Assessing the rationale of prescribing carbapenems among hospitalized patients with documented penicillin allergy: implications for stewardship.

Background: A reported history of penicillin allergy frequently leads to the prescription of carbapenems as a substitute for penicillin to avoid allergic reactions. Such self-reported allergies need to be accurately characterized to identify targeted antibiotic stewardship interventions that potentially minimize unnecessary carbapenem use. Design: Retrospective cohort study. Method: The proportion of hospitalized patients with penicillin allergy history receiving carbapenem prescriptions was evaluated between January 1st, 2017 and December 31st, 2018 at the University Hospital Basel, Switzerland. The appropriateness of carbapenem prescription of each patient was evaluated using institutional guidelines based on previously published recommendations. Results: Our analysis revealed that among 212 patients with recorded penicillin allergy, of the 247 carbapenem treatment episodes, 79 (32%) were unjustified. Abdominal and lower respiratory tract infections were most frequently associated with inappropriate carbapenem use (OR 2.64, 95% CI 1.22-5.71, P = .014 and OR 2.26, 95% CI 1.08-4.73, P = .031). The recorded allergy type was not documented or unclear in 153 patients (72%) and penicillin allergy was only confirmed in 2 patients (0.9%). Inconsistencies in allergic symptom documentation and allergy types were found between the institution's two software programs. Conclusion: While a multimodal approach to identify and accurately label penicillin allergies remains essential to reduce inappropriate carbapenem use, our findings highlight the need for comprehensive and easily accessible guidelines for carbapenem utilization and structured history-based allergy assessment as an initial screening tool, embedded in a tailored digital allergy record template.

Air temperature and incidence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae.

BACKGROUND: Higher outdoor temperature may be related to an increase in antibiotic resistant bacteria. We investigated the association between local outdoor air temperature and the incidence of extended-spectrum betalactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) correcting for known drivers of antibiotic resistance. METHODS: We performed a time-series regression study using prospectively collected weekly surveillance data on all ESBL-PE isolated from in- and outpatients of the University Hospital Basel, a tertiary care center in Switzerland, between 01/2008-12/2017. Temperature was measured hourly at the meteorological institute of the University Basel next to our institution over this time period. A time-series approach using a Poisson regression model and different lag terms for delayed exposure effects was performed to assess associations between minimal, mean and maximal weekly temperature and the number of ESBL-PE recovered. RESULTS: Over 10 years, recovery of ESBL-PE increased (annual incidence rate ratio [IRR] 1.14, 95%CI 1.13-1.16), while mean weekly temperature measures remained stable. In multivariable analyses, increasing temperature was associated with higher recovery rates of ESBL-PE after three to four weeks, correcting for potential confounders, such as the number of admissions, proportion of long-term nursing facility- and ICU-admissions, age, Charlson comorbidity index and consumption of antimicrobials (IRRs per 10 °C ranging from 1.14 to 1.22, 95%CIs 1.07-1.33). These trends remained when analyzing correlations between temperature with the proportion of extended spectrum cephalosporin resistance of all recovered Enterobacteriaceae. CONCLUSIONS: Higher outdoor temperature may be associated with an increase of ESBL-PE-incidence, independent of important confounders, such as antimicrobial consumption and thus should be considered for future resistance-trajectories.

Drug-Associated Risk Tool: development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems.

INTRODUCTION: Identifying patients with a high risk for drug-related problems (DRPs) might optimise the allocation of targeted pharmaceutical care during the hospital stay and on discharge. OBJECTIVE: To develop a self-assessment screening tool to identify patients at risk for DRPs and validate the tool regarding feasibility, acceptability and the reliability of the patients' answers. DESIGN: Prospective validation study. SETTING: Two mid-sized hospitals (300-400 beds). PARTICIPANTS: 195 patients, exclusion criteria: under 18 years old, patients with a health status not allowing a meaningful communication (eg, delirium, acute psychosis, advanced dementia, aphasia, clouded consciousness state), palliative or terminally ill patients. METHODS: Twenty-seven risk factors for the development of DRPs, identified in a previous study, provided the basis of the self-assessment questionnaire, the Drug-Associated Risk Tool (DART). Consenting patients filled in DART, and we compared their answers with objective patient data from medical records and laboratory data. RESULTS: One hundred and sixty-four patients filled in DART V.1.0 in an average time of 7 min. After a first validation, we identified statements with a low sensitivity and revised the wording of the questions related to heart insufficiency, renal impairment or liver impairment. The revised DART (V.2.0) was validated in 31 patients presenting heart insufficiency, renal impairment or liver impairment as comorbidity and reached an average specificity of 88% (range 27-100) and an average sensitivity of 67% (range 21-100). CONCLUSIONS: DART showed a satisfying feasibility and reliability. The specificity of the statements was mostly high. The sensitivity varied and was higher in statements concerning diseases that require regular disease control and attention to self-care and drug management. Asking patients about their conditions, medications and related problems can facilitate getting a first, broad picture of the risk for DRPs and possible pharmaceutical needs.

