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BACKGROUND: There is growing interest in the utilization of daptomycin for the treatment of multi-drug-resistant, Gram-positive infections. Pharmacokinetic studies suggest that daptomycin could penetrate into the cerebrospinal fluid, albeit to a small extent. The objective of this review was to evaluate the available clinical evidence for the use of daptomycin in acute bacterial meningitis of both paediatric and adult patients. METHODS: Electronic databases were searched up to June 2022 for studies published on the topic. The inclusion criteria were met if the study reported the use of intravenous daptomycin (more than a single dose) for the treatment of diagnosed acute bacterial meningitis. RESULTS: In total, 21 case reports were identified that met the inclusion criteria. These suggest that daptomycin could be a safe and effective alternative to achieve clinical cure of meningitis. In these studies, daptomycin was used in the event of treatment failure, patient intolerance or bacterial resistance to first-line agents. CONCLUSIONS: Daptomycin has potential to be an alternative to standard care for meningitis caused by Gram-positive bacteria in the future. However, more robust research is required to establish an optimal dosing regimen, duration of therapy, and place in therapy for the management of meningitis.
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Daptomicina , Infecciones por Bacterias Grampositivas , Meningitis Bacterianas , Adulto , Humanos , Niño , Daptomicina/farmacocinética , Antibacterianos , Meningitis Bacterianas/tratamiento farmacológico , Meningitis Bacterianas/microbiología , Administración Intravenosa , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/microbiología , Resultado del TratamientoRESUMEN
Clinical guidelines recommend empirical fluoroquinolone therapy for urinary tract infections (UTIs) only where local Escherichia coli resistance does not exceed 10%; however, access to local susceptibility data is not uniform across Canada and it is not known which regions meet this threshold. Our objective was to collect susceptibility data from across Canada to evaluate regional trends of E. coli resistance to fluoroquinolones. Antibiogram data were collected retrospectively for the years 2015-2019 from the most local level within each province, typically regional health authorities (RHAs) or local health zones. Antibiogram data were collected from publicly available sources or by directly contacting RHAs or health zones. Susceptibility data were aggregated into regional or population-level data. Antibiograms were collected from 72 regions across 10 provinces. These included 1 949 515 E. coli isolates. Only seven regions throughout Canada met the IDSA target of <10% resistance to consider empirical fluoroquinolone therapy at any point during the study period. The data consistently show that outpatient populations tend to have the highest susceptibility to fluoroquinolones, followed by inpatient populations, and finally long-term care patients. Rural populations also generally had higher susceptibility than urban. Nationally, the Atlantic provinces tended to show the highest susceptibility, especially towards the end of the study period. Fluoroquinolone resistance in E. coli appears to be plateauing within Canada after a rapid increase in the past 20 years. However, fluoroquinolones are rarely appropriate first-line treatment options for UTIs within Canada in the absence of factors eliminating other therapeutic options.
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Infecciones por Escherichia coli , Infecciones Urinarias , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Ciprofloxacina/farmacología , Ciprofloxacina/uso terapéutico , Farmacorresistencia Bacteriana , Escherichia coli , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/epidemiología , Fluoroquinolonas/farmacología , Fluoroquinolonas/uso terapéutico , Humanos , Pruebas de Sensibilidad Microbiana , Estudios Retrospectivos , Infecciones Urinarias/tratamiento farmacológico , Infecciones Urinarias/epidemiologíaRESUMEN
BACKGROUND: The uptake of clinical practice guidelines into practice is limited for many chronic conditions, including hypertension. The aim of this study was to ascertain the importance of the educational competencies for the development of the Hypertension Canada Professional Certification Program (HC-PCP) among frontline, primary care professionals (e.g., pharmacists, physicians, nurses). METHODS: A group of hypertension experts developed 15 competencies believed to be important for primary care professionals to master when providing hypertension management. These competencies were surveyed for consensus by frontline clinicians through the Hypertension Canada e-newsletter in 2018. Clinicians were asked to rank the importance of each competency for a primary care provider to acquire when undertaking a certification in hypertension management, using a Likert scale from 1 (not important) to 5 (very important). RESULTS: A total of 121 clinicians responded to the survey. Of these, 38% were pharmacists, 31.4% were registered nurses, 10.7% were physicians and 7% were nurse practitioners. There was at least 1 respondent from each Canadian province and territory, except for the Northwest Territories. All 15 competencies received a mean rank of at least 4. The competency with the highest ranking was Competency 6: Ability to screen and identify hypertension (mean 4.83 [0.04]). The competencies with the lowest average ranks were Competency 1: Demonstrates a sound knowledge of the epidemiology of hypertension (mean 4.07 [0.85]) and Competency 5: Demonstrates an understanding of the validation process for blood pressure devices (mean 4.15 [0.08]). CONCLUSIONS: Clinicians generally ranked all 15 competencies to be of high importance for a provider who is certified in hypertension management to possess. These competencies and the current Hypertension Canada guidelines were used as the foundation for the development of an education program called the Hypertension Canada Professional Certification Program. Can Pharm J (Ott) 2021;154:xx-xx.
