Putting Antimicrobial Stewardship Into Practice

Listen in as our expert panel reviews important concepts behind antimicrobial stewardship along with tips to help limit unnecessary antimicrobial use.

Special guests:

• Madeline King, PharmD, MPH, BCIDP
  • Co-Director, Outpatient Antimicrobial Stewardship
  • Cooper University Health Care
  • Assistant Professor of Medicine
  • Cooper Medical School at Rowan University
• Michael A. Deaney, PharmD, AAHIVP
  • Infectious Diseases Clinical Pharmacy Specialist
  • Denver Health & Hospital Authority

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Stephen Carek, MD, CAQSM, DipABLM
  • Clinical Associate Professor of Family Medicine
  • Prisma Health/USC-SOMG Family Medicine Residency Program
  • USC School of Medicine Greenville
• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University 

For the purposes of disclosure, Dr. Madeline King reports a relevant financial relationship with Shionogi (speakers bureau for cefiderocol).

The other speakers have nothing to disclose.  All relevant financial relationships have been mitigated.

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in January 2026.

Use code mt1026 at checkout for 10% off a new or upgraded subscription.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

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The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Toolbox: Antimicrobial Stewardship
• Algorithm: Investigating Possible Drug Allergy
• CE Course: Implementing Rapid Diagnostic Testing
• Chart: Antibiotic Therapy: When Are Shorter Courses Better?

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Chapters

• 0:30 Introduction
• 2:39 CE Information
• 3:29 Why Antimicrobial Stewardship Matters
• 5:31 Inappropriate Antibiotic Use: Scope and Examples
• 10:48 Addressing Questionable Antibiotic Allergies
• 15:43 Delayed Prescribing & Watchful Waiting Approaches
• 17:12 Ensuring the Right Drug, Dose, and Duration
• 20:24 Stewardship in Community Pharmacies
• 23:40 Go‑To Resources for Duration & Stewardship Support
• 28:01 Pharmacy Technician Roles in Stewardship
• 29:31 Communicating Stewardship Interventions with Prescribers & Patients
• 36:58 Conclusion

Transcript

This transcript is automatically generated. 

00:00:07 Craig Williams
 My good rule of thumb is if you graduated pharmacy or medical school more than five years ago, take wherever you were taught for duration and cut it in half.

00:00:14 Craig Williams
 Seven's a new 14 and five's a new 10.

00:00:17 Craig Williams
 We just historically have given too long of a duration.

00:00:21 Michael Deaney
 The conversations around antimicrobial stewardship and actually making the intervention, easier said than done sometimes, and certainly more art than science.

00:00:30 Michael Deaney
 So I think when you're approaching clinicians, making sure to give them that benefit of doubt by asking open-ended questions, let them know why you're asking, making sure that you're coming at it from a patient advocate perspective, because that's truly what you're doing at the end of the day is advocating for patients.

00:00:50 Narrator
 Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources.

00:01:00 Narrator
 On this episode, our expert panel reviews important concepts behind antimicrobial stewardship, along with tips to help limit unnecessary antimicrobial use.

00:01:11 Narrator
 Our guests today are Dr. Madeline King, an infectious diseases clinical pharmacist and co-director of outpatient antimicrobial stewardship at Cooper University Healthcare.

00:01:22 Narrator
 She is also an assistant professor of medicine at Cooper Medical School at Rowan University.

00:01:28 Narrator
 And Dr. Michael Deaney, he is an infectious diseases clinical pharmacist at Denver Health.

00:01:34 Narrator
 He supports the hospital's inpatient antimicrobial stewardship program and infectious diseases consult service.

00:01:41 Narrator
 You'll also hear practical advice from panelists on TRC's editorial advisory board, Dr.

00:01:47 Narrator
 Stephen Carek from the USC School of Medicine, Greenville, and Dr.

00:01:51 Narrator
 Craig Williams from the Oregon Health and Science University.

00:01:55 Narrator
 This podcast is an excerpt from one of TRC's monthly live CE webinars.

00:02:00 Narrator
 Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

00:02:11 CE Narrator
 And now, the CE information.

00:02:14 Narrator
 This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses.

00:02:21 Narrator
 Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

00:02:31 Narrator
 For the purposes of disclosure, Dr. King reports a relevant financial relationship with Shionogi by serving on the speaker's bureau for cefiderocol.

00:02:40 Narrator
 The other speakers you'll hear have nothing to disclose.

00:02:43 Narrator
 All relevant financial relationships have been mitigated.

00:02:51 Narrator
 Now, let's join TRC editors, Drs. Stephen Small and Sarah Klockars, and start our discussion.

00:03:00 Steve Small
 Now, we know that antimicrobial resistance is a significant issue in modern health care.

00:03:05 Steve Small
 In fact, resistant bacteria are responsible for almost 3 million infections each year in the United States, and they lead to over 35,000 deaths in that same time frame.

00:03:15 Steve Small
 Antimicrobial stewardship can help limit growing resistance, but some viewers may be asking, what is considered stewardship?

00:03:24 Steve Small
 There are many activities across healthcare that fall under the antimicrobial stewardship umbrella.

