Nominations for two-year terms are due TODAY. 

Please complete the nomination form by clicking here or at left and return to MPA Executive Administrative Assistant Karyn Peddicord.

Reflecting on my journey with the Michigan Society of Health-System Pharmacists (MSHP) – from committee member to committee co-chair and now first-year board member – I remember the moment when Nancy MacDonald, past president, approached me nearly 10 years ago to talk about the formation of the MSHP Ambulatory Care Committee. I could hear the passion and excitement in her voice, and it was contagious. When I stepped into the room at my first MSHP Committee Day, I didn’t know many people, but I just “knew” that I was in the presence of great leaders, and I felt honored and humbled to join. It truly felt like a small community, and I developed a sense of belonging that Becky Maynard, past president, articulated so well in the March MSHP Monitor. It is a feeling that I want all pharmacists in Michigan to experience.

This led me to question if there are generational differences that might explain this. If we accept that organizations are a community, then data from San Diego State University supports that Generation X and Millennials considered goals related to intrinsic values (self-acceptance, affiliation, community) less important, and there were trends toward reduced community feeling in both groups, though community service increased with Millennials.¹ In addition, Millennials and Generation Z (born after 2000) prefer webinars and online technology to traditional lecture-based presentations or in-person meetings. Members of Gen Z, also known as Zoomers or the “New Silent” generation, are our first “digital natives,” for whom information is immediately accessible, but the increased screen time can lead to isolation, underdeveloped interpersonal skills and a diminished ability to develop relationships. They may have a cyberspace community with many acquaintances, but without direct personal connections.² This could potentially explain some of the declines in membership. If information is easily accessible, then why join an organization? If digital acquaintances fulfill a need for interpersonal interaction, then why network in person and try to form relationships? There are so many questions that we can ask, and we also have Generation Alpha (Gen A) to consider, as well, which will change the landscape in the future.

What doesn’t get measured doesn’t get managed. A play on the clichéd quotation from the creator of management thinking Peter Drucker, who said, “What gets measured gets managed,” this applies very nicely to the vast use of antimicrobials in the outpatient setting – over 250 million antibiotic courses per year in the U.S. alone.¹ For the everyday pharmacist involved in ambulatory care or antimicrobial stewardship, it is nearly impossible to track antimicrobial use in the community. Even if there was a way to track this data at one health system, there is no easy way to organize, display and benchmark this data to other facilities. In steps the Collaboration to Harmonize Antimicrobial Registry Measures (CHARM) project. The core CHARM team consists of faculty from Ferris State University and antimicrobial stewardship leaders from the Michigan Department of Health and Human Services (MDHHS).

To date, there are 28 hospitals or health systems in Michigan that are reporting data into the CHARM dashboard. Because this project is partially funded by an MDHHS grant, it is FREE for health systems to sign up. The CHARM leadership team works with the information systems group within the health system and can extract data from any electronic health record that utilizes electronic outpatient prescriptions. Once extracted, CHARM provides partners with an interactive dashboard to facilitate data visualization. The dashboard is updated as frequently as monthly as new data are submitted. The dashboard currently has eight pages of content and is continuously improving from year to year.

Merely listing these metrics on paper does not do the dashboard justice. The interactive dashboard allows the user to drill down into a specific primary care office or facility (or even multiple selections), and all of the parameters on the page will change to highlight the data from the user’s selection. See Figure 1 below for an example of the Antibiotic Use Summary page.

Figure 1: Antibiotic Use Summary example of the CHARM Dashboard

Utilizing this dashboard at Munson Healthcare in Traverse City, Bryant Froberg, PGY2 infectious diseases pharmacy resident at Munson Medical Center in 2020-21, was able to compare antibiotic prescribing patterns before and after the COVID-19 pandemic. In a cross-sectional study, Dr. Froberg compared the average number of antibiotic visits per 1,000 patient visits at 28 ambulatory care clinics starting 14 months preceding the COVID-19 pandemic, and 10 months after the start of the pandemic. The average number of antibiotic visits per 1,000 patient visits decreased from 142 (pre-COVID-19) to 119 (COVID-19) (p<0.001) – Figure 2. According to this study, the COVID-19 pandemic was associated with a decrease in ambulatory antibiotic prescribing rates per 1,000 patient visits, a decreased use of broad-spectrum antibiotics and a decrease in guideline-concordant drug choice for several common disease states.

