1 The Role of the Antimicrobial Stewardship In the Acute Care Inpatient SettingKimberly Sarosky, MS, PharmD, BCPS Clinical Pharmacy Specialist Infectious Diseases & Critical Care Mount Sinai St. Luke’s

3 Objectives Introduce the Future of Antibiotics in an Era of ResistanceDiscuss the goals & purposes of hospital antimicrobial stewardship program (ASP) [Maximize clinical outcomes, Minimize toxicity & adverse events, Reduce occurrence of Multidrug Resistant Organisms (MDROs), Control cost] Review the Center for Disease Control and Prevention 7 Core Elements of Hospital ASP [Leadership Commitment, Accountability, Drug Expertise, Action, Tracking, Reporting, Education]

4 Antibiotic Resistance: An Unintended ConsequenceUncontrollable Factors Bacterial mutations Antibiotic use in food production Livestock feed more stringent regulations effective January 2017 Results hopefully lessen produce contamination of soil & water Controllable Factors Antibiotic Overuse Overprescribing in outpatient & inpatient Resistance development Increased Antibiotic Associated Adverse Events Poor Infection Control & Prevention Practices in Healthcare Organizations Minimize the spread of multidrug resistant organisms (MDROs) U.S. National Institutes of Health, “Search for Studies,”

5 Timeline of Antibiotic Resistance

6 Current State: Nothing New in Antibiotic ClassesNo new antibiotic classes developed in past 10+ years New medications derived from existing classes Ceftolozane-tazobactam (Zerbaxa®), Ceftazidime-avibactam (Avycaz®) Telavancin (Vibativ®), Dalbavancin (Dalvance®), Oritavancin (Orbactiv®) Tedizolid (Sivextro®) Isavuconazonium sulfate (Cresemba®) In the Pipeline (Phase 3) derived from existing classes Imipenem cilastatin-relebactam, Meropenem-vaborbactam (Carbavance®) Eravacycline Plazomicin U.S. National Institutes of Health, “Search for Studies,”

7 Documented Resistance to Newly Marketed Agents

8 Carbapenem-Resistant Enterobacteriaceae (CRE)https://www.cdc.gov/hai/organisms/cre/TrackingCRE.html#

9 Toxic Antibiotics for Treating Common InfectionsColistin & Polymyxin Activity: Gram Negative Organisms only Multidrug resistant strains Carbapenem Resistant Enterobacteriaceae (E. coli, Klebsiella, Acinetobacter, Pseudomonas) Toxicity Nephrotoxicity – similar to aminoglycosides Neurotoxicity – dizziness, weakness, paresthesias, vertigo, confusion Bronchospasm – inhalational delivery Susceptibility testing Poorly standardized Li et al. Lancet Infect Dis ; 6:589

10 Resistance to Last Resort Agents: A Real Concern

11 PAN-Resistant Bacteria Have Arrived!

12 National Statistics on a Growing Crisis2 million people infected with antibiotic resistant bacteria 23,000 deaths annually as a direct result of these infections Organism Total Annual Cases Annual MDR Cases Annual Deaths Methicillin-Resistant Staphylococcus aureus (MRSA) 80,461 -- 11,285 Streptococcus pneumoniae 1,200,000 7,000 Extended-Spectrum β-Lactamase (ESBL) + Enterobacteriaceae 140,000 26,000 1,700 VRE 66,000 20,000 1,300 CRE Enterobacteriaceae 7,900 Klebsiella spp. 1,400 E. coli 600 Pseudomonas 51,000 6,700 440 Neisseria gonorrhoeae 820,000 246,000 Candida 46,000 3,400 (fluconazole resistant) 220

13 Predictions for the Future by 2050AMR = Antimicrobial Resistance

14 Unintended Consequences of Antibiotic Use (In)Appropriate UseAntibiotics are the 2nd most prescribed medication class 200–300 million prescriptions per year (~80% population) 55% within inpatient setting 30 – 50% of Antibiotic use is inappropriate Both Inpatient & Outpatient in United States 25 – 40% of Hospitalized Patients Receive Antibiotics Fridkin S, et a. MMWR. 2014; 63(9):

