Monica V. Mahoney, PharmD, BCPS (AQID), BCIDP, on Formulary Management Strategies

At the Making a Difference in Infectious Diseases (MAD-ID 2019) annual meeting, Monica V. Mahoney, PharmD, BCPS (AQID), BCIDP, clinical pharmacy specialist of outpatient ID clinics/OPAT clinic in the Department of Pharmacy at Beth Israel Deaconess Medical Center, and Contagion®’s In the Literature Section Editor, gave a presentation on formulary management strategies for antimicrobial stewardship.

Following her presentation, Mahoney sat down with Contagion®’s editorial team to recap her workshop and share valuable insight on steps that can be taken to encourage communication between stakeholders during the event of a drug shortage.

Interview transcript (modified slightly for readability):

There are a number of different activities that we can use to extend the formulary that we do have or deal with a lot of the drug shortages are currently plaguing a lot of antibiotic stewardship pharmacists and clinicians and institutions. It seems like every day, every week there's a new antibiotic that's going on shortage and how do we best manage the supply that we do have, get more supply, figure out which patients we should reserve these antibiotics for if it comes down to that need. So, the workshop that I led was on formulary management in antibiotic stewardship and we talked about a number of different methods that we can use. The number 1 takeaway point was that if your institution does not have a drug shortage task force then that's something that you should look into creating when you get back. The drug shortage task force includes pharmacists, physicians, nurses, your c-suite, your microbiology, your information technology, because when 1 drug is unsure that it's going to impact who we can give the drug to, what other drugs we're going to be using, there's going to be reprogramming of our computer systems, of our order entry systems, reprogramming of infusion pumps of what drugs we’re going to be giving, you know are we giving things as a push rather than a 30-minute infusion or a 3-hour infusion, so there's a lot of different departments and disciplines that need to be involved in the conversation.

When we opened it up to the attendees to talk about what problems they have and what successes they've had in managing their formulary, a common theme that emerged is that communication is key. A physician commented that his pharmacy department does so good at managing these shortages that he oftentimes isn't even aware that there is a shortage because the end product is so seamless. And, we need to advertise what we are doing, we need to alert other departments when there is a shortage and give them options. You know nobody wants to know that the patient they booked for that day, the patient that they brought in, all of a sudden, we have to cancel that appointment after the patient arrived because we don't have that drug anymore.

So, we can do daily communication with our pharmacy department, in their purchasing department, we could do weekly communication with maybe the ID physicians, or if it's a particular drug that's affecting your hemo population, communicate with them weekly if it's a drug that's affecting your ICU population target them and communicate weekly and then broad communication for everyone involved. If you have an intranet page at your institution and a landing page have some kind of quick reference, use a stoplight red, yellow, green do we have these drugs or not? Everyone has cell phones these days we know what the battery icon means so you know how much charge do we have, how many antibiotics do we have. And just communication is key so that nobody is caught off guard when we don't have something in stock.

Other methods that we can do is if you have rapid diagnostics at your institution. If a patient is empirically started in a broad-spectrum antibiotic, which is appropriate, use the rapid diagnostics to de-escalate and instead of having them on it for 3 or 4 days, have them on only for a day or 2. So, then you save that extra day or 2 for the next patient.

We have a lot of studies coming out that we're treating patients for longer than we need to, so shorten your duration of therapy, build in automatic stop dates into your electronic medical records, so that instead of it being up to clinician discretion when to discontinue, they have to intentionally continue beyond the set 5 days or 7 days. IV to PO — a lot of more studies are coming out supporting the oral use of antibiotics for conditions that we thought we historically need to treat with IV throughout the whole time. IV to PO for bloodstream infections, both gram-positive and gram-negative – in the last 2 years we've had about 5 different studies come out supporting that, so we definitely have more literature supporting using alternative durations or dosing formulations that can help extend the amount of IV antibiotics that we do have. So, clinicians have a lot more support and tools and references to help bridge while we have drugs in shortage.