Sara Dong: Hey, everyone.
Welcome to Febrile, a cultured podcast about all things infectious disease.
We use consult questions to dive into ID clinical reasoning, diagnostics,
and anti-microbial management.
I'm Sara Dong, your host.
I am excited to introduce our guests today.
First up is our cohost Dr.
Reinaldo or Rey Perez.
He has a third year ID fellow at Duke University Medical Center.
He works with the Duke Center for Antimicrobial Stewardship and
Infection Prevention to further their mission of improving patient
safety and enhancing quality of care.
His research interests include implementation of anti-microbial
stewardship interventions and leveraging interprofessional teams.
He also has additional interest as a medical educator with a passion for
curriculum development and effective assessment of educational interventions.
Rey Perez: Hey Sara, thanks so much for having me.
This is so exciting to be here.
Sara Dong: Next meet Dr.
Andrew Watkins.
He is an infectious diseases pharmacist at Saint Dominic Jackson Memorial Hospital
in Jackson, Mississippi, and serves as the pharmacy stewardship lead for the
hospital, as well as the Franciscan Missionaries of Our Lady Health System.
His responsibilities include prospective audit and feedback, policy and
protocol development, implementation of stewardship initiatives, antimicrobial
use tracking and reporting, and education of frontline staff on ID and
anti-microbial stewardship related topics.
He also precepts pharmacy residents on anti-microbial
stewardship learning experiences.
Andrew Watkins: Hey Sara, this is Andrew Watkins.
Thanks for having me.
Sara Dong: And last but not least is an old friend of the show, Dr.
Jonathan Ryder.
He is an Assistant Professor in the Division of Infectious Diseases at
University of Nebraska Medical Center.
He serves as an Associate Medical Director of Antimicrobial Stewardship,
with interest in diagnostic stewardship and stewardship in rural settings.
He is also an Associate Hospital Epidemiologist with the infection
control and epidemiology program.
Lastly, he has interest in digital medical education and is co-director
of the microbiology block for the first year medical students.
Jonathan Ryder: Hi, this is Jonathan Ryder.
I am really excited to be back on Febrile.
Sara Dong: Okay.
You guys know the drill.
Before we talk about the case and the episode today, we always ask about sharing
a piece of culture because Febrile is everyone's favorite cultured podcast.
So I would love to hear about something that you have had fun with
recently, or that has brought you joy.
Jonathan Ryder: Yeah, so today's episode is nearing Thanksgiving, and so I thought
I'd come up with a piece of culture related to that, mainly pointing out
that I think Thanksgiving is my personal favorite of the holidays with its triple
threat of, uh, family, food and football.
And, since my football team isn't playing this year, uh, on Thursday, I am going
to choose my favorite Thanksgiving dish as my culture recommendation.
And, uh, my favorite is, uh, my mom's sweet potato casserole.
Uh, it has pecans on top, not a fan of the marshmallows that some
people do, uh, for that dish.
So that's gonna be my pick.
Sara Dong: Well, I feel like I have to ask, do you just not like marshmallows.
Are you morally opposed to having them on top of sweet potatoes?
You know, I grew up having marshmallows on my like super potato, yam casserole,
so I actually didn't realize until recently that that was something that
some people thought was, uh, a bit weird.
Jonathan Ryder: I love marshmallows, but not in that dish.
Um, and I think that's not how that dish was made for me growing up and
so that concept doesn't work for me.
But, uh, over an open campfire, big marshmallow fan.
Sara Dong: Got it.
So, uh, how about you, Rey?
Rey Perez: So sticking with the holiday theme as well with, uh, Thanksgiving
and Christmas around the corner.
My family comes from Puerto Rico and we have a very special tradition there.
It's a unique version of Christmas caroling called parrandas, where you go
around the neighborhood creating a bigger and bigger band essentially to sing
Christmas carols and then everyone who you sing at their house has to feed you.
So it's just a really special and really, uh, fun and crazy tradition.
Sara Dong: Amazing.
Uh, Andrew, you want to finish this up?
Andrew Watkins: Yeah, I'm, I'm gonna stick with the holidays
too and we'll kinda look ahead.
No, no offense to Thanksgiving 'cause I do enjoy that.
But really looking forward to Christmas.
Um, it's really fun time of year, you know, it's almost
time to start decorating.
I'm very much a Black Friday Christmas decoration person.
Um, so I do give Thanksgiving it's due, but then we jump into the decorations,
um, you know, getting the kids to really get involved in that and enjoy that.
And then seeing family.
So really busy time of year, but one I really enjoy.
Track 1: So This week is US Antibiotic Awareness Week, this annual campaign
from the Centers for Disease Control Prevention seeks to highlight the steps
everyone can take to improve antibiotic prescribing and use, as well as being
a rallying cry in the fight against increasing antimicrobial resistance.
In honor of this, today's case will be focused on hospital
antibiotic stewardship programs.
Uh, and this episode is brought to you in collaboration with the Society of
Hospital Epidemiology Antimicrobial Stewardship Committee, for which Dr.
