Dionne, 2022 - Which Pharmacists Are Performing Antimicrobial Stewardship
Dionne, 2022 - Which Pharmacists Are Performing Antimicrobial Stewardship
Dionne, 2022 - Which Pharmacists Are Performing Antimicrobial Stewardship
doi:10.1017/ash.2021.245
Original Article
Abstract
Objectives: To determine how pharmacists with formal antimicrobial stewardship program (ASP) responsibilities prioritize their time and
pharmacists without formal antimicrobial stewardship program responsibilities contribute to ASP activities.
Design: A nationwide survey.
Respondents: Members of the American College of Clinical Pharmacy who subscribe to the following practice and research network e-mail
listservs: infectious diseases, adult medicine, cardiology, critical care, hematology–oncology, immunology and transplantation, and pediatrics.
Methods: A survey was distributed via listservs. Respondents were asked about their personal and institutional demographics and ASP activities.
Results: In total, 245 pharmacists responded: 135 pharmacists with formal antimicrobial stewardship program responsibilities; 110 pharma-
cists without formal antimicrobial stewardship program responsibilities. Although most respondents had completed a general pharmacy res-
idency (85%), only 20% had completed an infectious diseases (ID) specialty residency. Among pharmacists with formal antimicrobial
stewardship program responsibilities, one-third had no formal training or certification in ID or ASP. Pharmacists without formal antimicro-
bial stewardship program responsibilities spent ∼12.5% of their time per week on ASP activities, whereas pharmacists with formal antimi-
crobial stewardship program responsibilities spent 28% of their time performing non-ASP activities. Pharmacists with formal antimicrobial
stewardship program responsibilities were more likely than pharmacists without formal antimicrobial stewardship program responsibilities to
perform antibiotic guideline development (P < .001), antibiotic-related education (P = .002), and direct notification of rapid diagnostic results
(P = .018). Pharmacists with formal antimicrobial stewardship program responsibilities without formal ID training or certification spent less
time on ASP activities and were more likely to perform lower-level interventions.
Conclusions: Many ASP activities are being performed by pharmacists without formal ID training. To ensure the future success of ASPs,
pharmacists with formal antimicrobial stewardship program responsibilities should have adequate training to meet more advanced metrics,
and more pharmacists without formal antimicrobial stewardship program responsibilities should be included in basic interventions.
(Received 12 April 2021; accepted 21 November 2021)
Antimicrobial stewardship programs (ASPs) have recently and Medicaid, which has led to a rapid expansion in the number
become a requirement for accreditation by The Joint and scope of ASPs. In 2019, 89% of hospitals reported that they
Commission and a Condition of Participation for Medicare met all 7 of the Centers for Disease Control and Prevention
(CDC) Core Elements of a hospital ASP, up from just 41% in
Author for correspondence: Brandon Dionne, PharmD, Northeastern University 2014.1 Although the Core Elements are an essential foundation,
School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy and only one element, the “action” component, deals with the daily inter-
Health Systems Sciences, 360 Huntington Ave, R218TF, Boston, MA 02115. E-mail: b. ventions utilized by an ASP. The Infectious Diseases Society of
[email protected]
PREVIOUS PRESENTATION. These findings were presented, in part, as 2 poster pre-
America (IDSA) and Society for Healthcare Epidemiology of
sentations at the American College of Clinical Pharmacy Annual Meeting on October 29, America (SHEA) ASP guidelines provide a list of strategies that
2019, in New York City. institutions can utilize, but these guidelines do not provide clear
Cite this article: Dionne B, et al. (2022). Which pharmacists are performing guidance on which to prioritize.2 Thus, the implementation of
antimicrobial stewardship: A national survey and a call for collaborative efforts.
ASPs among institutions varies significantly, even those of similar
Antimicrobial Stewardship & Healthcare Epidemiology, https://doi.org/10.1017/
ash.2021.245 size and setting.3
© The Author(s), 2022. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America. This is an Open Access article, distributed under the
terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original
article is properly cited.