15 Unintended Consequences of Antibiotic Use Antibiotic-Associated Adverse EventsMost Common Adverse Events Allergic Reactions (80%) Adverse effects (18%) Diarrhea, headache, dizziness Serious Adverse Events Macrolides, Fluoroquinolones Cardiac Arrhythmias Drug-drug interactions [Fluoroquinolone FDA Drug Safety Communication May 2016, Update July 2016] Antibiotics account for 1 in 5 Adverse Drug Events 140,000+ ER visits annually 6.1% of these require admission

17 Purpose & Goals of Antimicrobial Stewardship ProgramsWhy is it Necessary?

18 Definition: Antimicrobial Stewardship Program (ASP)“Systematic and multidisciplinary approach to the appropriate use of antimicrobial agents to achieve optimal patient outcomes” Not just about reducing antibiotic use, but a focus upon quality care for the patient Assures the patient: Receives antibiotics when appropriately indicated Correct medication, dose, route and duration Fridkin SK, Srinivasan A. Clin Infect Dis Oct 25 Dellit TH, et al. Clin Infect Dis. 2007; 44:

19 Goals of ASP Maximize clinical outcomesIncreased infection cure rates Reduced treatment failures Increased frequency of correct prescribing for therapy & prophylaxis Minimize unintended consequences Adverse events & toxicities Unintended consequences such as CDI Emergence & Spread of MDROs Improve cost-effectiveness Duration of therapy Length of stay Fridkin SK, Srinivasan A. Clin Infect Dis Oct 25 Dellit TH, et al. Clin Infect Dis. 2007; 44:

20 Regulatory Agencies on Board Policy Implementation Effective January 2017Centers for Medicare & Medicaid Services §482.42 Hospitals required to have ”policies and procedures for, and to demonstrate evidence of, an active and hospital-wide ASP” as a Condition of Participation Contains prescriptive FTE attributes The Joint Commission Standard MM Eight elements on performance Hospital ASP required to educate, monitor, track and measure antibiotic use Includes CDC’s 7 Core Elements for Hospital ASPs

21 Centers for Medicare & Medicaid Services §482.42ASP Leader Responsible for: Development & Implementation of the hospital-wide ASP based upon nationally recognized guidelines Communication & collaboration on antimicrobial use issues Competency-based training & education on ASP guidelines, policies and procedures ASP Must Demonstrate: Coordination among all hospital staff, services & programs responsible for antimicrobial use and resistance Document evidence-based use of antimicrobials Improvements in proper antimicrobial use by all hospital departments & services “Average-size” Hospital (124 beds): 0.25 pharmacist full-time equivalent (FTE) 0.1 physician FTE 0.05 network data analyst FTE American Society of Health-system Pharmacists. Antimicrobial Stewardship in Hospitals to Become National Requirement.   Accessed 9/30/2016.

22 The Joint Commission Standard MM.09.01.01One appointed Leader responsible for: ASP as an organization priority ASP Must Educate: All hospital staff involved with antimicrobial ordering, dispensing, administration & monitoring on resistance and ASP policies Patients & families as needed on appropriate use of antimicrobials Multidisciplinary Team (part-time or consultant staff acceptable): Infectious disease physician Infection preventionist(s) Pharmacist(s) – at least one Practitioner Includes Centers for Disease Control and Prevention’s 7 Core Elements of Hospital ASP Utilizes Organization-approved multidisciplinary protocols Collects, Analyzes & Reports ASP Data for improvement opportunities American Society of Health-system Pharmacists. Antimicrobial Stewardship in Hospitals to Become National Requirement.   Accessed 9/30/2016.

