Engaging Pharmacy Students, Residents, and Fellows in Antimicrobial Stewardship

The New Precision Stewards?

The precision health era is likely to reduce and respond to antimicrobial resistance (AMR). Our stewardship and precision efforts share terminology, seeking to deliver the “right drug, at the right dose, at the right time.” Already, rapid diagnostic testing, phylogenetic surveillance, and real-time outbreak response provide just a few examples of molecular advances we dub “precision stewardship.” However, the AMR causal factors range from the molecular to that of global health policy. Mirroring the cross-sectoral nature of AMR science, the research addressing the ethical, legal and social implications (ELSI) of AMR ranges across academic scholarship. As the rise of AMR is accompanied by an escalating sense of its moral and social significance, what is needed is a parallel field of study. In this paper, we offer a gap analysis of this terrain, or an agenda for “the ELSI of precision stewardship.” In the first section, we discuss the accomplishments of a multi-decade U.S. national investment in ELSI research attending to the advances in human genetics. In the next section, we provide an overview of distinct ELSI topics pertinent to AMR. The distinctiveness of an ELSI agenda for precision stewardship suggests new opportunities for collaboration to build the stewardship teams of the future.

Investigating pharmacy students' therapeutic decision-making with respect to antimicrobial stewardship cases

BACKGROUND

Antimicrobial stewardship programs (ASPs) play a big role in minimizing antimicrobial resistance. Pharmacists are essential members of the health care team and in order for them to fulfill roles on ASP teams and become antimicrobial stewards, they must be prepared adequately by pharmacy schools prior to entry into actual practice. Although programming has been implemented into entry-to-practice programs worldwide, little is known about how students interpret antimicrobial stewardship (AMS) data and arrive at clinical decisions. We aimed to explore students' cognitive processes and determine how they formulate therapeutic decisions when presented with AMS cases.

METHODS

This was a qualitative study conducted using a case study approach, in which a sample (n=20) of pharmacy students was recruited to interpret AMS cases. Semi-structured 1-on-1 interviews were arranged with each participant. A think-aloud procedure with verbal protocol analysis was adopted to determine students' decision-making processes. Thematic analysis was used to interpret themes from the interview data.

RESULTS

Two themes were interpreted from the data: students' focus and students' approach to case interpretation. Students' focus relates to external factors students consider when interpreting AMS case data and use to make and justify therapeutic decisions including patient-centered factors, drug-related factors, AMS interventions, and pharmacist's role. Students' clinical reasoning describes the approach that students use to interpret the data and the decision-making processes they employ to arrive at a clinical decision including a systematic approach versus non-systematic approach.

CONCLUSIONS

Students vary in their focus and the cognitive strategies used to interpret AMS cases. Findings support the notion that clinical reasoning and decision-making should be explicitly taught in pharmacy curricula, in order to help students become aware of their own cognitive processes and decision-making abilities.

A Scoping Review of Antimicrobial Stewardship Teaching in Pharmacy Education Curricula

Objective. To conduct a scoping review of the existing literature to identify published studies on innovative teaching and assessment practices for antimicrobial stewardship in the Doctor of Pharmacy curriculum and to provide a foundation for future scholarly research in this important area.Findings. Seven studies were found that met the inclusion criteria. Two of the studies explored the extent, content, and methods of delivery of antimicrobial stewardship, four studies described elective courses in antimicrobial stewardship, and one study described an interprofessional module. Most studies were conducted in the United States. Several pharmacy schools in the UK and the US incorporated antimicrobial stewardship teaching into their curriculum. Learning objectives for the elective courses focused on guidelines issued by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), antimicrobial stewardship literature appraisal and principal application. The most used teaching strategy was didactic lectures, followed by case studies. Active-learning approaches like simulators, problem-based learning, and presentations were also used but to a lesser extent.Summary. Antimicrobial stewardship curricular reform may be influenced by the timing of the course, teaching approaches, and performance assessment of students. Antimicrobial stewardship learning should be a required of all pharmacy students. The scarcity of scholarly activity in the teaching of and assessment of learning in antimicrobial stewardship suggests that curricular planning should be guided by national or international organizations to ensure pharmacy students learn such important material.