Ryder is a member.
Sara Dong: So this week, you're on call for the hospital's antimicrobial
stewardship pager, and today's consult question comes after you receive a
call from the cardiac surgery team requesting approval for daptomycin
after a preoperative urine culture grew vancomycin resistant Enterococcus
faecium in a penicillin allergic patient.
Rey Perez: So Jonathan, before we really get started, not everyone here
may be familiar with the structure of antimicrobial stewardship teams or
some of the techniques that we commonly use when we're serving this role.
So before we get into the details of this case, I think it'd be great if we
discuss some of the essential components of a stewardship team and think about
two of the core interventions that we utilize - antibiotic restriction
and post prescription review.
So just to start, Jonathan, why do we need stewardship teams?
Jonathan Ryder: Thanks, Ray.
Such a, such a great question and I'm glad we're starting with the basics
after, uh, hearing that consult question.
So there's kind of a, kind of a lot going on there.
So there there's several reasons why we need stewardship teams.
So antimicrobial resistance is a, is a growing problem of international scale,
and a 2014 report estimated that if antimicrobial resistance continues on
its current trajectory, that by 2050, about 10 million people would die
each year as a result of antimicrobial resistance, with a global cost up
to a hundred trillion US dollars.
And so, while, uh, antimicrobial resistance is, is a growing issue,
we also have a pretty big issue with appropriate antibiotic prescribing.
And so when you look at common reasons for antimicrobial, uh, uh, prescriptions,
the, the data show that it, it was inappropriate in about 80% of patients
that have community acquired pneumonia, about three quarters that have urinary
tract infections, half of patients who are prescribed fluoroquinolones and about
a quarter of patients who are receiving intravenous vancomycin, uh, antibiotics.
And, and the reasons why we see inappropriate antibiotics are usually
due to inappropriately uh, long therapy in patients with, uh, community acquired
pneumonia and in urinary tract infection, about half of patients, um, don't have
any signs or symptoms of infection.
And so ultimately, antimicrobial stewardship programs are in place because
as infectious disease doctors, we can't, uh, be consultants on every single patient
on antibiotics, and so we need to have larger systems-based interventions that
improve our utilization of antimicrobials.
And, and similarly, you have to track what you do, uh, in order to make
changes and to make improvements and having a dedicated stewardship team and
program really helps with tracking and reporting and, and building accountability
to help drive these improvements.
And ultimately, antimicrobial stewardship teams are about improving patient care.
And I always want to emphasize this point because sometimes people really
see these as more, uh, health system or, more societally driven, uh, programs.
And while those things are certainly true, that there are downstream benefits,
uh, to society and the health system, ultimately what we do on the day-to-Day
is about optimizing patient care.
That we're making sure that each patient receives the right drug, for the
right bug, at the right dose, for the right duration, and at the right time.
And so I always think that stewardship programs really at the core of them
are taking care of our patients.
Rey Perez: Thanks for that.
Jonathan, I think you really helped put into context what the
nature of the problem is here.
And uh, Andrew, just to pull you in, you know, when you think about what really
makes a great stewardship team, what are those core features that make it work?
You know, what do you think about?
Andrew Watkins: Yeah, so luckily CDC has done a lot of the homework
for me and has a really great list of those CDC core elements.
So what are their basic, the most essential parts of a stewardship program?
And they have seven that are very clearly defined.
They have hospital leadership commitment, they have accountability,
they have pharmacy expertise,
action, . tracking, reporting and education.
So I just wanna kind of run through those and give a very high level view
of what is involved with each of those.
And so looking at hospital leadership commitment.
CMS is very clear that institutional leadership, along with quality
improvement must address issues that are identified by the infection prevention
and the stewardship committees.
Uh, and this open communication between stewardship and hospital leaderships
really helps facilitate this.
And this is really important 'cause a lot of the bigger stewardship initiatives
can really flounder if you don't have that administrative support and kind
of like leadership weight behind them.
Hospitals can demonstrate this leadership through funding positions, and so
actually having dedicated funding for salary for these positions, having
dedicated FTEs for these positions.
Um, and another way that you can show leadership support is just by
having some public statements of support that leadership can sign.
You can display these across your institution, um, or publish them
on websites, um, just to show that that leadership is, committed to
supporting antimicrobial stewardship.
Talking about the accountability piece, uh, is, is more centered around
having a clear leadership structure within the stewardship program.
So typically that's gonna take the form of a physician leader, uh,
and a pharmacist as co-leaders.
Um, but you can have stewardship programs that have just a single leader.
These roles should ideally be clarified, so it's always clear who's
running the stewardship program and who's accountable for the metrics and
outcomes with the stewardship program.
One often overlooked point, things that we've seen
Or not thought about in a lot of surveys, um, is that these leaders should have
some sort of education or training or experience in infectious diseases
or antimicrobial stewardship, um, as outlined by Joint Commission in CMS.