2 Brandon Dionne et al
The growth in ASPs has also outpaced the number of infectious metrics they use or report as part of the ASP. These ASP activities
diseases (ID)–trained pharmacists, often requiring those without were categorized into basic stewardship (system-wide) interven-
formal training through an ID residency or fellowship to take tions, intermediate stewardship (patient-specific) interventions,
on ASP roles, sometimes in addition to their other duties.3 and advanced stewardship (diagnosis- and infection-specific) inter-
Although expertise in infectious diseases is not required by accred- ventions according to the National Quality Partners Playbook clas-
iting organizations to serve in the role of an ASP pharmacist, it is sification of ASP responsibilities.8 Basic ASP activities included
highly encouraged.4 Certification programs in antimicrobial stew- antibiotic spectrum recommendations, intravenous-to-oral (IV-
ardship exist to help bridge this gap in training, whereas board cer- to-PO) conversions, and pharmacokinetic dosing and adjustments.
tification provides a pathway for pharmacists practicing Intermediate metrics included antibiotic-related healthcare educa-
antimicrobial stewardship to demonstrate expertise in infectious tion, antibiotic duration of therapy recommendations, and antibiotic
diseases. Unfortunately, data are lacking regarding how pharma- protocol, policy, and guideline development. Advanced metrics
cists who have formal ID training or certification compare to those included recommendations to obtain antibiotic cultures or labora-
without when fulfilling the role of an ASP pharmacist. tory tests, provision of antibiotic-related healthcare education, and
Although pharmacists with dedicated time for ASPs are most receipt of notification of rapid diagnostic results.
successful, those without formal responsibility for an ASP also con- Pharmacists with formal ASP responsibilities were specifically
tribute to antimicrobial stewardship efforts.5–7 Previous studies asked to indicate their percentage of time spent on direct and indi-
have evaluated the number of full-time equivalents (FTEs) and rect ASP activities. Pharmacists with formal ASP responsibilities
interventions used by ASP pharmacists; however, information were also asked how they would prioritize 6 different ASP activ-
on how these strategies are prioritized or how non-ASP pharma- ities: dose optimization, formulary restriction and preauthoriza-
cists contribute is lacking. Because pharmacists often carry out the tion, guideline and clinical pathway development, IV-to-PO
daily activities of an ASP, it is important to understand how these conversion, prospective audit with intervention and feedback,
duties are currently performed. The objective of this survey was to and streamlining or de-escalation of therapy.
determine how stewardship activities compare between pharma- We used SPSS version 26.0 software (IBM, Chicago, IL) for all data
cists with and without formal responsibility for an ASP as well analyses. All nominal data were analyzed using the χ2 or the Fisher
as how pharmacists with formal responsibility for an ASP compare exact test, as appropriate, and all continuous variables were analyzed
in prioritization of stewardship strategies. using the Student t test or Mann-Whitney U test, as appropriate.
Statistical significance was reached if P values were <.05.
Methods
Results
A cross-sectional online survey was used to achieve the study
objectives. Pharmacists who were members of the American In total, 245 pharmacists responded to the survey, representing 44
College of Clinical Pharmacy and subscribe to the following states: 135 FR ASP pharmacists and 110 NFR ASP pharmacists. Of
Practice and Research Network (PRN) listservs were invited to par- the 135 pharmacists with formal ASP responsibilities, 59 (44%)
ticipate in a survey on antimicrobial stewardship practices: adult also had a formal job title that included “infectious diseases” or
medicine, cardiology, critical care, hematology–oncology, immu- “antimicrobial stewardship,” and 90 (67%) participants received
nology and transplantation, infectious diseases, and/or pediatrics. formal training in ID through an ID residency or fellowship, com-
The PRN listservs members were e-mailed in August 2019, and a pleted an ASP certificate program, and/or were currently board
follow-up reminder e-mail was sent 1 week later. certified in ID. The median duration respondents had been prac-
The main purposes of this survey were to characterize specific ticing as a pharmacist since completing training was 10 years (IQR,
interventions and strategies used by ASP pharmacists, to quantify 6–15). Additional respondent training and credentialing can be
the time allocated to each of those activities, and to quantify and found in Table 1. Respondents were from a variety of institution
characterize how frontline pharmacists are performing ASP- types; however, similar ASP practices were performed at each site
related activities. Respondents were asked questions about their (Table 2).
