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Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy181/5063444 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Open Forum Infectious Diseases PODCAST ARTICLE en, l Th ater in high school, my biology teacher suggested e ID P Th harmacist’s Critical Role in I would like Laurie Garrett’s “e C Th oming Plague.” And I did. Improving Patient Outcomes: Dr. Paul I read it, it was my favorite book of the time, and I’ve been an ID Sax Interviews Dr. Susan Davis nerd ever since. Then, when it came to career plans, pharmacy was not the driver, it was really ID. Pharmacy became the way e a Th udio file is available at https://academic.oup.com/ofid/ that made sense for me to approach that. pages/Podcasts. Not medicine? Medicine was never an interest. It’s the data, the types of Hello. This is Paul Sax. I’m Editor-in-Chief of Open Forum patient interactions, the interventions that we make with physi- Infectious Diseases, and that’s O-F-I-D not “Ofid.” And wel- cians, the focus on chemistry, and mechanisms, that’s what gets come to the next OFID podcast. me excited. Pharmacy is a fit for me. If you asked 100 ID doctors in clinical practice where they Yes and your geography so far—Michigan, Michigan, turn when they are stuck on a tricky antibiotic issue—tox- Michigan, Michigan, right? icity or drug interaction, spectrum, dosing—there is a good Absolutely. I wouldn’t have it any other way. chance that 99 out the 100 would ask a doctor of pharmacy Don’t get me started about college football. We might have or a PharmD, specifically one with specialty training in ID. a lot in common, but not that, I can tell you right now. I’ve had the good fortune of working with several excep- It’s okay. tional PharmDs over the years, and I also have the good for- I think that most of the listeners to this podcast are ID tune of having with me today Susan Davis who is a Clinical physicians and may not be familiar with pharmacy training. Professor of Pharmacy Practice at Wayne State University I am hoping you can give us a primer on pharmacy school and and ID Pharmacist at Henry Ford Health System in Detroit, getting the PharmD degree because a lot more is involved, Michigan. Thank you so much for joining me today, Susan. I think, than people know. No problem. a Th nks for having me. I am certainly a fan of the Yes, no problem, and you probably have more pharmacy lis- journal and your social media account. teners than you have counted. We tend to lurk. Thank you. Let’s start off by your telling us a little bit about er Th e are over 130 pharmacy schools in the US, and all of the yourself, where you are from originally, your background, curricula are implemented in slightly different ways, but pretty and then specifically how you became interested in being a universally the didactic curriculum is very focused on chemis- PharmD and in infectious disease in particular. try, pharmacology, therapeutics of all sorts of areas. And then, I grew up in a small town in west Michigan called Sturgis. along with that go courses that focus on skills for evidence-based I went to undergrad and pharmacy school at the University of medicine, problem solving, team-based collaboration, patient Michigan—Go blue! Then, I did my residency and fellowship at assessments, some of those social administrative things. Detroit Medical Center at Wayne State. Students might be able to take elective tracks or do research But honestly, my ID interest goes back way farther than my projects, but to me the most important part of our curriculum training. It goes back to two biology teachers, one of which was is really the experiential curriculum. Students can have early my dad. My dad, in the summers, would work with the state and experiences where they go and get exposure to different prac- local farmers to raise walleye and other fish. While I was in mid- tice models, to talking with patients. That starts usually in the dle school, one of my jobs was to help with the water samples, first year, but it culminates in the fourth-year rotations where and I got to play with the microscope and identify the algae. It students spend their whole year doing the advanced pharmacy was my first introduction to microbiology, and it felt like I was practice experiences and developing those real skills in patient doing real science even at that age. That was just an awesome care. They get to explore some of their specialty interests, and introduction to what the impact could be. it’s those rotations that to me make the biggest difference in whether those student pharmacists are well prepared to enter the workforce or go on and do whatever their next step is. I’m interested in what kind of interventions are they making—what Open Forum Infectious Diseases kind of relationships did they build with patients or with