Q&A: Addressing Antimicrobial Resistance Through Pharmacist-Led Stewardship

As antimicrobial resistance continues to evolve into a growing public health challenge, pharmacists are increasingly being called upon to expand stewardship efforts beyond the hospital setting and into communities, outpatient clinics, and long-term care facilities.

In this Q&A, Tho Pham, PharmD, BCIDP, antimicrobial resistance and antimicrobial stewardship lead at the Arizona Department of Health Services and clinical assistant professor at the University of Arizona R. Ken Coit College of Pharmacy, discusses emerging priorities in antimicrobial stewardship highlighted at the MAD-ID/SIDP Joint Meeting, including antifungal resistance, rapid diagnostics, and community-based stewardship models. Pham also explores the expanding leadership role of pharmacists in antimicrobial stewardship, vaccine advocacy, and public health efforts aimed at preserving the effectiveness of life-saving antibiotics.

Pharmacy Times: Can you introduce yourself?

Tho Pham, PharmD, BCIDP: Yeah, it's a pleasure to be here. So my name is Tho Pham. I am an infectious disease trained pharmacist. I currently serve as the antimicrobial resistant/antimicrobial stewardship lead at the Arizona Department of Health Services. And in addition to my public health role, I'm
also a clinical assistant professor at the University of Arizona
R. Ken Coit College of Pharmacy.

My current work focuses is really to bridge the gap between, you know, the clinical excellence at the bedside with the strategic
stewardship initiative at the state level.

Pharmacy Times: As an attendee of MAD-ID this year, what themes or trends in antimicrobial stewardship are you most interested in following?

Pham: Yeah, absolutely. So what excites me the most about this year
agenda is seeing the antifungal resistance and antifungal stewardship finally
getting the spotlight it deserves. We spent quite a lot of time over the past few
decades refining the antimicrobial stewardship, but now with the rise of the multidrug-resistant Candida species and also invasive mold, the sessions on optimizing antifungal management, yeah, definitely very intriguing and actually very critical. I'm also following, you know, the nuts and bolts of acute care stewardship, specifically discussions on the rapid diagnostic as well as some other rapid fire poster sessions to see how we can shave off those extra hours of the time to optimal therapy. But honestly, I'm always looking for to see how these acute care successes can be translated into long-term care as well as outpatient setting, which remain the final frontiers for a
comprehensive stewardship program.

Pharmacy Times: Have there been any recent shifts in stewardship priorities—either nationally or at the state level—that pharmacists should be aware of?

Pham: Yeah, great question. I'm glad you asked. So one of the most critical shifts that we're seeing is the transitions of stewardship from a hospital-centric model, in a sense, to a more comprehensive community-based approach. You know, for years, our focus, like I said earlier, was almost exclusively on the acute care setting, but we're now recognizing that there's many more, that there are more, like, long-term care and also outpatient facilities. I feel like the priority right now for us is to really address that resource gap because unlike large academic centers, these community settings or long-term care settings, they face very unique challenges, mostly due to the lack of dedicated manpower and also the constant competing priorities or high staff turnover.

So for us specifically in Arizona, like, we are focusing on to really expand that stewardship uptake and also equity. It's about ensuring that a patient in a rural nursing facility or rural area has access to the same level of stewardship expertise as a patient in, like, a metropolitan of Phoenix in the ICU.

And may if, if may I add, another one is this really tie into a broader one health perspective. We are now looking at stewardship not just a
clinical task, but more as this public health infrastructure. We are working to provide these, resource-limiting setting with toolkits as well as pharmacist-led support that they need to manage the infection safely, and as well as, like, acknowledging that the nuts and bolts look very different from a 500-bed hospital. So a lot of exciting things going on.

Pharmacy Times: As a pharmacist leader, how do you see the role of pharmacists evolving in antimicrobial stewardship efforts?

Pham: Yeah, absolutely, one thing that I think is very exciting for us as a pharmacist, as a profession, is now is the time for us to move from a supportive functions to one of the essential as co-leadership because pharmacists, we are, you know, clinical drug experts who bridge the gap across every health care setting, whether is it in the ICU to the independent community pharmacy.

For example, pharmacists have been leading charges in removing inaccurate penicillin allergy labels. And by doing so, like, we directly facilitate the use of more of that narrow-spectrum, safer first-line therapies, which is honestly one of the most effective tools we have to reduce selection of those resistant organism and specifically Clostridioides difficile colitis, as we know, is very detrimental. And as a nationally recognized vaccine provider, we have to really recognize that vaccines are actually a primary yet often underutilized tools in antimicrobial resistance.

Like, for example, like by driving the vaccine uptake, whether it's gonna be for pneumococcal, against invasive pneumococcal disease, influenza, or RSV, we prevent these infections that lead to the antibiotic use in the first place. Because upper respiratory tract infections are like the number one driver for inappropriate use of antibiotic in an outpatient setting. So that's why, like, I've always, like, you know, like to remind my trainees as well as I share with my colleagues that for every infection that we prevented by a vaccine is an antibiotic prescription that never had to be written in the first place.

And then another one, of course, because I'm in a public health arena, I'm of course gonna have to put a plug for my public health folks. Pharmacists, along with nurses and also other physicians, we are consistently ranked among the most trusted health care professionals and as well as the often the most accessible health care providers, and we have the unique power to educate the public on the appropriate use of antibiotics. So by fostering a better understanding of the viral versus bacterial illnesses, we can definitely shift that conversation away from antibiotics as default solutions for every infections, because we know it's not true anymore. And by engaging patients in the community, we can now foster a more sustainable understanding that antibiotic is, you know, a necessity in ensuring that these life-saving medications are preserved for those who truly need them the most, because they come a very long way, right? Especially since the development of penicillin in 1960s.

And, long story short, ultimately, as, you know, co-leaders of stewardship program, pharmacists, we aren't just managing medications. Like, we are managing public health, which honestly I didn't think about it before I joined this role, so it's very eye-opening for me, but there's so much overlap between pharmacy and public health. So yeah, we definitely just gotta practice on top of our license and utilize every tools in our clinical arsenal to really help drive that.

Pharmacy Times: What key message would you want pharmacists and clinicians attending MAD-ID to take back to their practice?

Pham: The biggest thing is just be open-minded, and stewardship is not just a hospital specialty. I think that's the most important, key take-home point. Because I know MAD-ID provide incredible nuts and bolts for hospital practices, like the session you're gonna see on resistance evolution or rapid diagnostic, or I call it the "fancy toys." But the true challenge and the opportunity really lie on that scalability. Like, we want to be able to take this high-level expertise that we gain from the meeting and find ways so that we can translate those for the outpatient and for those long-term care settings, because it is a clinical and public health necessity, right? And whether or not they're gonna talk about penicillin allergy delivery initiative or driving vaccine uptake, or if it's supporting a rural nursing home or a critical care access hospital, like, your expertise as a pharmacist is probably the most powerful tool we have. And take those clinical pearls back to your practice, use them to build the bridges, to the community where, you know, the manpower and resources are often needed the most.