Opting to do an infectious diseases pharmacy school rotation can be anxiety-inducing given it is a challenging field of study for most. Here, a P4 pharmacy student who completed one provides tips to help prepare for a pharmacy school rotation in infectious diseases. Additional commentary is provided by an infectious diseases pharmacist.
Authored By: Ralph Reyes, Pharm.D. Candidate 2018
Edited By: Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
Infectious Diseases (ID) seems to be a polarizing topic in pharmacy school, as some students thoroughly enjoy learning ID and others can struggle initially. That struggle can be overwhelming for some students, particularly those (like myself) who may not quickly grasp the intricacies of clinical microbiology that set the foundation for the field of ID. Whether you chose to challenge yourself with a rotation in ID, were randomly assigned an ID rotation, or you are just curious about what a rotation in ID would be like, this article seeks to outline the 5 ways a pharmacy student could prepare for a rotation in ID.
As some background, I completed an ID rotation at a leading hospital in Boston, MA and found it to be a challenging yet rewarding experience. I chose to write this article to help guide pharmacy students who are prospectively looking at an ID rotation and want to know how they can best equip themselves for success.
Here are five tips to help you prepare for a pharmacy school rotation in infectious diseases…
1. Familiarize yourself with pertinent infectious diseases clinical resources
It is absolutely impossible to revisit all the topics that can come up when working with an ID team. You may even have to find information on topics you have never been exposed to. If nothing else, I argue that a student should at least know what clinical resources are out there, to answer a question from either their preceptor or from the broader healthcare team.
In the world of evidence based medicine, justification of clinical decisions is built upon the collection of pertinent factual evidence from scientific and medical sources. There are an amazing number of websites, databases, documents, and more that are helpful in navigating ID topics. A good pharmacy student knows what to use and when.
Some clinical questions may require a review of primary literature (i.e., an original research journal article), while other inquiries can be answered with tertiary sources (i.e., textbook, review articles, etc.). To prepare for an ID rotation, I strongly recommend for you to revisit resources such as MicroMedex and UpToDate. Try to understand when to use each, and their individual strengths and weaknesses. Finally, on your first day, you should inquire about where to access hospital-specific resources such as institutional guidelines and the hospital’s latest antibiogram.
EDITOR’S NOTE: A robust list of ID resources is available to you here. Note the first section has institution-specific antimicrobial stewardship program websites. Many of these provide open-access to protocols, algorithms, policies and more. Note the second section is a list of clinical tools. Several of these can be helpful in the day-to-day tasks of an ID rotation. Finally, note the third section, which is a list of educational resource related to ID and antimicrobial stewardship. Many of these resources are free and easy to access.
2. Brush up on bugs and drugs as well as antimicrobial pharmacology
It is important to begin to memorize the general coverage patterns for common antimicrobial agents and start formulating general ideas of when certain agents are used (e.g. empiric versus as targeted therapy). You can anticipate you will be expected to know when to “go broad” with vancomycin + piperacillin-tazobactam, and when to “go narrow” with something like cefazolin.
Try get a good grasp on what drugs are used for important Gram positive bacteria (e.g., Streptoocci, Staphylococci, Enterococci), Gram negative bacteria (e.g., E. coli, Pseudomonas aeruginosa), and anaerobes (i.e., Clostridium difficile, Bacteroides fragilis).
Having this foundational knowledge going into an ID rotation will allow for a more rich, in-depth experience in an area where the knowledge is constantly evolving.
EDITOR’S NOTE: A quick and easy bugs and drugs study table is available here. The first step is always to determine if an antibiotic is needed at all. If an antibiotic is needed, the second step is to figure out what drugs are options and which drugs are not options. Knowing general antimicrobial spectra and the local antibiogram will help you with this task. There is also a free study guide here.
3. Revisit common infectious diseases syndromes
In your pharmacy school classes, the most common ID states should have been covered in depth, along with the foundational knowledge of ID pharmacotherapy. Start by reviewing the common topics that you anticipate to see in your site’s specific practice setting. For example, in an acute care setting start by reviewing pneumonia, osteomyelitis, skin and soft tissue infections, urinary tract infections, and sepsis to prepare.
TIP: You can create a list and run it by your preceptor before the first day of rotation. That is what I did and it worked out well, so maybe it will work for you too!
When considering a patient’s initial presentation to a health care setting, keep in mind that ID works in a way in which certain disease states may not be present, but they are suspected. In these cases, empiric therapy can involve coverage for multiple microorganisms specific to different disease states (e.g., covering for a urinary and respiratory process simultaneously). Because of this, it is important to re-visit the published guidelines on these topics. Not that you need to necessarily memorize the information, but you will want to re-familiarize yourself with the microbiology and drug treatment options that are to be considered. Maybe create your own personal database of the most recent clinical guidelines for your future reference.
EDITOR’S NOTE: I find uptodate to be one of the best resources for getting a quick review on different disease states. Another go-to site for things like vaccination recommendations or treatment of sexually transmitted diseases is CDC.
4. Revisit pharmacokinetic and pharmacodynamic principles and calculations
Applying pharmacokinetic and pharmacodynamic (PK-PD) principles to patient specific cases was a huge part of my rotation on the hospital’s ID consult team.
Pharmacists have the knowledge to be able to follow evolving patient laboratory data (i.e., culture and susceptibilities) on a daily basis and make recommendations that optimize drug therapy for the patients. Pharmacists in ID spend a lot of time tracking emergent information about the patient’s disease state and recommending patient-specific doses of common hospital antimicrobials.
I recommend brushing up on pertinent PK calculations learned in therapeutics courses, especially for vancomycin and the aminoglycosides. Practice adjusting antimicrobial therapy using the equations and methods taught in the classroom, as it applies to your practice site. By preparing in this area, you will be able to play a larger role on the healthcare team and make effective recommendations and changes to patient’s drug therapy.
EDITOR’S NOTE: There is a quick review of PK-PD from Dr. Ambrose that is worth a read to reinforce Pk-Pd principles, available here. He is also one of the brains behind PK-PD compass, which is a really neat app that you may find helpful during your ID rotation. Check it out here.
5. Prepare ahead of time to think like a health care professional
The foundations of medicine are often overlooked as students prepare for clinical rotations, but it is important to keep this in mind. You will want a solid foundation in medical terminology, navigating a medical chart, writing patient notes, and identifying pertinent lab values in ID.
The patient work-up in any setting is key in being prepared to make effective recommendations and changes to the patient’s therapy. I spent a lot of time reading and deciphering medical notes during my rotation. The step-wise process was: collect information, process information, evaluate information, compose plan and try to predict what barriers or challenges may be ahead. Nobody can get to a solid plan unless they are able to properly collect the information and digest it quickly and efficiently.
EDITOR’S NOTE: While most preceptors will not expect a rotation student to be able to effectively navigate the step-wise process above with ease, you should recognize that most preceptors will want to see progress in this area throughout the rotation. ID is a really hard topic riddled with exceptions and the field is literally evolving. Do not feel bad if you are not in a great place when you start your rotation. As long as you work at it and challenge yourself you will make progress.
Closing comments
Follow the 5 steps above to have a solid foundation to start a clinical rotation inID. It is a very rewarding area for pharmacists to work in, as there are so many opportunities for intervention and optimization of drug therapy with a pharmacist’s oversight.
With accrediting agencies such as the Joint Commission bringing more attention to the field of antimicrobial stewardship and ID, this is definitely a progressively evolving field for pharmacists.
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