85: WAAW - Being a Stewie

Sara Dong: 00:00:08

Hey, everyone.

Sara Dong: 00:00:09

Welcome to Febrile, a cultured podcast about all things infectious disease.

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We use consult questions to dive into ID clinical reasoning, diagnostics,

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and anti-microbial management.

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I'm Sara Dong, your host.

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I am excited to introduce our guests today.

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First up is our cohost Dr.

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Reinaldo or Rey Perez.

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He has a third year ID fellow at Duke University Medical Center.

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He works with the Duke Center for Antimicrobial Stewardship and

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Infection Prevention to further their mission of improving patient

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safety and enhancing quality of care.

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His research interests include implementation of anti-microbial

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stewardship interventions and leveraging interprofessional teams.

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He also has additional interest as a medical educator with a passion for

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curriculum development and effective assessment of educational interventions.

Rey Perez: 00:00:58

Hey Sara, thanks so much for having me.

Rey Perez: 00:01:00

This is so exciting to be here.

Sara Dong: 00:01:01

Next meet Dr.

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Andrew Watkins.

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He is an infectious diseases pharmacist at Saint Dominic Jackson Memorial Hospital

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in Jackson, Mississippi, and serves as the pharmacy stewardship lead for the

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hospital, as well as the Franciscan Missionaries of Our Lady Health System.

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His responsibilities include prospective audit and feedback, policy and

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protocol development, implementation of stewardship initiatives, antimicrobial

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use tracking and reporting, and education of frontline staff on ID and

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anti-microbial stewardship related topics.

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He also precepts pharmacy residents on anti-microbial

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stewardship learning experiences.

Andrew Watkins: 00:01:37

Hey Sara, this is Andrew Watkins.

Andrew Watkins: 00:01:39

Thanks for having me.

Sara Dong: 00:01:40

And last but not least is an old friend of the show, Dr.

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Jonathan Ryder.

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He is an Assistant Professor in the Division of Infectious Diseases at

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University of Nebraska Medical Center.

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He serves as an Associate Medical Director of Antimicrobial Stewardship,

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with interest in diagnostic stewardship and stewardship in rural settings.

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He is also an Associate Hospital Epidemiologist with the infection

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control and epidemiology program.

Sara Dong: 00:02:04

Lastly, he has interest in digital medical education and is co-director

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of the microbiology block for the first year medical students.

Jonathan Ryder: 00:02:11

Hi, this is Jonathan Ryder.

Jonathan Ryder: 00:02:13

I am really excited to be back on Febrile.

Sara Dong: 00:02:16

Okay.

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You guys know the drill.

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Before we talk about the case and the episode today, we always ask about sharing

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a piece of culture because Febrile is everyone's favorite cultured podcast.

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So I would love to hear about something that you have had fun with

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recently, or that has brought you joy.

Jonathan Ryder: 00:02:34

Yeah, so today's episode is nearing Thanksgiving, and so I thought

Jonathan Ryder: 00:02:38

I'd come up with a piece of culture related to that, mainly pointing out

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that I think Thanksgiving is my personal favorite of the holidays with its triple

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threat of, uh, family, food and football.

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And, since my football team isn't playing this year, uh, on Thursday, I am going

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to choose my favorite Thanksgiving dish as my culture recommendation.

Jonathan Ryder: 00:03:00

And, uh, my favorite is, uh, my mom's sweet potato casserole.

Jonathan Ryder: 00:03:05

Uh, it has pecans on top, not a fan of the marshmallows that some

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people do, uh, for that dish.

Jonathan Ryder: 00:03:12

So that's gonna be my pick.

Sara Dong: 00:03:15

Well, I feel like I have to ask, do you just not like marshmallows.

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Are you morally opposed to having them on top of sweet potatoes?

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You know, I grew up having marshmallows on my like super potato, yam casserole,

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so I actually didn't realize until recently that that was something that

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some people thought was, uh, a bit weird.

Jonathan Ryder: 00:03:34

I love marshmallows, but not in that dish.

Jonathan Ryder: 00:03:38

Um, and I think that's not how that dish was made for me growing up and

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so that concept doesn't work for me.

Jonathan Ryder: 00:03:46

But, uh, over an open campfire, big marshmallow fan.

Sara Dong: 00:03:50

Got it.

Sara Dong: 00:03:51

So, uh, how about you, Rey?

Rey Perez: 00:03:53

So sticking with the holiday theme as well with, uh, Thanksgiving

Rey Perez: 00:03:57

and Christmas around the corner.

Rey Perez: 00:03:58

My family comes from Puerto Rico and we have a very special tradition there.

Rey Perez: 00:04:02

It's a unique version of Christmas caroling called parrandas, where you go

Rey Perez: 00:04:06

around the neighborhood creating a bigger and bigger band essentially to sing

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Christmas carols and then everyone who you sing at their house has to feed you.

Rey Perez: 00:04:14

So it's just a really special and really, uh, fun and crazy tradition.

Sara Dong: 00:04:18

Amazing.

Sara Dong: 00:04:20

Uh, Andrew, you want to finish this up?

Andrew Watkins: 00:04:23

Yeah, I'm, I'm gonna stick with the holidays

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too and we'll kinda look ahead.

Andrew Watkins: 00:04:26

No, no offense to Thanksgiving 'cause I do enjoy that.

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But really looking forward to Christmas.

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Um, it's really fun time of year, you know, it's almost

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time to start decorating.

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I'm very much a Black Friday Christmas decoration person.

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Um, so I do give Thanksgiving it's due, but then we jump into the decorations,

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um, you know, getting the kids to really get involved in that and enjoy that.

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And then seeing family.

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So really busy time of year, but one I really enjoy.

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So This week is US Antibiotic Awareness Week, this annual campaign

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from the Centers for Disease Control Prevention seeks to highlight the steps

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everyone can take to improve antibiotic prescribing and use, as well as being

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a rallying cry in the fight against increasing antimicrobial resistance.

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In honor of this, today's case will be focused on hospital

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antibiotic stewardship programs.

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Uh, and this episode is brought to you in collaboration with the Society of

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Hospital Epidemiology Antimicrobial Stewardship Committee, for which Dr.

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Ryder is a member.

Sara Dong: 00:05:22

So this week, you're on call for the hospital's antimicrobial

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stewardship pager, and today's consult question comes after you receive a

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call from the cardiac surgery team requesting approval for daptomycin

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after a preoperative urine culture grew vancomycin resistant Enterococcus

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faecium in a penicillin allergic patient.

Rey Perez: 00:05:42

So Jonathan, before we really get started, not everyone here

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may be familiar with the structure of antimicrobial stewardship teams or

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some of the techniques that we commonly use when we're serving this role.

Rey Perez: 00:05:54

So before we get into the details of this case, I think it'd be great if we

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discuss some of the essential components of a stewardship team and think about

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two of the core interventions that we utilize - antibiotic restriction

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and post prescription review.

Rey Perez: 00:06:07

So just to start, Jonathan, why do we need stewardship teams?

Jonathan Ryder: 00:06:10

Thanks, Ray.

Jonathan Ryder: 00:06:11

Such a, such a great question and I'm glad we're starting with the basics

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after, uh, hearing that consult question.

Jonathan Ryder: 00:06:16

So there's kind of a, kind of a lot going on there.

Jonathan Ryder: 00:06:19

So there there's several reasons why we need stewardship teams.

Jonathan Ryder: 00:06:22

So antimicrobial resistance is a, is a growing problem of international scale,

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and a 2014 report estimated that if antimicrobial resistance continues on

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its current trajectory, that by 2050, about 10 million people would die

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each year as a result of antimicrobial resistance, with a global cost up

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to a hundred trillion US dollars.

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And so, while, uh, antimicrobial resistance is, is a growing issue,

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we also have a pretty big issue with appropriate antibiotic prescribing.

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And so when you look at common reasons for antimicrobial, uh, uh, prescriptions,

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the, the data show that it, it was inappropriate in about 80% of patients

Jonathan Ryder: 00:07:05

that have community acquired pneumonia, about three quarters that have urinary

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tract infections, half of patients who are prescribed fluoroquinolones and about

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a quarter of patients who are receiving intravenous vancomycin, uh, antibiotics.

