Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older p...Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selectionin older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drugdrug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.展开更多
BACKGROUND Clinical decision-making in urinary tract infections depends heavily on accurately distinguishing between pathogenic and non-pathogenic organisms.The interpretation of urine culture results is influenced by...BACKGROUND Clinical decision-making in urinary tract infections depends heavily on accurately distinguishing between pathogenic and non-pathogenic organisms.The interpretation of urine culture results is influenced by proper sample collection,the patient's clinical context,and organism-specific characteristics.However,there is currently no definitive method to determine whether a urinary isolate is truly pathogenic.This distinction is critical,as treatment decisions hinge on it.This pioneering study systematically applies a stepwise model to differentiate pathogenic from non-pathogenic urinary isolates—an approach not previously described.AIM To determine whether a urinary isolate is pathogenic(commensal,colonizer,or direct pathogen)or non-pathogenic(commensal,colonizer,or contaminant)using a structured,stepwise approach.METHODS This prospective,longitudinal,exploratory study was conducted over 24 months,starting in January 2022,at All India Institute of Medical Sciences Rishikesh,following approval from the Institutional Ethics Committee.A stepwise model developed by the investigators was applied to assess the nature of the isolates.Data recorded using REDCap,and analysis was performed using SPSS Version 25.RESULTS A total of 275 consecutive patients aged over 18 years with positive urine cultures—initially treated with antibiotics based on microbiological and clinical assessment—were included.The stepwise model classified 90.54% of cases as pathogenic(commensals:61.81%,colonizers:14.18%,and direct pathogens:14.54%)and 9.45% as non-pathogenic.The model showed that there could be a significant reduction in average hospital stay by over 13 days,along with saving approximately Rs.981 per patient in antibiotic costs in non-pathogenic cohort.CONCLUSION This novel model identified that approximately one in ten urinary isolates,initially considered pathogenic and treated with antibiotics,were in fact non-pathogenic.The model is safe,feasible,and potentially valuable in resource-limited settings,warranting broader validation and implementation.展开更多
文摘Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selectionin older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drugdrug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.
文摘BACKGROUND Clinical decision-making in urinary tract infections depends heavily on accurately distinguishing between pathogenic and non-pathogenic organisms.The interpretation of urine culture results is influenced by proper sample collection,the patient's clinical context,and organism-specific characteristics.However,there is currently no definitive method to determine whether a urinary isolate is truly pathogenic.This distinction is critical,as treatment decisions hinge on it.This pioneering study systematically applies a stepwise model to differentiate pathogenic from non-pathogenic urinary isolates—an approach not previously described.AIM To determine whether a urinary isolate is pathogenic(commensal,colonizer,or direct pathogen)or non-pathogenic(commensal,colonizer,or contaminant)using a structured,stepwise approach.METHODS This prospective,longitudinal,exploratory study was conducted over 24 months,starting in January 2022,at All India Institute of Medical Sciences Rishikesh,following approval from the Institutional Ethics Committee.A stepwise model developed by the investigators was applied to assess the nature of the isolates.Data recorded using REDCap,and analysis was performed using SPSS Version 25.RESULTS A total of 275 consecutive patients aged over 18 years with positive urine cultures—initially treated with antibiotics based on microbiological and clinical assessment—were included.The stepwise model classified 90.54% of cases as pathogenic(commensals:61.81%,colonizers:14.18%,and direct pathogens:14.54%)and 9.45% as non-pathogenic.The model showed that there could be a significant reduction in average hospital stay by over 13 days,along with saving approximately Rs.981 per patient in antibiotic costs in non-pathogenic cohort.CONCLUSION This novel model identified that approximately one in ten urinary isolates,initially considered pathogenic and treated with antibiotics,were in fact non-pathogenic.The model is safe,feasible,and potentially valuable in resource-limited settings,warranting broader validation and implementation.
