In this article, an antimicrobial stewardship pharmacists provides five tips for new pharmacists.
Authored By: Stephanie Hsieh, Pharm.D.
@SHsieh_rx on Twitter
Article Posted 1 September 2022
I remembered how overwhelming it was when I first started my job as a clinical pharmacist. Most new pharmacists go through a steep learning curve during their first 2 years of working. It is daunting to no longer have a preceptor to double check your work. It is also stressful when your workload suddenly increases from less than 5 patients per day to more than 20 patients per day. Reflecting back on my transition from a new graduate into the pharmacy workforce, I want to share some tips below to help your transition go as smoothly as possible.
And…since I am an Antimicrobial Stewardship Pharmacist, meaning I spend my days reviewing and optimizing patient’s antimicrobial therapies, I will also introduce some simple stewardship principles that everyone can incorporate into their practice. This is so important because antimicrobial resistance is deemed as a global threat according to the Centers for Disease Control and Prevention (CDC) . It contributes to more than 23,000 deaths and more than 2 million illnesses per year. Overuse of antibiotics is one of the primary factors driving this. Therefore, it is never too late to start building habits of a good antimicrobial steward.
Here are my five top tips for new pharmacists…
Tip #1. Prioritize patients that have urgent drug therapy issues
You might ask – what are considered “urgent” issues? Well that can be a bit subjective, but here are a few examples:
- Patients experiencing persistent signs/symptoms despite receiving medications for the specific indication. For example, I came into work one day hearing a post-surgery patient persistently dry wretching and vomiting despite receiving around the clock dimenhydrinate, ondansetron, and metoclopramide. Her wretching could be heard throughout the whole ward. To address this, I prioritized looking up other alternatives to her antiemetic therapy regimen with the hopes of alleviating her discomfort. The medical team was extremely grateful for my help as they were also very concerned about the patient. This gained me extra brownie points with the team as I was able to identify the urgency of this situation and help them out with a challenging medication-related issue in a timely manner.
- Patients experiencing an actual drug therapy problem that is causing immediate harm or have a high risk of causing significant harm to the patient (e.g., getting back a supratherapeutic vancomycin level result in a patient with MRSA bacteremia who is in septic shock with concurrent acute kidney injury).
- Patients with conditions such as sepsis, myocardial infarction, and/or stroke where timely verification, dispensing, and administration of medication is important to ensure optimal clinical outcomes.
- Patients who have been prescribed medications that will require time to obtain access and/or to make. For example, when a physician prescribes a non-formulary medication, there may need to be coordination with: your inventory technicians to figure out where to source this medication, IV technicians to provide appropriate compounding instructions to make the IV bag, and nursing staff to provide education on proper administration and monitoring. Therefore, it is important to work on this sooner so that it minimizes the amount of time to get the medication to the patient.
Antimicrobial stewardship tip: any patients receiving broad-spectrum antimicrobial therapies (e.g. carbapenems, piperacillin-tazobactam, vancomycin) should also warrant your attention. It is important to prioritize these patients so that we can ensure their appropriate use, in order to reduce adverse events (e.g., antimicrobial resistance and Clostridioides difficile diarrhea) associated with their use. When reviewing these patients, make sure to review…
- The indication of therapy (e.g., Is there an indication for its use? Is there even an infection that needs treatment?)
- If it is the most effective agent (e.g., does it penetrate to the site of action, is the bug sensitive to the antimicrobial therapy, is the dose effective for the indication?)
- Is the patient experiencing side effects from the antimicrobial therapy (e.g., diarrhea, renal toxicity, liver toxicity), and
- Does infectious disease specialist need to be involved (if not already involved)
Make sure to check your local institution’s internal policy to see if there are certain indications where an infectious disease specialist consultation is required. For example, my institution requires that anyone with Staphylococcus aureus bacteremia, invasive fungemia, Clostridioides difficile diarrhea, and on carbapenem therapies, gets an Infectious Disease specialist consultation. Although this is written in our policy, it sometimes gets missed, therefore pharmacists can help in facilitating this.