Jonathan Ryder: 00:07:18

And, and the reasons why we see inappropriate antibiotics are usually

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due to inappropriately uh, long therapy in patients with, uh, community acquired

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pneumonia and in urinary tract infection, about half of patients, um, don't have

Jonathan Ryder: 00:07:32

any signs or symptoms of infection.

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And so ultimately, antimicrobial stewardship programs are in place because

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as infectious disease doctors, we can't, uh, be consultants on every single patient

Jonathan Ryder: 00:07:44

on antibiotics, and so we need to have larger systems-based interventions that

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improve our utilization of antimicrobials.

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And, and similarly, you have to track what you do, uh, in order to make

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changes and to make improvements and having a dedicated stewardship team and

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program really helps with tracking and reporting and, and building accountability

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to help drive these improvements.

Jonathan Ryder: 00:08:09

And ultimately, antimicrobial stewardship teams are about improving patient care.

Jonathan Ryder: 00:08:13

And I always want to emphasize this point because sometimes people really

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see these as more, uh, health system or, more societally driven, uh, programs.

Jonathan Ryder: 00:08:23

And while those things are certainly true, that there are downstream benefits,

Jonathan Ryder: 00:08:27

uh, to society and the health system, ultimately what we do on the day-to-Day

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is about optimizing patient care.

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That we're making sure that each patient receives the right drug, for the

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right bug, at the right dose, for the right duration, and at the right time.

Jonathan Ryder: 00:08:40

And so I always think that stewardship programs really at the core of them

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are taking care of our patients.

Rey Perez: 00:08:46

Thanks for that.

Rey Perez: 00:08:47

Jonathan, I think you really helped put into context what the

Rey Perez: 00:08:49

nature of the problem is here.

Rey Perez: 00:08:51

And uh, Andrew, just to pull you in, you know, when you think about what really

Rey Perez: 00:08:55

makes a great stewardship team, what are those core features that make it work?

Rey Perez: 00:08:59

You know, what do you think about?

Andrew Watkins: 00:09:01

Yeah, so luckily CDC has done a lot of the homework

Andrew Watkins: 00:09:03

for me and has a really great list of those CDC core elements.

Andrew Watkins: 00:09:07

So what are their basic, the most essential parts of a stewardship program?

Andrew Watkins: 00:09:13

And they have seven that are very clearly defined.

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They have hospital leadership commitment, they have accountability,

Andrew Watkins: 00:09:20

they have pharmacy expertise,

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action, . tracking, reporting and education.

Andrew Watkins: 00:09:27

So I just wanna kind of run through those and give a very high level view

Andrew Watkins: 00:09:30

of what is involved with each of those.

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And so looking at hospital leadership commitment.

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CMS is very clear that institutional leadership, along with quality

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improvement must address issues that are identified by the infection prevention

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and the stewardship committees.

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Uh, and this open communication between stewardship and hospital leaderships

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really helps facilitate this.

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And this is really important 'cause a lot of the bigger stewardship initiatives

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can really flounder if you don't have that administrative support and kind

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of like leadership weight behind them.

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Hospitals can demonstrate this leadership through funding positions, and so

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actually having dedicated funding for salary for these positions, having

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dedicated FTEs for these positions.

Andrew Watkins: 00:10:10

Um, and another way that you can show leadership support is just by

Andrew Watkins: 00:10:13

having some public statements of support that leadership can sign.

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You can display these across your institution, um, or publish them

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on websites, um, just to show that that leadership is, committed to

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supporting antimicrobial stewardship.

Andrew Watkins: 00:10:25

Talking about the accountability piece, uh, is, is more centered around

Andrew Watkins: 00:10:29

having a clear leadership structure within the stewardship program.

Andrew Watkins: 00:10:32

So typically that's gonna take the form of a physician leader, uh,

Andrew Watkins: 00:10:36

and a pharmacist as co-leaders.

Andrew Watkins: 00:10:37

Um, but you can have stewardship programs that have just a single leader.

Andrew Watkins: 00:10:41

These roles should ideally be clarified, so it's always clear who's

Andrew Watkins: 00:10:44

running the stewardship program and who's accountable for the metrics and

Andrew Watkins: 00:10:48

outcomes with the stewardship program.

Andrew Watkins: 00:10:49

One often overlooked point, things that we've seen

Andrew Watkins: 00:10:52

Or not thought about in a lot of surveys, um, is that these leaders should have

Andrew Watkins: 00:10:57

some sort of education or training or experience in infectious diseases

Andrew Watkins: 00:11:01

or antimicrobial stewardship, um, as outlined by Joint Commission in CMS.

Andrew Watkins: 00:11:05

And so this can be your kind of classic post-graduate training with an ID

Andrew Watkins: 00:11:09

fellowship or ID pharmacy residency, um, or can be through certificate

Andrew Watkins: 00:11:13

courses plus ongoing continuing education kind of year to year.

Andrew Watkins: 00:11:17

Looking at pharmacy expertise really focuses more on the pharmacy co-leader

Andrew Watkins: 00:11:21

of the stewardship program, and really is another essential element of that.

Andrew Watkins: 00:11:25

You know, I'm biased as a pharmacist, but I will say that because of the

Andrew Watkins: 00:11:29

positioning of pharmacists within the healthcare system, kind of our roles,

Andrew Watkins: 00:11:33

we can be really helpful in stewardship programs because we interface with so many

Andrew Watkins: 00:11:36

different aspects of the healthcare team.

Andrew Watkins: 00:11:39

We also are situated really well to have access to antibiotic use, to

Andrew Watkins: 00:11:42

help kind of track that over time and help with that reporting piece.

Andrew Watkins: 00:11:46

Um, already integrated into the Pharmacy and Therapeutics committee, which

Andrew Watkins: 00:11:49

really helps, uh, with integration with that for leadership and quality.

Andrew Watkins: 00:11:53

They're also just very familiar with drug specific information like

Andrew Watkins: 00:11:57

pharmacokinetics and dynamics and all those fun things that go into how

Andrew Watkins: 00:12:01

we optimize dosing of antibiotics.

Andrew Watkins: 00:12:03

So all in all, really helpful to have a pharmacist co-leader, um, in stewardship.

Andrew Watkins: 00:12:07

The action core element, um, has intervention such as prospective audit

Andrew Watkins: 00:12:11

and feedback or pre-authorization, which we'll talk about here in a little bit.

Andrew Watkins: 00:12:15

Um, also facility specific treatment guidelines.

Andrew Watkins: 00:12:18

They're also a very key action element, and will be required by

Andrew Watkins: 00:12:21

Joint Commission, uh, as of this year.

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having at least two of those implemented.

Andrew Watkins: 00:12:25

So really important from a, a regulatory standpoint as well.

Andrew Watkins: 00:12:28

And overall action is probably the broadest and most vague of all of

Andrew Watkins: 00:12:32

the core elements because there are so many things that you can do.

Andrew Watkins: 00:12:35

You could have automatic protocols, uh, for renal dosing or IV to PO

Andrew Watkins: 00:12:39

conversions, kinetics based dosing, antibiotic timeout processes or

Andrew Watkins: 00:12:43

handshake rounds, automatic stop dates.

Andrew Watkins: 00:12:46

So this is where you can really fit in a lot of the, the

Andrew Watkins: 00:12:48

interventions in the day-to-Day.

Andrew Watkins: 00:12:49

Like big projects in the stewardship programs.

Andrew Watkins: 00:12:52

Tracking is vital because of its utility in helping to find opportunities for

Andrew Watkins: 00:12:56

improvement, for tracking progress of any interventions you've implemented,

Andrew Watkins: 00:13:01

and helping to build accountability.

Andrew Watkins: 00:13:02

There are tons of different metrics.

Andrew Watkins: 00:13:04

We could probably have a whole hour talk on just what metrics

Andrew Watkins: 00:13:06

you could track but really one of the most basic is antibiotic use.

Andrew Watkins: 00:13:09

Uh, and so actually tracking and reporting antibiotic use to NHSN, which is the

Andrew Watkins: 00:13:15

National Healthcare Safety Network, is a regulatory requirement starting in 2024.