00:03:30 Steve Small
 They can include direct patient care, such as prescribing the right antibiotic and lab tests, but they also include indirect patient care, things like monitoring antimicrobial use overall and educating colleagues about best practices.

00:03:42 Steve Small
 All of these are interconnected to enhance antimicrobial stewardship.

00:03:48 Steve Small
 And stewardship doesn't fall on just one person.

00:03:50 Steve Small
 It takes a team.

00:03:52 Steve Small
 For example, while prescribers can ensure they order appropriate cultures and tests, pharmacists can help guide appropriate antibiotic choices, along with optimized dosing and duration.

00:04:00 Steve Small
 And the list goes on.

00:04:03 Steve Small
 And with that, why is antimicrobial stewardship important, Madeline?

00:04:07 Steve Small
 I can see some viewers asking, what are the risks from, for example, antibiotic overprescribing here, and why do we need to care about this?

00:04:16 Madeline King
 There's a lot of things that go into antimicrobial stewardship.

00:04:21 Madeline King
 It's important to ensure that antibiotic use is appropriate.

00:04:24 Madeline King
 So one, not over-prescribing, but also not under-prescribing or inappropriately prescribing.

00:04:30 Madeline King
 We want to make sure that we're not losing antibiotics that we have in our arsenal due to development of resistance from over-prescribing.

00:04:39 Madeline King
 We still want to avoid unwanted side effects in patients by giving them antibiotics that maybe they don't need or inappropriate antibiotics.

00:04:47 Madeline King
 If they do need antibiotics, make sure we're getting the correct ones.

00:04:50 Madeline King
 So I think really focusing on an individual as well as a population level is really important, and that can be very hard to do, but I think it's crucial that we think about both of those components.

00:05:04 Steve Small
 And that sets the stage to discuss how we can be effective antimicrobial stewards.

00:05:09 Steve Small
 First off, Michael, how often would you say antibiotic prescriptions are inappropriate?

00:05:13 Steve Small
 How common of a problem is this?

00:05:17 Michael Deaney
 Sure. So antibiotic prescriptions are pretty frequently inappropriate, I would say.

00:05:22 Michael Deaney
 About 30% of antibiotics in the outpatient setting are considered unnecessary, and that is true to inpatient.

00:05:29 Michael Deaney
 It's where it's between 20 and 50% of antibiotics in hospitals that don't follow evidence-based recommendations.

00:05:36 Michael Deaney
 Some examples of inappropriate antibiotic prescriptions that I've seen in my practice, I think overly long durations, are probably some of the most common.

00:05:45 Michael Deaney
 Bug-drug mismatch can happen pretty commonly as well.

00:05:49 Michael Deaney
 And by that we mean selecting an antibiotic that does not appropriately cover the pathogen associated with the infection.

00:05:56 Michael Deaney
 Drug-disease mismatch can happen sometimes too, where people pick drugs

00:06:01 Michael Deaney
 that are not necessarily effective at penetrating into different spots where infections can exist.

00:06:07 Michael Deaney
 I think renal dose adjustments, lack of renal dose adjustments are an issue that can happen too.

00:06:12 Michael Deaney
 Lack of adjusting for things like weight, either overweight or underweight patients, and kind of like double coverage where you have multiple antibiotics that are achieving a very similar coverage in terms of pathogens, potentially just exposing patients to more toxicity.

00:06:28 Michael Deaney
 doses that are either too high or too low, and then one of the most striking ones for antimicrobial stewardship, unnecessarily broad antibiotics that are wiping out a lot of a patient's normal microflora as opposed to targeting specific pathogens.

00:06:45 Steve Small
 And maybe going to the outpatient arena, Madeline, what inappropriate antibiotic indications do you see the most in your practice?

00:06:54 Madeline King
 Yeah, that's a great question, especially thinking about the outpatient setting, which can be really hard to monitor.

00:07:00 Madeline King
 I think one of the things that we think about, which is a mix between in and outpatient, is treating asymptomatic bacteriuria.

00:07:07 Madeline King
 So patients who have bacteria in their urine just due to like maybe pre-admission testing for a surgical procedure that has nothing to do with the urinary tract.

00:07:15 Madeline King
 And kind of educating people that, just because there's bacteria in the urine doesn't mean that the patient's at risk of developing an infection somewhere else in the body.

00:07:24 Madeline King
 So that's one that we think about and focus on a lot.

00:07:27 Madeline King
 And the other one kind of strictly in the outpatient setting is patients coming in to primary care, urgent care with respiratory symptoms and being given antibiotics when they likely have a viral respiratory tract infection or being given antibiotics for too long of a period based on what their material respiratory tract infection is.

00:07:47 Madeline King
 So I would say those are the ones that we see a lot in the outpatient setting.

00:07:54 Michael Deaney
 Piggybacking a little bit off of what Madeline was saying, this is really common in pediatric patients with viral causes of things like acute otitis media, extremely common in kids.

00:08:06 Michael Deaney
 Oftentimes group A strep too is carried asymptomatically but still tested for in a lot of children.

00:08:14 Michael Deaney
 So when they have symptoms of sore throat, they can often receive antibiotics for that, when in fact that is a viral cause as well.

