Empirical prescribing of penicillin G/V reduces risk of readmission of hospitalized patients with community-acquired pneumonia in Norway: a retrospective observational study.

BACKGROUND: Norwegian guideline recommendations on first-line empirical antibiotic prescribing in hospitalised patients with community-acquired pneumonia (CAP) are penicillin G/V in monotherapy, or penicillin G in combination with gentamicin (or cefotaxime) in severely ill patients. The aim of this study was to explore how different empirical antibiotic treatments impact on length of hospital stay (LOS) and 30-day hospital readmission. A secondary aim was to describe median intravenous- and total treatment duration. METHODS: We included CAP patients (≥18 years age) hospitalised in North Norway during 2010 and 2012 in a retrospective study. Patients with negative chest x-ray, malignancies or immunosuppression or frequent readmissions were excluded. We collected data on patient characteristics, empirical antibiotic prescribing, treatment duration and clinical outcomes from electronic patient records and the hospital administrative system. We used directed acyclic graphs for statistical model selection, and analysed data with mulitvariable logistic and linear regression. RESULTS: We included 651 patients. Median age was 77 years [IQR; 64-84] and 46.5% were female. Median LOS was 4 days [IQR; 3-6], 30-day readmission rate was 14.4% and 30-day mortality rate was 6.9%. Penicillin G/V were empirically prescribed in monotherapy in 51.5% of patients, penicillin G and gentamicin in combination in 22.9% and other antibiotics in 25.6% of patients. Prescribing other antibiotics than penicillin G/V monotherapy was associated with increased risk of readmission [OR 1.9, 95% CI; 1.08-3.42]. Empirical antibiotic prescribing was not associated with LOS. Median intravenous- and total treatment duration was 3.0 [IQR; 2-5] and 11.0 [IQR; 9.8-13] days. CONCLUSIONS: Our findings show that empirical prescribing with penicillin G/V in monotherapy in hospitalised non-severe CAP-patients, without complicating factors such as malignancy, immunosuppression and frequent readmission, is associated with lower risk of 30-day readmission compared to other antibiotic treatments. Median total treatment duration exceeds treatment recommendations.

An audit and feedback intervention study increased adherence to antibiotic prescribing guidelines at a Norwegian hospital.

BACKGROUND: Appropriate antibiotic prescribing is associated with favourable levels of antimicrobial resistance (AMR) and clinical outcomes. Most intervention studies on antibiotic prescribing originate from settings with high level of AMR. In a Norwegian hospital setting with low level of AMR, the literature on interventions for promoting guideline-recommended antibiotic prescribing in hospital is scarce and requested. Preliminary studies have shown improvement potentials regarding antibiotic prescribing according to guidelines. We aimed to promote appropriate antibiotic prescribing in patients with community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) at a respiratory medicine department in a Norwegian University hospital. Our specific objectives were to increase prescribing of appropriate empirical antibiotics, reduce high-dose benzylpenicillin and reduce total treatment duration. METHODS: We performed an audit and feedback intervention study, combined with distribution of a recently published pocket version of the national clinical practice guideline. We included patients discharged with CAP or AECOPD and prescribed antibiotics during hospital stay, and excluded those presenting with aspiration, nosocomial infection and co-infections. The pre- and post-intervention period was 9 and 6 months, respectively. Feedback was provided orally to the department physicians at an internal-educational meeting. To explore the effect of the intervention on appropriate empirical antibiotics and mean total treatment duration we applied before-after analysis (Student's t-test) and interrupted time series (ITS). We used Pearson's χ2 to compare dose changes. RESULTS: In the pre-and post-intervention period we included 253 and 155 patients, respectively. Following the intervention, overall mean prescribing of appropriate empirical antibiotics increased from 61.7 to 83.8 % (P < 0.001), overall mean total treatment duration decreased from 11.2 to 10.4 days (P = 0.015), and prescribing of high-dose benzylpenicillin decreased from 48.8 to 38.6 % (P = 0.125). With ITS we found that six months post-intervention, the effect on appropriate empirical antibiotic prescribing had increased and sustained, while the effect on treatment duration was at pre-intervention level. CONCLUSION: The combination of audit and feedback plus distribution of a pocket version of guideline recommendations led to a substantial increase in prescribing of appropriate empirical antibiotics, which is important due to favourable effect on AMR and clinical outcomes.