Assessing Pharmacy Students' and Preceptors' Understanding of and Exposure to Antimicrobial Stewardship Practices on Introductory Pharmacy Practice Experiences

Antimicrobial stewardship (AMS) is commonly employed, and may be required, in multiple healthcare settings, with pharmacists playing an integral role in developing and conducting AMS techniques. Despite its prevalence, AMS is minimally taught in pharmacy school curricula. In order to increase student and preceptor understanding and application of AMS techniques, the Medical College of Wisconsin School of Pharmacy required introductory pharmacy practice students to complete three checklists and reflections of AMS techniques observed at three different practice settings: inpatient, ambulatory, and community (retail) pharmacy. Student and preceptor understanding and application of AMS techniques were then assessed via voluntary survey. Survey response rates were 43% for pharmacy students, while preceptor response rates were 27%. Student understanding and application of AMS techniques increased after completion of the AMS checklist, with the largest magnitude of change seen with antibiotic selection recommendations and guideline and policy development. Preceptor understanding was minimally impacted by the activity; however, an increase in understanding was seen for allergy assessments, antibiotic time-outs, and vaccine assessments and recommendations. AMS is an important component of pharmacy practice today. Implementation of a checklist and reflection activity within experiential education increases perceived student understanding and application of relevant AMS techniques.

Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems

World Health Organization (WHO) has identified antimicrobial resistance as one of the top 10 threats to public health. The agency has formulated a global action plan to tackle antimicrobial resistance by reducing incidence of infectious diseases, increasing knowledge and awareness and promoting rational use of antimicrobials amongst other measures. While the core elements of successful antimicrobial stewardship (AMS) programs are much publicized, there application in resource limited settings is fraught with several challenges. The key limiting factors include lack of clear political commitment, inadequate funding, overcrowded healthcare systems, lax legal and regulatory frameworks, non-uniform access to diagnostics, absence of electronic health record systems, limited knowledge and awareness especially with existence of multiple systems of medicines, issues with access to quality assured medicines, in-house pharmacies, and shortage of trained manpower. Since these implementation-impeding issues may differ considerably from those experienced in developed economies, intervention efforts in low- and middle-income countries (LMICs) need to address the context and focus on the root causes prevailing locally. In this article, we review the evidence highlighting the magnitude of these challenges and suggest feasible models with effective application. We also share the evidence from our center where we have contextualized the core elements to resource constrained settings. These domains include delivering prospective audit and feedback, prescriber education, development of evidence-based and implementable guidelines, and optimization of surgical antibiotic prophylaxis. However, there is a tremendous need for scaling up, extending outreach and honing these models while at the same time, addressing the existing strategic challenges that curtail the full potential of global antimicrobial stewardship.

Stewardship-Hospitalist Collaboration

Hospitalists represent a rapidly emerging specialty group that treats a large proportion of hospitalized patients with infections. Antimicrobial stewardship programs and hospitalist groups that focus on building a collaborative approach have been extremely successful in optimizing antimicrobial prescribing and improving patient outcomes. We discuss the tools needed to build collaborative relationships, summarize published examples of successful stewardship-hospitalist collaboration, and provide guidance on developing collaborative interventions.

Role of postgraduate year 2 pharmacy residents in providing weekend antimicrobial stewardship coverage in an academic medical center

PURPOSE

The integration of pharmacy residents into an antimicrobial stewardship program (ASP) is described, and data on the residents' ASP interventions and outcomes are reported.

SUMMARY

ASP coverage of nighttime, holiday, and weekend shifts is often provided by infectious diseases (ID) medical fellows and staff pharmacists, potentially leading to inconsistent stewardship practices. As part of an initiative by a large urban hospital to provide around-the-clock, comprehensive ASP services 7 days a week, postgraduate year 2 (PGY2) pharmacy residents in ID or critical care were assigned to provide ASP coverage on weekends. Over a 12-month period, residents providing ASP weekend coverage documented a total of 1,443 interventions, of which 1,000 (69%) were pursuant to 72-hour prospective audit and feedback review and 443 (31%) occurred during ASP phone coverage. A comparison of overall antimicrobial utilization (mean ± S.D. days of therapy [DOT] per 1,000 patient-days [PD]) before and after implementation of resident ASP coverage on weekends showed a decrease in aggregate antimicrobial use from 799.3 ± 46.8 to 740.7 ± 17.3 DOT/1,000 PD (a difference of 58.6 DOT/1,000 PD, p = 0.08), with a corresponding decline in the incidence of hospital-onset Clostridium difficile infection (from 1.18 cases to 0.9 case per 1,000 PD).

CONCLUSION

By expanding the hospital's ASP services by assigning PGY2 pharmacy residents to weekend coverage, the institution was able to provide high-level clinical care 7 days per week, which benefited both patients and PGY2 pharmacy residents while meeting national ASP regulatory requirements.