phy- © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@ sicians? Those are the things that I try to really nail down when oup.com. we’re looking at candidates for our residency program. DOI: 10.1093/ofid/ofy181 PODCAST TRANSCRIPT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy181/5063444 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Would you say that communication skills play a very as fellows’ primary resource for antibiotic teaching.” How prominent role or other skills? would you define the role of pharmacists in these programs? Absolutely. Effective and empathic communication is pretty First, I would say I loved that paper, naturally. But not just the important—being persuasive and confident. And if you’re not message. It was nicely done, very thoughtful. I think ID phar- out there as a student getting some of that experience of having macists are pretty underutilized. There are things we could be to go up to the ID attending and say, “You know, can I help you doing that we aren’t necessarily. Hearing that ID fellows appre- fix that dose?” That’s something you should be doing. If people ciate that kind of education is really fabulous. I know I’m not are doing that in their training programs early, I think it makes alone in saying I love it when our division asks me or other ID for a good, smooth transition to real life. pharmacists to come talk about antibiotics. We are the med- When I’m on rounds and the PharmD who is rounding ication experts. I don’t think ID fellows could have a better with us says something to me like, “I noticed this person’s resource for that kind of information. creatinine is up a bit, maybe you should come down a little But honestly, I might even take it further. There are ID phar - bit on this drug?” To me it’s the ideal collaborative experience macists who are fabulous at research, and we as a profession because they’re focusing on an area of the case that otherwise have been requiring stewardship in our training programs for I might have missed. These interactions are so valuable. We years. As ID fellows look for additional mentorship opportu- learn a ton; it improves patient care. Why do you think this nities, I think there are other things where that collaboration isn’t more well known? could be taken advantage of. I think there are probably a few reasons for that, and sadly Certainly PharmD is critical for our antibiotic steward- I agree. It isn’t that well known. But the first is we are a lim- ship programs, so I think we’re using our resource appro- ited resource, especially ID pharmacists. There are only about priately. I want to switch to a different antibiotic topic, one 100 training programs between ID residencies and fellowships that is one of my pet peeves and that is outpatient parenteral in the US. There are not enough of us to go around. We talk antimicrobial therapy or OPAT. Do you have any thoughts about how there are not enough ID physicians, there are even about OPAT in general and then the pharmacist’s role in fewer ID pharmacists. Not everyone has the opportunity to particular? work closely with an ID pharmacist. I think that is probably Yes. I want to be not too personal in my opinions here, but a big thing. I think people can be a little cavalier about sending patients e o Th ther might actually be more of an issue of personality. out on IV antibiotics, even when oral alternatives could do I don’t have data, but I would say anecdotally a lot of pharma- just as well. Not every patient with an ESBL [extended-spec- cists tend to be introverts. We’re just going to keep our heads trum beta-lactamases] needs ertapenem. I know it sounds con- down and keep getting more work done rather than be out in venient, but OPAT is a great option when it’s necessary, or if the spotlight. As a profession, we haven’t always done a great in-clinic infusion isn’t practical and there’s a process in place to job of advocating for ourselves, although that is changing with keep it safe. some of our organizations. I think some of your concerns and pet peeves would be more I think most of us personally would like to be contently with the complexity of that monitoring on the outpatient side appreciated in our individual interactions and not worry so and lack of reimbursement for that pretty intense care, correct? much about that more public or national acknowledgement. Yes. In fact, I heard from an Australian colleague that the Do you know Dr. [Brad] Spellberg out at UCLA, the ID way their healthcare system is set up, a person who is dis- doctor? charged on IV antibiotics in Australia, the people who con- I have interacted with him in a number of meetings, tinue to follow them continue to get credit for doing so. absolutely. Imagine that. I would say the converse of the introverted pharmacist is Imagine that. That does not happen here. When they’re Dr. Spellberg, who