Andrew Watkins: 00:13:20

Uh, and it serves as a great method of not only tracking your use, but

Andrew Watkins: 00:13:23

help establish some benchmarking and comparisons to similar hospitals.

Andrew Watkins: 00:13:27

It's especially helpful to track in relation to any particular

Andrew Watkins: 00:13:30

initiatives you have going on.

Andrew Watkins: 00:13:31

So maybe you have, you know, new guidance to help decrease use of

Andrew Watkins: 00:13:35

broad spectrum hospital agents.

Andrew Watkins: 00:13:37

And then you can actually track this over time.

Andrew Watkins: 00:13:39

And CDC has a ton of great examples on their website of some of these

Andrew Watkins: 00:13:42

ways to actually track this data.

Andrew Watkins: 00:13:44

But then you can also encompass other aspects of tracking.

Andrew Watkins: 00:13:47

So, you know, number or type of audit and feedback patient interventions.

Andrew Watkins: 00:13:51

And so that's really helpful 'cause it can highlight the

Andrew Watkins: 00:13:53

impact of your stewardship group.

Andrew Watkins: 00:13:55

You know, how many interventions are you having, what's your acceptance

Andrew Watkins: 00:13:57

rate, um, and then also helping to justify some of those continued

Andrew Watkins: 00:14:02

funding and additional, uh, positions.

Andrew Watkins: 00:14:03

You can also track other outcomes like c diff or MDRO infections.

Andrew Watkins: 00:14:07

And so the list is really long on tracking, but what's really important is

Andrew Watkins: 00:14:11

that after you track, you actually go to the next core element, which is reporting.

Andrew Watkins: 00:14:15

So really reporting is your kind of actionable.

Andrew Watkins: 00:14:17

Back inside of tracking where you take the data that you've actually, uh, tracked and

Andrew Watkins: 00:14:22

you've deemed most important, and then you relay that back to your frontline staff.

Andrew Watkins: 00:14:26

And so that's important because it's gonna increase transparency and buy-in

Andrew Watkins: 00:14:29

for those providers, especially when you pair that with the reporting and

Andrew Watkins: 00:14:32

education and ongoing interventions.

Andrew Watkins: 00:14:35

It also makes the data more actionable and helps with modifying initiatives that may

Andrew Watkins: 00:14:39

not be doing so well from the beginning, you look and say, you know, Hey, we

Andrew Watkins: 00:14:42

implemented this a month ago and we're not seeing really any movement in our use.

Andrew Watkins: 00:14:46

What can we do better?

Andrew Watkins: 00:14:47

Can we educate better?

Andrew Watkins: 00:14:49

Can we communicate this?

Andrew Watkins: 00:14:50

Um, or maybe you highlight some early successes that you can take

Andrew Watkins: 00:14:53

back immediately and say, look, we started this last month and we're

Andrew Watkins: 00:14:55

having, we're seeing a huge impact.

Andrew Watkins: 00:14:57

Like keep good job, keep going, and really helps with that kind of morale and buy-in.

Andrew Watkins: 00:15:01

Overall, the combination of tracking and reporting really helped drive

Andrew Watkins: 00:15:04

the program forward, uh, and work as a great accountability piece.

Andrew Watkins: 00:15:08

And then lastly, education.

Andrew Watkins: 00:15:10

It's really kind of one of the more nebulous topics of core elements because

Andrew Watkins: 00:15:13

it can take so many different forms, have so many different audiences.

Andrew Watkins: 00:15:16

Education can involve prescribers or pharmacists, nurses, you can

Andrew Watkins: 00:15:21

educate patients and family.

Andrew Watkins: 00:15:22

And then you could cover a whole host of topics from resistance.

Andrew Watkins: 00:15:26

You know, the harms of antibiotics, optimal prescribing.

Andrew Watkins: 00:15:29

Uh, it can really take the form of institutional guidelines or

Andrew Watkins: 00:15:33

antibiograms, uh, hospital policies in-service presentation handouts.

Andrew Watkins: 00:15:37

I mean, you name it, and you can educate on it essentially.

Andrew Watkins: 00:15:40

And so because of that, usually I recommend keeping a log of education,

Andrew Watkins: 00:15:43

things that you've done, you know.

Andrew Watkins: 00:15:45

Who you educated, when you educated, and then what did you actually educate about?

Andrew Watkins: 00:15:49

Um, so that if you're ever asked by a surveyor, you know, prove

Andrew Watkins: 00:15:52

to me what education you've done, you can have a list there.

Andrew Watkins: 00:15:54

They'll say, oh yeah, we went to this session back in July.

Andrew Watkins: 00:15:57

Um, and then also just to make your lives easier.

Andrew Watkins: 00:16:00

'cause there's so much going on, uh, in the day-to-Day of a stewardship program.

Andrew Watkins: 00:16:04

Try to pair your education with whatever initiative you're

Andrew Watkins: 00:16:07

really trying to push forward.

Andrew Watkins: 00:16:08

So, you know, you're, you're implementing this new initiative

Andrew Watkins: 00:16:10

that's part of the action core element.

Andrew Watkins: 00:16:12

Uh, and then you, you're educating providers on that as well.

Andrew Watkins: 00:16:15

You're reporting back and so you really hit a lot of these core elements

Andrew Watkins: 00:16:17

all at one time with one initiative.

Rey Perez: 00:16:20

Well, thanks so much Andrew, for that really comprehensive overview.

Rey Perez: 00:16:23

I feel like I can just see the stewardship team in action already with

Rey Perez: 00:16:26

everything that you've described there.

Rey Perez: 00:16:28

Now, uh, Jonathan, to pop back to you, I did want to expand a little bit

Rey Perez: 00:16:32

on one thing that Andrew was talking about, and that's 'cause the CDC

Rey Perez: 00:16:34

highlights as a priority intervention,

Rey Perez: 00:16:38

two of the things that stewardship programs do that have the most evidence

Rey Perez: 00:16:42

for efficacy, and that's prospective audit and feedback and pre-authorization.

Rey Perez: 00:16:47

Can you tell us a little bit more about what these tools are and how they work?

Jonathan Ryder: 00:16:50

Thanks, Ray.

Jonathan Ryder: 00:16:51

Yeah, so there's these sort of two, um, philosophies and approaches to

Jonathan Ryder: 00:16:55

antimicrobial stewardship and, and how it takes place, uh, in action.

Jonathan Ryder: 00:17:00

And so prospective audit and feedback is really kind of reviewing from an external

Jonathan Ryder: 00:17:06

standpoint how antibiotics are being used.

Jonathan Ryder: 00:17:08

And then, uh, after reviewing cases, identifying opportunities

Jonathan Ryder: 00:17:13

to improve that use.

Jonathan Ryder: 00:17:14

Audit and feedback occurs after an antibiotic is prescribed.

Jonathan Ryder: 00:17:18

And this can take place in many different formats, either by messaging

Jonathan Ryder: 00:17:23

or calling a team, or actually in a face-to-face format, which is known as

Jonathan Ryder: 00:17:28

handshake stewardship in which, uh, the recommendations actually occur in person.

Jonathan Ryder: 00:17:33

And so, in contrast to prospective audit and feedback is pre-authorization, also

Jonathan Ryder: 00:17:38

known sometimes by restriction, and this is really requiring some sort of approval,

Jonathan Ryder: 00:17:44

uh, by the antimicrobial stewardship team in order to use a certain antibiotic.

Jonathan Ryder: 00:17:49

And this really allows for the antimicrobial stewardship team to give

Jonathan Ryder: 00:17:54

their input whenever a prescriber is interested in using that antibiotic.

Jonathan Ryder: 00:17:59

And really prevent unnecessary initiation of antibiotics as well.

Jonathan Ryder: 00:18:03

And so these two different forms have actually been compared, uh, directly and

Jonathan Ryder: 00:18:08

generally prospective audit and feedback has been shown to be more effective.

Jonathan Ryder: 00:18:13

However, there's really a use for both of these in stewardship

Jonathan Ryder: 00:18:17

programs depending on some of the different situations that pop up.

Rey Perez: 00:18:24

Could you expand on that a little bit more?

