PharmDs ‘have done more with less’ during COVID-19
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Infectious disease pharmacists provide a broad spectrum of services for patients, but like other health care professionals, they have faced changes since the emergence of COVID-19, and their role has expanded.
“Infectious disease PharmDs can bring so much to the table, both in the inpatient and outpatient settings,” Amy Hirsch Shumaker, PharmD, BCPS, AAHIVP, clinical pharmacy specialist in infectious disease at the VA Northeast Ohio Healthcare System and senior clinical instructor at Case Western Reserve University School of Medicine, told Healio | Infectious Disease News.
Source: Patrick Luce
For example, ID pharmacists are the medication experts on multidisciplinary HIV care teams, providing recommendations on the management of complex drug interactions and helping construct regimens for patients with HIV drug resistance. They round with inpatient ID teams, providing on-the-spot advice and recommendations for complex cases.
“I have to also mention the role PharmDs have played in community pharmacies since the start of the pandemic, providing testing, vaccination and, most recently, the provision of antiviral medications to patients with COVID-19,” Shumaker said. “They have done more with less, and they deserve a lot of credit for the work.”
We spoke with Shumaker and other PharmDs about the role pharmacists, including ID pharmacists, play in patient care and how that role has evolved in the pandemic.
Clinical care
Pharmacists “bring a lot to the table to help with clinical care,” including expertise in antimicrobials, said Infectious Disease News Editorial Board Member Jeff Brock, PharmD, MBA, BCPS AQ-ID.
“We can screen for and manage drug-drug interactions, optimize dosing and help avoid unnecessary use of antimicrobial agents,” said Brock, an ID pharmacy specialist at MercyOne Medical Center in Des Moines, Iowa.
In the hospital, ID pharmacists can monitor rapid diagnostic test results to streamline antibiotic therapy, clarify medication or penicillin allergies and manage certain infections and blood culture results.
Many studies have shown that PharmD involvement greatly benefits patient care in ID. One study of more than 120 VA hospitals that was published in Clinical Infectious Diseases in 2020 demonstrated that patients in hospitals with an ID pharmacist or specialist on staff received fewer antibiotics overall, including fewer broad-spectrum antibiotics, and were more likely to receive narrow-spectrum antibiotics.
“Usually, the person who’s doing the day-to-day management — I don’t want to say the scut work, but the boots on the ground stuff — is an ID pharmacist, ” said Jason C. Gallagher, PharmD, FCCP, FIDP, FIDSA, BCPS, clinical professor at the Temple University School of Pharmacy.
A study published earlier this year assessed which pharmacists are making antimicrobial stewardship changes and implementing antimicrobial stewardship programs. The study showed that, among 245 pharmacists surveyed — 20% of whom had completed an ID specialty residency — 135 had formal antimicrobial stewardship program responsibilities. Of these, one-third had no formal training or certification in ID or antimicrobial stewardship. The pharmacists with formal stewardship responsibilities were more likely than pharmacists without formal responsibilities to perform antibiotic guideline development (P < .001), antibiotic-related education (P = .002) and direct notification of rapid diagnostic results (P = .018).
The authors said pharmacists with these responsibilities “should have adequate training to meet more advanced metrics, and more pharmacists without formal antimicrobial stewardship program responsibilities should be included in basic interventions.”
“With so many emerging, multidrug-resistant pathogens as well as antibiotic overuse during COVID, we need more pharmacists to be involved in this work,” Shumaker said.
She said other ways pharmacists can incorporate antimicrobial stewardship into their daily workflow include ensuring that durations of therapy for community-acquired pneumonia are capped at 5 days when appropriate. Specifically in terms of the pandemic, they should ensure that patients with COVID-19 are not prescribed antibiotics like azithromycin or doxycycline when their symptoms could be explained by SARS-CoV-2 infection.
“By coordinating stewardship efforts among many health care workers, pharmacists can lead the stewardship response,” said Kerry LaPlante, PharmD, FCCP, FIDSA, FIDP, department chair and professor of pharmacy at the University of Rhode Island College of Pharmacy.
