Efficacy and Safety of Colistin versus Tigecycline for Multi-Drug-Resistant and Extensively Drug-Resistant Gram-Negative Pathogens-A Meta-Analysis.

Background: We intended to compare the efficacy and safety outcomes of colistin versus tigecycline as monotherapy or combination therapy against multi-drug resistant (MDR) and extensively drug-resistant (XDR) pathogens. Methods: A search was conducted in PubMed, Cochrane CENTRAL, EMBASE, and in the grey literature (i.e., ClinicalTrials.gov and Google Scholar) up to May 2021. Outcomes were clinical response, mortality, infection recurrence, and renal and hepatic toxicity. We pooled odd ratios (OR) using heterogeneity-guided random or fixed models at a statistical significance of p < 0.05. Results: Fourteen observational studies involving 1163 MDR/XDR pathogens, receiving tigecycline versus colistin monotherapy or combination, were included. Base-case analyses revealed insignificant differences in the clinical response, reinfection, and hepatic impairment. The 30-day mortality was significantly relatively reduced with tigecycline monotherapy (OR = 0.35, 95% CI 0.16−0.75, p = 0.007). The colistin monotherapy significantly relatively reduced in-hospital mortality (OR = 2.27, 95%CI 1.24−4.16, p = 0.008). Renal impairment rates were lower with tigecycline monotherapy or in combination, and were lower with monotherapy versus colistin-tigecycline combination. Low-risk of bias and moderate/high evidence quality were associated with all studies. Conclusions: Within the limitations of this study, it can be concluded that there were no statistically significant differences in main efficacy outcomes between colistin and tigecycline monotherapies or combinations against MDR/XDR infections, except for lower rates of 30-day mortality with tigecycline and in-hospital mortality with colistin. Tigecycline was associated with favourable renal toxicity outcomes.

Investigating pharmacy students' therapeutic decision-making with respect to antimicrobial stewardship cases.

BACKGROUND: Antimicrobial stewardship programs (ASPs) play a big role in minimizing antimicrobial resistance. Pharmacists are essential members of the health care team and in order for them to fulfill roles on ASP teams and become antimicrobial stewards, they must be prepared adequately by pharmacy schools prior to entry into actual practice. Although programming has been implemented into entry-to-practice programs worldwide, little is known about how students interpret antimicrobial stewardship (AMS) data and arrive at clinical decisions. We aimed to explore students' cognitive processes and determine how they formulate therapeutic decisions when presented with AMS cases. METHODS: This was a qualitative study conducted using a case study approach, in which a sample (n=20) of pharmacy students was recruited to interpret AMS cases. Semi-structured 1-on-1 interviews were arranged with each participant. A think-aloud procedure with verbal protocol analysis was adopted to determine students' decision-making processes. Thematic analysis was used to interpret themes from the interview data. RESULTS: Two themes were interpreted from the data: students' focus and students' approach to case interpretation. Students' focus relates to external factors students consider when interpreting AMS case data and use to make and justify therapeutic decisions including patient-centered factors, drug-related factors, AMS interventions, and pharmacist's role. Students' clinical reasoning describes the approach that students use to interpret the data and the decision-making processes they employ to arrive at a clinical decision including a systematic approach versus non-systematic approach. CONCLUSIONS: Students vary in their focus and the cognitive strategies used to interpret AMS cases. Findings support the notion that clinical reasoning and decision-making should be explicitly taught in pharmacy curricula, in order to help students become aware of their own cognitive processes and decision-making abilities.

An Interventional Call-Back Service to Improve Appropriate Use of Antibiotics in Community Pharmacies.

