AntibiogramDSM: a combined local antibiogram and educational intervention.

Objective: To describe the development of a combined local antibiogram and assess its utility in an educational intervention. Design: Retrospective analysis of a combined, multi-healthcare system antibiogram with an educational intervention and pre-post analysis. Setting: Creation of the combined antibiogram included all health systems in Des Moines, Iowa. The educational intervention was delivered live via webinar and remained available on demand for one year. Participants: The combined antibiogram participants included four health systems representing eight hospitals. The educational intervention included 45 healthcare providers (15 live, 30 on demand) who elected to participate. Methods: Yearly antibiograms were collected from four health systems for 2017 and 2018 and from three health systems for 2019 and 2020. Each was aggregated into a single antibiogram, posted online, and analyzed retrospectively. In 2021, an educational intervention took place, which included pre-educational assessments, a one-hour presentation on local resistance rates and impact on common infections, and post-education assessments. The educational session was available online for one year. Correct responses before and after education were compared using NcNemar's test. Results: Over 4 yr, 123,168 isolates were included in the antibiogram, representing 57 species and 46 tested antibiotics. Before education, prediction of local resistance rates for E. coli and S. pneumoniae was poor. After the education session, there was improvement in the proportion of correct responses to case-based questions: pneumonia (31.8% vs 58.8%, P = 0.022), UTI (47.7% vs 85.3%, P < 0.001), sinusitis (75% vs 91.2%, P = 0.109), and diverticulitis (43.2% vs 88.2%, P = 0.002). Conclusions: A combined local antibiogram was useful in supporting an outpatient education program.

Delayed and Non-Antibiotic Therapy for Urinary Tract Infections: A Literature Review.

Urinary tract infections are among the most common infections encountered in the clinic and remain a top indication for women to receive antibiotics. Delayed antibiotic prescribing and non-antibiotic symptomatic therapies are treatment paradigms common to other uncomplicated infectious diseases, such as upper respiratory infections. We aimed to review the literature on delayed antibiotics and non-antibiotic treatments as alternatives to immediate antibiotic prescriptions for uncomplicated cystitis. A literature search was performed in PubMed, Google Scholar, and Web of Science to identify relevant clinical trials and reference lists of included articles were examined to find additional studies. All published trials where same day treatment with antibiotics was compared to scenarios where antibiotics were intentionally delayed or withheld or where antibiotics were compared to non-antimicrobial agents or placebo were analyzed. A total of 13 articles were included. Trials were grouped into categories based on their comparator groups: placebo (n = 5), delayed antibiotic therapy (n = 3), and symptomatic treatment (n = 5). Antibiotic delay and ibuprofen, while less effective than antibiotics in early microbiologic and clinical cure, may still be considered plausible alternatives to immediate antibiotic treatment in non-pregnant women with cystitis. Day 7 and later symptomatic resolution ranges from 26-75% with delayed or placebo therapy and 70-83% with nonsteroidal anti-inflammatory drugs. Symptom improvement, however, may be delayed compared to immediate antibiotics. These approaches have shown to decrease antibiotic use in primary care settings with low rates of pyelonephritis. Methodology included in these studies may be considered in stewardship interventions for outpatient clinics.

Incidence of a negative hidden curriculum, cynicism, and burnout within pharmacy resident education: A nationwide survey.

INTRODUCTION: The term "hidden curriculum" (HC) is a set of ethical, moral, and value-based teachings communicated in a non-explicit manner. Recent literature has described increasing awareness of the prevalence of the HC and potential negative impact on medical learners; however, this information is lacking in pharmacy resident education. Consequently, we conducted a survey study of United States pharmacy residents to learn their perceptions concerning the HC in pharmacy residency training. METHODS: A nationwide survey of pharmacy residents was conducted in June 2019. The survey assessed the following: presence of negative HC (score 0 to 80), cynicism (score 0 to 25), burnout via Maslach Burnout Inventory depersonalization (MBI-D) (range 0 to 30), and emotional exhaustion via Maslach Burnout Inventory emotional exhaustion (MBI-EE) (range 0 to 54). Higher scores represent increased occurrences of each domain. RESULTS: The mean HC score was 20 (SD 14.7), mean cynicism score was 9 (SD 5.5), MBI-D was 5.5 (SD 4.5), and MBI-EE was 24.2 (SD 12.4). Of those completing an MBI score, 40.4% (82/203) reported burnout in one area, while 15.8% (32/203) reported burnout in both areas. Residents reporting burnout had higher mean HC and cynicism scores. CONCLUSIONS: Awareness to develop and grow cultures that minimize the presence of a negative HC is essential to improve postgraduate pharmacy training.