Rey Perez: 00:18:26

Like what do you see as some of these pros and cons between these two

Rey Perez: 00:18:29

different approaches and how have you synthesized that and applied it

Rey Perez: 00:18:32

at your own institution for example?

Jonathan Ryder: 00:18:35

Yeah, so prospective audit and feedback's, uh, really strong

Jonathan Ryder: 00:18:39

points are that you are providing a direct education to the prescriber

Jonathan Ryder: 00:18:44

when you're providing that feedback.

Jonathan Ryder: 00:18:46

It also allows for a lot of autonomy for prescribers, and it really empowers those,

Jonathan Ryder: 00:18:51

um, team members to make their own initial decisions about what antibiotics to use.

Jonathan Ryder: 00:18:56

It really creates kind of a collegial environment because decisions are made

Jonathan Ryder: 00:18:59

in a, in a collective, uh, manner.

Jonathan Ryder: 00:19:02

One pro when you're running a program is that prospective audit and feedback

Jonathan Ryder: 00:19:06

is, is primarily during, uh, daytime hours, actually almost exclusively.

Jonathan Ryder: 00:19:11

Uh, so not a lot of phone calls in the middle of the night.

Jonathan Ryder: 00:19:14

The other part of this is since you're providing education, you may actually

Jonathan Ryder: 00:19:19

have kind of downstream impacts on multiple components of antibiotic

Jonathan Ryder: 00:19:23

use throughout your hospital system.

Jonathan Ryder: 00:19:25

And then you're also able to comment to that individual about both the

Jonathan Ryder: 00:19:30

antibiotic that's being used, but also dosing, duration, deescalation.

Jonathan Ryder: 00:19:34

And so . There's multiple components that can be affected.

Jonathan Ryder: 00:19:39

The problems with prospective audit and feedback is it can be kind of

Jonathan Ryder: 00:19:42

resource intensive to actually go through a, a list, for example, every

Jonathan Ryder: 00:19:46

day, uh, spend time in those patient charts, reviewing the indications,

Jonathan Ryder: 00:19:50

the dosing, the durations, et cetera, for each of those individual patients.

Jonathan Ryder: 00:19:54

Another disadvantage is that the patient already receives usually at

Jonathan Ryder: 00:19:59

least one dose of antibiotics, if not several D doses, or even several days of

Jonathan Ryder: 00:20:03

antibiotics before an intervention occurs.

Jonathan Ryder: 00:20:05

And so some of that upfront antibiotic use, uh, when deemed

Jonathan Ryder: 00:20:09

inappropriate already has occurred.

Jonathan Ryder: 00:20:12

And then ultimately the prescribers can do what they want.

Jonathan Ryder: 00:20:15

That autonomy does allow, uh, for the prescribers to disagree with

Jonathan Ryder: 00:20:20

the stewardship team, and that may mean that, um, the recommendations

Jonathan Ryder: 00:20:25

do not have a great uptake.

Jonathan Ryder: 00:20:27

So to, to contrast that with pre-authorization, its big advantage

Jonathan Ryder: 00:20:31

is it really allows more control by the stewardship team over antibiotic

Jonathan Ryder: 00:20:36

prescribing es, especially in that upfront empiric and initial antibiotic choice

Jonathan Ryder: 00:20:41

or, or choice to not initiate therapy.

Jonathan Ryder: 00:20:44

And I think this is especially effective and useful when you're

Jonathan Ryder: 00:20:48

talking about really expensive antibiotics, newer antibiotics that

Jonathan Ryder: 00:20:52

people may be less familiar with.

Jonathan Ryder: 00:20:54

Or, antimicrobials that may be more toxic or for example, antifungal

Jonathan Ryder: 00:21:00

agents or certain antiviral agents.

Jonathan Ryder: 00:21:02

Another situation can be whenever, um, you're facing shortages and there's

Jonathan Ryder: 00:21:06

just a very limited supply that a few wasted doses goes a long way.

Jonathan Ryder: 00:21:11

So the concept pre-authorization are that there's a lot less prescriber autonomy.

Jonathan Ryder: 00:21:15

There's usually some sort of phone call that has to take place, usually

Jonathan Ryder: 00:21:19

asking for some sort of permission for antibiotics, which can be a, a fairly

Jonathan Ryder: 00:21:24

adversarial interaction at some points in time, and this oftentimes will also

Jonathan Ryder: 00:21:28

involve some sort of overnight call.

Jonathan Ryder: 00:21:31

And this intervention is really limited only to the antibiotics

Jonathan Ryder: 00:21:34

that are on the restricted list.

Jonathan Ryder: 00:21:35

So it doesn't help with antibiotic durations or dosing

Jonathan Ryder: 00:21:40

or non-restricted antibiotics.

Jonathan Ryder: 00:21:42

And of course, the, the last concern I'll bring up is that this pre-authorization

Jonathan Ryder: 00:21:47

process could result in delays of therapy to patients who are especially

Jonathan Ryder: 00:21:52

critically ill, which, uh, could be a, a downstream consequence.

Jonathan Ryder: 00:21:56

So my experience at my institution is that we largely use prospective

Jonathan Ryder: 00:22:01

audit and feedback for our daily stewardship activities, which does

Jonathan Ryder: 00:22:05

take a, a really dedicated stewardship team that's dedicating time to this.

Jonathan Ryder: 00:22:09

But we review lists of key antibiotics and diagnostic tests.

Jonathan Ryder: 00:22:13

So for example, all positive blood cultures and rapid molecular diagnostic

Jonathan Ryder: 00:22:18

testing results and antibiotics that are higher risk for, uh, uh,

Jonathan Ryder: 00:22:22

Clostridoides difficile, such as, uh, fluoroquinolones and clindamycin.

Jonathan Ryder: 00:22:26

And then we look at broad spectrum agents like vancomycin, piperacillin-tazobactam,

Jonathan Ryder: 00:22:29

cefepime et cetera.

Jonathan Ryder: 00:22:31

And, and we provide that, uh, feedback to clinicians based on, um, the

Jonathan Ryder: 00:22:35

antibiotics that they've prescribed.

Jonathan Ryder: 00:22:37

But we also use pre-authorization and restrictions on certain antibiotics,

Jonathan Ryder: 00:22:42

such as those that I mentioned that have higher adverse, uh, event

Jonathan Ryder: 00:22:45

profiles or, that are more expensive.

Jonathan Ryder: 00:22:48

And these are also reviewed as part of the, uh, prospective audit and

Jonathan Ryder: 00:22:52

feedback process where oftentimes clinicians may be able to access a

Jonathan Ryder: 00:22:56

dose overnight, but then the next day, uh, feedback is given to adjust that.

Rey Perez: 00:23:00

Awesome.

Rey Perez: 00:23:01

Well, now that our toolkits are filled with all of these new useful

Rey Perez: 00:23:06

ideas to tackle the this case, why don't we go ahead and dive right in.

Rey Perez: 00:23:10

So, our patient is a 67 year old male with a past medical history

Rey Perez: 00:23:14

of hypertension, type two diabetes, obesity, and coronary artery disease.

Rey Perez: 00:23:19

Over the last two months, he developed symptoms of stable angina

Rey Perez: 00:23:22

and outpatient coronary angiography demonstrated three vessel disease.

Rey Perez: 00:23:27

He was seen by cardiothoracic surgery as an outpatient, and he has planned for

Rey Perez: 00:23:30

coronary artery bypass grafting tomorrow.

Rey Perez: 00:23:33

The cardiothoracic surgery team has the practice of collecting a urine

Rey Perez: 00:23:37

culture on all patients as part of their routine preoperative labs.

Rey Perez: 00:23:41

He has not reported any fever, dysuria, frequency, urgency,

Rey Perez: 00:23:46

or other urinary symptoms

Rey Perez: 00:23:47

of note.

Rey Perez: 00:23:49

His allergy history is significant for a listed penicillin allergy.

Rey Perez: 00:23:52

Patient's mother reportedly told him in childhood around seven,

Rey Perez: 00:23:56

he developed a rash after being given penicillin for a sore throat.

Rey Perez: 00:24:00

He does not believe that it required treatment at that time.

Rey Perez: 00:24:03

He has avoided repeat exposure since then.