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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.
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Background: Urinary tract infections (UTIs) often lead to suboptimal antibacterial use. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of pharmacists' antibacterial prescribing for patients with uncomplicated UTI. Methods: We conducted a prospective registry trial with 39 community pharmacies in New Brunswick, Canada. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (pharmacist-initial arm) or an antibacterial prescription for UTI from a physician (physician-initial arm). Pharmacists assessed patients; patients with complicating factors or red flags for systemic illness or pyelonephritis were excluded. Pharmacists prescribed antibacterial therapy or modified antibacterial therapy, provided education only, or referred to a physician, as appropriate. Antibacterial therapy prescribed was compared between study arms. Results: Seven hundred fifty patients were enrolled (87% pharmacist-initial arm). The most commonly prescribed agents in the pharmacist-initial arm were nitrofurantoin (88.4%), sulfamethoxazole-trimethoprim (TMP-SMX) (7.8%), and fosfomycin (2.1%); in the physician-initial arm, nitrofurantoin (55.3%), TMP-SMX (25.5%), and fluoroquinolones (10.6%) were prescribed. Therapy was guideline concordant for 95.1% of patients in the pharmacist-initial arm and 35.1% of patients in the physician-initial arm (p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 45.9% of patients. Conclusion: Treatment was highly guideline concordant when pharmacist initiated, with physicians prescribing longer treatment durations and more fluoroquinolones. This represents an important opportunity for antimicrobial stewardship interventions by pharmacists in the community.
Historique : Les infections urinaires sont souvent associées à une utilisation sous-optimale d'antibactériens. Les pharmaciens sont des professionnels de la santé de première ligne accessibles qui ont un rôle important à jouer dans la gouvernance antimicrobienne. Les chercheurs visaient évaluer la pertinence des prescriptions antimicrobiennes. Ils s'étaient donné comme objectif d'évaluer la pertinence des prescriptions des pharmaciens aux patients atteints d'une infection urinaire sans complication. Méthodolodie : Les chercheurs ont réalisé une étude de registres prospectifs dans 39 pharmacies communautaires du Nouveau-Brunswick, au Canada. Les patients adultes participaient à l'étude s'ils se présentaient à la pharmacie à cause de symptômes d'infection urinaire non traités par des antibactériens (volet initial pharmacien) ou s'ils se présentaient avec une prescription d'antibactériens fournie par un médecin (volet initial médecin). Ils évaluaient les patients, excluaient de l'étude des facteurs de complication ou des signes de maladie systémique ou de pyélonéphrite. Ils prescrivaient un traitement antibactérien, un traitement antibactérien modifié, ne transmettaient que de l'information ou dirigeaient le patient vers un médecin, selon la situation. Les chercheurs ont comparé la thérapie antibactérienne prescrite dans les volets de l'étude. Résultats : Au total, 750 patients ont été inscrits (87 % dans le volet initial pharmacien). La nitrofurantoïne (88.4 %), le sulfaméthoxazole-triméthoprime (TMP-SMX) (7.8 %) et la fosfomycine (2.1 %) étaient les traitements les plus prescrits du volet initial pharmacien, alors que la nitrofurantoïne (55.3 %), le TMP-SMX (25.5 %) et les fluoroquinolones (10.6 %) étaient surtout prescrits dans le volet initial médecin. Le traitement respectait les lignes directrices dans 95,1 % des cas du volet initial pharmacien et dans 35,1 % des cas du volet initial médecin (p < 0,001). En cas de traitement prescrit par des médecins ne respectant pas les lignes directrices, les prescriptions des pharmaciens ont optimisé le traitement chez 45.9 % des patients. Conclusion : Le traitement concordait fortement avec les lignes directrices lorsqu'il était amorcé par des pharmaciens. Les médecins prescrivaient des traitements plus longs, surtout composés de fluoroquinolones. Il s'agit d'une occasion importante d'interventions en gouvernance antimicrobienne de la part de pharmaciens communautaires.
