Improving metronidazole prescription practices in surgical patients: a full cycle audit

2021 ◽  
pp. postgradmedj-2021-139940
Author(s):  
Alessandro Sgrò ◽  
Diana A Wu ◽  
Satheesh Yalamarthi
Keyword(s):  
Chart Review ◽  
Oral Route ◽  
Surgical Patients ◽  
First Line ◽  
Prescription Practices ◽  
Pharmacokinetic Properties ◽  
Oral Preparation ◽  
Abdominal Infections ◽  
High Bioavailability ◽  
Oral Metronidazole

IntroductionMetronidazole is commonly prescribed for intra-abdominal infections. Oral metronidazole has high bioavailability (>95%) and intravenous metronidazole should be reserved for patients not suitable for oral preparations.Methods and materialsThis full cycle audit evaluated the type of metronidazole preparation prescribed in adult emergency surgical patients requiring first-line empirical antimicrobial therapy for intra-abdominal infections. The criterion for audit was the proportion of patients who were prescribed intravenous metronidazole when the oral route was available. The first cycle included all consecutive eligible patients between 20 April and 14 May 2020. After an intervention phase educating prescribers about the similar pharmacokinetic properties of oral and intravenous metronidazole, clinical practice was reaudited between 22 June and 16 July 2020. Data were collected by case note and drug chart review.ResultsA total of 54 patients were included in the first audit cycle. Of these, 11 (20.4%) were prescribed oral metronidazole and 43 (79.6%) were prescribed intravenous metronidazole. In the majority of cases (35/43, 81.4%), intravenous metronidazole was prescribed in the absence of clear contraindications to the oral preparation. Of the 61 patients included in the reaudit cycle, 23 (37.7%) were prescribed oral metronidazole and 38 (62.3%) were prescribed intravenous metronidazole. The proportion of patients prescribed intravenous metronidazole despite being suitable for oral preparation decreased from 81.4% in the first cycle to 34.2% (13/38) in the reaudit cycle (risk ratio 0.42, 95% CI: 0.26 to 0.67, p<0.0001). Prescribing oral metronidazole when suitable saved up to £10.53/day per patient.ConclusionThis full cycle audit led to a significant improvement in the use of oral metronidazole in suitable patients, as well as a considerable reduction in healthcare costs.

scholarly journals Botulinum Toxin: An Update on Pharmacology and Newer Products in Development

Toxins ◽  
2021 ◽  
Vol 13 (1) ◽  
pp. 58
Author(s):  
Supriyo Choudhury ◽  
Mark R. Baker ◽  
Suparna Chatterjee ◽  
Hrishikesh Kumar
Keyword(s):  
Botulinum Toxin ◽  
Clinical Use ◽  
First Line ◽  
High Demand ◽  
Short Term ◽  
Medical Specialties ◽  
Naturally Occurring ◽  
Pharmacokinetic Properties ◽  
Clinical Benefits ◽  
First Line Treatment

Since its introduction as a treatment for strabismus, botulinum toxin (BoNT) has had a phenomenal journey and is now recommended as first-line treatment for focal dystonia, despite short-term clinical benefits and the risks of adverse effects. To cater for the high demand across various medical specialties, at least six US Food and Drug Administration (FDA)-approved formulations of BoNT are currently available for diverse labelled indications. The toxo-pharmacological properties of these formulations are not uniform and thus should not be used interchangeably. Synthetic BoNTs and BoNTs from non-clostridial sources are not far from clinical use. Moreover, the study of mutations in naturally occurring toxins has led to modulation in the toxo-pharmacokinetic properties of BoNTs, including the duration and potency. We present an overview of the toxo-pharmacology of conventional and novel BoNT preparations, including those awaiting imminent translation from the laboratory to the clinic.

Clostridium difficile—Associated Diarrhea, an Emerging Epidemic: Therapeutic Options

2007 ◽  
Vol 20 (4) ◽  
pp. 347-353
Author(s):  
Christopher R. Emerson
Keyword(s):  
Clostridium Difficile ◽  
Hospital Admissions ◽  
Treatment Options ◽  
Infectious Diarrhea ◽  
First Line ◽  
Oral Vancomycin ◽  
Considerable Morbidity ◽  
Clostridium Difficile Associated Diarrhea ◽  
Pharmacologic Agents ◽  
Oral Metronidazole