Figure 2: Number of Antibiotic Visits per 1,000 patient visits Pre-COVID-19 and after COVID-19 at 28 ambulatory care clinics in Northern Michigan.

This may have seemed like quite a bit of information, but it merely scratches the surface of the policy recommendations. As one can see in the complete list below, many of the other policy recommendations will also be of significant interest to MSHP members, and they all will affect us as health-system pharmacists. Feel free to review the proposed policies and contact one of the delegates with any questions or comments you may have (Jesse Hogue, Jessica Jones, Rox Gatia and Steve Stout). ASHP members can view the official language of the policy recommendations at the ASHP House of Delegates Web site, as well as follow online discussions via the House of Delegates community within ASHP Connect. There has already been quite a bit of good discussion on ASHP Connect; feel free to join the conversation! 

More than 2.8 million antibiotic-resistant infections occur in the U.S. each year.¹ Two major concerns for resistance include the increasing trends of extended-spectrum beta-lactamases (ESBLs) and methicillin-resistant staphylococcus aureus (MRSA) in the community. The Centers for Disease Control and Prevention (CDC) lists ESBLs as a serious threat because the number of ESBL-producing Enterobacteriaceae has increased since 2012.¹ Furthermore, the CDC Emerging Infections Program (EIP) reports an increase in the rate of community-associated MRSA infections.² The inappropriate use of antibiotics is one of the main drivers causing antimicrobial resistance, and a large portion of antibiotics are given in the outpatient setting. In 2019, the CDC reported that 251.1 million antibiotics were prescribed in the outpatient setting.³ Recent reports also suggest that up to 50 percent of outpatient antibiotics may be inappropriate based on choice, dose and duration; this could have resulted in up to 125 million inappropriate outpatient antibiotic prescriptions in 2019.

In order to focus outpatient stewardship efforts, the CDC assessed Medicare Part D data to identify high-volume prescribers. Among the high-volume prescribers identified, the highest rate of antimicrobial prescribing was among dentists.⁴ Antibiotic prescribing by dentists has increased 62.2 percent from 1996 to 2013, according to Marra and colleagues. Increased antimicrobial prescribing among dentists is thought to be from the slow adoption of guidelines into daily practice, a larger aging population and utilizing antibiotics instead of surgical treatment methods. Generally, in dentistry, antibiotics are prescribed for either prophylaxis or treatment indications, with amoxicillin and clindamycin being the most commonly used. Prophylactic antibiotics have been shown to be utilized in invasive procedures in patients who are healthy, immunocompromised, and who have certain cardiac and joint conditions.⁵ However, retrospective data from Suda and colleagues have shown that prophylactic antibiotic prescribing among dentists is excessive. Their unadjusted analyses showed that 80.9 percent of the antibiotics prescribed were discordant with guidelines. The increase of unnecessary antibiotic prescribing not only contributes to growing antimicrobial resistance but also puts patients at risk of adverse side effects such as Clostridioides difficile infections.⁶

The American Dental Association (ADA) recently updated its antimicrobial stewardship recommendations for the treatment of common dental complications. In immunocompetent patients, the ADA recommends avoiding antibiotic prescribing and optimizing source control through definitive, conservative dental treatment rather than systemic antimicrobial therapy. However, if there are signs of systemic involvement, the ADA recommends prescribing narrow-spectrum antibiotics such as amoxicillin or penicillin.⁷

The ADA guideline also recommends that antibiotic prophylaxis prior to dental procedures should be reserved for patients who are at the greatest risk of post-treatment bacterial-related complications. In general, antibiotics are not recommended prior to dental procedures for patients with prosthetic joint implants. However, the American Academy of Orthopaedic Surgeons (AAOS) and the ADA jointly decided that prophylactic antibiotics may be warranted in patients with prior complications.⁸ The ADA recommends that the patient’s orthopedic surgeon assess the patient and prescribe antibiotics, if necessary. Similarly, the ADA supports the recommendations from the American Heart Association (AHA) guidelines for the prevention of infective endocarditis surrounding dental procedures. Table 1 contains the most recent recommendations.⁹