And so this can be your kind of classic post-graduate training with an ID
fellowship or ID pharmacy residency, um, or can be through certificate
courses plus ongoing continuing education kind of year to year.
Looking at pharmacy expertise really focuses more on the pharmacy co-leader
of the stewardship program, and really is another essential element of that.
You know, I'm biased as a pharmacist, but I will say that because of the
positioning of pharmacists within the healthcare system, kind of our roles,
we can be really helpful in stewardship programs because we interface with so many
different aspects of the healthcare team.
We also are situated really well to have access to antibiotic use, to
help kind of track that over time and help with that reporting piece.
Um, already integrated into the Pharmacy and Therapeutics committee, which
really helps, uh, with integration with that for leadership and quality.
They're also just very familiar with drug specific information like
pharmacokinetics and dynamics and all those fun things that go into how
we optimize dosing of antibiotics.
So all in all, really helpful to have a pharmacist co-leader, um, in stewardship.
The action core element, um, has intervention such as prospective audit
and feedback or pre-authorization, which we'll talk about here in a little bit.
Um, also facility specific treatment guidelines.
They're also a very key action element, and will be required by
Joint Commission, uh, as of this year.
having at least two of those implemented.
So really important from a, a regulatory standpoint as well.
And overall action is probably the broadest and most vague of all of
the core elements because there are so many things that you can do.
You could have automatic protocols, uh, for renal dosing or IV to PO
conversions, kinetics based dosing, antibiotic timeout processes or
handshake rounds, automatic stop dates.
So this is where you can really fit in a lot of the, the
interventions in the day-to-Day.
Like big projects in the stewardship programs.
Tracking is vital because of its utility in helping to find opportunities for
improvement, for tracking progress of any interventions you've implemented,
and helping to build accountability.
There are tons of different metrics.
We could probably have a whole hour talk on just what metrics
you could track but really one of the most basic is antibiotic use.
Uh, and so actually tracking and reporting antibiotic use to NHSN, which is the
National Healthcare Safety Network, is a regulatory requirement starting in 2024.
Uh, and it serves as a great method of not only tracking your use, but
help establish some benchmarking and comparisons to similar hospitals.
It's especially helpful to track in relation to any particular
initiatives you have going on.
So maybe you have, you know, new guidance to help decrease use of
broad spectrum hospital agents.
And then you can actually track this over time.
And CDC has a ton of great examples on their website of some of these
ways to actually track this data.
But then you can also encompass other aspects of tracking.
So, you know, number or type of audit and feedback patient interventions.
And so that's really helpful 'cause it can highlight the
impact of your stewardship group.
You know, how many interventions are you having, what's your acceptance
rate, um, and then also helping to justify some of those continued
funding and additional, uh, positions.
You can also track other outcomes like c diff or MDRO infections.
And so the list is really long on tracking, but what's really important is
that after you track, you actually go to the next core element, which is reporting.
So really reporting is your kind of actionable.
Back inside of tracking where you take the data that you've actually, uh, tracked and
you've deemed most important, and then you relay that back to your frontline staff.
And so that's important because it's gonna increase transparency and buy-in
for those providers, especially when you pair that with the reporting and
education and ongoing interventions.
It also makes the data more actionable and helps with modifying initiatives that may
not be doing so well from the beginning, you look and say, you know, Hey, we
implemented this a month ago and we're not seeing really any movement in our use.
What can we do better?
Can we educate better?
Can we communicate this?
Um, or maybe you highlight some early successes that you can take
back immediately and say, look, we started this last month and we're
having, we're seeing a huge impact.
Like keep good job, keep going, and really helps with that kind of morale and buy-in.
Overall, the combination of tracking and reporting really helped drive
the program forward, uh, and work as a great accountability piece.
And then lastly, education.
It's really kind of one of the more nebulous topics of core elements because
it can take so many different forms, have so many different audiences.
Education can involve prescribers or pharmacists, nurses, you can
educate patients and family.
And then you could cover a whole host of topics from resistance.
You know, the harms of antibiotics, optimal prescribing.
Uh, it can really take the form of institutional guidelines or
antibiograms, uh, hospital policies in-service presentation handouts.
I mean, you name it, and you can educate on it essentially.
And so because of that, usually I recommend keeping a log of education,
things that you've done, you know.
Who you educated, when you educated, and then what did you actually educate about?
Um, so that if you're ever asked by a surveyor, you know, prove
to me what education you've done, you can have a list there.
They'll say, oh yeah, we went to this session back in July.
Um, and then also just to make your lives easier.
'cause there's so much going on, uh, in the day-to-Day of a stewardship program.
Try to pair your education with whatever initiative you're
really trying to push forward.
So, you know, you're, you're implementing this new initiative
that's part of the action core element.
Uh, and then you, you're educating providers on that as well.
You're reporting back and so you really hit a lot of these core elements
all at one time with one initiative.
Rey Perez: Well, thanks so much Andrew, for that really comprehensive overview.
I feel like I can just see the stewardship team in action already with
everything that you've described there.
