Keith Loria

Keith Loria is a contributing writer to Medical Economics.

Antibiotics pose a conundrum: These drugs are crucial for destroying or slowing certain types of bacteria, but concern about overuse in hospitals and inappropriate prescribing practices fuels debate about the complex relationship between antibiotic use and antimicrobial resistance.

“Pharmacists play a pivotal role in antimicrobial stewardship in an organization, and it’s really around a multidisciplinary approach and a coordinated effort, with the goal to improve and measure appropriate use of antibiotics,” said Onisis Stefas, PharmD, MBA, vice president and chief pharmacy officer at Northwell Health in New York. “We look to promote high-quality care and positive clinical outcomes, we look to decrease length of stay where possible, and we also look to decrease microbial resistance.”

He explained that patients tend to first receive broad-spectrum antibiotics, which may then be replaced with a more appropriate narrow-spectrum antibiotic based on the subsequent lab results identifying the specific bacteria involved.

“We work hand in hand with providers,” Stefas said. “It is an interdisciplinary action to get the patient on the right drug at the right time.”

Antibiotics are generally overused, especially in patients in the emergency department, according to Michael J. Brown, RPh, BCPS, BCPP, a hospital pharmacist in Lake Oswego, Oregon, who specializes in psychiatry.

“There seems to be a tendency to use Zosyn [piperacillin and tazobactam] and vancomycin initially in patients who present with infectious symptoms,” he said. “This is what we call the shotgun approach and is effective in killing most bacteria. The downside is, this combination is hard on the kidneys, and overuse can lead to bacterial resistance.”

Sarah Jones, PharmD, BCPS-AQ ID, a clinical pharmacist in infectious diseases at Boston Children’s Hospital in Massachusetts, said the hospital is “a very antibiotic-using institution compared to many of its peers.”

“There is a lot of empiric antibiotic use in pediatrics still in all facets, though we have been trying over the last 2 to 3 years to chisel away antibiotic use,” she said. “There is a lot of movement in most centers to have antimicrobial stewardship programs up and running and trying to get to more of an appropriate antibiotic use.”

Surgeons are quick to add antibiotic therapy for patients looking unwell and then later question the drugs’ necessity, according to Jones.

“We are not a proactive stewardship program, but we look back retrospectively a day or 2 into therapy,” Jones said. “We try to explain why an antibiotic is not necessary in the setting that [it was started] for.”

The good news: Many hospital pharmacists have become much more involved in antibiotic de-escalation. Hospital pharmacies have developed protocols for not only narrowing antibiotic therapy but also reducing costs by altering the route of the antibiotics used when appropriate. For instance, changing from an intravenous to an oral form can save a lot of money. Steps to reduce use involve better screening and lab testing, according to Brown.

“Broad-spectrum antibiotics should only be used initially if the infection is severe or life-threatening,” he said. “Clinical judgment is important, as well. Many antibiotics are used for urinary tract infections in elderly patients. This is often unnecessary unless the patient has symptoms such as altered mental status, pain with urination, or an increased urge to urinate.”

Pharmacists often act as gatekeepers to avoid misuse of antibiotics, Stefas noted, and are charged with reviewing antibiotics, providing recommendations on antimicrobial regimens, and reducing inappropriate or unnecessary use.

Boston Children’s Hospital practices “handshake stewardship,” in which pharmacists intervene with prescribing physicians and have a direct line of communication to residents, asking them to question their attending in a decision made by the team. According to Jones, the program has had lingering effects on future cases, with durations of antimicrobial therapy being more regularly followed.

J. Russell May, PharmD, FASHP, a clinical professor at the University of Georgia College of Pharmacy in Athens, practices at Augusta University Medical Center, where his students do amicrobial stewardship activities. He said that 53 of the antibiotics used in the hospital require a dose adjustment if the patient has decreased kidney function.

“Pharmacists can reduce the dosage of those antibiotics by protocol based on the level of kidney impairment,” he said. “That decreases the chance of a patient having an adverse reaction (and) prevents any toxicity from the drugs. And conversely, if the kidney function improves, we can go the other direction and increase dose to proper dosage.”

