R.Ph.s vital in treating tough hospital infections

Drug-resistant infections remain a major concern for most hospitals. In large tertiary care centers, teams of infectious disease physicians and health-system pharmacists work to manage potentially life-threatening drug-resistant infections.

Howard Belzberg, M.D., director of critical care services at University of Southern California Medical Center in Los Angeles, said that pharmacists are an integral part of the healthcare delivery team and they bring an expertise that nobody else has in the management of infectious diseases. "The pharmacist is the most knowledgeable in terms of the relative costs of various agents too," he said.

While pharmacists can't look at every single infection or antibiotic therapy, they can publish and promote empiric guidelines throughout the hospital system. "When you get a culture back and the patient has a specific organism, then you would modify the therapy to match the culture, instead of using broad-spectrum agents," said Fossaceca.

Experts assert that infectious disease is the weak link in medical school training and that R.Ph.s can play a vital role in the education process. "It's an opportunity for pharmacists to educate the physician and medical students in choosing appropriate therapy and proper dosing and teaching kinetics," said Fossaceca.

For example, in the case of vancomycin resistance, a common problem in intensive care units, doctors work in conjunction with pharmacists in developing a dosing regimen customized to fit a specific patient's needs. However, the pharmacy department has to be willing to "put itself out there," noted Fossaceca. "We are a valuable part of the healthcare team and we have to be able to say to physicians that this is what we can offer you."

Data from numerous studies indicate that when R.Ph.s are involved in guiding therapies, dosing is more accurate, excessive and inappropriate dosing is diminished, and overall patient outcomes are improved.

Pharmacists can be a valuable resource in guiding physician decisions. For example, regarding the appropriate duration of therapy, in some cases, antibiotics that should be used for seven days are used for weeks. Doctors often overload patients with several drugs when monotherapy is appropriate, Fossaceca said.

In many cases, doctors avoid prescribing first-line drugs and in doing so they go select a broad-spectrum antibiotic or an overly expensive agent that should be reserved for patients in specific instances. As a result of the overutilization of certain drug classes, many hospitals are starting to see the development of resistance and the significant emergence of Clostridium difficile, a bacterial infection from using inappropriate drug therapy that causes intractable diarrhea and vancomycin-resistant enterococcal infections.

George Sakoulas, M.D., assistant professor of medicine in the division of infectious diseases at New York Medical College, said that there is a perception among physicians that antibiotics are benign and that starting an antibiotic can't hurt. "Many physicians have adopted a strategy of broad antibiotic coverage just in case a patient has an infection, when the patient clearly has other reasons to be sick," he said. "Some people have taken this 'it can't hurt approach' a little bit too far. Now the pendulum has swung in the other direction, and many physicians are starting to realize that maybe antibiotics can hurt by increasing resistance that makes subsequent infections harder to treat."