Elevating Antimicrobial Stewardship: Insights From Pharmacist-Led Initiatives Combatting Health Care–Associated C diff


Laura Gillespie, PharmD, discusses the impact of pharmacist-led initiatives on health care–associated C diff rates for health care systems.

Pharmacy Times interviewed Laura Gillespie, PharmD, regional antimicrobial stewardship pharmacist, Mishawaka and Plymouth Medical Centers, Saint Joseph Health System, on her paper “Impact of Pharmacist-Led Initiatives on Health Care–Associated Clostridioides difficile Rates” published in the March issue of Pharmacy Practice in Focus: Health Systems and her presentation of that paper at the Peggy Lillis Foundation’s 2024 National C diff Advocacy Summit. Gillespie discusses why the impact of pharmacist-led initiatives on health care–associated Clostridioides difficile (C diff) rates is important for health care systems and other health care professionals to understand.

Pharmacy Times: What is the focus of your paper published in the March 2024 issue of Pharmacy Practice in Focus: Health Systems and presented at the Peggy Lillis Foundation's 2024 National C diff Advocacy Summit?

Image Credit: © luchschenF - stock.adobe.com

Image Credit: © luchschenF - stock.adobe.com

Laura Gillespie, PharmD: So, the article that we published and the talk that we just gave really focused on how pharmacist-led interventions can really impact the amount of C diff that occurs in a hospital or health care setting. Basically, some key interventions that we discussed were making sure that we are setting guidelines for a health care system. So, looking not only at what our national guidelines are for how to treat some disease states, but looking at your own health care system and what types of infections you have, what your patient population is, and what your susceptibility rates are. So, the susceptibility rates at our health care institution may be different from somebody who's in a more rural setting, or who's in a big city. So, you have to know what your type of population is. So, once you know that, basically marrying those guidelines together, and knowing your patient population, and then looking at what patients have certain allergies, so knowing what the top drugs are that you want to give to somebody, and what are some things that are going to prohibit you from giving those antibiotics.

So, if a patient, for example, has allergies, and you want to investigate those a little further, sometimes it's just speaking with a patient and asking them what their allergies are, and sometimes it's doing an allergy test to clarify what they are, so that we can give the most appropriate antibiotics that we need to give. Then also highlighting those infectious disease states where we mistreat the most. So, looking at [urinary tract infections (UTIs)] and how do we treat those most appropriately or community-acquired pneumonia? Are we giving the right antibiotics, are we following the guidelines appropriately, and then setting those guidelines for providers to look at their hospital and making sure that we're following those.

Another thing that we did was looking at β-lactam allergies and doing education on those and making sure that providers know that ‘Hey, if you have a patient who has an allergy to penicillin, it doesn't mean that you can't give any penicillin antibiotics anymore. It doesn't mean that you have to stay away from the whole class of cephalosporins either and go to something much broader spectrum and maybe more toxic like clindamycin or the fluoroquinolones or even really talking really broad spectrum like carbapenems, you can still potentially give a penicillin or cephalosporin.’ Classically, we give those because they have the most efficacious outcomes for patients, they kill the most rapidly, and are oftentimes the safest for our patients. So, we want to make sure that really getting down to the bottom of what allergies do you have, and then you can still give another cephalosporin or another penicillin, if you have an allergy looking at what are the crosser activities, what are the chemical structures of each of the antibiotics and making sure that we're educating on that.

Another thing that we did was if a patient we believe truly did have an allergy to a certain medication, we can do allergy testing. So, at our particular institution, we implemented penicillin skin testing. And if a patient says, ‘Hey, I had an allergy, and this is what it was,’ and they qualify, then we'll give them a penicillin allergy test and see if, in fact, they do have an allergy. So, 10% to 20% of the US population believes that they have a true allergy and less than 1% actually does [sic]. So, we've done a lot of allergy testing, and I can count on one hand as to how many patients actually truly did have an allergy. So, it's pretty cool that we can get rid of that and debunk the allergy.

