CEimpact Podcast

Antibiotic Stewardship Strategies for Pharmacists

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Antibiotic resistance is a growing global crisis, and pharmacists are on the frontlines of combating this threat through effective stewardship practices. This episode explores the latest updates in antimicrobial stewardship and shares actionable strategies to combat resistance and optimize antibiotic use. Tune in to strengthen your role as a steward of antibiotic efficacy and help preserve these life-saving medications for future generations.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Geoff Wall, PharmD, FCCP, BCPS
Professor of Pharmacy Practice
Iowa Methodist Medical Center

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Explain the impact of antibiotic resistance on public health and the role of antimicrobial stewardship in addressing this crisis.
2. Identify evidence-based strategies pharmacists can implement to optimize antibiotic use and combat resistance in their practice settings.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-057-H01-P
Initial release date: 3/3/2025
Expiration date: 3/3/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and as always, I'm excited about our conversation today. Antibiotic resistance continues to dominate headlines as new data highlights its growing threat to global health. In this episode, we'll discuss the latest updates in antimicrobial stewardship, recent advancements in combating resistance and how pharmacists can stay at the forefront of preserving the effectiveness of these critical therapies. It's so great to have Jeff Wall with us as our guest expert for today's episode. Welcome, jeff, thank you. Most of you, if you are longtime listeners of Game Changers, jeff is no new person for you. He has been a mainstay on the podcast for several years and we're so excited to have Jeff back with us today. But just in case we do have some new listeners, jeff, go ahead and tell us a little bit about yourself, maybe your practice side, and things you're passionate about.

Speaker 2:

Yeah, yeah, no, we were lucky enough that I was actually one of the first people on board with the podcast, so, yeah, it's hard to believe it's been four or five years now.

Speaker 2:

So this is our sixth season, so yeah, so yeah, jeff Wall, I'm a professor of pharmacy practice at Drake University in Des Moines, iowa. I'm also internal medicine clinical pharmacist at Iowa Methodist Medical Center, also in Des Moines, and I'm also director of the Drake Drug Information Center as well. So kind of wear a lot of hats, but yeah, my practice is mostly internal medicine and critical care at Methodist Hospital, which is a large community-based tertiary care center teaching hospital, and I've been at this a long time and still love what I do and love seeing different things and stuff. So yeah, that's it. And since the two pillars of internal medicine are largely considered to be cardiology and infectious diseases, I deal with with ID stuff pretty much every day.

Speaker 1:

Yeah, yeah, awesome. Well, and again, as I mentioned, jeff is not just an expert in this, this particular topic. He is an expert in several topics, given his background and critical care. So we greatly appreciate you taking your time out this morning to join us. So all right, so I love to just jump right in, so let so thank you. All right, so I love to just jump right in, so let's go ahead and jump in. So I want to kind of talk a little bit about just to kind of I always like to bring foundational level for the listeners. So let's just briefly talk about antibiotic resistance in general. What, what really is it? What's the cause of it, what's the impact of it? So I'll give you kind of the floor to touch on that for a little bit. Sure.

Speaker 2:

Well, I mean, you know, I think everybody has kind of an operational definition of antibiotic resistance where standard antibiotics that have long worked against and reached clinical cure of an infection just don't seem to do that anymore.

Speaker 1:

And it's not a new phenomenon.

Speaker 2:

When I teach bugs and drugs to my students, I often mention to them that you know penicillin came out you know, plain old pen G came out in the 1950s and when it first came out on the market it killed everything. You know. I mean it was, it was this, you know, incredibly powerful tool.

Speaker 2:

You know, and you know if you read medical literature of that era if you read, you know, the New England Journal of Medicine and stuff in the 1950s, they're like era. If you read, you know, the new england journal of medicine and stuff in the 1950s, they're like you know, is there anything penicillin doesn't work against? This is incredible, you know well. Of course, you know very rapidly, uh, we started to realize that. You know. Uh, the bugs always win. As a joke is a phrase I always use and you know, eventually, uh, you know evolutionarily uh, bugs will always find a way to become resistant to any antibiotic you throw at them. So you know, when penicillin was a mainstay for almost every infection in the 1950s and early 1960s.

