1 00:00:08,330 --> 00:00:09,260 Sara Dong: Hey, everyone. 2 00:00:09,320 --> 00:00:13,670 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:14,060 --> 00:00:17,930 We use consult questions to dive into ID clinical reasoning, diagnostics, 4 00:00:17,930 --> 00:00:19,250 and anti-microbial management. 5 00:00:20,067 --> 00:00:21,747 I'm Sara Dong, your host. 6 00:00:22,407 --> 00:00:25,407 I am excited to introduce our guests today. 7 00:00:25,407 --> 00:00:27,807 First up is our cohost Dr. 8 00:00:27,807 --> 00:00:29,787 Reinaldo or Rey Perez. 9 00:00:30,417 --> 00:00:34,197 He has a third year ID fellow at Duke University Medical Center. 10 00:00:34,677 --> 00:00:37,257 He works with the Duke Center for Antimicrobial Stewardship and 11 00:00:37,257 --> 00:00:40,587 Infection Prevention to further their mission of improving patient 12 00:00:40,587 --> 00:00:43,017 safety and enhancing quality of care. 13 00:00:43,277 --> 00:00:46,247 His research interests include implementation of anti-microbial 14 00:00:46,247 --> 00:00:49,837 stewardship interventions and leveraging interprofessional teams. 15 00:00:50,437 --> 00:00:53,840 He also has additional interest as a medical educator with a passion for 16 00:00:53,840 --> 00:00:57,740 curriculum development and effective assessment of educational interventions. 17 00:00:58,530 --> 00:01:00,110 Rey Perez: Hey Sara, thanks so much for having me. 18 00:01:00,110 --> 00:01:01,590 This is so exciting to be here. 19 00:01:01,992 --> 00:01:03,162 Sara Dong: Next meet Dr. 20 00:01:03,162 --> 00:01:04,272 Andrew Watkins. 21 00:01:04,432 --> 00:01:08,602 He is an infectious diseases pharmacist at Saint Dominic Jackson Memorial Hospital 22 00:01:08,602 --> 00:01:12,292 in Jackson, Mississippi, and serves as the pharmacy stewardship lead for the 23 00:01:12,292 --> 00:01:16,532 hospital, as well as the Franciscan Missionaries of Our Lady Health System. 24 00:01:17,022 --> 00:01:21,012 His responsibilities include prospective audit and feedback, policy and 25 00:01:21,012 --> 00:01:25,732 protocol development, implementation of stewardship initiatives, antimicrobial 26 00:01:25,752 --> 00:01:30,162 use tracking and reporting, and education of frontline staff on ID and 27 00:01:30,162 --> 00:01:32,322 anti-microbial stewardship related topics. 28 00:01:32,682 --> 00:01:35,442 He also precepts pharmacy residents on anti-microbial 29 00:01:35,442 --> 00:01:37,212 stewardship learning experiences. 30 00:01:37,865 --> 00:01:39,365 Andrew Watkins: Hey Sara, this is Andrew Watkins. 31 00:01:39,365 --> 00:01:40,085 Thanks for having me. 32 00:01:40,554 --> 00:01:43,044 Sara Dong: And last but not least is an old friend of the show, Dr. 33 00:01:43,044 --> 00:01:43,964 Jonathan Ryder. 34 00:01:44,514 --> 00:01:47,634 He is an Assistant Professor in the Division of Infectious Diseases at 35 00:01:47,634 --> 00:01:49,554 University of Nebraska Medical Center. 36 00:01:50,184 --> 00:01:54,324 He serves as an Associate Medical Director of Antimicrobial Stewardship, 37 00:01:54,594 --> 00:01:58,494 with interest in diagnostic stewardship and stewardship in rural settings. 38 00:01:58,854 --> 00:02:02,244 He is also an Associate Hospital Epidemiologist with the infection 39 00:02:02,244 --> 00:02:03,894 control and epidemiology program. 40 00:02:04,168 --> 00:02:08,068 Lastly, he has interest in digital medical education and is co-director 41 00:02:08,068 --> 00:02:10,678 of the microbiology block for the first year medical students. 42 00:02:11,628 --> 00:02:13,138 Jonathan Ryder: Hi, this is Jonathan Ryder. 43 00:02:13,248 --> 00:02:15,648 I am really excited to be back on Febrile. 44 00:02:16,053 --> 00:02:16,563 Sara Dong: Okay. 45 00:02:16,563 --> 00:02:17,673 You guys know the drill. 46 00:02:17,703 --> 00:02:22,263 Before we talk about the case and the episode today, we always ask about sharing 47 00:02:22,263 --> 00:02:26,703 a piece of culture because Febrile is everyone's favorite cultured podcast. 48 00:02:27,063 --> 00:02:30,903 So I would love to hear about something that you have had fun with 49 00:02:30,903 --> 00:02:33,183 recently, or that has brought you joy. 50 00:02:34,019 --> 00:02:38,629 Jonathan Ryder: Yeah, so today's episode is nearing Thanksgiving, and so I thought 51 00:02:38,689 --> 00:02:42,869 I'd come up with a piece of culture related to that, mainly pointing out 52 00:02:42,869 --> 00:02:47,719 that I think Thanksgiving is my personal favorite of the holidays with its triple 53 00:02:47,719 --> 00:02:50,969 threat of, uh, family, food and football. 54 00:02:51,674 --> 00:02:56,574 And, since my football team isn't playing this year, uh, on Thursday, I am going 55 00:02:56,574 --> 00:02:59,934 to choose my favorite Thanksgiving dish as my culture recommendation. 56 00:03:00,634 --> 00:03:04,974 And, uh, my favorite is, uh, my mom's sweet potato casserole. 57 00:03:05,474 --> 00:03:10,214 Uh, it has pecans on top, not a fan of the marshmallows that some 58 00:03:10,414 --> 00:03:11,934 people do, uh, for that dish. 59 00:03:12,114 --> 00:03:13,734 So that's gonna be my pick. 60 00:03:15,581 --> 00:03:20,044 Sara Dong: Well, I feel like I have to ask, do you just not like marshmallows. 61 00:03:20,254 --> 00:03:23,384 Are you morally opposed to having them on top of sweet potatoes? 62 00:03:23,704 --> 00:03:27,964 You know, I grew up having marshmallows on my like super potato, yam casserole, 63 00:03:27,994 --> 00:03:31,504 so I actually didn't realize until recently that that was something that 64 00:03:31,804 --> 00:03:34,174 some people thought was, uh, a bit weird. 65 00:03:34,688 --> 00:03:37,928 Jonathan Ryder: I love marshmallows, but not in that dish. 66 00:03:38,228 --> 00:03:43,908 Um, and I think that's not how that dish was made for me growing up and 67 00:03:43,908 --> 00:03:46,488 so that concept doesn't work for me. 68 00:03:46,788 --> 00:03:49,928 But, uh, over an open campfire, big marshmallow fan. 69 00:03:50,346 --> 00:03:51,156 Sara Dong: Got it. 70 00:03:51,216 --> 00:03:53,486 So, uh, how about you, Rey? 71 00:03:53,876 --> 00:03:57,256 Rey Perez: So sticking with the holiday theme as well with, uh, Thanksgiving 72 00:03:57,256 --> 00:03:58,376 and Christmas around the corner. 73 00:03:58,676 --> 00:04:02,336 My family comes from Puerto Rico and we have a very special tradition there. 74 00:04:02,516 --> 00:04:06,886 It's a unique version of Christmas caroling called parrandas, where you go 75 00:04:06,886 --> 00:04:10,886 around the neighborhood creating a bigger and bigger band essentially to sing 76 00:04:11,166 --> 00:04:14,486 Christmas carols and then everyone who you sing at their house has to feed you. 77 00:04:14,546 --> 00:04:18,326 So it's just a really special and really, uh, fun and crazy tradition. 78 00:04:18,697 --> 00:04:19,777 Sara Dong: Amazing. 79 00:04:20,497 --> 00:04:23,107 Uh, Andrew, you want to finish this up? 80 00:04:23,747 --> 00:04:25,187 Andrew Watkins: Yeah, I'm, I'm gonna stick with the holidays 81 00:04:25,187 --> 00:04:26,747 too and we'll kinda look ahead. 82 00:04:26,807 --> 00:04:29,107 No, no offense to Thanksgiving 'cause I do enjoy that. 83 00:04:29,167 --> 00:04:31,067 But really looking forward to Christmas. 84 00:04:31,127 --> 00:04:33,547 Um, it's really fun time of year, you know, it's almost 85 00:04:33,547 --> 00:04:34,707 time to start decorating. 86 00:04:34,807 --> 00:04:38,027 I'm very much a Black Friday Christmas decoration person. 87 00:04:38,687 --> 00:04:42,227 Um, so I do give Thanksgiving it's due, but then we jump into the decorations, 88 00:04:42,607 --> 00:04:46,307 um, you know, getting the kids to really get involved in that and enjoy that. 89 00:04:46,307 --> 00:04:46,987 And then seeing family. 90 00:04:47,047 --> 00:04:49,267 So really busy time of year, but one I really enjoy. 91 00:04:50,795 --> 00:04:55,255 Track 1: So This week is US Antibiotic Awareness Week, this annual campaign 92 00:04:55,255 --> 00:04:58,680 from the Centers for Disease Control Prevention seeks to highlight the steps 93 00:04:59,120 --> 00:05:03,320 everyone can take to improve antibiotic prescribing and use, as well as being 94 00:05:03,400 --> 00:05:07,080 a rallying cry in the fight against increasing antimicrobial resistance. 95 00:05:07,660 --> 00:05:11,280 In honor of this, today's case will be focused on hospital 96 00:05:11,280 --> 00:05:12,880 antibiotic stewardship programs. 97 00:05:13,340 --> 00:05:17,000 Uh, and this episode is brought to you in collaboration with the Society of 98 00:05:17,240 --> 00:05:21,000 Hospital Epidemiology Antimicrobial Stewardship Committee, for which Dr. 99 00:05:21,200 --> 00:05:21,760 Ryder is a member. 100 00:05:22,400 --> 00:05:25,610 Sara Dong: So this week, you're on call for the hospital's antimicrobial 101 00:05:25,610 --> 00:05:29,667 stewardship pager, and today's consult question comes after you receive a 102 00:05:29,667 --> 00:05:33,297 call from the cardiac surgery team requesting approval for daptomycin 103 00:05:33,627 --> 00:05:39,047 after a preoperative urine culture grew vancomycin resistant Enterococcus 104 00:05:39,067 --> 00:05:41,847 faecium in a penicillin allergic patient. 