Effectiveness of pharmaceutical care on treatment outcomes for patients with first-time pulmonary tuberculosis in China

Pharmacists' Role in Global TB Elimination: Practices, Pitfalls, and Potential

Tuberculosis (TB) is the top infectious killer in the world despite efforts to eliminate it. Pharmaceutical care roles are pillars of pharmacy practice, and pharmacists are well equipped to serve a unique role in the pathway to provide education about TB. Previous systematic reviews emphasize pharmacists' role in treating TB; however, pharmacists can and do play much broader roles in overall TB elimination efforts. Five researchers searched five electronic databases (PubMed, PsychInfo, CINAHL, Academic Search Premier, and Embase). Search terms included pharmacy, pharmacist, tuberculosis, antitubercular agents, supply, distribution, and drug therapy. Inclusion criteria were studies published from 2010 through March 2023, in English or Spanish, addressed a specific TB-related role for pharmacists/pharmacies, and were peer-reviewed. Exclusion criteria included pharmacology, pharmacokinetics, clinical trials on drug efficacy, and editorials. Two researchers conducted each level of review; for discordance, a third researcher reviewed, and a decision was reached by consensus. Roles were extracted and cross-referenced with traditional pharmaceutical care steps. Of the initial 682 hits, 133 were duplicates. After further review, we excluded 514 records, leaving 37 articles for full extraction. We found nine roles for pharmacists in TB prevention and classified them as implemented, not implemented, or recommended. These roles were: (1) TB symptom screening; (2) Referring to TB care systems; (3) TB testing; (4) Dispensing TB medication correctly and/or directly observed therapy; (5) Counseling; (6) Looking to reduce socioeconomic barriers; (7) Procurement of TB medications; (8) Quality assurance of TB medications; (9) Maintaining and using pharmacy data systems. Pharmacists are well situated to play a vital role in the global fight against TB. Findings suggested pharmacists in many settings have already expanded their roles related to TB elimination beyond traditional pharmaceutical care. Still others need to increase the understanding of TB procurement and treatment, their power to improve TB care, and their contributions to data systems that serve population health. Pharmacy curricula should increase TB-related training to better equip future pharmacists to contribute to TB elimination.

Impact of pharmaceutical care interventions in improving clinical outcomes among patients with pulmonary tuberculosis: a systematic review

Background

Pharmacists can play an important role in the fight against tuberculosis (TB) through optimising medication use and safety, promoting adherence to anti-TB drugs, and providing patient education. Limited evidence is available on the effectiveness of pharmacist's interventions on health outcomes in patients with pulmonary TB. This systematic review aims to assess the effectiveness of pharmaceutical care interventions in the management of pulmonary TB.

Methods

English language studies assessing the impact of pharmaceutical care interventions in TB management were searched across three electronic databases (PubMed, Embase, Cochrane), a RCT registry ClinicalTrial.gov, a peer-reviewed journal 'The Lancet Infectious Diseases', and the references of retrieved articles. Interventions delivered by pharmacists alone or as part of multidisciplinary teams were included in the review. Data were extracted using the modified Cochrane EPOC standardised data collection tool. The Cochrane Risk of Bias 2 and the NIH quality assessment tools were used to assess the risk of bias among included studies. Data were synthesised narratively. (PROSPERO Protocol Registration CRD42022325771).

Results

Thirteen studies, including two randomised controlled trials (RCTs) with a total of 3886 patients were included. Many of the included studies had a high risk of bias and lacked cohert reporting of treatment outcomes. The most common pharmaceutical care interventions were education and counselling regarding adverse drug reactions and resolution of drug-related problems. Five studies showed a relatively high TB completion rate yet only one study reached the targeted treatment success goal of (>90%).

Conclusion

The current evidence suggests that pharmaceutical care interventions can potentially improve treatment outcomes among patients with pulmonary TB. However, no definitive conclusion can be drawn given the low methodological quality of the included studies and lack of long-term follow-up data. Well-designed RCTs with careful attention to study methodology, standardised outcomes assessment aligned with the World Health Organization's guidelines are warranted to guide future practice and policy.

Clinical pharmacy services for tuberculosis management: a systematic review

Objective: This study aims to systematically review the content and potential effects of clinical pharmacy services in tuberculosis (TB) care management. Methods: Searches were performed in PubMed, Embase, Cochrane, Scopus, and Web of Science databases following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Study characteristics and outcomes were extracted, and clinical pharmacy service components were characterized using the Descriptive Elements of Pharmacist Intervention Characterization Tool. Results: Twenty articles were included for full-text assessment, of which 10 fulfilled inclusion criteria, comprising 1,168 patients (N = 39 to 258 per study). These articles included five prospective cohort studies, two case-control studies, two quasi-experimental studies, and one cross-sectional study. Intervention foci within clinical pharmacy services were medication adherence (50%), medication safety (40%), education to patients/caregivers regarding needs/beliefs (30%), optimizing medication/therapy effectiveness (30%), emphasizing HRQoL (10%), and drug selections (10%). The three most frequently applied interventions were drug information/patient counseling (80%), adverse drug reaction monitoring (50%), and drug use evaluation (20%). Based on the World Health Organization (WHO) outcome classification, treatment success ranged from 72% to 93%, with higher cure outcomes (53%-86%) than treatment completion (7%-19%). Other outcomes, including isoniazid metabolites, medication counts, sputum conversion, adherence/compliance, knowledge, and quality of life, were better in the intervention group than those in comparator groups, and/or they improved over time. Risk of bias analysis indicated that the included studies were not comparable to a randomized clinical trial. Conclusion: Clinical pharmacy services as single or composite interventions potentially improve TB outcomes, but its evidence is still inconsistent and limited due to the lack of randomized controlled studies using the WHO outcome classification. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199028, identifier CRD42020199028.