Speaker 2:

Here in the 21st century, we, you know for the pharmacist in the audience, when's the last time you filled a prescription for plain old penicillin BK, I mean, we just don't use it anymore because of the resistance.

Speaker 2:

And so you know, the development of antibiotics in the last 80 years has really tried for us to kind of stay one step ahead of resistance, and until about 2000 I think we had done a pretty good job of that. But in the 1990s and 2000 we started to see the rapid increase of resistance, uh, particularly to gram-negative organisms, uh, like e coli and and klebsiella and stuff like that, uh, where, uh, and it's very regional. You know, if you're, if you're, certain regions, you have terrible resistance. If you're in other areas, you have no resistance. So it really is kind of a regional thing. But that has now led to, you know, uh, entire groups of organisms which are resistant to vast swaths of of antibacterials, and so we're forced either to have antibiotic failure which of course isn't, or to use very, very expensive antibiotics. And it's important to remember that the pipeline for antibiotics is not inexhaustible.

Speaker 2:

We've run out of kind of low-hanging fruit to attack to come up with new antibiotics and, frankly, there's no financial incentive for drug companies to come up with new antibiotics. I mean, if you're the head of R&D of a major drug company, what would you rather spend your?

Speaker 2:

money on, you know, another drug for hyperlipidemia that people are going to take for the rest of their life, or an antibiotic that hardly anybody's going to take, and when they do take it it's for 10 days, you know, and so there's very little financial incentive for drug companies to do innovation in this area.

Speaker 2:

And that's worth noting, and so you know, antimicrobial resistance is a huge global health threat. It's responsible for about 1 million deaths globally a year and that's not, you know, in our world. In the United States probably a little bit less than that. But I mean, now we're talking mostly about, you know, super drug resistant tuberculosis and stuff like that, which is now very common in other parts of the world. It's a huge economic impact and it's estimated that you know that costs of antimicrobial resistance could lead into the trillions of dollars worldwide, you know, by the end of 2050. So, you know, this is just. It's a very expensive problem. It's a problem that's going to lead to deaths, it's a problem that's going to lead to other issues.

Speaker 1:

So it's just, you know, it's a big it's a big problem yeah, it's definitely a big issue.

Speaker 1:

I mean that number, the, that that number is staggering to me, the million deaths a year. Like I I would have. I would have never come close to guessing that number if you'd said how many do you think die because of that? So wow, um. So one thing I'd like to also point out is sometimes therapies and guidelines change based on the new data we have, you know, regarding antibiotic resistance or anything like that. One of recent was H pylori treatment. Can you speak on that just briefly?

Speaker 2:

So H pylori is you know as it is you is, you know, I mean you could write an entire book. I wish somebody would you know about hb, because remember that this was a bug that uh was discovered in the 1980s by, uh, the australian researcher barry marshall. Um, um, and it's kind of a, it's almost kind of an apocryphal story of how, you know, he, you know, left some stomach tissue, went on vacation, came back there was a whole bunch of bugs on it. He thought it was a contaminant but he kept growing it, so you know, and he tried to convince people that that was the cause of peptic ulcers. No one believed him, so he drank a bottle of H pylori and gave himself an ulcer and then figured out the antibiotics to treat it. I mean, you know, again, I've never heard that story. That's fascinating. Yeah, it's almost, it's almost an apocryphal story, but it's true. And he actually won the noble prize for it.

Speaker 2:

Wow, um, you know so, so you know, but the problem with h pylori is that it is a hard bug to kill, um, which makes sense. It lives in your stomach, which has a ph of three, right. So I mean, you know it would eat away my skin. You know, because you know, you're essentially got one normal hydrochloric acid in your stomach. So I mean it would essentially burn my skin and there it's able to thrive in this low oxygen, high acid environment, and so because of that, you need multiple antibiotics to eradicate it, and the problem with doing doing looking up the research of how to how to treat H pylori becomes very dicey, because the global resistance rates are unbelievably different from one country to another. Some countries have had very bad resistance issues for decades, whereas others have not, and the United States, fortunately, up until about four or five years ago, had not no-transcript, the amoxicillin-based regimen that I'm sure we've all filled a million times, we have memorized, and all that stuff just wasn't going gonna work in a significant minority of patients. And so in the new set of guidelines that came out for the American College of Gastroenterology, they said sorry, it's time to go to a bismuth-based regimen, and so that is now the recommended regimen, which unfortunately for patients, is a real pain, right, because you have to take the medication four times a day. Nobody's going to remember to take a medication correctly four times a day, and it's, you know, four, four drugs and it's a real pain.

