In this article, a pharmacy student discusses tips for doing journal clubs on infectious diseases articles
Authored By: Benjamin Gal, Pharm.D. Candidate and Crystal Howell, BCIDP, BCPS
Last updated: 17 August 2020
Journal club. Two of the most feared words in pharmacy school. Many students find journal clubs tedious and challenging, while others love them. Regardless of how you feel about journal clubs, their existence represents a constant reminder that the art of medicine is always changing. As students and clinicians, our patients depend on us to continuously –or at least periodically— update our knowledge with the most current and best quality information available.
As a pharmacy student on an APPE rotation with an infectious diseases (ID) pharmacist, the concept of the evolution of medicine and the importance of staying up to date is continuously illustrated through journal clubs, topic discussions, and even ID Twitter discussions. Throughout these experiences, I have noticed key differences between the evaluation of ID literature and non-ID literature. These differences can make evaluating ID articles more challenging for us pharmacy students, as we are more accustomed to the large randomized control trials (RCTs) commonly seen in the cardiovascular or diabetes worlds. For this reason, I decided to come up with five tips that I have found helpful and might be helpful to anyone else that is beginning to evaluate ID literature. They are provided here with the guidance of my preceptor Dr. Howell.
1. Preparation is key. Familiarize yourself with the ID resources available to you and use them to get ready.
Most of us are familiar with resources such as PubMed, famous journals such as the New England Journal of Medicine, and of course Lexicomp. However, each area of practice usually has additional journals or organizations that provide information specifically related to that field. Here’s a short list of a few useful ID resources.
- IDSA – Leading authoritative body in infectious diseases. Provides up to date practice guidelines, public health information, and other useful information
- Clinical Infectious Diseases – High impact factor journal of IDSA. Regularly publishes high quality articles relating to the field of ID. Great place to find articles for ID-related journal club. Other high impact ID journals include: Open Forum of Infectious Diseases, Journal of Infectious Diseases, Antimicrobial Agents and Chemotherapy, and Emerging infectious diseases.
- Twitter- There are several great ID pages on twitter, the most relevant to this article being @IDJClub. The first Monday of every month @IDJClub hosts a journal club for ID professionals from around the world in the form of Twitter threads.
- IDStewardship.com – This site has a wide range of useful educational tools on here such as Learn Antibiotics or the pharmacotherapy Study Guide. Also, check out the resources tab for a large, organized list of additional ID resources.
- Society of Infectious Diseases Pharmacists (SIDP) –Offers several educational ID resources including ID-related podcasts, an antibiotic stewardship certification program, and journal club recertification credits for Board Certified Infectious Diseases Pharmacists.
2. Selecting an article to discuss
I have mentioned some sources you could use to find an article, but what are some key factors to consider when selecting an ID article? First, try to ensure that the article relates to your preceptor’s practice setting. For example, if you are doing an ID rotation at a hospital, you may want to avoid choosing a trial on an outpatient infection. Always keep in mind that journal clubs are not only about learning to evaluate literature, but about being a part of a team and sharing information to help educate the team. For this reason, it is also recommended to pick an article published within the previous six to twelve months.
Second, don’t forget about the bugs! One of the unique (and fun!) things about ID is that there is a foreign target for our drugs to kill. This means that not all “gram negative bacteremia” or “community acquired pneumonias” are the same. Evaluate the most common microorganisms seen in the study and the geographic area where the study is being conducted. Are the pathogen(s) causing infection in the study also seen frequently at the practice site where you are learning? What are the rates of resistance of that pathogen at the center(s) where the study was conducted? How does that compare to your rotation site (hint: look at the site’s antibiogram)? These are all things that should be considered when making your article selection and are also good topics of discussion during the journal club presentation.