Practical Models of Pharmaceutical Care for Improving Tuberculosis Patient Detection and Treatment Outcomes: A Systematic Scoping Review

Decreasing global tuberculosis (TB) notifications indicate problems related to TB patient detection and treatment outcomes. Pharmaceutical care (PC) has potential roles in managing these issues. However, PC practices have not yet become widespread in the real world. This systematic scoping review aimed to identify and analyze the current literature on practical models of pharmaceutical care for improving tuberculosis patient detection and treatment outcomes. We then discussed the present challenges and future considerations for the successful implementation of PC services in TB. A systematic scoping review was performed to identify the practice models of PC in TB. Systematic searches and screening were used to identify relevant articles in the PubMed and Cochrane databases. We then discussed the challenges and recommendations for successful implementation using a framework to improve professional healthcare practice. Our analysis included 14 of 201 eligible articles. We identified that the focuses in the PC of TB are on increasing patient detection (four articles) and improving TB treatment outcomes (ten articles). Practices cover services in the community and hospital settings, such as screening and referring people with presumptive TB, tuberculin test services, collaborative practices for treatment completion, directly observed treatment, the solution of drug-related problems, reporting and managing adverse drug reactions, and medication adherence programs. Although PC services positively increase TB patient detection and treatment outcomes, hidden challenges in the actual practice are analyzed. Several factors should be comprehensively considered in successful implementation, such as guidelines, individual pharmacy personnel, patient, professional interaction, organizational capacity, regulation, incentive, and resource factors. Hence, a collaborative PC program that involves all related stakeholders should be considered to create successful and sustainable PC services in TB.

Implementation and Effectiveness of a Pharmacotherapeutic Follow-Up Service for People with Tuberculosis in Primary Healthcare

Tuberculosis (TB) is a disease of great relevance, responsible for 1.5 million deaths worldwide. Therefore, actions to control TB are necessary, and pharmacists may play an important role, especially in primary healthcare (PHC), where the diagnosis and management of this infection occurs. In a large Brazilian city, pharmacotherapeutic follow-up in PHC has been offered by pharmacists to people with TB since 2018. The objective of this study was to evaluate the implementation and effectiveness of this service though a longitudinal type 1 effectiveness-implementation hybrid study. Data were collected from January 2018 to February 2020 in the pharmaceutical services system. The service indicators were described and effectiveness was evaluated using Poisson regression analysis to compare the incidence of cure among patients using and not using the service. The service was performed in 148 PHC units by 82 pharmacists. Of the total of 1076 treatments, 721 were followed up by pharmacists, and TB was cured more frequently in these cases (90.4% attended vs. 73.5% unattended). The adjusted hazard ratio of cure among patients enrolled in the pharmacotherapeutic follow-up service was 2.71 (2.04-3.61; p < 0.001). Pharmacotherapeutic follow-up for people with TB significantly increased the incidence of cure and should be encouraged.

The Role of Clinical Pharmacist in Pediatrics' Adherence to Antiepileptic Drugs

Background

Rate of nonadherence to antiepileptic drugs (AEDs) in children is about 33%. Engaging clinical pharmacists in the management of patients has proved to increase adherence to medications which will improve the outcomes of treatment.

Objectives

To investigate the effect of a clinical pharmacist-led education on the adherence to AEDs in pediatric patients with epilepsy. Secondary outcomes include effectiveness and safety of AEDs, satisfaction with information about AEDs provided to the caregivers, and patients quality of life (QoL).

Methods

This was an interventional study where pediatric patients were randomly assigned to the intervention (n = 41) or the control (n = 40) group. A 30-minute clinical pharmacist-led educational interview to the parent/caregiver was provided to the first group as add-on to standard medical care received by latter. Outcomes were measured at baseline and after 8-week follow-up.

Results

The intervention group had an increase in mean adherence score from 6 ± 1.09 at baseline to 7.6 ± 0.9 at follow-up (P value < 0.001), while the control group had no significant change (P value > 0.05), the difference between the 2 groups at follow-up was significant (P value < 0.0001). No significant difference was observed between groups at follow-up with regard to effectiveness (P value > 0.05), and safety (P value = 0.08). While higher satisfaction with information (P value < 0.0001), and higher QoL (P value < 0.05) was observed in the intervention group.