Speaker 2:

And um, at the di center we've certainly run into issues from our physicians who are like you know, you know, okay, I heard we can't use amoxicillin based regimens anymore. Like nope, you know okay. Well, you know, my patient is, you know they can't take, you know, uh uh, metronidazole, or can't. You know it can't take tetracycline. Now what do I do? You know, and you know, it's multiplied the difficulty of treating h pylori significantly, and it goes beyond just curing ulcers. I mean, obviously that's a big thing, but remember that h pylori is also a big player in certain types of gastric cancer. So I mean, you know, once you've detected it, you pretty much have to treat it.

Speaker 1:

You got it right. Yeah, you gotta get rid of it, yeah, yeah, yeah. I mean I am coming up on a milestone anniversary this year 20 years from graduating from pharmacy school, and I remember the original pack. I won't call the name, the brand name of it, but I remember the original pack that was used back in the day for H pylori Absolutely. So it's interesting to see how it was still kind of the mainstay until just recently.

Speaker 2:

So that's kind of wild. No, I mean we've certainly been lucky, I think. But I think infectious disease experts knew that sooner or later it was coming.

Speaker 1:

Yeah for sure. Well, let's kind of roll into again. That was kind of the impetus for the discussion for today was to kind of let's bring focus to antibiotic resistance and stewardship and whatnot. So let's kind of segue into the role of antimicrobial stewardship. But first let's define what that means. What is stewardship and what are kind of the overarching goals for?

Speaker 2:

that I mean the Infectious Disease Society of America has an official definition, but I think if you talk to most ID practitioners, id pharmacists, they'll tell you that really, stewardship is basically making sure that we use, you know, the right antibiotic for the right length of time for the right patient. You know that it minimizes cost, that minimizes resistance and that minimizes side effects. Right, and you can practice and I think most, I think a lot of pharmacists do practice stewardship at the patient level right. You know, okay, well, you know, you know, just today on rounds I had a patient who was on piperacillin-tazobactam for something that they absolutely did not need that powerful of an antibiotic for so we were able to deescalate to cetraxone.

Speaker 2:

So that's a patient level, simple, that I suspect pharmacists do every day, right.

Speaker 2:

But you can also practice stewardship initiatives at the population level or at the system level, and that's, I think, where a lot of ID physicians and ID pharmacists really find themselves at that crossroads, where, yeah, they're working with individual patients but they're also trying to set up systems so that appropriate antibiotics are selected more frequently than inappropriate antibiotics are right, and a good example of that would be you know, a lot of hospitals have have for urinary tract isolates, for urine isolates have dropped, have intentionally not reported quinolone susceptibilities on their, for example, e coli, and they're doing that not to harm patients or anything, but that it frankly is it, it, it, it, it, it, it and studies have shown this is that physicians are less likely to pick quinolones if it's not on the susceptibility report. Right, and since we don't want to use quinolones unless we absolutely have to because of the myriad adverse effects associated with them, um, that that's. That's an example of a of a system, uh, antimicrobial stewardship initiative that has largely been pretty successful.

Speaker 1:

Yeah, wow, that's great. So what is the pharmacist's unique position? You kind of touched on it, but I think obviously antimicrobial stewardship and combating the resistance to antibiotics is a multi-team effort, you know, interdisciplinary, and lots of people have to be involved. But what specifically is the pharmacist's unique position? Like, how can we position ourselves to really interact and to make a difference? Right?

