Applying the Principles of Antimicrobial Stewardship to HIV
By now, most pharmacists are aware of the antimicrobial stewardship movement. They don’t usually associate these programs with antiretroviral (ARV) drugs, but antibiotics and ARVs have many things in common. Appropriate use is a problem with both, as is simple and multidrug resistance. Pharmacists who are unfamiliar with either the principles of infectious disease or HIV may miss errors.
A team of researchers from several institutions in New York, NY, established a program to implement the principles of antimicrobial stewardship and an HIV treatment program after conducting a pilot program that identified numerous order verification issues related to ART and in particular, protease inhibitors (PI) and nucleoside reverse transcriptase inhibitors (nRTI). The results of their prospective study were published in the Journal of Pharmacy Practice.
The investigators enhanced their electronic medical record order sets and concurrently improved education directed at staff pharmacists. Their hypothesis was that doing both concurrently would significantly reduce antiretroviral medication errors.
Building on a previous study that indicated that PIs account for approximately 70% of ART errors, and that nRTIs account for a significant proportion of the remainder, they looked at their own institution's track record. They found that PIs and nRTIs accounted for 48% and 39% of errors respectively.
Following guidance promulgated by the American Society of Health-System Pharmacists, the researchers developed standardized order sets for HIV prescribing. These order sets addressed renal dosing options and PI boosting in addition to other basic prescribing considerations. Following its implementation, ART-related errors, which had been identified in 34% of orders previously, were found in only 23% of orders placed using the standardized order sets.
Their data also indicated that educating pharmacists and prescribers consistently about interventions, new guidelines, and how to update the electronic medical record also reduces medication error rates. Staff pharmacists were educated to check clinical pharmacists’ work, and the investigators noted that this intervention helped improve the quality of orders. The one intervention that produced the best results was perspective audit and feedback to pharmacists.
The principles of antimicrobial stewardship have successfully addressed many of the issues related to antibiotics. This study demonstrates that these principles are applicable to other areas of prescribing.
Mehta D, Kohn B, Blumenfeld M, et al. To assess the success of computerized order sets and pharmacy education modules in improving antiretroviral prescribing. J Pharm Pract. 2017 Jan 1:897190017729599. doi: 10.1177/0897190017729599. [Epub ahead of print]