Reslan Zainab, Lindsay Julian, Kerridge Ian, Gellatly Rochelle
Pharmacy Department, Royal North Shore Hospital, Level 1 ASB, Reserve Road, Sydney, NSW, Australia.
Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
Int J Clin Pharm. 2020 Dec;42(6):1412-1418. doi: 10.1007/s11096-020-01090-5. Epub 2020 Oct 3.
Background Patients with haematological malignancies are at high risk of invasive fungal infections. However, there is a lack of information about the utilisation of the recommended Australian antifungal prophylaxis guidelines in haematology outpatients. Objective To assess the impact of a weekly pharmacist review of high-risk adult haematology outpatients on the utilisation of appropriate antifungal prophylaxis. Setting Outpatient cancer centre, tertiary referral hospital in Sydney, Australia. Method A 3-month pre-and post-interventional study was conducted. A retrospective audit was conducted to obtain baseline utilisation of antifungal guidelines in adult haematology outpatients with acute myeloid leukemia, acute lymphoblastic leukemia and myelodysplastic syndrome receiving chemotherapy. This was followed by a weekly pharmacist review over a 3-month period of all eligible outpatients assessing the appropriateness of antifungal agent, dose, use of therapeutic drug monitoring and presence of drug-interactions/contraindications. Recommendations to physicians were conveyed weekly and outcomes recorded. Main outcome measure Appropriate utilisation of antifungal prophylaxis guidelines in outpatient haematology patients before and after implementation of a 3-month weekly pharmacist review service. Results Forty patients were included in the retrospective group, equating to 348 reviews, while 42 patients equating to 269 reviews were included in the prospective group. Appropriate utilisation of antifungal prophylaxis guidelines increased from 31 to 54% post implementation of a pharmacist review (Odds Ratio = 2.44, 95% Confidence Interval: 1.07-5.58, p = 0.0344). The most common reason for nonadherence to guidelines in both groups was lack of therapeutic drug monitoring and failure to prescribe antifungal prophylaxis where indicated. The percentage of appropriate use of antifungal prophylaxis in patients with acute myeloid leukemia increased from 13 to 46% (p value < 0.01) after pharmacist intervention. The pharmacist made 153 recommendations from 269 reviews, with a percentage uptake of 40%. Moderate to severe drug interactions were identified in 19 reviews from 10 patients. One major azole antifungal-chemotherapy interaction was avoided. Conclusions Appropriate utilisation of antifungal prophylaxis guidelines can be improved through a regular pharmacist review. Future studies should identify whether improving adherence to antifungal guidelines leads to improved patient outcomes.
血液系统恶性肿瘤患者发生侵袭性真菌感染的风险很高。然而，关于澳大利亚血液学门诊患者推荐的抗真菌预防指南的应用情况，目前尚缺乏相关信息。目的：评估药师每周对高危成年血液学门诊患者进行审查对适当应用抗真菌预防措施的影响。地点：澳大利亚悉尼一家三级转诊医院的门诊癌症中心。方法：进行了一项为期3个月的干预前后研究。通过回顾性审计获取接受化疗的急性髓系白血病、急性淋巴细胞白血病和骨髓增生异常综合征成年血液学门诊患者抗真菌指南的基线应用情况。随后，药师在3个月内每周对所有符合条件的门诊患者进行审查，评估抗真菌药物的适用性、剂量、治疗药物监测的使用情况以及药物相互作用/禁忌的存在情况。每周向医生传达建议并记录结果。主要结局指标：在实施为期3个月的药师每周审查服务前后，门诊血液学患者对抗真菌预防指南的适当应用情况。结果：回顾性组纳入40例患者，共计348次审查，前瞻性组纳入42例患者，共计269次审查。药师审查实施后，抗真菌预防指南的适当应用率从31%提高到54%（优势比=2.44,95%置信区间：1.07 - 5.58，p = 0.0344）。两组中不遵守指南的最常见原因是缺乏治疗药物监测以及在有指征时未开具抗真菌预防药物。药师干预后，急性髓系白血病患者抗真菌预防的适当使用率从13%提高到46%（p值<0.01）。药师在269次审查中提出了153条建议，采纳率为40%。在10例患者的19次审查中发现了中度至重度药物相互作用。避免了1例主要的唑类抗真菌药与化疗药物的相互作用。结论：通过药师定期审查可提高抗真菌预防指南的适当应用率。未来的研究应确定改善对抗真菌指南的依从性是否能改善患者结局。