Clostridum difficile—associated disease (CDAD) is the leading cause of infectious diarrhea and is associated with considerable morbidity and mortality. The incidence is estimated to range from 3.4 to 8.4 cases per 1000 hospital admissions, and it has become a growing problem at many institutions. Treatment options for CDAD are limited due to a paucity of new pharmacologic agents and studies examining other potential treatments. Historically oral metronidazole and oral vancomycin have been used as first-line agents in the treating CDAD, however recent reports of treatment failure and recurrence with these agents have surfaced. These reports illustrate a need for novel pharmacologic agents and a thorough review of currently available agents that may have activity against C difficile. Available data on the treatment of CDAD were extracted and reviewed to outline the appropriate management of CDAD.

scholarly journals Chart review of diagnostic methods, baseline characteristics and symptoms for European patients with pancreatic cancer

2021 ◽  
Vol 17 (15) ◽  
pp. 1843-1854
Author(s):  
Alfredo Carrato ◽  
Davide Melisi ◽  
Gerald Prager ◽  
Christoph B Westphalen ◽  
Anabel Ferreras ◽  
...  
Keyword(s):  
Chart Review ◽  
Diagnostic Technique ◽  
Tumor Location ◽  
Diagnostic Methods ◽  
Ductal Adenocarcinoma ◽  
Inclusion Criteria ◽  
First Line ◽  
Patient Age ◽  
Patient Âgé ◽  
Baseline Characteristics

Aim: To survey European physicians managing patients with metastatic pancreatic ductal adenocarcinoma (PDAC) and understand differences in baseline characteristics, diagnostic methods, symptoms and co-morbidities. Materials & methods: Patient record inclusion criteria were: ≥18 years old, metastatic PDAC diagnosis and completion of first-line treatment between July 2014 and January 2016. Records were grouped by patient age, gender and primary tumor location. Results: Records (n = 2565) were collected from nine countries. Baseline characteristics varied between subgroups. Computed tomography was the most frequently used diagnostic technique. Symptoms at diagnosis included abdominal and/or mid-back pain (72% of patients) and weight loss (61.5%). Co-morbidities varied with patient age. Conclusion: Greater awareness of symptoms, diagnostic methods and co-morbidities present at PDAC diagnosis may support better patient management decisions.

Treatment Patterns and Splenectomy Failure Rates in Patients with Chronic Immune Thrombocytopenic Purpura in Canada: A Retrospective Chart Review

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 4565-4565
Author(s):  
Joseph Mikhael ◽  
Alan Tinmouth ◽  
Tazmin Merali ◽  
Mo Amin ◽  
Wendy Lam
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenic Purpura ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Initial Therapy ◽  
Second Line ◽  
First Line ◽  
Bleeding Events ◽  
Thrombocytopenic Purpura ◽  
Line Therapy

Abstract Background: In clinical practice there is little consensus on treating patients with chronic immune thrombocytopenic purpura (ITP) beyond first line therapy with steroids. Objectives: Describe the demographic and disease characteristics of adult ITP patients who receive treatment; Obtain the treatment approach for patients with ITP beyond first line treatment with steroids, with an emphasis on splenectomy; and Evaluate adverse bleeding outcomes associated with ITP. Methods: A retrospective chart review of ITP patients after initial therapy with steroids was conducted. Ten physicians (oncologists and hematologists) were recruited from across Canada and each physician provided at least 5 ITP cases for review. A total of 51 cases were reviewed and patients (&gt; 18 years old) were required to have had more than 1 course of steroids as treatment to be eligible. Results: The average age of patients at diagnosis was 42 (range 3 to 82 years); 37 (73%) of the patients were female, and 37 (73%) were Caucasian. The median platelet count upon presentation was 5×109/L. Median lines of therapy after initial therapy was 3 (range 0 to 6). Second line therapies varied, but most commonly patients underwent splenectomy (43%), followed by continued steroid treatment (16%), steroids plus IV Ig (16%), IV Ig alone (14%), immunosuppressant alone (2%), and anti-D plus steroids (2%). Of the patients reviewed, 40 (78%) eventually underwent splenectomy. Of the 40 splenectomized patients, 27 were splenectomized within the first year of diagnosis and 35 underwent splenectomy during the first 5 years. In addition, 62 of the splenectomies were laparoscopic, and the median hospital stay for all procedures was 5 days (range 1 to 60 days). Immediate failure of splenectomy occurred in 18% of patients, and the one- and five- year relapse/failure rates (defined as platelet count &lt; 30×109/L) were 38% and 55%, respectively. Other therapies following splenectomy included IV Ig, azathioprine, cyclosporine, danazol, mycophenolate, rituximab, vincristine, cyclophosphamide, and anti-D. Only 6% of IV Ig use was for chronic maintenance therapy and 74% of use was for urgent therapy. A total of 61 bleeding events occurred, of which 10 were major (upper GI, mouth, rectal, and nose). Major bleeding events required hospitalization of the patient with an average length of stay of 5 days (range 2 to 14 days). Conclusions: Notwithstanding several limitations, the retrospective chart review suggests that there is wide variation in long-term therapy for patients with chronic ITP in Canada. Splenectomy was the most widely used second line therapy, although 18% of the patients were non-responders and the five-year relapse/failure rate was 55%.