Most progressive hospitals have pharmacy protocols regarding antibiotic therapy. For example, where Brown practices, staff follow all patients on antibiotics and monitor for appropriate agents, duration of therapy, and drug-drug interactions. “We also switch patients from intravenous therapy to oral as soon as possible,” he said.

“We may also suggest an infectious disease consult in certain circumstances,” Brown added. “We read progress notes from the physicians daily and review lab results. Our aim is to reduce cost, improve outcomes, and decrease drug resistance.”
	An important part of the hospital pharmacist’s job involves looking at orders and ensuring that there are no duplicates, Stefas said. It’s also important to avoid dangerous drug-drug interactions, such as with warfarin and ciprofloxacin, which could increase bleeds.

“We look at food and drug allergies, as well, making sure a medication is used with food or without food and making sure the timing of that medication is not when patients are receiving their meals,” he added. “We’re also looking to make sure the right drug is used based on indication and the lab results.”

When a patient is discharged, a pharmacist on the floor should provide instructions, Stefas said.

“We let people know how important it is for a patient to continue that antibiotic, if necessary, out in the community,” he said. “We stress the importance to the patient and family because [otherwise] it can cause additional issues.” According to Stefas, early discontinuation of the regimen may contribute to the development of resistance to the antibiotic. This could result in the drug becoming less effective against that bacteria in the future.

A hospital pharmacist also does a lot of data analysis on prescribers and prescriptions and then passes that
	information to providers to share what’s working, best practices with certain bacteria, and lab result trends.

The CDC reported that every year, Americans fight more than 2.8 million serious infections caused by antibiotic-resistant bacteria, with approximately 35,000 deaths. A sustained and robust pipeline of antibacterial drugs and novel therapies is critical to ensure that new interventions keep pace with evolving pathogens.

Brown noted that newer options include meropenem-vaborbactam (Vabomere), a newer agent to fight carbapenem-resistant Enterobacteriaceae (CRE).

“It is the first carbapenem Î²-lactamase inhibitor combination with activity against broad-spectrum Î²-lactamases,” he said. “We often use meropenem for patients who are sensitive to penicillin.”

In November 2019, the FDA approved cefiderocol, an antibacterial drug for patients aged 18 years or older with complicated urinary tract infections (cUTIs), including kidney infections caused by susceptible gram-negative microorganisms, who have limited or no treatment options.

Another newer addition: plazomicin (Zemdri), an aminoglycoside that received FDA approval in June 2018. Brown warns that this agent should be used only in patients with cUTIs, including pyelonephritis, who have limited or no options.
	Eravacycline (Xerava), which is a tetracycline-class compound, was approved by the FDA in August 2018 to treat complicated intra-abdominal infections. Omadacycline (Nuzyra), another tetracycline, received approval in October 2018 and is indicated for community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections.

Articles

Though antibiotics are crucial, concern about overuse in hospitals and inappropriate prescribing practices fuels debate about the complex relationship between antibiotic use and antimicrobial resistance.

Hospital Pharmacists Face Challenges in Reducing Antibiotic Overuse

Health system pharmacies collaborate with a variety of groups and other health professionals, depending on the topic or area with which they want input and collaboration. For patient care, they collaborate with other health professionals (ie physicians, physician extenders, nurses, case managers, social workers, laboratory and radiology technicians, or other pharmacists). They will also review current literature and reference articles-and may even contact the drug manufacturer-when determining the appropriateness of drug therapy for a patient’s condition.

Pharmacies collaborate with professional associations, regulatory agencies, drug wholesalers, and peers when they are seeking information related to regulatory requirements, best practices, and drug shortages. Pharmacies will also seek out consultants and other subject matter experts to do the best job possible. Although pharmacists are known as the drug experts, they aren’t afraid to seek out others for guidance and to make sure they are following the appropriate rules and guidelines.

“While medications are based in science, there is also patient variability, so collaborating is important when a patient does not fit the standard indications for a drug therapy or is experiencing a side effect,” said Barbara Giacomelli, PharmD, FASHP, vice president, advisory services for McKesson RxO. “Pharmacy as a profession is highly regulated, and like other aspects of health care, changing rapidly, whether related to medication therapy advancement, insurance coverage, technology advancement, drug shortages, or new regulations.”