105 00:05:42,092 --> 00:05:45,672 Rey Perez: So Jonathan, before we really get started, not everyone here 106 00:05:45,732 --> 00:05:49,632 may be familiar with the structure of antimicrobial stewardship teams or 107 00:05:49,632 --> 00:05:53,512 some of the techniques that we commonly use when we're serving this role. 108 00:05:54,212 --> 00:05:57,452 So before we get into the details of this case, I think it'd be great if we 109 00:05:57,452 --> 00:06:01,362 discuss some of the essential components of a stewardship team and think about 110 00:06:01,382 --> 00:06:05,162 two of the core interventions that we utilize - antibiotic restriction 111 00:06:05,262 --> 00:06:06,762 and post prescription review. 112 00:06:07,342 --> 00:06:10,262 So just to start, Jonathan, why do we need stewardship teams? 113 00:06:10,677 --> 00:06:11,417 Jonathan Ryder: Thanks, Ray. 114 00:06:11,647 --> 00:06:14,617 Such a, such a great question and I'm glad we're starting with the basics 115 00:06:14,617 --> 00:06:16,697 after, uh, hearing that consult question. 116 00:06:16,877 --> 00:06:18,937 So there's kind of a, kind of a lot going on there. 117 00:06:19,477 --> 00:06:22,257 So there there's several reasons why we need stewardship teams. 118 00:06:22,397 --> 00:06:27,337 So antimicrobial resistance is a, is a growing problem of international scale, 119 00:06:27,717 --> 00:06:33,927 and a 2014 report estimated that if antimicrobial resistance continues on 120 00:06:33,987 --> 00:06:38,657 its current trajectory, that by 2050, about 10 million people would die 121 00:06:38,687 --> 00:06:43,027 each year as a result of antimicrobial resistance, with a global cost up 122 00:06:43,027 --> 00:06:45,287 to a hundred trillion US dollars. 123 00:06:46,267 --> 00:06:50,567 And so, while, uh, antimicrobial resistance is, is a growing issue, 124 00:06:50,827 --> 00:06:54,907 we also have a pretty big issue with appropriate antibiotic prescribing. 125 00:06:54,927 --> 00:07:00,067 And so when you look at common reasons for antimicrobial, uh, uh, prescriptions, 126 00:07:00,687 --> 00:07:05,227 the, the data show that it, it was inappropriate in about 80% of patients 127 00:07:05,227 --> 00:07:08,907 that have community acquired pneumonia, about three quarters that have urinary 128 00:07:08,907 --> 00:07:13,302 tract infections, half of patients who are prescribed fluoroquinolones and about 129 00:07:13,342 --> 00:07:17,862 a quarter of patients who are receiving intravenous vancomycin, uh, antibiotics. 130 00:07:18,482 --> 00:07:22,742 And, and the reasons why we see inappropriate antibiotics are usually 131 00:07:22,802 --> 00:07:27,372 due to inappropriately uh, long therapy in patients with, uh, community acquired 132 00:07:27,372 --> 00:07:32,812 pneumonia and in urinary tract infection, about half of patients, um, don't have 133 00:07:32,812 --> 00:07:35,012 any signs or symptoms of infection. 134 00:07:35,872 --> 00:07:40,477 And so ultimately, antimicrobial stewardship programs are in place because 135 00:07:40,657 --> 00:07:44,797 as infectious disease doctors, we can't, uh, be consultants on every single patient 136 00:07:44,937 --> 00:07:49,522 on antibiotics, and so we need to have larger systems-based interventions that 137 00:07:49,672 --> 00:07:53,095 improve our utilization of antimicrobials. 138 00:07:53,745 --> 00:07:58,172 And, and similarly, you have to track what you do, uh, in order to make 139 00:07:58,172 --> 00:08:02,872 changes and to make improvements and having a dedicated stewardship team and 140 00:08:02,872 --> 00:08:07,152 program really helps with tracking and reporting and, and building accountability 141 00:08:07,172 --> 00:08:08,712 to help drive these improvements. 142 00:08:09,372 --> 00:08:13,632 And ultimately, antimicrobial stewardship teams are about improving patient care. 143 00:08:13,812 --> 00:08:17,552 And I always want to emphasize this point because sometimes people really 144 00:08:17,572 --> 00:08:23,525 see these as more, uh, health system or, more societally driven, uh, programs. 145 00:08:23,525 --> 00:08:27,499 And while those things are certainly true, that there are downstream benefits, 146 00:08:27,719 --> 00:08:32,074 uh, to society and the health system, ultimately what we do on the day-to-Day 147 00:08:32,074 --> 00:08:33,594 is about optimizing patient care. 148 00:08:33,704 --> 00:08:37,114 That we're making sure that each patient receives the right drug, for the 149 00:08:37,364 --> 00:08:40,674 right bug, at the right dose, for the right duration, and at the right time. 150 00:08:40,974 --> 00:08:44,364 And so I always think that stewardship programs really at the core of them 151 00:08:44,364 --> 00:08:45,404 are taking care of our patients. 152 00:08:46,159 --> 00:08:46,859 Rey Perez: Thanks for that. 153 00:08:47,149 --> 00:08:49,589 Jonathan, I think you really helped put into context what the 154 00:08:49,589 --> 00:08:50,909 nature of the problem is here. 155 00:08:51,089 --> 00:08:55,069 And uh, Andrew, just to pull you in, you know, when you think about what really 156 00:08:55,079 --> 00:08:59,349 makes a great stewardship team, what are those core features that make it work? 157 00:08:59,449 --> 00:09:00,669 You know, what do you think about? 158 00:09:01,499 --> 00:09:03,909 Andrew Watkins: Yeah, so luckily CDC has done a lot of the homework 159 00:09:03,929 --> 00:09:07,989 for me and has a really great list of those CDC core elements. 160 00:09:07,989 --> 00:09:13,029 So what are their basic, the most essential parts of a stewardship program? 161 00:09:13,489 --> 00:09:15,909 And they have seven that are very clearly defined. 162 00:09:16,029 --> 00:09:20,029 They have hospital leadership commitment, they have accountability, 163 00:09:20,819 --> 00:09:22,549 they have pharmacy expertise, 164 00:09:23,489 --> 00:09:27,569 action, . tracking, reporting and education. 165 00:09:27,589 --> 00:09:30,489 So I just wanna kind of run through those and give a very high level view 166 00:09:30,489 --> 00:09:32,529 of what is involved with each of those. 167 00:09:32,589 --> 00:09:35,209 And so looking at hospital leadership commitment. 168 00:09:36,084 --> 00:09:39,524 CMS is very clear that institutional leadership, along with quality 169 00:09:39,524 --> 00:09:44,484 improvement must address issues that are identified by the infection prevention 170 00:09:44,484 --> 00:09:45,844 and the stewardship committees. 171 00:09:46,184 --> 00:09:49,724 Uh, and this open communication between stewardship and hospital leaderships 172 00:09:49,724 --> 00:09:51,084 really helps facilitate this. 173 00:09:51,494 --> 00:09:54,474 And this is really important 'cause a lot of the bigger stewardship initiatives 174 00:09:54,514 --> 00:09:58,354 can really flounder if you don't have that administrative support and kind 175 00:09:58,354 --> 00:09:59,874 of like leadership weight behind them. 176 00:10:01,069 --> 00:10:04,589 Hospitals can demonstrate this leadership through funding positions, and so 177 00:10:04,909 --> 00:10:08,229 actually having dedicated funding for salary for these positions, having 178 00:10:08,229 --> 00:10:10,349 dedicated FTEs for these positions. 179 00:10:10,849 --> 00:10:13,389 Um, and another way that you can show leadership support is just by 180 00:10:13,389 --> 00:10:16,389 having some public statements of support that leadership can sign. 181 00:10:16,389 --> 00:10:20,339 You can display these across your institution, um, or publish them 182 00:10:20,339 --> 00:10:24,219 on websites, um, just to show that that leadership is, committed to 183 00:10:24,219 --> 00:10:25,659 supporting antimicrobial stewardship. 184 00:10:25,944 --> 00:10:29,584 Talking about the accountability piece, uh, is, is more centered around 185 00:10:29,584 --> 00:10:32,504 having a clear leadership structure within the stewardship program. 186 00:10:32,924 --> 00:10:36,024 So typically that's gonna take the form of a physician leader, uh, 187 00:10:36,024 --> 00:10:37,664 and a pharmacist as co-leaders. 188 00:10:37,964 --> 00:10:40,904 Um, but you can have stewardship programs that have just a single leader. 189 00:10:41,314 --> 00:10:44,594 These roles should ideally be clarified, so it's always clear who's 190 00:10:44,594 --> 00:10:48,074 running the stewardship program and who's accountable for the metrics and 191 00:10:48,314 --> 00:10:49,474 outcomes with the stewardship program. 192 00:10:49,894 --> 00:10:51,994 One often overlooked point, things that we've seen 193 00:10:52,814 --> 00:10:57,194 Or not thought about in a lot of surveys, um, is that these leaders should have 194 00:10:57,194 --> 00:11:01,514 some sort of education or training or experience in infectious diseases 195 00:11:01,514 --> 00:11:05,954 or antimicrobial stewardship, um, as outlined by Joint Commission in CMS. 196 00:11:05,954 --> 00:11:09,474 And so this can be your kind of classic post-graduate training with an ID 197 00:11:09,474 --> 00:11:13,394 fellowship or ID pharmacy residency, um, or can be through certificate 198 00:11:13,394 --> 00:11:16,514 courses plus ongoing continuing education kind of year to year. 199 00:11:17,854 --> 00:11:21,544 Looking at pharmacy expertise really focuses more on the pharmacy co-leader 200 00:11:21,564 --> 00:11:25,304 of the stewardship program, and really is another essential element of that. 201 00:11:25,364 --> 00:11:28,984 You know, I'm biased as a pharmacist, but I will say that because of the 202 00:11:29,224 --> 00:11:32,384 positioning of pharmacists within the healthcare system, kind of our roles, 203 00:11:33,024 --> 00:11:36,884 we can be really helpful in stewardship programs because we interface with so many 204 00:11:36,884 --> 00:11:38,924 different aspects of the healthcare team. 205 00:11:39,344 --> 00:11:42,924 We also are situated really well to have access to antibiotic use, to 206 00:11:42,924 --> 00:11:45,684 help kind of track that over time and help with that reporting piece. 