Tip #2. Prioritize review of patients on discharge
Patients being discharged from the hospital back to their home are vulnerable to drug therapy issues. One study found that up to 23% of patients discharged from hospital experience at least one adverse event and of these, 72% were deemed to be related to medications . This also increases their hospital readmission rates post-discharge.
Hospital discharge is also a prime time for reviewing the patients’ prescribed antimicrobial therapies. A retrospective cohort study found that nearly 50% of patients were prescribed unnecessary antibiotics or prescribed antibiotics for a longer than necessary duration . Therefore, prioritizing your assessment of patients with an imminent discharge time (e.g., reconciling medication discrepancies with their medications on admission and transfer; reviewing indications, efficacy, safety, dosage, and adherence of all medications prescribed) can significantly improve patient outcomes.
Tip #3. Look up any unfamiliar conditions and terms
When you first start work as a clinical pharmacist, you will undoubtedly encounter medical terms that you are unfamiliar with (I still do!). It is important to look these up to make sure you are not assuming anything during your clinical work-up of the patient.
During a busy clinical day, it may not always be possible to conduct a comprehensive literature search on all unfamiliar medical conditions or medications that you encounter. In these cases, using databases like Uptodate (a point of care resource that can give you a quick and general overview of the epidemiology, presentation, diagnosis and management approaches for many commonly encountered medical conditions) or Pubmed Clinical Queries (to look up clinical questions) can be helpful. I know this is taboo for me to say since we are often drilled during pharmacy school to not rely on tertiary resources such as Uptodate to answer clinical questions. However, I find that they are useful to get a basic understanding of an unfamiliar topic during a busy workday. I would just caution you to avoid citing Uptodate as your reference when you are justifying your treatment decisions.
In addition, do not assume that you will remember everything you look up. I often need to re-look up topics multiple times, especially if it is something I do not encounter often. Examples of topics that I found myself constantly looking up when I first started include:
- How to interpret pleural fluid analysis to determine whether the pleural effusion is transudative or exudative and thus the likelihood of an bacterial infection in the pleural space
- How to interpret cerebral spinal fluid analysis to determine whether this might be consistent with bacterial versus viral meningitis
- The minimal inhibitory concentration (MIC) cut-off of when one could consider extended infusion meropenem as a potential option for treatment for a multidrug resistant Enterobacterales infection.
Learning from my experience, it would save you a lot of time in the future to note down the key points from your research on a running document and file them in a place that you can easily find and refer to in the future. For example, I have a running Microsoft Word document in which I keep all of these notes (e.g., key numbers to consider when interpreting pleural fluid and CSF fluid, MIC cut off for when extended meropenem infusion is reasonable for a multidrug resistant Enterobacterales infection). I also store all guidelines, relevant landmark studies, and useful articles for medical conditions that I had looked up previously in their respective folders in my desktop so that I have them ready at my fingertip.
Tip #4. Be aware not to assume that a positive culture is the same thing as an infection
One of the most common misconceptions that new pharmacists have is assuming that all positive cultures represent a true infection. Let me surprise you by saying that this is not always the case!
Assessing whether a positive culture represents a true infection includes knowing whether that pathogen is capable of causing an infection at the specific body site that the culture was taken (versus just being a colonizer or commensal organism), the immune status of the patient, and how the culture was collected (e.g., were proper sterile procedures followed to avoid contamination of the collected specimen). When you come across a trick case, an infectious disease specialist consult could help in determining whether antimicrobial therapy is needed or not.
One of the most common scenarios encountered in the hospital setting is a positive urine culture. Not all positive urine cultures represent a urinary tract infection (UTI). A positive urine culture without urinary symptoms (e.g., dysuria, suprapubic tenderness, urinary frequency, flank pain) and/or other signs of infections (e.g., fever) is considered asymptomatic bacteriuria – bacteria in the urine without symptoms. Considering that up to 50% of elderly patients are colonized with a urinary pathogen in their genitourinary tract, many of the urine specimen we collect from them will most likely come back positive . These do not all require treatment, which puts patients at risk for drug toxicity.
