(upbeat music) - Welcome to the ASHP official podcast. Your guide to issues related to medication use, public health, and the profession of pharmacy. - Thank you for joining us for hot topics in community pharmacy practice. This podcast is a forum where you can listen in as members share strategies, best practices, and exchange ideas about key topics in community pharmacy practice and education. In today's episode, we will be discussing antimicrobial stewardship in the community pharmacy setting. My name is Amanda, and I'm an ambulatory care clinical and community-based pharmacist. I will be your host today. With me today are Reese Cosme, director of quality with a focus on antimicrobial stewardship with Ascension National Team and Carlos Sanchez, who is currently completing his community-based PGY1 pharmacy residency at Ascension St. Vincent in Indianapolis. Thanks for joining us today. Let's get started. So to jump right into this discussion, what conditions can community pharmacy antimicrobial stewardship efforts impact? - You know, Amanda, I think that's a really good question. And in order to better understand antimicrobial stewardship, we need to look at it from a global standpoint. In 2014, the CDC had put out the core elements of a hospital acute care or inpatient antimicrobial stewardship program. And after that time in 2015, the Joint Commission made it a requirement that hospitals develop and implement an antimicrobial stewardship program. And by 2018, the majority of hospitals across the United States were confined. So this has been a priority for much time now for acute care setting. Those core elements, which include but are not limited to champions, firing a multidisciplinary team, education, tracking and reporting have been instilled in a hospital-based antimicrobial stewardship program for a long time. But to date, the outpatient setting has remained untouched. There have been outpatient ambulatory antimicrobial stewardship core elements, which were released. And those were required for all joint commission accredited antimicrobial stewardship clinics. But between the 2016 release of those, we saw, of course, the COVID-19 pandemic. So implementation may have fallen by the wayside and may not have been uptake in quite as well as they've been in the inpatient setting. And all of that does not include the community farms we space, which again, like I said, has been largely. - So when we think about what's going on in the ambulatory setting, Rhys, I know that we absolutely looked at what was going on with those core standards and elements from the CDC in 2016. And as we go through, we find that there are a lot of things that we can absolutely dig our teeth into. So prescribing an upper respiratory tract infections and appropriate use of antivirals for things like influenza and the coronavirus, and also components that impact how we prescribe for things like urinary tract infections and skin and soft tissue infections. But what's interesting, if you dive into the text of those, is that they talk about urgent care clinics and employer clinics and primary care offices. And they reference community pharmacists and community pharmacies as partners, but they don't specifically mention community pharmacists or pharmacies settings as being active participants in that particular type of work. - You know, Amanda, I am kind of surprised at the exclusion of community pharmacists from these core standards. As a community PGY-1 resident, I've spent quite a bit of time in the pharmacy and seen how community pharmacists can help with these efforts in many ways. Some examples include ensuring appropriateness of dosing and dosing intervals on a prescription for an ear infection or seeking to change an oral makeomycin to an alternative agent when it isn't used for CEDIF or similar to our colleagues in the inpatient side, such as updating and expanding on allergy histories, checking drug interactions, and navigating best practice recommendations for patients with potential precautions or contraindications. Not only that, but as a community pharmacist, we are a patient facing field, which allows us to impact patient care through specific recommendations when patients have comic infections, such as upper respiratory tract infection or a urinary tract infection, and then educating them on proper antibiotic use. - I really love those examples, Carlos. You know, UTIs and URIs affect almost everyone at some point in time. I can't even fathom how many of the premise impacts like holding my day in retail. And patients come to the pharmacy with many questions. So I'm curious if you can elaborate on how community pharmacists can target these conditions and then you miss you to the antibiotic. - One way is utilizing the OTC aisle to its fullest potential to treat symptoms without resorting to using anti-infectives or a provider's visit. There are many options that patients can use that are found in the OTC aisle for common ailments or minor symptoms, such as pseudofedron per congestion, acetaminophen, and insets for pain and fevers, and cough drops and choreceptic sprays for short throats, just to name a few. Patients can also use non-pharmacologic treatments such as herbal teas, saltwater, gargling, finis rinses, and others can be used just as effectively as egged onto treatments to help with symptom relief. However, when these options are not enough to provide sufficient relief or those symptoms worsen over a few days, it is time to escalate to see a physician or physician extender. These situations include difficulty breathing or swallowing temperature higher than 104 degrees Fahrenheit or lasting more than three