Now, uh, Jonathan, to pop back to you, I did want to expand a little bit
on one thing that Andrew was talking about, and that's 'cause the CDC
highlights as a priority intervention,
two of the things that stewardship programs do that have the most evidence
for efficacy, and that's prospective audit and feedback and pre-authorization.
Can you tell us a little bit more about what these tools are and how they work?
Jonathan Ryder: Thanks, Ray.
Yeah, so there's these sort of two, um, philosophies and approaches to
antimicrobial stewardship and, and how it takes place, uh, in action.
And so prospective audit and feedback is really kind of reviewing from an external
standpoint how antibiotics are being used.
And then, uh, after reviewing cases, identifying opportunities
to improve that use.
Audit and feedback occurs after an antibiotic is prescribed.
And this can take place in many different formats, either by messaging
or calling a team, or actually in a face-to-face format, which is known as
handshake stewardship in which, uh, the recommendations actually occur in person.
And so, in contrast to prospective audit and feedback is pre-authorization, also
known sometimes by restriction, and this is really requiring some sort of approval,
uh, by the antimicrobial stewardship team in order to use a certain antibiotic.
And this really allows for the antimicrobial stewardship team to give
their input whenever a prescriber is interested in using that antibiotic.
And really prevent unnecessary initiation of antibiotics as well.
And so these two different forms have actually been compared, uh, directly and
generally prospective audit and feedback has been shown to be more effective.
However, there's really a use for both of these in stewardship
programs depending on some of the different situations that pop up.
Rey Perez: Could you expand on that a little bit more?
Like what do you see as some of these pros and cons between these two
different approaches and how have you synthesized that and applied it
at your own institution for example?
Jonathan Ryder: Yeah, so prospective audit and feedback's, uh, really strong
points are that you are providing a direct education to the prescriber
when you're providing that feedback.
It also allows for a lot of autonomy for prescribers, and it really empowers those,
um, team members to make their own initial decisions about what antibiotics to use.
It really creates kind of a collegial environment because decisions are made
in a, in a collective, uh, manner.
One pro when you're running a program is that prospective audit and feedback
is, is primarily during, uh, daytime hours, actually almost exclusively.
Uh, so not a lot of phone calls in the middle of the night.
The other part of this is since you're providing education, you may actually
have kind of downstream impacts on multiple components of antibiotic
use throughout your hospital system.
And then you're also able to comment to that individual about both the
antibiotic that's being used, but also dosing, duration, deescalation.
And so . There's multiple components that can be affected.
The problems with prospective audit and feedback is it can be kind of
resource intensive to actually go through a, a list, for example, every
day, uh, spend time in those patient charts, reviewing the indications,
the dosing, the durations, et cetera, for each of those individual patients.
Another disadvantage is that the patient already receives usually at
least one dose of antibiotics, if not several D doses, or even several days of
antibiotics before an intervention occurs.
And so some of that upfront antibiotic use, uh, when deemed
inappropriate already has occurred.
And then ultimately the prescribers can do what they want.
That autonomy does allow, uh, for the prescribers to disagree with
the stewardship team, and that may mean that, um, the recommendations
do not have a great uptake.
So to, to contrast that with pre-authorization, its big advantage
is it really allows more control by the stewardship team over antibiotic
prescribing es, especially in that upfront empiric and initial antibiotic choice
or, or choice to not initiate therapy.
And I think this is especially effective and useful when you're
talking about really expensive antibiotics, newer antibiotics that
people may be less familiar with.
Or, antimicrobials that may be more toxic or for example, antifungal
agents or certain antiviral agents.
Another situation can be whenever, um, you're facing shortages and there's
just a very limited supply that a few wasted doses goes a long way.
So the concept pre-authorization are that there's a lot less prescriber autonomy.
There's usually some sort of phone call that has to take place, usually
asking for some sort of permission for antibiotics, which can be a, a fairly
adversarial interaction at some points in time, and this oftentimes will also
involve some sort of overnight call.
And this intervention is really limited only to the antibiotics
that are on the restricted list.
So it doesn't help with antibiotic durations or dosing
or non-restricted antibiotics.
And of course, the, the last concern I'll bring up is that this pre-authorization
process could result in delays of therapy to patients who are especially
critically ill, which, uh, could be a, a downstream consequence.
So my experience at my institution is that we largely use prospective
audit and feedback for our daily stewardship activities, which does
take a, a really dedicated stewardship team that's dedicating time to this.
But we review lists of key antibiotics and diagnostic tests.
So for example, all positive blood cultures and rapid molecular diagnostic
testing results and antibiotics that are higher risk for, uh, uh,
Clostridoides difficile, such as, uh, fluoroquinolones and clindamycin.
And then we look at broad spectrum agents like vancomycin, piperacillin-tazobactam,
cefepime et cetera.
And, and we provide that, uh, feedback to clinicians based on, um, the
antibiotics that they've prescribed.