Speaker 2:

I think, for I think one of the big kind of low-hanging fruit for community-based pharmacists and hospital pharmacists is to clarify and assess antibiotic allergy. You know, you know someone says they're allergic to penicillin. That forces the, the prescriber, to pick something they would never normally pick, that is more expensive, that has more side effects, that is more likely to cause resistance, right. So you know. You know, if you know you get, you get a. You know, if you get, you get a a. You know a community-based pharmacist gets a prescription for linazolid orally, in addition to it being hundreds of dollars. You know, and looks at the patient's profile, says oh, you're allergic to penicillin. What happens when you take penicillin? Oh, I got a rash when I was six and now I'm 80, you know. Okay, well, you know there's a pretty good chance you're not actually allergic to penicillin anymore. You know.

Speaker 2:

You know we can pick a cephalosporin. That would work just as well, you know. So let me call, let me call the physician, let them know that. You know, not only is linazolid unbelievably expensive and has side effects, but it's going to increase the risk of resistance down the road. We can pick, you know, cathlex or cephalexin, and it will be work just as fine, or cephalexin, and it would be worth just as fine sort of thing. So I think that's, I think that's a pretty low-hanging fruit, because I think many prescribers are are just not up to date on what the latest information is on antibiotic allergy. So I think that's one way. Um, you know, and then I think all sorts of you know all sorts of other ways. You know whether you're in the community or the hospital. In the hospital we have a we have, you know, a formulary where if someone usually antibiotic is selected.

Speaker 2:

You know, we can kind of that kind of a red flag for us and say, ok, you know why is there a reason why you pick this antibiotic, particularly if it's not appropriate Exactly it's appropriate, we can maybe, you know, come up with it with another option for you and stuff like that. So again, I think I think community and hospital based pharmacists are I work mostly at the patient level and I think that they, you know, since they know the costs, they know the side effects of the drugs pretty well, I think that they play a really good role at that patient level of saying, okay, this is a pretty unusual antibiotic for this infection. Let me do some more digging to figure out is this the right choice?

Speaker 1:

basically yeah Well, and I'll take a question a step further in that role. So that makes perfect sense and I agree with that. I know that there are some out there that may struggle with the courage to reach out to the prescriber and say, hey, what about this? Do you have any tips or tricks to kind of share with our pharmacist listeners on that?

Speaker 2:

You know, I mean, it's always the problem, right? Or you're never going to get through to the doctor. You're going to get through to the front staff secretary, who her automatic response is the doctor wrote it that way. Just fill it you know sort of thing which I know drives my community colleagues up the wall, as it should. I think the best way to approach that sort of stuff is always to have the information readily available.

Speaker 1:

And the.

Speaker 2:

Infectious Disease Society of America has guidelines for just about every infectious disease. There's very, very few infectious diseases out there that IDSA doesn't have official guidelines on, and that would be my first stop, my first shop stop for them.

Speaker 1:

So someone comes in with a weird antibiotic and you're like okay, well first up, I'm not even sure I have this.

Speaker 2:

Second, if I do, it's going to be really expensive insurance Probably going to pay for it, right?

Speaker 1:

But before I, before I started, going through all that rigmarole.

Speaker 2:

You know, let me do some investigation. Okay, no, actually I think we could pick this antibiotic and then, I think you know, leaving a message. You know, because that's probably what's going to happen. You're rarely going to get the prescriber on the phone, you know, and just say, look, you know, idsa basically says that this is the correct. You know, this is the right antibiotic. I see the patient had an allergy to X. You know, we could certainly use Y, and that would be in the IDSA guidelines too, sort of thing.

Speaker 2:

I think that you're you know you're never going to get a hundred percent, but I think more likely to get your recommendations accepted both in a hospital and a community when you've got the guidelines on your side or you've got, you've got the, the evidence on your side yeah, no, that's great feedback and that's great advice too, because you know, I think a lot of times pharmacists, they, they have the knowledge, they have the no doubt about it.

Speaker 1:

Yeah, they have the know-how and the power and whatever, and they've probably done that research, but sometimes it's the communication that right, just making sure that you're giving it to the prescriber in the way in which they're going to receive it you know positively, and so I think it's good feedback to say go in there with the guidelines first and foremost, because that's really what's going to speak to the prescriber, so yeah, and for the IDC they're completely free.

