The Centers for Disease Control and Prevention (CDC) published community antibiotic stewardship guidelines late in 2016.1 Although there are references to pharmacists sprinkled in the new guidelines, most pharmacists agree that we could have received more significant mention and responsibility based on our professional capabilities. Michael Cawley, PharmD, RRT, CPFT, FCCM, expressed his views in an article titled “CDC Antibiotic Stewardship Guidelines Overlook Pharmacists.”2 In his article, Dr Cawley expresses disappointment regarding the lack of emphasis and inclusion of the pharmacist’s role in the new guidelines. Although the CDC was not trying to slight the pharmacy profession, in some parts of the guidelines, pharmacists appear to be omitted or grouped in with other healthcare practitioners.
In this issue of Inside Patient Care, Natalie Kokta, PharmD candidate, describes how community pharmacists can help in preventing antimicrobial resistance. I think you will find her article, “Antimicrobial Stewardship: How the Community Pharmacist Can Help,” a fresh approach to the pharmacist’s role as a gateway practitioner, educator, and promoter of vaccinations.
Looking at the retail pharmacist’s role in antimicrobial stewardship, several areas stand out. When clinics are located inside of or in close proximity to a retail pharmacy, the pharmacist has an excellent opportunity to work with the clinic practitioners to support antimicrobial stewardship. When patients hear consistent information from physicians and pharmacists about when antibiotic or antiviral therapy is needed, it reinforces appropriate use of over-the-counter and nondrug therapy and minimizes unnecessary antibiotic use.
Pharmacists can work with the retail clinic to include the diagnosis on the physical or electronic prescription. If the retail clinic is entering a diagnosis into the electronic medical record (EMR) system, it would not be too difficult or require much additional effort to include the diagnosis on the prescription. Some EMR systems may be configured to have that automatically occur, and this process could be extended to the leading prescribers in your pharmacy’s community. In this manner, pharmacists can determine whether the antibiotic, the strength, and duration of therapy are appropriate. Pharmacists can help educate patients about how antibiotics have no benefit if taken for the wrong organism, and are likely to wipe out healthy, protective bacteria, resulting in side effects, such as diarrhea and secondary infections.
Recently, I became aware of pharmacy chains that are evaluating strep and influenza testing under collaborative practice agreements with local physicians. The pharmacists will have additional education, training, and certification to administer the tests, interpret the results, and follow treatment guidelines established by the physicians. These treatment guidelines include antibiotics for a positive strep test or antiviral oseltamivir if a test for influenza is positive. The guidelines differentiate patients who should receive additional medical treatment from those who could receive over-the-counter medications and other supportive measures. These collaborative practice agreements are an excellent opportunity for pharmacists to practice at the “top of their license,” and to support appropriate use of antibiotic and antiviral therapies.
Finally, I would like to see a method for pharmacists to document their work and be compensated for preventing inappropriate antimicrobial therapy. Today’s pharmacy economics only compensate the pharmacy for the dispensing of a prescription. If a pharmacy prevents an inappropriate antibiotic from being dispensed, there is no compensation for that activity. Perhaps a proactive pharmacy benefit manager (PBM) could implement a program compensating their pharmacy network for not dispensing an inappropriate antimicrobial drug. PBMs have programs that compensate pharmacies for not dispensing duplicative drugs—a “service claim” with appropriate documentation and compensation to the pharmacy in an amount equal to the nondrug component on submission of a “dummy” National Drug Code or a service code.
A long-term approach would be for the government to implement a quality measure supporting antimicrobial stewardship. Although I believe that the CDC and the Centers for Medicare & Medicaid Services (CMS) could make this happen, it would take several years. For pharmacies, evaluating quality metrics is a less direct approach than the process discussed above of submitting a “service claim.” As is the case today with CMS’s quality measures, it will be up to health plans to determine if, and how, they reward a pharmacy for positive behavior.
- Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. November 11, 2016. www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e. Accessed January 10, 2017.
- Cawley M. CDC Antibiotic Stewardship Guidelines Overlook Pharmacists. December 5, 2016. www.managedhealthcareconnect.com/blog/cdc-outpatient-antibiotic-stewardship-guidelines-pharmacists-have-limited-role. Accessed December 29, 2016.