Pharmacists play a key role in tackling antibiotic misuse through counseling and education of patients and healthcare providers. The study aim is to evaluate the appropriateness of antibiotic prescriptions in community pharmacy settings while implementing an interventional call-back service to assess adherence and symptom resolution among patients prescribed an antibiotic. Patients were recruited by community pharmacists who were assigned to either the call-back, structured counseling, or standard care arms. Patients in the call-back group received intensive antibiotic counseling and a phone call from the study pharmacist 3 to 5 days after antibiotic initiation. The counseling arm patients received intensive antibiotic counseling from the study pharmacist while patients in the standard care arm received routine care. Antibiotic adherence rates among the standard care (n = 25), counseling (n = 29), and call-back (n = 26) groups were 64%, 86.2%, and 88.5%, respectively (X2 = 5.862, p = 0.053). Symptom severity scores after completion of antibiotic treatment among all groups were rated as excellent. Twenty-nine percent of the outpatient antibiotic prescriptions were deemed as inappropriate. A pharmacist call-back service is a simple and inexpensive intervention which can effectively identify opportunities for improving appropriate antibiotic use, particularly with respect to adherence.

A Scoping Review of Antimicrobial Stewardship Teaching in Pharmacy Education Curricula.

Objective. To conduct a scoping review of the existing literature to identify published studies on innovative teaching and assessment practices for antimicrobial stewardship in the Doctor of Pharmacy curriculum and to provide a foundation for future scholarly research in this important area.Findings. Seven studies were found that met the inclusion criteria. Two of the studies explored the extent, content, and methods of delivery of antimicrobial stewardship, four studies described elective courses in antimicrobial stewardship, and one study described an interprofessional module. Most studies were conducted in the United States. Several pharmacy schools in the UK and the US incorporated antimicrobial stewardship teaching into their curriculum. Learning objectives for the elective courses focused on guidelines issued by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), antimicrobial stewardship literature appraisal and principal application. The most used teaching strategy was didactic lectures, followed by case studies. Active-learning approaches like simulators, problem-based learning, and presentations were also used but to a lesser extent.Summary. Antimicrobial stewardship curricular reform may be influenced by the timing of the course, teaching approaches, and performance assessment of students. Antimicrobial stewardship learning should be a required of all pharmacy students. The scarcity of scholarly activity in the teaching of and assessment of learning in antimicrobial stewardship suggests that curricular planning should be guided by national or international organizations to ensure pharmacy students learn such important material.

Assessment of antimicrobial stewardship programs within governmental hospitals in Qatar: a SWOC analysis.

OBJECTIVES: Antimicrobial resistance is a worldwide public health issue that requires emergent action. Antimicrobial stewardship programs (ASPs) have been proposed as a strategy to minimise resistance. Although ASPs were implemented in governmental hospitals in Qatar since 2015, a formal evaluation of these programs has not been conducted. We aimed to assess the status of ASPs in Qatar and to identify strengths, weaknesses, opportunities and challenges (SWOC) to further enhance ASPs within Hamad Medical Corporation (HMC). METHODS: Lead stakeholders of ASPs in HMC filled a questionnaire adapted from the 2019 Centers for Disease Control Prevention checklist for ASPs. Notes were taken by research team to assist in formulating a SWOC analysis. KEY FINDINGS: All hospitals (12/12) had an infectious diseases physician and pharmacist designated as an ASP leader (major strength identified). Almost all hospitals lack a financial statement and information technology resources to support ASPs (major weaknesses identified). Nine hospitals had an antibiotic pre-authorisation policy and adopted a prospective audit with feedback strategy. Among hospitals surveyed, 11 hospitals tracked antibiotic use by measuring the defined daily dose, and only four hospitals tracked rates of Clostridioides difficile infection. Qatar's rich economy supports the allocation of financial resources and budgeting to improve ASPs despite the increased emergence of resistant organisms and the limited resources currently available to expand ASPs across the country's healthcare settings. CONCLUSIONS: Although ASPs were implemented in all governmental hospitals in Qatar, national efforts and more resources are needed to further develop and improve these programs.

Exploring the gaps between education and pharmacy practice on antimicrobial stewardship: a qualitative study among pharmacists in Qatar.

