Long-Term Impact of a Smartphone App on Prescriber Adherence to Antibiotic Guidelines for Adult Patients With Community-Acquired Pneumonia: Interrupted Time-Series Study

BACKGROUND

Mobile health platforms like smartphone apps that provide clinical guidelines are ubiquitous, yet their long-term impact on guideline adherence remains unclear. In 2016, an antibiotic guidelines app, called SCRIPT, was introduced in Auckland City Hospital, New Zealand, to provide local antibiotic guidelines to clinicians on their smartphones.

OBJECTIVE

We aimed to assess whether the provision of antibiotic guidelines in a smartphone app resulted in sustained changes in antibiotic guideline adherence by prescribers.

METHODS

We analyzed antibiotic guideline adherence rates during the first 24 hours of hospital admission in adults diagnosed with community-acquired pneumonia using an interrupted time-series study with 3 distinct periods post app implementation (ie, 3, 12, and 24 months).

RESULTS

Adherence increased from 23% (46/200) at baseline to 31% (73/237) at 3 months and 34% (69/200) at 12 months, reducing to 31% (62/200) at 24 months post app implementation (P=.07 vs baseline). However, increased adherence was sustained in patients with pulmonary consolidation on x-ray (9/63, 14% at baseline; 23/77, 30% after 3 months; 32/92, 35% after 12 month; and 32/102, 31% after 24 months; P=.04 vs baseline).

CONCLUSIONS

An antibiotic guidelines app increased overall adherence, but this was not sustained. In patients with pulmonary consolidation, the increased adherence was sustained.

Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19

BACKGROUND

The efficacy of interleukin-6 receptor antagonists in critically ill patients with coronavirus disease 2019 (Covid-19) is unclear.

METHODS

We evaluated tocilizumab and sarilumab in an ongoing international, multifactorial, adaptive platform trial. Adult patients with Covid-19, within 24 hours after starting organ support in the intensive care unit (ICU), were randomly assigned to receive tocilizumab (8 mg per kilogram of body weight), sarilumab (400 mg), or standard care (control). The primary outcome was respiratory and cardiovascular organ support-free days, on an ordinal scale combining in-hospital death (assigned a value of -1) and days free of organ support to day 21. The trial uses a Bayesian statistical model with predefined criteria for superiority, efficacy, equivalence, or futility. An odds ratio greater than 1 represented improved survival, more organ support-free days, or both.

RESULTS

Both tocilizumab and sarilumab met the predefined criteria for efficacy. At that time, 353 patients had been assigned to tocilizumab, 48 to sarilumab, and 402 to control. The median number of organ support-free days was 10 (interquartile range, -1 to 16) in the tocilizumab group, 11 (interquartile range, 0 to 16) in the sarilumab group, and 0 (interquartile range, -1 to 15) in the control group. The median adjusted cumulative odds ratios were 1.64 (95% credible interval, 1.25 to 2.14) for tocilizumab and 1.76 (95% credible interval, 1.17 to 2.91) for sarilumab as compared with control, yielding posterior probabilities of superiority to control of more than 99.9% and of 99.5%, respectively. An analysis of 90-day survival showed improved survival in the pooled interleukin-6 receptor antagonist groups, yielding a hazard ratio for the comparison with the control group of 1.61 (95% credible interval, 1.25 to 2.08) and a posterior probability of superiority of more than 99.9%. All secondary analyses supported efficacy of these interleukin-6 receptor antagonists.

CONCLUSIONS

In critically ill patients with Covid-19 receiving organ support in ICUs, treatment with the interleukin-6 receptor antagonists tocilizumab and sarilumab improved outcomes, including survival. (REMAP-CAP ClinicalTrials.gov number, NCT02735707.).

