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A survey of oral antibiotic prescriptions was carried out in a semi-urban general practice. From this a practice formulary was devised. The formulary was put into operation and the results of its introduction were reviewed after 12 months. There was a reduction in antibiotic costs without an increase in the number of patient consultations, home visits or referrals to hospital.
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A drug formulary comprising 249 preparations of 132 drugs and drug combinations was prepared by the partners in a three-doctor general practice serving more than 5000 patients. No attempt was made to change to generic prescribing nor were repeat prescription drugs altered. Introduction of the formulary in September 1981 was followed by an increase in the proportion of prescriptions containing drugs from the formulary from about 55% to more than 60% for both repeat and non-repeat prescriptions. The proportion of formulary drugs on non-repeat prescriptions reached a maximum of 78% within the first year with the additional influence of information feedback. Over the first year the level of formulary drugs used for both repeat and nonrepeat prescribing levelled off at about 62%. Even with these modest changes, when compared with the costs of general practice prescribing in Scotland as a whole, the introduction of the formulary resulted in savings of approximately 10% within the practice for the mean ingredient costs both per patient and per prescription.
The prescribing of a group of young general practitioners was assessed, before and after educational intervention, using five parameters of rational prescribing. The proportion of drugs prescribed by their generic name, and the proportion falling within a basic formulary for general practice increased significantly even though the participating doctors had neither been involved in the compilation of the formulary nor been given a copy of it. Items prescribed bygeneric name rose from 45 to 74% and the proportions of new and repeat items within the formulary rose by 73 to 83% and 68 to 77% respectively. It appears that discussions about rational prescribing lead to similar changes in prescribing as involvement in the compilation of a formulary.The notion of an ;essential drugs list' for general practice is described, and three easily applied measures of rational prescribing are suggested: (1) the proportion of patients not given a prescription, (2) the proportion of drugs written in their generic form and (3) the proportion of drugs falling within a general practice ;essential drugs list'.
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The chemistry, antiprotozoal activity, pharmacology, clinical efficacy, adverse effects, dosage, administration, and hospital formulary considerations of pentamidine isethionate are reviewed. Pentamidine, an aromatic diamidine, has been used since the 1940s to treat a variety of protozoal infections. It is now most commonly administered in the treatment of Pneumocystis carinii pneumonia (PCP). It is generally not metabolized, and it is stored or bound to tissue and excreted slowly as the parent compound. Pentamidine is clearly effective in the treatment of PCP; however, the high incidence of adverse reactions associated with the drug led to the use of trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line agent for PCP. Recent studies have reported a high incidence of adverse reactions, including leukopenia and hepatotoxicity, associated with the use of TMP-SMX therapy for PCP in patients with the acquired immunodeficiency syndrome (AIDS). The severity and frequency of these reactions suggest a possible new role for pentamidine in patients with AIDS who have PCP. The recommended intramuscular and intravenous dosage of pentamidine isethionate for adults and children is 4 mg/kg/day for 14 days. Intramuscular administration is recommended; however, intravenous administration is a safe alternative if the dose is infused over a 60-minute period. Pentamidine isethionate has specific application in the treatment of PCP as a second-line agent reserved for patients who cannot tolerate TMP-SMX.
The chemistry, in vitro activity, pharmacokinetics, adverse reactions, and clinical use of the monobactam antimicrobial aztreonam are reviewed. Aztreonam, an investigational agent nearing approval in the United States and Canada, is the first in a class of monobactam antimicrobials to be evaluated extensively in vitro and in vivo. It has a narrow spectrum of activity, encompassing only aerobic gram-negative microorganisms including Pseudomonas aeruginosa and most multiply resistant Enterobacteriaceae. Aztreonam has no useful activity against gram-positive or anaerobic microorganisms. In preliminary studies, aztreonam achieved high tissue concentrations and was usually well tolerated. Approximately 65-75% of an administered dose is excreted unchanged into the urine, and the elimination half-life is 1.6-2.2 hours in subjects with normal renal function. Dosage should be adjusted in patients with renal impairment. Aztreonam was shown equivalent to gentamicin and cefamandole for treating serious urinary-tract infections and produced cure rates greater than 85% in gonococcal, lower respiratory tract, orthopedic, serious urinary tract, acute uncomplicated lower urinary-tract, gynecologic, and intraabdominal infections. Development of resistance during therapy may be less likely with aztreonam than with other new cephalosporins. Aztreonam will probably have an important role in antimicrobial therapy, but much further study is necessary to assess clinical efficacy and toxicity. The clinical importance of aztreonam's superior activity under anaerobic conditions compared with aminoglycosides and the theoretical reduced alteration in GI colonization resistance must be assessed in controlled trials. Evaluation of aztreonam versus ceftazidime, the carbapenems, and the carboxyquinolones is needed, and the likelihood of gram-positive superinfection, especially with enterococci, must be further assessed.