To practice good stewardship and to reduce unnecessary antimicrobial use with a positive urine culture, I suggest doing some investigative work prior to contacting a physician with a potential intervention. Look into what prompted the urine culture to be taken in the first place (e.g., Was it collected because of signs/symptoms of an infection such as a fever and/or urinary symptoms endorsed by the patient? Was it collected as part of some sort of routine testing?). After obtaining the clinical history, determine whether this supports a diagnosis of a UTI or asymptomatic bacteriuria. If it is asymptomatic bacteriuria, it probably does not require treatment, except in pregnant patients and those undergoing an invasive urologic procedure. Getting the additional clinical history will help you determine whether it is necessary to contact the physician (e.g., to start antibiotics if it has not already been started or to suggest discontinuing antibiotics if the clinical history is not consistent with a UTI).
When a culture is positive and a true infection is present, remember to use historical culture results for that patient to help guide antibiotic selection. Obviously, if you have a culture and sensitivity data available, then tailor their antimicrobial therapy based on these most recent results. When using historical cultures to guide therapy be mindful of how long ago the culture was drawn and the patients current clinical state.
Tip #5. Do not overlook basic antimicrobial stewardship principles
In addition to assessing the necessity of treatment with a positive microbiological culture, other antimicrobial stewardship strategies that you can easily incorporate into your clinical practice include:
- Advocate to change a broader-spectrum antimicrobial agent to a narrower spectrum agent if the culture and sensitivity result reveal that the pathogen is susceptible to something narrower (e.g., if a patient is receiving ceftriaxone for a UTI and the Escherichia coli in the urine turns out to be sensitive to ampicillin, then you could suggest changing the ceftriaxone to ampicillin or amoxicillin to complete the treatment course).
- Review antimicrobial doses to ensure that the dose is optimized for the patient’s renal/liver function, body weight, and the specific indication (e.g., antimicrobial therapy for treating meningitis often requires higher dosing to achieve adequate central nervous system penetration). In hospitalized patients these reviews should be done routinely, not just upon treatment initiation.
- Reviewing for opportunities to change intravenous antimicrobial therapy to an appropriate oral option (IV to PO), especially for antimicrobial agents that are highly bioavailable (e.g,. ciprofloxacin, levofloxacin, moxifloxacin, sulfamethoxazole/trimethoprim, fluconazole)
In addition to the above tips, it is important to build a good collaborative relationship with your pharmacy colleagues (e.g,. pharmacy technicians, clinical pharmacists) and allied health professionals (e.g,. registered nurses, dieticians, physicians). Patients do not receive treatment in silos, so we need to draw on the expertise of other team members to optimize the patient experience. For example, you would likely need the dietician’s help to adjust the patient’s enteral feed rates when the feeds need to be held for 8 hours per day with enteral ciprofloxacin administration to avoid the drug-feeds interaction.
For any antimicrobial stewardship questions, do not hesitate to befriend and reach out to your hospital’s ASP pharmacist too. We are always happy that pharmacists are taking the initiative to review patients’ antimicrobial therapies and are eager to share our knowledge with you.
Helpful Resources For New Pharmacists
- LearnAntibiotics.com and IDstewardship.com, of course!
- Uptodate (requires a subscription, most hospitals that I’ve work for has an institution subscription that you can access free of charge; inquire about this at your institution)
- PubMed Clinical Queries (free)
- For more in-depth literature search, these databases are best for medication-related searches
(accessing these database requires a subscription through your institution or a university library; I access them through my alma mater’s library using my alumni library card):
- Your local hospital’s Antimicrobial Stewardship guidelines. Most Antimicrobial Stewardship Programs develop institution-specific guidance on recommended empiric treatment for common infections, tailored to their area’s resistance patterns. Ask your ASP pharmacist to see where you can access them (if available).
- IDSA Practice Guidelines (free; also has a mobile app)
- Association of Medical Microbiology and Infectious Disease Canada. Publications – AMMI. They
have some Canadian specific guidelines for infectious disease (such as for Clostridium difficile infection, duration of antimicrobial therapy for common infection), although IDSA is still more comprehensive.