Rey Perez: 00:24:06

His labs are fairly unremarkable.

Rey Perez: 00:24:07

His CBC had a white blood cell count of 7.6 with a normal differential, a

Rey Perez: 00:24:12

hemoglobin of 12.7 and platelets of 256.

Rey Perez: 00:24:16

His complete metabolic panel showed normal electrolytes and

Rey Perez: 00:24:20

normal liver transaminases.

Rey Perez: 00:24:22

A serum glucose of 183 and a serum creatinine of 1.2, which was his baseline.

Rey Perez: 00:24:27

His urinalysis had an unremarkable dipstick and on microscopic analysis

Rey Perez: 00:24:32

showed five white blood cells per high powered field, one red blood cell per

Rey Perez: 00:24:36

high powered field, and 10 squamous epithelial cells per high powered

Rey Perez: 00:24:39

field without any cast visualized.

Rey Perez: 00:24:42

His urine culture grew Enterococcus faecium that was susceptible to

Rey Perez: 00:24:46

ampicillin and resistant to vancomycin.

Rey Perez: 00:24:49

As mentioned earlier, you are on the antimicrobial stewardship pager.

Rey Perez: 00:24:53

And you get a call for linezolid, a drug that requires

Rey Perez: 00:24:56

pre-authorization at your institution.

Rey Perez: 00:24:58

So Jonathan, to go back to you, you know, as you think about this case, I know that

Rey Perez: 00:25:03

for me, being in the pre-authorization role as a fellow was sometimes awkward.

Rey Perez: 00:25:08

Uh, unlike a consult where you're being asked for help by the team, you're kind

Rey Perez: 00:25:12

of inserting yourself and sometimes perceived as the antibiotic police.

Rey Perez: 00:25:17

So how do you frame your role, or what other techniques do you use when

Rey Perez: 00:25:21

having to give this unsolicited advice?

Jonathan Ryder: 00:25:24

Yeah, this is, this is, um, a great, a great scenario

Jonathan Ryder: 00:25:27

here, and so . Um, you know, usually I, I start with introducing myself.

Jonathan Ryder: 00:25:33

Say, you know, hi, I am Jonathan.

Jonathan Ryder: 00:25:34

I'm with the antimicrobial stewardship team.

Jonathan Ryder: 00:25:37

And then I use an approach that I learned actually during the IDSA Antimicrobial

Jonathan Ryder: 00:25:42

Stewardship training course, which I'm gonna highly recommend and, and provide

Jonathan Ryder: 00:25:46

a little bit of a plug for, but this is, uh, known as the NARROWS, uh, mnemonic.

Jonathan Ryder: 00:25:51

I print this off and I hang it on my wall and, anytime I am, uh, facing a case or

Jonathan Ryder: 00:25:56

working with a trainee in stewardship, I always kind of review this and take a

Jonathan Ryder: 00:26:00

deep breath and really make sure I'm in the right place to kind of have this,

Jonathan Ryder: 00:26:03

um, conversation because sometimes there is a little bit of negotiation

Jonathan Ryder: 00:26:08

that happens through this process.

Jonathan Ryder: 00:26:10

So just gonna go through this mnemonic briefly and use this case as an example.

Jonathan Ryder: 00:26:14

But the first part of, uh, NARROWS is n and that's to name the issue.

Jonathan Ryder: 00:26:20

And so, you know, this is the patient, whoever that we're talking about.

Jonathan Ryder: 00:26:24

And, um, you're, you're calling asking about linezolid for, uh,

Jonathan Ryder: 00:26:29

treating a urinary tract infection is basically what you're calling me.

Jonathan Ryder: 00:26:33

And so I, I then go to a, which is to ask, what, what is the reason why,

Jonathan Ryder: 00:26:38

why do you want to use linezolid?

Jonathan Ryder: 00:26:40

What about this patient's uh, urinalysis and urine culture make you concerned?

Jonathan Ryder: 00:26:44

Um, and then r is to reflect their emotion.

Jonathan Ryder: 00:26:49

And so.

Jonathan Ryder: 00:26:50

I, I always try to empathize with the team and say, yeah, this patient's really sick,

Jonathan Ryder: 00:26:54

or in this situation, yeah, this patient's going for a big surgery tomorrow.

Jonathan Ryder: 00:26:58

I understand that we want to make sure this patient is optimized for this,

Jonathan Ryder: 00:27:02

uh, surgical intervention and they don't develop any sort of postoperative

Jonathan Ryder: 00:27:06

complications, uh, as a result.

Jonathan Ryder: 00:27:08

so the next r in narrows is to relate with personal experience.

Jonathan Ryder: 00:27:12

And so saying something like . Yeah, I remember, um, whenever I, uh, worked in

Jonathan Ryder: 00:27:18

the ICU and I was worried about a patient, um, uh, something to really kind of show

Jonathan Ryder: 00:27:23

that you care about that individual patient, you know, whatever your

Jonathan Ryder: 00:27:27

personal story or, or memory is, that's relevant for that particular situation.

Jonathan Ryder: 00:27:32

The O in narrows is to orient to the suggested management.

Jonathan Ryder: 00:27:35

So, um, I would say something like, in this case that you could use linezolid.

Jonathan Ryder: 00:27:40

It's a, it's, it actually is a really good option for treating someone with a true,

Jonathan Ryder: 00:27:45

uh, VRE, uh, urinary tract infection.

Jonathan Ryder: 00:27:47

However, in this situation, it, it doesn't seem like there's a lot of inflammation.

Jonathan Ryder: 00:27:52

I.

Jonathan Ryder: 00:27:52

Uh, on the urine culture, and, and the patient doesn't sound like they

Jonathan Ryder: 00:27:55

have any symptoms, and so this seems more like asymptomatic bacteruria.

Jonathan Ryder: 00:27:59

And so w then is working together on a plan.

Jonathan Ryder: 00:28:03

And so I then make a suggestion like, you know, do you feel . Comfortable, like,

Jonathan Ryder: 00:28:08

uh, discontinuing antibiotic therapy in this case and, and monitoring for, uh, the

Jonathan Ryder: 00:28:13

development of further urinary symptoms.

Jonathan Ryder: 00:28:15

And this is where sometimes there's a little negotiation that takes place.

Jonathan Ryder: 00:28:18

Maybe they're concerned for another reason.

Jonathan Ryder: 00:28:20

Maybe, maybe they tell me that they actually do have urinary symptoms and

Jonathan Ryder: 00:28:24

that, um, they're actually symptomatic.

Jonathan Ryder: 00:28:27

And that maybe what I understand from what they first told me or what I read

Jonathan Ryder: 00:28:30

in the chart actually isn't the case.

Jonathan Ryder: 00:28:33

And then s is to set follow up.

Jonathan Ryder: 00:28:35

And so, um, it, it can always be reassuring to say, Hey, call me back

Jonathan Ryder: 00:28:39

if, if the patient develops symptoms, or I'll keep an eye on the chart and

Jonathan Ryder: 00:28:42

wait on the susceptibilities or, the next set of labs or whatever the next

Jonathan Ryder: 00:28:46

marker is to really figure out, you know, how can I help this patient?

Rey Perez: 00:28:50

Thanks Jonathan for that really wonderful framework.

Rey Perez: 00:28:53

I think I'm gonna have to print it and hang it on my wall too.

Rey Perez: 00:28:56

Now, you know, as we think about this case, it, it has a ton of different

Rey Perez: 00:29:01

potential intervention points.

Rey Perez: 00:29:02

We could be talking with the team about diagnostic stewardship and

Rey Perez: 00:29:06

reducing unnecessary urine cultures.

Rey Perez: 00:29:08

We could go into a conversation about asymptomatic bacteruria like

Rey Perez: 00:29:12

you kind of alluded to earlier.

Rey Perez: 00:29:14

We could dive into this penicillin allergy that may or may not be real,

Rey Perez: 00:29:19

and talk about opportunities for de labeling penicillin allergies.

Rey Perez: 00:29:23

Andrew, to jump to you this time, how do you decide on the

Rey Perez: 00:29:27

priority of these interventions?

Rey Perez: 00:29:28

When you have lots of things on the menu in front of you, how

Rey Perez: 00:29:31

do you decide what to focus on?

