By Michael E. Klepser, PharmD, FCCP

In 2007, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published guidelines that outlined the development and justification of institutional antimicrobial stewardship programs.1 Although this document was not the genesis of antimicrobial stewardship, it definitely helped the concept gain wider acceptance. An infectious diseases physician and an infectious disease-trained pharmacist are advocated as being central to the construct of an antimicrobial stewardship program/team. Identification of an ID-trained physician is relatively simple as the processes of specialty training and certification are relatively well established. Unfortunately, finding an ID-trained pharmacist is not as straightforward. Historically, especially at smaller institutions, the title of ID pharmacist was often given to the individual with the greatest interest in ID, even if they had little to no formal training in this area. Furthermore, these clinicians were often given little direction or resources to assist them in cultivating a broad-based knowledge in ID. Unfortunately, this scenario created a situation where the knowledge level and clinical competency of “ID pharmacists” varied greatly and was often highly biased toward a narrow scope of practice.

Training ID Clinical Specialists
Formal training for pharmacists with an interest in ID is not a novel idea. Fellowships, specialty residencies, and graduate programs aimed at providing pharmacists with formal training in ID have been in existence for decades. Although these training programs are all designed to provide the trainee with a focused ID experience, the balance between research and clinical experiences vary tremendously. In response to the aforementioned publication on antimicrobial stewardship1, the Society of Infectious Diseases Pharmacists (SIDP) and the ID Practice and Research Network of the American College of Clinical Pharmacy published a joint opinion paper in 2009 providing recommendations for training and certification of pharmacists practicing, mentoring, and educating  in ID pharmacotherapy.2 One of the purposes of the document was to provide hospitals and clinics with definitions for the qualifications and scope of practice abilities that should be possessed and maintained by pharmacists practicing ID pharmacotherapy. The document was not meant to discredit those self-taught practitioners, rather it was intended to be a forward-looking document serving as a roadmap outlining requirements for future ID-trained clinical pharmacists.

For individuals completing their coursework in pharmacy, the path for ID-
training has been well defined (Figure 1). It is recommended that new graduates seeking clinical training in ID complete a post-graduate year (PGY) 1 residency followed by a PGY2 residency in ID. Recently the ASHP Commission of Credentialing and the SIDP revised the goals, objectives, and educational outcomes for ID-focused PGY2 programs.3 The intent of the opinion paper was to establish standards to increase residents’ depth of knowledge, skills, attitudes, and abilities in order to raise their expertise in drug therapy management and clinical leadership in ID. Required educational outcomes intended to serve as the foundation of the specialty experience include:

1. Promoting health improvement, wellness, and the prevention of ID
2. Optimizing the outcomes of individuals with an infectious disease by providing evidence-based, patient-centered drug therapy as an integral member of an interdisciplinary team or as an independent clinician
3. Managing and improving the anti-infective use process
4. Demonstrating excellence in the provision of educational activities for both health care professionals and health care professionals in-training that focuses on optimizing anti-infective pharmacotherapy
5. Serving as an authoritative resource on the optimal use of drugs for the treatment of individuals with an infectious disease
6. Demonstrating leadership and practice management skills
7. Conducting infectious diseases pharmacy practice research
8. The opinion paper also outlines a variety of education realms in which the trainee should demonstrate proficiency. Such realms include, but are not limited to, clinical microbiology, ambulatory care, antimicrobial surveillance, transplantation, infection control, AIDS management, ICUs, hematology/oncology, and health economics. Furthermore, a basic curriculum of ID topics is presented. Upon completion of the PGY2 residency in ID, individuals should exhibit competency in the educational domains outlined by ASHP and possess the knowledge and skill needed to practice as a clinical specialist in ID. This process produces practitioners who have received a broad and structured experience in ID. Unfortunately, the same breadth of experiences cannot be assured among individuals who do not receive this formal training.

Critics of this training process cite examples of many well-respected ID clinicians who have not completed such formalized training and question the feasibility of this approach. Interestingly, many of the individuals cited by critics are quick to admit that the path they followed is not a good model for ensuring a large and qualified cadre of ID specialists. These self-trained individuals admit that theirs was often a long and difficult path and support the idea of a formalized training process. Some critics also note that there are currently only about 40 PGY2 residency programs that offer ID training. As the value of ID-trained pharmacists is further documented, the pressure to develop additional programs should increase. Additionally, as more clinicians complete PGY2 residencies in ID, there will be increased numbers of preceptors qualified to offer these training programs.

Bridging the Training Gap
Perhaps the biggest question currently facing administrators is what to do until an adequately trained clinical workforce is in place. Unfortunately, there is no consensus on a solution. While the creation of an ID certification examination for pharmacists has been proposed by some, this approach is probably cost prohibitive. Until the time when such an exam becomes feasible, it has been suggested that clinicians lacking formal training in ID complete a PGY1 residency, obtain certification as a board-certified pharmacotherapy specialist, and attain added qualifications in ID from the Board of Pharmaceutical Specialties. Other routes that have been suggested as a means to bridge the gap in ID clinical pharmacy training have included attending national certification programs, participating in focused mentor programs, and completing sabbaticals.

Continuing Education
Beyond the initial training of ID specialists, it is imperative that clinicians maintain a contemporary knowledge base and up-to-date practice skills. ID-trained pharmacists should undertake a structured and focused approach to continuing education. This can be accomplished by maintaining a professional portfolio. Such a tool draws focus to core domains of practice and assists individuals in planning their self-development efforts. The portfolio should be structured to incorporate a variety of experiences such as live programs, literature reviews, completion of case-based exercises, and hands-on experiences/mentorships. The focus and type of experience should be documented, allowing individuals to track their progress, review core knowledge, and prevent the formation of knowledge and skill gaps.

Recruiting an ID-Trained Clinical Pharmacist
While recruiting new pharmacist staff members is never an easy process, it can be even more challenging when looking to hire an ID-trained clinical pharmacist. Simply identifying potential candidates can be a difficult task. Although the traditional recruiting process may prove to be fruitful, I would also suggest reaching out to the programs that offer PGY2 residencies in ID. A list of training programs can be found on the ACCP Web site (www.accp.com/resandfel/index.aspx). Maintaining communication with program directors can help you identify candidates early on and streamline the recruiting process.

Expanding ID Practice
The value of ID pharmacists in the hospital has been established and their roles outlined. Moving forward, the expertise of ID specialists will prove beneficial in broader practice settings. As patient care continues to shift to non-hospital settings, the practice of ID also will change. As a result, ID-trained pharmacists will demonstrate their value in ambulatory, long-term, and outpatient care settings. The role of formally trained ID clinical pharmacists in optimizing patient care, slowing the spread of resistance, and controlling costs across the patient care continuum will be recognized as an important contribution of pharmacists for years to come.

Michael E. Klepser, PharmD, FCCP, received his doctor of pharmacy from the University of Michigan College of Pharmacy in 1992. He completed his pharmacy practice residency at Detroit Receiving Hospital and University Health Center, as well as a fellowship in infectious diseases at Hartford Hospital in Hartford, Connecticut. Dr. Klepser has been in academia for 15 years and is currently a professor of pharmacy practice at Ferris State University. Dr. Klepser is involved with programs and research aimed at expanding ID pharmacy services into community pharmacy practice.

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