But we also use pre-authorization and restrictions on certain antibiotics,
such as those that I mentioned that have higher adverse, uh, event
profiles or, that are more expensive.
And these are also reviewed as part of the, uh, prospective audit and
feedback process where oftentimes clinicians may be able to access a
dose overnight, but then the next day, uh, feedback is given to adjust that.
Rey Perez: Awesome.
Well, now that our toolkits are filled with all of these new useful
ideas to tackle the this case, why don't we go ahead and dive right in.
So, our patient is a 67 year old male with a past medical history
of hypertension, type two diabetes, obesity, and coronary artery disease.
Over the last two months, he developed symptoms of stable angina
and outpatient coronary angiography demonstrated three vessel disease.
He was seen by cardiothoracic surgery as an outpatient, and he has planned for
coronary artery bypass grafting tomorrow.
The cardiothoracic surgery team has the practice of collecting a urine
culture on all patients as part of their routine preoperative labs.
He has not reported any fever, dysuria, frequency, urgency,
or other urinary symptoms
of note.
His allergy history is significant for a listed penicillin allergy.
Patient's mother reportedly told him in childhood around seven,
he developed a rash after being given penicillin for a sore throat.
He does not believe that it required treatment at that time.
He has avoided repeat exposure since then.
His labs are fairly unremarkable.
His CBC had a white blood cell count of 7.6 with a normal differential, a
hemoglobin of 12.7 and platelets of 256.
His complete metabolic panel showed normal electrolytes and
normal liver transaminases.
A serum glucose of 183 and a serum creatinine of 1.2, which was his baseline.
His urinalysis had an unremarkable dipstick and on microscopic analysis
showed five white blood cells per high powered field, one red blood cell per
high powered field, and 10 squamous epithelial cells per high powered
field without any cast visualized.
His urine culture grew Enterococcus faecium that was susceptible to
ampicillin and resistant to vancomycin.
As mentioned earlier, you are on the antimicrobial stewardship pager.
And you get a call for linezolid, a drug that requires
pre-authorization at your institution.
So Jonathan, to go back to you, you know, as you think about this case, I know that
for me, being in the pre-authorization role as a fellow was sometimes awkward.
Uh, unlike a consult where you're being asked for help by the team, you're kind
of inserting yourself and sometimes perceived as the antibiotic police.
So how do you frame your role, or what other techniques do you use when
having to give this unsolicited advice?
Jonathan Ryder: Yeah, this is, this is, um, a great, a great scenario
here, and so . Um, you know, usually I, I start with introducing myself.
Say, you know, hi, I am Jonathan.
I'm with the antimicrobial stewardship team.
And then I use an approach that I learned actually during the IDSA Antimicrobial
Stewardship training course, which I'm gonna highly recommend and, and provide
a little bit of a plug for, but this is, uh, known as the NARROWS, uh, mnemonic.
I print this off and I hang it on my wall and, anytime I am, uh, facing a case or
working with a trainee in stewardship, I always kind of review this and take a
deep breath and really make sure I'm in the right place to kind of have this,
um, conversation because sometimes there is a little bit of negotiation
that happens through this process.
So just gonna go through this mnemonic briefly and use this case as an example.
But the first part of, uh, NARROWS is n and that's to name the issue.
And so, you know, this is the patient, whoever that we're talking about.
And, um, you're, you're calling asking about linezolid for, uh,
treating a urinary tract infection is basically what you're calling me.
And so I, I then go to a, which is to ask, what, what is the reason why,
why do you want to use linezolid?
What about this patient's uh, urinalysis and urine culture make you concerned?
Um, and then r is to reflect their emotion.
And so.
I, I always try to empathize with the team and say, yeah, this patient's really sick,
or in this situation, yeah, this patient's going for a big surgery tomorrow.
I understand that we want to make sure this patient is optimized for this,
uh, surgical intervention and they don't develop any sort of postoperative
complications, uh, as a result.
so the next r in narrows is to relate with personal experience.
And so saying something like . Yeah, I remember, um, whenever I, uh, worked in
the ICU and I was worried about a patient, um, uh, something to really kind of show
that you care about that individual patient, you know, whatever your
personal story or, or memory is, that's relevant for that particular situation.
The O in narrows is to orient to the suggested management.
So, um, I would say something like, in this case that you could use linezolid.
It's a, it's, it actually is a really good option for treating someone with a true,
uh, VRE, uh, urinary tract infection.
However, in this situation, it, it doesn't seem like there's a lot of inflammation.
I.
Uh, on the urine culture, and, and the patient doesn't sound like they
have any symptoms, and so this seems more like asymptomatic bacteruria.
And so w then is working together on a plan.
And so I then make a suggestion like, you know, do you feel . Comfortable, like,
uh, discontinuing antibiotic therapy in this case and, and monitoring for, uh, the
development of further urinary symptoms.
And this is where sometimes there's a little negotiation that takes place.
Maybe they're concerned for another reason.
Maybe, maybe they tell me that they actually do have urinary symptoms and
that, um, they're actually symptomatic.