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There has been growing interest in fosfomycin for the treatment of bacterial prostatitis due to evidence suggesting that it achieves adequate prostatic concentrations for antimicrobial effect, has activity against resistant micro-organisms, and has a low-toxicity profile. This review evaluated the current clinical evidence for fosfomycin in acute and chronic bacterial prostatitis to elucidate the clinical implications of fosfomycin in an era of increasing antimicrobial resistance. PubMed, Scopus, EMBASE, Web of Science, Google Scholar and ClinicalTrials.gov were searched for studies published in the English language from January 1984 to November 2019. The inclusion criteria were met if the study reported the use of fosfomycin (more than one dose) to treat bacterial prostatitis. Ten observational studies were identified that met the inclusion criteria. The evidence for the use of fosfomycin in acute bacterial prostatitis is sparse. The majority of the available evidence is for chronic bacterial prostatitis caused by Escherichia coli. Despite the implementation of variable dosing regimens, extended courses of fosfomycin appear to be safe and effective in achieving clinical and microbiological cure. In these studies, the use of fosfomycin was restricted to cases of treatment failure, intolerance to first-line therapy, or multi-resistant organisms. However, given the development of resistant organisms and the undesirable adverse effects of many first-line therapeutic options, fosfomycin has the potential to be considered as an effective first-line alternative for acute and chronic bacterial prostatitis in the future. Further studies, including randomized controlled trials, would be helpful to firmly establish its optimal dosing regimen, efficacy and place in therapy.
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Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Fosfomicina/uso terapéutico , Prostatitis/tratamiento farmacológico , Programas de Optimización del Uso de los Antimicrobianos , Infecciones Bacterianas/microbiología , Enterobacteriaceae/efectos de los fármacos , Enterococcus faecium/efectos de los fármacos , Escherichia coli/efectos de los fármacos , Humanos , Masculino , Próstata/microbiología , Próstata/patología , Prostatitis/microbiología , Pseudomonas aeruginosa/efectos de los fármacos , Resultado del TratamientoRESUMEN
BACKGROUND: Urinary tract infections (UTI) are one of the most common infections treated in primary care and the emergency department. The RxOUTMAP study demonstrated that management of uncomplicated UTI by community pharmacists resulted in high clinical cure rates similar to those reported in the literature and a high degree of patient satisfaction. The objective of this study was to assess the cost-effectiveness and budget impact of community pharmacist-initiated compared to family or emergency physician-initiated management of uncomplicated UTI. METHODS: A decision analytic model was used to compare costs and outcomes of community pharmacist-initiated management of uncomplicated UTI to family or emergency physician-initiated management. Cure rates and utilities were derived from published studies. Costs of antibiotic treatment and health services use were calculated based on cost data from Canada. We used a probabilistic analysis to evaluate the impact of treatment strategies on costs and quality-adjusted-life-months (QALMs). In addition, a budget impact analysis was conducted to evaluate the financial impact of community pharmacist-initiated uncomplicated UTI management in this target population. This study was conducted from the perspective of the public health care system of Canada. RESULTS: Pharmacist-initiated management was lower cost ($72.47) when compared to family and emergency physician-initiated management, $141.53 and $368.16, respectively. The QALMs gained were comparable across the management strategies. If even only 25% of Canadians with uncomplicated UTI were managed by community pharmacists over the next 5 years, the resulting net total savings was estimated at $51 million. CONCLUSION: From a Canadian public health care system perspective, community pharmacist-initiated management would likely be a cost-effective strategy for uncomplicated UTI. In an era of limited health care resources, expanded roles of community pharmacists or other non-physician community based prescribers are important mechanisms through which accessible, high-quality and cost-effective care may be achieved. Further studies to evaluate other conditions which can be managed in the community and their cost effectiveness are essential.