Andrew Watkins: 00:29:34

Yeah, it's a great question and this was a really

Andrew Watkins: 00:29:36

great case that highlights that, but in my view, the prioritization

Andrew Watkins: 00:29:39

really depends on . What you think is gonna have the largest impact.

Andrew Watkins: 00:29:43

So what's gonna touch the most patients, uh, but also be the

Andrew Watkins: 00:29:46

most manageable and realistic from an implementation standpoint.

Andrew Watkins: 00:29:49

And so really what's gonna give you the best bang for your buck from a

Andrew Watkins: 00:29:52

stewardship intervention standpoint?

Andrew Watkins: 00:29:55

And so in this case, you know, if you're looking big picture, I think

Andrew Watkins: 00:29:58

asymptomatic bacteruria really stands out as the greatest opportunity for

Andrew Watkins: 00:30:03

a targeted initiative because of how often it's treated unnecessarily

Andrew Watkins: 00:30:07

and how widespread the issue is.

Andrew Watkins: 00:30:08

I mean, I know where I practice and where I've practiced in the past.

Andrew Watkins: 00:30:11

You see antibiotics started for asymptomatic bacteruria

Andrew Watkins: 00:30:14

numerous times every day.

Andrew Watkins: 00:30:16

It's clearly a driver of antibiotic use.

Andrew Watkins: 00:30:19

and so it's also a great example because it can be tackled from numerous angles.

Andrew Watkins: 00:30:23

So a lot of the things that you mentioned are kind of

Andrew Watkins: 00:30:26

pieces that we can target for asymptomatic bacteruria.

Andrew Watkins: 00:30:29

So, you know, first and most importantly, you can roll out education and some

Andrew Watkins: 00:30:33

targeted messaging to really highlight the lack of benefit and frankly, risk of

Andrew Watkins: 00:30:38

harm, of giving unnecessary antibiotics.

Andrew Watkins: 00:30:40

Uh, when you're talking about treating an asymptomatic bacteruria.

Andrew Watkins: 00:30:44

Uh, this education and the targeted messaging pairs really nicely with

Andrew Watkins: 00:30:47

reinforcing these concepts through some patient review, audit and feedback

Andrew Watkins: 00:30:51

practices, reaching out to providers so you're providing overarching

Andrew Watkins: 00:30:55

education, and then you're also reaching out on a patient by patient case to

Andrew Watkins: 00:30:59

kind of discuss this with providers.

Andrew Watkins: 00:31:01

Uh, it's also a really great chance to include some of this information

Andrew Watkins: 00:31:05

in local treatment guidance.

Andrew Watkins: 00:31:06

Um, so again, circling back that helps with your action core element

Andrew Watkins: 00:31:10

and with some of those regulatory requirements we mentioned.

Andrew Watkins: 00:31:12

Then aside from education about just appropriate non-treatment of

Andrew Watkins: 00:31:15

asymptomatic bacteruria, there's also really a great opportunity

Andrew Watkins: 00:31:18

for some diagnostic stewardship.

Andrew Watkins: 00:31:20

So there's a growing amount of literature highlighting some great strategies to

Andrew Watkins: 00:31:24

really help leverage the electronic health record to help with appropriate

Andrew Watkins: 00:31:28

urine culturing, uh, through different algorithms, alerts, order questions.

Andrew Watkins: 00:31:33

To be sure that, you know, we're steering providers to only order

Andrew Watkins: 00:31:36

urine cultures when it's appropriate.

Andrew Watkins: 00:31:37

Because if you never have the urine culture that grew something, you

Andrew Watkins: 00:31:40

can never really have that prompt of, oh, I really need to treat that

Andrew Watkins: 00:31:43

and, and you can prevent the whole cascade from occurring by just not

Andrew Watkins: 00:31:46

sending the inappropriate, uh, test.

Andrew Watkins: 00:31:48

Studies have shown that a lot of these practices can have positive

Andrew Watkins: 00:31:51

impacts on antibiotic use as well as lab and nursing workflow due to

Andrew Watkins: 00:31:56

decreasing the amount of inappropriate cultures actually being ordered.

Andrew Watkins: 00:31:59

And I'd say that this also ties into the case really well because of the patient's

Andrew Watkins: 00:32:03

routine, preoperative, uh, quote unquote urine culture that kicked off the whole

Andrew Watkins: 00:32:07

decision tree, uh, in, in this case.

Andrew Watkins: 00:32:10

So I know surgical teams can often get really nervous about asymptomatic

Andrew Watkins: 00:32:13

bacteruria, uh, in particular, especially when you're talking

Andrew Watkins: 00:32:16

about hardware being implanted.

Andrew Watkins: 00:32:18

and I actually just had an example of this happen in a patient

Andrew Watkins: 00:32:20

a few weeks ago that I saw.

Andrew Watkins: 00:32:21

So this, this case really hit home there.

Andrew Watkins: 00:32:24

Um, you know, obviously we empathize with providers who

Andrew Watkins: 00:32:26

see a positive urine culture.

Andrew Watkins: 00:32:28

You know, they wanna do what's best for the patient.

Andrew Watkins: 00:32:30

They wanna treat that, um, because especially when they're gonna be placed

Andrew Watkins: 00:32:34

in hardware, they don't wanna put patients at increased risk of post-op infections.

Andrew Watkins: 00:32:37

Um, there was a really large study done a few years ago in JAMA surgery that

Andrew Watkins: 00:32:41

actually found that in patients who are undergoing cardiac, orthopedic, or

Andrew Watkins: 00:32:46

vascular surgery, . Giving antibiotics that were active against the urinary

Andrew Watkins: 00:32:50

bacteria, uh, in those patients with asymptomatic bacteruria had no effect on

Andrew Watkins: 00:32:55

the incidence of surgical site infection.

Andrew Watkins: 00:32:58

And then a step further, the study actually found that when surgical

Andrew Watkins: 00:33:01

site infections did occur, the causative organisms were actually

Andrew Watkins: 00:33:04

different than what grew in the pre-surgical urine culture.

Andrew Watkins: 00:33:08

So really highlighting the practice of widespread pre-surgical urine culturing

Andrew Watkins: 00:33:12

that should likely be discontinued because there's just not a lot of, uh,

Andrew Watkins: 00:33:15

additional benefit, um, in the decision making process that it provides.

Andrew Watkins: 00:33:20

It also highlights a really good opportunity to work collaboratively

Andrew Watkins: 00:33:24

with surgical leadership, with pre-op teams to educate and optimize

Andrew Watkins: 00:33:28

some of those screening practices.

Andrew Watkins: 00:33:29

and then in general, just wanna put a plug that diagnostic stewardship

Andrew Watkins: 00:33:33

can really have large impacts across the board, not just in, uh,

Andrew Watkins: 00:33:36

the surgical patient population.

Andrew Watkins: 00:33:37

And it's gonna be even more important as more complex and

Andrew Watkins: 00:33:40

sensitive molecular tests come out.

Andrew Watkins: 00:33:41

I just heard the other day about a urinary PCR test that is gonna wake me

Andrew Watkins: 00:33:46

up at night and with nightmares, um, because just all of the, um, potential

Andrew Watkins: 00:33:51

overuse of antibiotics it may cause.

Andrew Watkins: 00:33:53

And so this diagnostic stewardship, uh, is a really important piece.

: 00:33:58

Awesome.

: 00:33:58

Thanks so much for that, Andrew.

: 00:34:00

And so as our case continues, you are going through all this patient's

: 00:34:04

information, you're chatting with the team, and you notice that the patient

: 00:34:09

is only ordered for Vancomycin as his perioperative prophylaxis for

: 00:34:14

his surgery tomorrow in the setting of this listed penicillin allergy.

: 00:34:18

And so, uh, for either of you, any thoughts on what you might do

: 00:34:22

to recommend the optimization of their perioperative prophylaxis?

Andrew Watkins: 00:34:27

Yeah, so I'd say that we could safely optimize this patient's

Andrew Watkins: 00:34:30

prophylaxis, uh, from Vancomycin to more of a first line option like cefazolin.