And that maybe what I understand from what they first told me or what I read
in the chart actually isn't the case.
And then s is to set follow up.
And so, um, it, it can always be reassuring to say, Hey, call me back
if, if the patient develops symptoms, or I'll keep an eye on the chart and
wait on the susceptibilities or, the next set of labs or whatever the next
marker is to really figure out, you know, how can I help this patient?
Rey Perez: Thanks Jonathan for that really wonderful framework.
I think I'm gonna have to print it and hang it on my wall too.
Now, you know, as we think about this case, it, it has a ton of different
potential intervention points.
We could be talking with the team about diagnostic stewardship and
reducing unnecessary urine cultures.
We could go into a conversation about asymptomatic bacteruria like
you kind of alluded to earlier.
We could dive into this penicillin allergy that may or may not be real,
and talk about opportunities for de labeling penicillin allergies.
Andrew, to jump to you this time, how do you decide on the
priority of these interventions?
When you have lots of things on the menu in front of you, how
do you decide what to focus on?
Andrew Watkins: Yeah, it's a great question and this was a really
great case that highlights that, but in my view, the prioritization
really depends on . What you think is gonna have the largest impact.
So what's gonna touch the most patients, uh, but also be the
most manageable and realistic from an implementation standpoint.
And so really what's gonna give you the best bang for your buck from a
stewardship intervention standpoint?
And so in this case, you know, if you're looking big picture, I think
asymptomatic bacteruria really stands out as the greatest opportunity for
a targeted initiative because of how often it's treated unnecessarily
and how widespread the issue is.
I mean, I know where I practice and where I've practiced in the past.
You see antibiotics started for asymptomatic bacteruria
numerous times every day.
It's clearly a driver of antibiotic use.
and so it's also a great example because it can be tackled from numerous angles.
So a lot of the things that you mentioned are kind of
pieces that we can target for asymptomatic bacteruria.
So, you know, first and most importantly, you can roll out education and some
targeted messaging to really highlight the lack of benefit and frankly, risk of
harm, of giving unnecessary antibiotics.
Uh, when you're talking about treating an asymptomatic bacteruria.
Uh, this education and the targeted messaging pairs really nicely with
reinforcing these concepts through some patient review, audit and feedback
practices, reaching out to providers so you're providing overarching
education, and then you're also reaching out on a patient by patient case to
kind of discuss this with providers.
Uh, it's also a really great chance to include some of this information
in local treatment guidance.
Um, so again, circling back that helps with your action core element
and with some of those regulatory requirements we mentioned.
Then aside from education about just appropriate non-treatment of
asymptomatic bacteruria, there's also really a great opportunity
for some diagnostic stewardship.
So there's a growing amount of literature highlighting some great strategies to
really help leverage the electronic health record to help with appropriate
urine culturing, uh, through different algorithms, alerts, order questions.
To be sure that, you know, we're steering providers to only order
urine cultures when it's appropriate.
Because if you never have the urine culture that grew something, you
can never really have that prompt of, oh, I really need to treat that
and, and you can prevent the whole cascade from occurring by just not
sending the inappropriate, uh, test.
Studies have shown that a lot of these practices can have positive
impacts on antibiotic use as well as lab and nursing workflow due to
decreasing the amount of inappropriate cultures actually being ordered.
And I'd say that this also ties into the case really well because of the patient's
routine, preoperative, uh, quote unquote urine culture that kicked off the whole
decision tree, uh, in, in this case.
So I know surgical teams can often get really nervous about asymptomatic
bacteruria, uh, in particular, especially when you're talking
about hardware being implanted.
and I actually just had an example of this happen in a patient
a few weeks ago that I saw.
So this, this case really hit home there.
Um, you know, obviously we empathize with providers who
see a positive urine culture.
You know, they wanna do what's best for the patient.
They wanna treat that, um, because especially when they're gonna be placed
in hardware, they don't wanna put patients at increased risk of post-op infections.
Um, there was a really large study done a few years ago in JAMA surgery that
actually found that in patients who are undergoing cardiac, orthopedic, or
vascular surgery, . Giving antibiotics that were active against the urinary
bacteria, uh, in those patients with asymptomatic bacteruria had no effect on
the incidence of surgical site infection.
And then a step further, the study actually found that when surgical
site infections did occur, the causative organisms were actually
different than what grew in the pre-surgical urine culture.
So really highlighting the practice of widespread pre-surgical urine culturing
that should likely be discontinued because there's just not a lot of, uh,
additional benefit, um, in the decision making process that it provides.
It also highlights a really good opportunity to work collaboratively
with surgical leadership, with pre-op teams to educate and optimize
some of those screening practices.
and then in general, just wanna put a plug that diagnostic stewardship
can really have large impacts across the board, not just in, uh,
the surgical patient population.
And it's gonna be even more important as more complex and
sensitive molecular tests come out.
I just heard the other day about a urinary PCR test that is gonna wake me
up at night and with nightmares, um, because just all of the, um, potential
overuse of antibiotics it may cause.