00:08:21 Michael Deaney
 So lots of opportunities in both adults and pediatrics for this.

00:08:28 Steve Small
 And Michael, I know you've done some work on stewardship in the dental arena.

00:08:32 Steve Small
 Can you tell us more about that?

00:08:36 Michael Deaney
 Yeah, there's definitely some opportunities.

00:08:38 Michael Deaney
 There actually are some guidelines published by the American Dental Association over the last couple of years that have come out of trying to guide this question because historically it's been kind of vague when and how to use them, what agents, what duration for what indications.

00:08:53 Michael Deaney
 I think what's really, really interesting when you dig into the guideline is that truly the indication for antibiotics in dentistry is extremely narrow.

00:09:01 Michael Deaney
 You need to be having specifically an apical abscess that is not able to be treated with direct conservative procedures by a dentist.

00:09:11 Michael Deaney
 And then there needs to be both pain and swelling on exam to really warrant antibiotics, as long as no systemic signs of infection are present.

00:09:20 Michael Deaney

So truly, most patients don't warrant antibiotics.

00:09:24 Michael Deaney

And if they do, it's very short courses of narrow agents like amoxicillin.

00:09:29 Michael Deaney

The other indication for antibiotics in dentistry is for prophylaxis, either for patients at high risk of endocarditis or bone and joint infections with a prosthetic material involved.

00:09:43 Michael Deaney

It's another thing that's worth familiarizing yourself a little bit with too, because the guidelines for endocarditis prophylaxis, both for patients undergoing high-risk dental procedures.

00:09:54 Michael Deaney

It's really high-risk dental procedures, very invasive, not just your average cavity filling, A.

00:10:00 Michael Deaney

And B, the high-risk criteria are pretty specific and would not include a lot of patients.

00:10:06 Michael Deaney

So it's usually worth a second look from a stewardship perspective.

00:10:12 Steve Small

Those are great tips, and it's a good chance to brush up on some dental aspects to stewardship.

00:10:20 Steve Small

We know that antibiotic allergies and many ones that are dubious can have negative impacts on patients.

00:10:26 Steve Small

Craig, how do you address questionable antibiotic allergies and why is this important?

00:10:30 Steve Small

And maybe, Stephen, you can give us your provider perspective on that and how you address that?

00:10:37 Craig Williams

Yeah, I'm going to say the huge thing here, and again, I have the luxury of practicing on the inpatient side where

00:10:42 Craig Williams

We have patients with us for, a day or a couple of days and folks that kind of help us in this area specifically.

00:10:47 Craig Williams

It's a more challenging on the outpatient side.

00:10:49 Craig Williams

And one of the things we can really do on the inpatient side is try to remove those unnecessary allergies so they're not recurring in the outpatient realm.

00:10:57 Craig Williams

The big thing here is penicillin allergy is by far the most common allergy listed.

00:11:01 Craig Williams

And we appreciate now many, many of those allergies, probably north of 80% are not actually true allergies.

00:11:08 Craig Williams

So the very first thing to do is just explore with the patient, what is this allergy?

00:11:12 Craig Williams

And there's a couple of nice algorithms out there to think about.

00:11:15 Craig Williams

Is this really something I need to be worried about?

00:11:17 Craig Williams

So what we classically worry about is the anaphylactic IgE mediated or something relatively immediate.

00:11:23 Craig Williams

So what we're looking for from the patient was, was there some severe reaction that occurred within several hours of you getting an antibiotic?

00:11:30 Craig Williams

And that could be a huge red flag for us.

00:11:33 Craig Williams

Something like that, if the patient says, I had a severe reaction and I was hospitalized, I was in the hospital and I got worse, that's not something we would challenge in the outpatient side and only cautiously on the inpatient side.

00:11:44 Craig Williams

But very often that first discussion with a patient opens up a beautiful can of worms you can explore where it's like, well, my mom told me I had this allergy when I was a kid and I've never actually had this antibiotic or I think I had some nausea from this like 10 years ago.

00:11:58 Craig Williams

So just having that conversation is fantastic with patients.

00:12:02 Craig Williams

And the reason to do this is because beta-lactams are really very good for much of what we want to treat.

00:12:07 Craig Williams

So we're trying to kind of use beta-lactams and spare other drug classes where we can.

00:12:12 Craig Williams

And for us on the inpatient side, getting it off that list so it's not on the outpatient side is something we can do for our outpatient colleagues.

00:12:22 Stephen Carek

Yeah, to piggyback off of Craig, 100% agree that this is a huge problem that we face and that significant, overwhelming majority of these patients that say they have an allergy to penicillin antibiotics and it tends to not be the case.

00:12:35 Stephen Carek

And so just in our practice, all we do is it's getting their history.

00:12:38 Stephen Carek

It's gauging, you know, is this a true allergy or is this a side effect or an intolerance you may have had from a certain antibiotic?

00:12:44 Stephen Carek

It's exploring, you know, the history of the story and then learning more about what the patient's experience, what this was.

00:12:50 Stephen Carek

There's a few options that we have in terms of, okay, when's the next step if we want to actually pursue your allergy testing or which case we can refer them to allergists and they can do skin testing, or even if we feel like it's a pretty low risk environment, prescribe the medicine and just have them take the first dose of the medicine in the clinic, assuming that we have all the necessary supplies and on the very off chance that there is an anaphylactic response, so we have epinephrine or the ability to triage and get the patient emergent care if they need it.

