WEBVTT 00:00:07.330 --> 00:00:10.710 Welcome to the Canadian Breakpoint, a Canadian 00:00:10.710 --> 00:00:13.589 infectious diseases podcast by Canadian infectious 00:00:13.589 --> 00:00:16.829 diseases physicians. I'm Summer Stewart, back 00:00:16.829 --> 00:00:19.789 with Dr. Rupina Pirwal, Pediatric Infectious 00:00:19.789 --> 00:00:23.629 Diseases Specialist in Saskatoon. For this episode, 00:00:23.649 --> 00:00:26.989 we welcome pharmacist Dr. Roseanne Dallacotta. 00:00:27.519 --> 00:00:30.640 and ID specialist Dr. Shaquille Pir -Mohamed 00:00:30.640 --> 00:00:34.439 to discuss the Aspire's five -spot audit. Dr. 00:00:34.539 --> 00:00:38.859 Pirwal. All right. Thank you, everyone, for joining 00:00:38.859 --> 00:00:41.100 us for another episode of our podcast at Canadian 00:00:41.100 --> 00:00:45.179 Breakpoint. Today, we have two very special guests 00:00:45.179 --> 00:00:48.840 with us who will be speaking about a very important 00:00:48.840 --> 00:00:53.619 topic or topics in regards to antimicrobials. 00:00:54.170 --> 00:00:56.909 and some work that they have done, including 00:00:56.909 --> 00:01:01.130 audits and through Aspires. So one of our guests 00:01:01.130 --> 00:01:04.569 today has done a previous podcast with us, and 00:01:04.569 --> 00:01:07.209 that's Dr. Pierre Mohamed. So I'm sure everyone 00:01:07.209 --> 00:01:11.290 who's tuned in to Season 2, Episode 5, which 00:01:11.290 --> 00:01:14.650 is Gamification in Medicine, had an opportunity 00:01:14.650 --> 00:01:17.430 to hear a lot about that. And that's been a great 00:01:17.430 --> 00:01:20.510 episode for us. And so we're grateful to have 00:01:20.510 --> 00:01:23.629 Dr. Pierre Mohamed back here today. So thanks 00:01:23.629 --> 00:01:26.540 so much for joining us. And then our second guest 00:01:26.540 --> 00:01:29.040 speaker, who hasn't been on the podcast, but 00:01:29.040 --> 00:01:31.659 we're super excited because we get to see more 00:01:31.659 --> 00:01:35.560 of a pharmacy specialist approach as well in 00:01:35.560 --> 00:01:38.079 antimicrobials. And so without further ado, I'm 00:01:38.079 --> 00:01:42.840 going to introduce Dr. Roseanne Thalakata, who's 00:01:42.840 --> 00:01:46.159 a clinical pharmacy specialist with the Antimicrobial 00:01:46.159 --> 00:01:48.840 Stewardship Team at Vancouver General Hospital, 00:01:49.060 --> 00:01:52.780 Aspires, and clinical instructor with the University 00:01:52.780 --> 00:01:55.329 of British Columbia Faculty. of Pharmaceutical 00:01:55.329 --> 00:01:58.549 Sciences. She completed her post -baccalaureate 00:01:58.549 --> 00:02:01.189 Doctor of Pharmacy degree from the University 00:02:01.189 --> 00:02:04.950 of Toronto in 2013. She's passionate about the 00:02:04.950 --> 00:02:08.509 judicious use of antimicrobials to limit the 00:02:08.509 --> 00:02:11.650 development of antimicrobial resistance and their 00:02:11.650 --> 00:02:14.689 effect on the environment. Outside of the hospital, 00:02:14.729 --> 00:02:18.490 she enjoys traveling, skiing, and hiking. So 00:02:18.490 --> 00:02:21.270 thank you so much, Dr. Thalakata, for being here 00:02:21.270 --> 00:02:24.169 today. Thanks for having me. Awesome. And then, 00:02:24.189 --> 00:02:26.509 as I mentioned, Dr. Pierre -Mohamed, I think 00:02:26.509 --> 00:02:29.770 most of us know him from the previous episode, 00:02:29.870 --> 00:02:32.750 but I would like to do a formal introduction 00:02:32.750 --> 00:02:35.270 for him as well. So Dr. Pierre -Mohamed completed 00:02:35.270 --> 00:02:37.530 his fellowship in infectious disease at the University 00:02:37.530 --> 00:02:40.509 of Toronto in 2016. He began his career with 00:02:40.509 --> 00:02:42.669 Saskatchewan Health Authority and the University 00:02:42.669 --> 00:02:45.669 of Saskatchewan as an infectious disease consultant 00:02:45.669 --> 00:02:47.949 and physician lead of antimicrobial stewardship 00:02:47.949 --> 00:02:50.740 in Saskatoon. And so that's how we