[Validation of the German Translation of the Revised Trauma Symptom Inventory (TSI-2) to Assess Complex Posttraumatic Stress Symptoms]. / Validierung der deutschen Übersetzung des revidierten Trauma Symptom Inventory (TSI-2) zur Erfassung komplexer posttraumatischer Belastungssymptomatik.

The study aimed to validate the German version of the revised Trauma Symptom Inventory (TSI-2) by John Briere. TSI-2 assesses complex posttraumatic stress symptoms. In order to validate it, further instruments were applied, namely the Adverse Childhood Experience Scale, the CIDI list, the revised Impact of Event-Scale, the interview for complex posttraumatic stress disorder, the revised symptom checklist 90, the dissociative experiences scale, the inventory for interpersonal problems, and the self-efficacy questionnaire. The participants were N=100 traumatized psychiatric in-patients of a psychiatric hospital localized in the German-speaking part of Switzerland. The sample consisted of N=42 women. The study design was longitudinal with 2 assessments. The second assessment took place 4 weeks after the first, in order to investigate retest reliability. Here, N=17 patients participated, of whom N=8 were women. Regarding the results, on average, 3.5 aversive or traumatic experiences during childhood were reported, and 2,1 during adulthood. The diagnosis of (classical) PTSD was estimated at 33%. The results indicate that TSI-2 is both reliable and valid with respect to different criteria: Most scales and subscales of the TSI-2 showed acceptable to very good internal consistencies (α from 0.73 to 0.95) as well as good discriminatory power, and an acceptable retest reliability. Results also indicate good divergent and convergent construct validity as well as good criterion validity. It was not possible to replicate the 4-factor-model presented by the original author of the TSI-2. Instead, in line with the study that validated the German translation of the first version of the TSI-1, a 2-factor-model was found. There were gender differences regarding the TSI-2 scales with higher posttraumatic stress symptoms in women. In conclusion, there is evidence that indicates that the German translation of the TSI-2 is a reliable and valid instrument for the assessment of complex posttraumatic stress symptoms.

Determination of risk factors for drug-related problems: a multidisciplinary triangulation process.

INTRODUCTION AND OBJECTIVES: Drug-related problems (DRPs) constitute a frequent safety issue among hospitalised patients leading to patient harm and increased healthcare costs. Because many DRPs are preventable, the specific risk factors that facilitate their occurrence are of considerable interest. The objective of our study was to assess risk factors for the occurrence of DRPs with the intention to identify patients at risk for DRPs to guide and target preventive measures where they are needed most in patients. DESIGN: Triangulation process using a mixed methods approach. METHODS: We conducted an expert panel, using the nominal group technique (NGT) and a qualitative analysis, to gather risk factors for DRPs. The expert panel consisted of two consultant hospital physicians (internal medicine and geriatrics), one emergency physician, one independent general practitioner, one clinical pharmacologist, one clinical pharmacist, one registered nurse, one home care nurse and two independent community pharmacists. The literature was searched for additional risk factors. Gathered factors from the literature search and the NGT were assembled and validated in a two-round Delphi questionnaire. RESULTS: The NGT resulted in the identification of 33 items with 13 additional risk factors from the qualitative analysis of the discussion. The literature search delivered another 39 risk factors. The 85 risk factors were refined to produce 42 statements for the Delphi online questionnaire. Of these, 27 risk factors were judged to be 'important' or 'rather important'. CONCLUSIONS: The gathered risk factors may help to characterise and identify patients at risk for DRPs and may enable clinical pharmacists to guide and target preventive measures in order to limit the occurrence of DRPs. As a further step, these risk factors will serve as the basis for a screening tool to identify patients at risk for DRPs.

Inappropriate prescribing: a systematic overview of published assessment tools.

BACKGROUND: Criteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient's pharmacotherapy. OBJECTIVE: To create a comprehensive and structured overview of existing tools to assess inappropriate prescribing. METHOD: Systematic literature search in Pubmed (1991-2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing. RESULTS: The literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described. CONCLUSION: This overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use.