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Farmacéuticos/economía , Infecciones Urinarias/tratamiento farmacológico , Infecciones Urinarias/economía , Presupuestos , Canadá , Análisis Costo-Beneficio , Investigación sobre Servicios de Salud , HumanosRESUMEN
Objectives: Despite the convenience of once-daily dosing, the use of ceftriaxone for Staphylococcus aureus infections has significant limitations, including scarce clinical evidence and increasingly questionable pharmacodynamic activity. Our goal was to conduct an integrated pharmacokinetic-pharmacodynamic analysis of the appropriateness of ceftriaxone compared with cefazolin for treating serious MSSA infections. Methods: Ceftriaxone and cefazolin activity against five clinical MSSA isolates was characterized in an in vitro pharmacodynamic model. Monte Carlo simulations were then used to evaluate various dosing regimens of ceftriaxone and cefazolin based on relevant patient pharmacokinetic data, significant pharmacodynamic targets derived from the in vitro studies (55%ƒT>MIC for bacteriostasis, 75%ƒT>MIC for 1 log10 bacterial kill, 100%ƒT>MIC for ≥3 log10 bacterial kill) and MIC distributions for MSSA from national surveillance data. Results: Ceftriaxone at 1 g once daily had poor activity against MSSA with net bacterial growth predicted in 76% of simulated subjects. The standard 2 g of ceftriaxone once daily had predicted bacterial growth or bacteriostasis in 54% of cases with bactericidal effects in only 17%. Cefazolin at 2 g once daily was notably similar to ceftriaxone in expected target attainments. Cefazolin at 2 g twice daily demonstrated maximal pharmacodynamic activity with bactericidal effects in 97% of simulated subjects. Conclusions: Given the limited activity of ceftriaxone against S. aureus, particularly for serious infections when bacterial kill is desired, the convenience of once-daily dosing should be weighed against the risks of using an overly broad, suboptimal therapy. Cefazolin warrants further consideration, particularly as optimal pharmacodynamics against MSSA may be achieved with twice-daily dosing in most patients.
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Antibacterianos/farmacocinética , Antibacterianos/normas , Ceftriaxona/farmacocinética , Ceftriaxona/normas , Staphylococcus aureus/efectos de los fármacos , Antibacterianos/farmacología , Ceftriaxona/farmacología , Humanos , Pruebas de Sensibilidad Microbiana , Modelos Biológicos , Método de Montecarlo , Infecciones Estafilocócicas/tratamiento farmacológicoRESUMEN
OBJECTIVE: To develop a clinical practice guideline for a simplified approach to medical cannabinoid use in primary care; the focus was on primary care application, with a strong emphasis on best available evidence and a promotion of shared, informed decision making. METHODS: The Evidence Review Group performed a detailed systematic review of 4 clinical areas with the best evidence around cannabinoids: pain, nausea and vomiting, spasticity, and adverse events. Nine health professionals (2 generalist family physicians, 2 pain management-focused family physicians, 1 inner-city family physician, 1 neurologist, 1 oncologist, 1 nurse practitioner, and 1 pharmacist) and a patient representative comprised the Prescribing Guideline Committee (PGC), along with 2 nonvoting members (pharmacist project managers). Member selection was based on profession, practice setting, location, and lack of financial conflicts of interest. The guideline process was iterative through content distribution, evidence review, and telephone and online meetings. The PGC directed the Evidence Review Group to address and provide evidence for additional questions as needed. The key recommendations were derived through consensus of the PGC. The guideline was drafted, refined, and distributed to a group of clinicians and patients for feedback, then refined again and finalized by the PGC. RECOMMENDATIONS: Recommendations include limiting medical cannabinoid use in general, but also outline potential restricted use in a small subset of medical conditions for which there is some evidence (neuropathic pain, palliative and end-of-life pain, chemotherapy-induced nausea and vomiting, and spasticity due to multiple sclerosis or spinal cord injury). Other important considerations regarding prescribing are reviewed in detail, and content is offered to support shared, informed decision making. CONCLUSION: This simplified medical cannabinoid prescribing guideline provides practical recommendations for the use of medical cannabinoids in primary care. All recommendations are intended to assist with, not dictate, decision making in conjunction with patients.
