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 an interview with Pharmacy Times, 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 in Tucson, 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 to preserve the effectiveness of life-saving antibiotics.

Pharmacy Times: Please introduce yourself.

Tho Pham, PharmD, BCIDP: It's a pleasure to be here. My name is Tho Pham. I am an infectious disease–trained pharmacist. I am 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 is really to bridge the gap between, you know, the clinical excellence at the bedside and 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’s
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 invasive mold, the sessions on optimizing antifungal management [were] definitely very intriguing and actually very critical. I’m also following the nuts and bolts of acute care stewardship, specifically discussions on rapid diagnostics, as well as other rapid-fire poster sessions, to see how we can shave off those extra hours to optimal therapy. But honestly, I'm always looking to see how these acute care successes can be translated into long-term care as well as the 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: Great question. I'm glad you asked. One of the most critical shifts that we're seeing is the transition of stewardship from a hospital-centric model, in a sense, to a more comprehensive community-based approach. You know, for years, our focus, as I said earlier, was almost exclusively on the acute care setting, but we're now recognizing that there are many more 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 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, we are focusing on expanding 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 a metropolitan [area] ICU [intensive care unit].

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

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

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

For example, pharmacists have been leading charges in removing inaccurate penicillin allergy labels. And by doing so, we directly facilitate the use of more of those narrow-spectrum, safer first-line therapies, which are honestly some of the most effective tools we have to reduce selection of those resistant organisms and specifically Clostridioides difficile colitis, which, 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 tool in antimicrobial resistance.

For example, by driving vaccine uptake, whether it's going to be for pneumococcal, invasive pneumococcal disease, influenza, or RSV [respiratory syncytial virus], we prevent these infections that lead to the antibiotic use in the first place. Upper respiratory tract infections are the No. 1 driver for inappropriate use of antibiotics in an outpatient setting. So that's why I like to remind my trainees, as well as share with my colleagues, that for every infection we prevent with a vaccine is an antibiotic prescription that never had to be written in the first place.

And, of course, I’m going to have to put a plug for my public health folks. Pharmacists, along with nurses and physicians, are consistently ranked among the most trusted health care professionals. [And because we are] often the most accessible health care providers, we have the unique power to educate the public on the appropriate use of antibiotics. So by fostering a better understanding of viral vs bacterial illnesses, we can definitely shift that conversation away from antibiotics as the default solution for every infection, because we know that’s not true anymore. And by engaging patients in the community, we can now foster a more sustainable understanding that antibiotic is a necessity in ensuring that these lifesaving 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 the 1960s.

And, long story short, ultimately, as co-leaders of the stewardship program, pharmacists aren't just managing medications. We are managing public health, which, honestly, I didn’t think about before I joined this role, so it’s very eye-opening for me, but there’s so much overlap between pharmacy and public health. We definitely must practice at the top of our license and utilize every tool 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 things are just to be open-minded, and that stewardship is not just a hospital specialty. I think that's the most important key take-home point. Because I know MAD-ID provides incredible nuts and bolts for hospital practices, like the session you're going to see on resistance evolution or rapid diagnostics, or as I call it, the "fancy toys." But the true challenge and the opportunity really lie in that scalability. We want to be able to take this high-level expertise that we gain from the meeting and find ways to translate it for the outpatient and long-term care settings, because it is a clinical and public health necessity, right? And whether or not they're going to 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, your expertise as a pharmacist is probably the most powerful tool you have. Take those clinical pearls back to your practice, use them to build bridges to the community where manpower and resources are often needed the most.