Section 23.5: Common Rounding Scenarios: The Pharmacist’s Playbook

23.5.1 The “Why”: Mastering the “Bread and Butter” of Clinical Pharmacy

While hospital medicine is filled with rare diseases and complex, esoteric therapeutic dilemmas, the daily practice of a clinical pharmacist is built upon a foundation of mastering a handful of core, high-frequency scenarios. These are the “bread and butter” of your work—the situations that arise every single day, on nearly every patient, where a pharmacist’s intervention can have a direct, immediate, and profound impact on patient safety, clinical outcomes, and cost of care. This section is dedicated to a masterclass in four of these cornerstone scenarios: optimizing antibiotic therapy, transitioning from IV to PO medications, adjusting doses for renal dysfunction, and ensuring appropriate prophylaxis against hospital-acquired conditions.

Why this intense focus? Because excellence in these four domains is what defines an effective clinical pharmacist in the eyes of the medical team. These are the areas where your expertise is most visible, most needed, and most valued. Consistently delivering high-quality, evidence-based recommendations in these areas is how you build trust and establish your credibility as a medication expert. Mastering these scenarios is the fastest way to transition from being a perceived “outsider” to becoming a truly integrated and indispensable member of the patient care team. Each one represents a core pillar of modern pharmacotherapy:

• Antimicrobial Stewardship: Your role as the guardian against antibiotic resistance and overuse.
• Care Transitions & Cost-Effectiveness: Your role as a facilitator of safe, timely, and cost-conscious discharge planning.
• Patient Safety & Toxicity Prevention: Your role as the safety net, preventing harm from drug accumulation.
• Proactive Risk Mitigation: Your role in preventing complications before they ever have a chance to occur.

This is not just about learning clinical facts; it’s about developing a repeatable, systematic “playbook” for each scenario that you can execute with confidence and efficiency on rounds.

23.5.2 Masterclass on Antimicrobial Stewardship: De-escalation and Duration

Antimicrobial stewardship is one of the most important responsibilities of a hospital pharmacist. It is the systematic effort to optimize antimicrobial use to improve patient outcomes, minimize toxicity, and reduce the emergence of resistance. On rounds, you are the frontline soldier in this effort. Your two primary weapons are promoting the de-escalation of therapy and ensuring appropriate duration of treatment.

Playbook 1: The Art of De-escalation

De-escalation is the practice of narrowing the spectrum of antibiotic coverage once more clinical or microbiological data becomes available. We start broad to cover all likely pathogens in a sick patient, but continuing this broad coverage unnecessarily is harmful. It’s like using a firehose to water a houseplant—inefficient and likely to cause collateral damage (like C. difficile).

Your De-escalation Checklist (To run through for every patient on broad-spectrum antibiotics):

1. Have final culture and sensitivity (C&S) results returned? This is the most important trigger. The C&S report is your roadmap to de-escalation.
2. If C&S is positive: Is there a narrower-spectrum agent that will cover the identified pathogen(s)? (e.g., Is the MSSA sensitive to cefazolin? Is the E. coli sensitive to ceftriaxone?)
3. If C&S is negative: Is the patient clinically improving? Is there a low suspicion for a bacterial infection? Could antibiotics be stopped altogether? Consider non-infectious mimics like heart failure or pulmonary embolism.
4. Is the patient on double anaerobic coverage? A common error. Piperacillin-tazobactam and metronidazole are both excellent anaerobic drugs. Using them together is almost always redundant.
5. Is the patient on double Gram-positive coverage? (e.g., Vancomycin + Piperacillin-tazobactam). If cultures show no MRSA, the vancomycin is likely unnecessary.

Playbook 2: Duration Optimization

There has been a massive paradigm shift in infectious diseases, with numerous clinical trials demonstrating that shorter courses of antibiotics are just as effective as traditional longer courses for many common infections. Your role is to champion these evidence-based, shorter durations to prevent unnecessary side effects, cost, and resistance.

Your Key Action: The moment an antibiotic is started, you should be asking “What is the plan for the duration?” On day 3 or 4 of therapy, if the patient is improving, that is the perfect time to propose a specific stop date. This simple act of “dating the antibiotic” is a cornerstone of good stewardship.

23.5.3 Masterclass on IV-to-PO Conversion: Unchaining the Patient

Every dose of an intravenous medication carries inherent risks—phlebitis, infiltration, and the potentially devastating risk of a central line-associated bloodstream infection (CLABSI). Furthermore, being tethered to an IV pole limits patient mobility, which is crucial for recovery, and is a significant barrier to discharge. The IV-to-PO conversion is therefore not just a cost-saving measure; it is a critical patient safety and quality-of-care initiative. You are the team’s expert in identifying the right patient, the right drug, and the right time to make this switch.

Playbook 3: The IV-to-PO Candidate Checklist

Before recommending a switch, you must perform a systematic assessment. A patient must meet criteria in three domains: clinical stability, GI function, and the drug itself.