207 00:11:46,304 --> 00:11:49,724 Um, already integrated into the Pharmacy and Therapeutics committee, which 208 00:11:49,724 --> 00:11:53,164 really helps, uh, with integration with that for leadership and quality. 209 00:11:53,744 --> 00:11:56,824 They're also just very familiar with drug specific information like 210 00:11:57,004 --> 00:12:01,024 pharmacokinetics and dynamics and all those fun things that go into how 211 00:12:01,024 --> 00:12:02,904 we optimize dosing of antibiotics. 212 00:12:03,604 --> 00:12:07,544 So all in all, really helpful to have a pharmacist co-leader, um, in stewardship. 213 00:12:07,854 --> 00:12:11,674 The action core element, um, has intervention such as prospective audit 214 00:12:11,674 --> 00:12:14,794 and feedback or pre-authorization, which we'll talk about here in a little bit. 215 00:12:15,294 --> 00:12:18,234 Um, also facility specific treatment guidelines. 216 00:12:18,264 --> 00:12:21,324 They're also a very key action element, and will be required by 217 00:12:21,324 --> 00:12:22,764 Joint Commission, uh, as of this year. 218 00:12:23,634 --> 00:12:25,334 having at least two of those implemented. 219 00:12:25,354 --> 00:12:27,934 So really important from a, a regulatory standpoint as well. 220 00:12:28,524 --> 00:12:32,184 And overall action is probably the broadest and most vague of all of 221 00:12:32,184 --> 00:12:34,784 the core elements because there are so many things that you can do. 222 00:12:35,114 --> 00:12:39,034 You could have automatic protocols, uh, for renal dosing or IV to PO 223 00:12:39,034 --> 00:12:43,719 conversions, kinetics based dosing, antibiotic timeout processes or 224 00:12:43,719 --> 00:12:46,059 handshake rounds, automatic stop dates. 225 00:12:46,119 --> 00:12:48,579 So this is where you can really fit in a lot of the, the 226 00:12:48,819 --> 00:12:49,859 interventions in the day-to-Day. 227 00:12:49,859 --> 00:12:52,179 Like big projects in the stewardship programs. 228 00:12:52,962 --> 00:12:56,962 Tracking is vital because of its utility in helping to find opportunities for 229 00:12:56,962 --> 00:13:00,762 improvement, for tracking progress of any interventions you've implemented, 230 00:13:01,037 --> 00:13:02,417 and helping to build accountability. 231 00:13:02,917 --> 00:13:04,347 There are tons of different metrics. 232 00:13:04,407 --> 00:13:06,747 We could probably have a whole hour talk on just what metrics 233 00:13:06,887 --> 00:13:09,727 you could track but really one of the most basic is antibiotic use. 234 00:13:09,947 --> 00:13:14,727 Uh, and so actually tracking and reporting antibiotic use to NHSN, which is the 235 00:13:15,327 --> 00:13:19,687 National Healthcare Safety Network, is a regulatory requirement starting in 2024. 236 00:13:20,267 --> 00:13:23,767 Uh, and it serves as a great method of not only tracking your use, but 237 00:13:23,767 --> 00:13:27,367 help establish some benchmarking and comparisons to similar hospitals. 238 00:13:27,877 --> 00:13:30,607 It's especially helpful to track in relation to any particular 239 00:13:30,607 --> 00:13:31,927 initiatives you have going on. 240 00:13:31,947 --> 00:13:35,727 So maybe you have, you know, new guidance to help decrease use of 241 00:13:35,737 --> 00:13:37,247 broad spectrum hospital agents. 242 00:13:37,247 --> 00:13:39,087 And then you can actually track this over time. 243 00:13:39,347 --> 00:13:42,167 And CDC has a ton of great examples on their website of some of these 244 00:13:42,742 --> 00:13:44,512 ways to actually track this data. 245 00:13:44,925 --> 00:13:47,345 But then you can also encompass other aspects of tracking. 246 00:13:47,445 --> 00:13:51,185 So, you know, number or type of audit and feedback patient interventions. 247 00:13:51,185 --> 00:13:53,585 And so that's really helpful 'cause it can highlight the 248 00:13:53,585 --> 00:13:54,945 impact of your stewardship group. 249 00:13:55,125 --> 00:13:57,505 You know, how many interventions are you having, what's your acceptance 250 00:13:57,505 --> 00:14:02,015 rate, um, and then also helping to justify some of those continued 251 00:14:02,015 --> 00:14:03,815 funding and additional, uh, positions. 252 00:14:03,865 --> 00:14:07,525 You can also track other outcomes like c diff or MDRO infections. 253 00:14:07,905 --> 00:14:11,365 And so the list is really long on tracking, but what's really important is 254 00:14:11,365 --> 00:14:15,125 that after you track, you actually go to the next core element, which is reporting. 255 00:14:15,125 --> 00:14:17,145 So really reporting is your kind of actionable. 256 00:14:17,760 --> 00:14:22,490 Back inside of tracking where you take the data that you've actually, uh, tracked and 257 00:14:22,490 --> 00:14:25,970 you've deemed most important, and then you relay that back to your frontline staff. 258 00:14:26,190 --> 00:14:29,290 And so that's important because it's gonna increase transparency and buy-in 259 00:14:29,290 --> 00:14:32,770 for those providers, especially when you pair that with the reporting and 260 00:14:32,770 --> 00:14:34,650 education and ongoing interventions. 261 00:14:35,397 --> 00:14:39,647 It also makes the data more actionable and helps with modifying initiatives that may 262 00:14:39,647 --> 00:14:42,887 not be doing so well from the beginning, you look and say, you know, Hey, we 263 00:14:42,887 --> 00:14:46,767 implemented this a month ago and we're not seeing really any movement in our use. 264 00:14:46,877 --> 00:14:47,767 What can we do better? 265 00:14:47,827 --> 00:14:48,927 Can we educate better? 266 00:14:49,027 --> 00:14:50,287 Can we communicate this? 267 00:14:50,747 --> 00:14:53,607 Um, or maybe you highlight some early successes that you can take 268 00:14:53,607 --> 00:14:55,927 back immediately and say, look, we started this last month and we're 269 00:14:55,927 --> 00:14:57,007 having, we're seeing a huge impact. 270 00:14:57,007 --> 00:15:01,007 Like keep good job, keep going, and really helps with that kind of morale and buy-in. 271 00:15:01,427 --> 00:15:04,757 Overall, the combination of tracking and reporting really helped drive 272 00:15:04,857 --> 00:15:08,037 the program forward, uh, and work as a great accountability piece. 273 00:15:08,377 --> 00:15:09,797 And then lastly, education. 274 00:15:10,067 --> 00:15:13,317 It's really kind of one of the more nebulous topics of core elements because 275 00:15:13,337 --> 00:15:16,157 it can take so many different forms, have so many different audiences. 276 00:15:16,607 --> 00:15:21,322 Education can involve prescribers or pharmacists, nurses, you can 277 00:15:21,322 --> 00:15:22,602 educate patients and family. 278 00:15:22,782 --> 00:15:26,202 And then you could cover a whole host of topics from resistance. 279 00:15:26,502 --> 00:15:29,082 You know, the harms of antibiotics, optimal prescribing. 280 00:15:29,552 --> 00:15:33,452 Uh, it can really take the form of institutional guidelines or 281 00:15:33,452 --> 00:15:37,612 antibiograms, uh, hospital policies in-service presentation handouts. 282 00:15:37,612 --> 00:15:39,892 I mean, you name it, and you can educate on it essentially. 283 00:15:40,312 --> 00:15:43,652 And so because of that, usually I recommend keeping a log of education, 284 00:15:43,862 --> 00:15:45,142 things that you've done, you know. 285 00:15:45,772 --> 00:15:49,472 Who you educated, when you educated, and then what did you actually educate about? 286 00:15:49,812 --> 00:15:52,592 Um, so that if you're ever asked by a surveyor, you know, prove 287 00:15:52,592 --> 00:15:54,832 to me what education you've done, you can have a list there. 288 00:15:54,832 --> 00:15:56,992 They'll say, oh yeah, we went to this session back in July. 289 00:15:57,452 --> 00:15:59,832 Um, and then also just to make your lives easier. 290 00:16:00,032 --> 00:16:03,632 'cause there's so much going on, uh, in the day-to-Day of a stewardship program. 291 00:16:04,687 --> 00:16:07,547 Try to pair your education with whatever initiative you're 292 00:16:07,547 --> 00:16:08,507 really trying to push forward. 293 00:16:08,647 --> 00:16:10,707 So, you know, you're, you're implementing this new initiative 294 00:16:10,707 --> 00:16:12,227 that's part of the action core element. 295 00:16:12,607 --> 00:16:15,107 Uh, and then you, you're educating providers on that as well. 296 00:16:15,107 --> 00:16:17,667 You're reporting back and so you really hit a lot of these core elements 297 00:16:17,667 --> 00:16:19,357 all at one time with one initiative. 298 00:16:20,442 --> 00:16:23,172 Rey Perez: Well, thanks so much Andrew, for that really comprehensive overview. 299 00:16:23,292 --> 00:16:26,652 I feel like I can just see the stewardship team in action already with 300 00:16:26,652 --> 00:16:28,012 everything that you've described there. 