Quality of antimicrobial prescribing improved by the introduction of ePrescribing at Auckland City Hospital

Improving antimicrobial prescribing is a difficult process often requiring labour-intensive, multi-modal interventions. Many hospitals have introduced ePrescribing systems but the effect on antimicrobial prescribing, without treatment choice decision support systems, has not been well described. We sought to determine whether the introduction of ePrescribing improved prescribing quality. Patient records for inpatients on four rehabilitation wards, two using ePrescribing and two using the National Medication Chart, during February 2017, were retrospectively reviewed to identify all antimicrobial prescriptions, which were then reviewed for quality. Documentation of indication was significantly better on ePrescribing wards (45/46, 98%) compared to National Medication Chart wards (47/59, 80%). Adherence to guidelines (32/46, 70% vs 33/59, 56%), appropriateness of therapy (42/46, 91% vs 50/59, 85%) and documentation of duration, stop or review dates (35/46, 76% vs 38/59, 64%) did not significantly differ. ePrescribing can improve the quality of antimicrobial prescribing when Antimicrobial Stewardship principles are used in system customisation but cannot address all factors impacting on prescribing quality.

Impact of a smartphone app on prescriber adherence to antibiotic guidelines in adult patients with community acquired pneumonia or urinary tract infections

Background

Mobile phone apps have been shown to enhance guideline adherence by prescribers, but have not been widely evaluated for their impact on guideline adherence by prescribers caring for inpatients with infections.

Objectives

To determine whether providing the Auckland City Hospital (ACH) antibiotic guidelines in a mobile phone app increased guideline adherence by prescribers caring for inpatients with community acquired pneumonia (CAP) or urinary tract infections (UTIs).

Methods

We audited antibiotic prescribing during the first 24 hours after hospital admission in adults admitted during a baseline and an intervention period to determine whether provision of the app increased the level of guideline adherence. To control for changes in prescriber adherence arising from other factors, we performed similar audits of adherence to antibiotic guidelines in two adjacent hospitals.

Results

The app was downloaded by 145 healthcare workers and accessed a total of 3985 times during the three month intervention period. There was an increase in adherence to the ACH antibiotic guidelines by prescribers caring for patients with CAP from 19% (37/199) to 27% (64/237) in the intervention period (p = 0.04); but no change in guideline adherence at an adjacent hospital. There was no change in adherence to the antibiotic guidelines by prescribers caring for patients with UTI at ACH or at the two adjacent hospitals.

Conclusions

Provision of antibiotic guidelines in a mobile phone app can significantly increase guideline adherence by prescribers. However, providing an app which allows easy access to antibiotic guidelines is not sufficient to achieve high levels of prescriber adherence.

Previous antibiotic-related adverse drug reactions do not reduce expectations for antibiotic treatment of upper respiratory tract infections

BACKGROUND

Patients' expectations may influence prescribers' decisions about antibiotic prescribing for upper respiratory tract infection (URTI). We examined whether a history of an antibiotic related adverse drug reaction (aADR) influenced a person's perception about the safety of antibiotics or their expectation of receiving an antibiotic prescription for an URTI.

METHODS

We developed a questionnaire and surveyed 103 hospital inpatients, 38 of whom (37%) reported past experience of aADR.

RESULTS

Of the 88 participants who reported recent antibiotic use, participants with a history of aADR reported increased perception of harm from their last antibiotic treatment (P<0.05). Overall, 41/103 (40%) participants expected their doctors to prescribe antibiotics to treat an URTI. Participants' perceptions of antibiotic safety or expectation of antibiotic treatment for an URTI did not differ between those who had personal experience of an aADR compared with those with no history of aADR.

CONCLUSIONS

The almost universal belief that antibiotics are safe, beneficial medications, even among people with prior aADR, helps to explain the strong patient expectations for antibiotic treatment in a range of conditions. Educational campaigns about the prescription of antibiotics for viral URTI should include information that the risk of harm far outweighs any potential benefits.

Survey of antimicrobial stewardship practices in public hospitals in New Zealand district health boards

AIMS

To determine what antimicrobial stewardship (AMS) practices exist in New Zealand public hospitals.

METHODS

A quantitative survey based on recommended components of hospital AMS programmes was sent to the 20 DHBs in June 2016.