very kindly appeared on this OFID pod- discharged, they go off into this world where nobody wants cast. He’s an ID doctor, and he has really raised the whole to pay, nobody wants to be responsible. It’s the classic hot antibiotic stewardship game to a very high level, and the potato. Do you feel like pharmacists have a special role for whole idea that we should be controlling antibiotic use so OPAT programs? that they are appropriately used and are resources that other I think we sure could. Pharmacists could actually help take people can benet f fi rom. some of the burden o. ff My hospital requires an ID consult Since we’re talking about that, I’m sure you saw the paper before discharging patients on OPAT, but pharmacists can help we just published in OFID that highlighted the influence of with that role if you don’t have the ability to take on quite that pharmacists in stewardship programs, especially for the ID much load to your consult team. Inpatient pharmacists can be fellows. In fact, if I can just quote from that paper it said, helping with patient selection, patient education, setting up the “Pharmacists, not ID physician leaders, were identified right lab for really encouraging usable options. 2 • OFID • PODCAST TRANSCRIPT Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy181/5063444 by Ed 'DeepDyve' Gillespie user on 16 October 2019 But even on the outpatient side, I think if you have an ID whatever you want about them. Topic number one, vancomy- pharmacist in your clinic, if you have an HIV pharmacist, cin levels. maybe he has some time to help triage that follow up. I do think How much time do we have? [Laughter]. Pharmacists in gen- there is a place for us to help facilitate that monitoring. eral, we spend so much time chasing aer t ft he perfect vanco- You mentioned the Australian system, I like what the British mycin level. My gut reaction is I don’t know how much value it Society of Antimicrobial Chemotherapy has. Their E-OPAT adds. Meghan Jeffres has a great review article on the true cost registry has some pretty cool resources. of vancomycin that says a lot of this really well and better than Very interesting. I know that they have recently done this I can. Sure, there are some conditions where that vancomycin study; we are all eagerly awaiting the publication of looking optimization matters a lot, but half the time we’re using it, and it at oral options for osteomyelitis. We’ve seen the data pre- might not even be necessary in the first place. sented at a meeting, but we haven’t had a published paper. Now when we’re shifting to more intense monitoring with But I guarantee it will help reduce the number of patients AUC (area under the curve) instead of troughs, I get a little on OPAT. skeptical on how scalable that intervention is given the volume Eagerly awaiting. of vancomycin-treated patients. Yes. We’re looking forward to that study. What do you guys I’m going to say out-and-out it is not scalable. think of as some of your go-to sites for medical informa- Right. In a selected population sure, let’s go there, but I’d tion, for antibiotic information? I know what we ID doctors rather have my pharmacists doing something that really use, but I wonder if there are any differences between what improves outcomes like rounding with their primary teams, PharmDs use and what ID doctors use. facilitating transition of care. That time that could be freed up I think we probably use a lot of the same specific sites, a lot of with the patients with a serious infection, maybe we can shift to the same textbooks. I don’t think that’s going to differ too much, appropriate alternative therapies and reduce vancomycin from but when you are looking more in the pharmacy silo of things the get go. that are usually attributed to the pharmacist’s role, I know drug One of my pet peeves on vancomycin is the person who interactions is one of the things that you guys can rely on us is discharged from the hospital on every-eight-hour vanco- for. To be honest, I don’t think we actually have to do a ton of mycin and these prolonged infusion times and the levels… investigation into most drug interactions because so many of It’s almost undoable. To me, that’s almost automatic switch them are those things we see fairly oen w ft ithin our specialty. to daptomycin or linezolid. Now that we’re on the topic of Quinolones, azoles, rifampin, I’ve kind of got this. gram-positive drugs, I’m going to ask what is the right dose For you, it’s like nothing, no big deal. For us… of daptomycin? It’s not easy, but you see it so often that, “Okay, I have a Well pharmacists debate this hotly. I’m a big believer in high- plan.” But what I suggest for trainees who don’t necessarily dose daptomycin at 8 or 10 mg/kg, depending on the indication. have that off-the-top-of-their-head kind of thing, I want a e co Th ntroversy I