met as well. 00:02:51.020 --> 00:02:54.479 And then in 2023, Dr. Pierre -Mohamed embarked 00:02:54.479 --> 00:02:57.300 upon the next phase of his career, moved to Vancouver, 00:02:57.460 --> 00:03:00.060 BC, and is currently an infectious disease consultant 00:03:00.060 --> 00:03:03.919 with Vancouver Coastal Health and also the regional 00:03:03.919 --> 00:03:08.740 medical director of Aspires. In his spare time, 00:03:09.000 --> 00:03:11.039 Dr. Pierre -Mohamed enjoys tabletop games and 00:03:11.039 --> 00:03:15.439 escape rooms, which is also fun. All right. So 00:03:15.439 --> 00:03:17.879 today we're talking about and I don't think I 00:03:17.879 --> 00:03:20.340 even introduced the topic because I'm super excited 00:03:20.340 --> 00:03:23.139 that you guys are here today. And so we will 00:03:23.139 --> 00:03:26.860 be talking primarily about the five spot audit 00:03:26.860 --> 00:03:31.419 with Aspires. And not only that, we will hear 00:03:31.419 --> 00:03:35.560 from Dr. Thalakata about. Findings of the audit 00:03:35.560 --> 00:03:39.460 and other initiatives. And so excited about that, 00:03:39.460 --> 00:03:42.159 along with the planetary health study. And then 00:03:42.159 --> 00:03:45.400 Dr. Pierre -Mohamed will give us his expertise, 00:03:45.599 --> 00:03:48.680 which this area is, I think, really important 00:03:48.680 --> 00:03:51.900 for clinicians as well to kind of discuss what's 00:03:51.900 --> 00:03:54.400 that IV to oral switch. And that question you 00:03:54.400 --> 00:03:56.840 get pretty much when you're on call every single 00:03:56.840 --> 00:04:01.259 time. So super excited to hear about his experiences 00:04:01.259 --> 00:04:04.569 and his recommendations. So why don't we start 00:04:04.569 --> 00:04:07.870 with Dr. Thalakata. For our audience, just because 00:04:07.870 --> 00:04:11.110 most of us aren't really aware about kind of 00:04:11.110 --> 00:04:13.810 some of the work that's been done in this area. 00:04:14.129 --> 00:04:17.009 Can you summarize the five spot audit for us 00:04:17.009 --> 00:04:19.550 that was done by Aspires and really what was 00:04:19.550 --> 00:04:22.970 the goal and how was the audit done? Yeah, sure. 00:04:23.610 --> 00:04:26.589 So starting with the goal of antimicrobial stewardship, 00:04:26.970 --> 00:04:30.930 which is to ensure that the right patient receives 00:04:30.930 --> 00:04:34.750 the right drug at the right time and by the right 00:04:34.750 --> 00:04:39.110 route. And we know that switching intravenous 00:04:39.110 --> 00:04:42.670 antimicrobials to oral administration has many 00:04:42.670 --> 00:04:45.310 patient care and healthcare system benefits, 00:04:45.430 --> 00:04:48.970 such as reduced line -related adverse effects 00:04:48.970 --> 00:04:53.110 like clots and infections. reduced length of 00:04:53.110 --> 00:04:56.689 stay in hospital for patients, as well as reduced 00:04:56.689 --> 00:05:01.170 costs for the healthcare system. We also know 00:05:01.170 --> 00:05:04.709 that the IV formulation has a significantly higher 00:05:04.709 --> 00:05:08.170 carbon footprint compared to their oral counterparts, 00:05:08.509 --> 00:05:11.689 particularly in relation to the manufacturing 00:05:11.689 --> 00:05:16.449 and disposal of the drug delivery systems. And 00:05:16.449 --> 00:05:20.290 so the goal of this audit was to quantify our 00:05:20.290 --> 00:05:24.569 IV use of antimicrobials, specifically the highly 00:05:24.569 --> 00:05:28.329 bioavailable antimicrobials, when oral administration 00:05:28.329 --> 00:05:33.410 was feasible. And we also wanted to quantify 00:05:33.410 --> 00:05:37.439 the carbon footprints and costs. And so we did 00:05:37.439 --> 00:05:40.620 a retrospective chart review of all inpatients 00:05:40.620 --> 00:05:44.079 at Vancouver General Hospital who received IV 00:05:44.079 --> 00:05:48.779 antimicrobials on five days between August 2023 00:05:48.779 --> 00:05:54.319 and April 2024. And all