301 00:16:28,672 --> 00:16:32,372 Now, uh, Jonathan, to pop back to you, I did want to expand a little bit 302 00:16:32,372 --> 00:16:34,972 on one thing that Andrew was talking about, and that's 'cause the CDC 303 00:16:34,972 --> 00:16:37,492 highlights as a priority intervention, 304 00:16:38,427 --> 00:16:42,447 two of the things that stewardship programs do that have the most evidence 305 00:16:42,447 --> 00:16:47,007 for efficacy, and that's prospective audit and feedback and pre-authorization. 306 00:16:47,587 --> 00:16:50,287 Can you tell us a little bit more about what these tools are and how they work? 307 00:16:50,287 --> 00:16:51,400 Jonathan Ryder: Thanks, Ray. 308 00:16:51,430 --> 00:16:55,800 Yeah, so there's these sort of two, um, philosophies and approaches to 309 00:16:55,800 --> 00:17:00,020 antimicrobial stewardship and, and how it takes place, uh, in action. 310 00:17:00,200 --> 00:17:05,910 And so prospective audit and feedback is really kind of reviewing from an external 311 00:17:06,040 --> 00:17:08,790 standpoint how antibiotics are being used. 312 00:17:08,810 --> 00:17:12,950 And then, uh, after reviewing cases, identifying opportunities 313 00:17:13,050 --> 00:17:14,270 to improve that use. 314 00:17:14,790 --> 00:17:18,344 Audit and feedback occurs after an antibiotic is prescribed. 315 00:17:18,684 --> 00:17:22,984 And this can take place in many different formats, either by messaging 316 00:17:23,004 --> 00:17:28,424 or calling a team, or actually in a face-to-face format, which is known as 317 00:17:28,574 --> 00:17:32,864 handshake stewardship in which, uh, the recommendations actually occur in person. 318 00:17:33,604 --> 00:17:38,764 And so, in contrast to prospective audit and feedback is pre-authorization, also 319 00:17:38,764 --> 00:17:43,834 known sometimes by restriction, and this is really requiring some sort of approval, 320 00:17:44,414 --> 00:17:48,954 uh, by the antimicrobial stewardship team in order to use a certain antibiotic. 321 00:17:49,534 --> 00:17:54,474 And this really allows for the antimicrobial stewardship team to give 322 00:17:54,474 --> 00:17:58,754 their input whenever a prescriber is interested in using that antibiotic. 323 00:17:59,369 --> 00:18:03,229 And really prevent unnecessary initiation of antibiotics as well. 324 00:18:03,529 --> 00:18:08,709 And so these two different forms have actually been compared, uh, directly and 325 00:18:08,709 --> 00:18:12,749 generally prospective audit and feedback has been shown to be more effective. 326 00:18:13,659 --> 00:18:17,549 However, there's really a use for both of these in stewardship 327 00:18:17,549 --> 00:18:24,219 programs depending on some of the different situations that pop up. 328 00:18:24,519 --> 00:18:26,149 Rey Perez: Could you expand on that a little bit more? 329 00:18:26,179 --> 00:18:29,389 Like what do you see as some of these pros and cons between these two 330 00:18:29,389 --> 00:18:32,519 different approaches and how have you synthesized that and applied it 331 00:18:32,519 --> 00:18:33,919 at your own institution for example? 332 00:18:35,344 --> 00:18:39,154 Jonathan Ryder: Yeah, so prospective audit and feedback's, uh, really strong 333 00:18:39,154 --> 00:18:44,394 points are that you are providing a direct education to the prescriber 334 00:18:44,774 --> 00:18:46,264 when you're providing that feedback. 335 00:18:46,874 --> 00:18:51,254 It also allows for a lot of autonomy for prescribers, and it really empowers those, 336 00:18:51,474 --> 00:18:55,814 um, team members to make their own initial decisions about what antibiotics to use. 337 00:18:56,274 --> 00:18:59,774 It really creates kind of a collegial environment because decisions are made 338 00:18:59,774 --> 00:19:01,934 in a, in a collective, uh, manner. 339 00:19:02,474 --> 00:19:06,494 One pro when you're running a program is that prospective audit and feedback 340 00:19:06,594 --> 00:19:11,164 is, is primarily during, uh, daytime hours, actually almost exclusively. 341 00:19:11,544 --> 00:19:14,004 Uh, so not a lot of phone calls in the middle of the night. 342 00:19:14,584 --> 00:19:19,074 The other part of this is since you're providing education, you may actually 343 00:19:19,074 --> 00:19:23,474 have kind of downstream impacts on multiple components of antibiotic 344 00:19:23,574 --> 00:19:25,034 use throughout your hospital system. 345 00:19:25,494 --> 00:19:30,674 And then you're also able to comment to that individual about both the 346 00:19:30,844 --> 00:19:34,834 antibiotic that's being used, but also dosing, duration, deescalation. 347 00:19:34,854 --> 00:19:38,604 And so . There's multiple components that can be affected. 348 00:19:39,144 --> 00:19:41,924 The problems with prospective audit and feedback is it can be kind of 349 00:19:42,164 --> 00:19:46,564 resource intensive to actually go through a, a list, for example, every 350 00:19:46,624 --> 00:19:50,364 day, uh, spend time in those patient charts, reviewing the indications, 351 00:19:50,384 --> 00:19:54,284 the dosing, the durations, et cetera, for each of those individual patients. 352 00:19:54,934 --> 00:19:59,169 Another disadvantage is that the patient already receives usually at 353 00:19:59,169 --> 00:20:03,169 least one dose of antibiotics, if not several D doses, or even several days of 354 00:20:03,169 --> 00:20:05,249 antibiotics before an intervention occurs. 355 00:20:05,669 --> 00:20:09,609 And so some of that upfront antibiotic use, uh, when deemed 356 00:20:09,609 --> 00:20:11,959 inappropriate already has occurred. 357 00:20:12,899 --> 00:20:15,959 And then ultimately the prescribers can do what they want. 358 00:20:15,989 --> 00:20:20,679 That autonomy does allow, uh, for the prescribers to disagree with 359 00:20:20,679 --> 00:20:24,839 the stewardship team, and that may mean that, um, the recommendations 360 00:20:25,099 --> 00:20:26,919 do not have a great uptake. 361 00:20:27,522 --> 00:20:31,582 So to, to contrast that with pre-authorization, its big advantage 362 00:20:31,682 --> 00:20:36,022 is it really allows more control by the stewardship team over antibiotic 363 00:20:36,382 --> 00:20:41,392 prescribing es, especially in that upfront empiric and initial antibiotic choice 364 00:20:41,612 --> 00:20:43,752 or, or choice to not initiate therapy. 365 00:20:44,412 --> 00:20:48,952 And I think this is especially effective and useful when you're 366 00:20:48,952 --> 00:20:52,712 talking about really expensive antibiotics, newer antibiotics that 367 00:20:52,712 --> 00:20:54,072 people may be less familiar with. 368 00:20:54,732 --> 00:21:00,202 Or, antimicrobials that may be more toxic or for example, antifungal 369 00:21:00,222 --> 00:21:02,562 agents or certain antiviral agents. 370 00:21:02,752 --> 00:21:06,722 Another situation can be whenever, um, you're facing shortages and there's 371 00:21:06,722 --> 00:21:10,702 just a very limited supply that a few wasted doses goes a long way. 372 00:21:11,282 --> 00:21:15,662 So the concept pre-authorization are that there's a lot less prescriber autonomy. 373 00:21:15,662 --> 00:21:19,142 There's usually some sort of phone call that has to take place, usually 374 00:21:19,142 --> 00:21:23,912 asking for some sort of permission for antibiotics, which can be a, a fairly 375 00:21:24,062 --> 00:21:28,699 adversarial interaction at some points in time, and this oftentimes will also 376 00:21:28,699 --> 00:21:30,339 involve some sort of overnight call. 377 00:21:31,224 --> 00:21:34,604 And this intervention is really limited only to the antibiotics 378 00:21:34,604 --> 00:21:35,804 that are on the restricted list. 379 00:21:35,864 --> 00:21:40,247 So it doesn't help with antibiotic durations or dosing 380 00:21:40,387 --> 00:21:42,527 or non-restricted antibiotics. 381 00:21:42,827 --> 00:21:47,367 And of course, the, the last concern I'll bring up is that this pre-authorization 382 00:21:47,367 --> 00:21:52,237 process could result in delays of therapy to patients who are especially 383 00:21:52,737 --> 00:21:55,977 critically ill, which, uh, could be a, a downstream consequence. 384 00:21:56,317 --> 00:22:01,374 So my experience at my institution is that we largely use prospective 385 00:22:01,374 --> 00:22:05,134 audit and feedback for our daily stewardship activities, which does 386 00:22:05,134 --> 00:22:08,974 take a, a really dedicated stewardship team that's dedicating time to this. 387 00:22:09,074 --> 00:22:13,454 But we review lists of key antibiotics and diagnostic tests. 388 00:22:13,514 --> 00:22:18,089 So for example, all positive blood cultures and rapid molecular diagnostic 389 00:22:18,089 --> 00:22:22,209 testing results and antibiotics that are higher risk for, uh, uh, 390 00:22:22,209 --> 00:22:26,209 Clostridoides difficile, such as, uh, fluoroquinolones and clindamycin. 391 00:22:26,229 --> 00:22:29,469 And then we look at broad spectrum agents like vancomycin, piperacillin-tazobactam, 392 00:22:29,469 --> 00:22:31,169 cefepime et cetera. 393 00:22:31,989 --> 00:22:35,849 And, and we provide that, uh, feedback to clinicians based on, um, the 394 00:22:35,849 --> 00:22:37,129 antibiotics that they've prescribed. 