Domain	Key Assessment Questions	Rationale
1. Clinical Stability	Has the patient been afebrile (e.g., T < 38.0°C) for at least 24 hours? Are their vital signs (HR, BP) stable and normalizing? Is their WBC count trending down towards normal? Is the patient showing overall signs of clinical improvement for their infectious process?	You must ensure the infection is under control before relying on oral absorption. A clinically unstable or deteriorating patient needs the guaranteed 100% bioavailability of IV therapy.
2. GI Function	Is the patient able to tolerate oral intake (food/liquids) without issue? Are they free from significant nausea, vomiting, or diarrhea? Is there any reason to suspect poor absorption (e.g., ileus, short gut syndrome, severe Crohn’s flare)? Is the patient NPO (nothing by mouth) for an upcoming procedure?	If the gut isn’t working, oral medications won’t work either. This seems obvious but is a commonly overlooked check. Confirming the patient is eating and drinking is a simple but crucial step.
3. The Drug Itself	Does the IV medication have a suitable oral equivalent? Does the oral form have high bioavailability (>90%)? Are there any absorption issues (e.g., chelation with cations for fluoroquinolones)? Is there a specific reason IV therapy is required (e.g., certain CNS infections, endocarditis where very high serum concentrations are needed)?	Not all drugs are created equal. You must select an oral agent that you are confident will achieve therapeutic concentrations comparable to the IV form.

23.5.4 Masterclass on Renal Dose Adjustment: Guardian of the Kidney

Drug-induced nephrotoxicity and the accumulation of renally-cleared drugs are among the most common, and most preventable, causes of adverse drug events in the hospital. The patient’s renal function is not a static variable; it can change dramatically day-to-day, especially in acutely ill patients. Your role is to be the vigilant monitor of this dynamic process, calculating creatinine clearance daily for at-risk patients and ensuring that all applicable medication doses are adjusted accordingly.

Playbook 4: The Daily Renal Assessment

For every patient on your service with a serum creatinine > 1.5 mg/dL, an acute rise in SCr, or who is elderly (>65), you should perform this daily check.

1. Calculate the Creatinine Clearance (CrCl): Use the Cockcroft-Gault equation as it is the standard for most drug-dosing references.

   $$ \text{CrCl (mL/\min)} = \frac{(140 – \text{Age}) \times \text{Weight (kg)}}{72 \times \text{SCr (mg/dL)}} \times (0.85 \text{ if female}) $$

   A Critical Note on Weight

   The choice of weight in the C-G equation is critical. For patients whose actual body weight is close to their ideal, use actual. For obese patients (e.g., >125% of their IBW), using actual weight will overestimate CrCl. In this case, an adjusted body weight is most appropriate. This nuance is a key pharmacist contribution.

2. Scan the Medication List for Red Flags: With the calculated CrCl in mind, scan the patient’s entire active medication list. Your brain should be trained to flag drugs known to be cleared by the kidneys.
3. Consult Dosing References: For each flagged drug, consult your institution’s dosing guidelines, Lexicomp, or another reliable reference to find the recommended dose for the patient’s specific level of renal function.
4. Formulate the Recommendation: If a discrepancy exists, prepare your SBAR. Be ready to state the calculated CrCl, the current (incorrect) dose, and your recommended (adjusted) dose.

23.5.5 Masterclass on Prophylaxis: Preventing the Preventable

A significant portion of a pharmacist’s value lies in proactive risk mitigation. Two of the most common preventable hospital-acquired conditions are venous thromboembolism (VTE) and stress-related mucosal damage (stress ulcers). Ensuring that every patient is on the correct prophylactic regimen—and, just as importantly, that prophylaxis is discontinued when no longer needed—is a key safety and stewardship function.

Playbook 5: The Daily Prophylaxis Check

For every patient, every day, you should be able to answer two simple questions: “Does this patient need VTE prophylaxis?” and “Does this patient need stress ulcer prophylaxis (SUP)?”

Prophylaxis Type	Who NEEDS It? (Common Indications)	Who DOESN’T Need It? (Discontinuation Opportunities)
Venous Thromboembolism (VTE) Prophylaxis	Most acutely ill medical patients who are bed-bound or have limited mobility. Post-operative surgical patients. Patients with a history of VTE, active cancer, or other hypercoagulable states.	Patients who are fully ambulatory (walking the halls). Patients on therapeutic doses of anticoagulation for another reason (e.g., A-Fib). Patients with a high bleed risk (e.g., active GI bleed, severe thrombocytopenia – Plt < 50). In this case, mechanical prophylaxis (SCDs) should be used.
Stress Ulcer Prophylaxis (SUP)	High-risk ICU patients only: Mechanically ventilated for >48h, or coagulopathic (Plt < 50, INR > 1.5). Other specific high-risk states (e.g., severe burns, head trauma).	Nearly all non-ICU, general medical floor patients. This is a major stewardship opportunity. ICU patients once they are extubated or their coagulopathy resolves. Patients who are able to eat and drink (enteral nutrition is protective).