RESULTS

Ten of the 20 DHBs had an AMS committee, nine had dedicated AMS pharmacist full-time equivalents (FTEs) and eight had lead clinician FTEs. Only one DHB met FTE recommendations for AMS pharmacists and two for clinicians (0.3 and 0.1 FTEs per 100 acute beds, respectively). All DHBs had conducted at least one antimicrobial audit in the preceding 12 months, most had their own antimicrobial guidelines (19/20) and prescribing policies (18/20), and 12 reported on antimicrobial usage by at least one metric (eg, defined daily doses). Staff education on AMS had been given at most DHBs in the previous year, but only three reported having AMS ward rounds. All DHBs had surveillance programmes for resistant organisms and most produced antibiograms (16/20). All reported barriers to implementation of an AMS programme.

CONCLUSIONS

Hospital AMS programmes are in their infancy in New Zealand, with wide variation in practices seen. National co-ordination is required to assist DHBs in developing effective programmes to improve antimicrobial use.

Clinical biochemistry guidelines in Wales: their impact on laboratory services

Background

Evidence of significant variations in clinical biochemistry practice in Wales led to the formation of the All Wales Clinical Biochemistry Audit Group (AWCBAG) in 1993, with the aim of auditing laboratory services to ensure that they are optimally used. As part of this process, clinical guidelines are produced and circulated to all clinical biochemistry departments in Wales. The current aim of the AWCBAG is to assess the extent and impact of adoption of these guidelines across Wales.

Methods

Three surveys were despatched at intervals over a decade to all clinical biochemistry departments in Wales to investigate practice in: (1) urine albumin testing to screen for diabetic nephropathy; (2) biochemical investigation of menopausal status and the monitoring of hormone replacement therapy; (3) screening for Cushing's syndrome.

Results

The results show that laboratories across Wales are generally following guideline criteria and are adapting their practice in-line with changing recommendations.

Conclusion

The introduction of AWCBAG guidelines has been widely accepted by clinical biochemistry departments in Wales. These guidelines have led to a more efficient and effective use of laboratory services.

Expression and purification of the human thrombin receptor

The human thrombin receptor has been overexpressed in Sf9 (Spodoptera frugiperda) insect cells using a baculovirus vector. Cell surface expression of the receptor was confirmed by immunocytochemistry with polyclonal antibodies raised against the extracellular domain of the receptor. The expressed receptor was functional; both thrombin and the thrombin receptor agonist peptide produced increases in intracellular calcium in transfected cells. The concentration of thrombin causing the half-maximal increase (EC50) in intracellular calcium was 3.9 nM, whereas the EC50 for the agonist peptide was 2.7 microM. However, the observed maximum increase in intracellular calcium concentration with the agonist peptide (547 nM) was twofold greater than that observed with thrombin (258 nM). The recombinant receptor was purified by immunoaffinity chromatography using a monoclonal antibody raised against the receptor extracellular domain. The purified preparation contained two species with apparent molecular masses of 48 and 90 kDa, both of which were recognized by mono- and polyclonal antibodies against the thrombin receptor. The yield of the purified receptor was 0.78 mg/liter of insect cells suspension culture (10(6) cells/ml). The purified thrombin receptor will be useful in future structural and functional studies.

Allosteric modulation of the activity of thrombin

Substrates containing a P3 aspartic residue are in general cleaved poorly by thrombin. This may be partly due to an unfavourable interaction between the P3 aspartate and Glu192 in the active site of thrombin. In Protein C activation and perhaps also thrombin receptor cleavage, binding of ligands at the anion-binding exosite of thrombin seems to improve the activity of thrombin with substrates containing a P3 aspartate. To investigate the importance of Glu192 and exosite-binding in modulating thrombin's interactions with a P3 aspartate, peptidyl chloromethanes based on the sequence of the thrombin receptor (containing a P3 aspartate) have been synthesized and the kinetics of their inactivation of alpha-thrombin and the mutant Glu192-->Gln determined. The values of the inactivation rate constant (ki) for the chloromethanes containing a P3 aspartate were about two-fold higher with the Glu192-->Gln mutant. A peptide based on the sequence of hirudin (rhir52 65), which binds to the anion-binding exosite of thrombin, was an allosteric modulator of the amidolytic activity of the Glu192-->Gln mutant; a 5-fold decrease in the K(m) value for the substrate D-Phe-pipecolyl-Arg-p-nitroanilide was observed in the presence of saturating concentrations of rhir52-65. This exosite-binding peptide also increased the ki values of chloromethanes containing a P3 aspartate with both alpha-thrombin and the Glu192-->Gln mutant. However, the increases in the ki values were greater with the Glu192-->Gln mutant (5-fold compared with 2-fold for alpha-thrombin). Thus exosite binding does not seem to mitigate putative unfavourable interactions between Glu192 and the P3 aspartate. Moreover, increases in the ki caused by exosite binding were not unique to chloromethanes containing a P3 aspartate; increases of the same magnitude were also observed when the P3 position was occupied by the favourable D-phenylalanine in place of the unfavourable aspartate. The results obtained were consistent with exosite binding's causing changes in the conformation of the S2 and/or S1 site of thrombin.