395 00:22:37,149 --> 00:22:41,289 But we also use pre-authorization and restrictions on certain antibiotics, 396 00:22:42,064 --> 00:22:45,394 such as those that I mentioned that have higher adverse, uh, event 397 00:22:45,474 --> 00:22:48,184 profiles or, that are more expensive. 398 00:22:48,604 --> 00:22:52,504 And these are also reviewed as part of the, uh, prospective audit and 399 00:22:52,744 --> 00:22:56,187 feedback process where oftentimes clinicians may be able to access a 400 00:22:56,187 --> 00:23:00,347 dose overnight, but then the next day, uh, feedback is given to adjust that. 401 00:23:00,770 --> 00:23:01,260 Rey Perez: Awesome. 402 00:23:01,450 --> 00:23:05,980 Well, now that our toolkits are filled with all of these new useful 403 00:23:06,440 --> 00:23:10,110 ideas to tackle the this case, why don't we go ahead and dive right in. 404 00:23:10,650 --> 00:23:14,670 So, our patient is a 67 year old male with a past medical history 405 00:23:14,670 --> 00:23:19,070 of hypertension, type two diabetes, obesity, and coronary artery disease. 406 00:23:19,540 --> 00:23:22,470 Over the last two months, he developed symptoms of stable angina 407 00:23:22,650 --> 00:23:26,510 and outpatient coronary angiography demonstrated three vessel disease. 408 00:23:27,210 --> 00:23:30,620 He was seen by cardiothoracic surgery as an outpatient, and he has planned for 409 00:23:30,620 --> 00:23:32,420 coronary artery bypass grafting tomorrow. 410 00:23:33,360 --> 00:23:37,060 The cardiothoracic surgery team has the practice of collecting a urine 411 00:23:37,060 --> 00:23:40,620 culture on all patients as part of their routine preoperative labs. 412 00:23:41,280 --> 00:23:45,780 He has not reported any fever, dysuria, frequency, urgency, 413 00:23:46,000 --> 00:23:47,140 or other urinary symptoms 414 00:23:47,220 --> 00:23:47,620 of note. 415 00:23:49,000 --> 00:23:52,300 His allergy history is significant for a listed penicillin allergy. 416 00:23:52,850 --> 00:23:56,500 Patient's mother reportedly told him in childhood around seven, 417 00:23:56,935 --> 00:24:00,235 he developed a rash after being given penicillin for a sore throat. 418 00:24:00,935 --> 00:24:03,115 He does not believe that it required treatment at that time. 419 00:24:03,655 --> 00:24:05,635 He has avoided repeat exposure since then. 420 00:24:06,069 --> 00:24:07,529 His labs are fairly unremarkable. 421 00:24:07,789 --> 00:24:12,129 His CBC had a white blood cell count of 7.6 with a normal differential, a 422 00:24:12,179 --> 00:24:15,969 hemoglobin of 12.7 and platelets of 256. 423 00:24:16,869 --> 00:24:20,289 His complete metabolic panel showed normal electrolytes and 424 00:24:20,289 --> 00:24:22,049 normal liver transaminases. 425 00:24:22,425 --> 00:24:27,465 A serum glucose of 183 and a serum creatinine of 1.2, which was his baseline. 426 00:24:27,665 --> 00:24:32,285 His urinalysis had an unremarkable dipstick and on microscopic analysis 427 00:24:32,305 --> 00:24:36,165 showed five white blood cells per high powered field, one red blood cell per 428 00:24:36,165 --> 00:24:39,885 high powered field, and 10 squamous epithelial cells per high powered 429 00:24:39,885 --> 00:24:41,925 field without any cast visualized. 430 00:24:42,505 --> 00:24:46,165 His urine culture grew Enterococcus faecium that was susceptible to 431 00:24:46,165 --> 00:24:48,805 ampicillin and resistant to vancomycin. 432 00:24:49,705 --> 00:24:53,125 As mentioned earlier, you are on the antimicrobial stewardship pager. 433 00:24:53,480 --> 00:24:56,100 And you get a call for linezolid, a drug that requires 434 00:24:56,280 --> 00:24:58,420 pre-authorization at your institution. 435 00:24:58,997 --> 00:25:03,777 So Jonathan, to go back to you, you know, as you think about this case, I know that 436 00:25:03,877 --> 00:25:07,697 for me, being in the pre-authorization role as a fellow was sometimes awkward. 437 00:25:08,167 --> 00:25:12,587 Uh, unlike a consult where you're being asked for help by the team, you're kind 438 00:25:12,587 --> 00:25:16,427 of inserting yourself and sometimes perceived as the antibiotic police. 439 00:25:17,207 --> 00:25:21,187 So how do you frame your role, or what other techniques do you use when 440 00:25:21,247 --> 00:25:23,587 having to give this unsolicited advice? 441 00:25:24,195 --> 00:25:27,205 Jonathan Ryder: Yeah, this is, this is, um, a great, a great scenario 442 00:25:27,315 --> 00:25:32,825 here, and so . Um, you know, usually I, I start with introducing myself. 443 00:25:33,005 --> 00:25:34,505 Say, you know, hi, I am Jonathan. 444 00:25:34,645 --> 00:25:36,465 I'm with the antimicrobial stewardship team. 445 00:25:37,165 --> 00:25:42,335 And then I use an approach that I learned actually during the IDSA Antimicrobial 446 00:25:42,335 --> 00:25:46,295 Stewardship training course, which I'm gonna highly recommend and, and provide 447 00:25:46,295 --> 00:25:51,335 a little bit of a plug for, but this is, uh, known as the NARROWS, uh, mnemonic. 448 00:25:51,545 --> 00:25:56,610 I print this off and I hang it on my wall and, anytime I am, uh, facing a case or 449 00:25:56,610 --> 00:26:00,370 working with a trainee in stewardship, I always kind of review this and take a 450 00:26:00,370 --> 00:26:03,730 deep breath and really make sure I'm in the right place to kind of have this, 451 00:26:03,910 --> 00:26:08,130 um, conversation because sometimes there is a little bit of negotiation 452 00:26:08,130 --> 00:26:09,250 that happens through this process. 453 00:26:10,035 --> 00:26:14,655 So just gonna go through this mnemonic briefly and use this case as an example. 454 00:26:14,835 --> 00:26:20,135 But the first part of, uh, NARROWS is n and that's to name the issue. 455 00:26:20,435 --> 00:26:24,455 And so, you know, this is the patient, whoever that we're talking about. 456 00:26:24,675 --> 00:26:29,175 And, um, you're, you're calling asking about linezolid for, uh, 457 00:26:29,535 --> 00:26:33,035 treating a urinary tract infection is basically what you're calling me. 458 00:26:33,035 --> 00:26:38,515 And so I, I then go to a, which is to ask, what, what is the reason why, 459 00:26:38,615 --> 00:26:40,015 why do you want to use linezolid? 460 00:26:40,035 --> 00:26:44,085 What about this patient's uh, urinalysis and urine culture make you concerned? 461 00:26:44,705 --> 00:26:48,885 Um, and then r is to reflect their emotion. 462 00:26:49,185 --> 00:26:49,565 And so. 463 00:26:50,290 --> 00:26:54,530 I, I always try to empathize with the team and say, yeah, this patient's really sick, 464 00:26:54,630 --> 00:26:58,250 or in this situation, yeah, this patient's going for a big surgery tomorrow. 465 00:26:58,910 --> 00:27:02,070 I understand that we want to make sure this patient is optimized for this, 466 00:27:02,130 --> 00:27:06,030 uh, surgical intervention and they don't develop any sort of postoperative 467 00:27:06,030 --> 00:27:08,230 complications, uh, as a result. 468 00:27:08,547 --> 00:27:12,327 so the next r in narrows is to relate with personal experience. 469 00:27:12,387 --> 00:27:18,242 And so saying something like . Yeah, I remember, um, whenever I, uh, worked in 470 00:27:18,242 --> 00:27:23,712 the ICU and I was worried about a patient, um, uh, something to really kind of show 471 00:27:23,712 --> 00:27:27,112 that you care about that individual patient, you know, whatever your 472 00:27:27,392 --> 00:27:32,112 personal story or, or memory is, that's relevant for that particular situation. 473 00:27:32,532 --> 00:27:35,632 The O in narrows is to orient to the suggested management. 474 00:27:35,812 --> 00:27:40,415 So, um, I would say something like, in this case that you could use linezolid. 475 00:27:40,435 --> 00:27:44,932 It's a, it's, it actually is a really good option for treating someone with a true, 476 00:27:45,152 --> 00:27:47,772 uh, VRE, uh, urinary tract infection. 477 00:27:47,772 --> 00:27:51,732 However, in this situation, it, it doesn't seem like there's a lot of inflammation. 478 00:27:52,292 --> 00:27:52,412 I. 479 00:27:52,412 --> 00:27:55,652 Uh, on the urine culture, and, and the patient doesn't sound like they 480 00:27:55,652 --> 00:27:59,212 have any symptoms, and so this seems more like asymptomatic bacteruria. 481 00:27:59,952 --> 00:28:03,052 And so w then is working together on a plan. 482 00:28:03,352 --> 00:28:08,362 And so I then make a suggestion like, you know, do you feel . Comfortable, like, 483 00:28:08,422 --> 00:28:13,402 uh, discontinuing antibiotic therapy in this case and, and monitoring for, uh, the 484 00:28:13,402 --> 00:28:15,282 development of further urinary symptoms. 485 00:28:15,702 --> 00:28:18,882 And this is where sometimes there's a little negotiation that takes place. 486 00:28:18,972 --> 00:28:20,682 Maybe they're concerned for another reason. 487 00:28:20,812 --> 00:28:24,322 Maybe, maybe they tell me that they actually do have urinary symptoms and 488 00:28:24,322 --> 00:28:27,002 that, um, they're actually symptomatic. 489 00:28:27,262 --> 00:28:30,722 And that maybe what I understand from what they first told me or what I read 490 00:28:30,722 --> 00:28:32,442 in the chart actually isn't the case. 491 00:28:33,262 --> 00:28:35,002 And then s is to set follow up. 492 00:28:35,022 --> 00:28:39,042 And so, um, it, it can always be reassuring to say, Hey, call me back 493 00:28:39,042 --> 00:28:42,322 if, if the patient develops symptoms, or I'll keep an eye on the chart and 494 00:28:42,322 --> 00:28:46,522 wait on the susceptibilities or, the next set of labs or whatever the next 495 00:28:46,522 --> 00:28:50,082 marker is to really figure out, you know, how can I help this patient? 