23 Seven Key Elements for an Effective ASP in the Inpatient SettingDisclaimer: Elements are NOT overly prescriptive & should be tailored to an institution’s individual needs According to the New York State Department of Health (DOH) Hospital-Acquired Infection (HAI) 2013 Report, only 53% of New York hospitals report having an existing antibiotic stewardship program and many have identified shortcomings in current approaches

24 Seven Hospital ASP Core ElementsLeadership Commitment Accountability Drug Expertise Action Tracking Reporting Education Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

25 Leadership CommitmentRole of Physician Leaders Critical Players for ASP Success Determining Program Goals Support facility efforts to improve & monitor antimicrobial use Job descriptions & annual appraisals denote ASP involvement Ensure participation from all healthcare members for ASP activities Adequate resources (human, financial & IT) for key players Communicates expectations, monitor & enforce ASP policies Qualifications Interest in antibiotic use & patient safety Diplomatic & collegial Ideally Infectious Diseases Trained Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

26 Accountability & Drug ExpertiseStewardship Program Leader Ultimately responsible for program outcomes Physicians with formal training in Infectious Diseases is most ideal (Preferably full-time staff member) Hospitalists w/o ID training with commitment to quality improvement with antibiotic use Pharmacy Leader Co-leader of ASP Bridge to pharmacy staff & pharmacy specialists Comfortable advising physicians & other healthcare providers Pharmacy & Therapeutics Committee alone should not take on the sole responsibility of ASP Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

27 Key Support of Other Healthcare ProvidersClinicians & Department Heads Should be fully aware of, engaged & supportive of ASP efforts Infection Preventionists & Hospital Epidemiologists Assist with monitoring and reporting resistance & HAI trends Quality Improvement Staff Antibiotic optimization is a quality & patient safety issue Laboratory Staff Ensure lab results presented in a manner that optimizes appropriate antibiotic use Information Technology Staff Integration of new ASP protocols, clinical decision support & action prompts within hospital computerized provider order entry (CPOE) system Nursing Assure cultures obtained prior to antibiotics; prompt discussion regarding antibiotic duration Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

28 Action ASP Interventions – should be specific to hospital needs, resource availability & content expertise Three Intervention Categories: Broad Antibiotic “Time Outs” Prior Authorization (Requires Full-Time Coverage) Prospective Audit and Feedback (More Flexible Coverage) Pharmacy Driven Automatic IV to PO interchange Dose adjustment & optimization Time-sensitive automatic stop orders Automated alerts for therapy duplication & drug interactions Infection & Syndrome Specific Community-acquired Pneumonia (CAP) Urinary tract infections (UTIs) Skin and soft tissue infections CDI Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

29 Tracking Monitoring antibiotic prescribing Examples:Identifies improvement opportunities & assess impact of outcomes Prospective Process or Retrospective Outcome reviews Documentation of efforts & feedback on acceptance is critical Examples: Accurate application of diagnostic criteria for infection Cultures & relevant tests obtained prior to therapy initiation Recommended antimicrobial prescribed for indication Indication & duration of therapy documented Appropriate modification of therapy based on microbiological cultures Timely administration of antibiotics Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

30 Reporting: Common TermsDays of therapy (DOT) Total # of antibiotics administered Assumes antibiotic dosing is appropriate at all times Takes into account acute changes in organ impairment Usually requires EHR with eMAR to extract data Defined Daily Dose (DDD) Average daily dose of antibiotic in a standard patient established Focuses on population-based parameters Does not account for organ impairment Common Denominator Patient Days – daily count of number of patients in a specific ward location during a time period 1,000 Patient Days Duration Of Therapy X Centers for Disease Control and Prevention. Core Elements of Hospital Antimicrobial Stewardship Programs.  http://www.cdc.gov/getsmart/healthcare/. Accessed 9/30/2016.

31 Reporting Outcomes Clinical Process Economic Humanistic Length of stayClinical cure/failure rates Readmission rates (30 days) Resistance rates Infection-related mortality C. Difficile infections Process Dose optimization Adherence to hospital specific guidelines Appropriate de-escalation/streamlining Appropriateness of therapy Cultures before antibiotics Humanistic Adverse drug events avoided Time to receipt of appropriate antimicrobials Duration of antimicrobial therapy IV/PO conversion rates Outpatient intravenous therapy rates Economic Antimicrobial utilization (DDD or DOT) Hospital wide antimicrobial expenditures Relative consumption Rate of intravenous antimicrobial use Nonformulary agents avoided Moehring RW et al. Curr Infect Dis Rep. 2012; 14(6): 592 – 600.