individual backgrounds, specifically years in practice since com- When respondents were asked which ASP activities they per-
pleting their training, any postgraduate training, certifications sonally performed, >90% of their efforts focused on 4 main
and credentials currently held, whether their job title or description activities: antibiotic spectrum recommendations (98%; n = 182
included “infectious diseases” or “antimicrobial stewardship” or of 186), antibiotic duration of therapy recommendations (96%;
described antimicrobial stewardship activities, and whether they n = 178 of 186), IV-to-PO conversions (94%; n = 176 of 186),
were formally responsible for an ASP regardless of their job title and pharmacokinetic dosing and adjustments (94%; n = 175
or description. of 186). Notably, pharmacists without formal ASP responsibil-
Questions surrounding the respondents’ practice sites included ities were more likely to rely upon team-based rounds as a pri-
size and type of the institution, as well as the use of an electronic mary method of identifying interventions than FR ASP
health record and computerized provider order entry. All respon- pharmacists (33% vs 12%, P < .001). Pharmacists with formal
dents were also asked information about the status of the ASPs at ASP responsibilities performed a similar number of basic met-
their practice site, including duration of the formal program, rics to pharmacists without formal ASP responsibilities; how-
physician or pharmacist involvement, methods to identify ASP ever, they performed more intermediate and advanced metric
interventions, ASP tools and practices, and personal ASP activities interventions. Specific activities asked of the respondents can
performed. Respondents were then divided into 2 groups based be found in Table 3. Pharmacists with formal ASP responsibil-
upon whether they reported having formal ASP responsibilities. ities were more likely to engage in antibiotic-related healthcare
Those with formal responsibilities were also asked to comment education and protocol development and to receive notification
on the percentage of time specifically dedicated to certain ASP of rapid diagnostic results than pharmacists without formal ASP
activities, how they prioritize ASP responsibilities, and what responsibilities.
Antimicrobial Stewardship & Healthcare Epidemiology 3
Note. FR ASP, formal responsibilities for antimicrobial stewardship; NFR ASP, non-formal responsibilities for antimicrobial stewardship; PGY, postgraduate year; BCPS, board certified
pharmacotherapy specialist; BCIDP, board certified infectious diseases pharmacist; BCCCP, board certified critical care pharmacist; BCCP, board certified cardiology pharmacist; BCPPS, board
certified pediatric pharmacy specialist; BCOP, board certified oncology pharmacist; CACP, certified anticoagulation care provider; AQ ID, added qualifications in infectious diseases;
AQ Cardiology, added qualifications in cardiology; AAHIVM, American Academy of HIV Medicine.
a
>1 certification or credential could be selected.
For pharmacists with formal ASP responsibilities, ∼60% of to-PO conversion (50%), with guideline and clinical pathway
their time was spent performing direct ASP activities for all development close behind (36%).
respondents. However, we identified significant differences
between pharmacists with formal ASP responsibilities who had
Discussion
formal ID training or certification and those who did not.
Namely, for pharmacists with formal ASP responsibilities, the In our study, pharmacists with and without formal ASP respon-
percentage of time spent on direct compared to indirect ASP sibilities contributed to antimicrobial stewardship, but the amount
activities was significantly higher for those with formal ID train- of time expended and levels of complexity of interventions differed
ing (70% of time) than those without formal ID training (35% of significantly between groups. Although pharmacists without for-
time; P < .001). A detailed breakdown of time is displayed in mal ASP responsibilities spent an average of 0.125 FTE on antimi-
Table 4. Almost 50% of pharmacists with formal ASP respon- crobial stewardship, pharmacists with formal ASP responsibilities
sibilities indicated that prospective audit with intervention dedicated ∼0.6 FTE on antimicrobial stewardship clinical activ-
and feedback was the most important ASP activity, followed ities, even though the average program had 1 FTE allocated for
closely by streamlining or de-escalation of therapy (44%) an ASP pharmacist. An increase in pharmacist FTE has been asso-
(Table 5). The least important ASP activity surveyed was IV- ciated with increased effectiveness of an ASP, and our findings
4 Brandon Dionne et al
Note. FR ASP, formal responsibilities for antimicrobial stewardship; NFR ASP, nonformal responsibilities for antimicrobial stewardship; ASP, antimicrobial stewardship program; FTEs, full-time
equivalents; ID, infectious diseases.
a
>1 answer could be selected.
