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85: WAAW - Being a Stewie
Episode 8520th November 2023 • Febrile • Sara Dong
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Celebrate World Antimicrobial Awareness Week with Drs. Rey Perez, Andrew Watkins, and Jonathan Ryder, who describe antimicrobial stewardship teams and share their strategies for navigating a message sent to the antimicrobial stewardship pager!  A introduction to being a Stewie!

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Sara Dong:

Hey, everyone.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

and anti-microbial management.

Sara Dong:

I'm Sara Dong, your host.

Sara Dong:

I am excited to introduce our guests today.

Sara Dong:

First up is our cohost Dr.

Sara Dong:

Reinaldo or Rey Perez.

Sara Dong:

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

Sara Dong:

He works with the Duke Center for Antimicrobial Stewardship and

Sara Dong:

Infection Prevention to further their mission of improving patient

Sara Dong:

safety and enhancing quality of care.

Sara Dong:

His research interests include implementation of anti-microbial

Sara Dong:

stewardship interventions and leveraging interprofessional teams.

Sara Dong:

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

Sara Dong:

curriculum development and effective assessment of educational interventions.

Rey Perez:

Hey Sara, thanks so much for having me.

Rey Perez:

This is so exciting to be here.

Sara Dong:

Next meet Dr.

Sara Dong:

Andrew Watkins.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

His responsibilities include prospective audit and feedback, policy and

Sara Dong:

protocol development, implementation of stewardship initiatives, antimicrobial

Sara Dong:

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

Sara Dong:

anti-microbial stewardship related topics.

Sara Dong:

He also precepts pharmacy residents on anti-microbial

Sara Dong:

stewardship learning experiences.

Andrew Watkins:

Hey Sara, this is Andrew Watkins.

Andrew Watkins:

Thanks for having me.

Sara Dong:

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

Sara Dong:

Jonathan Ryder.

Sara Dong:

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

Sara Dong:

University of Nebraska Medical Center.

Sara Dong:

He serves as an Associate Medical Director of Antimicrobial Stewardship,

Sara Dong:

with interest in diagnostic stewardship and stewardship in rural settings.

Sara Dong:

He is also an Associate Hospital Epidemiologist with the infection

Sara Dong:

control and epidemiology program.

Sara Dong:

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

Sara Dong:

of the microbiology block for the first year medical students.

Jonathan Ryder:

Hi, this is Jonathan Ryder.

Jonathan Ryder:

I am really excited to be back on Febrile.

Sara Dong:

Okay.

Sara Dong:

You guys know the drill.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

recently, or that has brought you joy.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

threat of, uh, family, food and football.

Jonathan Ryder:

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

Jonathan Ryder:

to choose my favorite Thanksgiving dish as my culture recommendation.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

people do, uh, for that dish.

Jonathan Ryder:

So that's gonna be my pick.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

some people thought was, uh, a bit weird.

Jonathan Ryder:

I love marshmallows, but not in that dish.

Jonathan Ryder:

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

Jonathan Ryder:

so that concept doesn't work for me.

Jonathan Ryder:

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

Sara Dong:

Got it.

Sara Dong:

So, uh, how about you, Rey?

Rey Perez:

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

Rey Perez:

and Christmas around the corner.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Sara Dong:

Amazing.

Sara Dong:

Uh, Andrew, you want to finish this up?

Andrew Watkins:

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

Andrew Watkins:

too and we'll kinda look ahead.

Andrew Watkins:

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

Andrew Watkins:

But really looking forward to Christmas.

Andrew Watkins:

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

Andrew Watkins:

time to start decorating.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

And then seeing family.

Andrew Watkins:

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

:

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

Sara Dong:

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

Sara Dong:

call from the cardiac surgery team requesting approval for daptomycin

Sara Dong:

after a preoperative urine culture grew vancomycin resistant Enterococcus

Sara Dong:

faecium in a penicillin allergic patient.

Rey Perez:

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

Rey Perez:

may be familiar with the structure of antimicrobial stewardship teams or

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

two of the core interventions that we utilize - antibiotic restriction

Rey Perez:

and post prescription review.

Rey Perez:

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

Jonathan Ryder:

Thanks, Ray.