And so this diagnostic stewardship, uh, is a really important piece.
Track 1: Awesome.
Thanks so much for that, Andrew.
And so as our case continues, you are going through all this patient's
information, you're chatting with the team, and you notice that the patient
is only ordered for Vancomycin as his perioperative prophylaxis for
his surgery tomorrow in the setting of this listed penicillin allergy.
And so, uh, for either of you, any thoughts on what you might do
to recommend the optimization of their perioperative prophylaxis?
Andrew Watkins: Yeah, so I'd say that we could safely optimize this patient's
prophylaxis, uh, from Vancomycin to more of a first line option like cefazolin.
And so we know that patients that have listed penicillin allergies
have about 50% increased odds of, uh.
Surgical site infections likely due to using the second
line agents for prophylaxis.
I know we end up giving a lot of vancomycin, uh, in patients
with listed allergies and often we give 'em for too long.
And so you're talking about increased risk of acute kidney injury and
that's could lead to patient worse patient outcomes, increased cost.
Uh, and so this patient had a listed allergy of rash 60 years
ago, um, that didn't require any intervention or treatment.
Um, so he is a really great candidate to receive an agent that has minimal
risk of allergy cross reactivity.
And so with penicillin allergies, the reaction occurs
based on the drug side chain.
So if we pick agents that have a different side chain to penicillin,
we can generally give them because of the low risk of cross reactivity.
Cefazolin is one of those first line surgical prophylaxis options
that has a completely different side chain to penicillin.
So it's usually a safe option, uh, in this patients and is
in this patient for the case.
Um, the allergy and immunology expert community actually just updated guidelines
last year to recommend that even in patients who have a history of anaphylaxis
to penicillin, a non cross-reactive cephalosporin like cefazolin can be
administered without prior testing.
And I also wanna put a plug that another stewardship intervention related to
surgical pro prophylaxis is to eliminate prolonged courses postoperatively.
There was a recent SHEA compendium that recommended against extending
prophylaxis past closure in the OR, and now there's numerous other guidelines
that have come out recommended to really limit surgical prophylaxis
to pre and intraoperatively only.
Extending prophylaxis after closure really provides no additional benefit
in patient outcomes, and so just another great low hanging fruit stewardship
intervention that can really help cut back on some inappropriate use.
Rey Perez: Awesome.
Thanks so much, Andrew.
And you know, the, making these recommendations can be hard
sometimes, though many of these practices are deeply ingrained.
And so Jonathan, to bump back to you, are there any strategies that you
recommend communication techniques that you find particularly helpful when
working with our surgical colleagues?
Jonathan Ryder: Yeah, so this is a, a really interesting area
in stewardship, which is really optimizing how we communicate with
others and really the sociologic component, um, uh, to stewardship.
And one of my favorite, um, studies was a, an ethnographic, uh, study
done in London a few years ago.
They really looked at differences in how, uh, internal medicine or
medical teams approached antibiotics in comparison to surgical teams and
how they communicated with each other and others around antibiotic use.
And so, as an internist myself, uh, who works with medical teams quite a bit,
it's really important to kind of have some perspective on how we interact with
each other and ourselves, um, as well.
But medical teams tend to have kind of a collectivist
approach in, in decision making.
Everyone wants to work together and want to come to a consensus and an
agreed upon plan really as a group.
And this is usually quite interdisciplinary.
We involve pharmacists and our consultant colleagues.
Um, and this is kind of unique to the, to the medical team.
And in contrast to this, surgical teams are often more individualistic where
residents are often kind of left making their own decisions as the senior surgeons
are in the operating room or in the clinic and are not necessarily on rounds with
them when these decisions are being made.
Surgical teams are also less likely to have pharmacists available, and
there was really less time, um, spent dedicated to reviewing and stopping
antibiotics by surgeons, which often led to these prolonged antibiotic courses.
The surgeons were primarily focused on preventing poor surgical outcomes,
and so they started, um, antibiotics to try to prevent those things, but
then didn't review them later on.
Medical teams, however, really focused more on not disrupting
their team dynamics or were disagreeing with other consultants.
And so, um, medical teams really struggled when it came to antibiotics when there
was a transition from the emergency department to the ward, as there was
kind of a hesitancy to question the decision that was already made in the
emergency department to start antibiotics, um, which led to antibiotics being
continued for longer periods of time.
And so the key when communicating with colleagues as a steward is to
really know who are you dealing with?
What are the, what are the cultural factors at your institution,
on that team, um, what are their methods of communication
and what is important to them?
Um, and so a lot of the keys when interacting with surgical colleagues
is to focus on the issues that are really important to them.
They, they care a lot about their surgical outcomes.
They care a lot about preventing surgical site infections, things like length
of stay, um, and, and then trying to find ways to communicate with them.
Uh, via the methods that work best for them.
And sometimes this means, you know, that uh, rather than talking, um,
necessarily with the intern that is on the team, uh, on the wards, talk
to the attending that might be making the decisions about antibiotics.
