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The Role of Pharmacists in the World of Pediatric Antimicrobial Stewardship

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Contagion, Contagion, September 2022 (Vol. 07, No. 4),

The limitation in the number of pediatric-specific guidelines by professional organizations, and results from large randomized clinical trials, may place an additional emphasis on literature evaluation skills for pediatric ASP pharmacists.

Antimicrobial misuse carries a heavy price tag, contributing to over 2.8 million infections of antimicrobial resistance each year in the United States alone.1 Children are not spared from antimicrobial resistance, with recent and dramatic increases in prevalence, including extended-spectrum β-lactamase–producing Enterobacterales.2,3

The complexity of antimicrobial use in children is higher due to individualization of dose regimens and limited pediatric data for guiding appropriate use of antimicrobials, which necessitates assessment by a pharmacist. Pharmacists are essential to navigate the intricacies of incorporating pharmacokinetics (PK), pharmacodynamics (PD), and clinical outcomes data to determine the best antimicrobial therapy for children. As highlighted by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America, pharmacy expertise strengthens antimicrobial stewardship (ASP) in any clinical setting.4,5

Although ASP and infectious diseases (ID) pharmacists focus their roles and responsibilities on judicious and appropriate use of antimicrobials, all pharmacists play a role in ASP and reducing the rate of antimicrobial resistance. In this article, we will focus on the role and impact of pediatric ASP pharmacists, touching on the applicable skills, training, and potential barriers to highlight opportunities for all pharmacists’ involvement in pediatric ASP.

PHARMACIST TRAINING

A pharmacist’s scope and accessibility to patients span across inpatient and outpatient settings of all age groups, enabling them to play a pivotal role in ASP and therapeutic decision-making in the pediatric population, especially in settings with limited resources. A pharmacist’s collegiate, fundamental training is centered around the development of knowledge and skills necessary for medication therapy selection.6 These foundational skills are applied and further refined through residency training and/or work experience.

The most common first step to becoming an ASP/ID pediatric pharmacist is to complete a PGY1 residency training program. After completing this program, there are opportunities for PGY2 programs in ID7; however, for pharmacists interested in pediatric ASP or ID, the path is not clear and is highly variable. Currently, there is only 1 PGY2 program offering specialty training in ID at a pediatric institution in the United States, limiting the number of pediatric-specific ASP/ID training positions available each year. Possible alternative training paths include completion of a PGY2 program in adult ID, but pediatric skills specific to medication selection and administration feasibility will require additional learning.

In contrast, a PGY2 in pediatrics may include a rotation in ID but the opportunity for a robust, longitudinal experience in ID will be absent. Despite the differences in settings and experiences, given the standard objectives for accredited residency programs, there are common skills developed that cross all disciplines, including coordination of patient care, drug information and literature evaluation, practice improvement, and teaching. Each year of residency training is estimated to equal 3 years of experience; hence, these skills can be developed through work experience and additional education opportunities. Access to learning opportunities for all pharmacists are readily available and important to expand their knowledge and skills to steward antimicrobials.

Several certificate programs, live didactic sessions during professional conferences, and selfstudy materials from numerous organizations, such as the Society of Infectious Diseases Pharmacists, Making a Difference in Infectious Diseases, and the American Society of Health-System Pharmacists, are available.8-10 However, these trainings have limited pediatric ID content to differentiate between the approach to children and adult diagnostics and treatments of infection. Pediatric-specific learning opportunities from the Pediatric Infectious Diseases Society (PIDS) include attending the annual IDWeek conference, with PIDS-endorsed programming, to obtain continuing pharmacy education credit, as well as numerous resources online such as the Pediatric ASP Toolkit. This tool kit is a compilation of countless references to contextualize the importance of pediatric ASP and guide the implementation of both outpatient and inpatient ASP, and many more settings pertinent to stewardship.11

The track to becoming a pediatric ASP/ ID pharmacist includes a variety of options and combinations of residency training, professional organization–offered programs, and work experiences. Given the overlap in skills attained through residency and work experience, all pharmacists have the potential to further develop their stewardship skills and support stewardship initiatives to improve antimicrobial prescribing.