Background: Antimicrobial resistance is a public health issue and is the focus of antimicrobial stewardship (AMS) teams within health care institutions. However, AMS is not comprehensively and fully taught in medical or pharmacy curricula and little is known about the relevance of pharmacist training to meet AMS needs in the Middle East region. We aimed to explore the discord that may exist between infectious diseases education and actual clinical practice with regard to AMS knowledge and training skills in Qatar. Then, we sought to further explore pharmacist perceptions of their AMS roles in hospital environments. Methods: A qualitative study was undertaken at Qatar University using three focus groups consisting of 15 pharmacy alumni who are currently practicing as clinical pharmacists in Qatar. Focus groups were facilitated using a topic guide developed by study investigators. Discussions were audio-recorded and transcribed verbatim. Results were analyzed using framework analysis. Results: Two major themes related to the first objective emerged throughout the discussions and associated recommendations made to improve (i) infectious diseases (ID) module content and delivery and (ii) ID knowledge and skills application. Two themes related to the second objective included (i) impact of pharmacist's interventions on decision-making and (ii) continuing professional development programming. Conclusion: Our findings guide ongoing efforts to enhance ID content in the curriculum and will close gaps related to AMS training. Pharmacists are core AMS team members where there is an ongoing need to align continuing education for health professionals with realities of practice.

Practice implications of an antimicrobial stewardship intervention in a tertiary care teaching hospital, Qatar.

BACKGROUND: Antibiotic misuse is a worldwide public health problem and has been associated with increased morbidity, length of hospital stay, mortality, healthcare costs, and most importantly antibiotic resistance. AIMS: We aimed to evaluate the compliance of antibiotic prescribing with national guidelines, assess how educational interventions can best be utilized to make impact and fill gaps for optimal antibiotic utilization, and to identify facilitators and barriers to implementing ASPs in Qatar. METHODS: Six cross-sectional baseline audits of antibiotic prescribing were conducted over a two-week period at a tertiary care teaching hospital. A sub-analysis of prescriptions with follow up has followed. An educational intervention utilizing the PDSA (Plan-Do-Study-Act) tool was implemented to address gaps identified. A repeated audit was done to assess the impact of change. Lastly, interviews were conducted to recognize perceived facilitators and barriers for ASP implementation, identify strategies to overcome barriers, and evaluate the effectiveness of educational interventions. RESULTS: The most common indication for antibiotic prescribing was febrile neutropenia (20.7%). The most frequently used class of antibiotics was carbapenems (21.4%). Sixty percent of prescriptions complied with guidelines. The rationale behind choosing not to adhere to guidelines was not documented in 37.2% of cases. Suboptimal documentation in records was targeted through our intervention. The audit post intervention showed slight improvement in documentation. Facilitators and barriers included: collaboration and communication among teams, compliance with guidelines, interventions documented by clinical pharmacists, and electronic system errors. CONCLUSIONS: Effective communication, continuous documentation in records, and repetitive education promote rational antibiotic prescribing and enhance ASPs.

Exploring the Influence of Language on Assessment Given a Mismatch Between Language of Instruction and Language of Practice.

STATEMENT: A phenomenon is occurring in international settings where the language of program delivery and assessment does not match the primary language of practice. It is unknown whether determining competence in English disadvantages students for practice in non-English settings. As such, we conducted a pilot study to determine student performance and perceptions after completion of two Objective Structured Clinical Examinations (OSCEs) examinations, one conducted in English and one conducted in Arabic within an Arabic-speaking Middle Eastern setting. Twenty-two students completed both OSCEs. Overall scores were similar but student rankings differed. Students were more confident performing in Arabic, felt that the Arabic examination was more reflective of practice, and believed that use of Arabic OSCEs can promote better patient care. Findings support the notion that student success may be influenced by language of assessment and that we may need to rethink how we determine assessment validity in these emerging international education settings.

Critical appraisal of clinical practice guidelines for adult cancer patients with febrile neutropenia.

