Peter L. Salgo, MD: Isn’t this—and I don’t know which is which—vertical versus horizontal integration in these institutions? Somebody has got to take, here’s a word, stewardship, of the money and stewardship of these drugs. So, what are the core elements of stewardship here, both money and medical?
Jason Pogue, PharmD, BCPS-AQID: The core elements of an antimicrobial stewardship program basically come into 3 buckets. One is that you have the right personnel involved and that starts at the very top. So, to your point that you just brought up, you need administrative support. If you’re going to be successful, if you’re going to have initiatives, if you’re going to try to optimize the antibiotic use—things like we’re talking about right now—you have to ultimately have support from the C-suite from that standpoint. In addition to that, you need the actual players, the developers of these policies who are going to do day-to-day processes, they need to be involved, too. So, that’s things like ID physician support; that’s things like drug expertise if you look in the CDC documents from that standpoint. But it’s also the importance of all of the peripheral players. The end users of this are ultimately who are the most important.
Peter L. Salgo, MD: They’ve got to buy in.
Jason Pogue, PharmD, BCPS-AQID: Not only have they got to buy in. You’ve got to understand what they need, and you’ve got to work with them. Because everybody’s goal is the same, it’s to optimize patient care.
Peter L. Salgo, MD: The needs have to be defined. The need can’t be, “I want this drug, I want this drug, I want this drug.” And how often have you heard that need expressed?
Debra Goff, PharmD, FCCP: A lot, a lot. And so, stewardship’s role is really to assure and oversee the responsible use of antimicrobials in a hospital to offset antibiotic resistance and to assure medication safety—so, to decrease adverse events. I call it the 5 Ds. You make the correct diagnosis. The physician is the key player there. That’s not the pharmacist’s job, that’s the physician. Do they know how to diagnose pneumonia or is it CHF, and Lasix was the cure, for example? So, that’s step 1. If all you look at is antibiotic use, you’re missing the picture. You have to have more than just the physician who might be labeled as in charge of stewardship. You need all physicians engaged. I say, if you prescribe an antibiotic, you’re a steward, you just don’t know it. So, the correct diagnosis. Then it goes to the correct drug or the correct antibiotic, at the correct dose, at the correct duration, and then the potential for de-escalation. It’s the 5 Ds of stewardship, and that’s really the goal and the mission, and everybody needs to be a part of it.
Peter L. Salgo, MD: Who’s responsible for that? Does it have to be one central figure or is every physician invested in this?
Debra Goff, PharmD, FCCP: So, every physician needs to be invested, but you need someone steering the ship. That’s what I call it. Stewardship steers the ship, but you need all hands on deck. Everybody has an obligation to do what’s best, but it’s not every physician’s responsibility to know the first-line therapy for CRE. That’s our obligation. I don’t expect a surgeon to know what CRE is. It didn’t exist.
Peter L. Salgo, MD: Ouch.
Debra Goff, PharmD, FCCP: And so, I tell them, “That’s not your job. What I need you engaged with is to engage with us and follow the guidelines. And so, we’ll give you the rationale, we’ll give you the guidance. And at some point, then you don’t need us.” So, as we teach them how to use the drugs responsibly, then when you get the call for an antibiotic on the protected list, all these newer agents, it’s a 2-second phone call. “Hey, I’ve got this, here’s the cultures, no problem,” instead of the 5-minute discussion when they’re first trying to understand it. So, it’s really everyone’s responsibility. We just provide the oversight.
Peter L. Salgo, MD: What about systems? There seems to be a systems issue here. You need to know who’s getting infected, what the bugs are, and what the best bug drug match is. So, who’s responsible for that system? What kind of systems exist? How do we get that in place? Anybody have an idea?
Sandy J. Estrada Lopez, PharmD, BCPS (AQID): I think we have lots of ideas, but it’s a scenario we’re also still working on. So, really in the past few years, electronic health records have changed a lot. A lot of hospitals have integrated into one electronic health record with pretty much everything being electronic and computerized. And so, ideally all of that would be at our fingertips, but in many, many cases, it’s not. Sometimes there’s things still on paper. There’s things that you have to go into more than one system to get all of that information that you need. So, some institutions have used add-on systems, like TheraDoc or MedMined or something else, to come in and bring all of that information to your fingertips. Other systems like Epic—we use Epic in our health system—have been working to develop more robust infection prevention and antimicrobial stewardship modules such that we can have all of that on a dashboard. It’s not perfect yet though, but it’s better than it has ever been.
Peter L. Salgo, MD: So, is your EMR actually—this is an MRSA—picking up the antibiotics that have been ordered and comparing it electronically or is it just popping it onto your screen?
Sandy J. Estrada Lopez, PharmD, BCPS (AQID): Right now, it’s just popping it onto my screen, but the promise is, when we have fully implemented the next layer, it will do that. So, ask me again in 6 months.
Jason Pogue, PharmD, BCPS-AQID: So, that’s the forever promise in the future, and that’s why a lot of us have used some of the third-party software in the meantime where I can actually get alerted. Any time a patient has MRSA, an ineffective therapy, I get an email.
Peter L. Salgo, MD: Right. You get the electronic equivalent of you’re giving that for that.
Jason Pogue, PharmD, BCPS-AQID: Yes, but there is still some stuff that you can do. Again, the problem is none of it’s out of the box in any of these, or none of it significantly is out of the box. So, it requires a lot of local IT help to do so, but we do create things. Like in my institution, if you’re ready to order for ceftriaxone and you put it in the EMR, and that patient just had a ceftriaxone resistant organism a month ago, it’s going to put up a bell and whistle and ask, “Hey, you sure that this is something that you want to do?”
Peter L. Salgo, MD: It will.
Jason Pogue, PharmD, BCPS-AQID: It will do that but we had to create that.
Peter L. Salgo, MD: OK, because I haven’t seen it. Maybe I haven’t looked because I think that’s tough to do.
Sandy J. Estrada Lopez, PharmD, BCPS (AQID): It is tough to do.
Jason Pogue, PharmD, BCPS-AQID: Well, you also have to pick how many times you’re going to do that. You have to use it, because people get alert fatigue, right? And so, you have to pick your high impact things, and we would consider that to be a high impact thing. They’re going to get it wrong up front. We’ve talked about how bad that is for patients.