to four days. Any bloody mucus or urine or having an improvement of symptoms and then worsening a few days later, symptoms lasting more than 10 days without improving and more. Now moving back behind the counter to dispensing review, what should a community pharmacist be looking for when feeling an antimicrobial agent? - So Carlos, you said it. We are a patient-facing field and I think we would miss an opportunity if we failed to identify the fact that we need to be engaging our patients consistently at the time of drop-off, at the time of pickup, and doing some extensive patient education. What I think may be less comfortable for us as community pharmacists is the idea that we also have the opportunity to be ensuring that what's been prescribed is really best possible, optimizing to ensure the right dose, the right formulation, no drug interactions. All of those are things that community pharmacists do on a daily basis and maybe don't think about the idea that this is also antimicrobial stewardship. But the understanding that if I'm giving a dosage form of nitro-fiantine that is a short-acting dosage form intended to be dosed four times a day, like nitro-fiantine macro-crystal, and I'm giving it as a twice-a-dodosing for a urinary tract infection, data out there shows that the patient may fail to clear their infection, not because the drug doesn't work, but because we never got high enough concentrations. And so a pharmacist can easily intervene and suggest a change in that dosage form to make sure that the patient goes home with a therapy that is truly gonna work. As we think about other things, we may not always have labs, but surrogate markers can be used, so a patient filling a phosphate binder probably is a patient who is receiving dialysis. And so then also ensuring that the antibiotics that they're picking up are appropriately just for somebody who is seeking dialysis. And then never underestimate the power of the patient with regards to information about their own health. They may be aware of things that you need to know, like if they are pregnant or if they are breastfeeding, and so making sure that we're targeting those as well. Adding to all of these other considerations, however, patient allergies are often a concern. Reese, I know you've had a lot of experience in navigating allergy concerns with the antibiotics. What are your thoughts here? - I'm glad you brought that up, Amanda, because yes, in the inpatient space, we go above and beyond the label patients that report penicillin or other antibiotic allergy, whether that's oral challenges, desensitization pathways, or even certifying pharmacists and nurses who ducts penicillin's been testing within the inpatient space. But although we do prioritize that there, we also should be equally prioritizing it in the outpatient space as well. We know that the majority of antibiotics that are filled and prescribed across the United States are within this outpatient space. So we really have the the onus on us as outpatient pharmacists to validate those allergies, ask the patient, interview them, try to figure out what actually happened when they were exposed that antibiotic. Did it recur? Was it the antibiotics that they're currently prescribed now? And if we can confirm and validate that allergy, then great. But if we're able to de-label them, then we have the opportunity to be great antibiotic stewards and to streamline them down to an antibiotic that's more appropriate and probably safer and more effective for their infection. - One other thing that I'm pretty excited about too, that community pharmacists can be involved with are the opportunities to engage in test and treat or test and refer. This is something that really came to the forefront during the coronavirus pandemic, with the idea that pharmacists could participate in testing. And then as the antivirals were released, also then participate in ensuring that the patients who needed that medication could access it at the point of care. This is something that's available not only for the coronaviruses though, but also for influenza, maybe even group A, strep pharyngitis and other things. Many states have differing opportunities to get involved with the testing and then potentially initiating treatment at the point of care. Several professional pharmacy organizations offer certificate programs for pharmacists with great resources to support practitioners and organizations in implementing this type of service. In addition, the National Alliance of State Pharmacy Association has published an implementation guide, a free implementation guide for point of care testing that is available for download that contains some practical implementation tips and resources. - Those are some great resources, Amanda. Thank you for bringing those up. Can you tell me more about other patient-facing education efforts? - Sure, we've all been in that position where a patient comes to the pharmacy counter and asks for help or guidance, thinking about presenting with certain types of rashes or respiratory symptoms, trying to help triage their own symptoms and seek care immediately. I think this is a great opportunity for us to be chatting with them about what their conditions are and helping them understand when treatment is necessary, but we don't have to do this alone. So the Centers for Disease Control have amazing resources that are designed to help with patient education on a general level. When is an infection needing antibiotics? What symptoms are influenza versus what symptoms are related more to an infection? And these can be posted both in providers' offices, but in the pharmacy, we can point patients