496 00:28:50,888 --> 00:28:53,348 Rey Perez: Thanks Jonathan for that really wonderful framework. 497 00:28:53,388 --> 00:28:55,508 I think I'm gonna have to print it and hang it on my wall too. 498 00:28:56,448 --> 00:29:01,228 Now, you know, as we think about this case, it, it has a ton of different 499 00:29:01,228 --> 00:29:02,588 potential intervention points. 500 00:29:02,808 --> 00:29:06,228 We could be talking with the team about diagnostic stewardship and 501 00:29:06,428 --> 00:29:08,148 reducing unnecessary urine cultures. 502 00:29:08,208 --> 00:29:12,908 We could go into a conversation about asymptomatic bacteruria like 503 00:29:12,908 --> 00:29:14,148 you kind of alluded to earlier. 504 00:29:14,488 --> 00:29:19,108 We could dive into this penicillin allergy that may or may not be real, 505 00:29:19,168 --> 00:29:23,072 and talk about opportunities for de labeling penicillin allergies. 506 00:29:23,852 --> 00:29:26,992 Andrew, to jump to you this time, how do you decide on the 507 00:29:27,232 --> 00:29:28,312 priority of these interventions? 508 00:29:28,342 --> 00:29:31,882 When you have lots of things on the menu in front of you, how 509 00:29:31,882 --> 00:29:32,962 do you decide what to focus on? 510 00:29:34,082 --> 00:29:36,092 Andrew Watkins: Yeah, it's a great question and this was a really 511 00:29:36,092 --> 00:29:39,772 great case that highlights that, but in my view, the prioritization 512 00:29:39,772 --> 00:29:43,337 really depends on . What you think is gonna have the largest impact. 513 00:29:43,357 --> 00:29:46,737 So what's gonna touch the most patients, uh, but also be the 514 00:29:46,737 --> 00:29:49,657 most manageable and realistic from an implementation standpoint. 515 00:29:49,657 --> 00:29:52,897 And so really what's gonna give you the best bang for your buck from a 516 00:29:52,897 --> 00:29:54,817 stewardship intervention standpoint? 517 00:29:55,237 --> 00:29:58,417 And so in this case, you know, if you're looking big picture, I think 518 00:29:58,417 --> 00:30:03,137 asymptomatic bacteruria really stands out as the greatest opportunity for 519 00:30:03,177 --> 00:30:07,042 a targeted initiative because of how often it's treated unnecessarily 520 00:30:07,102 --> 00:30:08,682 and how widespread the issue is. 521 00:30:08,762 --> 00:30:11,602 I mean, I know where I practice and where I've practiced in the past. 522 00:30:11,982 --> 00:30:14,902 You see antibiotics started for asymptomatic bacteruria 523 00:30:14,922 --> 00:30:16,082 numerous times every day. 524 00:30:16,752 --> 00:30:18,882 It's clearly a driver of antibiotic use. 525 00:30:19,482 --> 00:30:23,822 and so it's also a great example because it can be tackled from numerous angles. 526 00:30:23,822 --> 00:30:25,742 So a lot of the things that you mentioned are kind of 527 00:30:26,547 --> 00:30:29,527 pieces that we can target for asymptomatic bacteruria. 528 00:30:29,547 --> 00:30:33,607 So, you know, first and most importantly, you can roll out education and some 529 00:30:33,887 --> 00:30:38,167 targeted messaging to really highlight the lack of benefit and frankly, risk of 530 00:30:38,277 --> 00:30:40,167 harm, of giving unnecessary antibiotics. 531 00:30:40,427 --> 00:30:43,697 Uh, when you're talking about treating an asymptomatic bacteruria. 532 00:30:44,067 --> 00:30:47,607 Uh, this education and the targeted messaging pairs really nicely with 533 00:30:47,927 --> 00:30:51,607 reinforcing these concepts through some patient review, audit and feedback 534 00:30:51,927 --> 00:30:55,407 practices, reaching out to providers so you're providing overarching 535 00:30:55,407 --> 00:30:59,007 education, and then you're also reaching out on a patient by patient case to 536 00:30:59,037 --> 00:31:00,327 kind of discuss this with providers. 537 00:31:01,792 --> 00:31:05,172 Uh, it's also a really great chance to include some of this information 538 00:31:05,172 --> 00:31:06,332 in local treatment guidance. 539 00:31:06,752 --> 00:31:10,292 Um, so again, circling back that helps with your action core element 540 00:31:10,292 --> 00:31:12,492 and with some of those regulatory requirements we mentioned. 541 00:31:12,902 --> 00:31:15,702 Then aside from education about just appropriate non-treatment of 542 00:31:15,702 --> 00:31:18,742 asymptomatic bacteruria, there's also really a great opportunity 543 00:31:18,742 --> 00:31:20,702 for some diagnostic stewardship. 544 00:31:20,962 --> 00:31:24,742 So there's a growing amount of literature highlighting some great strategies to 545 00:31:24,742 --> 00:31:28,462 really help leverage the electronic health record to help with appropriate 546 00:31:28,462 --> 00:31:32,947 urine culturing, uh, through different algorithms, alerts, order questions. 547 00:31:33,007 --> 00:31:36,027 To be sure that, you know, we're steering providers to only order 548 00:31:36,027 --> 00:31:37,427 urine cultures when it's appropriate. 549 00:31:37,427 --> 00:31:40,227 Because if you never have the urine culture that grew something, you 550 00:31:40,227 --> 00:31:43,107 can never really have that prompt of, oh, I really need to treat that 551 00:31:43,107 --> 00:31:46,227 and, and you can prevent the whole cascade from occurring by just not 552 00:31:46,227 --> 00:31:48,147 sending the inappropriate, uh, test. 553 00:31:48,980 --> 00:31:51,990 Studies have shown that a lot of these practices can have positive 554 00:31:51,990 --> 00:31:56,350 impacts on antibiotic use as well as lab and nursing workflow due to 555 00:31:56,350 --> 00:31:59,190 decreasing the amount of inappropriate cultures actually being ordered. 556 00:31:59,907 --> 00:32:03,607 And I'd say that this also ties into the case really well because of the patient's 557 00:32:03,607 --> 00:32:07,727 routine, preoperative, uh, quote unquote urine culture that kicked off the whole 558 00:32:07,967 --> 00:32:09,607 decision tree, uh, in, in this case. 559 00:32:10,067 --> 00:32:13,767 So I know surgical teams can often get really nervous about asymptomatic 560 00:32:13,767 --> 00:32:16,567 bacteruria, uh, in particular, especially when you're talking 561 00:32:16,567 --> 00:32:18,247 about hardware being implanted. 562 00:32:18,537 --> 00:32:20,563 and I actually just had an example of this happen in a patient 563 00:32:20,683 --> 00:32:21,923 a few weeks ago that I saw. 564 00:32:21,923 --> 00:32:23,563 So this, this case really hit home there. 565 00:32:24,198 --> 00:32:26,858 Um, you know, obviously we empathize with providers who 566 00:32:26,858 --> 00:32:27,978 see a positive urine culture. 567 00:32:28,198 --> 00:32:29,938 You know, they wanna do what's best for the patient. 568 00:32:30,008 --> 00:32:34,098 They wanna treat that, um, because especially when they're gonna be placed 569 00:32:34,098 --> 00:32:37,178 in hardware, they don't wanna put patients at increased risk of post-op infections. 570 00:32:37,838 --> 00:32:41,298 Um, there was a really large study done a few years ago in JAMA surgery that 571 00:32:41,538 --> 00:32:45,898 actually found that in patients who are undergoing cardiac, orthopedic, or 572 00:32:46,138 --> 00:32:50,658 vascular surgery, . Giving antibiotics that were active against the urinary 573 00:32:50,938 --> 00:32:55,938 bacteria, uh, in those patients with asymptomatic bacteruria had no effect on 574 00:32:55,938 --> 00:32:57,658 the incidence of surgical site infection. 575 00:32:58,398 --> 00:33:01,618 And then a step further, the study actually found that when surgical 576 00:33:01,648 --> 00:33:04,738 site infections did occur, the causative organisms were actually 577 00:33:04,738 --> 00:33:07,538 different than what grew in the pre-surgical urine culture. 578 00:33:08,118 --> 00:33:11,938 So really highlighting the practice of widespread pre-surgical urine culturing 579 00:33:12,398 --> 00:33:15,928 that should likely be discontinued because there's just not a lot of, uh, 580 00:33:15,928 --> 00:33:19,448 additional benefit, um, in the decision making process that it provides. 581 00:33:20,388 --> 00:33:24,008 It also highlights a really good opportunity to work collaboratively 582 00:33:24,008 --> 00:33:28,008 with surgical leadership, with pre-op teams to educate and optimize 583 00:33:28,008 --> 00:33:29,328 some of those screening practices. 584 00:33:29,938 --> 00:33:32,798 and then in general, just wanna put a plug that diagnostic stewardship 585 00:33:33,038 --> 00:33:36,098 can really have large impacts across the board, not just in, uh, 586 00:33:36,098 --> 00:33:37,418 the surgical patient population. 587 00:33:37,838 --> 00:33:40,258 And it's gonna be even more important as more complex and 588 00:33:40,538 --> 00:33:41,898 sensitive molecular tests come out. 589 00:33:41,938 --> 00:33:46,258 I just heard the other day about a urinary PCR test that is gonna wake me 590 00:33:46,258 --> 00:33:50,818 up at night and with nightmares, um, because just all of the, um, potential 591 00:33:51,488 --> 00:33:53,178 overuse of antibiotics it may cause. 592 00:33:53,178 --> 00:33:56,418 And so this diagnostic stewardship, uh, is a really important piece. 