3. Review trial designs other than RCTs
It is difficult to conduct an ID RCT due to ethical and practical reasons. Because of this, the ID literature relies heavily on trial designs that may not be randomized or well controlled. Most pharmacy school drug information courses heavily emphasize the RCT because it is the only study design that can determine cause and effect. However, this also means that students, like myself, may be less familiar with evaluating non-RCT literature. So if you anticipate the need to critically evaluate an ID article in the near future, consider reviewing non-RCT trial designs such as a retrospective cohort or the quasi-experimental design.
While you are at it, make sure to review statistics. A variety of trial designs also means a variety of applicable statistical tests. Reviewing different study designs while on rotations will also help you to practice real world incorporation of literature into practice.
4. The devil is in the details. Do the details align with practice?
Look at the definitions in the study. Make sure that seemingly self-explanatory terms like “complicated bacteremia” or “severe infection” are consistent with how current guidelines define them and what makes sense logically. Also, evaluate the study’s use of clinical criteria. For example, if the study you are reviewing uses the pneumonia severity index score, do you know what factors go into calculating it? How may the results be different if they used the CURB-65 criteria instead? Which is more rigorous, and which is easier to implement? Why did the investigators choose to use one definition or criteria over another? If the authors chose to do something different than what is recommended by the guidelines, did they justify the reasoning? Were the guidelines released before or after the study results were published? For some infections our most recent guideline is from decades ago (ex: skin and soft tissue infections) and there may be new drugs and new literature to consider.
At the end of the day, even if you feel relatively confident about the topic that you are covering, make time for a refresher of the disease state, microorganisms, and drugs to provide more context for the article.
Pro tip: school notes are helpful to get started in jogging your memory but are generally insufficient. Always review the relevant clinical practice guidelines and previously published literature.
5. The importance of ID and Stewardship
With so much information to keep track of, it’s easy to forget one of the key principles that differentiates ID from other disciplines; infectious diseases are caused by microorganisms. Those organisms can spread and gain resistance to antibiotics. This makes preventing the spread of infections and minimizing the inappropriate use of antibiotics fundamental in ID and the basis of antibiotic stewardship. Consider if basic ID principles such as source control are included in the study that you are evaluating. If source control was possible for the type of infection, in how many participants was it achieved? Also consider stewardship principles such as the spectrum of the antibiotics utilized in the study. Were they appropriately targeted to the organism(s)? What about the duration of therapy? Were there any cases of multi-drug resistant organisms? Did the data collection and evaluation make sense from an ID and stewardship standpoint?
Keeping ID and antibiotic stewardship principles in the back of your mind while evaluating an ID article may ultimately help you in making a sound, evidence-based decision regarding whether to implement the therapeutic approach investigated in an ID study.
Closing comments
Finally, while it may be easy to get lost in the intricacies of ID and the minutia of microbiology, don’t forget about the basics of a literature review. Go back to your old notes on evidence-based medicine and review the important aspects of a literature evaluation. Consider facets such as study objectives, patient baseline characteristics, intervention methods such as the use of placebo or active control, blinding, randomization method, etc.. Most importantly though, don’t let the stress of having to do an ID journal club deter you from trying. Journal clubs and ID may be some of the most feared topics in pharmacy school, but hopefully having a guide on key points to evaluate ID literature will make it a bit more manageable. Good luck and have fun!
About the Authors
Ben Gal is a fourth-year pharmacy student at the University of North Texas System College of Pharmacy in Fort Worth, TX, expected to graduate in May of 2021. Ben has three years of experience in the community setting as a pharmacy technician and currently works as a tutor for the University’s Center for Academic Performance. He is a member of the Epsilon Pi chapter of the Rho Chi pharmaceutical honor society, and his interests include infectious diseases, cardiology, and ambulatory care. Though he is uncertain what area of pharmacy practice he wishes to pursue, Ben plans on completing a post-graduate year 1 (PGY1) residency and possibly a post-graduate year 2 (PGY2) to enhance his clinical experience.
Also, visit Dr. Crystal Howell’s contributor page here.
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