00:13:13 Stephen Carek

But those are potential options that we may have.

00:13:16 Stephen Carek

And sometimes it's just correcting and understanding their history and they say, hey, I've had a history, three to penicillin in the past, but I did take Augmentin once and actually did fine with it.

00:13:23 Stephen Carek

So I think I'll be fine with taking that antibiotic.

00:13:26 Stephen Carek

A lot of this just, there's momentum from previous prescribers that I think carries forward with some of these.

00:13:30 Stephen Carek

And sometimes we may not have the ability or the wherewithal to go in the EMR and change the leads and update some of these allergies.

00:13:37 Madeline King

Yeah, I'm glad you mentioned some of the challenges in the outpatient setting earlier and the skin testing.

00:13:43 Madeline King

We were able to establish a skin testing clinic under our infectious disease division at my institution after working with our allergists because

00:13:51 Madeline King

like you're saying, it can be really uncomfortable for other providers to want to prescribe beta-lactams or penicillins when they see that allergy in the chart.

00:14:00 Madeline King

And in our case, our allergists were overwhelmed with their patient population of other things to see.

00:14:06 Madeline King

So they were grateful that we wanted to take on penicillin skin testing and take some of that away from them.

00:14:13 Madeline King

And I know there's some literature about other clinics who have done similar things, but I think being able to actually de-label the patient, like you were saying, and take that out of their chart very confidently will help every other provider that accesses their chart, especially in these large health systems, feel confident in prescribing those antibiotics going forward.

00:14:35 Steve Small

Yeah, documentation is absolutely key, as comprehensive as you can.

00:14:39 Steve Small

Something I've been seeing recently is a lot of patients reporting that their family has a history of drug allergy, so that's why they report it.

00:14:46 Steve Small

And we know that drug allergies aren't really inherited that way.

00:14:49 Steve Small

So that info is so helpful.

00:14:52 Craig Williams

Yeah, put that in the EMR.

00:14:53 Craig Williams

Tell us that if that's what it is.

00:14:55 Craig Williams

Yeah, let us know.

00:14:58 Steve Small

And this is a great chance to spotlight our resource in investigating possible drug allergy or sensitivity.

00:15:04 Steve Small

It lists helpful questions to ask patients when updating allergy histories to ensure they're complete, and this info can be vital for helping optimize decisions around antimicrobials.

00:15:14 Steve Small

Stephen, what are best practices for using delayed prescribing strategies or watchful waiting approaches?

00:15:22 Stephen Carek

One practice I probably use the most is just dealing with upper respiratory type infections, sinus infections, patients coming in experiencing a few days of congestion or sinus pressure, just feeling crummy.

00:15:33 Stephen Carek

You know, that there's typically the patients that come in are demanding some sort of antibiotic because they feel that it's helped in the past, but you know, based on our assessment, we believe it's more probably some sort of viral etiology.

00:15:44 Stephen Carek

So typically these patients, for those common parts that I have is we can kind of come to a shared agreement that, okay, let's try two, three, 4 days of aggressive symptom management, let their body be able to fight off whatever this viral illness may be if that's the case, and then utilize either over-the-counter or even prescribed medicines to manage symptoms.

00:16:04 Stephen Carek

And then part of that visit too is we send an additional prescription for an antibiotic to treat some sort of bacterial rhinosinusitis, whether it's amoxicillin or doxycycline, but really prescribe strict instructions for the pharmacy not to fill it until a certain day that we agree upon with the patient.

00:16:20 Stephen Carek

So it does a few things.

00:16:21 Stephen Carek

Hopefully it allows the patient to clear whatever infection they may be having, but if truly they're having persistent symptoms, that may be a sign that they have some more complicated infection, and now they have to sort of take the initiative to go to the pharmacy again to pick up that prescription if they're still having those prolonged symptoms.

00:16:36 Stephen Carek

At least in my practice, that's probably the most common use of delayed antibiotic prescriptions.

00:16:42 Steve Small

Excellent.

00:16:43 Steve Small

And then, Michael, could you give us some tips to help clarify if something is the right drug and or dose for the right infection?

00:16:52 Steve Small

What can we do to help prescribers and pharmacists there?

00:16:58 Michael Deaney

Sure. It's a tough question because it really depends on what setting you're working in and how much information you have at your disposal, whether you can help clarify that information.

00:17:07 Michael Deaney

Certainly on the inpatient side, there's lots of resources, usually institutional protocols, multiple team members to consult with about the patient, as well as chart information

00:17:19 Michael Deaney

that gives you all that you need to know regarding patient's weight, their renal function, culture data.

00:17:25 Michael Deaney

You can make very in-depth decisions that way.

00:17:27 Michael Deaney

I think it's a little bit more difficult in the outpatient setting for sure.

00:17:30 Michael Deaney

So one of the things that I think is good to highlight here, something that outpatient pharmacists and providers can do to kind of help clarify this information when they don't have a wealth of info at their disposal.