32 Education Engage ALL stakeholders across continuum of careDidactic Education General principles of antimicrobial therapy Interpretation of antibiogram & culture susceptibilites Diagnostic & treatment guidelines or pathways Most effective with combined with active intervention Useful Resources: National Foundation for Infectious Diseases American Hospital Association’s physician leadership forum

33 Considerations for ASP Implementation

34 Implementing an Antimicrobial Stewardship Program at Mt. Sinai StImplementing an Antimicrobial Stewardship Program at Mt. Sinai St. Luke’s

35 Background: Mt. Sinai St. Luke’s (MSSL)523 Licensed Beds Morningside Heights & West Harlem Teaching Hospital (438 FTEs Interns & Residents) Level I Trauma & Stroke Center Medical, Surgical, Cardiac & Cardiothoracic Surgical Intensive Care Units September 2013 Merger of Continuum Health Partners (St. Luke’s – Roosevelt Hospitals, Beth Israel Petrie & King’s Highway Brooklyn Divisions, and NY Eye & Ear Infirmary) with Mt. Sinai Health System

36 MSSL Structure & Resources:Infectious Diseases and Pharmacy Services Two Inpatient ID Services (HIV Inpatient & General ID Consult; 7 days per week) 10 ID Physicians rotate coverage for Consult Service Infectious Diseases Fellowship (2 years – 2 Fellows per year) 24-hour Inpatient Pharmacy Services 1 Director of Pharmacy, 1 Assistant Director of Clinical Services, 1 Pharmacy Operations Manager 1 Clinical Pharmacy Specialist, 1 Clinical Pharmacy Manager 18 Staff Pharmacists (14 Full-Time, 1 Part-Time, 3 Per Diem) PGY-1 Pharmacy Residency (1 year – 4 Residents per year) Laboratory On-site facility, performs services & reports results in Electronic Health Record (EHR) Rapid diagnostic testing using polymerase chain reaction (PCR) for MRSA, C. difficile & other organisms Information Technology Bar Coding Medication Administration (BCMA) System (Oral dosage forms only) GE Centricity PRISM (Inpatient EHR, CPOE, eMAR) EmStat – Emergency Department EHR & CPOE Pharmacy OneSource Quantifi

37 Development of ASP at MSSL: Sept 2007 to Dec 2015Clinical Pharmacy Manager – collaborates with Department of Infectious Diseases (ID) and Infection Prevention & Control to develop ASP initiatives ASP data compilation & presentation to Antimicrobial Stewardship Group Review of Antimicrobial & Antiviral Formulary Restriction Processes Approval provided by ID Fellows & ID Attendings Education to hospital staff for new ASP policies Primary preceptor for PGY-1 pharmacy residents on Infectious Disease Clinical Rotation (4 weeks) Pharmacy Residents – trained by clinical pharmacy manager to perform ASP interventions: IV to po, dose adjustment, therapeutic monitoring, restriction approval requests, C. difficle report Data entry of own ASP interventions & those done by staff pharmacists

38 Broadening ASP at MSSL: July 2016 to PresentClinical Pharmacy Specialist – hired as part of CMS & Joint Commission January 2017 Mandate Performs all duties as noted by prior Clinical Pharmacy Manager NEW Responsibilities Approval of Restricted Antimicrobials Weekdays 8:00AM to 4:00PM (Weekends, after hours & holidays by ID Fellows) Attends daily rounds with Inpatient ID Consult Service Pharmacy Residents – Perform all ASP duties as previously described Trained by Clinical Pharmacy Specialist to approve restricted antimicrobials & antivirals during ID Clinical Rotation (upon licensure) Pharmacy ASP liaison to interdisciplinary teams while on other clinical rotations

39 Leadership CommitmentChief Medical Officer Joined MSSL August 2014 Pulmonary – Critical Care Medicine 30+ years experience Leads & Implements clinical direction of ASP & Infection Prevention & Control Program at MSSL Chief of Division of Infectious Diseases Joined MSSL July 2016 Infectious Diseases Medicine 20+ years experience Defines the mission & oversees operation ID section of medicine at MSSL & Mt. Sinai West (MSW) ASP Program Director Joined MSSL July 1988 Infectious Disease Medicine Coordinates efforts between ASP clinical pharmacy specialists & responsible for ASP outcomes at MSSL & MSW