Andrew Watkins: 00:34:35

And so we know that patients that have listed penicillin allergies

Andrew Watkins: 00:34:38

have about 50% increased odds of, uh.

Andrew Watkins: 00:34:41

Surgical site infections likely due to using the second

Andrew Watkins: 00:34:44

line agents for prophylaxis.

Andrew Watkins: 00:34:46

I know we end up giving a lot of vancomycin, uh, in patients

Andrew Watkins: 00:34:49

with listed allergies and often we give 'em for too long.

Andrew Watkins: 00:34:52

And so you're talking about increased risk of acute kidney injury and

Andrew Watkins: 00:34:55

that's could lead to patient worse patient outcomes, increased cost.

Andrew Watkins: 00:34:59

Uh, and so this patient had a listed allergy of rash 60 years

Andrew Watkins: 00:35:02

ago, um, that didn't require any intervention or treatment.

Andrew Watkins: 00:35:05

Um, so he is a really great candidate to receive an agent that has minimal

Andrew Watkins: 00:35:09

risk of allergy cross reactivity.

Andrew Watkins: 00:35:11

And so with penicillin allergies, the reaction occurs

Andrew Watkins: 00:35:15

based on the drug side chain.

Andrew Watkins: 00:35:16

So if we pick agents that have a different side chain to penicillin,

Andrew Watkins: 00:35:20

we can generally give them because of the low risk of cross reactivity.

Andrew Watkins: 00:35:25

Cefazolin is one of those first line surgical prophylaxis options

Andrew Watkins: 00:35:28

that has a completely different side chain to penicillin.

Andrew Watkins: 00:35:31

So it's usually a safe option, uh, in this patients and is

Andrew Watkins: 00:35:33

in this patient for the case.

Andrew Watkins: 00:35:35

Um, the allergy and immunology expert community actually just updated guidelines

Andrew Watkins: 00:35:39

last year to recommend that even in patients who have a history of anaphylaxis

Andrew Watkins: 00:35:42

to penicillin, a non cross-reactive cephalosporin like cefazolin can be

Andrew Watkins: 00:35:47

administered without prior testing.

Andrew Watkins: 00:35:49

And I also wanna put a plug that another stewardship intervention related to

Andrew Watkins: 00:35:53

surgical pro prophylaxis is to eliminate prolonged courses postoperatively.

Andrew Watkins: 00:35:58

There was a recent SHEA compendium that recommended against extending

Andrew Watkins: 00:36:02

prophylaxis past closure in the OR, and now there's numerous other guidelines

Andrew Watkins: 00:36:06

that have come out recommended to really limit surgical prophylaxis

Andrew Watkins: 00:36:09

to pre and intraoperatively only.

Andrew Watkins: 00:36:12

Extending prophylaxis after closure really provides no additional benefit

Andrew Watkins: 00:36:16

in patient outcomes, and so just another great low hanging fruit stewardship

Andrew Watkins: 00:36:20

intervention that can really help cut back on some inappropriate use.

Rey Perez: 00:36:23

Awesome.

Rey Perez: 00:36:24

Thanks so much, Andrew.

Rey Perez: 00:36:25

And you know, the, making these recommendations can be hard

Rey Perez: 00:36:27

sometimes, though many of these practices are deeply ingrained.

Rey Perez: 00:36:31

And so Jonathan, to bump back to you, are there any strategies that you

Rey Perez: 00:36:36

recommend communication techniques that you find particularly helpful when

Rey Perez: 00:36:39

working with our surgical colleagues?

Jonathan Ryder: 00:36:42

Yeah, so this is a, a really interesting area

Jonathan Ryder: 00:36:45

in stewardship, which is really optimizing how we communicate with

Jonathan Ryder: 00:36:48

others and really the sociologic component, um, uh, to stewardship.

Jonathan Ryder: 00:36:53

And one of my favorite, um, studies was a, an ethnographic, uh, study

Jonathan Ryder: 00:36:59

done in London a few years ago.

Jonathan Ryder: 00:37:02

They really looked at differences in how, uh, internal medicine or

Jonathan Ryder: 00:37:06

medical teams approached antibiotics in comparison to surgical teams and

Jonathan Ryder: 00:37:11

how they communicated with each other and others around antibiotic use.

Jonathan Ryder: 00:37:16

And so, as an internist myself, uh, who works with medical teams quite a bit,

Jonathan Ryder: 00:37:21

it's really important to kind of have some perspective on how we interact with

Jonathan Ryder: 00:37:25

each other and ourselves, um, as well.

Jonathan Ryder: 00:37:27

But medical teams tend to have kind of a collectivist

Jonathan Ryder: 00:37:31

approach in, in decision making.

Jonathan Ryder: 00:37:33

Everyone wants to work together and want to come to a consensus and an

Jonathan Ryder: 00:37:37

agreed upon plan really as a group.

Jonathan Ryder: 00:37:40

And this is usually quite interdisciplinary.

Jonathan Ryder: 00:37:43

We involve pharmacists and our consultant colleagues.

Jonathan Ryder: 00:37:46

Um, and this is kind of unique to the, to the medical team.

Jonathan Ryder: 00:37:50

And in contrast to this, surgical teams are often more individualistic where

Jonathan Ryder: 00:37:56

residents are often kind of left making their own decisions as the senior surgeons

Jonathan Ryder: 00:38:01

are in the operating room or in the clinic and are not necessarily on rounds with

Jonathan Ryder: 00:38:05

them when these decisions are being made.

Jonathan Ryder: 00:38:09

Surgical teams are also less likely to have pharmacists available, and

Jonathan Ryder: 00:38:12

there was really less time, um, spent dedicated to reviewing and stopping

Jonathan Ryder: 00:38:18

antibiotics by surgeons, which often led to these prolonged antibiotic courses.

Jonathan Ryder: 00:38:22

The surgeons were primarily focused on preventing poor surgical outcomes,

Jonathan Ryder: 00:38:26

and so they started, um, antibiotics to try to prevent those things, but

Jonathan Ryder: 00:38:30

then didn't review them later on.

Jonathan Ryder: 00:38:32

Medical teams, however, really focused more on not disrupting

Jonathan Ryder: 00:38:36

their team dynamics or were disagreeing with other consultants.

Jonathan Ryder: 00:38:38

And so, um, medical teams really struggled when it came to antibiotics when there

Jonathan Ryder: 00:38:44

was a transition from the emergency department to the ward, as there was

Jonathan Ryder: 00:38:47

kind of a hesitancy to question the decision that was already made in the

Jonathan Ryder: 00:38:51

emergency department to start antibiotics, um, which led to antibiotics being

Jonathan Ryder: 00:38:55

continued for longer periods of time.

Jonathan Ryder: 00:38:57

And so the key when communicating with colleagues as a steward is to

Jonathan Ryder: 00:39:02

really know who are you dealing with?

Jonathan Ryder: 00:39:04

What are the, what are the cultural factors at your institution,

Jonathan Ryder: 00:39:07

on that team, um, what are their methods of communication

Jonathan Ryder: 00:39:11

and what is important to them?

Jonathan Ryder: 00:39:13

Um, and so a lot of the keys when interacting with surgical colleagues

Jonathan Ryder: 00:39:16

is to focus on the issues that are really important to them.

Jonathan Ryder: 00:39:19

They, they care a lot about their surgical outcomes.

Jonathan Ryder: 00:39:21

They care a lot about preventing surgical site infections, things like length

Jonathan Ryder: 00:39:25

of stay, um, and, and then trying to find ways to communicate with them.

Jonathan Ryder: 00:39:29

Uh, via the methods that work best for them.

Jonathan Ryder: 00:39:32

And sometimes this means, you know, that uh, rather than talking, um,

Jonathan Ryder: 00:39:36

necessarily with the intern that is on the team, uh, on the wards, talk

Jonathan Ryder: 00:39:41

to the attending that might be making the decisions about antibiotics.

Jonathan Ryder: 00:39:45

Or if they do have a pharmacist that works, uh, closely with their team and

Jonathan Ryder: 00:39:48

that they trust, um, for example, I know our, our transplant team has a pharmacist

Jonathan Ryder: 00:39:53

that does a lot of their antibiotics.