00:17:41 Michael Deaney

is to really approach it from a patient counseling standpoint.

00:17:45 Michael Deaney

Ask the patient, you know, what did your provider say this was for?

00:17:47 Michael Deaney

Clarify with them direct from the source, what kind of infection do they have?

00:17:51 Michael Deaney

That can help you figure out if it is a drug disease mismatch or not, which is a potentially high yield intervention.

00:17:59 Michael Deaney

Ask where the infection is, if they're able to answer that.

00:18:02 Michael Deaney

Ask how severe are your symptoms now?

00:18:05 Michael Deaney

I think trying to gauge the severity of symptoms is helpful, especially for some of the outpatient infections that patients are prescribed antibiotics for, so things like dental pain, acute otitis media, strep throat, things like that.

00:18:20 Michael Deaney

While patients are sometimes symptomatic when they see their physicians, oftentimes if they're not having active symptoms at the time that they're presenting for their antimicrobial, they might not need that course anymore.

00:18:33 Michael Deaney

So that's another way that you can tell if it's being done for the right infection or not.

00:18:37 Michael Deaney

Otherwise, focusing your interventions really on clear mismatches.

00:18:41 Michael Deaney

So infection drug, bug drug, if you have that information, any kind of safety issues where it's clear that something is being underdosed or overdosed.

00:18:50 Michael Deaney

I think with duration, particularly in the outpatient, five days is common for most outpatient infections.

00:18:57 Michael Deaney

seven days for some more significant ones or inpatient infections.

00:19:01 Michael Deaney

Antibiotic courses that go on for longer than that are certainly not out of the question.

00:19:06 Michael Deaney

There's many cases where patients may need prolonged courses of antibiotics for various reasons, but they're usually special case scenarios.

00:19:13 Michael Deaney

And they're at least valid to flag for further investigation on your part as a clinician or for further intervention.

00:19:21 Michael Deaney

I think also something to just sort of flag when a prescription comes through is any kind of high-risk agents.

00:19:27 Michael Deaney

So seeing things like fluoroquinolones, clindamycin, that are either just very broad antibiotics or associated with a lot of adverse drug events, seeing if there's a reason that a more narrow antibiotic couldn't be chosen.

00:19:44 Steve Small
 Excellent.

00:19:45 Steve Small
 Those are great points to ask patients for sure.

00:19:48 Steve Small
 And with that, I'll turn over the mic to Sara.

00:19:54 Sara Klockars
 Thanks, Steve.

00:19:55 Sara Klockars
 I do want to jump back to Madeline quick and see if she has any additional thoughts on improving stewardship in community pharmacies.

00:20:04 Madeline King
 I think stewardship practices in community pharmacy settings are probably the most challenging because community pharmacists, especially in a lot of the big retail chains, have essentially no information on the patient because they can't access, you know, the hospital records, the clinic records.

00:20:22 Madeline King
 So I would love to say, you know, empower community pharmacists and retail pharmacists to be more involved, to call physicians, to call providers and clarify things.

00:20:32 Madeline King
 But that would really require complete overhaul of the structure of community and retail pharmacies to allow the pharmacist dedicated time to do this.

00:20:40 Madeline King
 I think in their current structure, that's really just not feasible.

00:20:44 Madeline King
 But, you know, going along those lines, I think point of care tests can be great.

00:20:49 Madeline King
 There are more and more companies coming out with rapid respiratory viral panels that can give results in 15 to 20 minutes.

00:20:58 Madeline King
 which we've talked about in some of our outpatient clinics in my health system, but those still require someone to be dedicated to taking a sample and monitoring the tests for 20 minutes until the results come back.

00:21:11 Madeline King
 Depending on state laws, pharmacists may or may not be able to administer those, interpret the results.

00:21:17 Madeline King
 And then what if you have a respiratory viral panel that comes back negative, meaning the patient might have a potential bacterial infection.

00:21:24 Madeline King
 And so then you have to send them to

00:21:26 Madeline King
 a clinic if you don't have someone who can prescribe on staff.

00:21:30 Madeline King
 So I think there are definitely some key areas where community pharmacies and community pharmacy staff can play a role.

00:21:36 Madeline King
 But I think the biggest limitation is the structure of retail pharmacies and having the time and resources to do that.

00:21:45 Sara Klockars
 Yes, thanks, Madeline.

00:21:46 Sara Klockars
 And this is a great chance to spotlight one of our updated continuing education courses, implementing rapid diagnostic testing, as more pharmacies are doing this.

00:21:56 Sara Klockars
 So search our available CEs by typing implementing or rapid in the search field of the CE portion of the website.

00:22:04 Sara Klockars
 And this CE is a thorough review of rapid diagnostic point of care tests, such as those that detect influenza, strep, COVID‑19, hepatitis C, and test and treat models that can be used in conjunction with these tests.

00:22:18 Sara Klockars
 And Craig, I see, did you want to chime in here?

00:22:23 Craig Williams
 Yeah, it is an issue in the community setting not having the data on the patient, but like the huge thing you have is the patient.

00:22:30 Craig Williams
 If you find out it's a urinary tract infection and you've got a prescription for 21 days of Bactrim in your hand, at the very least, we shouldn't be part of the ongoing problem.