The last thing that we did was we decreased our fluoroquinolones use. And again, a lot of our fluoroquinolone use comes from the misconception that a patient has an allergy and actually can't take other antibiotics. So, then we end up giving them a fluoroquinolone. So, one of the things that we did was we did an [medication use evaluation (MUE)], and we looked at medication use evaluation, and we looked at why are prescribers using fluoroquinolones. Are they appropriate? They are appropriate in some instances, they have a very good need some times, but other times we're just giving them because of the allergies and then we're saying ‘Okay, well we'll just give them this because they're allergic to everything else that we want to give.’ So really looking at deep down what is the reason for it and then decreasing fluoroquinolone use actually decreases C diff rates. And one of the cool things is that it they actually can cause them one of the most toxigenic forms of C diff—the 027 strain or ribotype. So, by decreasing the rate of use of fluoroquinolones we're actually decreasing, not only C diff rates but also the topmost toxigenic strains as well.

Pharmacy Times: In your view, why is it important to highlight the impact of pharmacist-led initiatives on health care–associated C diff rates?

Key Takeaways

  1. Pharmacist-Led Interventions Reduce C difficile Rates: Gillespie emphasizes the significant impact pharmacist-led initiatives can have on reducing health care–associated Clostridioides difficile (C diff) rates. By implementing interventions such as setting tailored guidelines for antibiotic use based on local susceptibility rates, addressing β-lactam allergies with education and testing, and decreasing unnecessary fluoroquinolone use, pharmacists can effectively mitigate the risk of C diff infections.
  2. Unique Role of Pharmacists in Antimicrobial Stewardship: Gillespie highlights the pharmacist's pivotal role in antimicrobial stewardship within health care systems. Pharmacists, through their expertise in medications, review every prescription and have the knowledge to identify inappropriate antibiotic use that can contribute to C diff infections. This role extends beyond simply dispensing medications; pharmacists are essential in optimizing antibiotic therapy to enhance patient outcomes and reduce antimicrobial resistance.
  3. Patient and Provider Awareness: Gillespie acknowledges a gap in understanding among patients and other health care professionals regarding the impact pharmacists can have on antimicrobial stewardship. Patients may not initially recognize the pharmacist's role in their care beyond dispensing medications. However, through direct patient education and involvement in treatment decisions (eg, addressing medication allergies), pharmacists can actively engage patients in their care. Similarly, while providers may historically have focused on direct patient care, they are increasingly recognizing pharmacists as valuable partners in optimizing antibiotic use and preventing C diff infections, leading to increased collaboration and trust in pharmacist-led initiatives.

Gillespie: Yeah, so I think there is a misconception that only infection preventionists who are the nurses in the hospitals making sure that we're utilizing proper hand hygiene, and we're making sure that we're properly sanitizing patient rooms and making sure we don't spread from one patient to the next different disease states. And I think that there's a misconception that that's what it is that stops C diff. Really, the risk of C diff really occurs most of the time when we overuse or inappropriately use antibiotics, and who better to stop the inappropriate use than a pharmacist. So, pharmacists basically see every single order that comes through the health care system, because a physician writes for a prescription, and then the pharmacist reviews it and makes sure it's okay, and then we verify it. So, we have this unique ability to really look at every single antibiotic or prescription that comes through so we can analyze every single thing that comes through, and we [are] the expert of medications. That's what we have been trained to do. So, we know very intimately and intricately which antibiotics or which medications in general have the highest risk for causing C diff, and making sure that we're not developing and producing these superbugs when we don't need to. So, we have a really unique role and health care system in being able to do that.

Pharmacy Times: What is the focus of your work as an antimicrobial stewardship pharmacist in a health system in Indiana?

