The audio file is available at https://academic.oup.com/ofid/pages/Podcasts.
Hello. This is Paul Sax. I’m Editor-in-Chief of Open Forum Infectious Diseases, and that’s O-F-I-D not “Ofid.” And welcome to the next OFID podcast.
If you asked 100 ID doctors in clinical practice where they turn when they are stuck on a tricky antibiotic issue—toxicity or drug interaction, spectrum, dosing—there is a good chance that 99 out the 100 would ask a doctor of pharmacy or a PharmD, specifically one with specialty training in ID.
I’ve had the good fortune of working with several exceptional PharmDs over the years, and I also have the good fortune of having with me today Susan Davis who is a Clinical Professor of Pharmacy Practice at Wayne State University and ID Pharmacist at Henry Ford Health System in Detroit, Michigan. Thank you so much for joining me today, Susan.
No problem. Thanks for having me. I am certainly a fan of the journal and your social media account.
Thank you. Let’s start off by your telling us a little bit about yourself, where you are from originally, your background, and then specifically how you became interested in being a PharmD and in infectious disease in particular.
I grew up in a small town in west Michigan called Sturgis. I went to undergrad and pharmacy school at the University of Michigan—Go blue! Then, I did my residency and fellowship at Detroit Medical Center at Wayne State.
But honestly, my ID interest goes back way farther than my training. It goes back to two biology teachers, one of which was my dad. My dad, in the summers, would work with the state and local farmers to raise walleye and other fish. While I was in middle school, one of my jobs was to help with the water samples, and I got to play with the microscope and identify the algae. It was my first introduction to microbiology, and it felt like I was doing real science even at that age. That was just an awesome introduction to what the impact could be.
Then, later in high school, my biology teacher suggested I would like Laurie Garrett’s “The Coming Plague.” And I did. I read it, it was my favorite book of the time, and I’ve been an ID nerd ever since. Then, when it came to career plans, pharmacy was not the driver, it was really ID. Pharmacy became the way that made sense for me to approach that.
Not medicine?
Medicine was never an interest. It’s the data, the types of patient interactions, the interventions that we make with physicians, the focus on chemistry, and mechanisms, that’s what gets me excited. Pharmacy is a fit for me.
Yes and your geography so far—Michigan, Michigan, Michigan, Michigan, right?
Absolutely. I wouldn’t have it any other way.
Don’t get me started about college football. We might have a lot in common, but not that, I can tell you right now.
It’s okay.
I think that most of the listeners to this podcast are ID physicians and may not be familiar with pharmacy training. I am hoping you can give us a primer on pharmacy school and getting the PharmD degree because a lot more is involved, I think, than people know.
Yes, no problem, and you probably have more pharmacy listeners than you have counted. We tend to lurk.
There are over 130 pharmacy schools in the US, and all of the curricula are implemented in slightly different ways, but pretty universally the didactic curriculum is very focused on chemistry, pharmacology, therapeutics of all sorts of areas. And then, along with that go courses that focus on skills for evidence-based medicine, problem solving, team-based collaboration, patient assessments, some of those social administrative things.
Students might be able to take elective tracks or do research projects, but to me the most important part of our curriculum is really the experiential curriculum. Students can have early experiences where they go and get exposure to different practice models, to talking with patients. That starts usually in the first year, but it culminates in the fourth-year rotations where students spend their whole year doing the advanced pharmacy practice experiences and developing those real skills in patient care. They get to explore some of their specialty interests, and it’s those rotations that to me make the biggest difference in whether those student pharmacists are well prepared to enter the workforce or go on and do whatever their next step is. I’m interested in what kind of interventions are they making—what kind of relationships did they build with patients or with physicians? Those are the things that I try to really nail down when we’re looking at candidates for our residency program.
Would you say that communication skills play a very prominent role or other skills?
Absolutely. Effective and empathic communication is pretty important—being persuasive and confident. And if you’re not out there as a student getting some of that experience of having to go up to the ID attending and say, “You know, can I help you fix that dose?” That’s something you should be doing. If people are doing that in their training programs early, I think it makes for a good, smooth transition to real life.
When I’m on rounds and the PharmD who is rounding with us says something to me like, “I noticed this person’s creatinine is up a bit, maybe you should come down a little bit on this drug?” To me it’s the ideal collaborative experience because they’re focusing on an area of the case that otherwise I might have missed. These interactions are so valuable. We learn a ton; it improves patient care. Why do you think this isn’t more well known?
I think there are probably a few reasons for that, and sadly I agree. It isn’t that well known. But the first is we are a limited resource, especially ID pharmacists. There are only about 100 training programs between ID residencies and fellowships in the US. There are not enough of us to go around. We talk about how there are not enough ID physicians, there are even fewer ID pharmacists. Not everyone has the opportunity to work closely with an ID pharmacist. I think that is probably a big thing.