40 Drug Expertise Clinical Pharmacy SpecialistTwo years post-graduate residency training at hospitals with well-established ASP The Brooklyn Hospital Center (Established 2006) University of Massachusetts Memorial Medical Center (Established 1996) Joined MSSL August 2010 Faculty at Long Island University School of Pharmacy Preceptor of pharmacy students for Internal Medicine & Critical Care and PGY-1 pharmacy residents for Medical Intensive Care Unit (MICU) Critical Care Pharmacotherapy Focus Daily interdisciplinary rounds at MSSL MICU Development of Hospital Policies & Protocols Sepsis Code Policy Vancomycin Dosing Protocol & Automatic Stop Orders Revisions to perioperative antimicrobial prophylaxis (SCIP) Responsible for reporting antibiotic use data & collaborating with other ASP leads

41 Action: Restrictions & Prospective ReviewProspective Review of Antimicrobials Daily Automated list of patients on Antibiotics (Restricted & Non-restricted) Average census 50 to 60 patients (~20 on HIV Inpatient Service or ID Consult Services) Approval of Restricted Antimicrobials 8:00AM to 4:00PM – Alpha-numeric Text Paged or Direct Phone Call by: Hospital Staff Members Internal Medicine Residents Midlevel Providers - Nurse Practitioners & Physician Assistants Surgical Residents Attending Physicians – Internal Medicine Non-teaching Service Staff Pharmacists Notification of new orders written by Hospital Provider requiring ASP approval

42 Action: Restrictions & Prospective ReviewOvernight: Supply Doses until 10AM

43 Action: MSSL Restricted AntimicrobialsUnrestricted Antibiotics First Dose Dispensed w/o ID Approval Approval by ID Required for First Dose Approval by ASP Program Director Acyclovir Oral Valacyclovir Amoxicillin-Clavulanate Ampicillin Ampicillin-sulbactam 1.5g Azithromycin Oral Cefazolin Ceftriaxone (CAP only) Ciprofloxacin Oral Doxycycline Fluconazole Metronidazole Nafcillin Nitrofurantoin All Oral Cephalosporins All Forms of Penicillin Sulfamethoxazole-Trimethoprim Oral Vancomycin IV Acyclovir IV Amioglycosides Azithromycin IV Aztreonam Ampicillin-sulbactam 3g Piperacillin-tazobactam Cefepime Cefotaxime Cefoxitin Ceftazidime Ceftriaxone (non-CAP) Clindamycin Ciprofloxacin IV Levofloxacin Oral & IV Imipenem Oseltamivir Sulfamethoxazole-Trimethoprim IV Vancomycin oral Amphotericin B Atovaquone Caspofungin Colistin Ganciclovir Polymyxin Ertapenem Meropenem Foscarnet Tigecycline Linezolid Itraconazole Posaconazole Voriconazole Rifabutin Rifampin Ceftaroline Daptomycin Fosfomycin

44 Action: Automated Pharmacy IV to PODaily Automated Reports ed to Pharmacy Residents Following 48 hours of IV therapy with documented clinical improvement & tolerate po Ampicillin-sulbactam  Amoxicillin-clavulanate Azithromycin* Cefazolin  Cephalexin* Ceftriaxone  Cefpodoxime* Ciprofloxacin* Clindamycin* Doxycycline Fluconazole Linezolid* Metronidazole* Ordersets built in CPOE system for common medications

45 Action: Vancomycin UtilizationReview in Medical Intensive Care Units at MSSL & MSW Demographics MSSL (n = 47) MSW (n = 15) Total (n = 62) Sex, Age Male Female 28 19 7 8 35 27 Mean Age (years) 66 63 65 Indications Empiric, n (%) 43 (91.5) 15 (100) 58 (93.5) Treatment, n (%) 4 (8.5)* 0 (0) 4 (6.5) Risk Factors for MRSA Colonization, n (%) 7 (14.9) 7 (11.3) Recent antibiotic use, n (%) 18 (38.3) 7 (46.7) 25 (40) ESRD on HD, n (%) 2 (4.2) 2 (3.2) SNF/NH, n (%) 6 (12.8) 6 (9.7) Recent Hospitalization, n (%) 22 (46.8) 6 (40) 28 (45.2) Immunocompromised, n (%) 4 (26.7) 11 (17.7) > 2 RF’s, n (%) 20 (42.6) 3 (20) 23 (37) 0 RF’s, n (%)** 14 (29.8) 18 (29) MRSA Surveillance Positive 5 (10.6) 5 (8) Negative 37 (78.7) 52 (83.9) Ordered Pending 3 (6.4) 3 (4.8)