Exploring the gaps between education and pharmacy practice on antimicrobial stewardship: a qualitative study among pharmacists in Qatar

Background: Antimicrobial resistance is a public health issue and is the focus of antimicrobial stewardship (AMS) teams within health care institutions. However, AMS is not comprehensively and fully taught in medical or pharmacy curricula and little is known about the relevance of pharmacist training to meet AMS needs in the Middle East region. We aimed to explore the discord that may exist between infectious diseases education and actual clinical practice with regard to AMS knowledge and training skills in Qatar. Then, we sought to further explore pharmacist perceptions of their AMS roles in hospital environments. Methods: A qualitative study was undertaken at Qatar University using three focus groups consisting of 15 pharmacy alumni who are currently practicing as clinical pharmacists in Qatar. Focus groups were facilitated using a topic guide developed by study investigators. Discussions were audio-recorded and transcribed verbatim. Results were analyzed using framework analysis. Results: Two major themes related to the first objective emerged throughout the discussions and associated recommendations made to improve (i) infectious diseases (ID) module content and delivery and (ii) ID knowledge and skills application. Two themes related to the second objective included (i) impact of pharmacist's interventions on decision-making and (ii) continuing professional development programming. Conclusion: Our findings guide ongoing efforts to enhance ID content in the curriculum and will close gaps related to AMS training. Pharmacists are core AMS team members where there is an ongoing need to align continuing education for health professionals with realities of practice.

All aboard!: Involvement of medical and pharmacy trainees in antimicrobial stewardship

Antimicrobial stewardship (AS) involves the appropriate selection of antimicrobials. Antimicrobial stewardship programs are mandated in hospitals and are expanding to involve outpatient arenas. Multiple articles have been published describing the need for AS education for medical and pharmacy students, beginning early in the students’ career to develop into competent AS practitioners. Additionally, publications have described the role and impact of medical and pharmacy trainees on AS programs. Here, we review the published evidence describing medical and pharmacy trainees’ involvement in AS and call for future research in this area.

Perceptions and current practices of community pharmacists regarding antimicrobial stewardship in Tasmania

Background Despite increasing interest in antimicrobial stewardship (AMS), little is known about the related practices and perceptions of community pharmacists. Objective To develop and validate a questionnaire to measure the current practices of, and barriers to community pharmacists’ participation in AMS. Setting Community pharmacists in Tasmania, Australia. Method A questionnaire to explore AMS knowledge, current practices and perceptions of community pharmacists was developed. It was designed after rigorous literature review, expert opinion, and feedback from a group of community pharmacists. A convenience sample of 140 Tasmanian community pharmacists was used for this study. Cronbach’s alpha and exploratory factor analysis (EFA) were used for reliability and validity. The questionnaire was hosted online, a link to which was sent by invitation e-mails, fax and post to community pharmacists in Tasmania, Australia. Main outcome measure Current AMS practices, perceived importance, barriers and facilitators of AMS. Results Eighty-five pharmacists responded to the survey yielding a response rate of 61%. EFA identified one factor solution for each of three perceptions scales and showed acceptable reliability. The Cronbach’s alpha of perceived importance-understanding was 0.699, perceived importance-motivating was 0.734, perceived support from GPs was 0.890, operational barriers was 0.585, general facilitators was 0.615. Most pharmacists reported that they counselled patients on adverse effects (86%), drug interactions (94%), and allergies (96%). In contrast, less than half (43%) intervened with prescribers regarding antibiotic selection. Lack of training, lack of access to patients’ records, limited interactions with general practitioners and absence of a reimbursement model were major barriers limiting community pharmacists’ participation in AMS. Conclusion The questionnaire was of acceptable reliability and validity; a larger study will further contribute in its reliability and validity. Future studies utilising the questionnaire at national and international level may provide further insights into the determinants of community pharmacist’s involvement in AMS.

Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center

Purpose: Leveraging pharmacy personnel resources for the purpose of antimicrobial stewardship program (ASP) operations presents a challenging task. We describe our experience integrating all pharmacists into an ASP, and evaluate the impact on ASP interventions, antimicrobial utilization, rate of selected hospital-onset infections and readmission. Summary: During a study period (January 1 to December 31, 2015), a total of 14 552 ASP-related pharmacy interventions were performed (ASP clinical pharmacotherapy specialists [CPS] n = 4025; non-ASP CPS n = 4888; hospital pharmacists n = 5639). Sixty percent of interventions by ASP CPS were initiated utilizing the dedicated ASP phone, and 40% through prospective audit and feedback. Non-ASP CPS performed interventions during bedside rounds (dose adjustment 23%, initiate new or alternative anti-infective 21%, discontinue antibiotic(s) 12%, therapeutic drug monitoring 11%, de-escalation 4%), whereas hospital pharmacists participated at the point of verification (dose adjustment 75%, restricted antibiotic verification 15%, and reporting major drug-drug interactions 4%). The acceptance rate of interventions by providers and clinicians was >90% for all groups. Annual aggregate antimicrobial use decreased by 6.4 days of therapy/1000 patient-days (DOT/1000 PD; P = 1.0). Ceftriaxone use increased by 8.4 DOT/1000 PD (P = .029) without a significant compensatory increase in the use of antipseudomonal agents. Sustained low rates of hospital-onset Clostridium difficile (CDI) and carbapenem-resistant Enterobacteriaceae (CRE) infections were observed in 2015 compared with the prior year (1.1 and 1.2 cases/1000 PD, 0.2 and 0.1 cases/1000 PD, respectively). Thirty-day readmission rate decreased by 0.6% (P = .019). Conclusions: Integration of all pharmacists into ASP activities based on the level of patient care and responsibilities is an effective strategy to expand clinical services provided by ASP.