Cathy Kuhn, PharmD, director of strategy consulting at Updox and the APhA-APPM president and board trustee with the American Pharmacists Association, said it’s also important for health-system pharmacies to collaborate with pharmacies outside of the health system, which may include a patient’s community pharmacy. “Collaboration is critical to ensuring patient safety and optimal clinical outcomes, ultimately enhancing high-value care,” she said. “When pharmacists and prescribers work together as one cohesive unit, they can effectively impact health care by minimizing prescription confusion, reducing health care costs, and transforming the patient experience.”

Charles Lee, MD, senior director of clinical knowledge for First Databank, a provider of integrated drug and medical device databases that supports health care professionals, said the health system pharmacist is in a unique position as the coordinator of the team’s medication therapy plan and education for the patient. “In many organizations, the health system pharmacist has been evolving from just dispensing medications into being a member of a coordinated clinical care team in collaboration with prescribers, nurses, caregivers, and other pharmacists,” he said. “They often make clinical rounds with other team members. They participate in developing medication therapy plans, dispensing (including compounding) [medications], monitoring patients’ responses to treatments, and providing patient education.”

These collaborations all come back to patient safety. Kuhn noted that, although providers are tasked with consulting patients, diagnosing illnesses, and prescribing medication, pharmacists work every day to ensure patients are properly taking their medications as prescribed and avoiding any harmful effects-acting as a vital component in the patient care cycle. “And since patients expect the care they receive to be seamless, both parties must communicate and collaborate accordingly to ensure patient needs are being met, thus resulting in improved health outcomes,” she said.

Giacomelli noted that advances in medication therapies mean disease states that were once difficult to manage now have drugs that can benefit patients, but these therapies tend to be higher in cost and out-of-pocket expenses for patients. “Drug shortages also are a challenge for patients, and pharmacists collaborate to determine best alternative therapies so patient care isn’t compromised,” she said. “The patient comes first, and pharmacists collaborate to make sure they receive the best care possible.”

Quality patient care requires health care professionals to work as a team. With the complexities of medical care, PBMs, drug shortages, new therapies versus traditional therapies, etc, it is important for pharmacists to collaborate with the entire health care team. “As drug treatment becomes more personalized-such as genomic treatments- therapy team models with health system pharmacists in a central coordinator role will becoming increasingly more important to improve cost efficiencies and to optimize medication therapy outcomes among the health systems population,” Lee said.

Health System Pharmacy Collaboration

Millennials are often classified as being born between 1981 and 1996, which means the older end of the cohort are nearing 40 years old and are more likely to be regular visitors to a pharmacy. But even those on the younger end of the generational range still have plenty of reasons for coming in, which is why pharmacists should find ways to attract millennials of all ages to their locations.

Aaron Gilbert, PharmD, a pharmacist in Louisville, Kentucky, said millennials live “in the now,” so you have to sell to them “in the now.” Gilbert said, “These customers have 1 primary shopping platform: their cell phone. The era of waiting in lines and dealing with [salespeople] is over. It’s archaic, and to most millennials, undesirable. In almost every industry you can see the shift from traditional, retail experiences to digital, convenient experiences. Pharmacy is no different and must evolve along with the rest of the American market.”

That means providing patients with a robust digital solution and using digital marketing strategies to keep your brand top of mind. “Millennials don’t leave their doctor’s office with a prescription and walk into their neighborhood pharmacy...they Google” to find a pharmacy where they can fill their prescription, Gilbert said. “Millennials learn about brands through AdWords [Google Ads], shopping, display, social, and more.”

The millennial generation is also more likely to become loyal to brands through Facebook, Instagram, blogs, and podcasts. “The millennial consumer is also a very intelligent consumer, with a world of knowledge at their fingertips, so online reputation and social proofing are critical in the acquisition funnel,” Gilbert said.

Shelley Roberts, PharmD, owner of Grassroots Pharmacy in Lexington, Kentucky, said millennial customers appear to care a lot more about the experience than simply the products pharmacies carry. “We focus on a welcoming environment that is clean and inviting, with interesting displays and decor,” she said. “Social media is also a big focus for us. Many times, a customer will get to know us on social media before ever coming into the store. They come in for the first time and say, ‘I feel like I already know you!’ from watching my videos online.”