Mechanism-based isocoumarin inhibitors for blood coagulation serine proteases. Effect of the 7-substituent in 7-amino-4-chloro-3-(isothioureidoalkoxy)isocoumarins on inhibitory and anticoagulant potency

A series of 7-amino-4-chloro-3-(3-isothioureidopropoxy)isocoumarin (NH2-CiTPrOIC) derivatives with various substituents at the 7- and 3-positions have been synthesized as inhibitors of several blood coagulation enzymes. Isocoumarins substituted with basic groups such as guanidino or isothioureidoalkoxy groups were previously shown to be potent irreversible inhibitors of blood coagulation enzymes [Kam et al. Biochemistry 1988, 27, 2547-2557]. Substituted isocoumarins with an isothioureidoethoxy group at the 3-position and a large hydrophobic group at the 7-position are better inhibitors for thrombin, factor VIIa, factor Xa, factor XIa, factor IIa, and factor IXa than NH2-CiTPrOIC (4). PhNHCONH-CiTEtOIC (14), (S)-Ph(CH3)CHNHCONH-CiTEtOIC (25), and (R)-Ph(CH3)CHNHCONH-CiTEtOIC (26) inhibit thrombin quite potently and have kobs/[I] values of (1-4) x 10(4) M-1 s-1. Modeled structures of several isocoumarins noncovalently complexed with human alpha-thrombin suggest that H-bonding between the 7-substituent and the Lys-60F NH3+ relates to the inhibitory potency. Thrombin inhibited by 14, 25, or 26 is quite stable, and only 4-16% of enzymatic activity is regained after incubation for 20 days in 0.1 M Hepes, pH 7.5 buffer. However, 100, 67, and 65% of enzyme activity, respectively, is regained with the addition of 0.38 M hydroxylamine. With normal citrated pig or human plasma, these isocoumarin derivatives prolong the prothrombin time ca. 1.3-3.1-fold and also prolong the activated partial thromboplastin time more than 3-7-fold at 32 microM. Thus, these compounds are effective anticoagulants in vitro and may be useful in vivo.

Binding of factor VIIIa and factor VIII to factor IXa on phospholipid vesicles

The activation of factor X by factor IXa (fIXa) in the presence of phosphatidylcholine-phosphatidylserine (PCPS) vesicles is markedly accelerated by thrombin-activated factor VIII (fVIIIa). The interaction between highly purified fVIIIa and fIXa in this complex was studied fluorometrically at 25 degrees C by using a derivative of D-phenylalanyl-prolyl-arginyl-fIXa which was modified at the active site with fluorescein-5-maleimide (Fl-M-FPR-fIXa). Titration of Fl-M-FPR-fIXa with fVIIIa at fixed PCPS resulted in a large, saturable increase in anisotropy (delta r = 0.09). The titration data were fit to a model assuming a reversible equilibrium between fVIIIa and fIXa, resulting in an apparent dissociation constant of 2 nM and a stoichiometry of 1 mol of fVIIIa/mol of Fl-M-FPR-fIXa. The initial velocity of factor X activation was measured under identical conditions except that active fIXa and factor X were included, which yielded binding parameters similar to those determined fluorometrically. Thus, the fluorescence method accurately reflects complex formation between fVIIIa and fIXa on the phospholipid surface, and the fVIIIa-fIXa interaction is not influenced by the presence of the substrate, factor X. Addition of fVIII to Fl-M-FPR-fIXa and PCPS produced a small, saturable increase in anisotropy (delta r = 0.03), followed by a larger increase (delta r = 0.07) upon addition of thrombin to activate fVIII. Thus, fVIII binds fIXa, but proteolytic modification of fVIII must occur before the complete fVIIIa-dependent structural change in the active site of fIXa, as reflected in the anisotropy change, occurs