Speaker 2:

They're on the idsocietyorg website, you know. I mean you know, maybe you know, maybe have that bookmarked on your computer at work and whenever you need to pull them out.

Speaker 1:

Absolutely, yeah, and I think that you know we always try to talk about ways, too, that pharmacists can utilize their team members on their team to kind of help with that too, and so I think you talking about the allergies and really digging deeper to find out if they're true allergies, that can be kind of a triage point for the technicians and other staff members to say are you allergic to anything, you know whatever? And get some more information to pull the pharmacist in for that discussion. So, exactly, that's great. Okay, so let's talk a little bit about some opportunities and challenges that we're that our pharmacists are likely going to face as they try to go through, you know, assisting with antibiotic resistance at whatever level, like you said, whether they're community-based or hospital-based or, you know, in a consulting role in long-term care or whatever. What are some of the opportunities, obviously, that we have, of course, to reduce resistance rates, but how does that actually like? How are our efforts actually going to reduce rates, resistance- rates you know kind of make the connection.

Speaker 2:

It makes it tough because, of course, resistance is a global phenomenon, right? I mean, of course it's a patient level phenomenon, but it's. But it happens because of a change in ecosystem.

Speaker 2:

It happens because of a change in, in, in, in what's going on with the, with the, with the, the bug itself. And so you know it's always been a challenge to study this at the patient level because you know you could, you know you'll do the right thing and spend, you know, six months making a hundred interventions on patients to optimize stewardship and optimize antibiotic regimens. You know it's going to be very hard to study that. So did that hundred lead to a decrease in resistance? And how are you going to measure that sort of stuff? So I think when you're looking at this, you have to look a little bit less at the. You know well, you know, if I keep doing this, I'm going to see, you know the community around me is going to see less resistance.

Speaker 2:

I think that's true, but I think it's going to be very difficult to measure. And so I think you know, and so I think what you do is you say to yourself okay, you know, mrs Smith, this is her second urinary tract infection this year. I know she gets them several times a year. A year. You know, sooner or later, if we keep using big gun antibiotics on her, the E coli she's inevitably going to grow is going to be resistant to everything we throw at it.

Speaker 2:

And now we're going to have to admit her to the hospital for IV antibiotics or an infusion center or something along those lines. So I think that, unfortunately, systematically studying stewardship responses at a system level has always been challenging, and so I think for the individual practitioner you just have to kind of say I'm not I, you know, yes, I'm doing this for the system, but I'm really doing it for this patient in front of you, because patients who get out of I get, who get infections, tend to get more infections. Right, sure, whatever reason, right?

Speaker 2:

you know, you got a fully catherine's you're going to get lots of lots of utis.

Speaker 2:

You've got bronchiectasis you're going to get lots of pneumonias and things along those lines, and so you know, every antibiotic course they get puts them one step closer to to developing a resistant organism. So I think that's, I think that's one of the ways you approach it, and then the other, of course, is just education. Sure, you know, um just recently the uh again idsa had come out with a new set of guidelines for treatment of resistant gram-negative organisms, and if you work, especially in a hospital setting, there's some big changes in this and it has fundamentally changed my recommendations, and I think you know should be read by just about every pharmacist who dispense or recommends antibiotics.

Speaker 2:

Some of the big, you know, paradigms that we had kind of hung our hat on antibiotics, some of the big paradigms that we had kind of hung our hat on probably one big example is extended spectrum adenolactamacy coli is getting pretty common, even here in Iowa. I mean, we've been in the center of the country. We've dodged a lot of the oh my God, terrible resistance that colleagues of mine on both coasts commonly deal with. I'll talk to them and I'm like, wow, yeah, I haven't seen one of those and with luck I won't.

Speaker 2:

You know, but even here in Iowa we've seen a real spike in extended circumvental actinase E coli. Well, that becomes a real problem because previous to the set of guidelines, the standard of care was, unfortunately, to use parenteral carbapenems on these patients, which meant they had to come in and get an IV placed and get IV stuff and it was just, it was just, it was a pain and it was hard to do and stuff. Oh no, the new set of guidelines say no, actually there's evidence now that shows that for just cystitis, just for bladder infections, that nitroferantoin and Bactrim often work against E coli, esbl E coli. So if just for cystitis, not for bacteremia or anything, that's reasonable to do. So again, how's the pharmacist get involved with that? They know the guidelines and when they see an order for outpatient you know erdapenem, you know they can go and say well, you know actually, you know. Here's what the brand new guidelines say Is it okay if we went to nitroferantone on this patient?