Jonathan Ryder:

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

Jonathan Ryder:

after, uh, hearing that consult question.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

and a 2014 report estimated that if antimicrobial resistance continues on

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

to a hundred trillion US dollars.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

any signs or symptoms of infection.

Jonathan Ryder:

And so ultimately, antimicrobial stewardship programs are in place because

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

improve our utilization of antimicrobials.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

to help drive these improvements.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

is about optimizing patient care.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

are taking care of our patients.

Rey Perez:

Thanks for that.

Rey Perez:

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

Rey Perez:

nature of the problem is here.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

You know, what do you think about?

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

And they have seven that are very clearly defined.

Andrew Watkins:

They have hospital leadership commitment, they have accountability,

Andrew Watkins:

they have pharmacy expertise,

Andrew Watkins:

action, . tracking, reporting and education.

Andrew Watkins:

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

Andrew Watkins:

of what is involved with each of those.

Andrew Watkins:

And so looking at hospital leadership commitment.

Andrew Watkins:

CMS is very clear that institutional leadership, along with quality

Andrew Watkins:

improvement must address issues that are identified by the infection prevention

Andrew Watkins:

and the stewardship committees.

Andrew Watkins:

Uh, and this open communication between stewardship and hospital leaderships

Andrew Watkins:

really helps facilitate this.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

of like leadership weight behind them.

Andrew Watkins:

Hospitals can demonstrate this leadership through funding positions, and so

Andrew Watkins:

actually having dedicated funding for salary for these positions, having

Andrew Watkins:

dedicated FTEs for these positions.

Andrew Watkins:

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

Andrew Watkins:

having some public statements of support that leadership can sign.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

supporting antimicrobial stewardship.

Andrew Watkins:

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

Andrew Watkins:

having a clear leadership structure within the stewardship program.

Andrew Watkins:

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

Andrew Watkins:

and a pharmacist as co-leaders.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

outcomes with the stewardship program.

Andrew Watkins:

One often overlooked point, things that we've seen

Andrew Watkins:

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

Andrew Watkins:

some sort of education or training or experience in infectious diseases

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

courses plus ongoing continuing education kind of year to year.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

different aspects of the healthcare team.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

we optimize dosing of antibiotics.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

Um, also facility specific treatment guidelines.

Andrew Watkins:

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

Andrew Watkins:

Joint Commission, uh, as of this year.

Andrew Watkins:

having at least two of those implemented.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

conversions, kinetics based dosing, antibiotic timeout processes or

Andrew Watkins:

handshake rounds, automatic stop dates.

Andrew Watkins:

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

Andrew Watkins:

interventions in the day-to-Day.

Andrew Watkins:

Like big projects in the stewardship programs.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

and helping to build accountability.

Andrew Watkins:

There are tons of different metrics.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

help establish some benchmarking and comparisons to similar hospitals.

Andrew Watkins:

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

Andrew Watkins:

initiatives you have going on.

Andrew Watkins:

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

Andrew Watkins:

broad spectrum hospital agents.

Andrew Watkins:

And then you can actually track this over time.

Andrew Watkins:

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

Andrew Watkins:

ways to actually track this data.

Andrew Watkins:

But then you can also encompass other aspects of tracking.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

impact of your stewardship group.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

funding and additional, uh, positions.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

So really reporting is your kind of actionable.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

education and ongoing interventions.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

What can we do better?

Andrew Watkins:

Can we educate better?

Andrew Watkins:

Can we communicate this?

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

having, we're seeing a huge impact.

Andrew Watkins:

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

Andrew Watkins:

Overall, the combination of tracking and reporting really helped drive

Andrew Watkins:

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

Andrew Watkins:

And then lastly, education.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

Education can involve prescribers or pharmacists, nurses, you can

Andrew Watkins:

educate patients and family.

Andrew Watkins:

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

Andrew Watkins:

You know, the harms of antibiotics, optimal prescribing.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

things that you've done, you know.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

Try to pair your education with whatever initiative you're

Andrew Watkins:

really trying to push forward.