46 Action: Vancomycin UtilizationResults Composites MSSL (n = 47) MSW (n = 15) Total (n = 62) Total Vancomycin Use Days 210 117 327 Mean Days/Patient 4.5 7.8 5.2 Excess Days 69 45 109 Excess Doses 110 60 170 Excess Cost $1,104.00 $602.18 $1,706.18 Total Vancomycin Levels Number 59 37 96 Levels/Patient 1.3 2.4 1.5 Excess Levels 18 39 Excess Levels/Patient 0.6 1.2 0.63 $129.78 $259.56 Total Excess Cost $1,233.78 $731.96 $1,965.74 Estimated Annual Excess Cost $10,692.76 $12,687.31 $23,380.07

47 Action – Future Initiatives72 Hour Automatic Stop Orders Vancomycin Continuation Requires ID Approval Implementation Hospital Wide Pathways for Management of Common Infections Appropriate Diagnosis, Treatment, Duration Minimize Utilization of Fluoroquinolones

48 Tracking & Reporting Healthcare Association of New York State (HANYS) Antibiotic Stewardship Collaborative Antimicrobial Monitoring Group (MSSL & MSW) Hospital Acquired Infections (HAIs) CLABSI CAUTI VAP C. Difficile Antimicrobial Subcommittee Pharmacy & Therapeutics Committee HANYS statewide hospital and continuing care association in New York. We are located near Albany and represent 500 not-for-profit and public hospitals, nursing homes, home care agencies, and other healthcare organizations. HANYS is committed to supporting members as they accelerate their focus on antibiotic stewardship, providing tools and resources to reduce drug-resistant organisms, prevent Clostridium difficile infections, and prepare for future mandates. (IPRO)

49 Education Patient Education on Therapy Initiation & DischargeAntibiogram on Intranet Annual Housestaff Presentation on ASP Online Annual Competencies through Portal for Education & Advancement of Knowledge (PEAK) Infection Prevention and Control & Hand Hygiene (All Staff) IV to PO Conversion of Antimicrobial Agents (Specific to Pharmacy) Sepsis Education (All Staff) Debriefing for all Hospital Acquired Infections (HAIs) Catheter-Associated Urinary Tract Infection (CAUTI) Central Line-Associated Blood Stream Infecdtion (CLABSI) C. Difficile Ventilator-Associated Pneumonia (VAP) Patient Education on Therapy Initiation & Discharge IC&P CLABSI-Biopatch for nursing

50 Summary Antimicrobial Resistance Antimicrobial Stewardship ProgramsGlobal Concern with minimal options for future antimicrobial therapy Results from inappropriate use of antibiotics (i.e. over-prescribing) Utilization of last line options increasing adverse consequences (i.e. nephrotoxicity, hospital-acquired infections) Antimicrobial Stewardship Programs Systematic and multidisciplinary approach Appropriate use of antimicrobial agents to achieve optimal patient outcomes Effective January 1, 2017 required implementation for all hospitals by TJC & CMS ASP Should Incorporate Goals appropriate for needs & resources available Coordination among staff, services & programs responsible for antimicrobial use and resistance Documentation of antimicrobial utilization, evidence based policies & protocols, Education to all hospital staff involved and patients Strategies for implementing improvement processes for ASP

51 QUESTIONS?

52 The Role of the Antimicrobial Stewardship In the Acute Care Inpatient SettingKimberly Sarosky, MS, PharmD, BCPS Clinical Pharmacy Specialist Infectious Diseases & Critical Care Mount Sinai St. Luke’s