A pharmacist-led follow-up program for patients with established coronary heart disease in North Norway - a randomized controlled trial / / Programa farmacéutico de seguimiento para pacientes con enfermedad coronaria establecida en el norte de Noruega - Ensayo controlado aleatorizado

Objectives: The aim of the study was twofold; 1) to develop a clinical pharmacist-led 12 month lasting followup program for patients with established coronary heart disease (CHD) discharged from the University Hospital of North Norway, and 2) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors. Methods: A total of 102 patients aged 18-82 years were enrolled in a non-blinded randomized controlled trial with an intervention group and a control group. The intervention comprised medication reconciliation, medication review and patient education during three meetings; at discharge, after three months and after twelve months. The control group received standard care from their general practitioner. Primary outcomes were adherence to clinical guideline recommendations concerning prescription, therapy goal achievement and lifestyle education defined in the medication assessment tool for secondary prevention of CHD (MAT-CHDSP). Secondary outcomes included changes in the biomedical risk factors cholesterol, blood pressure and blood glucose. Results: Ninety-four patients completed the trial, 48 intervention group patients and 46 controls. Appropriate prescribing was high, but therapy goal achievement was low in both groups. Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end, 78.4% vs. 62.0%, p<0.001. The difference was statistically significant for the documented lifestyle advices in intervention group patients. No significant improvements in biomedical risk factors were observed in favor of the intervention group. Conclusions: The study showed an increased guideline adherence in both study groups. This indicates that attention to clinical practice guideline recommendations in itself increases adherence - which may be a clinical pharmacist task. A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention. Amendments to the follow-up program are suggested before implementation in standard patient care can be recommended (AU)

Objetivos: El objetivo del presente estudio fue doble: 1) desarrollar un programa de seguimiento farmacéutico de 12 meses de duración para pacientes con enfermedad coronaria establecida (CHD) dados de alta del Hospital Universitario de Noruega del Norte, y 2) explorar el impacto del programa en relación a un instrumento de evaluación para la prevención secundaria de CHD y cambios en los factores de riesgo biomédicos. Métodos: Se incluyeron en un estudio controlado aleatorizado no cegado un total de 102 pacientes de 18- 82 años. La intervención consistió en reconciliación de la medicación, revisión de la medicación, y educación del paciente en tres encuentros: al alta, después de 3 meses y después de 12 meses. El grupo control recibió los cuidados habituales de su médico general. Los outcomes primarios fueron la adherencia a las guías de práctica clínica relativa a la prescripción, la consecución de los objetivos terapéuticos y los hábitos de vida definidos en el instrumento de evaluación de la prevención secundaria de CHD (el MAT-CHDSP). Los outcomes secundarios incluían cambios en los factores biomédicos de riesgo, como colesterol, presión arterial y glucemia. Resultados: 94 pacientes completaron el ensayo, 48 en el grupo intervención y 46 controles. La prescripción adecuada fue elevada, pero la consecución de los objetivos terapéuticos fue baja en ambos grupos a lo largo del estudio. La adherencia total a los criterios del MAT-CHDSP aumentó en ambos grupos, y fue significativamente mayor en el grupo intervención al final del estudio, comparado con el control (78.4% vs. 60.2%, respectivamente, p<0.001). La diferencia fue estadísticamente significativa para los estilos de vida aconsejados en los pacientes del grupo intervención. No se observaron cambios significativos en los factores biomédicos de riesgo a favor del grupo intervención. Conclusiones: El estudio mostró un aumento de adherencia a las guías en ambos grupos. Esto indica que la atención a las recomendaciones de las guías de práctica clínica por sí mismo aumenta la adherencia - lo que podría ser una tarea del farmacéutico. Se necesita un estudio mayor y con más poder para mostrar una diferencia significativa en la mejoría a favor de la intervención de los factores biomédicos de riesgo. Pueden recomendarse modificaciones a los programas de seguimiento que mejoren la implantación en los cuidados normales de los pacientes (AU)

MAT-CAP: a novel medication assessment tool to explore adherence to clinical practice guidelines in community-acquired pneumonia.

BACKGROUND/PURPOSE: Community-acquired pneumonia (CAP) is a disease with high morbidity and mortality. Adherence to clinical practice guidelines (CPGs) in treatment of CAP is associated with favourable outcome. We aimed to develop and validate a medication assessment tool (MAT) to explore adherence to CPG recommendations in patients with CAP admitted to a Norwegian hospital. The tool is named MAT-CAP. METHOD: Sixteen quality indicators (QIs) based on local and international CPGs were developed. Content validity was explored in an expert panel using a two-round modified Delphi technique. QIs demonstrating content valdity were reformulated into review criteria forming the MAT-CAP. Feasibility and adherence to MAT-CAP were explored in a retrospective study using data from electronic patient records of CAP patients admitted to the University Hospital of North Norway Tromso during 2008. Reliability was explored using Cohen's kappa (ĸ) statistics for inter- and intra-observer agreements. RESULTS: Content validity was demonstrated for 15 QIs covering areas as initial empirical treatment, microbiological diagnostics, pathogen specific treatment, dose adjustment according to renal function, switch from intravenous to oral treatment and treatment duration. Overall reliability was excellent with ĸ-values of 0.88 and 0.95 for inter-observer and intra-observer agreements, respectively. Overall applicability was 37.2%, and mean application times were 3.1 and 3.8 min for the two observers. Overall adherence to 812 criteria applied was 59% (range 0-100). CONCLUSIONS: We have demonstrated content validity, feasibility and reliability of a 15-criterion MAT-CAP. Adherence results from applying MAT-CAP criteria pinpointed areas with good clinical performance and areas with improvement potentials.