Dynamic Interplay of Pharmacy Learners During a Solid Organ Transplantation Learning Experience

Institutions with established clinical pharmacy services have the ability to offer focused patient care learning experiences, often led by a clinical specialist, for pharmacy residents and pharmacy students. Since all parties are continually involved in professional development and lifelong learning, the aforementioned groups can all be considered “pharmacy learners.” By utilizing the dynamic interplay and collaboration between pharmacy learners through direct and nondirect patient care activities, experiential and educational opportunities may be improved and enhanced for each learner. A tiered learning approach engages individuals in areas such as direct patient care, patient education, presentations, research projects, career development, and the feedback process. We describe our experience during a solid organ transplantation learning experience using a layered learning practice model that included a clinical pharmacy specialist, a postgraduate year 2 specialty pharmacy resident, a postgraduate year 1 pharmacy resident, and a pharmacy student.

The intersection of antimicrobial stewardship and microbiology: educating the next generation of health care professionals

With the alarming rise of antibiotic resistance, clinical professionals are called upon to manage antibiotic therapies using the most relevant and recent clinical and laboratory data. To this end, antimicrobial stewardship (AMS) programs aim to reduce unnecessary or suboptimal use of antibiotics while maximizing outcomes for the patient. For AMS programs to succeed, the active participation of clinical professionals at all levels of patient care is required. Although programs exist to train established clinicians in AMS, there is a paucity of literature on how and when to integrate AMS concepts and skills in pre-clinical and clinical coursework. Here, we discuss the crucial microbiology concepts and proficiencies that are necessary for building and supporting an AMS program. We provide recommendations for key points to include in clinical curricula in order to develop the necessary microbiology interpretation skills to participate in AMS. The influence of AMS programs on local organism susceptibility patterns is emphasized. The importance of antibiograms, rapid diagnostic testing and the practical interpretations of microbiology laboratory reporting are discussed in regard to prioritization in clinical curricula. We also review the current literature on instructional strategies for introducing AMS into clinical programs, and propose concepts that should be included in didactic coursework in order to provide a foundation for AMS education.

Recognition of Advanced Pharmacy Practice Experience Student Participation Within Antimicrobial Stewardship Activities

Background: Antimicrobial stewardship is important in managing patients with infectious diseases. Limited data exist documenting the extent of pharmacy student involvement within antimicrobial stewardship activities. Objectives: The purpose of this study was to document the types of hospital-based antimicrobial stewardship activities in which Advanced Pharmacy Practice Experience (APPE) students are involved. Methods: A questionnaire was developed using the most current guideline for developing an institutional antimicrobial stewardship program. It was designed to collect preceptor-reported perceptions and APPE student involvement in antimicrobial stewardship activities. Pharmacist preceptors of APPE students from 2 Florida Colleges of Pharmacy were surveyed in October 2011. Questionnaires fully completed by hospital pharmacists currently serving as an APPE preceptor were included. Results: Forty-eight questionnaires met all inclusion criteria, collectively reporting APPE student participation within every element of antimicrobial stewardship. The most common areas of student participation were dose optimization based on patient characteristics (n = 40, 83%), acquiring patient information for prospective audit with feedback (n = 39, 81%), intravenous to oral conversion (n = 37, 77%), and pharmacokinetic services (n = 36, 75%). Anti-infective subcommittee participation (n = 3, 6%) was uncommon. Respondent perceptions were overall favorable regarding student participation in antimicrobial stewardship activities. Conclusion: With supervision from pharmacist preceptors, APPE students from 2 Florida colleges of pharmacy were reported to participate in each element and activity of antimicrobial stewardship as set forth by current guidelines. The role and value of such involvement is not fully understood. Future research investigating activity-specific outcomes and policy creation are needed to guide appropriate use of APPE students as a resource for optimizing antimicrobial use in hospitals.