to these resources online and as well provide them handouts as it is appropriate. And I really appreciate these because these speak to the foundations of those patient discussions and really help to bring our patient education up when we're having those conversations with the patients. However, one thing that I was excited to identify are some resources that are available coming from our professional colleagues across the ocean from the UK, the National Health Services, in addition to the Royal College of General Practitioners, publish a whole series of patient facing leaflets and pharmacy tools and checklists that are designed to be used at the point of filling the prescription. What I really like about this is that they are targeted towards community antimicrobial stewardship. So targeting the types of conditions that we would see more in the community like UTIs or respiratory tract infections, they do pull out specific resources for our older adult population as well as pulling in some of the infections that we might not otherwise think about in an antimicrobial stewardship manner, like dental infections. The other nice thing about these leaflets is that they're targeted for patients who might have lower health literacy or where we need to think about having maybe a limited proficiency with English and many of their leaflets that have a pictorial component to them, which enables us to have that conversation with patients. And in many cases, these leaflets are available in up to 25 different languages on their websites. Again, all for free and available to help us support our patients and our providers in making great choices. I really think this allows us to have those conversations at the point of care and help to build the understanding of the patient when they're in the moment of experiencing these symptoms or seeking improvement. One of the challenges though, is that we realize we also need to be thinking about the broader population and how we help our patients on a broader scale. Reece, what's going on in this space? - Amanda, you're absolutely correct that it's critical to have those other stations at the point of care with those individual patients. So the information impact on their antibiotic choices, the drugs, the things that they're, and et cetera, but as I mentioned, driving the shit and really steering things at a global perspective, we do need to develop public health campaigns as well. So public health campaigns may not look like they did 20, 30 years ago, where we were going out in community, handing out flyers, hoping people would create them. Now everyone is plugged into technology. So public health campaigns can be through the radio. You can have ads that promote whatever you want. You can have public health campaigns through social media apps, through TikTok, through LinkedIn, through other avenues that everyone pretty much has access to and would be on a regular basis. So there are multiple avenues in which we can get our information out there. The double life stored is making sure that people are seeing the information that we're buying. And that's evidence-based. It is coming from health care facilities and practitioners, it has been approved by those that are actually practicing medicine. So that individual is receiving the accurate information that's going to be important, but that's something that we certainly as health care professionals can promote and ensure that that information. Other borders of public health campaigns rely on promoting prevention of infectious diseases. And that in turn would serve as an antibiotic stewardship effort. So vaccine clinics that are held within your local pharmacies, that are held within your local physician offices, those are another form of antimicrobial stewardship in that we are reducing the rate of respiratory infection for other infections that may necessitate or not, not necessitate antibiotic. You know, one that's supposed to be a platform that is really good to get off with is TikTok. Carla, I don't know if you have any examples of creators that create information about it or others. - Of course, Rhys, I have a few examples of some creators that I've run into on my time on TikTok. Some of those are Ethan Milio or Millennial RX. He's a pharmacist practicing out in Rhode Island. Then we also have Dr. Knock, who is a PhD in infectious diseases, who is spreading information about proper antibiotic use in the community space. We also have Dr. Easton, who is practicing in a community pharmacy, and creates a lot of helpful and informative videos. And finally, Dr. Mike, who is a family medicine doctor, who practices out in New York and provides a lot of great information for patients and the public at large. These are great examples, Carla. So we talked about what can be done at a person well, but I'll have at a system. Are there any interventions that could be hard to be pharmacy studying from about in a microbial system? - Okay, Rhys, I'm gonna take this one because I gotta say I am such a huge quality improvement person and systems is a really interesting word. We can use systems to be higher level with quality improvement, medication safety and educational support coming from the administration of our health systems or the administration of our specific locations offering us the support that we need to do our jobs in a daily basis. But systems can also talk about the processes that are built into supporting this work day to day. So things like standard work, those checklists from the National Health Services would be a great example of standard work. You're asking the same questions of the patients every time you have that