Andrew Watkins:

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

Andrew Watkins:

that's part of the action core element.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

all at one time with one initiative.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

everything that you've described there.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

highlights as a priority intervention,

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Jonathan Ryder:

Thanks, Ray.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

standpoint how antibiotics are being used.

Jonathan Ryder:

And then, uh, after reviewing cases, identifying opportunities

Jonathan Ryder:

to improve that use.

Jonathan Ryder:

Audit and feedback occurs after an antibiotic is prescribed.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

And this really allows for the antimicrobial stewardship team to give

Jonathan Ryder:

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

Jonathan Ryder:

And really prevent unnecessary initiation of antibiotics as well.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Rey Perez:

Could you expand on that a little bit more?

Rey Perez:

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

Rey Perez:

different approaches and how have you synthesized that and applied it

Rey Perez:

at your own institution for example?

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

when you're providing that feedback.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

in a, in a collective, uh, manner.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

have kind of downstream impacts on multiple components of antibiotic

Jonathan Ryder:

use throughout your hospital system.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

Another disadvantage is that the patient already receives usually at

Jonathan Ryder:

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

Jonathan Ryder:

antibiotics before an intervention occurs.

Jonathan Ryder:

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

Jonathan Ryder:

inappropriate already has occurred.

Jonathan Ryder:

And then ultimately the prescribers can do what they want.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

do not have a great uptake.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

or, or choice to not initiate therapy.

Jonathan Ryder:

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

Jonathan Ryder:

talking about really expensive antibiotics, newer antibiotics that

Jonathan Ryder:

people may be less familiar with.

Jonathan Ryder:

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

Jonathan Ryder:

agents or certain antiviral agents.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

involve some sort of overnight call.

Jonathan Ryder:

And this intervention is really limited only to the antibiotics

Jonathan Ryder:

that are on the restricted list.

Jonathan Ryder:

So it doesn't help with antibiotic durations or dosing

Jonathan Ryder:

or non-restricted antibiotics.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

audit and feedback for our daily stewardship activities, which does

Jonathan Ryder:

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

Jonathan Ryder:

But we review lists of key antibiotics and diagnostic tests.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

cefepime et cetera.

Jonathan Ryder:

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

Jonathan Ryder:

antibiotics that they've prescribed.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

profiles or, that are more expensive.

Jonathan Ryder:

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

Jonathan Ryder:

feedback process where oftentimes clinicians may be able to access a

Jonathan Ryder:

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

Rey Perez:

Awesome.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

and outpatient coronary angiography demonstrated three vessel disease.

Rey Perez:

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

Rey Perez:

coronary artery bypass grafting tomorrow.

Rey Perez:

The cardiothoracic surgery team has the practice of collecting a urine

Rey Perez:

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

Rey Perez:

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

Rey Perez:

or other urinary symptoms

Rey Perez:

of note.

Rey Perez:

His allergy history is significant for a listed penicillin allergy.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

He has avoided repeat exposure since then.

Rey Perez:

His labs are fairly unremarkable.

Rey Perez:

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

Rey Perez:

hemoglobin of 12.7 and platelets of 256.

Rey Perez:

His complete metabolic panel showed normal electrolytes and

Rey Perez:

normal liver transaminases.

Rey Perez:

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

Rey Perez:

His urinalysis had an unremarkable dipstick and on microscopic analysis

Rey Perez:

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

Rey Perez:

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

Rey Perez:

field without any cast visualized.

Rey Perez:

His urine culture grew Enterococcus faecium that was susceptible to

Rey Perez:

ampicillin and resistant to vancomycin.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

pre-authorization at your institution.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

of inserting yourself and sometimes perceived as the antibiotic police.

Rey Perez:

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

Rey Perez:

having to give this unsolicited advice?

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

Say, you know, hi, I am Jonathan.

Jonathan Ryder:

I'm with the antimicrobial stewardship team.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

that happens through this process.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

why do you want to use linezolid?

Jonathan Ryder:

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

Jonathan Ryder:

Um, and then r is to reflect their emotion.

Jonathan Ryder:

And so.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

complications, uh, as a result.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

uh, VRE, uh, urinary tract infection.

Jonathan Ryder:

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

Jonathan Ryder:

I.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

And so w then is working together on a plan.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

development of further urinary symptoms.