00:22:38 Craig Williams
 So hopefully no one is saying,

00:22:40 Craig Williams
 take off the antibiotic until it's gone, because that is like 1990s advice that we're trying to get out of our curriculum.

00:22:46 Craig Williams
 So we're treating patients and symptoms, and if it seems inappropriately long, at least don't say take this until it's gone.

00:22:53 Craig Williams
 So we're making sure our graduates know what's the appropriate duration for urinary tract infection and community‑acquired pneumonia, and they feel empowered to say, if you're beyond day five or day 10 and you feel great, hold on to this.

00:23:04 Craig Williams
 Don't necessarily finish it, and let's follow up with your prescriber.

00:23:10 Sara Klockars
 Excellent.

00:23:11 Sara Klockars
 We have an audience comment and question that fits well here.

00:23:14 Sara Klockars
 The viewer is saying, I struggle with antibiotic durations and asking, are there rules of thumb or resources I should use to help with this?

00:23:23 Sara Klockars
 So Michael, do you have any go‑to resources that you can recommend for our listeners?

00:23:31 Michael Deaney
 Sure.

00:23:31 Michael Deaney
 I can tell you that locally what we did at Denver Health to address this issue

00:23:36 Michael Deaney
 We had something called a Take Five campaign that we publicized to our urgent cares, our ED, as well as our retail pharmacies and our integrated health system, kind of promoting the fact that five‑day durations are standard durations for many outpatient infections that are commonly treated.

00:23:56 Michael Deaney
 So acute otitis media, community‑acquired pneumonia, at least for now.

00:24:00 Michael Deaney
 New guidelines are advocating for potentially even shorter durations in mild cases, skin and soft tissue infections, potentially sinusitis, urinary tract infections, et cetera, and kind of encourage providers and pharmacists to say, you know, if not five days, ask yourself why and is there a reason?

00:24:18 Michael Deaney
 So certainly anything that your own institution is doing.

00:24:21 Michael Deaney
 A lot of institutions are now publicizing their protocols on an app called Firstline, which is publicly available, and different institutions from different states do that.

00:24:32 Michael Deaney
 So if you're curious what a certain institution might recommend for different common disease states, it might be worth a look.

00:24:38 Michael Deaney
 Other resources that you could consider, certainly the Sanford Guide, which is available both in print and on a mobile application that's really user‑friendly and easy to search.

00:24:48 Michael Deaney
 If your institution has a local antibiogram that's published, that can be helpful.

00:24:52 Michael Deaney
 Sometimes that's available in Firstline too, if you want to look at antibiogram data from nearby hospitals that serve different patient populations that might match the patient that you're interacting with.

00:25:04 Michael Deaney
 Some hospitals serve patients that are more immunocompromised, large academic medical centers.

00:25:09 Michael Deaney
 Some hospitals are more pediatric focused.

00:25:11 Michael Deaney
 Maybe those would be ones to look at for that.

00:25:14 Michael Deaney
 And then certainly there's tons of CE out there as well as guidelines through the IDSA for most common infections that are worth brushing up on, especially as new ones come out.

00:25:24 Michael Deaney
 Community‑acquired pneumonia recently had new guidelines published through the ATS this year that are worth looking at too that address durations of therapy for community‑acquired pneumonia.

00:25:35 Craig Williams
 Yeah, I'll say briefly, Sara, that my good rule of thumb is if you graduated from medical school more than five years ago, take whatever you were taught for duration and cut it in half.

00:25:46 Craig Williams
 So 7's a new 14 and 5's a new 10.

00:25:48 Craig Williams
 And if to Michael's point, you want to call 5 a new 14, that's generally fine, especially in the outpatient setting as well.

00:25:54 Craig Williams
 So we just historically have given too long of a duration.

00:25:57 Craig Williams
 So that's a good like operation framework.

00:26:00 Madeline King
 I would also put a plug in for anybody who's not aware, so Dr. Brad Spellberg had an article out several years ago called, I think, Shorter is Better, where he did kind of like a literature review of antibiotic courses durations.

00:26:15 Madeline King
 And he has a website that he updates, I think, pretty frequently.

00:26:19 Madeline King
 And what's nice about it is it lists the recommended durations for many different infectious diseases, strep throat, all kinds of things.

00:26:28 Madeline King
 And, the nice thing is that he lists the literature that supports the shorter durations in those things.

00:26:33 Madeline King
 And I find it a really nice, concise resource.

00:26:36 Madeline King
 And I use it a lot when I do teaching to like the medical students.

00:26:42 Sara Klockars
 These are all great resources.

00:26:43 Sara Klockars
 Thanks for sharing.

00:26:44 Sara Klockars
 I do want to briefly talk about Firstline that Michael mentioned.

00:26:48 Sara Klockars
 We've had a few audience questions about it.

00:26:50 Sara Klockars
 And if you aren't familiar with it, Firstline is a customizable app or website that some organizations are using.

00:26:58 Sara Klockars
 And you can add institution‑specific guidelines to help with the decision‑making at the point of care.

00:27:04 Sara Klockars
 So really, helping that antimicrobial stewardship effort.