Roberts added that this is a population that pharmacies can still make an impression on. “They are not only here for prescriptions, they have an interest in alternative therapies and supplements as well,” she said. “They are an age group [for which] we can truly change health care outcomes by catching them earlier in life. While they may not have a lot of prescriptions themselves right now, they will have aging parents that we could help in the long term.”

With access to information more available than ever, consumers have more ways to research and educate themselves before they buy. In fact, 23% of millennials say they like to research before they buy something. Approximately 80% of millennials use their phones to research prices, whereas 68.9% use their phones to read reviews. That’s why it’s important to encourage customers to post reviews on Yelp and other sites.

Of course, no matter how much millennials value online resources, face-to-face medical consultation remains irreplaceable, which is why there’s still an important need to speak with the licensed technicians and pharmacists who oversee and help manage a patient’s prescription needs. Ross Goetz, PharmD, a pharmacist in Cincinnati, Ohio, said pharmacists must still offer the level of compassionate care that all patients deserve. This can come in digital forms, such as HIPAA compliant live chat, app messaging, push notifications, and SMS.

“Pharmacies were built on high traffic roads to meet the needs of patients. Millennials still drive those roads, but they also navigate and explore the internet, and if you want to attract them then you need to have your store on the digital highway,” he said. “A digital solution isn’t exclusive to millennials though. All patients, regardless of [their] generation, can benefit from having more options in their health care experience. With options, they can use the solution that best meets their needs.”

Alex Evans, PharmD, founder of Pharmacy Compliance Specialists, LLC, in Jacksonville, Florida, said pharmacists must maximize the use of their software systems in the store. Creating apps for the pharmacy is another important step. Some important questions to ask about pharmacy technology: Do you have an app to order refills? Do you have a website to not only order, but check your available medications? Do you have text or call alerts when the medications are ready? Do you accept Apple Pay and similar payment systems?

“Most millennials want convenience, and they also grew up with technology, so if you aren’t in that space, you’re already behind,” Evans said. “The good news is that the vast majority of computer systems have all of these features available. When I got to my pharmacy the first time, we had none of these things, and now we have every one- without switching systems. All it took was some phone calls and a small addition to our monthly maintenance fees.”

And don’t forget about email marketing. Millennials are in the age range of when email adoption was widespread. “If you have potential patients’ email addresses, you can send them targeted emails proving your pharmacy’s value, and this will help convince them to become customers,” Goetz said. “To gain these emails you should offer lead magnets and subscriber-only content on your website. You can also use other incentives, like contests at events and giveaways on social media, to gather email addresses.”

These emails don’t have to be all about sales; too many can turn them off and annoy them. Instead, substitute branding emails, such as sending them your e-newsletter, or direct them to your blog, where you can establish credibility over time with informative and helpful articles.

Many millennials are accustomed to making online purchases on their computers and smartphones, so convenience is key for attracting this generation of shoppers. Evans explained that a pharmacy looking to boost its business should offer home delivery or mail order options to cater to their needs. “You’re going to need to do this to attract a generation accustomed to 1-click ordering on Amazon,” he said. “Mail order might be regulated by state law, but most states should at least allow home delivery. This is a great way to attract millennials and baby boomers at the same time.”

A pharmacy is more than just the prescriptions it fills, which is why pharmacy owners should think about what else is in the store and carry the front- end items that millennials are looking for. “Get feedback from customers, such as what cosmetic brands they like or food products they want to buy,” Evans said. “This is a great time to target the so-called LOHAS [Lifestyle Of Health And Sustainability] market, focused on healthy living and sustainability, that is so popular with this generation. Offering organic, non-GMO, vegan, etc, products, and a wide array of nutraceuticals, will give you a boost to your front-end sales and keep this generation of customers.”

Other convenient services at the pharmacy include compliance packaging, which generally comes at the request of the children of aging parents, and extended days supplies at discount pricing for reducing trips to the pharmacy.

