Stewardship Across the Care Continuum: Antimicrobial Use in Ambulatory Care

Briefly describe your daily role as a clinical pharmacist.

I spend my time covering both inpatient and ambulatory settings on a weekly basis. While inpatient I cover inpatient staffing and internal medicine based clinical coverage. I also spend time each week in our kidney transplant and anticoagulation clinics. My major passion is ambulatory care, but I am a passionate antimicrobial steward in both inpatient and ambulatory settings!

What are some ways your team optimizes antibiotic use?

There are many ways that my colleagues and I optimize antibiotic use. One of the simplest ways is to verify antibiotic allergies, including penicillin allergies. While clarifying allergy details, it is important to take the time to educate patients around why it is so important to have accurate allergy documentation. Additionally, working in the kidney transplant clinic we see lots of urine cultures, which provides a great opportunity to focus on avoiding antibiotics to treat asymptomatic bacteriuria.  When antibiotics are appropriate, we work to follow both cultures and guideline recommendations for solid organ transplant patients to choose the right drug for the right bug and appropriate treatment duration. Finally, another unique opportunity for optimizing antibiotic use is the collaboration in managing prophylactic antibiotics for stent removal after kidney transplant. Pharmacists follow new kidney transplant patients' urine cultures post-transplant and any cultures prior to transplant to aid in developing treatment plans for antimicrobials and/or antifungals to be given prior to stent removal. Pharmacists work with nurse coordinators to send prescriptions and consult the antimicrobial stewardship team or transplant nephrologists as needed.

What are the most important areas of focus for antimicrobial stewardship in the ambulatory care setting?

Both education and audit and feedback are important areas of focus.  However, it is important to not tackle too many interventions at once. A large number of issues can first be addressed with broad education. For specific interventions, prioritizing high needs for a specific clinic such as fluoroquinolone prescribing for UTI or antibiotics for viral sinusitis might be helpful. Initial success may be increased by starting with a disease state that is less controversial and has clear cut guidelines on when to prescribe and what antimicrobials are recommended or not recommended. Interventions can be strengthened by tying both local antibiograms and prescribing recommendations to national guideline recommendations.

What does "Being Antibiotics Aware" mean to you?

It means using the right drug for the right bug for an appropriate duration. As antibiotic stewards we can help educate colleagues and patients about each of these!

What is one pearl you have for all pharmacists to help them be antibiotic stewards?

Take opportunities to educate, whether the education is for patients, colleagues, family or friends! Taking time to discuss and educate on even seemingly minor issues can make a big difference and have a ripple effect.

Kristen Johnson, PharmD, BCPS

Clinical Pharmacist, Inpatient and Ambulatory Care 

Mercy Health Saint Mary's, Grand Rapids, MI