encounter, or things that are built into our pharmacy operating needs systems that would prompt dosage checks for pediatric patients or evaluation of doses for our older patients or potentially looking at allergy checks as well as surrogate markers. We mentioned those phosphate binders and how that flags for patients that may be undergoing dialysis, but really using the resources that we have that are built in in the same way that we do all of our standard work and our processes to ensure that we provide the same quality of output every time that we do it. In addition, we can use our systems not only to correct and improve behavior at the point of care, at the point of sale and within our organization, but the more that we're able to look at this data and provide global data on what is coming in from physicians in our area, from providers in our area, especially as we look at those prescribing patterns that are locally, that can help us look at the patterns but also identify the outliers and help to figure out if those outliers are representing a current trend or if it's something that's up and coming. And then, of course, you know what we always say, good data can empower good discussions. Now, all of this put together, sounds amazing. And I'm inspired myself to go back and do some more practice, but we know that it isn't easy. What are some of the most pressing challenges and barriers to doing this that the two of you have seen and how can pharmacist in the community work to overcome those barriers? Personally, finding time to fully complete the clinical work or proper education of patients has been a hurdle in my early career so far. I find it difficult to ensure that every single antibiotic that is released has at least some education or proper use, about proper use, side effects and adjunct therapies as well. I've also encountered some hesitation or lack of confidence among pharmacists when it comes to providing clinical services such as making recommendations or interventions to providers about proper antibiotic use. Usually, unless there is a strict contraindication for an antibiotic, it'll be pushed through and processed. However, this is where pharmacists can help curb the amount of antibiotics that are being dispensed if they make appropriate interventions such as recommending OTC products and non-pharmacologic therapies as well. And then also selecting better agents. There's also the elements of patient customer service. As a customer service saying goes, the customer is always right. However, in many cases, patients seek medical care and specifically ask to be prescribed an antibiotic so they can experience quick relief of their symptoms when it may not be appropriate. This then can affect community pharmacists who may feel pressured or do not have enough information to question prescriptions or have a conversation with a patient about their symptoms and options for treatment. I also find that the lack of available labs and cultures can be a hurdle for many community pharmacists as they cannot make specific recommendations about dosing or agent without this information. Adding access to health portals for community pharmacists could significantly improve antibiotic prescribing habits and use. And should be looked at to be implemented by clinicians and health systems. Speaking of clinicians, Rhys, tell us how we can get clinicians to buy into changing their practice around antibiotic prescribing and how they can be receptive to feedback and interventions for pharmacists. - Yes, Carlos, you know, that's a very important aspect that we've discussed in that we have fun with this that are ready to go. They want to be stored now and to bake it in class on antibiotic resistance and the state to be able to use the antibiotics that they're created by whether they have all the tools that their fingertips are not, they need the rest of its being to buy it. And that is start to finish. So clinicians, pharmacists, patients, everyone needs to be bought in to be antibiotic stewards. Otherwise, it's going to be very hard to make it. So starting with patients, we know that to do clinics. And if they're not feeling well, they have an expectation of tone with some, whether that's an antibiotic or it's some other symptom management, whether it's another drug over the counter or just some care that they should be applying at home. But patients that are more health literate have been found in recent literature to have greater satisfaction with their care even if they did not receive any antibiotic research. So what they found is that patients that do not understand why they're receiving the care that they are receiving or the antibiotic they're receiving do not have as great a satisfaction as their care. So our health literacy is very important. If we can get in front of this to be proactive, educate patients, whether that's not at point of fear or through public health care, then patients will be more satisfied and not necessarily expect to receive their antibiotics. Additionally, clinicians need to buy it. And interestingly enough, like we talked about, the CDC core elements were released for outpatient and gladiatorial clinics. But they may not have an implemented class before, class of the United States. With that being said, there was a very interesting, huge charitable trust survey that was conducted in 2020. So pre-pandemic, that found with that 60% of outpatient clinicians believed that they subscribed to antibiotics more conservatively than their peers. So that means they felt that they were better antimicrobial stewards than their peers. And that pediatrician felt the least empowered to improve the