Gillespie: So, as I said, I work really closely with our infection preventionist. We work hand in hand. If she does one thing to decrease or prevent C diff, and I do another thing, and together, we kind of have the synergism that we're working together and providing this. I have also talked about how I work really closely with our dieticians and our microbiologist. You might think, well, what does that have anything to do with anything, right? Well, the dietician and me had put together a pamphlet for our patients who we send home on antibiotics, or they're in the hospital, and we educate on how we can really protect our gut microbiome, so that's our good gut flora. When we give antibiotics, we're killing that good gut flora off and it's setting the perfect stage for C diff infection or other infections to set in. So, we put together something that really promotes the use of prebiotics and probiotics, which are in foods, so that's the healthier version, then going ‘Well, what can I go to the pharmacy and get in pill form that's a good probiotic?’ I get asked that question a lot. And really, the safest and most efficacious way of getting your pre and probiotics is by eating good, healthy foods.

Prebiotics are basically foods that feed our good gut flora, they're already in our body. That's the type of flora that we want the most. So, we feed them by giving them for example, different fibers. So, hummus or chickpeas are really good, you've got your fruits and vegetables with the skin on them. So, giving those is restoring and keeping our gut healthy for what we already have. And then after we take our antibiotics, we're killing off those good gut flora. So how can we replace them safely? Well, you can have foods that are fermented or have probiotics, for example. So, you've got your kefir, you've got your kombucha, you've got your Greek yogurts, and those are restoring what microbes you might have already killed off and putting them back into place. So, utilizing those together. So that's the work I've done with some dieticians.

The work I do with microbiologists—I can't even speak highly enough of how important their work is—we depend on the microbiologist to keep up to date with the guidelines and what the susceptibility rates are vs the microbes that have grown out. So, again, we're each other's checks and balances and making sure we're up to date with all of our guidelines. So, they provide us with an antibiogram, which is basically all of our hospitals microbes that grew out for the past year. And then what are the susceptibility rates, again, making sure that they're following the most up-to-date breakpoints, and knowing which antibiotics will work best for our patient population. So, all that work together comes together to keep our patients healthy and safe. You really wouldn't know that all that stuff is going on in the background, but that's how we're making sure our patients have good, effective care.

Pharmacy Times: Do you feel that the impact pharmacists can have on antimicrobial stewardship is broadly understood by patients and other health care professionals?

Gillespie: No, I don't think so. Well, let me start with the patients. So, I shared a story recently of how when I go and talk to a patient, let's say they have a penicillin allergy and our physician thinks that they need to prescribe something more broad spectrum, or more toxic, because that's what oftentimes happens because they have this penicillin allergy, and I'll say ‘Okay, hold on just a second. We're going to put a pause on this. I'm going to go talk to the patient and find out what their allergy is.’ And you'd be surprised as to how many times the patient's like, ‘Wait, who are you, you're not my nurse, you're not my physician, who is this person.’ Classically, the pharmacist sits in the basement of a pharmacy in the hospital. That's where the pharmacy is, and we just kind of do our computer work. And we don't talk to patients, right? So, it's kind of funny when I do come and talk to them. They're like, ‘Wow, I've got my own pharmacists that's coming to talk to me.’ And, I think, they really enjoy the conversation. So, they start talking about all their medications. But when we talk about their allergies, and what it implies in their health care, and how we're going to actually be able to treat them, they're just amazed by it. So, I think they're just starting to learn, as we provide that education, and hopefully, sometimes their family members or their friends are in the room too. And I can kind of educate them at the same time. I love that. So, I think we're not there yet with the patients, but we're really starting to impact that.

Then with the providers, again, we're really working on that. I think what's been really cool over the past few years is we have had these initiatives that we're implementing, and sometimes they just kind of say, ‘Okay, we'll do what you say, Laura,’ but in the end, they see the impact, and results and data are really what drives providers in the end. So, they're going to say, ‘Oh my gosh, we really did that. That's what we were able to accomplish.’ And so, then they start trusting in what we can do as pharmacists and antimicrobial stewards. And they say, ‘Okay,’ and sometimes now I find them coming to my office and seeking me out and asking questions. ‘So, what should I do with this patient? I have this type of patient. What should we do about [the patient who has] this allergy. What do we do, Laura?’ So that's pretty cool. So, I think they are starting to learn what we can provide for them.

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