MedsScan, Issue 1, 2025

MedsScan, Issue 1, 2026

These reviews provide updates on the international literature on therapeutics. Expert pharmacy practitioners — via AdPha’s Specialty Practice Groups — scan major peer-reviewed journals in areas relevant to Australian pharmacy practice and present precis on major clinical trials, important pharmacoepidemiology studies and pharmacoeconomic research, and other updates relevant to practice. Interested readers are encouraged to explore the original publications in greater detail.

Compounding services
Emergency medicine
General medicine
Infectious diseases
Mental health
Nephrology
Oncology and haematology
Paediatrics and neonatology
Pain management
Pharmacy informatics and technology

COMPOUNDING SERVICES

MedsScan Editor for Compounding services SPG: Rachel Berry

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EMERGENCY MEDICINE

MedsScan Editors for Emergency medicine SPG: Jill Upton and Alicia Thomas

Pyelonephritis in the emergency department

Acute pyelonephritis (APN) is a common presentation in the emergency department (ED). With a global rise in antimicrobial resistance, it is important to assess whether the antibiotics prescribed are appropriate for current causative pathogens. This single-centre retrospective cohort study was conducted at a major metropolitan adult tertiary public hospital in Melbourne. A retrospective review of patients with an ICD-10 [International statistical classification of diseases and related health problems, tenth revision]¹ discharge diagnosis of APN was conducted over a 5-year period from 2018–2022, to determine the appropriateness of antibiotic choice.

Five hundred and fifty-seven patients with APN were included and 569 urine samples were cultured. Escherichia coli (E. Coli) was the most frequently cultured organism and was identified in 40.8% (n = 232) of culture results. Most patients were treated with appropriate antibiotics. However, initial antibiotic therapy was inappropriate in 26patients (4.7%, 95% confidence interval [CI] 3.1–6.6). The most common reason for this was monotherapy with amoxicillin or ampicillin. Seventy-six (13.6%) patients were discharged with inappropriate antibiotic therapy. The most common reason for this was that no antibiotic was prescribed on discharge. Of note, among the 232 specimens where E. coli was cultured, a high proportion (53%) of specimens were resistant to ampicillin or amoxicillin.

The study did not evaluate diagnostic accuracy or appropriateness of management or follow patient outcomes after discharge. Generalisability of the results is limited as the study was conducted at a single site. Further, because this study was retrospective the authors were unable to determine why certain antibiotic regimens were selected or why selection deviated from clinical guidelines. Further research here would be useful to improve prescribing appropriateness.

References

World Health Organization (WHO). International statistical classification of diseases and related health problems, tenth revision. Geneva: WHO; 2019.

Yu J, Koolstra C, De Villiers S, Mitra B. Antibiotic therapy for pyelonephritis in the emergency department. Emerg Med Australas 2025; 37: e70130.

Faster administration of fibrinolytic therapy with pharmacist involvement

Special contributor: Aleksandra Trakilovic

Administration of fibrinolytic therapy in acute ischemic stroke (AIS) is a time-sensitive standard of care. Measured by the metric door-to-needle (DTN) time, earlier administration improves functional outcomes. Pharmacist-assisted Stroke Treatments I (PhAST-1) was a systematic review and meta-analysis that assessed the impact of emergency medicine pharmacist (EMP) involvement and impact on DTN time in adult patients in the emergency department.

Nine studies met the inclusion criteria, all of which were single centre, retrospective, observational cohort studies and examined patients receiving alteplase. Studies with patients experiencing an AIS without defined pharmacist involvement and patients who received fibrinolytic therapy outside the study facility were excluded.

A total of 1064 patients were included for meta-analysis: 441 in the EMP present group and 623 in the EMP absent group. A mean reduction in DTN time of 14.6 min (95% CI -18.1 to -11.1 min) was found in the EMP present group. EMP presence increased the odds of achieving a DTN time within 60 min (odds ratio [OR] 2.75, 95% CI 1.99–3.79) and within 45 min (OR 2.85, 95% CI 1.4–5.79). There was no difference between the EMPs present and absent groups in hospital length of stay (LOS).

The findings of this meta-analysis should be interpreted with caution due to the low number of studies included, with the majority deemed to be of poor quality with respect to risk of bias. Confounding of daytime presence of EMPs and staff availability, as well as shift-timing (weekday versus weekend), was not explored. While higher-quality studies are required to establish causality, this meta-analysis supports the integration of EMPs in stroke response teams to expedite the administration of fibrinolytics.

Mercer KJ, Howington GT, Brown CS, Gilbert BW, Cole K, Acquisto NM, et al. Assessing the impact of emergency medicine pharmacists on fibrinolytic door-to-needle times in acute ischemic stroke: a systematic review and meta-analysis (Pharmacist-assisted Stroke Treatments I (PhAST-1)). Am J Emerg Med 2025; 98: 57–64.

Rapid administration of antiseizure medicines is safe and efficient

Special contributor: Gary Ward

Rapid control of seizures in important to prevent severe neurological damage. Administration of antiseizure medications by intravenous push (IVP) and intravenous piggyback (IVPB) has been proposed to improve time to administration compared to the licensed administration rate.

This narrative review summarised articles reporting on rapid administration of lacosamide, levetiracetam and valproate. Fourteen articles investigated rapid administration of lacosamide (5–30 min). Administration of undiluted lacosamide was not associated with an increase in adverse effects, although studies were inconsistent in reporting dilution status. Increased efficiency was reported with IVP lacosamide, with similar safety concerns noted between IVP and IVPB administration. There may be an increased risk of cardiac arrhythmias, with a small, dose-dependent increase in the PR interval, although clinical significance is unclear.

Eighteen papers examined rapid administration of levetiracetam (2–10 min), with doses ranging from 1000 mg to 4500 mg. Undiluted levetiracetam appeared to be safe, with no increased incidence of adverse effects compared with diluted drug. Use of IVP was associated with a decreased time to administration compared to IVPB in some reports, and significant cost savings were noted with IVP administration.

Thirteen studies investigated rapid administration of valproate (2–60 min), with most not specifying whether the drug was given via IVP or IVPB. There were few adverse events, and there was no correlation with faster administration rates or according to dilution status (where reported). IVP was found to be more efficient than IVPB in the one study measuring this outcome.

Rapid administration of intravenous antiseizure medications appears safe and can improve efficiency. The use of IVP, or faster IVPB administration should be considered by healthcare organisations.

Laswell E, Peterson K, Duan H, Grinalds M. Rapid administration of antiseizure medications: review of safety, effectiveness, and implications for pharmacy practice. Am J Health Syst Pharm 2026; 83: 131–150.

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