The other might actually be more of an issue of personality. I don’t have data, but I would say anecdotally a lot of pharmacists tend to be introverts. We’re just going to keep our heads down and keep getting more work done rather than be out in the spotlight. As a profession, we haven’t always done a great job of advocating for ourselves, although that is changing with some of our organizations.
I think most of us personally would like to be contently appreciated in our individual interactions and not worry so much about that more public or national acknowledgement.
Do you know Dr. [Brad] Spellberg out at UCLA, the ID doctor?
I have interacted with him in a number of meetings, absolutely.
I would say the converse of the introverted pharmacist is Dr. Spellberg, who very kindly appeared on this OFID podcast. He’s an ID doctor, and he has really raised the whole antibiotic stewardship game to a very high level, and the whole idea that we should be controlling antibiotic use so that they are appropriately used and are resources that other people can benefit from.
Since we’re talking about that, I’m sure you saw the paper we just published in OFID that highlighted the influence of pharmacists in stewardship programs, especially for the ID fellows. In fact, if I can just quote from that paper it said, “Pharmacists, not ID physician leaders, were identified as fellows’ primary resource for antibiotic teaching.” How would you define the role of pharmacists in these programs?
First, I would say I loved that paper, naturally. But not just the message. It was nicely done, very thoughtful. I think ID pharmacists are pretty underutilized. There are things we could be doing that we aren’t necessarily. Hearing that ID fellows appreciate that kind of education is really fabulous. I know I’m not alone in saying I love it when our division asks me or other ID pharmacists to come talk about antibiotics. We are the medication experts. I don’t think ID fellows could have a better resource for that kind of information.
But honestly, I might even take it further. There are ID pharmacists who are fabulous at research, and we as a profession have been requiring stewardship in our training programs for years. As ID fellows look for additional mentorship opportunities, I think there are other things where that collaboration could be taken advantage of.
Certainly PharmD is critical for our antibiotic stewardship programs, so I think we’re using our resource appropriately. I want to switch to a different antibiotic topic, one that is one of my pet peeves and that is outpatient parenteral antimicrobial therapy or OPAT. Do you have any thoughts about OPAT in general and then the pharmacist’s role in particular?
Yes. I want to be not too personal in my opinions here, but I think people can be a little cavalier about sending patients out on IV antibiotics, even when oral alternatives could do just as well. Not every patient with an ESBL [extended-spectrum beta-lactamases] needs ertapenem. I know it sounds convenient, but OPAT is a great option when it’s necessary, or if in-clinic infusion isn’t practical and there’s a process in place to keep it safe.
I think some of your concerns and pet peeves would be more with the complexity of that monitoring on the outpatient side and lack of reimbursement for that pretty intense care, correct?
Yes. In fact, I heard from an Australian colleague that the way their healthcare system is set up, a person who is discharged on IV antibiotics in Australia, the people who continue to follow them continue to get credit for doing so.
Imagine that.
Imagine that. That does not happen here. When they’re discharged, they go off into this world where nobody wants to pay, nobody wants to be responsible. It’s the classic hot potato. Do you feel like pharmacists have a special role for OPAT programs?
I think we sure could. Pharmacists could actually help take some of the burden off. My hospital requires an ID consult before discharging patients on OPAT, but pharmacists can help with that role if you don’t have the ability to take on quite that much load to your consult team. Inpatient pharmacists can be helping with patient selection, patient education, setting up the right lab for really encouraging usable options.
But even on the outpatient side, I think if you have an ID pharmacist in your clinic, if you have an HIV pharmacist, maybe he has some time to help triage that follow up. I do think there is a place for us to help facilitate that monitoring.
You mentioned the Australian system, I like what the British Society of Antimicrobial Chemotherapy has. Their E-OPAT registry has some pretty cool resources.
Very interesting. I know that they have recently done this study; we are all eagerly awaiting the publication of looking at oral options for osteomyelitis. We’ve seen the data presented at a meeting, but we haven’t had a published paper. But I guarantee it will help reduce the number of patients on OPAT.
Eagerly awaiting.
Yes. We’re looking forward to that study. What do you guys think of as some of your go-to sites for medical information, for antibiotic information? I know what we ID doctors use, but I wonder if there are any differences between what PharmDs use and what ID doctors use.
I think we probably use a lot of the same specific sites, a lot of the same textbooks. I don’t think that’s going to differ too much, but when you are looking more in the pharmacy silo of things that are usually attributed to the pharmacist’s role, I know drug interactions is one of the things that you guys can rely on us for. To be honest, I don’t think we actually have to do a ton of investigation into most drug interactions because so many of them are those things we see fairly often within our specialty. Quinolones, azoles, rifampin, I’ve kind of got this.