antimicrobial prosthetic and other practice. So that really showed that there is a baseline feeling that's incensement that prescribers are doing the right thing and there's not a ton of opportunity for it to work. We know that there is opportunity out there, so we need to get out as pharmacists on other clinicians to educate the prescrowers of baby opportunities and their prescribing practice. And we can partner with them to drive those improved prescribing habits to promote a better team. - The last piece that I want to touch on is financial incentives. And we know that the hospitals have financial incentives coming from payers, from the federal funds that drive antimicrobial stewardship services and require honestly that they have an antimicrobial stewardship program in place and are making true efforts to set goals and achieve those goals related to appropriate antimicrobial prescribed. Now this has recently been translated over to the allocation space where the value-based purchasing metrics under he does have done something similar with setting very specific, mostly related to upper respiratory tract infection incentives for the clinics to track their antimicrobial prescribing and to improve upon. So all of that is great, but we really need the final gatekeepers who are the community pharmacists to have similar incentives, to promote appropriate antimicrobial prescribing and have time to actually do the work, the clinical work or even the clerical work to ensure that antibiotics are prescribed appropriately and even the use of antibiotics is reduced. So we talked a lot about really great opportunities and interventions that can be implemented today or down the line in the community pharmacy space. But I want to round us out with asking Carlos and Amanda, what would you do if you could pick one thing to do tomorrow? And then what would be your shooting for the moon goal that you would hope to achieve down the line? - You know what, for me, that's pretty straightforward. I talked about the nitrogen-fryantooing earlier in this podcast and that for me has been kind of this personal mission with the understanding that we absolutely could and should be fixing this. We know it has an impact on patient payment or patient improvement and patient effectiveness of the therapy that they're taking. So fix the nitrogen-fryantooing. That's my first goal. But then also looking at test and treat, I think this is going to be a really great way for pharmacy providers to expand into the community space and continue to provide care for patients at the point of care. And then lastly, one of my big personal goals as I'm working with providers is to do that feedback and to get the buy-in and really start to build those relationships so that we recognize that we're all partners trying to take care of patients and do a better job as we work together. Carlos, what about you? - In the short term, I would like there to be more of a concerted effort to screen for appropriate dosing forms and dosing adjustments such as renal dose adjustments. This could be done by simply asking providers to send over relevant labs or information that is attached to the prescription or through fax. And that's a little bit easier. As for a pie in the sky long-term goal, I would pick implementing EHR access and community pharmacies so that pharmacists can review patient labs and charts. Having more information will allow me as a pharmacist to ensure that what I'm dispensing is indeed appropriate for the patients. I would love to have access to BMPs, cultures and specific indications to be able to make informed decisions for each antibiotic and other prescriptions as well. What about you, Rhys? - I love all of what you both just said. I will say if my near future goal would be to promote health literacy, our patients, whether that is through the point of care education or public health campaigns. Honestly, I had never seen those NHS efforts that you were sharing with us Amanda and I'm really eager to incorporate them into my current practice. I think they're fantastic and a tool that we had not used previously. For my pie in the sky bowl, I'd really go from more of a systems-based approach, something that can be hardwired and this may be shooting for the stars, but I would love to see the payer support, a structure of antimicrobial stewardship in the community setting. I think that that's down the line, but it's something that we can continue to work toward. And I really hope to see that happen in the coming years. - That's great. And, Rhys, I think we're gonna provide the links to some of those handouts or some of those websites in the information associated with this podcast. So you can check that out and hopefully our listeners will too. But that's all the time we have today. I wanna thank our speakers for joining us today to discuss community-based antimicrobial stewardship. If you have it before, I encourage you all to check out ASHP's online resources for community pharmacy practitioners at ashp.org. You can find member exclusive offerings such as the Community Pharmacists Resource Center, which includes examples of best practices, advanced practice case studies, and more. Thanks again for joining us for this episode of Hot Topics in Community Pharmacy. - Thank you for listening to ASHP official, the Voice of Pharmacists Advancing Healthcare. Be sure to visit ashp.org/podcast to discover more great episodes, access show notes, and download the episode transcript. If you loved the episode and wanna hear more, be sure to subscribe, rate, or leave a review. Join us next time on ASHP official. (upbeat music) (upbeat music) (upbeat music) You