THE PHARMACIST’S ROLE IN PEDIATRIC ASP

Pharmacist involvement with ASP is not a novel idea; on the contrary, studies have shown both the financial and clinical impact on antimicrobial prescribing in pediatric populations.12-14 The role of an ASP pharmacist typically includes administrative-, clinical-, educational-, and research-related responsibilities. The limitation in the number of pediatric-specific guidelines by professional organizations, and results from large randomized clinical trials, may place an additional emphasis on literature evaluation skills for pediatric ASP pharmacists. Pediatric ASP pharmacists often utilize data extrapolated from adult studies and guidelines, along with their PK and PD expertise, to determine patient-specific therapy plans and indication-specific guidelines for antimicrobial use.

Similar to adult ASP pharmacists, common strategies to steward antimicrobials and improve clinical outcomes include prospective audit and feedback and antimicrobial restriction in the inpatient setting.15 Educating and collaborating with staff on the importance of stewardship and ASP initiatives within the institution is also a focus. However, sharing outcomes of successful interventions with external colleagues, such as through the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative, and Practice and Research Networks (PRN) groups, such as the Pediatric Pharmacy Association’s Pediatric ID Special Interest Group, is most important for pediatric ASPs.16,17

PHARMACIST INVOLVEMENT: ECONOMIC AND CLINICAL IMPACT

Non-ASP pharmacists have been involved in improving antimicrobial selection and duration appropriateness. Numerous studies have demonstrated reduction in antimicrobial utilization and improved appropriateness through both ASP and non-ASP–guided interventions; however, the impact on patient outcomes has proven difficult to capture due to a variety of external factors also affecting outcomes.

In a study conducted at 2 freestanding urgent care sites, emergency department and ID pharmacists were leveraged to follow-up urine and wound culture results from adult and pediatric patients to modify therapy, if necessary, based on a “stewardship-focused protocol.”13 This led to a significant improvement in the total number of guideline-concordant antimicrobial prescriptions, but no reduction in the frequency of urgent care or emergency department visits within 72 hours of discharge or hospital admission within 30 days were observed. Leveraging non-ASP pharmacists integrated in patient care to employ institutional guidelines can improve adherence and antimicrobial appropriateness, but the larger impact on readmissions has yet to be determined.

When developing a stewardship intervention, seeking the expertise of an ASP/ ID pharmacist is recommended regardless of setting, as recommended by the Joint Commission.15 This recommendation is supported by a study comparing 2 similar hospitals with ASP teams with and without a dedicated ID pharmacist based on local treatment guideline compliance. The number of initiated antimicrobial regimens adherent to local treatment guidelines and therapeutic modification within 24 hours were significantly higher at the hospital with a dedicated ID pharmacist.18 Collaboration among pharmacists with formal ASP/ID training and those without is imperative to strengthen ASP efforts.

FUTURE DIRECTIONS

Barriers to non-ASP or ID pharmacists supporting stewardship activities may include “lack of clinical knowledge, experience, and empowerment to contribute actively to physicians’ antimicrobial-prescribing decisions,” but also competing work demands.19 As previously discussed, the lack of readily available pediatric ASP/ ID pharmacy training programs serves as one of the primary limitations to the availability of pharmacists specifically trained in pediatric ASP/ID. Therefore, non-ASP pharmacists being placed in pediatric ASP roles can benefit from institutional support, both financially and culturally, to complete educational programs outside of residency training and attend conferences for the opportunity to collaborate with pediatric ASP pharmacists from other institutions.

CONCLUSION

All pharmacists play a role in ASP, regardless of title, and can be leveraged to support initiatives led by pediatric ASP pharmacists. Furthermore, pharmacists seeking additional knowledge and skills to steward antimicrobials have numerous opportunities available, but pediatric-specific options are limited. Pediatric ASP pharmacists can serve as collaborative partners with other institutions to support outreach and ASP initiatives to reduce the development of antimicrobial resistance.