medical services were 00:05:54.319 --> 00:05:58.740 included. No patients were excluded. We reviewed 00:05:58.740 --> 00:06:02.100 all patients to determine what proportion could 00:06:02.100 --> 00:06:06.149 have received oral rather than IV. And then what 00:06:06.149 --> 00:06:09.610 were your main findings with this audit? So a 00:06:09.610 --> 00:06:13.189 total of 128 patients were identified in our 00:06:13.189 --> 00:06:18.209 audits. And our results show that 62 % of patients 00:06:18.209 --> 00:06:21.829 received IV when they were eligible to receive 00:06:21.829 --> 00:06:25.540 at least one dose orally. And the antimicrobials 00:06:25.540 --> 00:06:29.740 with the highest eligibility for IV to PO switch 00:06:29.740 --> 00:06:33.980 were azithromycin being used for respiratory 00:06:33.980 --> 00:06:38.300 infections and metronidazole being used for intra 00:06:38.300 --> 00:06:41.680 -abdominal infections. And we partnered with 00:06:41.680 --> 00:06:45.180 researchers at the University of British Columbia 00:06:45.180 --> 00:06:49.779 to do the carbon footprinting work. And we found 00:06:49.779 --> 00:06:54.100 that over the five days, we could have saved 00:06:54.100 --> 00:06:58.720 approximately 82 ,000 grams of CO2 equivalents 00:06:58.720 --> 00:07:03.879 if we had used oral over IV in the patients that 00:07:03.879 --> 00:07:07.339 were deemed eligible to receive oral. And so 00:07:07.339 --> 00:07:11.879 to put this in perspective, this is the equivalent 00:07:11.879 --> 00:07:14.779 of driving approximately 400 kilometers in a 00:07:14.779 --> 00:07:19.100 gas -powered car. could have saved approximately 00:07:19.100 --> 00:07:24.100 $835 in antimicrobial costs over those five dates. 00:07:24.459 --> 00:07:28.420 And so if you scale these numbers up to one year, 00:07:28.579 --> 00:07:32.160 this would be a significant carbon footprint 00:07:32.160 --> 00:07:35.600 and cost savings. So it would be roughly the 00:07:35.600 --> 00:07:39.959 equivalent of saving 6 million grams of CO2 equivalents, 00:07:39.980 --> 00:07:44.079 which is driving about 29 ,000 kilometers in 00:07:44.079 --> 00:07:47.730 your gas -powered vehicle. Or for cost savings, 00:07:47.810 --> 00:07:52.790 it would be about saving $61 ,000 per year. Okay, 00:07:52.810 --> 00:07:55.829 so quite significant for sure. And probably things 00:07:55.829 --> 00:07:58.269 that we have never, I think as a clinician, I 00:07:58.269 --> 00:08:00.750 probably have never thought about. And I use 00:08:00.750 --> 00:08:04.029 medications like azithromycin and metronidazole 00:08:04.029 --> 00:08:07.769 probably lately feels daily because of mycoplasma 00:08:07.769 --> 00:08:11.569 and the surge there, but that's kind of slowed 00:08:11.569 --> 00:08:14.550 down. So that's good. And so In terms of our 00:08:14.550 --> 00:08:17.769 clinical practice, so I'm guessing at your local 00:08:17.769 --> 00:08:20.569 site, this information, once it was presented, 00:08:20.930 --> 00:08:24.670 has that changed kind of practices or how have 00:08:24.670 --> 00:08:28.589 clinicians used this information? Yeah, it's 00:08:28.589 --> 00:08:32.549 been received very well, I would say at our site 00:08:32.549 --> 00:08:36.190 overall. And so I think the first question that 00:08:36.190 --> 00:08:39.509 we always need to ask ourselves is, does this 00:08:39.509 --> 00:08:42.940 patient need this antimicrobial? For example, 00:08:43.059 --> 00:08:45.240 azithromycin, if the patient doesn't need to 00:08:45.240 --> 00:08:48.820 be on azithromycin, we need to consider stopping 00:08:48.820 --> 00:08:52.940 the antimicrobial. So then, assuming that this 00:08:52.940 --> 00:08:56.720 is the right drug for the right patient at the 00:08:56.720 --> 00:08:59.740 right time, we then suggest that prescribers 00:08:59.740 --> 00:09:04.019 assess their patients daily for IV to PO switch, 00:09:04.360 --> 00:09:08.919 especially for these highly bioavailable antimicrobials. 