OBJECTIVES: To critically appraise published international clinical practice guidelines (CPGs) for management of febrile neutropenia in adult patients with cancer and to determine opportunities for improved development and reporting. METHODS: A literature search identified CPGs for adult cancer patients with febrile neutropenia. Four independent assessors evaluated each included CPG according to the Appraisal of Guidelines for Research and Evaluation II instrument. Standardized scores were calculated for each guideline and polled collectively. Reliability of assessment was determined using a two-way random model intraclass correlation coefficients. KEY FINDINGS: Eight CPGs were independently evaluated by four assessors. Collectively, the highest scoring domain was editorial independence (83.3), followed by clarity of presentation (55.4), scope and purpose (53.4), stakeholder involvement (53.1), rigour of development (52.7) and applicability (47.8). Overall assessments ranged from 28.6 to 96.4 of 100 possible points. Three (37.5%) guidelines were recommended for use without alterations, two (25%) guidelines were recommended with alterations, and three (37.5%) guidelines were not recommended for implementation into practice. Reliability varied between guidelines with intraclass correlation coefficients ranging from 0.41 to 0.82. CONCLUSIONS: Clinical practice guidelines for febrile neutropenia in adult patients with cancer were moderately rated with a 37.5% of guidelines being recommended for use in practice. Guideline developers should focus on improving CPG applicability and rigour in the development and reporting processes. Critical appraisal of guidelines should become a standard practice prior to implementation into clinical settings.

Introducing problem-based learning into a Canadian-accredited Middle Eastern educational setting.

BACKGROUND AND PURPOSE: Adaption of active learning strategies into new cultures and contexts requires careful consideration to maximize effectiveness and meet intended objectives. The aim of this paper was to describe the adaption and implementation of problem-based learning (PBL) within a pharmacy curriculum in a Middle Eastern context. EDUCATIONAL ACTIVITY AND SETTING: PBL was implemented into the curriculum at Qatar University in 2014 and expanded in subsequent years to include differing courses and contexts. The process was blueprinted to align with international accreditation standards. A SWOC (Strengths, Weaknesses, Opportunities, Challenges) analysis was completed to identify cultural and contextual facilitators and barriers regarding implementation and achievement of target outcomes. FINDINGS: Strengths included novelty, enhancement of learning, engagement, and accreditation alignment. Weaknesses included student preparation and buy in, facilitation inconsistency, and logistical support. Opportunities included expansion, departmental support, timing, and congruency with practice skills. Challenges included student resistance, departmental engagement, assessment, expansion, and cultural norms in teaching and learning. DISCUSSION AND SUMMARY: PBL provided benefit but also presented many cultural and contextual challenges of adaption from Western settings. Future work should focus addressing these cultural factors, to promote effectiveness of PBL as an active learning strategy.

The impact of antimicrobial stewardship strategies on antibiotic appropriateness and prescribing behaviours in selected countries in the Middle East: a systematic review.

Antimicrobial resistance is a global health problem and antimicrobial stewardship is an essential component of hospital policies worldwide yet little is known regarding effective implementation strategies in the Middle East. We conducted a review of studies carried out in this region that deployed different antimicrobial stewardship strategies to assess antimicrobial appropriateness and prescribing behaviours. A search of MEDLINE, EMBASE, International Pharmaceutical Abstracts, Google and Google Scholar was conducted. Twenty articles met the inclusion criteria; 2 studies evaluated strategies including prospective audit with feedback, while 18 others evaluated strategies including benchmarking antimicrobial utilization against guidelines. Recommendations for implementation of stewardship in the Middle East highlighted the importance of developing and updating local antimicrobial prescribing policies and using collaborative interdisciplinary approaches for success.

A Review of Clinical Outcomes Associated with Two Meropenem Dosing Strategies.