For you, it’s like nothing, no big deal. For us…
It’s not easy, but you see it so often that, “Okay, I have a plan.” But what I suggest for trainees who don’t necessarily have that off-the-top-of-their-head kind of thing, I want a resource that has information on the mechanism, the magnitude, the frequency, modifying circumstances like dose relatedness of timing, and I want it to give me an action that is recommended.
There are two that I think do a great job with that and that’s MicroMedex and Lexicomp. They both have drug interaction checkers that are pretty solid. They are subscription services, so if you are just searching the Internet, I might be a little more cautious. For HIV-specific interactions, I’m a big fan of both UCSF’s site and the University of Liverpool’s drug interactions site, they are both pretty well done.
Yes, they are terrific, and they update them regularly. I agree. It’s so funny what we’re comfortable in our own practice doing. For you, “Drug interactions? Big deal.” For a lot of us, once those EMR [electronic medical record] alerts pop up saying, “Two drugs that may prolong QT [quinolone toxicity] – Careful, careful, careful.” We are very worried about that.
I’m going to ask you now a few pet peeves, sort of a lighting round. We’re going to give you these topics, and you can say whatever you want about them. Topic number one, vancomycin levels.
How much time do we have? [Laughter]. Pharmacists in general, we spend so much time chasing after the perfect vancomycin level. My gut reaction is I don’t know how much value it adds. Meghan Jeffres has a great review article on the true cost of vancomycin that says a lot of this really well and better than I can. Sure, there are some conditions where that vancomycin optimization matters a lot, but half the time we’re using it, and it might not even be necessary in the first place.
Now when we’re shifting to more intense monitoring with AUC (area under the curve) instead of troughs, I get a little skeptical on how scalable that intervention is given the volume of vancomycin-treated patients.
I’m going to say out-and-out it is not scalable.
Right. In a selected population sure, let’s go there, but I’d rather have my pharmacists doing something that really improves outcomes like rounding with their primary teams, facilitating transition of care. That time that could be freed up with the patients with a serious infection, maybe we can shift to appropriate alternative therapies and reduce vancomycin from the get go.
One of my pet peeves on vancomycin is the person who is discharged from the hospital on every-eight-hour vancomycin and these prolonged infusion times and the levels… It’s almost undoable. To me, that’s almost automatic switch to daptomycin or linezolid. Now that we’re on the topic of gram-positive drugs, I’m going to ask what is the right dose of daptomycin?
Well pharmacists debate this hotly. I’m a big believer in high-dose daptomycin at 8 or 10 mg/kg, depending on the indication. The controversy I tend to get more pulled into now is which dosing weight to use in obese patients. That PKPD [pharmacokinetics/pharmacodynamics] data would suggest total body weight results in a higher exposure than necessary compared to using lean body weight in obese patients. But then, safety data would suggest symptomatic myalgia, not just CPK [creatine phosphokinase] elevation but real symptoms, that’s not more common with those higher exposures.
So which dosing weight is right? I think it comes down a little bit to your rationale and if you’re trying to skimp on the daptomycin dose just for drug costs. There are probably other things that might be more helpful like batching preparation of doses to minimize the number of vials you have to use when you are making a lot of those for patients.
Interesting. Next one, linezolid and SSRIs [selective serotonin reuptake inhibitors].
Well, it comes up a lot, and I think it’s a possible thing, and as we use more and more linezolid as an alternative we might actually see more of it. But, when we’re being really intentional about using linezolid for a serious indication, I think that benefit tends to outweigh the risk of serotonin syndrome. And patients are going to be on a long duration—if we can anticipate that and do something to taper or change their SSRI, then that’s great. But otherwise, if you’ve got a strong indication for linezolid, I think educating and monitoring is more than adequate.
It is a drug, as you say, we are going to use more of and that is because the cost has plummeted.
I know.
Boy, it’s really amazing. The thing is, as you are saying, some of the pharmacies still sell it at the original cost, and some are selling it at one tenth of the cost.
That is just brutal.
It’s brutal, patients really need to shop around. Next one. Fluoroquinolone toxicity, is it the real thing or just a scapegoat?
I don’t know that I care, and you’re talking about the multisystem toxicity syndrome?
Yes. I’m talking about the trigger of the 2016 FDA [U.S. Food and Drug Administration] action saying that in the outpatient setting fluoroquinolones should not be used for minor infections unless there are no alternatives.