Antimicrobial Stewardship & Healthcare Epidemiology 5
Table 3. ASP Activities Performed by Respondent According to National Quality Partners Playbook Classification of ASP Responsibilities
Note. FR ASP, formal responsibilities for antimicrobial stewardship; NFR ASP, nonformal responsibilities for antimicrobial stewardship.
a
Classified in >1 category due to complexity of activity.
Table 4. Percentage of Time Dedicated to the ASP in Pharmacists with Formal ASP Responsibilities
Formal ID Training/
Total (n = 118), Certification (n = 76), No Formal ID Training/
ASP Activity Median (IQR) Median (IQR) Certification (n = 42), Median (IQR) P Value
Pharmacist FTEs dedicated to ASP 1 (0.763–2) 1 (1–2) 1 (0.5–2) .171
Direct ASP activities
Review of restricted antimicrobials 4.5 (0–10) 5 (1–10) 0.5 (0–5) .002
Antimicrobial de-escalation 15 (7–30) 20 (10–30) 10 (5–20) <.001
Antimicrobial escalation/drug–pathogen mismatches 7.25 (5–10) 10 (5–15) 5 (2–10) .022
Guideline and clinical pathway development and maintenance 5 (1–10) 5 (2–10) 5 (0–6.25) .044
Parenteral to oral conversion 2.5 (0–5) 2 (0–5) 4.5 (1–10) .023
Provider education 5 (1–5) 5 (1–8.75) 3.5 (1–5) .396
Other ASP activities not listed 0 (0–10) 5 (0–10) 0 (0–5) .001
Total direct ASP activities 60 (32.88–80) 70 (45–81.88) 35 (20–65) <.001
Indirect or non-ASP activities
Administration (e.g., committee work) 10 (5–15) 10 (5–20) 5 (1.75–10) .001
Research 0 (0–5) 3.25 (1–8.75) 0 (0–5) .023
Non-ASP activities (details not requested) 15 (0.75–51.25) 10 (0–24.5) 52.5 (15–71.25) <.001
Total indirect or non-ASP activities 40 (20–67.13) 30 (12.13–55) 65 (35–80) <.001
Note. ASP, antimicrobial stewardship; ID, infectious diseases; FTE, full-time equivalent
suggest that this could potentially be accomplished by providing to personally complete most basic interventions, but they were
more protected time for pharmacists with formal ASP responsibil- more likely to accomplish advanced and intermediate stewardship
ities to focus on clinical stewardship activities.3 metrics. This finding may be explained by the higher proportion of ID
We detected minimal differences between stewardship strate- training or certification among pharmacists with formal ASP respon-
gies utilized by the institutions of the 2 groups, suggesting that sibilities, which allowed them to make more advanced interventions
any differences between the groups in terms of ASP activities com- as well as by the fact that pharmacists without formal ASP responsibil-
pleted were due to individual rather than institutional practices. ities were more likely to identify interventions by rounding, which
Pharmacists with formal ASP responsibilities were just as likely may have led to a higher proportion of basic interventions such as
6 Brandon Dionne et al
IV-to-PO interchange. By empowering pharmacists without formal Our study had several limitations. A response rate could not be
ASP responsibilities to complete more basic and intermediate-level calculated because pharmacists could be members of >1 PRN, and
interventions, pharmacists with formal ASP responsibilities may be membership also includes trainees and nonpracticing pharmacists,
free to focus on the more complex activities that they feel are more who were not eligible for the survey. The membership of ACCP
important, such as prospective audit and feedback, which has previ- includes clinical pharmacists from a variety of practice settings
ously been shown to be one of the most effective strategies.3,9,10 A and backgrounds, which was reflected in the demographics of
teamwork approach of pharmacists both with and without formal the respondents. The pharmacists without formal ASP responsibil-
ASP responsibilities involved in stewardship activities may be optimal ities worked primarily in medium- or larger-sized teaching hospi-
to successfully meet all metrics, irrespective of complexity. tals, and pharmacists without formal ASP responsibilities at
Although the guidelines recommend that ASPs include a pharma- smaller institutions may be less likely to attend rounds or be inte-
cist with ID training, currently only 126 PGY2 infectious diseases grated with the primary teams to be able to make interventions as
pharmacy residency programs are accredited by the American easily. Another limitation is that respondents only reported
