Welcome to the Canadian Breakpoint, a Canadian
infectious diseases podcast by Canadian infectious
diseases physicians. I'm Summer Stewart, back
with Dr. Rupina Pirwal, Pediatric Infectious
Diseases Specialist in Saskatoon. For this episode,
we welcome pharmacist Dr. Roseanne Dallacotta.
and ID specialist Dr. Shaquille Pir -Mohamed
to discuss the Aspire's five -spot audit. Dr.
Pirwal. All right. Thank you, everyone, for joining
us for another episode of our podcast at Canadian
Breakpoint. Today, we have two very special guests
with us who will be speaking about a very important
topic or topics in regards to antimicrobials.
and some work that they have done, including
audits and through Aspires. So one of our guests
today has done a previous podcast with us, and
that's Dr. Pierre Mohamed. So I'm sure everyone
who's tuned in to Season 2, Episode 5, which
is Gamification in Medicine, had an opportunity
to hear a lot about that. And that's been a great
episode for us. And so we're grateful to have
Dr. Pierre Mohamed back here today. So thanks
so much for joining us. And then our second guest
speaker, who hasn't been on the podcast, but
we're super excited because we get to see more
of a pharmacy specialist approach as well in
antimicrobials. And so without further ado, I'm
going to introduce Dr. Roseanne Thalakata, who's
a clinical pharmacy specialist with the Antimicrobial
Stewardship Team at Vancouver General Hospital,
Aspires, and clinical instructor with the University
of British Columbia Faculty. of Pharmaceutical
Sciences. She completed her post -baccalaureate
Doctor of Pharmacy degree from the University
of Toronto in 2013. She's passionate about the
judicious use of antimicrobials to limit the
development of antimicrobial resistance and their
effect on the environment. Outside of the hospital,
she enjoys traveling, skiing, and hiking. So
thank you so much, Dr. Thalakata, for being here
today. Thanks for having me. Awesome. And then,
as I mentioned, Dr. Pierre -Mohamed, I think
most of us know him from the previous episode,
but I would like to do a formal introduction
for him as well. So Dr. Pierre -Mohamed completed
his fellowship in infectious disease at the University
of Toronto in 2016. He began his career with
Saskatchewan Health Authority and the University
of Saskatchewan as an infectious disease consultant
and physician lead of antimicrobial stewardship
in Saskatoon. And so that's how we met as well.
And then in 2023, Dr. Pierre -Mohamed embarked
upon the next phase of his career, moved to Vancouver,
BC, and is currently an infectious disease consultant
with Vancouver Coastal Health and also the regional
medical director of Aspires. In his spare time,
Dr. Pierre -Mohamed enjoys tabletop games and
escape rooms, which is also fun. All right. So
today we're talking about and I don't think I
even introduced the topic because I'm super excited
that you guys are here today. And so we will
be talking primarily about the five spot audit
with Aspires. And not only that, we will hear
from Dr. Thalakata about. Findings of the audit
and other initiatives. And so excited about that,
along with the planetary health study. And then
Dr. Pierre -Mohamed will give us his expertise,
which this area is, I think, really important
for clinicians as well to kind of discuss what's
that IV to oral switch. And that question you
get pretty much when you're on call every single
time. So super excited to hear about his experiences
and his recommendations. So why don't we start
with Dr. Thalakata. For our audience, just because
most of us aren't really aware about kind of
some of the work that's been done in this area.
Can you summarize the five spot audit for us
that was done by Aspires and really what was
the goal and how was the audit done? Yeah, sure.