"Pimping" in Pharmacy Education: A Survey and Comparison of Student and Faculty Views.

BACKGROUND: "Pimping" is an informal teaching technique that is widely used in medical education. Pimping is characterized by questioning the learner with the intent of reinforcing clinical hierarchy. To date, there are no studies of the use of pimping in pharmacy education. OBJECTIVES: To describe the use of pimping as a teaching method in pharmacy education and to compare student and faculty perceptions of this technique. METHODS: Faculty and fourth-year PharmD (P4) students from 2 colleges of pharmacy were invited to participate in a survey about experiences and perceptions of pimping. Faculty and P4 surveys each contained up to 17 items to assess personal experiences, utilization, perceived risks and benefits, and preferences regarding the role of the technique in pharmacy education. RESULTS: The response rate was 49.5% (159 of 321). Of faculty, 74.1% reported they had been pimped in their training, but less than half (45.8%) use pimping themselves. Similarly, 73.7% of students reported that they had been pimped at some time in their pharmacy education. Students nearly equally viewed their experiences as positive (35.3%) versus negative (38.2%). Responses were similar between faculty and students recommending that the method should be avoided entirely ( P = .259), used sparingly ( P = .072), or used consistently ( P = .309). Perceived benefits and risks of pimping were similar between faculty and students, but there were many differences in rationales offered by faculty versus students' perceived rationales. CONCLUSION: Pimping is common in pharmacy education and its use is controversial. The perceived rationale for use of pimping differs, which may undermine student/faculty relationships.

Educating medical residents through podcasts developed by PharmD students.

BACKGROUND AND PURPOSE: Podcasts are increasingly popular in education due to their accessibility, portability, and scheduling flexibility. Pharmacy students often interact with resident physicians during advanced pharmacy practice experiences, but few studies have evaluated their ability to teach medical residents about pharmacotherapy concepts or how these interactions might impact their own development. We sought to evaluate the efficacy of pharmacy student-created podcasts in two areas: the ability to increase medical resident understanding of selected medical topics and the effect on the pharmacy student's confidence in teaching. EDUCATIONAL ACTIVITY AND SETTING: Eight fourth-year pharmacy students created enhanced podcasts and assessment questions on a medical topic. The assessment questions were split randomly into pre- and post-podcast assessments to be given to residents. The assessment quizzes and podcast comprised content modules that were delivered to consenting medical residents at two week intervals. Pharmacy student confidence was evaluated with pre- and post-experience surveys, which were administered before they created the podcast and after they viewed the aggregate results of resident assessments of their podcast. FINDINGS: Overall, 79.3% (23/29) of residents participated with an average of 44% participation on each module. Resident knowledge increased as evidenced by the overall aggregate score, significantly improving from 36% prior to podcasts to 76% following podcasts (p=0.001). When rated on a 1-10 scale, average pharmacy student confidence in teaching their topic also significantly increased from 5.63 to 8.00 (p=0.041). SUMMARY: Podcasts are an effective method for medical residents to learn from pharmacy students and may also improve pharmacy students' confidence in their abilities.

Irritable bowel syndrome: a concise review of current treatment concepts.

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders causing patients to seek medical treatment. It is relatively resource intensive and the source of significant morbidity. Recent insights into the pathophysiology and treatment of IBS has given clinicians more options than ever to contend with this disorder. The purpose of our paper is to review older, "classic" treatments for IBS as well as newer agents and "alternative" therapies. We discuss the evidence base of these drugs and provide context to help develop appropriate treatment plans for IBS patients.

Effects of depressive and other psychiatric disorders on anticoagulation control in a pharmacist-managed anticoagulation clinic.