Society of Health Systems Pharmacists in the United States. That whether or not they performed a stewardship intervention without
is, there is a shortage of programs to formally train all pharmacists information on frequency or effectiveness. Previous studies have
who participate in stewardship activities.2,11 This shortage was evident demonstrated that dedicated ASP pharmacists are more effective
in our results: only one-third of pharmacists with formal ASP respon- than decentralized pharmacists, so it would be important to mon-
sibilities had completed a second postgraduate year in ID and only 5% itor activities shifted to pharmacists without formal ASP respon-
had completed an ID fellowship. Even though most respondents had sibilities to ensure that they are being completed successfully.6,7
completed a 1-year postgraduate program, this training alone may not As ASPs continue to expand, it will be important to evaluate
adequately prepare pharmacists to practice in antimicrobial steward- how pharmacists’ roles and training impact the effectiveness and
ship, especially regarding intermediate and advanced interventions.12 efficiency of various strategies to determine how best to collaborate
Other ways to demonstrate competency include board certification or on the work of antimicrobial stewardship.
ASP certificate programs, but more than one-third of FR ASP respon- In conclusion, antimicrobial stewardship activities differ between
dents reported having neither. pharmacists with and without formal ASP responsibilities. Each
Pharmacists with formal ASP responsibilities but without ID group utilizes different methods to identify potential antimicrobial
training or certification spent half as much time on direct ASP stewardship interventions and practices to make recommendations.
activities as those with training, despite having a similar number Due to the lack of adequate training programs and substantial amount
of pharmacist FTEs dedicated to the program. Possibly, the of time pharmacists with formal ASP responsibilities spend on non-
FTEs for the program may be split among multiple pharmacists ASP, administrative, and research activities, many day-to-day clinical
who dedicated only part of their time to stewardship, but they still ASP activities are performed by pharmacists who lack antimicrobial
spent a higher proportion of their ASP time on basic activities such stewardship certification, formal ID training, and/or do not have for-
as IV-to-PO conversion and guideline development. There may mal ASP job titles. Pharmacists responsible for ASP who lack formal
also be pressure for ASPs, especially newly established programs, antimicrobial stewardship or ID training should seek opportunities to
to achieve “low-hanging fruit” process-measure metrics to meet obtain board certification in ID and/or ASP certification to ensure that
antimicrobial stewardship accreditation requirements, reduce pharmacists who complete more advanced stewardship activities are
costs, or to demonstrate their impact more easily.13 However, appropriately qualified while engaging frontline pharmacists without
improvements in outcome measures achieved by more advanced formal ASP responsibilities in basic and intermediate-level antimicro-
interventions are becoming increasingly important for both reim- bial stewardship activities. Future research should explore barriers to
bursement and accreditation.14 Additional education and training ASP training for these pharmacists as well as for other clinicians.
opportunities in ID and antimicrobial stewardship may allow these
Acknowledgments. The authors would like to thank Drs. Jennifer Toth and
pharmacists to spend more time executing higher-level interven- Keenan Ryan for their contributions to the design of the survey and Dr. Bruce
tions. Multiple training or certificate programs are available, Jones for his careful review of the manuscript.
including a free online program from the Centers for Disease
Control and Prevention (CDC); however, barriers to completion Financial support. No financial support was provided relevant to this article.
(e.g., awareness of these programs or the time or financial support Conflicts of interest. All authors report no conflicts of interest relevant to this
to complete them) were not investigated in this study. article.
Antimicrobial Stewardship & Healthcare Epidemiology 7