So starting with the goal of antimicrobial stewardship,
which is to ensure that the right patient receives
the right drug at the right time and by the right
route. And we know that switching intravenous
antimicrobials to oral administration has many
patient care and healthcare system benefits,
such as reduced line -related adverse effects
like clots and infections. reduced length of
stay in hospital for patients, as well as reduced
costs for the healthcare system. We also know
that the IV formulation has a significantly higher
carbon footprint compared to their oral counterparts,
particularly in relation to the manufacturing
and disposal of the drug delivery systems. And
so the goal of this audit was to quantify our
IV use of antimicrobials, specifically the highly
bioavailable antimicrobials, when oral administration
was feasible. And we also wanted to quantify
the carbon footprints and costs. And so we did
a retrospective chart review of all inpatients
at Vancouver General Hospital who received IV
antimicrobials on five days between August 2023
and April 2024. And all medical services were
included. No patients were excluded. We reviewed
all patients to determine what proportion could
have received oral rather than IV. And then what
were your main findings with this audit? So a
total of 128 patients were identified in our
audits. And our results show that 62 % of patients
received IV when they were eligible to receive
at least one dose orally. And the antimicrobials
with the highest eligibility for IV to PO switch
were azithromycin being used for respiratory
infections and metronidazole being used for intra
-abdominal infections. And we partnered with
researchers at the University of British Columbia
to do the carbon footprinting work. And we found
that over the five days, we could have saved
approximately 82 ,000 grams of CO2 equivalents
if we had used oral over IV in the patients that
were deemed eligible to receive oral. And so
to put this in perspective, this is the equivalent
of driving approximately 400 kilometers in a
gas -powered car. could have saved approximately
$835 in antimicrobial costs over those five dates.
And so if you scale these numbers up to one year,
this would be a significant carbon footprint
and cost savings. So it would be roughly the
equivalent of saving 6 million grams of CO2 equivalents,
which is driving about 29 ,000 kilometers in
your gas -powered vehicle. Or for cost savings,
it would be about saving $61 ,000 per year. Okay,
so quite significant for sure. And probably things
that we have never, I think as a clinician, I
probably have never thought about. And I use
medications like azithromycin and metronidazole
probably lately feels daily because of mycoplasma
and the surge there, but that's kind of slowed
down. So that's good. And so In terms of our
clinical practice, so I'm guessing at your local
site, this information, once it was presented,
has that changed kind of practices or how have
clinicians used this information? Yeah, it's
been received very well, I would say at our site
overall. And so I think the first question that
we always need to ask ourselves is, does this
patient need this antimicrobial? For example,
azithromycin, if the patient doesn't need to
be on azithromycin, we need to consider stopping
the antimicrobial. So then, assuming that this
is the right drug for the right patient at the
right time, we then suggest that prescribers
assess their patients daily for IV to PO switch,
especially for these highly bioavailable antimicrobials.
And to consider using oral instead of IV when
clinically appropriate. We also suggest that
prescribers use established IV to PO switch guidelines
to guide their decision making. So, for example,
we have a guideline which we launched along with
other therapeutic guidelines for Vancouver Closer
Health in the antimicrobial stewardship app first
line that clinicians can use. And this app is
free, it's really user friendly, and it's easily
accessible on phone or desktop. We also recommend
to work with other healthcare providers, for
example, pharmacy, who can also help champion
this work and help champion IV to PO switch.
And lastly, to consider adding prompts in your
EMR to help facilitate IV to PO switch of highly
bioavailable antimicrobials. And so that's, I
mean, you bring up really good points. And I
think having a network like Aspires definitely
is a benefit because you have kind of a structure
for those centers. I think like at some of our
smaller centers, including like the center we
work at, especially at the children's side, unfortunately,
sometimes we don't even have a proper instilled
antimicrobial stewardship program, which makes
it very tough to kind of instill some of these.
And I think Most of the time as clinicians, as
infectious disease physicians, we are kind of
pushing for, you know, diagnostic stewardship
and antimicrobial stewardship. And I think that's
been a huge drive over the last, we've been working
on it for probably a few years now to try to
drive kind of the use of antimicrobials or the
inappropriate use of antimicrobials. to reduce
the misuse or inappropriate use. But yeah, I
think it's been, I would say challenging, but
it's very nice because we do have similar supports
like Firstline app. I think that's helped a lot
of us who are maybe the smaller centers that
don't have that infrastructure. So I think that's
a really nice tool. And one of the reasons I
think I also like to spread this information
to the rest of our colleagues is that sometimes
it's not having kind of that team force with
you. You might need to outsource to apps and
other tools. And I think Firstline is a very,
very good tool. I think it has really good information
on antibiogram, local antibiogram data, which
is also super helpful. I guess for you guys,
this has been kind of a local audit. How is there
or how can we kind of see other support staff
or health care providers like myself? How can
we help with this initiative? Definitely like
awareness, I think, is one of the key things.