The active site of factor IXa is located far above the membrane surface and its conformation is altered upon association with factor VIIIa. A fluorescence study

The topography of membrane-bound blood coagulation factor IXa (fIXa) and the nature of its interaction with its cofactor, factor VIIIa (fVIIIa), were examined using fluorescent derivatives of fIXa. A fluorescein dye was covalently attached to the active-site histidine of fIXa via a D-Phe-Pro-Arg tripeptide tether to form Fl-A-FPR-fIXa; similarly, a 5-dimethylaminonaphthalene-1-sulfonyl (dansyl) dye was covalently attached via Glu-Gly-Arg to form DEGR-fIXa. When either Fl-A-FPR-fIXa or DEGR-fIXa was titrated with phosphatidylcholine-phosphatidylserine vesicles containing octadecylrhodamine in the presence of Ca2+, fluorescence energy transfer was observed. Assuming a random orientation of dyes, the distance of closest approach between the donor dyes in the active sites of the membrane-bound enzymes and the acceptor dyes at the membrane surface was found to be 89 +/- 3 A for Fl-A-FPR-fIXa and 73 +/- 4 A for DEGR-fIXa. Although the exact distance remains uncertain, it is clear that the active site of fIXa is positioned more than 70 A above the surface, and hence that the elongated fIXa molecule projects approximately perpendicularly from the surface when bound to the membrane. The binding of fVIIIa to membrane-bound Fl-A-FPR-fIXa or DEGR-fIXa did not alter the location of the active site relative to the membrane surface, but did alter both the emission intensity and anisotropy of the fluorescein and dansyl probes and hence their environments. Cofactor stimulation of fIXa activity therefore appears to be mediated, at least in part, by a conformational change in the active site that occurs when fVIIIa binds to the enzyme on the phospholipid surface.

Intrinsic pathway activation of factor X and its activation peptide-deficient derivative, factor Xdes-143-191

The role of the activation peptide in determining the substrate specificity of intrinsic pathway factor X (fX) activation was studied by using a novel derivative of fX in which 49 residues were removed enzymatically from the NH2 terminus of the 52-residue activation peptide by an enzyme from the venom of the snake Agkistrodon rhodostoma. The modified protein, designated fXdes-143-191, is inactive but is activated to alpha-fXa by either the intrinsic fX activation complex (intrinsic fXase) composed of factor IXa beta, thrombin-activated factor VIII (fVIIIaIIa), and phospholipid vesicles or by the fX coagulant protein from Russell's viper venom (RVV-XCP). Both the Km and kcat for the activation of fX by RVV-XCP were greater than for fXdes-143-191, resulting in less than a 2-fold difference in the catalytic efficiency (kcat/Km) suggestive of nonproductive binding of fXdes-143-191 to RVV-XCP. The activation of each substrate by intrinsic fXase revealed that the kcat was 100-fold greater for fX than fXdes-143-191 (16 and 0.16 s-1, respectively), although there was no detectable difference in Km (60 and 80 nM, respectively). Activations by fIXa beta/phospholipid in the absence of fVIIIaIIa also revealed a difference in kcat but not Km, but the difference in kcat was smaller (kcat of 0.007 and 0.002 s-1 and Km of 220 and 170 nM for fX and fXdes-143-191, respectively). Analysis of product versus time curves demonstrated that fVIIIaIIa promotes formation of the actyl-enzyme intermediate during fX activation. We conclude that the activation peptide plays a critical role during acyl-enzyme formation that is most pronounced in the presence of fVIIIaIIa. The absence of Km differences suggests that residues NH2-terminal to P3 do not contribute to the initial formation of the enzyme-substrate complex.