Monte Carlo simulations to optimize dosing to appropriate pharmacodynamic endpoints for this population. Pharmacokinetic profiles of initial and steady-state doses of 200 mg intravenous fluconazole twice daily were obtained from plasma and CVVHDF effluent. Nonlinear mixed-effects modeling (NONMEM) was used for data analysis and to perform Monte Carlo simulations. For each dosing regimen, the free drug area under the concentration-time curve (fAUC)/MIC ratio was calculated. The percentage of patients achieving an AUC/MIC ratio greater than 25 was then compared for a range of MIC values. A two-compartment model adequately described the disposition of fluconazole in plasma. The estimate for total fluconazole clearance was 2.67 liters/h and was notably 2.3 times faster than previously reported in healthy volunteers. Of this, fluconazole clearance by the CVVHDF route (CL(CVVHDF)) represented 62% of its total systemic clearance. Furthermore, the predicted efficiency of CL(CVVHDF) decreased to 36.8% when filters were in use >48 h. Monte Carlo simulations demonstrated that a dose of 400 mg twice daily maximizes empirical treatment against fungal organisms with MIC up to 16 mg/liter. This is the first study we are aware of that uses Monte Carlo simulations to inform dosing requirements in patients where tubular reabsorption of fluconazole is probably nonexistent.

Vancomycin pharmacokinetics in critically ill patients receiving continuous venovenous haemodiafiltration.

AIMS: To investigate the pharmacokinetics of vancomycin in critically ill patients on continuous venovenous haemodiafiltration (CVVHDF), a continuous renal replacement therapy (CRRT) and to see if routine measures approximate vancomycin clearance. METHODS: Pharmacokinetic profiles (15) of initial and steady-state doses of 750 mg twice daily intravenous vancomycin were obtained from blood and ultrafiltrate samples from 10 critically ill patients in the intensive care unit, with acute renal failure on CVVHDF (1 l h(-1) dialysate plus 2 l h(-1) filtration solution; 3 l h(-1) effluent; extracorporeal blood flow 200 ml min(-1)). RESULTS: CVVHDF clearance of vancomycin was 1.8 +/- 0.4 l h(-1) (30 +/- 6.7 ml min(-1)). This was 1.3-7.2 times that reported previously for vancomycin using other forms of CRRT. Total vancomycin body clearance was 2.5 +/- 0.7 l h(-1) (41.7 +/- 11.7 ml min(-1)). The clearance of vancomycin by CVVHDF was 76 +/- 16.5% of the total body clearance. CVVHDF removed approximately half the vancomycin dose during the 12-h period (A(CVVHDF) = 413 mg). The fraction eliminated by all routes was 60%. The sieving coefficient for vancomycin was 0.7 +/- 0.1 and for urea was 0.8 +/- 0.06. CONCLUSIONS: Vancomycin is cleared effectively by CVVHDF. Clearance was faster than other forms of CRRT, therefore doses need to be relatively high. Urea clearance slightly overestimates vancomycin clearance. The administered doses of 750 mg every 12 h were too high and accumulation occurred, as only approximately 60% of a dose was cleared over this period. The maintenance dose required to achieve a target average steady-state plasma concentration of 15 mg l(-1) can be calculated as 450 mg every 12 h.