But are there other ways that we can kind of
join networks or maybe help with information
spread with Firstline? That's a great question.
And yeah, I definitely think that medicine is
a team sport and we all have to work together.
An IV to PO switch is just another one of those
examples that requires a collaboration between
all healthcare providers to ensure success. And
for us at our site, we have a pharmacy policy
in place that allows pharmacists to really drive
this initiative. and to switch from IV to oral
for highly bioavailable antimicrobials when feasible
in accordance with two established criteria.
So this, yeah, this can be pharmacy driven, but
we really should be working together with the
whole medical team to ensure the appropriate
use and the delivery of medications. Also, I
think nurses can play a role here. And I think
that they can also advocate for their patients
to switch to PO if they are tolerating oral.
Yeah, that's a really good point. Yeah, especially
because they're doing the daily clinical assessments.
And so usually know the clinical status of the
patient prior to even us kind of entering the
room. So I think that's a really good point.
And I think your emphasis on kind of working
as a team is really important. I actually recently
went to Toronto for the AMR symposium, and it
was quite fascinating because it was a combined
event with AMR, obviously those enthusiasts that
are into AMR, and then also with Sepsis Canada.
And it was really neat to see. multiple areas
of medicine come together, but still fighting
for the exact same thing, which is to reduce
AMR. And it was nice to see that it comes in
layers. And there was pharmacists, there was
nursing staff there, there was other support
staff, there was pharmaceutical companies. I
think it was one of those things that it was
really nice to see that collaboration. And I
think bringing that back. home and you know bringing
it to your own center is really important because
this is not one person's fight. If we're going
to do this we're going to have to do it as a
team for sure. And so along those lines are there
ongoing studies or future research like are there
other audits or other areas that you guys are
exploring through Aspires? Well, based on our
findings from our audits, we have launched an
educational campaign at our site to target certain
medical services as well as pharmacy. And so
we have presented at rounds and we've developed
an infographic as well that is posted on select
units throughout the hospital. The infographic
is also posted on Firstline. attached to our
IV to PO switch guideline as well. And we are
also looking at our EMR to see where we can optimize
flags in the system, which can sort of nudge
providers to consider changing the route to oral
if there are no contraindications to oral therapy
and whether the patient is already receiving
other medications orally. Yeah, I would also
like to review our order sets in our electronic
system to see whether there are opportunities
to optimize the way that we list our antimicrobials.
For example, for these highly bioavailable antimicrobials
to list the oral route preferentially before
the IV route in certain cases. We plan to evaluate
the impact of our interventions by measuring
our proportional use of IV to PO of these highly
bioavailable antimicrobials over a long period
of time to see whether there will be a change
in prescribing behavior. And then we would like
to provide that feedback back to the target medical
services to let them know how their usage has
changed. changed over time. It's really nice
to see the kind of the overall like long term
action plan that you guys have. And then I think
the huge key point in there is looking at the
outcomes and measuring them and providing that
feedback. Because I think sometimes in our clinical
world, things just, you know, you become very
tunnel visioned and you kind of forget about
the rest of it. And you're just worried about
them being on pressers or clinical status changes,
their heart rate. And so you really need other
people to step in to remind you, like, is this
actually a hemodynamics instability due to an
antibiotic or is there something else going on?