Speaker 1:

So I think it's like that.

Speaker 1:

So what I'm hearing summarized is it's important and it's key for the pharmacist to be sure that they're updated on the guidelines, obviously. And another thing is to realize that you're not really gonna be able to necessarily quantify something, so you can't say, for every two antibiotics I change, I'm gonna save this many dollars for the whole economic system, you know, whatever. So it's more of a global community effect and, like you said, I love the idea of focusing on that patient, like I'm really making this change for this patient, because A, b, c, d down the road is going to be harder for them if we don't do this now. So, yeah, that's great. Okay, so let's talk, then, about some of the challenges before we run out of time. So, obviously, with everything that we do, there are challenges and barriers that we have to overcome. So what are some of those common ones that we're going to see when we're trying to implement resistance and stewardship?

Speaker 2:

I mean, I think you know, for pharmacists and I think for ID physicians too. I think that the territoriality of physicians and providers who are like no, I'm the person in charge of this patient. My God, this is what I'm going to prescribe.

Speaker 2:

I think, that has largely faded. They, you know, you know. Yes, the God complex with physicians is sometimes alive and well, but in my 34 years now being a pharmacist, I've seen it much. You know, most physicians are trained in a team-based situation. I think they're far more likely to listen to pharmacists than when I came out of school.

Speaker 1:

That's great news, yeah.

Speaker 2:

Oh yeah, no, no, not about it. So I think that's part of, but that's still going to be a challenge. You're still going to run into providers and not just physicians. You're going to run into other providers who feel like this is their territory or feel like if someone asks them to change something, then they're wrong. Right, they made a mistake.

Speaker 2:

They made a mistake, and I think it's important to say look, in so many areas of medicine, but in ID in particular, there are a million ways to skin a cat right? I mean, you know there, you know there's lots of antibiotics that would theoretically work for x infection, um, and so, uh, you know you have to. I think you have to say, look, what you did wasn't wrong. This isn't the most optimum way to deal with this if we don't use the most optimum way to deal with this.

Speaker 2:

Again to your point. This is where we're going to see point.

Speaker 2:

This is where we're going to see more resistance, et cetera, et cetera. So I think that's a challenge, I think, for community pharmacists in particular, not having local antibiotic resistance patterns at their hand is really difficult. In the hospitals we do antibiograms, where we have the ability to take a look at this. Last year We've looked at all the E coli organisms that we have grown and what's it? You know, globally, what's the resistance rate to backroom globally, what's the resistance rate to nitrofrenco? We have that information and I can use that information.

Speaker 2:

Um, I wish, and I know my colleague, andy Meisner, who's a colleague of mine at Drake and he's a community pharmacist or a clinical pharmacist at one of the neighboring hospitals in town. He's actually done a lot of work in this city trying to come up with kind of a global community antibiogram that can be put in the hands of community pharmacists, because I think that's important and you know, because you know, and I mean I'm sure he's much more of a tech Wiz than me being an old man, but but I think, I think he's, you know, he does, you know, he realizes also that needs to be, you know, integrated into the software that all pharmacists use, right? So when you know when an antibiotic pops up, you know when you're entering an antibiotic into into your into your computer system. You can just hit a button and it pops up and says okay for E coli in this city. The background resistance rates are X. Okay, well, that's pretty good or it's terrible, or whatever.

Speaker 2:

That, I think, plays a role. So I think having the information at your disposal, not just the IDSA guidelines but local resistance patterns, is very, very important and and I antibiograms have been shown time and time again in the hospital setting to help decrease resistance, because it allows us with confidence to say you don't need this gigantic big gun antibiotic. Our antibiogram says that 90% of all these bugs that we have had here are susceptible to augment or, or you know, bactrim or catcephalic, nice and easy. You know this is what we should go with, sort of stuff right.