Conclusion and relevance

Clinical pharmacist-led education had a positive outcome on pediatric patients with epilepsy with regard to adherence, effectiveness, safety, satisfaction with information about AEDs, and QoL.

Views of Pharmacists and Government Representatives Toward the Pilot Chief Pharmacist System in Chinese Hospitals: A Multicenter Exploratory Qualitative Study

Background

In China, the pharmacy departments of most hospitals have changed their main focus from drug procurement and distribution to providing pharmaceutical care services. Various regions of China have successively implemented the pilot Chief Pharmacist System (CPS) to help improve pharmaceutical care services and rational drug use in hospitals. This study was designed to explore the perspectives of pharmacists and government officials on CPS, including the advantages and barriers to the successful implementation of CPS.

Methods

A qualitative study, based on semi-structured interviews, was conducted from October 1, 2018 to March 1, 2019. The interview data were gathered from 18 pharmacy staff and government representatives working in five distinct regions of China using purposive sampling. A thematic analysis approach and NVivo version 12 Plus was utilized to code and analysis of all interviews.

Results

Five broad themes were identified: the role of the chief pharmacist; their attitudes toward the CPS; the advantages and results of the CPS; the barriers toward CPS; and their suggestions toward CPS. Most of the participants believed that the chief pharmacist played a vital role in a hospital. Under CPS, the hospital pharmacy department pays more attention to prescription review, medication monitoring, and pharmaceutical consultation. However, an insufficient number of pharmacy personnel, unclear authority, and inadequate salaries were the main barriers to the implementation of the CPS.

Conclusion

The attitudes of most of the participants were found to be positive toward CPS in China. The CPS can enhance the prestige of the hospital pharmacy department, improve the quality of hospital pharmaceutical care services, and promote rational drug use. Nevertheless, certain barriers highlighted in this study should be addressed promptly.

The impact of pharmacist intervention on prophylactic antibiotics use in orthopedic surgery at a hospital in China

This study aimed to assess the impact of the pharmacist-led intervention on perioperative antibiotic prophylaxis by standardizing the cephalosporin intradermal skin test in the orthopedic department.A pre-and postintervention study was conducted among patients in the Orthopedics Department at the Beijing Chao-Yang Hospital in China. Use of intradermal skin test, perioperative antibacterial prophylaxis, and cost of care were compared between the preintervention population (admitted from 6/1/2018 to 8/31/2018) and postintervention population (admitted from 1/1/2019 to 3/31/2019). Logistic regression and generalized linear regression were used to assess the intervention impact.425 patients from the preintervention period and 448 patients from the postintervention period were included in the study. After the implementation of the pharmacist intervention program, there was a decrease in the utilization of intradermal skin tests, from 95.8% to 16.5% (P < .001). Patients were more likely to have cephalosporin as prophylactic antimicrobials (OR = 5.28, P < .001) after the implementation. The cost of antimicrobials was significantly reduced by $150.21 (P < .001) for each patient.Pharmacist-involved intervention can reduce the utilization of cephalosporins skin tests and decrease the prescription of unnecessary high-cost antimicrobials.

Simvastatin Enhances the Immune Response Against Mycobacterium tuberculosis

Tuberculosis remains a serious threat worldwide. For this reason, it is necessary to identify agents that shorten the duration of treatment, strengthen the host immune system, and/or decrease the damage caused by the infection. Statins are drugs that reduce plasma cholesterol levels and have immunomodulatory, anti-inflammatory and antimicrobial effects. Although there is evidence that statins may contribute to the containment of Mycobacterium tuberculosis infection, their effects on peripheral blood mononuclear cells (PBMCs) involved in the immune response have not been previously described. Using PBMCs from 10 healthy subjects infected with M. tuberculosis H37Rv, we analyzed the effects of simvastatin on the treatment of the infections in an in vitro experimental model. Direct quantification of M. tuberculosis growth (in CFU/mL) was performed. Phenotypes and cell activation were assessed via multi-color flow cytometry. Culture supernatant cytokine levels were determined via cytokine bead arrays. The induction of apoptosis and autophagy was evaluated via flow cytometry and confocal microscopy. Simvastatin decreased the growth of M. tuberculosis in PBMCs, increased the proportion of NKT cells in culture, increased the expression of co-stimulatory molecules in monocytes, promoted the secretion of the cytokines IL-1β and IL-12p70, and activated apoptosis and autophagy in monocytes, resulting in a significant reduction in bacterial load. We also observed an increase in IL-10 production. We did not observe any direct antimycobacterial activity. This study provides new insight into the mechanism through which simvastatin reduces the mycobacterial load in infected PBMCs. These results demonstrate that simvastatin activates several immune mechanisms that favor the containment of M. tuberculosis infection, providing relevant evidence to consider statins as candidates for host-directed therapy. They also suggest that future studies are needed to define the roles of statin-induced anti-inflammatory mechanisms in tuberculosis treatment.