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Cannabinoides/efectos adversos , Cannabinoides/uso terapéutico , Medicina Basada en la Evidencia/normas , Atención Primaria de Salud/normas , Toma de Decisiones , Humanos , Espasticidad Muscular/tratamiento farmacológico , Náusea/tratamiento farmacológico , Dolor/tratamiento farmacológico , Vómitos/tratamiento farmacológicoRESUMEN
OBJECTIF: Élaborer des lignes directrices de pratique clinique visant à simplifier l'approche à l'emploi de cannabinoïdes à des fins médicales en soins de première ligne; le projet visait l'application en soins de première ligne, en insistant fortement sur les meilleures données probantes disponibles, et la promotion de la prise de décision éclairée et partagée. MÉTHODES: Le Groupe d'examen des données a effectué une revue systématique détaillée de 4 domaines cliniques dotés des meilleures données probantes en matière de cannabinoïdes : douleur, nausées et vomissements, spasticité et événements indésirables. Neuf professionnels de la santé (2 omnipraticiens, 2 médecins de famille spécialisés en gestion de la douleur, 1 médecin de famille en milieu urbain, 1 neurologue, 1 oncologue, 1 infirmière praticienne et 1 pharmacien) et une représentante de patients composaient le Comité des lignes directrices en matière de prescription (CLDP), de même que 2 membres sans droit de vote (pharmaciens gestionnaires de projet). Les membres ont été sélectionnés en fonction de leur profession, et de leur contexte et de leur lieu de pratique, de même qu'en fonction de l'absence d'un conflit d'intérêts de nature financière. Les lignes directrices sont le fruit d'un processus itératif incluant la distribution de contenu, l'examen minutieux des données probantes, et des rencontres téléphoniques et en ligne. Le CLDP a confié au Groupe d'examen des données la responsabilité de répondre aux questions additionnelles et de fournir des données probantes, au besoin. Les principales recommandations découlent d'un consensus au sein du CLDP. Les lignes directrices ont été rédigées, peaufinées et distribuées à un groupe de cliniciens et de patients aux fins de commentaires, puis ont été peaufinées à nouveau et finalisées par le CLDP. RECOMMANDATIONS: Les recommandations consistent à limiter la consommation générale de cannabinoïdes médicaux, mais elles décrivent aussi l'emploi restreint potentiel dans un petit sous-groupe de conditions de santé pour lesquelles des données probantes existent (douleur neuropathique, douleur en soins palliatifs et en fin de vie, nausées et vomissements induits par la chimiothérapie, et spasticité causée par la sclérose en plaques ou une lésion de la moelle épinière). L'article examine en détail d'autres points importants en matière de prescription, et offre du contenu étayant la prise de décision éclairée et partagée. CONCLUSION: Ces lignes directrices simplifiées en matière de prescription de cannabinoïdes médicaux offrent des recommandations pratiques quant à l'emploi de cannabinoïdes en soins de première ligne. Toutes les recommandations visent à contribuer à la prise de décision conjointement avec le patient et non à la dicter.
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BACKGROUND: Pharmacists have the authorization to prescribe medications for the treatment of uncomplicated urinary tract infections (UTI) in some provinces. However, there are limited data on the outcomes of this care by pharmacists. Our objective was to evaluate the effectiveness, safety and patient satisfaction with pharmacist prescribing and care in patients with uncomplicated UTI. METHODS: We conducted a prospective registry trial in 39 community pharmacies in the Canadian province of New Brunswick. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (Pharmacist-Initial Arm) or if they presented with a prescription for an antibacterial to treat UTI from another health care provider (Physician-Initial Arm). Pharmacists assessed patients and if they had complicating factors or red flags for systemic illness or pyelonephritis, they were excluded from the study. Pharmacists either prescribed antibacterial therapy, modified antibacterial therapy, provided education only or referred to physician, as appropriate. The primary outcome was clinical cure at 2 weeks and the secondary outcomes included adverse events and patient satisfaction. RESULTS: A total of 750 patients were enrolled (87.4% in the Pharmacist-Initial Arm), average age was 40.9 (SD 16.0) years. Clinical cure was achieved in 88.9% of patients. Of those that did not have sustained symptom resolution, most (5.5% overall) had symptom recurrence after completion of therapy. Adverse events were reported by 7.2% of patients and 88.9% of those continued their medication. Most adverse events were gastrointestinal-related and transient. The patient satisfaction survey reflected very high levels of satisfaction for the care they received, as well as for trust and accessibility of the pharmacist. CONCLUSION: Pharmacist management of uncomplicated UTI is effective, safe, and patient satisfaction appears very high.