00:27:09 Sara Klockars
 So it does sound like more and more institutions are using Firstline, so expect to hear more about this.

00:27:15 Sara Klockars
 And I also want to highlight this chart on our website titled Antibiotic Therapy, When are Shorter Courses Better?

00:27:22 Sara Klockars
 This also reviews the appropriate duration of antibiotic therapy along with other considerations.

00:27:28 Sara Klockars
 So you can print this out for the latest recommendations.

00:27:33 Sara Klockars
 And Madeline, we always get the question, how can technicians help?

00:27:38 Sara Klockars
 So what can technicians do to help improve stewardship?

00:27:45 Madeline King
 I think it really depends on obviously the in versus outpatient settings.

00:27:49 Madeline King
 Something that I've seen at our institution in the inpatient setting at least, when we document how long an antibiotic is approved for by our stewardship team.

00:27:59 Madeline King
 It shows up on the medication label.

00:28:01 Madeline King
 And our technicians are the ones that are preparing the medications, putting the label on, and those things.

00:28:07 Madeline King
 So, you know, they can really help the pharmacist out by noticing those dates, like the antibiotic is approved through today.

00:28:14 Madeline King
 They're going to need approval tomorrow, or maybe they need approval today, and kind of pointing that out before the medication gets sent to the floor, reminding the pharmacist or checking with the pharmacist that they noticed that date.

00:28:26 Madeline King
 In an outpatient setting, like with many other things, it's a lot more challenging.

00:28:30 Madeline King
 But for those technicians who are really interested and dedicated, giving them a little bit more education about durations, like, hey, if you see nitrofurantoin for 10 days or 20 days, just double check it with me because maybe that's not right, or point it out, things like that kind of small interventions that they can notice without necessarily having the knowledge of all the literature on treating different infections.

00:28:57 Steve Small
 And then this next question is interesting.

00:29:00 Steve Small
 Michael, maybe to ask you first, how do you address questionable prescriptions when you get them?

00:29:06 Steve Small
 How do you address it with prescribers without damaging relationships?

00:29:09 Steve Small
 I'm sure those discussions can get quite spicy.

00:29:12 Steve Small
 So how do you address that?

00:29:14 Steve Small
 And then also on the flip side, how do you address it with patients?

00:29:18 Steve Small
 I'd love to get your thoughts.

00:29:21 Michael Deaney
 Sure. So as I'm sure all of my co-presenters can attest, the conversations around antimicrobial stewardship and actually making the intervention easier said than done sometimes, and certainly more art than science.

00:29:36 Michael Deaney
 I think I would definitely encourage people that hope to make antimicrobial stewardship interventions that they really need to be sort of tailored by either the patient case or the person that you're speaking to.

00:29:48 Michael Deaney
 Some people prefer direct recommendations, very straightforward.

00:29:53 Michael Deaney
 Some people prefer to know the why behind what you're saying.

00:29:57 Michael Deaney
 And sometimes it's a little bit of art to try to figure out what each person appreciates and how to be most successful with them.

00:30:03 Michael Deaney
 I think the key thing in your approach is just when you're making the intervention, making sure you're just giving the other person the benefit of the doubt.

00:30:09 Michael Deaney
 I feel like that's the thing that's gotten you the farthest.

00:30:12 Michael Deaney
 You know, oftentimes pharmacists, whether they're inpatient or outpatient, they're not bedside typically and have a limited view of patients.

00:30:20 Michael Deaney
 You know, we get to know them really well from the chart.

00:30:22 Michael Deaney
 We certainly have a lot of information about their condition that way and the different factors, but we're not spending a lot of one-on-one time with patients often.

00:30:30 Michael Deaney
 and really seeing either the severity of their disease, particularly for high acuity patients in things like ICUs.

00:30:37 Michael Deaney
 So I think when you're approaching clinicians, making sure to give them that benefit of the doubt by asking open-ended questions, let them know why you're asking, making sure that you're coming at it from a patient advocate perspective, because that's truly what you're doing at the end of the day, is advocating for patients.

00:30:54 Michael Deaney
 If things go south, too, there's always a way to potentially escalate the situation to somebody else involved, like if you're speaking to a resident, if there's any way to talk to the fellow or anything like that.

00:31:05 Michael Deaney
 I'm a proponent of the idea that as long as there's not a major safety concern too, one stewardship intervention on one day isn't necessarily worth potentially ruining a relationship with a provider by pushing extra hard.

00:31:20 Michael Deaney
 Sometimes you may be the first person to deliver a new piece of evidence, for example, advocating for shorter durations.

00:31:27 Michael Deaney
 So while they may not alter their practice now, with repeated education and time, people often do come around, especially as you start to build rapport and trust with those people.

00:31:37 Michael Deaney
 Because we all have the same goal at the end of the day, and that's to help patients.

00:31:41 Michael Deaney
 I think that's important when talking to patients too.

00:31:44 Michael Deaney
 A lot of these same principles apply.

00:31:46 Michael Deaney
 Just kind of explaining why you're asking the questions you're asking and how you're doing it to advocate on their part, as opposed to interfere with any kind of care or act as any kind of antimicrobial police, particularly with antibiotic allergies.