Describe Your Role/Day in the Life: As a student who just completed my P4 rotations, I have been able to engage in a variety of clinical patient care activities. These varied depending on the practice setting of the rotation. I most recently completed my institutional/health system Advanced Pharmacy Practice Experience (APPE) rotation and had the opportunity to learn more about pharmacy operations, infectious diseases, cardiology pharmacy practice and other aspects of inpatient pharmacy practice. Most often, my day began with working up patients, presenting them to my preceptor and then making recommendations to prescribers. I also have had the opportunity to attend a variety of committee and workgroup meetings focused on safe and effective medication use. I’ve attended Drug Shortage Workgroup meetings, Pharmacy and Therapeutics Committee meetings, and educational presentations by current pharmacy residents at the rotation site. From my experiences on rotation, I’ve learned that there is a wide array of opportunities for a clinical pharmacist in health-system pharmacy practice.

Why You’re an MSHP/MPA Member: I decided to join MPA for a multitude of reasons. Membership in the organization facilitates networking opportunities with other pharmacy professionals and leaders within the state of Michigan. I’m sure that making these connections early on in my career will be an invaluable resource as I progress in my professional journey. MPA also offers a variety of educational opportunities, both virtually and in-person, to stay up to date on evidence-based practices while also learning about ways that pharmacy innovators in the state of Michigan are advancing health-system pharmacy practice.

Recent Accomplishments: Graduation from pharmacy school in May 2022. I gratefully matched with a PGY1 residency position with Ascension Genesys Hospital in Grand Blanc and will start in July 2022.

How MPA has helped you achieve any accomplishments? Through MPA and my local association, Genesee County Pharmacists Association (GCPA), I have been able to network with pharmacists who ended up helping me achieve some of my short-term professional and career goals. I look forward to continuing my involvement with professional pharmacy organizations during my residency year and aim to take a more active role with committees and volunteer opportunities that are available to me.

Originally developed as an antidiabetic agent, sodium-glucose cotransport-2 (SGLT-2) inhibitors have shown to be beneficial in patients with heart failure and chronic kidney disease. As a result of several landmark trials, the American College of Cardiology (ACC) updated its 2021 guidelines to include SGLT-2 inhibitors as a primary pillar of guideline-directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF) in patients with or without diabetes.¹ This recommendation was supported by the U.S. Food and Drug Administration (FDA) approval of dapagliflozin and empagliflozin for use in patients with HFrEF, which, in February 2022, was expanded to include the use of empagliflozin in heart failure with preserved ejection fraction (HFpEF).² As the utility of SGLT-2 inhibitors continues to increase, pharmacists need to understand their place in therapy and become familiar with the clinical pearls associated with the use of these agents. 

The three landmark trials that led to the FDA approval of dapagliflozin and empagliflozin in heart failure were DAPA-HF, EMPEROR-REDUCED and EMPEROR-PRESERVED. A summary of these three trials is listed below in Table 1.

Given the results of these trials, the 2021 ACC guidelines for the management of patients with HFrEF suggest SGLT-2 inhibitors may be added to a patient's medication regimen as part of GDMT without the need to titrate ACEi/ARB/ARNI and beta-blocker, aldosterone antagonist to their target dose.¹

Aside from their potential additive effects with traditional antidiabetic medications and diuretics, there are several adverse effects that must be considered when managing a patient on an SGLT-2 inhibitor. Patients are almost three times more likely to develop a genitourinary infection on an SGLT-2 inhibitor which can occur as early as five days after initiation.⁸ Fortunately, these are typically mild to moderate in severity and respond well to standard therapy. Patients should also be counseled to hold their medication when poor oral intake is expected (i.e. during “sick days”) and three to four days prior to surgery secondary to the risk of euglycemic ketoacidosis.⁹ Additional concerns are related to hypotension and hypoglycemia, which can be avoided with proper monitoring and adjustment of antihypertensive and antidiabetic regimens. Familiarity with these agents will ensure they are being used appropriately, improve patient clinical outcomes and avoid potential complications of therapy.

This year’s scholarship application will be available on the CAPA website in the summer of 2022 and is due Nov. 1, 2022. P1-P4 pharmacy students in the quad-county area are eligible to apply, as long as they were not awarded the CAPA scholarship the previous year.

Anyone interested in joining CAPA and becoming more involved can visit www.capapharm.org.