Infectious Diseases with Dr. Jarod Nagel

Posted by Patrick at Saturday, April 05, 2014

Managing antibiotic therapy is a core competency for the inpatient pharmacist and I am very grateful to have had the opportunity to spend five weeks honing my skills under the guidance of Dr. Jarod Nagel.

The rotation was split into two halves. For the first half, I joined the infectious disease consultation team. Myself, as well as one of the PGY2 residents, spent the mornings on topic discussions and examining patient charts. At 1:15 pm, we joined “micro-rounds” for a 15 minute microbiology slide show put together for the medical students on a topic relevant to recent patient cases (malaria, Chagas disease, and other tropical maladies were common during my time there). We then spent the afternoons rounding with the infectious diseases consult team, making recommendations when there were pharmacy relevant problems. Most of our recommendations were related to medication dosing and potential drug interactions. Working with the consult team was an excellent way to learn the nuts and bolts of managing complex antibiotic regimens. In school, we learned about the “big gun” antibiotics (as Dr. Carver calls them), but directed most of our energy towards the management of the more common antibiotics that pharmacists see much more regularly in practice. On the consult service, I had the opportunity to grapple with decisions regarding the tradeoffs of linezolid versus daptomycin versus tigecycline for various vancomycin resistant enterococcus. I also became very familiar with the side effect profiles of these agents and had the chance to participate in the management of various adverse events. As a result, I feel that my drug monitoring skills reached a new level over these five weeks.

After my time on the consult service ended, I moved on to the stewardship part of the rotation. I had a much expanded patient list, but was evaluating them on somewhat narrower criteria. The “list” was a collection of patients newly started on a list of restricted antibiotics (examples include daptomycin, meropenem, linezolid, collistin, and voriconazole). My role was to evaluate each patient and make recommendations as to whether the “restricted” antibiotic was appropriate. The hospital has particular criteria and I would read each patient’s case and make a judgment as to whether they either a). fit the criteria as written, or b). were such an unusual case that the therapy was appropriate despite not quite fitting the written criteria exactly, or c). the therapy was inappropriate. In the case of inappropriate therapy, I would (after conferring with my preceptor) make recommendations to the pharmacist directly covering that service to have a discussion with the primary team regarding a timeline for discontinuation.

As the decades progress, our arsenal of effective antibiotic agents becomes more limited by the changing patterns of antibiotic resistance. It is the job of the stewardship pharmacist to understand these trends in a quantitative way and to respond in a dynamic fashion. In addition to the active management of restricted antibiotic agents, the stewardship team is responsibility for the development of a large share of the hospital’s policies and procedures regarding appropriate antimicrobial use. They work with the physician stewardship team and the P&T committee to answer questions such as: For which patient populations will we sanction the use of fidaxomicin in place of vancomycin for C. Difficle infections? My primary project was in this sort of policy development. My role was to evaluate the recent literature regarding the use of probiotics for C. Difficile prevention. This type of project has traditionally been one of my strong suits, but as I delved deeper, it turned into something of a mess. It turned out that the question I had sought to answer, “Are probiotics save and effective for the prevention of C. Difficile infections?” was both too broad and too narrow. The necessary questions, for a hospital to actually produce a policy and make a decision required an evaluation of which probiotic and an evaluation of safe and effective in which patient populations. As for a summary of what I found, here is a one-liner: Many small, relatively low quality studies in high risk populations show a benefit to probiotic therapy; the one large, randomized controlled trial in a relatively low risk population showed no benefit. Making decisions based on this sort of conflicting data may be the core intellectual challenge of the job.