593 00:33:58,084 --> 00:33:58,574 Track 1: Awesome. 594 00:33:58,574 --> 00:33:59,934 Thanks so much for that, Andrew. 595 00:34:00,074 --> 00:34:04,524 And so as our case continues, you are going through all this patient's 596 00:34:04,524 --> 00:34:08,914 information, you're chatting with the team, and you notice that the patient 597 00:34:09,054 --> 00:34:14,194 is only ordered for Vancomycin as his perioperative prophylaxis for 598 00:34:14,194 --> 00:34:17,834 his surgery tomorrow in the setting of this listed penicillin allergy. 599 00:34:18,574 --> 00:34:22,274 And so, uh, for either of you, any thoughts on what you might do 600 00:34:22,294 --> 00:34:26,474 to recommend the optimization of their perioperative prophylaxis? 601 00:34:27,167 --> 00:34:30,257 Andrew Watkins: Yeah, so I'd say that we could safely optimize this patient's 602 00:34:30,287 --> 00:34:35,057 prophylaxis, uh, from Vancomycin to more of a first line option like cefazolin. 603 00:34:35,677 --> 00:34:38,977 And so we know that patients that have listed penicillin allergies 604 00:34:38,977 --> 00:34:41,377 have about 50% increased odds of, uh. 605 00:34:41,733 --> 00:34:44,613 Surgical site infections likely due to using the second 606 00:34:44,613 --> 00:34:46,093 line agents for prophylaxis. 607 00:34:46,653 --> 00:34:49,773 I know we end up giving a lot of vancomycin, uh, in patients 608 00:34:49,773 --> 00:34:52,293 with listed allergies and often we give 'em for too long. 609 00:34:52,393 --> 00:34:55,733 And so you're talking about increased risk of acute kidney injury and 610 00:34:55,733 --> 00:34:59,053 that's could lead to patient worse patient outcomes, increased cost. 611 00:34:59,513 --> 00:35:02,653 Uh, and so this patient had a listed allergy of rash 60 years 612 00:35:02,673 --> 00:35:05,693 ago, um, that didn't require any intervention or treatment. 613 00:35:05,953 --> 00:35:09,643 Um, so he is a really great candidate to receive an agent that has minimal 614 00:35:09,753 --> 00:35:11,603 risk of allergy cross reactivity. 615 00:35:11,663 --> 00:35:15,323 And so with penicillin allergies, the reaction occurs 616 00:35:15,323 --> 00:35:16,683 based on the drug side chain. 617 00:35:16,783 --> 00:35:20,523 So if we pick agents that have a different side chain to penicillin, 618 00:35:20,943 --> 00:35:23,803 we can generally give them because of the low risk of cross reactivity. 619 00:35:25,168 --> 00:35:28,258 Cefazolin is one of those first line surgical prophylaxis options 620 00:35:28,448 --> 00:35:31,018 that has a completely different side chain to penicillin. 621 00:35:31,018 --> 00:35:33,738 So it's usually a safe option, uh, in this patients and is 622 00:35:33,738 --> 00:35:34,738 in this patient for the case. 623 00:35:35,438 --> 00:35:39,218 Um, the allergy and immunology expert community actually just updated guidelines 624 00:35:39,248 --> 00:35:42,938 last year to recommend that even in patients who have a history of anaphylaxis 625 00:35:42,938 --> 00:35:47,858 to penicillin, a non cross-reactive cephalosporin like cefazolin can be 626 00:35:47,858 --> 00:35:49,218 administered without prior testing. 627 00:35:49,654 --> 00:35:52,914 And I also wanna put a plug that another stewardship intervention related to 628 00:35:53,154 --> 00:35:57,769 surgical pro prophylaxis is to eliminate prolonged courses postoperatively. 629 00:35:58,219 --> 00:36:02,169 There was a recent SHEA compendium that recommended against extending 630 00:36:02,319 --> 00:36:06,369 prophylaxis past closure in the OR, and now there's numerous other guidelines 631 00:36:06,369 --> 00:36:09,489 that have come out recommended to really limit surgical prophylaxis 632 00:36:09,869 --> 00:36:11,729 to pre and intraoperatively only. 633 00:36:12,119 --> 00:36:16,089 Extending prophylaxis after closure really provides no additional benefit 634 00:36:16,269 --> 00:36:20,089 in patient outcomes, and so just another great low hanging fruit stewardship 635 00:36:20,089 --> 00:36:23,089 intervention that can really help cut back on some inappropriate use. 636 00:36:23,754 --> 00:36:24,244 Rey Perez: Awesome. 637 00:36:24,244 --> 00:36:25,364 Thanks so much, Andrew. 638 00:36:25,464 --> 00:36:27,924 And you know, the, making these recommendations can be hard 639 00:36:27,924 --> 00:36:31,244 sometimes, though many of these practices are deeply ingrained. 640 00:36:31,504 --> 00:36:35,604 And so Jonathan, to bump back to you, are there any strategies that you 641 00:36:36,004 --> 00:36:39,204 recommend communication techniques that you find particularly helpful when 642 00:36:39,204 --> 00:36:41,044 working with our surgical colleagues? 643 00:36:42,169 --> 00:36:44,939 Jonathan Ryder: Yeah, so this is a, a really interesting area 644 00:36:45,079 --> 00:36:48,619 in stewardship, which is really optimizing how we communicate with 645 00:36:48,619 --> 00:36:53,449 others and really the sociologic component, um, uh, to stewardship. 646 00:36:53,989 --> 00:36:59,289 And one of my favorite, um, studies was a, an ethnographic, uh, study 647 00:36:59,679 --> 00:37:01,929 done in London a few years ago. 648 00:37:02,279 --> 00:37:06,409 They really looked at differences in how, uh, internal medicine or 649 00:37:06,409 --> 00:37:11,554 medical teams approached antibiotics in comparison to surgical teams and 650 00:37:11,654 --> 00:37:15,434 how they communicated with each other and others around antibiotic use. 651 00:37:16,094 --> 00:37:21,244 And so, as an internist myself, uh, who works with medical teams quite a bit, 652 00:37:21,244 --> 00:37:25,524 it's really important to kind of have some perspective on how we interact with 653 00:37:25,554 --> 00:37:27,924 each other and ourselves, um, as well. 654 00:37:27,984 --> 00:37:30,969 But medical teams tend to have kind of a collectivist 655 00:37:31,409 --> 00:37:32,929 approach in, in decision making. 656 00:37:33,689 --> 00:37:37,409 Everyone wants to work together and want to come to a consensus and an 657 00:37:37,409 --> 00:37:39,809 agreed upon plan really as a group. 658 00:37:40,309 --> 00:37:42,809 And this is usually quite interdisciplinary. 659 00:37:43,029 --> 00:37:45,769 We involve pharmacists and our consultant colleagues. 660 00:37:46,229 --> 00:37:50,169 Um, and this is kind of unique to the, to the medical team. 661 00:37:50,789 --> 00:37:56,129 And in contrast to this, surgical teams are often more individualistic where 662 00:37:56,939 --> 00:38:01,339 residents are often kind of left making their own decisions as the senior surgeons 663 00:38:01,339 --> 00:38:05,859 are in the operating room or in the clinic and are not necessarily on rounds with 664 00:38:05,859 --> 00:38:08,139 them when these decisions are being made. 665 00:38:09,409 --> 00:38:12,449 Surgical teams are also less likely to have pharmacists available, and 666 00:38:12,449 --> 00:38:18,009 there was really less time, um, spent dedicated to reviewing and stopping 667 00:38:18,159 --> 00:38:21,729 antibiotics by surgeons, which often led to these prolonged antibiotic courses. 668 00:38:22,309 --> 00:38:26,009 The surgeons were primarily focused on preventing poor surgical outcomes, 669 00:38:26,509 --> 00:38:30,449 and so they started, um, antibiotics to try to prevent those things, but 670 00:38:30,449 --> 00:38:32,209 then didn't review them later on. 671 00:38:32,839 --> 00:38:36,169 Medical teams, however, really focused more on not disrupting 672 00:38:36,169 --> 00:38:38,809 their team dynamics or were disagreeing with other consultants. 673 00:38:38,869 --> 00:38:44,364 And so, um, medical teams really struggled when it came to antibiotics when there 674 00:38:44,364 --> 00:38:47,964 was a transition from the emergency department to the ward, as there was 675 00:38:47,964 --> 00:38:51,204 kind of a hesitancy to question the decision that was already made in the 676 00:38:51,204 --> 00:38:55,444 emergency department to start antibiotics, um, which led to antibiotics being 677 00:38:55,444 --> 00:38:57,284 continued for longer periods of time. 678 00:38:57,944 --> 00:39:02,404 And so the key when communicating with colleagues as a steward is to 679 00:39:02,404 --> 00:39:04,164 really know who are you dealing with? 680 00:39:04,194 --> 00:39:07,549 What are the, what are the cultural factors at your institution, 681 00:39:07,689 --> 00:39:11,029 on that team, um, what are their methods of communication 682 00:39:11,029 --> 00:39:12,469 and what is important to them? 683 00:39:13,049 --> 00:39:16,349 Um, and so a lot of the keys when interacting with surgical colleagues 684 00:39:16,369 --> 00:39:19,029 is to focus on the issues that are really important to them. 685 00:39:19,099 --> 00:39:21,429 They, they care a lot about their surgical outcomes. 686 00:39:21,779 --> 00:39:25,709 They care a lot about preventing surgical site infections, things like length 687 00:39:25,729 --> 00:39:29,069 of stay, um, and, and then trying to find ways to communicate with them. 688 00:39:29,599 --> 00:39:31,899 Uh, via the methods that work best for them. 689 00:39:32,519 --> 00:39:36,819 And sometimes this means, you know, that uh, rather than talking, um, 690 00:39:36,969 --> 00:39:41,179 necessarily with the intern that is on the team, uh, on the wards, talk 691 00:39:41,179 --> 00:39:44,219 to the attending that might be making the decisions about antibiotics. 