- Sanford Guide (requires subscription for mobile access; also available as a book)
- This is an great resource to get an overview of commonly encountered infections (e.g.
epidemiology, common pathogen implicated in these infections, signs and symptoms, risk factors, empiric/targeted therapies, monitoring), suggested renal/liver/weight-based dosage adjustment for antimicrobial therapies, and the antimicrobial spectra
- Some pharmacy departments have funding to provide this resource free to their employees every year. Ask to see if your institution funds these books or mobile apps for their employees.
- This is an great resource to get an overview of commonly encountered infections (e.g.
- Firstline (free mobile app; this is institution specific, however, even if your institution didn’t sign up for this, you can still download the app and choose your closest institution to access the content). I use this to look up antimicrobial spectra of common antimicrobial therapies, pathogen information, and renal dosage adjustments information. Since this may not be specific to my institution, I use this resource mainly to compare the information I get from other references.
- Bugs and Drugs (mobile app is free to download; based out of Alberta, Canada). Similar to Firstline and Sanfords. It provides a general overview to common infections, empiric therapy recommendations, antimicrobial spectra, and renal dosage adjustments.
- Some Antimicrobial Stewardship Program guidelines from some Toronto institutions (free):
- SHS+UHN Antimicrobial Stewardship – Has guidelines on common infections, empiric
antimicrobial therapies tailored to our local resistance patterns, medication specific
resources, beta-lactam allergy assessment, etc.
- Antimicrobial Stewardship – Sunnybrook Hospital – Similar to SHS+UHN’s guidelines.
References (articles that I cited in my blog post)
- SHS+UHN Antimicrobial Stewardship – Has guidelines on common infections, empiric
- Centers for Disease Control and Prevention (CDC). CDC Global Health – Infographics – Antibiotic Resistance The Global Threat [Internet]. United States of America: Centers for Disease Control and Prevention; [reviewed 2019 Dec 30; cited 2022 Aug 27]. Available from: https://www.cdc.gov/globalhealth/infographics/antibiotic-resistance/antibiotic_resistance_global_t hreat.htm
- Cao J, Ng K, Ho C. Medication Incidents Associated with Hospital Discharge: A Multi-Incident Analysis By ISMP Canada. Pharmacy Connections. 2015:30-35.
- Vaughn VM, Gandhi TN, Chopra V, Petty LA, Giesler DL, Malani AN, Bernstein SJ, Hsaiky LM, Pogue JM, Dumkow L, Ratz D, McLaughlin ES, Flanders SA. Antibiotic Overuse After Hospital Discharge: A Multi-hospital Cohort Study. Clin Infect Dis . 2021 Dec 6;73(11):e4499-e4506.
- Walker S, McGeer A, Simor AE, Armstrong-Evans M, Loeb M. Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people?: A qualitative study of physicians’ and nurses’ perceptions. CMAJ August 08, 2000 163 (3) 273-277.
ABOUT THE AUTHOR
My name is Stephanie, and I am an Antimicrobial Stewardship Pharmacist (ASP) based out of Toronto, Canada. I completed my Bachelor of Science in Pharmacy degree at the University of British Columbia, my PGY1 residency in 2015, and my PharmD degree in 2020. Prior to my current position as an ASP pharmacist, I worked in a variety of clinical areas at a tertiary teaching hospital, including the atrial fibrillation/heart failure clinic and internal medicine units.
In 2020, amidst the first wave of the COVID-19 pandemic, I moved to Toronto with the hopes of experiencing pharmacy practice in another part of the country. I immediately fell in love with the “big city” feel and the “hustle and bustle” of its downtown core. One of my favorite aspects about Toronto is its large multiethnic food scene, and its arts and entertainment culture. During my free time, you will find me exploring the city, as well as working on my YouTube channel. I started my YouTube channel because I wanted to merge my creative side with my desire to share practical pharmacy tips with students and pharmacists. My goal is to share clinical pearls with students and pharmacists and to increase the transparency of the role of hospital pharmacist in the healthcare system #wedonotjustcountpills #pharmacyadvocacy
Find me on YouTube here
Find me on Twitter: @SHsieh_rx
Email me at: email@example.com
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