References

  1. About antimicrobial resistance. CDC. Reviewed December 13, 2021. Accessed August 10, 2022. https://www.cdc.gov/drugresistance/about.html
  2. Medernach RL, Logan LK. The growing threat of antibiotic resistance in children. Infect Dis Clin North Am. 2018;32(1):1-17. doi:10.1016/j.idc.2017.11.001
  3. Romandini A, Pani A, Schenardi PA, Pattarino GAC, De Giacomo C, Scaglione F. Antibiotic resistance in pediatric infections: global emerging threats, predicting the near future. Antibiotics (Basel). 2021;10(4):393. doi:10.3390/antibiotics10040393
  4. CDC. The Core Elements of Hospital Antibiotic Stewardship Programs: 2019. US Department of Health and Human Services; 2019. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf
  5. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77. doi:10.1093/cid/ciw118
  6. Knoer SJ, Eck AR, Lucas AJ. A review of American pharmacy: education, training, technology, and practice. J Pharm Health Care Sci. 2016;2:32. doi:10.1186/s40780-016-0066-3
  7. Residency directory. American Society of Health-System Pharmacists. Accessed August 14, 2022. https://accreditation.ashp.org/directory/#/program/residency
  8. Antimicrobial stewardship certificate programs. Society of Infectious Diseases Pharmacists. Accessed August 2, 2022. https://sidp.org/Stewardship-Certificate
  9. Antimicrobial stewardship programs. Making A Difference in Infectious Diseases. Accessed August 2, 2022. https://mad-id.org/antimicrobial-stewardship-programs/
  10. Infectious diseases. American Society of Health-System Pharmacists. Accessed August 8, 2022. https://www.ashp.org/pharmacy-practice/resource-centers/clinical-pharmacy-resources/infectious-diseases
  11. Pediatric ASP Toolkit. Pediatric Infectious Diseases Society. Accessed August 15, 2022. https://pids.org/pediatric-asp-toolkit/inpatient-settings/inpatient-cdc-core-elements/education/
  12. Lee SY, An SH. Impact of pharmacist intervention in antibiotic stewardship programmes for critically ill neonates: a systematic review and meta-analysis. J Clin Pharm Ther. 2022;47(4):430-444. doi:10.1111/jcpt.13553
  13. Fay LN, Wolf LM, Brandt KL, et al. Pharmacist-led antimicrobial stewardship program in an urgent care setting. Am J Health Syst Pharm. 2019;76(3):175-181. doi:10.1093/ajhp/zxy023
  14. Hamdy RF, Bhattarai S, Basu SK, et al. Reducing vancomycin use in a level IV NICU. Pediatrics. 2020;146(2):e20192963. doi:10.1542/peds.2019-2963
  15. Approved: new antimicrobial stewardship standard. Joint Commission Perspectives. July 2016. Accessed August 14, 2022. https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
  16. Sharing Antimicrobial Reports for Pediatric Stewardship Collaborative. Washington University School of Medicine in St Louis. Accessed August 14, 2022. https://pediatrics.wustl.edu/sharps/
  17. Special interest groups. Pediatric Pharmacy Association. Updated May 18, 2021. Accessed August 18, 2022. https://www.ppag.org/?pg=SpecialInterestGroups
  18. Bessesen MT, Ma A, Clegg D, et al. Antimicrobial stewardship programs: comparison of a program with infectious diseases pharmacist support to a program with a geographic pharmacist staffing model. Hosp Pharm. 2015;50(6):477-483. doi:10.1310/hpj5006-477
  19. Wong LH, Tay E, Heng ST, et al. Hospital pharmacists and antimicrobial stewardship: a qualitative analysis. Antibiotics (Basel). 2021;10(12):1441. doi:10.3390/antibiotics10121441