692 00:39:45,109 --> 00:39:48,759 Or if they do have a pharmacist that works, uh, closely with their team and 693 00:39:48,759 --> 00:39:53,519 that they trust, um, for example, I know our, our transplant team has a pharmacist 694 00:39:53,519 --> 00:39:55,786 that does a lot of their antibiotics. 695 00:39:56,046 --> 00:39:58,826 Uh, really communicating with that pharmacist might be the most effective 696 00:39:58,846 --> 00:40:03,266 way, um, because that pharmacist already knows that team and those dynamics even 697 00:40:03,266 --> 00:40:05,346 better than, uh, I do as an individual. 698 00:40:05,712 --> 00:40:07,131 Rey Perez: Thanks a ton, Jonathan. 699 00:40:07,311 --> 00:40:11,171 And so today we've already talked about so many wonderful and important things 700 00:40:11,281 --> 00:40:15,291 that stewardship teams do and how much really goes into that structure. 701 00:40:15,471 --> 00:40:18,691 But many of the trainees listening, for example, may not have as many 702 00:40:18,691 --> 00:40:22,588 opportunities to work with their institutions stewardship programs, and 703 00:40:22,628 --> 00:40:26,238 so what would you recommend that our listeners do in their day-to-Day practice 704 00:40:26,238 --> 00:40:29,878 to help support the stewardship mission in in honor of Antibiotic Awareness Week. 705 00:40:30,293 --> 00:40:33,093 Andrew Watkins: I had say that day to day I'd recommend to continue 706 00:40:33,333 --> 00:40:35,173 building relationships with providers. 707 00:40:35,263 --> 00:40:38,933 Being a visible group, force, program within the institution, 708 00:40:39,203 --> 00:40:42,133 everybody really benefits when decisions are made collaboratively. 709 00:40:42,133 --> 00:40:45,613 And so building those relationship now opens up more downstream 710 00:40:45,613 --> 00:40:50,533 opportunities, either through future, you know, peer-to-peer recommendations, 711 00:40:50,793 --> 00:40:54,748 um, and conversations or just identifying further opportunities 712 00:40:54,808 --> 00:40:56,068 for more initiatives in the future. 713 00:40:56,908 --> 00:41:00,108 I also say that for anybody who's interested in more information or 714 00:41:00,108 --> 00:41:03,108 if they're feeling like they're at a standstill at their site, you know, they 715 00:41:03,108 --> 00:41:06,788 just feel like they need kinda a breath of, uh, new life, uh, in their stewardship 716 00:41:06,788 --> 00:41:08,028 program and want some inspiration. 717 00:41:08,618 --> 00:41:11,668 Look into some of the antimicrobial stewardship certificate programs 718 00:41:12,408 --> 00:41:13,698 that we've mentioned throughout this. 719 00:41:13,718 --> 00:41:17,818 So I know SIDP, the Society for Infectious Diseases Pharmacist has a great one. 720 00:41:18,238 --> 00:41:22,138 Um, IDSA and SHEA, and I know Making a Difference in ID, you know, a lot. 721 00:41:22,138 --> 00:41:26,098 There are numerous programs and certificate classes, courses 722 00:41:26,288 --> 00:41:27,338 that can help with that. 723 00:41:27,478 --> 00:41:30,938 Um, sometimes it just takes some outside education or perspectives 724 00:41:30,938 --> 00:41:35,138 or expertise to really prompt ideas, bring some new direction in life in 725 00:41:35,138 --> 00:41:36,378 the clinical stewardship practice. 726 00:41:36,878 --> 00:41:39,178 And then lastly, I, I'm gonna get deep and, and say, you 727 00:41:39,178 --> 00:41:42,858 know, . As, as a stewardship clinician, give yourself grace. 728 00:41:43,078 --> 00:41:46,418 You're not always gonna have your recommendations accepted. 729 00:41:46,518 --> 00:41:49,338 You know, there's gonna be times where you have to compromise or maybe you even 730 00:41:49,338 --> 00:41:53,418 lose out on a compromise and you've got situations where what's happening is 731 00:41:53,418 --> 00:41:55,698 completely against what you would've liked to have happened and recommended. 732 00:41:56,038 --> 00:41:59,058 Um, but at the end of the day, you know, you're still trying to doing your best. 733 00:41:59,398 --> 00:42:02,058 And if at the worst, you at least planted a seed for what 734 00:42:02,058 --> 00:42:03,378 you think is optimal therapy. 735 00:42:03,918 --> 00:42:05,418 Uh, and so just give yourself some grace. 736 00:42:05,813 --> 00:42:08,713 Rey Perez: That's really important advice for all of us, Andrew. 737 00:42:08,713 --> 00:42:09,433 Thank you for that. 738 00:42:09,653 --> 00:42:13,713 And kind of on that theme, you know, as we close out in our attempt to 739 00:42:13,823 --> 00:42:17,633 recruit the next great generation of stewards, I want to hear from both of 740 00:42:17,633 --> 00:42:20,873 you, you know, what made you choose a career in antimicrobial stewardship, 741 00:42:21,133 --> 00:42:22,433 and what do you love about your job? 742 00:42:23,346 --> 00:42:27,766 Jonathan Ryder: So I think for me, the reason I chose to go into antimicrobial 743 00:42:27,766 --> 00:42:32,286 stewardship was, uh, you know, a multitude of reasons, but there's 744 00:42:32,286 --> 00:42:36,493 really an opportunity to optimize patient care really in the short 745 00:42:36,493 --> 00:42:38,053 term by making these interventions. 746 00:42:38,053 --> 00:42:43,509 And in the long term, I think you see a greater benefit, um, at, 747 00:42:43,509 --> 00:42:46,869 at a societal level by helping to reduce antimicrobial resistance. 748 00:42:47,514 --> 00:42:52,494 And also, um, across your institution by educating, uh, prescribers on 749 00:42:52,504 --> 00:42:54,894 antibiotic use, uh, strategies. 750 00:42:55,394 --> 00:42:58,974 But, also antimicrobial stewardship has a wealth of opportunities 751 00:42:59,274 --> 00:43:01,374 for doing quality improvement. 752 00:43:01,774 --> 00:43:04,554 There's a lot of opportunities for scholarship in this regard, 753 00:43:04,978 --> 00:43:09,358 and really it's just an amazing community within infectious diseases. 754 00:43:09,741 --> 00:43:15,251 As a member and participant of SHEA, it's really been just, uh, incredibly welcoming 755 00:43:15,711 --> 00:43:19,728 and really getting to know everyone within this community, has been amazing 756 00:43:19,868 --> 00:43:22,448 as a, as a young, uh, faculty member. 757 00:43:23,086 --> 00:43:25,856 Andrew Watkins: Yeah, and I don't know how I'm gonna follow Jonathan, because, you 758 00:43:25,856 --> 00:43:27,376 know, he, he nailed it right on the head. 759 00:43:27,396 --> 00:43:31,016 But I'll say similarly, I, I really value the opportunity to intervene 760 00:43:31,016 --> 00:43:35,296 on individual patients in complicated cases, but then also really work on 761 00:43:35,296 --> 00:43:39,391 more of the overarching protocols, policies, initiatives that can 762 00:43:39,391 --> 00:43:40,631 have further reaching impacts. 763 00:43:40,751 --> 00:43:44,111 I feel like you can do work that impacts not only patients that 764 00:43:44,111 --> 00:43:46,831 are in your hospital now, but also downstream, you know, in the future. 765 00:43:47,406 --> 00:43:50,594 and then I'll mention personally, I really love data tracking and analytics. 766 00:43:50,764 --> 00:43:54,244 Antimicrobial stewardship really allows me to have a lot of opportunities for this, 767 00:43:54,264 --> 00:43:55,764 and there's really scratch that itch. 768 00:43:55,984 --> 00:44:00,124 You know, pairing QI processes, uh, with data analytics and tracking to 769 00:44:00,124 --> 00:44:03,204 allow you to make changes and then evaluate your impact is just something 770 00:44:03,204 --> 00:44:04,404 I find really fulfilling as well. 771 00:44:05,254 --> 00:44:08,474 Jonathan Ryder: And Andrew, I'm just gonna add, uh, 'cause I, I should've 772 00:44:08,474 --> 00:44:12,954 said this the first time, but you know, stewardship is a interdisciplinary and 773 00:44:13,194 --> 00:44:18,590 collaborative, field and it's a great opportunity to have, ID clinicians work 774 00:44:18,590 --> 00:44:23,950 with our ID pharmacist, and I value that every single day I do stewardship. 775 00:44:24,005 --> 00:44:27,894 both, both groups bring unique perspective, um, to stewardship 776 00:44:27,894 --> 00:44:30,254 and I think it's a really key component of this whole thing. 777 00:44:30,713 --> 00:44:31,743 Andrew Watkins: Completely agree. 778 00:44:31,903 --> 00:44:35,066 I, I love the interdisciplinary approach and the, the collegiality 779 00:44:35,066 --> 00:44:38,146 that I feel like exists in the ID and stewardship community. 780 00:44:39,709 --> 00:44:43,459 Sara Dong: Thank you again to Rey, Andrew and Jonathan for joining Febrile today. 781 00:44:44,269 --> 00:44:48,899 Don't forget to check out the website, febrilepodcast.com to find the Consult 782 00:44:48,919 --> 00:44:53,419 Notes, which are written supplements of the show with links to references, 783 00:44:53,749 --> 00:44:57,079 our library of ID infographics, and a link to our merch store. 784 00:44:57,679 --> 00:45:00,439 Please reach out if you have any suggestions for future shows or want 785 00:45:00,439 --> 00:45:01,729 to be more involved with Febrile. 786 00:45:02,089 --> 00:45:02,959 Thanks for listening. 787 00:45:03,139 --> 00:45:03,769 Stay safe. 788 00:45:03,949 --> 00:45:04,759 I'll see you next time.