Provision of the emergency contraceptive pill without prescription : attitudes and practices of pharmacists in Australia

Background : As 5 years have elapsed since the emergency contraceptive pill (ECP) was made available without prescription in Australia, information was sought about the current attitudes and practices of pharmacists in relation to their increased role in ECP provision.

Study Design : A mail survey was implemented; questionnaires were distributed to 750 pharmacies across Australia during 2008-2009. Descriptive statistics were calculated and multiple logistic regression was used to examine factors associated with declining to dispense ECP.

Results : Response rate was 29%. Most pharmacists used a protocol to guide ECP dispensing (77.3%) and the majority had declined ECP provision (75.1%) in certain circumstances. Many usually counselled where confidentiality could be assured (62.8%), and agreed that it is a pharmacist's role to counsel on regular contraception (81.9%). Factors significantly associated (p≤.05) with dispensing practices included pharmacists' attitudes towards acceptability of advance prescription, their age, gender and pharmacy accessibility.

Conclusions : New information about Australian pharmacists' current attitudes and practices towards ECP dispensing was identified. Pharmacists had stronger, more conservative attitudes than overseas pharmacists; however, the issues that emerged were similar to those reported overseas. To address these, revised training for local pharmacists is recommended.

Prescription medication hoarding and borrowing or sharing behaviours in older residents in the Illawarra, New South Wales, Australia

Aim: To examine prescription medication hoarding and borrowing or sharing (PMHBS) behaviours in older people, particularly which medications are subject to these behaviours and the circumstances that enable these behaviours.

Methods: A mixed methods triangulation design, using consecutive qualitative (focus groups) and quantitative (survey) methodologies in a convenience sample of people older than 65 years, living independently in the Illawarra region (New South Wales).

Results: Focus group participants (n= 28) acknowledged PMHBS behaviours were widespread; however, very few survey respondents (n= 226) admitted to engaging in these behaviours. Main findings in the study were enablers for these behaviours: the prescription medication is considered the same as that prescribed previously; and self-medicating for pain relief.

Conclusions: The prevalence of PMHBS behaviours in this study was low, although it was acknowledged such behaviours occurred in the wider community. Sharing strong pain medication and the same prescription medication appeared to be acceptable in this population.

Co-prescription of medication for bipolar disorder and diabetes mellitus : a nationwide population based study with focus on gender differences

Background
Studies have shown a correlation between bipolar disorder and diabetes mellitus. It is unclear if this correlation is a part of common pathophysiological pathways, or if medication for bipolar disorder has negative effects on blood sugar regulation.
Methods
The Norwegian prescription database was analyzed. Prescriptions for lithium, lamotrigine, carbamazepine and valproate were used as proxies for bipolar disorder. Prescriptions for insulin and oral anti-diabetic agents were used as proxies for diabetes mellitus. We explored the association between medication for bipolar disorder and diabetes medication by logistic regression
Results
We found a strong association between concomitant use of medication to treat diabetes mellitus and mood stabilizers for the treatment of bipolar disorder. Females had a 30% higher risk compared to men of being treated for both disorders. Persons using oral anti-diabetic agents had higher odds of receiving valproate than either lithium or lamotrigine. Use of insulin as monotherapy seemed to have lower odds than oral anti-diabetic agents of co-prescription of mood stabilizers, compared to the general population.
Conclusions
This study showed a strong association between the use of mood stabilizers and anti-diabetic agents. The association was stronger among women than men.

Incidence, clinical spectrum, diagnostic features, treatment and predictors of paradoxical reactions during antibiotic treatment of Mycobacterium ulcerans infections

Background: Paradoxical reactions from antibiotic treatment of Mycobacterium ulcerans have recently been recognized. Data is lacking regarding their incidence, clinical and diagnostic features, treatment, outcomes and risk factors in an Australian population.

Methods: Data was collected prospectively on all confirmed cases of M. ulcerans infection managed at Barwon Health Services, Australia, from 1/1/1998-31/12/2011. Paradoxical reactions were defined on clinical and histological criteria and cases were determined by retrospectively reviewing the clinical history and histology of excised lesions. A Poisson regression model was used to examine associations with paradoxical reactions.

Results: Thirty-two of 156 (21%) patients developed paradoxical reactions a median 39 days (IQR 20-73 days) from antibiotic initiation. Forty-two paradoxical episodes occurred with 26 (81%) patients experiencing one and 6 (19%) multiple episodes. Thirty-two (76%) episodes occurred during antibiotic treatment and 10 (24%) episodes occurred a median 37 days after antibiotic treatment. The reaction site involved the original lesion (wound) in 23 (55%), was separate to but within 3 cm of the original lesion (local) in 11 (26%) and was more than 3 cm from the original lesion (distant) in 8 (19%) episodes. Mycobacterial cultures were negative in 33/33 (100%) paradoxical episodes. Post-February 2009 treatment involved more cases with no antibiotic modifications (12/15 compared with 11/27, OR 5.82, 95% CI 1.12-34.07, p = 0.02) and no further surgery (9/15 compared with 2/27, OR 18.75, 95% CI 2.62-172.73, p < 0.001). Six severe cases received prednisone with marked clinical improvement. On multivariable analysis, age ≥ 60 years (RR 2.84, 95% CI 1.12-7.17, p = 0.03), an oedematous lesion (RR 3.44, 95% CI 1.11-10.70, p=0.03) and use of amikacin in the initial antibiotic regimen (RR 6.33, 95% CI 2.09-19.18, p < 0.01) were associated with an increased incidence of paradoxical reactions.

Conclusions: Paradoxical reactions occur frequently during or after antibiotic treatment of M. ulcerans infections in an Australian population and may be increased in older adults, oedematous disease forms, and in those treated with amikacin. Recognition of paradoxical reactions led to changes in management with less surgery, fewer antibiotic modifications and use of prednisolone for severe reactions.

Antibiotic resistance in invasive Streptococcus pneumoniae isolates identified in Scotland between 1999 and 2007

Data from 4727 invasive isolates of Streptococcus pneumoniae submitted to the Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory between 1999 and 2007 were analysed to establish susceptibility profiles to penicillin, erythromycin and cefotaxime. Pneumococcal resistance to penicillin over the study period remained low, with only 0.2 % (n=7/4727) of isolates falling into this category (MIC ≥2 mg l−1). These isolates have been sporadic, and have mainly represented serogroup 14 (ST9) and 9 (ST156). In comparison, the ‘intermediate sensitivity’ group (MIC 0.12–1 mg l−1) ranged between 2 and 6 % per year, the majority from serogroup 9 (ST156). Over the study period, we found that 12 % (n=585/4727) of isolates were erythromycin-resistant (MIC >0.5 mg l−1), with the majority (n=467; 80 %) of these isolates identified as serogroup 14 (ST9). Cephalosporin resistance (cefotaxime MIC >1 mg l−1) was found in only 0.06 % (n=2/3135) of isolates. Internationally recognized clones (Pneumococcal Molecular Epidemiology Network) accounted for 35 % (n=28/81) of the penicillin non-susceptible isolates and 75 % (n=248/330) of the macrolide-resistant isolates, with ST9 and ST306 predominating. Between 1999 and 2007 we found that 11.6 % (n=18/155) of the penicillin non-susceptible isolates and 4.8 % (n=28/585) of the macrolide-resistant isolates were from serogroups not covered by the 7-valent conjugate pneumococcal vaccine in use in the UK since 2006. Susceptibility to first-line antimicrobial agents for invasive pneumococcal disease in Scotland remained high over the period 1999–2007.