So I think it's really important to kind of have
that reflection. As a clinician, for sure. I
would appreciate if somebody did this for us,
too. Great. That's awesome. And is there anything
else that, Dr. Thalathara, you wanted to let
us know about kind of the audit or the planetary
health study before we move on to Dr. Pierre
-Mohamed letting us know some more information
about the IV to oral switch? I just want to say
that it was great. experience for us. I think
we've all learned a lot along the way, and it's
just been really great to collaborate with all
these different medical services and groups,
healthcare providers, to really talk about this
topic, planetary health, and to raise that awareness
that is really needed. Yeah, and we're honestly
so grateful to hear all about it. And I think
it's encouraging to see that things like this
are happening and that maybe we could bring them
into our sites as well. And so we, yeah, definitely
are encouraged by the work that Aspires has done.
So thank you so much for discussing that today.
Thanks. Awesome. And then now I think some of
the... Clinicians and pharmacists and nurses
are all thinking, well, how do I decide? How
do I know when to go from IV to oral? And what's
really the benefit or which medications are those?
So Dr. Piram Mohamed is going to give us his
expertise in this area and walk us through that.
I think it's really interesting to reflect upon.
history and where these myths come from that
IV is better than oral antibiotics and a lot
of that came from the 1940s and 1950s when the
oral antibiotics that we had at that time were
quite limited and so this culture of IV being
better than oral was enshrined into us and it's
really gratifying. that there are more trials
coming out recently that are challenging that
notion that IV antibiotics are better than oral
antibiotics. So there's the OVEVA trial or the
POET trial that are challenging that notion and
have shown that oral antibiotics are just as
good as IV antibiotics when it comes to the treatment
of bone and joint infections and infective endocarditis
as well. So there is certain antimicrobials that
we would deem as being highly bioequivalent or
having high oral bioavailability, which essentially
means that whether you give them intravenously
or orally, there is no difference in terms of
absorption as long as your patient has a functioning
gut and is able to absorb the medication. So
these antibiotics include things like our fluoroquinolones.
ciprofloxacin, moxifloxacin, levofloxacin, and
other antimicrobials that are highly bioavailable
are things like metronidazole, limesolid, clindamycin,
septra, and some antifungals like gluconazole
and voriconazole would be part of that list of
highly bioequivalent antimicrobials. Awesome.
Yeah. So a huge list of probably all of those
ones that you went through right now, most of
us are sitting there going like, I prescribe
that all the time. And so really good to know
that for those, especially that aren't as familiar
with that property, I think it's really important
to know that it is equivalent and as efficacious.
And so kind of what are the benefits of using?
So obviously, one of the benefits is that we've
already talked about, which was cost effectiveness.
But what are some of the other benefits of using
oral antibiotics versus IV? So I like to think
about benefits in three different groups. I think
switching from IV antibiotics to oral antibiotics
has benefits to our patients, as well as benefits
to the health care system and the planet. I think
ultimately in medicine, our priority should be
optimizing patient care and improving outcomes,
but we can also see these co -benefits to the
healthcare system with reductions in costs and
co -benefits to the planet with reduction in
carbon footprint. So switching from IV antibiotics
to oral antibiotics has lots of benefits to our
patients. We can see reductions in adverse events,
especially if patients have an intravenous catheter
in place. So having a line can increase risk
of infection and clots. And we can also see from
literature that switching from IV antibiotics
to oral antibiotics also leads to earlier discharge
from the hospital. So less risk of acquiring
different infections while you're admitted to
the hospital. Switching from IV to oral antibiotics
can also benefit our healthcare system by decreasing
healthcare resources and decreasing costs. There
was a really interesting study that showed the
amount of time it takes a nurse to administer
an IV dose of an antibiotic is about 22 minutes.