Meropenem is a carbapenem antibiotic that exhibits time-dependent bactericidal activity, traditionally dosed intravenously at 1 g every 8 h. In order to maximize its pharmacodynamic activity and reduce costs, an alternative regimen employed by many institutions is 500 mg every 6 h. The objective of this review was to summarize and evaluate published literature comparing clinical outcomes associated with these two meropenem dosing regimens. The literature was searched up to October 2016 using the MEDLINE, EMBASE, and Google Scholar databases. Three retrospective cohort studies were identified that compared clinical outcomes in general infectious disease patients (two studies) and patients with febrile neutropenia (one study). All studies reported no difference in clinical outcomes (clinical success, time to defervescence, sign or symptom resolution, length of stay, mortality, need for other antibiotics, and seizure rates). One study reported reduced economic costs with the alternative dosing. Interpretation of findings was primarily limited by small sample sizes and generalizability. Based on the data reviewed, the alternative dosing regimen of meropenem 500 mg intravenously every 6 h could be considered a therapeutic option. Future studies are needed to confirm the findings of this review, especially in high-risk populations such as immunocompromised patients or those with severe infections.

Bridging theory and practice: Mixed methods approach to instruction of law and ethics within the pharmaceutical sciences.

Background: Professional responsibilities are guided by laws and ethics that must be introduced and mastered within pharmaceutical sciences training. Instructional design to teaching typically introduces concepts in a traditional didactic approach and requires student memorization prior to application within practice settings. Additionally, many centers rely on best practices from abroad, due to lack of locally published laws and guidance documents. Objectives: The aim of this paper was to summarize and critically evaluate a professional skills laboratory designed to enhance learning through diversity in instructional methods relating to pharmacy law and best practices regarding narcotics, controlled medications, and benzodiazepines. Setting: This study took place within the Professional Skills Laboratory at the College of Pharmacy at Qatar University. Method: A total of 25 students participated in a redesigned laboratory session administered by a faculty member, clinical lecturer, teaching assistant, and a professional skills laboratory technician. The laboratory consisted of eight independent stations that students rotated during the 3-h session. Stations were highly interactive in nature and were designed using non-traditional approaches such as charades, role-plays, and reflective drawings. All stations attempted to have students relate learned concepts to practice within Qatar. Main outcome measures: Student perceptions of the laboratory were measured on a post-questionnaire and were summarized descriptively. Using reflection and consensus techniques, two faculty members completed a SWOC (Strengths, Weaknesses, Opportunities, and Challenges) analysis in preparation for future cycles. Results: 100% (25/25) of students somewhat or strongly agreed that their knowledge regarding laws and best practices increased and that their learning experience was enhanced by a mixed-methods approach. A total of 96% (24/25) of students stated that the mixed-methods instructional approach should be continued in the future. The SWOC analysis identified the mixed methods approach and student feedback as strengths and opportunities, while resource shortages and lack of impact assessment were identified as weaknesses and challenges. Conclusion: Creative redesign of instructional methods pertaining to law and best practices was effective to achieve positive student perceptions regarding instructional methods and learning. Future cycles should include rigorous assessment methods to evaluate impact on student learning and practice.

Levetiracetam for seizure prevention in brain tumor patients: a systematic review.

Seizures are common complications for patients with brain tumors. No clear evidence exists regarding the use of antiepileptic agents for prophylactic use yet newer agents are being favoured in many clinical settings. The objective of this systematic review was to determine the efficacy of levetiracetam for preventing seizures in patients with brain tumors. A literature search was completed using the databases PubMed (1948 to December 2015), EMBASE (1980 to December 2015), Cochrane Database of Systematic Reviews, and Google Scholar. Studies were included if they reported seizure frequency data pertaining to levetiracetam use in patients with brain tumors as either monotherapy or as an add on agent. The literature search produced 21 articles (3 randomized controlled trials, seven prospective observational studies, and 11 retrospective observational studies). All studies were found to be at high risk of bias. Overall, studies show levetiracetam decreased seizure frequency in brain tumor patients with or without craniotomy. Safety outcomes were also favourable. As such, levetiracetam appears effective for reducing seizures in patients with brain tumors and may be considered a first-line agent. However, there is an urgent need for more high quality prospective data assessing levetiracetam and other antiepileptic drugs in this population.