Or if they do have a pharmacist that works, uh, closely with their team and
that they trust, um, for example, I know our, our transplant team has a pharmacist
that does a lot of their antibiotics.
Uh, really communicating with that pharmacist might be the most effective
way, um, because that pharmacist already knows that team and those dynamics even
better than, uh, I do as an individual.
Rey Perez: Thanks a ton, Jonathan.
And so today we've already talked about so many wonderful and important things
that stewardship teams do and how much really goes into that structure.
But many of the trainees listening, for example, may not have as many
opportunities to work with their institutions stewardship programs, and
so what would you recommend that our listeners do in their day-to-Day practice
to help support the stewardship mission in in honor of Antibiotic Awareness Week.
Andrew Watkins: I had say that day to day I'd recommend to continue
building relationships with providers.
Being a visible group, force, program within the institution,
everybody really benefits when decisions are made collaboratively.
And so building those relationship now opens up more downstream
opportunities, either through future, you know, peer-to-peer recommendations,
um, and conversations or just identifying further opportunities
for more initiatives in the future.
I also say that for anybody who's interested in more information or
if they're feeling like they're at a standstill at their site, you know, they
just feel like they need kinda a breath of, uh, new life, uh, in their stewardship
program and want some inspiration.
Look into some of the antimicrobial stewardship certificate programs
that we've mentioned throughout this.
So I know SIDP, the Society for Infectious Diseases Pharmacist has a great one.
Um, IDSA and SHEA, and I know Making a Difference in ID, you know, a lot.
There are numerous programs and certificate classes, courses
that can help with that.
Um, sometimes it just takes some outside education or perspectives
or expertise to really prompt ideas, bring some new direction in life in
the clinical stewardship practice.
And then lastly, I, I'm gonna get deep and, and say, you
know, . As, as a stewardship clinician, give yourself grace.
You're not always gonna have your recommendations accepted.
You know, there's gonna be times where you have to compromise or maybe you even
lose out on a compromise and you've got situations where what's happening is
completely against what you would've liked to have happened and recommended.
Um, but at the end of the day, you know, you're still trying to doing your best.
And if at the worst, you at least planted a seed for what
you think is optimal therapy.
Uh, and so just give yourself some grace.
Rey Perez: That's really important advice for all of us, Andrew.
Thank you for that.
And kind of on that theme, you know, as we close out in our attempt to
recruit the next great generation of stewards, I want to hear from both of
you, you know, what made you choose a career in antimicrobial stewardship,
and what do you love about your job?
Jonathan Ryder: So I think for me, the reason I chose to go into antimicrobial
stewardship was, uh, you know, a multitude of reasons, but there's
really an opportunity to optimize patient care really in the short
term by making these interventions.
And in the long term, I think you see a greater benefit, um, at,
at a societal level by helping to reduce antimicrobial resistance.
And also, um, across your institution by educating, uh, prescribers on
antibiotic use, uh, strategies.
But, also antimicrobial stewardship has a wealth of opportunities
for doing quality improvement.
There's a lot of opportunities for scholarship in this regard,
and really it's just an amazing community within infectious diseases.
As a member and participant of SHEA, it's really been just, uh, incredibly welcoming
and really getting to know everyone within this community, has been amazing
as a, as a young, uh, faculty member.
Andrew Watkins: Yeah, and I don't know how I'm gonna follow Jonathan, because, you
know, he, he nailed it right on the head.
But I'll say similarly, I, I really value the opportunity to intervene
on individual patients in complicated cases, but then also really work on
more of the overarching protocols, policies, initiatives that can
have further reaching impacts.
I feel like you can do work that impacts not only patients that
are in your hospital now, but also downstream, you know, in the future.
and then I'll mention personally, I really love data tracking and analytics.
Antimicrobial stewardship really allows me to have a lot of opportunities for this,
and there's really scratch that itch.
You know, pairing QI processes, uh, with data analytics and tracking to
allow you to make changes and then evaluate your impact is just something
I find really fulfilling as well.
Jonathan Ryder: And Andrew, I'm just gonna add, uh, 'cause I, I should've
said this the first time, but you know, stewardship is a interdisciplinary and
collaborative, field and it's a great opportunity to have, ID clinicians work
with our ID pharmacist, and I value that every single day I do stewardship.
both, both groups bring unique perspective, um, to stewardship
and I think it's a really key component of this whole thing.
Andrew Watkins: Completely agree.
I, I love the interdisciplinary approach and the, the collegiality
that I feel like exists in the ID and stewardship community.
Sara Dong: Thank you again to Rey, Andrew and Jonathan for joining Febrile today.
Don't forget to check out the website, febrilepodcast.com to find the Consult
Notes, which are written supplements of the show with links to references,
our library of ID infographics, and a link to our merch store.
Please reach out if you have any suggestions for future shows or want
to be more involved with Febrile.
Thanks for listening.
Stay safe.
I'll see you next time.