Whereas the amount of time it takes to administer
an oral antibiotic for a patient in the hospital
is about 80 seconds. So you can see significant
reductions in nursing time and health care resources
from switching from IV antibiotics to oral. And
then, like Roseanne mentioned, we can also see
lots of benefits to our planet by reducing unnecessary
environmental waste. I do want to emphasize again
that patient safety and patient quality of care
will always and should always be our primary
goal in health care. But it's nice to see that
these additional co -benefits can also occur
to our health care system and to our planet by
switching from IV to oral, especially for those
highly bioavailable antibiotics. In terms of
obviously like the harms, the benefits and the
harms will be opposite of each other. But in
terms of the carbon footprint, can you give us
some more information in terms of like what you
guys found and maybe some more details around
that? Kind of outline the direct harms that were
related to kind of IV versus the oral. So the
carbon footprint difference between IV and oral
antibiotics is predominantly driven by the amount
of plastic that's being used. So tubing, syringes,
IV bags. There was one prior study that looked
at a one -week course of oral ciprofloxacin compared
to IV ciprofloxacin for a one -week course. And
they found that a one -week course of oral ciprofloxacin
was associated with 1 .4 kilograms of carbon
dioxide equivalent, whereas IV ciprofloxacin
was associated with more than 100 kilograms of
carbon dioxide equivalent, which is a difference,
you know, if we use the example that Roseanne
gave with driving a gas -powered vehicle. We're
looking at 6 .8 kilometers driving your gas -powered
vehicle with an oral dose of ciprofloxacin for
a week versus nearly 500 kilometers. If you're
driving a gas -powered vehicle, that would be
kind of along the lines of a one -week course
of IV ciprofloxacin. huge differences there.
And we can see huge reductions in greenhouse
gas emissions and carbon footprint when we when
we switch from oral antibiotics, or when we switch
from IV antibiotics to oral antibiotics. Yeah,
and I honestly, as I think I've discussed this
with you guys before, I don't think that I've
ever thought about it in that terms when I'm
like prescribing the antibiotics. And I always
feel after I came across your guys's work, I
I almost had to think like do I ever think about
this and I should probably be thinking about
it and I think a lot of my listeners out there
are probably thinking the exact same thing because
sometimes again you just get that tunnel vision
right you don't think about how the effects are.
uh, not directly to the patient, but to the,
to the planet. And, and like you mentioned, Jack,
that's, I think a huge component of the work
that you guys have done is to kind of look at
those multiple factors and, and, and areas that
it's been affecting, which is really interesting
to hear, especially I've been in this field for
a while now. So I feel like I haven't ever thought
about it that way. And so it's really eyeopening
to even think about that. I mean, I think a lot
of us are probably thinking, well, I mean, sure,
like the patients are, you know, sick. So how
do I figure out, like, how am I going to make
this IV to oral switch? Or like, what are the
general recommendations? And I think it's difficult
because it's not an umbrella answer. And it's
probably case by case. But are there some...
basic recommendations when kind of a very kind
of black and white where yes like switch to oral
antibiotics is great and like you mentioned like
IV is not better than oral in all circumstances
and so are there some general recommendations
or can this always be done or is there situations
where we should kind of step back and probably
Very broad question, but if we just kind of get
a few words on your experience. I think it's
always important to think about the patient in
front of you and what type of infection are you
treating. There's emerging evidence that shows
no difference between using oral antibiotics
versus IV antibiotics for bone and joint infections,
bloodstream infections, and even infective endocarditis,
which is really interesting. You could always
use criteria to really know if your patient could
be switched from IV to PO in general terms. Are
they hemodynamically stable? Are they able to
take medications orally? And is there any reason
for them not to absorb the medication? And as
long as they're able to take other medications
orally and there's no concerns about absorbing
the drug, then... I think there's a strong case
that you could make switch to oral, especially
for the highly bioequivalent antibiotics where
there's no difference giving them intravenously
versus orally. There may be certain syndromes
where you might prefer an IV antibiotic. So I
think I would always encourage clinicians to
work with their local infectious disease specialists
and antimicrobial stewardship specialists. that
might have guidelines and tools and more information
at a local scale about when to use an IV antibiotic
versus an oral. That's great advice. And so we
talked a little bit about the tools. Roseanne
mentioned Firstline, and I think some of my listeners
might be familiar with it. So I think it would
be nice for us to kind of have an overview of.
