Impact of outpatient antimicrobial stewardship guideline implementation in an urgent care setting.

BACKGROUND: Urgent care medicine is a rapidly growing health care sector where patients are commonly treated for acute infectious diseases-related conditions. However, there are few antimicrobial stewardship interventions described in these settings. OBJECTIVE: The objective of this study is to determine whether implementing outpatient antimicrobial stewardship guidelines would improve antibiotic prescribing for acute upper respiratory tract infections (ARTIs), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) at a single urgent care site. METHODS: This was a pre-post interventional study comparing antibiotic prescribing patterns for ARTI, SSTI, and UTI at a single urgent care site in the preintervention group (November 2019 to January 2020) with the postintervention group (November 2020 to January 2021) after implementation of outpatient stewardship guidelines. A second urgent care site that did not receive any interventions served as a control. The outpatient stewardship guidelines were implemented in October 2020 via didactic provider education and pocket guide distribution. The primary end point was the rate of total guideline-concordant antibiotic prescribing. Secondary end points included the rates of guideline concordance of each component of the prescription, including antibiotic selection, duration, dose, therapy indication, and patient safety outcomes. RESULTS: The primary outcome of total guideline-concordant antibiotic prescribing significantly improved after implementation of outpatient antimicrobial stewardship guidelines at the study site (50% vs. 70%, P < 0.001), which was also reflected when comparing postintervention study site with postperiod control site (70% vs. 48%, P < 0.001). There was a statistically significant improvement in guideline-concordant duration of antibiotic therapy (43% vs. 61%, P = 0.001), driven by a reduction in antibiotic duration for UTI (7 [interquartile range (IQR) 5-7] vs. 5 [IQR 5-7] days, P = 0.007), which was also observed when comparing the postintervention study site with the postperiod control site (61% vs. 48%, P = 0.02). Patient safety outcomes were similar between groups. CONCLUSION: An antimicrobial stewardship intervention comprising institutional outpatient guideline implementation and provider education significantly improved total guideline-concordant antibiotic prescribing by 20% for ARTI, UTI, and SSTI in an urgent care site.

Impact of Pharmacist Education on Inhaler Technique and Adherence in an Outpatient Clinic.

Background and Objectives: To assess the impact that pharmacist education has on proper inhaler technique and adherence in a teaching clinic. Methods: This was prospective, non-randomized, pre-test/post-test study. Patients were 18 years or older, had a diagnosis of asthma or COPD, and prescribed at least 1 inhaled medication. Initial visits consisted of a baseline asthma control test (ACT) or COPD assessment test (CAT), the Test of Adherence to Inhalers (TAI), and a baseline inhaler technique evaluation. The pharmacist then educated the patient. Then inhaler technique was assessed again (post-education inhaler technique evaluation #1). Follow-up visits occurred 4 to 8 weeks later. ACT or CAT and TAI test were administered and inhaler technique was assessed again (post-education inhaler technique #2). The primary outcome was the comparison of the percentage of correct steps performed from baseline to post-education inhaler technique evaluation #1 and from baseline to post-education inhaler technique evaluation #2. Results: Eighteen patients were included, with a mean age of 58 years old. Over half had asthma, were female and African American. There was a significant difference in inhaler technique from baseline to post-education inhaler evaluation #1 and from baseline to post-education inhaler evaluation #2. The most common step missed was no exhalation before inhalation. There was no significant difference when comparing the individual and overall TAI test scores from initial to follow up visit. Conclusions: This study supports pharmacist-led inhaler technique education.

Urine Drug Test Interpretation: An Educational Program's Impact on Resident Knowledge and Comfort Level.

Introduction: Following the release of the Centers for Disease Control and Prevention guidelines in 2016, institutions are encouraged to have controlled substance agreements that require the use of drug screens for appropriate opioid prescribing. Correct evaluation of urine drug tests (UDTs) is essential for appropriate chronic prescribing of controlled substances. Anticipating the increase in use of these tests, our institution developed and implemented an educational program to improve knowledge of and comfort level with UDT interpretation. Methods: The educational program was 30 minutes in duration and consisted of a PowerPoint presentation followed by informal discussion. All internal medicine and medicine/pediatrics residents were encouraged to attend. A survey assessing knowledge of and comfort level with interpreting UDTs before, immediately after, and 2 months following the educational program was used as an assessment tool. Results: A total of 44 out of 76 residents at our institution attended the educational program. The majority (81.8%) had no prior education on UDT interpretation; however, most (97.7%) stated they interpreted UDTs monthly, and 22.7% had refused refills within the prior month based on UDT results. Change in residents' knowledge and change in residents' comfort were both found to be significantly increased following the educational program (p < .0001 for both variables). Discussion: Significant increases in both comfort with and knowledge of UDT interpretation occurred following the educational program provided for medical residents, which supports its expansion to other institutions as an easy and effective means of promoting appropriate UDT evaluation.

Vildagliptin: a novel oral therapy for type 2 diabetes mellitus.

PURPOSE: The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, drug interactions, and role in therapy of vildagliptin for the treatment of type 2 diabetes mellitus were reviewed. SUMMARY: Vildagliptin is an agent in a new class of medications called dipeptidyl peptidase IV (DPP4) inhibitors. By inhibiting DPP4, vildagliptin causes an increase in glucagon like peptide-1 (GLP-1), an intestinal hormone that aids in glucose homeostasis and insulin secretion. The manufacturer of vildagliptin received an approvable letter from the Food and Drug Administration in late February 2007. Vildagliptin has a halflife of about 90 minutes; however, > or =50% of DPP4 inhibition continues for more than 10 hours, allowing for once- or twice-daily dosing. Clinical trials have shown that vildagliptin is effective in significantly lowering glycosylated hemoglobin (HbA(1c)), fasting plasma glucose, and prandial glucose levels. Beta-cell function may also be improved. The most common adverse effects in patients receiving vildagliptin included headache, nasopharyngitis, cough, constipation, dizziness, and increased sweating. In most studies, the rate of hypoglycemia appeared to be similar to that of placebo. CONCLUSION: In clinical trials of patients with type 2 diabetes mellitus, vildagliptin has been shown to reduce HbA(1c), fasting plasma glucose levels, prandial glucose levels, and prandial glucagon secretion and to improve beta-cell function. If vildagliptin is approved for marketing, it will add to the available treatment options for diabetes and will provide patients and health care providers with another noninjectable therapy option.