Antimicrobial utilization and stewardship in patients with uncomplicated urinary tract infections managed by pharmacists in the community: A sub-study of the RxOUTMAP trial.

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.

The clinical impact of a urinary tract infection management bundle in a tertiary-care teaching hospital.

OBJECTIVE: The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs. DESIGN: Before-and-after intervention study.SettingsTertiary-care hospital.PatientsConsecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital. METHODS: The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists' prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle. RESULTS: Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment. CONCLUSIONS: A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.

Outcomes of Urinary Tract Infection Management by Pharmacists (RxOUTMAP): A study of pharmacist prescribing and care in patients with uncomplicated urinary tract infections in the community.

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.

The characteristics of Klebsiella pneumoniae that produce KPC-2 imported from Greece.

We report a case of lower urinary tract infection due to KPC-2-producing K. pneumoniae (KpCG02) in an elderly patient who had recently been hospitalized in Greece. The patient was treated successfully on an outpatient basis by removing the Foley catheter and with a prophylactic dose of gentamicin. KpCG02, which belonged to ST258, contained repFII plasmids that tested positive for the vagCD addiction system and the uge, wabG, urea, mrkD, and fimH virulence factors. This case reemphasizes the need for vigilance screening for carbapenem-resistant Gram negatives in patients with a history of travel to endemic areas, such as Greece.

A case of Pott's disease with epidural abscess and probable cerebral tuberculoma following Bacillus Calmette-Guérin therapy for superficial bladder cancer.

Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is an accepted treatment for transitional cell carcinoma of the bladder. Carcinoma in situ of the bladder progresses to invasive muscular disease in approximately 54% of untreated patients, mandating early initiation of therapy once the diagnosis is confirmed. Should BCG treatment fail, an additional course of BCG combined with interferon-alpha, both administered intravesically, is a promising second-line immunotherapy. In greater than 95% of patients, BCG is tolerated without significant morbidity or mortality. However, both early (within three months of the original treatment) and late presentations of systemic infection resulting from intravesical BCG treatment have been described. The present study describes the course of a 75-year-old man with a late presentation of BCG vertebral osteomyelitis, discitis, epidural abscess, bilateral psoas abscesses and probable cerebral tuberculoma, following treatment regimens of intravesical BCG followed by intravesical BCG plus interferon-alpha 2b.