That was the most recent of many FDA communications on quinolones. [Editor’s note: Since recording this podcast, there has been another FDA warning on quinolones.] I do think there is probably something there. I have honestly never directly observed it, but when you review the reports, not just random Internet searches, but it does seem like this is a legit thing—rare but credible, particularly with the older agents.
As for using that as the major rationale to restrict quinolones, I come from a long line of quinolone phobics. We have plenty of reasons to avoid them in the first place, like resistance, interactions, other known well established toxicities, the musculoskeletal stuff, and those harms are already pretty underappreciated. So, if the FDA raising the alarm on toxicity makes people think twice, I’m all in favor.
All right. For my own curiosity’s sake, I just went and looked at the latest price of linezolid. The lowest price is $97 for two weeks and the highest price is $1,622.
How does that happen?
I know.
Well, we all know how it happens.
Yes. Exactly because it can. The next pet peeve is about how our current electronic medical records handle notification of drug interactions. I’ve already brought this up several times. What do you think? How are we doing at giving this information—drug interactions or drug information in general, whether it’s interactions or dosing guidelines or whatever?
I think that’s a universal frustration. When you look at the data on this, there are some types of alerts, drug interactions and allergies in particular, that are overridden about 90 percent of the time, so they are not doing anything and probably more harm than good. There are plenty of people out there in informatics trying to suggest approaches, how to prioritize or filter alerts. Even then, even if you have a system in place to try to prioritize what alerts go through, that’s a never-ending process because new things come across all the time. That’s a challenge.
The other thing I think we have to talk about when we’re worried about alert fatigue is it’s not just reducing the number of alerts, but they’ve got to be designed well. If what we’re communicating is just information overload, that’s not good. They should be concise and actionable. I think we could probably use some best practices on that, and maybe stewardship is one way to make that happen for the things that we are focused on, at least.
I think if you wanted the very definition of alarm fatigue, the drug interaction alerts would be a good example. It’s really a problem. One last thing, how do you get around the inpatient doctors who seem to prescribe the same combination antimicrobials to every critically ill patient? I’m referring of course to vancomycin plus piperacillin-tazobactam.
In my system its vancospime, not Zosyn. I think getting around that takes some investigation into why. It’s not just individual physicians who are doing that, it’s not guidelines that encourage that. Some of the things we’ve done in our hospital are to try to put tools in the ICU pharmacists’ hands where they can help get more diagnostics ordered. If somebody has forgotten to do things, the pharmacists have ways of recommending that now, and we have some better ways of approaching how we report commensal flora in respiratory cultures that encourages de-escalation.
I think we’ve tried to work through our pharmacy model in the ICUs to get people communicating about why are we doing this choice in people up front and then remind, as microbe results come back, you don’t need to continue it.
Great. I always like to say to our ID fellows that the continued coverage of MRSA [methicillin-resistant Staphylococcus aureus] and the absence of MRSA-positive culture is sort of pointless. This is not a fastidious organism, it’s very easy to identify it and grow it, in fact just the opposite. If you are not seeing it, you don’t need to cover it.
Well, Susan, thank you very much for sharing your expertise with us today. I very much enjoyed chatting with you. Do you have any final thoughts before we end?
Well my final thought is I had hoped to ask you a question and take that opportunity if it’s all right?
It’s quite all right.
Thank you. Well earlier this year the ID organizations, the IDSA [Infectious Diseases Society of America], SHEA [Society for Healthcare Epidemiology of America], and PIDS [Pediatric Infectious Diseases Society], had a very nice paper advocating for ID physicians as leaders of stewardship programs. There are some really important needs there. But, ID pharmacy organizations, myself included, have replied, “Hey, we’re doing this too and we’d like to be part of that conversation.”
You are someone people in ID really admire. Is there anything you would recommend that ID pharmacists and physicians can be doing better to promote and advance stewardship?
First of all, thank you for that compliment. I’m not sure I totally agree with it, but thank you anyway.
Imposter syndrome.
I guess that’s the case. But, I will say that if one could just communicate the extraordinary value of the collaboration between ID physicians and ID pharmacists and the examples we cited in this conversation, examples that occur practically every day on rounds in the hospital, the examples that occur like when you are dealing with outpatients on OPAT or otherwise, just document those and make the case that it should be a team effort.
That is going to sound all kumbaya-ish, but I really mean it. We’re all trying to do the same thing, which is to improve patient care and the appropriate use of antibiotics.
So, this is Paul Sax, Editor-in-Chief of Open Forum Infectious Diseases, and on this OFID podcast I have been joined by Susan Davis—Clinical Professor of Pharmacy Practice at Wayne State University and ID Pharmacist at Henry Ford Health System Detroit.
Again, thank you so much, Susan, and I look forward to seeing you at ID Week.
Yes, me too. Thanks again for having me.