tend to get more pulled into now is which resource that has information on the mechanism, the magni- dosing weight to use in obese patients. That PKPD [pharma- tude, the frequency, modifying circumstances like dose relat- cokinetics/pharmacodynamics] data would suggest total body edness of timing, and I want it to give me an action that is weight results in a higher exposure than necessary compared to recommended. using lean body weight in obese patients. But then, safety data er Th e are two that I think do a great job with that and that’s would suggest symptomatic myalgia, not just CPK [creatine MicroMedex and Lexicomp. They both have drug interaction phosphokinase] elevation but real symptoms, that’s not more checkers that are pretty solid. They are subscription services, so common with those higher exposures. if you are just searching the Internet, I might be a little more So which dosing weight is right? I think it comes down a little cautious. For HIV-specific interactions, I’m a big fan of both bit to your rationale and if you’re trying to skimp on the dapto- UCSF’s site and the University of Liverpool’s drug interactions mycin dose just for drug costs. There are probably other things site, they are both pretty well done. that might be more helpful like batching preparation of doses Yes, they are terrific, and they update them regularly. to minimize the number of vials you have to use when you are I agree. It’s so funny what we’re comfortable in our own prac- making a lot of those for patients. tice doing. For you, “Drug interactions? Big deal.” For a lot Interesting. Next one, linezolid and SSRIs [selective sero- of us, once those EMR [electronic medical record] alerts pop tonin reuptake inhibitors]. up saying, “Two drugs that may prolong QT [quinolone tox- Well, it comes up a lot, and I think it’s a possible thing, and icity] – Careful, careful, careful.” We are very worried about as we use more and more linezolid as an alternative we might that. actually see more of it. But, when we’re being really intentional I’m going to ask you now a few pet peeves, sort of a lighting about using linezolid for a serious indication, I think that bene- round. We’re going to give you these topics, and you can say t t fi ends to outweigh the risk of serotonin syndrome. And PODCAST TRANSCRIPT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy181/5063444 by Ed 'DeepDyve' Gillespie user on 16 October 2019 patients are going to be on a long duration—if we can anticipate alerts. Even then, even if you have a system in place to try to that and do something to taper or change their SSRI, then that’s prioritize what alerts go through, that’s a never-ending process great. But otherwise, if you’ve got a strong indication for line- because new things come across all the time. That’s a challenge. zolid, I think educating and monitoring is more than adequate. e o Th ther thing I think we have to talk about when we’re wor - It is a drug, as you say, we are going to use more of and that ried about alert fatigue is it’s not just reducing the number of is because the cost has plummeted. alerts, but they’ve got to be designed well. If what we’re com- I know. municating is just information overload, that’s not good. They Boy, it’s really amazing. The thing is, as you are saying, should be concise and actionable. I think we could probably some of the pharmacies still sell it at the original cost, and use some best practices on that, and maybe stewardship is one some are selling it at one tenth of the cost. way to make that happen for the things that we are focused on, That is just brutal. at least. It’s brutal, patients really need to shop around. Next I think if you wanted the very definition of alarm one. Fluoroquinolone toxicity, is it the real thing or just a fatigue, the drug interaction alerts would be a good scapegoat? example. It’s really a problem. One last thing, how do you I don’t know that I care, and you’re talking about the multi- get around the inpatient doctors who seem to prescribe system toxicity syndrome? the same combination antimicrobials to every critically Yes. I’m talking about the trigger of the 2016 FDA [U.S. ill patient? I’m referring of course to vancomycin plus Food and Drug Administration] action saying that in the piperacillin-tazobactam. outpatient setting fluoroquinolones should not be used for In my system its vancospime, not Zosyn. I think getting minor infections unless there are no alternatives. around that takes some investigation into why. It’s not just indi- a Th t was the most recent of many FDA communications on vidual physicians who are doing that, it’s not guidelines that quinolones. [Editor’s note: Since recording this podcast, there encourage that. Some of the things we’ve done in our hospital has been another FDA warning on quinolones.] I do think there are to try to put