scholarly journals Recognition of Lynch Syndrome Amongst Newly Diagnosed Colorectal Cancers at St. Paul’s Hospital

2017 ◽  
Vol 2017 ◽  
pp. 1-6 ◽  
Author(s):  
Steven Pi ◽  
Estello Nap-Hill ◽  
Jennifer Telford ◽  
Robert Enns
Keyword(s):  
Lynch Syndrome ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Inclusion Criteria ◽  
First Line ◽  
Clinical Criteria ◽  
Immunohistochemistry Staining ◽  
Age Of Diagnosis ◽  
History Of ◽  
Specific Malignancy

Background. Lynch Syndrome (LS) is the most common cause of inherited colorectal cancer (CRC). In British Columbia, most centres still use clinical criteria (Amsterdam II, Revised Bethesda, or the BC Cancer Agency’s criteria) to determine who should undergo further first-line testing in the form of microsatellite instability or immunohistochemistry staining. Given the limitations with this strategy, LS is thought to be underrecognized. Objective. To investigate whether LS is truly underrecognized when compared to the reported prevalence. Methods. A retrospective chart review of all CRC cases diagnosed at St. Paul’s Hospital from 2010 to 2013 was conducted. Results. 246 patients met inclusion criteria. 76% (83/109) with a family history of malignancy were unable to recall the specific malignancy or age of diagnosis. 18% (43/235) were only asked about a history of gastrointestinal related malignancy and 26% (65/246) met at least one of the three criteria but only 21% (13/63) received further investigation. Only 1.6% (4/246) had LS compared to the reported prevalence of 2–5% of all CRC cases. Conclusion. This data supports our hypothesis that LS is underrecognized. Issues at the patient, physician, and systems level need to be evaluated to determine where the limitations preventing appropriate testing are occurring.

AUDIT OF PARACETAMOL PRESCRIPTIONS IN PAEDIATRIC SURGICAL PATIENTS

2016 ◽  
Vol 101 (9) ◽  
pp. e2.33-e2 ◽  
Author(s):  
Rowena McArtney ◽  
Angharad Atkinson
Keyword(s):  
Ideal Body Weight ◽  
Oral Route ◽  
Surgical Patients ◽  
Growth Charts ◽  
Obese Children ◽  
Ideal Weight ◽  
High Doses ◽  
And Gender ◽  
Renal Tubular ◽  
The Uk

AimLocal Guidelines for peri-operative pain management in children published in 2012 recommended that paracetamol dosing was calculated using ideal body weight (IBW) to prevent inadvertent overdosing in overweight and obese children.1 The purpose of this audit was to establish compliance with these guidelines. The oral paracetamol dose recommended was 20–30 mg/kg as a single dose then 15–20 mg/kg every 4–6 hrs with a maximum of 90 mg/kg/day. IV paracetamol doses were as recommended in BNF for Children (BNFC).2 BNFC states that paracetamol doses totalling 150 mg/kg may cause severe hepatocellular necrosis and renal tubular necrosis but the potential for adverse effects in some children can be seen with doses as little as 75 mg/kg in 24 hrs.MethodPaediatric Surgical patients prescribed paracetamol as an inpatient or on discharge over a 10 week period were included in the audit. For this audit patients were assessed as overweight or obese using age and gender specific UK growth charts endorsed by the Department of Health.Audit standards100% compliance with the following:1. inpatient charts and discharge prescriptions document patient weight and height.2. paracetamol prescriptions based on ideal weight for height in overweight and obese paediatric patients.3. prescriptions have IV route prescribed independently to oral (PO) or rectal route.4. patients prescribed IV paracetamol reviewed after 48 hrs for an oral switch.Results100 inpatient prescriptions (71 elective and 29 non-elective) and 35 discharge prescriptions were analysed.1. Weight was annotated for 84% of inpatient prescriptions and 94% of discharge prescriptions; height was not documented for any patient. Therefore data was analysed basing IBW on 50th centile of the UK growth charts.2. The following results are based on IBW: ▸ Six inpatients prescribed oral paracetamol were classified as overweight or obese; doses ranged from 17.4–30 mg/kg/dose. ▸ Four patients prescribed IV paracetamol were classified as overweight or obese; doses ranged from 20–23 mg/kg/dose. ▸ Four patients prescribed the combined route of PO/IV paracetamol were classified as overweight or obese; doses ranged from 18–24 mg/kg/dose. ▸ Six patients prescribed oral paracetamol on discharge were classified as overweight or obese; doses ranged from 13–33 mg/kg/dose.3. Paracetamol was prescribed as IV/PO in 32 inpatients.4. IV paracetamol was prescribed in 52 patients; 20 were not reviewed at 48 hrs for a switch to oral route. Of these, only 3 were appropriate prolonged IV prescriptions.Conclusion Audit findings showed inadequate compliance with local prescribing guidelines posing a risk of inappropriately high doses of paracetamol being prescribed to overweight and obese children. In addition, unnecessarily prolonged IV use was observed. Following feedback local guidelines were amended in 2015 to recommend that in obese children, dosing should reflect lean body mass and ideal weight for height. The maximum daily dose was also reduced to 75 mg/kg/day. Prescribers require education regarding this important issue.