Speaker 2:

So I think that's one, I think. And then I think you know, unfortunately, I think, for both community and hospital pharmacists in particular, you know who's going to pay, right, you know, everybody agrees that stewardship is important and resistance is terrible, but, like so many things in the world of pharmacy, nobody's actually willing to put their money where their mouth is. Sure, right, sure, you know, you know, really, we should be paying community pharmacists to do stewardship activities. We should be paying hospital pharmacists to do stewardship activities, right?

Speaker 2:

um, you know, and I think community in particular, you know when the phone is ringing off the hook and you got 87 people yelling at you and you know 57 vaccinations and all that I mean. You know, the idea of having to do one more thing is just like yeah, yeah and and you know, you know, like all humans, I think we tend to take the path of least resistance. Right, it's like, okay, I could call on this on this one a's lid, but you know, the insurance.

Speaker 2:

So, yeah, yeah, I mean that's what they want right and the insurance is taking it, so the patient's willing to pay for it. So peace out, you know sort of thing and and so I mean I think that, that, that, if you know, if uh insurance companies, if uh insurance companies, if, if the federal government, their state government, would be willing to put some money into this, yeah, and training into this, I think that community pharmacists in particular could be a force for stewardship, like you wouldn't believe, sure you know?

Speaker 2:

yeah, but yeah but you know, it's just it's just those things. So I think, yeah, money if local information, uh, and you know, and yeah, overcoming some of the territoriality of, of of prescribers yeah, yeah, that's great.

Speaker 1:

Well, um, wildly, as I always say in every episode, I can't believe we're already out of time. It goes by so quickly. So what we always like to do is kind of wrap things back to like what's the game changer? And clearly I think the game changer here is that antibiotic resistance is real and pharmacists have a role in, you know, antibiotic stewardship and trying to combat resistance. But I'd love for you to tell us like I will phrase this a little differently.

Speaker 1:

So typically, I ask you to do the game changer, you know summary, which I just kind of did. But what I want to ask you today is what is the like let's give our listeners like one thing that they can do so you mentioned several of different things that they can do, you know. Like, let's give our listeners like one thing that they can do. So you mentioned several of different things that they can do, you know. But like, what's the one thing to kind of take that small step Because we mentioned they don't really have a lot of time or maybe some lack of resources what would you say is the one step to do that our pharmacists can take as our take home today, to kind of really start helping with stewardship?

Speaker 2:

I think that the easiest thing is really what kind of started this game changer in the first place? I'm still seeing tons of prescriptions for amoxicillin-based H pylori regimens. The memo has not gotten out, I think, to most primary care practitioners, and so I would say, if you can do nothing else, you don't have time to do anything else. You know, you know you don't feel like you have the training to do anything else. Um, I I'd say the one thing you can do is, every single time a community pharmacist or hospital pharmacist sees an amoxicillin based regimen, you just have to know. You know this isn't, this isn't the standard care anymore, right, and so you need to be able to call the office and say here is, you know, I'm sorry, but unfortunately that's not. Here is my backup.

Speaker 2:

You know, and if they say, well, I was going to do that, but the patient's allergic to, you know, metronidazole or tetracycline, okay, well then, why don't we do a levofloxacin? Basically, we've got to have one or two backup regimens ready to roll on patients and I think if, if I think that right now I mean you we could do two hours on on on community-based and hospitalized interventions that pharmacists can do, but right now, that is is, I think, the most important because I'm still getting quite a few questions about that through the di center yeah, that's great.

Speaker 1:

That's that's that's great. A great tip and great feedback. So well as always, jeff, it's a pleasure. Thank you so much for your time. Yeah, we really appreciate you giving your expertise on this topic. As I know, it kind of spans multiple practice settings.

Speaker 1:

Yeah it's not just you know, I think. A lot of times we hear antibiotic stewardship and we think of the hospital, but, like you've pointed out numerous times a day, that's not the case. It spans every practice site. Well, thank you again, jeff, really appreciate it. Thank you, I appreciate it. If you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom. And, as always, have a great week and keep learning. I can't wait to dive into another game-changing topic with you all next week.