tools in the ICU pharmacists’ hands where they is probably something there. I have honestly never directly can help get more diagnostics ordered. If somebody has forgot- observed it, but when you review the reports, not just random ten to do things, the pharmacists have ways of recommending Internet searches, but it does seem like this is a legit thing—rare that now, and we have some better ways of approaching how we but credible, particularly with the older agents. report commensal flora in respiratory cultures that encourages As for using that as the major rationale to restrict quinolones, de-escalation. I come from a long line of quinolone phobics. We have plenty of I think we’ve tried to work through our pharmacy model in reasons to avoid them in the first place, like resistance, interac- the ICUs to get people communicating about why are we doing tions, other known well established toxicities, the musculoskel- this choice in people up front and then remind, as microbe etal stuff, and those harms are already pretty underappreciated. results come back, you don’t need to continue it. So, if the FDA raising the alarm on toxicity makes people think Great. I always like to say to our ID fellows that the contin- twice, I’m all in favor. ued coverage of MRSA [methicillin-resistant Staphylococcus All right. For my own curiosity’s sake, I just went and aureus] and the absence of MRSA-positive culture is sort of looked at the latest price of linezolid. The lowest price is $97 pointless. This is not a fastidious organism, it’s very easy to for two weeks and the highest price is $1,622. identify it and grow it, in fact just the opposite. If you are not How does that happen? seeing it, you don’t need to cover it. I know. Well, Susan, thank you very much for sharing your exper- Well, we all know how it happens. tise with us today. I very much enjoyed chatting with you. Do Yes. Exactly because it can. The next pet peeve is about how you have any final thoughts before we end? our current electronic medical records handle notification of Well my final thought is I had hoped to ask you a question drug interactions. I’ve already brought this up several times. and take that opportunity if it’s all right? What do you think? How are we doing at giving this infor- It’s quite all right. mation—drug interactions or drug information in general, a Th nk you. Well earlier this year the ID organizations, the whether it’s interactions or dosing guidelines or whatever? IDSA [Infectious Diseases Society of America], SHEA [Society I think that’s a universal frustration. When you look at the for Healthcare Epidemiology of America], and PIDS [Pediatric data on this, there are some types of alerts, drug interactions Infectious Diseases Society], had a very nice paper advocating and allergies in particular, that are overridden about 90 percent for ID physicians as leaders of stewardship programs. There are of the time, so they are not doing anything and probably more some really important needs there. But, ID pharmacy organiza- harm than good. There are plenty of people out there in infor - tions, myself included, have replied, “Hey, we’re doing this too matics trying to suggest approaches, how to prioritize or filter and we’d like to be part of that conversation.” 4 • OFID • PODCAST TRANSCRIPT Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy181/5063444 by Ed 'DeepDyve' Gillespie user on 16 October 2019 You are someone people in ID really admire. Is there or otherwise, just document those and make the case that it anything you would recommend that ID pharmacists and should be a team eo ff rt. physicians can be doing better to promote and advance That is going to sound all kumbaya-ish, but I really mean stewardship? it. We’re all trying to do the same thing, which is to improve First of all, thank you for that compliment. I’m not sure patient care and the appropriate use of antibiotics. I totally agree with it, but thank you anyway. So, this is Paul Sax, Editor-in-Chief of Open Forum Imposter syndrome. Infectious Diseases, and on this OFID podcast I have been I guess that’s the case. But, I will say that if one could just joined by Susan Davis—Clinical Professor of Pharmacy communicate the extraordinary value of the collaboration Practice at Wayne State University and ID Pharmacist at between ID physicians and ID pharmacists and the examples Henry Ford Health System Detroit. we cited in this conversation, examples that occur practi- Again, thank you so much, Susan, and I look forward to cally every day on rounds in the hospital, the examples that seeing you at ID Week. occur like when you are dealing with outpatients on OPAT Yes, me too. Thanks again for having me. PODCAST TRANSCRIPT • OFID • 5
Open Forum Infectious Diseases – Oxford University Press
Published: Jul 1, 2018
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