00:32:02 Michael Deaney
 I feel like as an inpatient ID pharmacist, I've encountered patients that will occasionally, when you're interviewing them about their allergy, it can get sometimes defensive when you're either trying to challenge their allergy or try to relabel it as something like an intolerance, just due to potential distrust in the healthcare system.

00:32:22 Michael Deaney
 letting them know, for example, in this situation, how you could mitigate that would be telling them why you're doing this.

00:32:28 Michael Deaney
 You know, I want to make sure that if you have an allergy that precludes use of the antibiotic, that that's something that we really need to take into consideration.

00:32:36 Michael Deaney
 The reason for that is that oftentimes these antimicrobials like beta-lactams that they commonly have an allergy to are first line for a reason, partially because of safety and partially because of side effects, partially because it's narrow spectrum, but oftentimes because they're the best choice.

00:32:52 Michael Deaney
 So for example, in Staph aureus infections, methicillin susceptible Staph aureus infections, there's data to suggest that there is better mortality with cefazolin rather than vancomycin.

00:33:03 Michael Deaney
 And that's outside of any kind of safety issues that go alongside with vancomycin too.

00:33:08 Michael Deaney
 And then usually when you come at it from that approach, people are able to at least, while your intervention may not be successful that time, are able to kind of get on the same level with you and you're able to have a peer-to-peer conversation.

00:33:23 Stephen Carek
 I will say that I always greatly appreciate all the antibiotic recommendations that our pharmacists make, because these are hard choices to make at the bedside with patients.

00:33:30 Stephen Carek
 There's so many variables to consider.

00:33:31 Stephen Carek
 And I think just an overarching theme with this conversation is that the evolution of these recommendations has really sort of dramatically changed the paradigm that most clinicians were taught, right?

00:33:41 Stephen Carek
 Sort of like antibiotic decisions are not static.

00:33:44 Stephen Carek
 They're very dynamic.

00:33:45 Stephen Carek
 There's a lot of variables to consider.

00:33:47 Stephen Carek
 And oftentimes what happens in practice is it's just one of many, many decisions that you have to make in the care of a patient.

00:33:53 Stephen Carek
 One that we can get wrong or maybe not think through as comprehensively to say of our pharmacy colleagues may have the knowledge and insight too.

00:34:02 Stephen Carek
 So again, with the core element, we want to take good care, high quality care of the patients.

00:34:07 Stephen Carek
 Pharmacists bringing up these conversations with physicians.

00:34:09 Stephen Carek
 From my perspective, it does nothing but help strengthen the relationship because it allows us to make better, more informed decisions that can help take better care of our patients.

00:34:19 Craig Williams
 So I'll just piggyback on briefly.

00:34:21 Craig Williams
 we like to teach it.

00:34:22 Craig Williams
 If you really disagree with an antibiotic prescription for some reason, it's just a teaching learning opportunity.

00:34:27 Craig Williams
 And so often I learn things.

00:34:29 Craig Williams
 So if I call up Stephen and say, this seems like the wrong antibiotic or a different duration, he may know something about that patient or why he wrote that I don't know.

00:34:36 Craig Williams
 So we've all got different pieces of information and just, it's a teaching learning opportunity to get on the same page together.

00:34:44 Madeline King
 Yeah, I totally agree about making sure that the relationship between the pharmacist or whoever and the prescriber stays on a positive note.

00:34:53 Madeline King
 That's more important than in a single intervention in most cases.

00:34:57 Madeline King
 And I think reminding each other that we're on the same team and that team is to fight for the patient.

00:35:02 Madeline King
 I think it can be challenging in the outpatient setting.

00:35:05 Madeline King
 On the inpatient setting, a lot of times you can catch something in real time as it's happening.

00:35:10 Madeline King
 But in the outpatient setting, what I've noticed, and I think we probably all would recognize, is that there's no one that's really catching these prescriptions in real time to call and say, hey, I see that you ordered this.

00:35:22 Madeline King
 I would do this instead. Or did you mean to do this?

00:35:25 Madeline King
 Did you want to try something else instead? Et cetera.

00:35:28 Madeline King
 So I think what I have found myself doing is I just have the opportunity to go out to our primary care, urgent care and family medicine sites and meet with them to provide education.

00:35:39 Madeline King
 Sometimes it's updated literature, like, hey, did you know the UTI guidelines were updated?

00:35:43 Madeline King
 Is there anything that we can add?

00:35:45 Madeline King
 Because we also use Firstline at my institution.

00:35:47 Madeline King
 Is there anything that we can add to Firstline from an outpatient infectious disease standpoint that would really help you.

00:35:54 Madeline King
 I need guidance.

00:35:55 Madeline King
 And then I always take CDC resources, like the patient education resources on delayed prescribing or watchful waiting or symptom relief.

00:36:04 Madeline King
 I take those every time I go and meet with providers so they can give them out to their patients.

00:36:08 Madeline King
 So not only are we trying to help the providers, but we're trying to help them help the patients understand when they're not being offered an antibiotic prescription, why that is.

00:36:18 Madeline King
 So I think reminding everyone that we're on the same team, but also providing some education as we go along can be really helpful and go a long way.

00:36:30 Narrator
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