Jonathan Ryder:

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

Jonathan Ryder:

Maybe they're concerned for another reason.

Jonathan Ryder:

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

Jonathan Ryder:

that, um, they're actually symptomatic.

Jonathan Ryder:

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

Jonathan Ryder:

in the chart actually isn't the case.

Jonathan Ryder:

And then s is to set follow up.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Rey Perez:

Thanks Jonathan for that really wonderful framework.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

potential intervention points.

Rey Perez:

We could be talking with the team about diagnostic stewardship and

Rey Perez:

reducing unnecessary urine cultures.

Rey Perez:

We could go into a conversation about asymptomatic bacteruria like

Rey Perez:

you kind of alluded to earlier.

Rey Perez:

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

Rey Perez:

and talk about opportunities for de labeling penicillin allergies.

Rey Perez:

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

Rey Perez:

priority of these interventions?

Rey Perez:

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

Rey Perez:

do you decide what to focus on?

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

most manageable and realistic from an implementation standpoint.

Andrew Watkins:

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

Andrew Watkins:

stewardship intervention standpoint?

Andrew Watkins:

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

Andrew Watkins:

asymptomatic bacteruria really stands out as the greatest opportunity for

Andrew Watkins:

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

Andrew Watkins:

and how widespread the issue is.

Andrew Watkins:

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

Andrew Watkins:

You see antibiotics started for asymptomatic bacteruria

Andrew Watkins:

numerous times every day.

Andrew Watkins:

It's clearly a driver of antibiotic use.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

pieces that we can target for asymptomatic bacteruria.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

harm, of giving unnecessary antibiotics.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

reinforcing these concepts through some patient review, audit and feedback

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

kind of discuss this with providers.

Andrew Watkins:

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

Andrew Watkins:

in local treatment guidance.

Andrew Watkins:

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

Andrew Watkins:

and with some of those regulatory requirements we mentioned.

Andrew Watkins:

Then aside from education about just appropriate non-treatment of

Andrew Watkins:

asymptomatic bacteruria, there's also really a great opportunity

Andrew Watkins:

for some diagnostic stewardship.

Andrew Watkins:

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

Andrew Watkins:

really help leverage the electronic health record to help with appropriate

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

urine cultures when it's appropriate.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

sending the inappropriate, uh, test.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

decreasing the amount of inappropriate cultures actually being ordered.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

decision tree, uh, in, in this case.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

about hardware being implanted.

Andrew Watkins:

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

Andrew Watkins:

a few weeks ago that I saw.

Andrew Watkins:

So this, this case really hit home there.

Andrew Watkins:

Um, you know, obviously we empathize with providers who

Andrew Watkins:

see a positive urine culture.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

the incidence of surgical site infection.

Andrew Watkins:

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

Andrew Watkins:

site infections did occur, the causative organisms were actually

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

It also highlights a really good opportunity to work collaboratively

Andrew Watkins:

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

Andrew Watkins:

some of those screening practices.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

the surgical patient population.

Andrew Watkins:

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

Andrew Watkins:

sensitive molecular tests come out.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

overuse of antibiotics it may cause.

Andrew Watkins:

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

:

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

Andrew Watkins:

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

Andrew Watkins:

And so we know that patients that have listed penicillin allergies

Andrew Watkins:

have about 50% increased odds of, uh.

Andrew Watkins:

Surgical site infections likely due to using the second

Andrew Watkins:

line agents for prophylaxis.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

risk of allergy cross reactivity.

Andrew Watkins:

And so with penicillin allergies, the reaction occurs

Andrew Watkins:

based on the drug side chain.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

Cefazolin is one of those first line surgical prophylaxis options

Andrew Watkins:

that has a completely different side chain to penicillin.

Andrew Watkins:

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

Andrew Watkins:

in this patient for the case.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

administered without prior testing.

Andrew Watkins:

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

Andrew Watkins:

surgical pro prophylaxis is to eliminate prolonged courses postoperatively.

Andrew Watkins:

There was a recent SHEA compendium that recommended against extending

Andrew Watkins:

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

Andrew Watkins:

that have come out recommended to really limit surgical prophylaxis

Andrew Watkins:

to pre and intraoperatively only.