Hussein El Khatib, PharmD, with Toledo Family Pharmacy in Ohio, said to attract the “cyber” generation, pharmacies need to offer delivery services, as well as programs like medication synchronization and compliance packaging in any sort of form, especially blister pouch packaging that is becoming more common with stores preferring automation in single and multi-dose packaging. “I think offering products like that, coupled with accepting coupons and programs that save the patient money, is key in all of this,” he said. “Never forget, superb customer service is a must.”

Getting on the bad side of a customer will usually mean they are going to go somewhere else. Goetz noted that ignoring their concerns or dismissing a problem is a sure way to lose business. “If someone has a problem, deal with it, and don’t make excuses or place blame, even if the customer is wrong,” he said. “You should immediately fix the issue.”

Keeping sustainability practices in mind will not only boost your millennial customer base, but also can potentially reduce a pharmacy’s operating costs. A store that offers reusable bags rather than plastic or doesn’t print out pages of receipts will be appreciated by those thinking green. “If you can demonstrate you are helping the environment, you will draw them in and possibly reduce your costs,” Evans said.

Retailers can also demonstrate their interest in making a difference by partnering with organizations or other brands that are known for their social consciences. Many places work with brands to help drive charitable donations, environmental awareness, and community impact in authentic ways.

Pharmacists weigh in on how to bring this generation to the pharmacy.

How to Attract Millennial Customers

Obtaining a PharmD has such broad value when it comes to career offerings, and those offerings can best align with not only one’s personal strengths, but professional goals. Sure, you can look to practice as a pharmacist in the community setting or within the hospital setting- where the majority of jobs still reside- but there are non-traditional roles that pharmacists play as well.

“Serving in the long-term care market, the specialty pharmacy market, or even the ambulatory care setting, pharmacists can use their clinical expertise to directly impact the patient’s utilization and response to taking medications,” said Jonathan Ogurchak, PharmD, CSP, founder and CEO of STACK, a compliance management software company for pharmacists. “Beyond that, pharmacists can be looked upon as educators, frequently being hired as medical science liaisons within the pharmaceutical industry and tasked with teaching providers about disease processes and the medications used to treat them.”

Pharmacy schools are tasked with a huge responsibility–not only training pharmacists to understand the complexities of disease states and the drugs to manage, but also with educating about career opportunities.

“The experiential education component of the curriculum plays a huge part in understanding what types of roles might be available, since it’s often one of the closest steps to direct practice that student pharmacists would have prior to graduation,” Ogurchak said.

Pharmacy students regularly do rotations during their last year of schooling, which places them in different industries and shows them how different segments of pharmacy operate. But just because they decide to go in one direction initially does not mean they are stuck in that area for their entire career.

Jeannie K Lee, PharmD, BCPS, BCGP, FASHP, associate professor for pharmacy practice and science at the University of Arizona College of Pharmacy, said that often students know about community pharmacy work, but not much more.

“Pharmacy is a broad and interesting field with many possibilities and opportunities in general and specialized practices, managed care, industry, research, academia, etc,” she said.

That’s why, at the University of Arizona College of Pharmacy, one of the courses students participate in their first semester is Pharmacy Practice, where students take a survey of their interest areas and learn how to explore and pursue those fields through resources that have been gathered for them.

“At the same time, practitioners from various pharmacy careers come into class to present their journey and engage students in a question and answer session,” Lee said. “Our students are surveyed each year to help them explore as many career paths in pharmacy as they wish.”

It’s not unusual for someone in the pharmacy field to want to find something new and pivot to a different career path in pharmacy, and it’s not as hard to do as some may think.

Lee noted that the best way to start a possible switch is to first explore the field of pharmacy they are passionate about and identify details-training needed, procedures, types of patients, niche opportunity, collaborators, settings, salary, benefits, etc.

“For each possible position, they may want to create a pro and con list to think about the choice deeply and to help with decision making,” she said. “It will help tremendously to talk with a pharmacist who is currently in the position to learn about their path and others they know of."

Nonye Uddoh, PharmD, BCACP, clinical pharmacist at CHC Health, pivoted from retail to managed care 5 years ago by gaining additional certifications and experience outside of her 9-to-5 schedule, and by networking with other pharmacists. She believes others can make a smooth transition.