In terms of HIV, a small pilot study demonstrated that a pharmacist-led PrEP program is a feasible way to increase uptake. Overall, participants in the study completed a total of 139 visits with pharmacists from a university-based HIV clinic, a community pharmacy and two community-based clinics. At 3 months, the participant retention rate was 73%. This declined to 58% at 6 months, 43% at 9 months and 28% at 12 months.
"Although disappointing, these retention rates are similar to retention rates seen in other real-world PrEP implementation studies," the authors wrote.
Of the participants who completed a patient satisfaction questionnaire at the end of the study, 100% said they would recommend the program, and pharmacists reported feeling comfortable conducting point-of-care testing. Importantly, there were no seroconversions among participants.
Another study evaluated pharmacists' role as part of a multidisciplinary team in hepatitis C virus treatment among patients with HIV/HCV coinfection. The study showed that for 135 patients who initiated treatment during the study, clinical pharmacists completed 150 prior authorizations, counseled on HCV medication adherence in 79.2% of patients, conducted HCV drug-drug interaction counseling and screening in 54.2%, and monitored HCV medication adverse events in 54.2%. They found that the pharmacist counseled patients on HCV treatment outcomes and risk of reinfection 53.1% of the time, ordered laboratory tests 44.8% of the time, and reported and interpreted laboratory values 44.8% of the time.
Among 59 patients with results available at 12 months, 94.9% achieved SVR.
“This cure rate is similar to real-world settings and clinical trials focused on this population,” the authors wrote.
‘All-consuming’ task
Many health care workers have had to take on additional responsibilities during the COVID-19 pandemic. Pharmacists had to adapt quickly.
“Community pharmacists are the most accessible health care provider, so millions of people have turned to their local pharmacists to get vaccinated and continue to return to their community pharmacist to stay up to date with booster doses,” LaPlante said.
Pharmacists also played a key role when COVID-19 vaccines were authorized in the United States by preparing vaccines, which “really helped accelerate the rollout of the COVID-19 vaccines, helping to keep patients alive and out of the hospital,” Shumaker said.
“It actually was one of the proudest moments I’ve had working at Temple. I volunteered to give vaccines,” Gallagher said.
Their roles have expanded even further to include a major role in treatments for COVID-19.
“Inpatient pharmacists have been essential at keeping prescribers up to date on the new monoclonal antibody treatment guidelines and ensuring that the most recent treatment guidelines are followed,” she said.
In July, the FDA amended its emergency use authorization for Paxlovid to allow for state-licensed pharmacists to prescribe the antiviral, although with some limitations.
“Pharmacists are in the best position to understand and appreciate the complex drug interactions that can be associated these antiviral medications, so to me, it just makes sense to have them involved in COVID treatment,” Shumaker said.
Keeping up with new research is something that pharmacists have had to do to provide the best care for patients, LaPlante said. This has gotten more difficult since the COVID-19 pandemic began. She said PharmDs find themselves reading articles late into the evenings so they can provide the latest treatment advice.
“I would use the analogy that it is like drinking water from a fire hose,” Shumaker said.
Sources: 1. Livorsi, et al. 2. Mahoney, et al. 3. LaPlante, Shumaker.
She is part of the Infectious Diseases Society of America guideline panel that reviews new literature monthly to identify studies that may alter clinical recommendations.
Gallagher said keeping up with the latest data became “all-consuming” while working on the IDSA guidelines for the treatment and management of COVID-19. He used the same analogy of drinking water from a fire hose.
“At times I seemed to be drowning in papers that needed to be read,” Brock said. “There’s just not enough time for practicing clinicians to sort through them all to find the clinically important studies.”
Thankfully, Shumaker said that this has gotten much easier, but in the early days, PharmDs were scouring the web, communicating with colleagues and translating randomized controlled trials in various languages to help guide early recommendations when evidence was “very scant.”
Brock said using social media — particularly Twitter — and listening to podcasts by virology experts also has been helpful.
“Finding ways to keep up to date efficiently is key,” he said.
Adding to the difficulty of keeping current was the wait for peer-reviewed data. Often, pharmacists and other health care professionals have relied on these data to stay up to date. However, COVID-19 presented a challenge because the situation sometimes evolved too quickly to wait.