How can they use that tool? What are the specific,
I guess, key points or when can they resort to
that tool? If you want to just kind of highlight
some of those features and then if there's other
specific guidelines that you support or encourage
physicians and pharmacists and other health care
providers to review when taking care of patients.
Firstline is an awesome tool. We were really
excited to launch it for Vancouver Coastal Health
in November of last year during World Antimicrobial
Resistance Awareness Week. We've seen great metrics
and high usage of the app in our center. So we
created an IV to PO switch guideline in Firstline
and have seen lots of uptake. It's a great tool
for clinicians to know. about how to switch from
an IV to oral antibiotic and dosing information,
as well as what criteria they can use to ensure
that there's no concerns with malabsorption of
the drug. And also, it's a free tool. It's very
accessible on your mobile device, which makes
it really easy to adopt into clinical practice
and access while at the bedside and making these
clinical decisions throughout the day. There's
also other resources out there like bugs and
drugs. And there's lots of organizations that
are championing IV to PO switching, as well as
trials coming out that are challenging that dogma
and stigma that IV antibiotics are better than
oral. So that's also very gratifying to see.
And I think we can all... play a role in challenging
that dogma and breaking that culture and creating
a new dogma that IV antibiotics are not necessarily
better than oral. Yeah. I think that if anybody
does take something home from today's episode,
I think that's one of the highlighted points.
Because like you mentioned, I think it's been
like ever since we've been in school, it's always
been, you know, IV, IV, IV if the patient's sick
and in certain circumstances that they can't
take oral or they're unable to tolerate it. Like
we mentioned, that would be the case, but it
doesn't have to be kind of a, it doesn't have
to be thought about if it's more of like an efficacy.
type of approach so so I definitely think that's
some of one of the highlights from today's episode
and we would like to emphasize that and to be
honest I think bringing up that we have so many
tools I think we are practicing in a very good
time because we do have a lot of these tools
at our fingertips which is makes our day -to
-day practice easier I think it's there's So
many approaches that you can do while you're
seeing consults or even teaching. I think it's
really important to emphasize that these tools
exist so that even our learners or younger trainees
can really familiarize themselves with these
tools. And so when they are in that bind of,
you know, can I start oral for this? This is
like a severe and complicated pneumonia. They
might make that decision. But my one of my motives
to bring you guys on to the podcast was to have
this discussion today because I want to make
others be aware that they're, you know, a huge
part of it is awareness and just not knowing
that these tools exist, how to utilize them and
where to look for them. Right. And so I think
it's important. It's important to see trials
that are happening. And so we're excited to see
kind of what that evidence shows as well. But
yeah. Definitely huge learning point for me today.
And I'm sure a lot of our listeners today feel
grateful that they tuned in. So thank you so
much. Are there any kind of key points that you
guys wanted to really hone in on for our audience
today? Besides what we've talked about? I think
my take home message would be that switching
from IV antibiotics to oral has benefits to our
patients, healthcare system and our planet. And
it's really gratifying to see more and more evidence
coming out that supports switching from IV to
oral antibiotics to break that stigma that IV
antibiotics are better than oral. And I just
wanted to say that we had a slogan for our initiative
and it's let's go PO. So keep that in mind. Nice.
I like that. Let's go PO. Perfect. Well, thank
you so much. I really appreciate both of you
taking the time out to come and speak about such
an important or important topics. And I hope
to have you guys back on the podcast for other
work that you guys do through Aspires or any
kind of work that you've done in the antimicrobial
resistance and stewardship area because it's
fascinating. And I think a lot of centers don't
have. a lot of the resources. And so it's always
a good way to kind of spread this information
and for us to kind of bring this information
back to our colleagues, some of our local smaller
centers or even centers that have. a well -tuned
stewardship program. Sometimes you just need
kind of that outside look and see what other
people are doing. So it's fantastic. So thank
you so much for doing such great work in this
area and giving us more information about such
an important topic. Thanks for having us. Thanks.
Take care. Have an episode suggestion? Email
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