Andrew R. Miesner

Inpatient, acute care clinical pharmacists have contributed to many notable improvements in patient outcomes. Several studies have shown a reduction in mortality and other clinical markers when pharmacists are integrated within the care team. Economic analyses of inpatient clinical pharmacy services (CPS) generally demonstrate cost savings related to specific medication classes, prevention of adverse drug events, decreased length of stay, and decreased rehospitalization. Studies also show high satisfaction from other health care professionals, noting improvements in medication‐related patient safety. Finally, studies conducted in tertiary care hospital settings report high levels of patient satisfaction with CPS. As such, the ECHO framework, based on economic, clinical, and humanistic outcomes, is used herein to organize the summary of literature associated with CPS. Given the growing body of evidence, numerous health professional and government organizations recognize the role of pharmacists as an integral part of the inpatient team. Yet implementation of CPS has not been fully realized by hospitals and health systems. This paper briefly describes inpatient CPS, highlights many benefits of and endorsements for clinical pharmacist participation on interdisciplinary teams, and provides high‐level recommendations for health system administrators and the profession of pharmacy to further encourage broader integration of CPS into patient care teams. Effectively positioning inpatient clinical pharmacists as indispensable team members will require intentional work and strategic planning with a focus on high‐impact value, visibility, and leadership.

Background: Cephalosporins are increasingly used to treat severe urinary tract infections (sUTI) due to rising resistance with standard antibioics. When switching from intravenous to oral cephalosporins there is limited clinical outcome data to guide selection. Objective: To compare the failure rate between cephalexin and cefdinir when used as oral step-down therapy in sUTI. Methods: In this retrospective study, we assessed patients admitted to 3 hospitals for sUTI over a 1-year period. Cases were identified using ICD-10 codes N10, N39.0, and A41.9. Patients who received intravenous antibiotics for >24 hours and completed treatment with cephalexin or cefdinir were included. The primary composite outcome was death, rehospitalization for UTI in 30 days, unplanned clinic or emergency visit for UTI in 30 days, hospitalization for any reason in 90 days, or Clostridoides difficile infection. Secondary outcomes included each individual composite outcome element. Results: Overall, 75 cefdinir and 135 cephalexin cases were included. Patients were similar in baseline characteristics. Pyelonephritis occurred among the cephalexin group (30.2% vs 46.7%, P = 0.024). Composite failure occurred in 8% of patients receiving cefdinir and 14.1% receiving cephalexin ( P = 0.193). Secondary outcomes did not differ except clinic or emergency visit for UTI was lower among patients receiving cefdinir than cephalexin (0% vs 7.2%; P = 0.028). Logistic regression revealed no significant variable associations with treatment failure, except for cephalexin use, which was associated with clinic or emergency visit for UTI (r ² = 0.075). Conclusions: Treatment failure rates did not differ between cefdinir and cephalexin; however, patients receiving cephalexin had more unplanned clinic and emergency visits.

Introduction: The impact of pharmacists has been described for many practice areas including critical care, emergency medicine, and transitions of care. Literature describing the extensive role of adult medicine (AMED) clinical pharmacists in the inpatient setting is limited.Objective: The objective of this study was to characterize clinical activities performed by inpatient AMED pharmacists nationally.Methods: This was a multicenter, prospective, observational study including AMED pharmacists who spend more than 50% of their time practicing in the acute care setting. A 65‐item electronic survey was developed and distributed to members of the American College of Clinical Pharmacy AMED Practice and Research Network (PRN). The survey collected demographics, clinical interventions, rates of intervention acceptance, and the significance of those interventions, where applicable. Respondents were asked to report all interventions made over any one‐week period while providing direct patient care. Descriptive statistics were used to summarize data. Chi‐square tests and Wilcoxon rank sum tests were used to compare nominal and continuous data, respectively.Results: Thirty three pharmacists representing 988.5 h of direct patient care reported activities, including profile review (97%), daily rounding with prescribers (94%), patient education (76%), and order entry or verification (64%). During the study period, 4488 interventions were documented. The most common interventions and activities documented were optimization of therapy (n = 1125, 25%), initiation of therapy (n = 770, 17%), and interpretation of diagnostic data or lab values (n = 331, 7%). The top three therapeutic classes with interventions were antimicrobials (n = 473, 25%), cardiovascular medications (n = 248, 13%), and antithrombotics (n = 190, 10%). Of the applicable interventions, 2775 (89%) were accepted, 2541 (81%) were pharmacist‐initiated, and 277 (9%) were classified as serious or very/extremely significant interventions.Conclusion: AMED pharmacists provide diverse recommendations across numerous medication therapeutic categories that are highly accepted. AMED pharmacists play an important role in optimizing medication use through care team and patient interactions.

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.

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.

“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. To describe the use of pimping as a teaching method in pharmacy education and to compare student and faculty perceptions of this technique. 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. 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. 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.