Jonathan Ryder: 00:39:56

Uh, really communicating with that pharmacist might be the most effective

Jonathan Ryder: 00:39:58

way, um, because that pharmacist already knows that team and those dynamics even

Jonathan Ryder: 00:40:03

better than, uh, I do as an individual.

Rey Perez: 00:40:05

Thanks a ton, Jonathan.

Rey Perez: 00:40:07

And so today we've already talked about so many wonderful and important things

Rey Perez: 00:40:11

that stewardship teams do and how much really goes into that structure.

Rey Perez: 00:40:15

But many of the trainees listening, for example, may not have as many

Rey Perez: 00:40:18

opportunities to work with their institutions stewardship programs, and

Rey Perez: 00:40:22

so what would you recommend that our listeners do in their day-to-Day practice

Rey Perez: 00:40:26

to help support the stewardship mission in in honor of Antibiotic Awareness Week.

Andrew Watkins: 00:40:30

I had say that day to day I'd recommend to continue

Andrew Watkins: 00:40:33

building relationships with providers.

Andrew Watkins: 00:40:35

Being a visible group, force, program within the institution,

Andrew Watkins: 00:40:39

everybody really benefits when decisions are made collaboratively.

Andrew Watkins: 00:40:42

And so building those relationship now opens up more downstream

Andrew Watkins: 00:40:45

opportunities, either through future, you know, peer-to-peer recommendations,

Andrew Watkins: 00:40:50

um, and conversations or just identifying further opportunities

Andrew Watkins: 00:40:54

for more initiatives in the future.

Andrew Watkins: 00:40:56

I also say that for anybody who's interested in more information or

Andrew Watkins: 00:41:00

if they're feeling like they're at a standstill at their site, you know, they

Andrew Watkins: 00:41:03

just feel like they need kinda a breath of, uh, new life, uh, in their stewardship

Andrew Watkins: 00:41:06

program and want some inspiration.

Andrew Watkins: 00:41:08

Look into some of the antimicrobial stewardship certificate programs

Andrew Watkins: 00:41:12

that we've mentioned throughout this.

Andrew Watkins: 00:41:13

So I know SIDP, the Society for Infectious Diseases Pharmacist has a great one.

Andrew Watkins: 00:41:18

Um, IDSA and SHEA, and I know Making a Difference in ID, you know, a lot.

Andrew Watkins: 00:41:22

There are numerous programs and certificate classes, courses

Andrew Watkins: 00:41:26

that can help with that.

Andrew Watkins: 00:41:27

Um, sometimes it just takes some outside education or perspectives

Andrew Watkins: 00:41:30

or expertise to really prompt ideas, bring some new direction in life in

Andrew Watkins: 00:41:35

the clinical stewardship practice.

Andrew Watkins: 00:41:36

And then lastly, I, I'm gonna get deep and, and say, you

Andrew Watkins: 00:41:39

know, . As, as a stewardship clinician, give yourself grace.

Andrew Watkins: 00:41:43

You're not always gonna have your recommendations accepted.

Andrew Watkins: 00:41:46

You know, there's gonna be times where you have to compromise or maybe you even

Andrew Watkins: 00:41:49

lose out on a compromise and you've got situations where what's happening is

Andrew Watkins: 00:41:53

completely against what you would've liked to have happened and recommended.

Andrew Watkins: 00:41:56

Um, but at the end of the day, you know, you're still trying to doing your best.

Andrew Watkins: 00:41:59

And if at the worst, you at least planted a seed for what

Andrew Watkins: 00:42:02

you think is optimal therapy.

Andrew Watkins: 00:42:03

Uh, and so just give yourself some grace.

Rey Perez: 00:42:05

That's really important advice for all of us, Andrew.

Rey Perez: 00:42:08

Thank you for that.

Rey Perez: 00:42:09

And kind of on that theme, you know, as we close out in our attempt to

Rey Perez: 00:42:13

recruit the next great generation of stewards, I want to hear from both of

Rey Perez: 00:42:17

you, you know, what made you choose a career in antimicrobial stewardship,

Rey Perez: 00:42:21

and what do you love about your job?

Jonathan Ryder: 00:42:23

So I think for me, the reason I chose to go into antimicrobial

Jonathan Ryder: 00:42:27

stewardship was, uh, you know, a multitude of reasons, but there's

Jonathan Ryder: 00:42:32

really an opportunity to optimize patient care really in the short

Jonathan Ryder: 00:42:36

term by making these interventions.

Jonathan Ryder: 00:42:38

And in the long term, I think you see a greater benefit, um, at,

Jonathan Ryder: 00:42:43

at a societal level by helping to reduce antimicrobial resistance.

Jonathan Ryder: 00:42:47

And also, um, across your institution by educating, uh, prescribers on

Jonathan Ryder: 00:42:52

antibiotic use, uh, strategies.

Jonathan Ryder: 00:42:55

But, also antimicrobial stewardship has a wealth of opportunities

Jonathan Ryder: 00:42:59

for doing quality improvement.

Jonathan Ryder: 00:43:01

There's a lot of opportunities for scholarship in this regard,

Jonathan Ryder: 00:43:04

and really it's just an amazing community within infectious diseases.

Jonathan Ryder: 00:43:09

As a member and participant of SHEA, it's really been just, uh, incredibly welcoming

Jonathan Ryder: 00:43:15

and really getting to know everyone within this community, has been amazing

Jonathan Ryder: 00:43:19

as a, as a young, uh, faculty member.

Andrew Watkins: 00:43:23

Yeah, and I don't know how I'm gonna follow Jonathan, because, you

Andrew Watkins: 00:43:25

know, he, he nailed it right on the head.

Andrew Watkins: 00:43:27

But I'll say similarly, I, I really value the opportunity to intervene

Andrew Watkins: 00:43:31

on individual patients in complicated cases, but then also really work on

Andrew Watkins: 00:43:35

more of the overarching protocols, policies, initiatives that can

Andrew Watkins: 00:43:39

have further reaching impacts.

Andrew Watkins: 00:43:40

I feel like you can do work that impacts not only patients that

Andrew Watkins: 00:43:44

are in your hospital now, but also downstream, you know, in the future.

Andrew Watkins: 00:43:47

and then I'll mention personally, I really love data tracking and analytics.

Andrew Watkins: 00:43:50

Antimicrobial stewardship really allows me to have a lot of opportunities for this,

Andrew Watkins: 00:43:54

and there's really scratch that itch.

Andrew Watkins: 00:43:55

You know, pairing QI processes, uh, with data analytics and tracking to

Andrew Watkins: 00:44:00

allow you to make changes and then evaluate your impact is just something

Andrew Watkins: 00:44:03

I find really fulfilling as well.

Jonathan Ryder: 00:44:05

And Andrew, I'm just gonna add, uh, 'cause I, I should've

Jonathan Ryder: 00:44:08

said this the first time, but you know, stewardship is a interdisciplinary and

Jonathan Ryder: 00:44:13

collaborative, field and it's a great opportunity to have, ID clinicians work

Jonathan Ryder: 00:44:18

with our ID pharmacist, and I value that every single day I do stewardship.

Jonathan Ryder: 00:44:24

both, both groups bring unique perspective, um, to stewardship

Jonathan Ryder: 00:44:27

and I think it's a really key component of this whole thing.

Andrew Watkins: 00:44:30

Completely agree.

Andrew Watkins: 00:44:31

I, I love the interdisciplinary approach and the, the collegiality

Andrew Watkins: 00:44:35

that I feel like exists in the ID and stewardship community.

Sara Dong: 00:44:39

Thank you again to Rey, Andrew and Jonathan for joining Febrile today.

Sara Dong: 00:44:44

Don't forget to check out the website, febrilepodcast.com to find the Consult

Sara Dong: 00:44:48

Notes, which are written supplements of the show with links to references,

Sara Dong: 00:44:53

our library of ID infographics, and a link to our merch store.

Sara Dong: 00:44:57

Please reach out if you have any suggestions for future shows or want

Sara Dong: 00:45:00

to be more involved with Febrile.

Sara Dong: 00:45:02

Thanks for listening.

Sara Dong: 00:45:03

Stay safe.

Sara Dong: 00:45:03

I'll see you next time.