Andrew Watkins:

Extending prophylaxis after closure really provides no additional benefit

Andrew Watkins:

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

Andrew Watkins:

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

Rey Perez:

Awesome.

Rey Perez:

Thanks so much, Andrew.

Rey Perez:

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

Rey Perez:

sometimes, though many of these practices are deeply ingrained.

Rey Perez:

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

Rey Perez:

recommend communication techniques that you find particularly helpful when

Rey Perez:

working with our surgical colleagues?

Jonathan Ryder:

Yeah, so this is a, a really interesting area

Jonathan Ryder:

in stewardship, which is really optimizing how we communicate with

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

done in London a few years ago.

Jonathan Ryder:

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

Jonathan Ryder:

medical teams approached antibiotics in comparison to surgical teams and

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

each other and ourselves, um, as well.

Jonathan Ryder:

But medical teams tend to have kind of a collectivist

Jonathan Ryder:

approach in, in decision making.

Jonathan Ryder:

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

Jonathan Ryder:

agreed upon plan really as a group.

Jonathan Ryder:

And this is usually quite interdisciplinary.

Jonathan Ryder:

We involve pharmacists and our consultant colleagues.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

them when these decisions are being made.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

The surgeons were primarily focused on preventing poor surgical outcomes,

Jonathan Ryder:

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

Jonathan Ryder:

then didn't review them later on.

Jonathan Ryder:

Medical teams, however, really focused more on not disrupting

Jonathan Ryder:

their team dynamics or were disagreeing with other consultants.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

continued for longer periods of time.

Jonathan Ryder:

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

Jonathan Ryder:

really know who are you dealing with?

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

and what is important to them?

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

They, they care a lot about their surgical outcomes.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

Uh, via the methods that work best for them.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

that does a lot of their antibiotics.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

better than, uh, I do as an individual.

Rey Perez:

Thanks a ton, Jonathan.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

opportunities to work with their institutions stewardship programs, and

Rey Perez:

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

Rey Perez:

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

Andrew Watkins:

building relationships with providers.

Andrew Watkins:

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

Andrew Watkins:

everybody really benefits when decisions are made collaboratively.

Andrew Watkins:

And so building those relationship now opens up more downstream

Andrew Watkins:

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

Andrew Watkins:

um, and conversations or just identifying further opportunities

Andrew Watkins:

for more initiatives in the future.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

program and want some inspiration.

Andrew Watkins:

Look into some of the antimicrobial stewardship certificate programs

Andrew Watkins:

that we've mentioned throughout this.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

There are numerous programs and certificate classes, courses

Andrew Watkins:

that can help with that.

Andrew Watkins:

Um, sometimes it just takes some outside education or perspectives

Andrew Watkins:

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

Andrew Watkins:

the clinical stewardship practice.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

You're not always gonna have your recommendations accepted.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

you think is optimal therapy.

Andrew Watkins:

Uh, and so just give yourself some grace.

Rey Perez:

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

Rey Perez:

Thank you for that.

Rey Perez:

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

Rey Perez:

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

Rey Perez:

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

Rey Perez:

and what do you love about your job?

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

really an opportunity to optimize patient care really in the short

Jonathan Ryder:

term by making these interventions.

Jonathan Ryder:

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

Jonathan Ryder:

at a societal level by helping to reduce antimicrobial resistance.

Jonathan Ryder:

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

Jonathan Ryder:

antibiotic use, uh, strategies.

Jonathan Ryder:

But, also antimicrobial stewardship has a wealth of opportunities

Jonathan Ryder:

for doing quality improvement.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

more of the overarching protocols, policies, initiatives that can

Andrew Watkins:

have further reaching impacts.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

and there's really scratch that itch.

Andrew Watkins:

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

Andrew Watkins:

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

Andrew Watkins:

I find really fulfilling as well.

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Jonathan Ryder:

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

Andrew Watkins:

Completely agree.

Andrew Watkins:

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

Andrew Watkins:

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.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

to be more involved with Febrile.

Sara Dong:

Thanks for listening.

Sara Dong:

Stay safe.

Sara Dong:

I'll see you next time.

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