“Ideally, we would love to have all of our recommendations informed from studies that have been peer reviewed; however, given the pace of the pandemic and need for timely guidance to inform front-line clinicians, we have used preprints at times to help us derive the evidence and inform our recommendations,” Shumaker said.
Early on, pharmacists had to base decisions on preprints “due to the urgency of the situation,” LaPlante said. Brock agreed that preprints were crucial to keep up with the quick pace.
“Preprints offered a quick way to distribute scientific information when we were desperate for improved treatments for these patients,” he explained. “Now that we have some treatment options, the rapid adoption of preprint information is less important.”
‘All hands on deck’
Responding to COVID-19 has taken a team effort.
“We developed a multidisciplinary committee when planning for the initial arrival of the COVID-19 vaccines,” Brock explained. “This committee evaluated all aspects of the vaccine planning, ranging from ordering, handling, storage and distribution.”
Early on, the committee also had to take into consideration priority groups when supplies were limited, and then planned mass vaccination clinics when vaccine access was expanded to the general public.
“As time has gone on, pharmacy has handled most of the planning for the different preparations and formulations of the vaccines, such as the new formulations that are not required to be stored in ultracold freezers, and the pediatric formulations,” Brock said, adding the pharmacy staff also handled communications to staff as different vaccines became available.
Not only did pharmacists have to know and understand the ins and outs of these vaccines, they also had to administer them.
“I would bet solid money that pharmacists have given most vaccinations for COVID,” Gallagher said. “Pharmacies are one of the things that didn’t shut down when we first locked down. Pharmacists had to be at work and had to be delivering medications and eventually that move toward vaccinating and toward, most recently, therapeutics as well.”
A commentary published in Antimicrobial Stewardship & Healthcare Epidemiology outlined how pharmacists’ “accessibility and trustworthiness” have been paramount throughout the pandemic. Of the 559 million COVID-19 vaccine doses administered at the time of the paper, more than 234 million (42%) were administered in pharmacies, the authors said.
“Given discrepancies in national vaccination rates with lower uptake in rural and minoritized communities, pharmacists have proven instrumental in decreasing inequities through innovative practices and greater accessibility,” the authors wrote.
Shumaker said the pharmacist’s job in the pandemic is not yet done and likely will not be for some time.
“At the outset there was an all-hands-on-deck approach, with providers of all types volunteering their time to make mass vaccination clinics a success,” she said. “As we continue into this multiyear pandemic, there has been an evolution of approaches as we have tried to regain normalcy in our workflow, thus building more dedicated teams to support vaccination efforts.”
She said both logistical and clinical partnerships are needed to make these vaccination clinics accessible and effective.
“As we have seen, many of the public are tired of the pandemic, and we now need people in those local teams who are able to effectively communicate with the public they serve about the benefits of vaccination as new, potentially more dangerous variants emerge,” she said.
- References:
- Coronavirus (COVID-19) Update: FDA authorizes pharmacists to prescribe Paxlovid with certain limitations. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pharmacists-prescribe-paxlovid-certain-limitations. Published July 6, 2022. Accessed July 20, 2022.
- Dionne B, et al. Antimicrobial Steward Healthcare Epidemiol. 2022;doi:10.1017/ash.2021.245.
- Havens JP, et al. Open Forum Infect Dis. 2019;doi:10.1093/ofid/ofz365.
- Livorsi DJ, et al. Clin Infect Dis. 2020;doi:10.1093/cid/ciaa388.
- Mahoney MV, et al. Antimicrobial Steward Healthcare Epidemiol. 2022;doi:10.1017/ash.2022.248.
- Olea A, et al. Integr Pharm Res Pract. 2018; doi:10.2147/IPRP.S169282
- For more Information:
- Jeff Brock, PharmD, MBA, BCPS AQ-ID, can be reached at jeff.brock@commonspirit.org.
- Jason C. Gallagher, PharmD, FCCP, FIDP, FIDSA, BCPS, can be reached at jason.gallagher@temple.edu.
- Kerry LaPlante, PharmD, FCCP, FIDSA, FIDP, can be reached at kerrylaplante@uri.edu.
- Amy Hirsch Shumaker, PharmD, BCPS, AAHIVP, can be reached at Amy.Hirsch@va.gov.
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