BACKGROUND: The impact of psychiatric disorders on International Normalized Ratio (INR) control and adverse events for patients receiving warfarin has not been fully elucidated. OBJECTIVE: To determine the effect of depressive and other psychiatric disorders on anticoagulation control in a pharmacist-managed anticoagulation clinic. METHODS: A retrospective chart review evaluated outcomes of patients with no history of psychiatric disorders and compare it with that of patients with either a history of depression or any form of psychiatric disorder. Data was obtained from patient medical records over a 24-month period. The primary outcome was a comparison of time in therapeutic range, calculated using 3 separate methods (percentage of INRs in therapeutic range, a modified Rosendaal's linear interpolation, and mean INR in goal). RESULTS: A total of 151 patients met the inclusion criteria (control = 79, psychiatric disorders = 72 patients). Control patients had a significantly greater proportion of INRs in the goal range compared with either the depression or psychiatric disorders groups (control, 55.7%; depression, 43.5%; psychiatric, 45.8%). Utilizing the Rosendaal's method, patients with psychiatric disorders were in the goal range significantly less often than those in the control group (53.0% vs 61.3%). No differences were seen when adjusting for multiple comparisons or when comparing the control and depression groups (54.5% vs 61.3%). There was no difference between the groups when comparing percentages of patients with a mean INR in their goal range. CONCLUSIONS: Patients with psychiatric disorders who take warfarin may spend less time in the therapeutic range.

A faculty-led mock residency interview exercise for fourth-year doctor of pharmacy students.

PURPOSE: To determine whether a faculty-led mock-interview activity enhanced pharmacy student preparation for the residency interview process and increased match rates. METHODS: Twenty-eight doctor of pharmacy students volunteered for a 40-minute mock-interview session with 2-person faculty teams. A standard roster of 12 interview questions was derived from published literature and the faculty members' experience. Feedback on the student's interview performance was provided verbally during the session. Following the interview, students were given a 2-part survey instrument. The first part of the survey was administered immediately following the mock-interview session and the second part was administered after the standard date for residency program results (known as "Match Day"). Participant match rates were compared to American Society of Health-System Pharmacists (ASHP) national rates. RESULTS: 82.5% (23 of 27) of students in the mock-interview group matched a postgraduate year 1 (PGY1) program. Compared to national rates (61.9%), more students in our surveyed mock-interview group matched a PGY1 residency (P = .015; odds ratio [OR] 3.546, 95% CI 1.161-12.116). CONCLUSIONS: Higher match rates were seen in the students completing the mock residency interview compared to ASHP national rates. In general, students completing the mock interview found the process helpful and felt better prepared for their residency interviews.

Elevated international normalized ratio from vitamin K supplement discontinuation.

OBJECTIVE: To report a case of a critically elevated international normalized ratio (INR) following discontinuation of a vitamin K supplement in a patient receiving warfarin. CASE SUMMARY: A 64-year-old man with atrial fibrillation received warfarin for primary stroke prevention. He was initiated on low-dose vitamin K supplementation therapy secondary to a high level of INR variability. The patient was stabilized on this therapy for approximately 9 months with a mean INR of 2.02 and a warfarin dose ranging from 6.5 to 7.5 mg/week. At a visit with his primary care physician, the patient's INR was subtherapeutic at 1.5. He had not been taking his vitamin K supplement for nearly a week, but had not missed any doses of warfarin. The vitamin K supplement was discontinued and his warfarin dose was increased by 14.3%. Nearly 2 weeks later the patient presented with a critically elevated INR of 8.5, but no acute bleeding. No other factors affecting the INR could be determined. After a dose of 2.5 mg of vitamin K was administered and warfarin was withheld for 2 days, the patient's INR returned to 2.9. Low-dose vitamin K supplementation and warfarin at a lower dose of 7 mg/week were restarted. His INR remained relatively stable, with no ensuing critical INR changes or other sequelae. DISCUSSION: Vitamin K supplement removal was believed to be a major contributor to the critically elevated INR. While the warfarin dose had been increased according to the clinic protocol (14.3% for an INR of 1.5), the timing of the INR elevation following supplement removal follows pharmacodynamic expectations of clotting factor synthesis. This case is labeled a category D error. CONCLUSIONS: Discontinuation of vitamin K supplementation therapy might result in elevation of INR.