scholarly journals Buprenorphine buccal film for chronic pain management

2020 ◽  
Vol 10 (4) ◽  
pp. 213-223 ◽  
Author(s):  
Martin Hale ◽  
Joseph Gimbel ◽  
Richard Rauck
Keyword(s):  
Chronic Pain ◽  
Pain Relief ◽  
Review Article ◽  
Chronic Pain Management ◽  
First Line ◽  
Safety And Efficacy ◽  
Safety Risks ◽  
Pharmacokinetic Properties ◽  
Film Formulation ◽  
Effective Analgesia

Buprenorphine is a Schedule III opioid with unique pharmacodynamic and pharmacokinetic properties that contribute to effective analgesia and fewer safety risks than other opioids. This review article focuses on the buccal film formulation, which is preferable to other buprenorphine formulations on the basis of bioavailability, safety and efficacy. The clinical studies reviewed here confirm that buprenorphine buccal film offers effective and continuous pain relief that is generally well tolerated, with no cases of respiratory depression reported in any of the studies. On the basis of these clinical data and individual patient risk/benefit assessments, clinicians should consider utilizing buprenorphine buccal film as a first-line opioid treatment for chronic pain over other buprenorphine formulations or other opioids.

scholarly journals First-line and second-line treatment of patients with metastatic pancreatic adenocarcinoma in routine clinical practice across Europe: a retrospective, observational chart review study

ESMO Open ◽  
2020 ◽  
Vol 5 (1) ◽  
pp. e000587 ◽  
Author(s):  
Julien Taieb ◽  
Gerald W Prager ◽  
Davide Melisi ◽  
C Benedikt Westphalen ◽  
Nathalie D'Esquermes ◽  
...  
Keyword(s):  
Chart Review ◽  
Line Treatment ◽  
Second Line ◽  
First Line ◽  
Treatment Choices ◽  
First Line Therapy ◽  
Line Therapy ◽  
Metastatic Pancreatic Adenocarcinoma ◽  
Review Study ◽  
The Uk

BackgroundTreatment of metastatic pancreatic adenocarcinoma (mPAC) relies on chemotherapeutic regimens. We investigated patterns of first-line and second-line treatment choices, their geographical variation between European countries, and alignment with current European recommendations.MethodsThis retrospective, observational chart review study was conducted between July 2014 and January 2016. Physicians were recruited from nine European countries. Patient data were collected in electronic patient record forms (PRFs) by physicians managing patients with mPAC. Patients with a current mPAC diagnosis aged ≥18 years old who had completed first-line therapy during the study period were included.ResultsParticipating physicians (n=225) completed 2565 PRFs. The vast majority of PRFs were from France, Germany, Italy, Spain and the UK. Most patients (86.6%) had stage IV disease at diagnosis. The most common first-line treatments were FOLFIRINOX (5-fluorouracil, leucovorin/folinic acid, irinotecan and oxaliplatin) (35.6%), gemcitabine+nab-paclitaxel (25.7%) and gemcitabine monotherapy (20.5%). Physicians in France and the UK prescribed FOLFIRINOX more frequently than gemcitabine+nab-paclitaxel. Gemcitabine-based therapies were more widely used at second-line, although 5-fluorouracil-based therapies were preferred in Italy and Spain, where gemcitabine-based treatments were more frequently selected for first-line. For patients receiving first-line modified FOLFIRINOX, second-line gemcitabine monotherapy was preferred in the overall population (45.9%).ConclusionAlthough treatment choices for patients with mPAC varied between countries, they align with current European guidelines. Factors including drug availability, reimbursement, patient characteristics, physician preference and prior first-line therapy affect treatment choices. Approved, recommended therapies for patients who progress following first-line treatment are lacking. These findings may influence the development of effective treatment plans, potentially improving future patient outcomes.

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