“What I’m noticing in the field is the focus on developing yourself with certifications and/or residency, consider gaining more than 1 state license, connect with your colleagues and add value as much as possible,” Uddoh said.

Conrad Dhing, PhD, assistant dean of student academic affairs at Husson University’s School of Pharmacy, noted that many hospitals and pharmacy chains have internal career development programs to help someone learn of other opportunities.

Ogurchak added that demonstrating an understanding of the profession, based on practice experience, carries a huge weight when looking to shift career opportunities.

“Often times, the ability to relate prior situations into more broad terms can highlight your ability to perform in new scenarios-especially if you're looking to move into a new setting for practice,” he said. “Demonstrating a desire to learn is also critical-either through highlighting continuing education that you’ve completed in a particular practice area, additional trainings, or certifications that you may have achieved as well.”

Lee believes a silo-thinking approach to different areas of pharmacy might make it more challenging, where people think that they are “stuck” in an area of pharmacy they started with. But the knowledge and skill sets are transferable.

For example, over a 20-year career in pharmacy, Lee has worked in community pharmacy (as a student); ambulatory care clinics in internal medicine/primary care, cardiology and geriatrics; home-based primary care and interprofessional home visits; hospital work in pain management and rehab, adult acute care and critical care; and academia, research, and administration.

Those wanting a similar career path can achieve it.

“I think engagement is key-seek out pharmacists in different areas of pharmacy to receive mentorship and guidance. Pharmacists are by and large kind and generous people, and you can benefit from their experiences and wisdom,” Lee said. “Also, advocate for the pharmacy profession so that our paths continue to enlarge and not become stagnant or narrow.”

Kelley D. Carlstrom, PharmD, BCOP, a clinical oncology pharmacist, is contacted often by pharmacists who want to pivot into oncology.

“It is rare to be handed an opportunity in oncology with no prior experience, although I’ve talked to a few pharmacists that were in the right place at the right time and recognized the opportunity,” she said. “So, keep your eyes/ears open for any opportunity to get exposure to oncology drugs, patients, or systems in any capacity.”

For example, if your site has a cancer center, she recommended volunteering to cross-train.

“Most pharmacists shy away from chemotherapy so that provides an opportunity for you,” Carlstrom said. “If you work in retail, spend extra time with patients that are filling supportive care medications; you may even dispense some oral chemotherapy.”

Furthermore, if your site doesn’t have a cancer or infusion center, Carlstrom suggested looking for one local to you that does and follow them on LinkedIn, and connect with others that work there.

“Build and grow your professional network-this is said a lot these days but can’t be overstated,” she said. “Don’t blindly grow your network, but be proactive by interacting with people regularly. I highly recommend LinkedIn but networking in person at local events is very impactful. There is also a great online community at the Pharmacist’s Slack."

For students or current pharmacists looking to learn about the many opportunities, there are plenty of easy ways to discover these on the web. Thankfully, students can learn about pharmacy career choices through the American Pharmacist Association (APhA) and many pharmacy programs encourage students to explore all options.

Pharmacyforme is geared toward students thinking about pharmacy as a career; the APhA site is for students and professionals exploring different areas of pharmacy. Pharmacists can also review the APhA career center information.

“A career as a pharmacist is so much more than 1 job-it’s a combination of all of one’s experiences from the time they enter school through the time they retire,” Ogurchak said. “Finding ways to utilize each one of those experiences across the course of a career helps one to practice as a better, well-rounded practitioner.”

It’s also important to keep in mind that pharmacy is a very small world.

“It is like ‘6 Degrees of Kevin Bacon.’ Someone is bound to know someone, who knows someone, who you’ve worked with,” Dhing said.“Being an engaged, professional employee who helps your organization reach its goals is always valued. When you help your organization reach their goals, you’re more likely to develop a positive reputation and reach your own personal goals.”

Pharmacy managers and educators offer career advice.

Author | Keith Loria

Articles

Hospital Pharmacists Face Challenges in Reducing Antibiotic Overuse

Health System Pharmacy Collaboration

How to Attract Millennial Customers

Making A Career Pivot