00:09:09.399 --> 00:09:12.700 And to consider using oral instead of IV when 00:09:12.700 --> 00:09:15.960 clinically appropriate. We also suggest that 00:09:15.960 --> 00:09:20.960 prescribers use established IV to PO switch guidelines 00:09:20.960 --> 00:09:24.820 to guide their decision making. So, for example, 00:09:24.980 --> 00:09:27.980 we have a guideline which we launched along with 00:09:27.980 --> 00:09:30.440 other therapeutic guidelines for Vancouver Closer 00:09:30.440 --> 00:09:33.740 Health in the antimicrobial stewardship app first 00:09:33.740 --> 00:09:38.139 line that clinicians can use. And this app is 00:09:38.139 --> 00:09:41.960 free, it's really user friendly, and it's easily 00:09:41.960 --> 00:09:47.009 accessible on phone or desktop. We also recommend 00:09:47.009 --> 00:09:50.389 to work with other healthcare providers, for 00:09:50.389 --> 00:09:53.389 example, pharmacy, who can also help champion 00:09:53.389 --> 00:09:56.250 this work and help champion IV to PO switch. 00:09:56.590 --> 00:10:00.850 And lastly, to consider adding prompts in your 00:10:00.850 --> 00:10:05.750 EMR to help facilitate IV to PO switch of highly 00:10:05.750 --> 00:10:09.480 bioavailable antimicrobials. And so that's, I 00:10:09.480 --> 00:10:11.299 mean, you bring up really good points. And I 00:10:11.299 --> 00:10:14.500 think having a network like Aspires definitely 00:10:14.500 --> 00:10:18.460 is a benefit because you have kind of a structure 00:10:18.460 --> 00:10:20.879 for those centers. I think like at some of our 00:10:20.879 --> 00:10:23.019 smaller centers, including like the center we 00:10:23.019 --> 00:10:25.840 work at, especially at the children's side, unfortunately, 00:10:25.919 --> 00:10:29.419 sometimes we don't even have a proper instilled 00:10:29.419 --> 00:10:32.440 antimicrobial stewardship program, which makes 00:10:32.440 --> 00:10:35.320 it very tough to kind of instill some of these. 00:10:35.360 --> 00:10:38.000 And I think Most of the time as clinicians, as 00:10:38.000 --> 00:10:41.039 infectious disease physicians, we are kind of 00:10:41.039 --> 00:10:43.700 pushing for, you know, diagnostic stewardship 00:10:43.700 --> 00:10:46.419 and antimicrobial stewardship. And I think that's 00:10:46.419 --> 00:10:51.519 been a huge drive over the last, we've been working 00:10:51.519 --> 00:10:55.539 on it for probably a few years now to try to 00:10:55.539 --> 00:10:59.019 drive kind of the use of antimicrobials or the 00:10:59.019 --> 00:11:02.769 inappropriate use of antimicrobials. to reduce 00:11:02.769 --> 00:11:06.309 the misuse or inappropriate use. But yeah, I 00:11:06.309 --> 00:11:08.610 think it's been, I would say challenging, but 00:11:08.610 --> 00:11:11.730 it's very nice because we do have similar supports 00:11:11.730 --> 00:11:15.629 like Firstline app. I think that's helped a lot 00:11:15.629 --> 00:11:18.529 of us who are maybe the smaller centers that 00:11:18.529 --> 00:11:21.389 don't have that infrastructure. So I think that's 00:11:21.389 --> 00:11:23.700 a really nice tool. And one of the reasons I 00:11:23.700 --> 00:11:26.039 think I also like to spread this information 00:11:26.039 --> 00:11:28.779 to the rest of our colleagues is that sometimes 00:11:28.779 --> 00:11:32.379 it's not having kind of that team force with 00:11:32.379 --> 00:11:35.960 you. You might need to outsource to apps and 00:11:35.960 --> 00:11:39.179 other tools. And I think Firstline is a very, 00:11:39.179 --> 00:11:42.840 very good tool. I think it has really good information 00:11:42.840 --> 00:11:46.720 on antibiogram, local antibiogram data, which 00:11:46.720 --> 00:11:50.000 is also super helpful. I guess for you guys, 00:11:50.220 --> 00:11:55.039 this has been kind of a local audit. How is there 00:11:55.039 --> 00:11:59.440 or how can we kind of see other support staff 00:11:59.440 --> 00:12:02.259 or health care providers like myself? How can 00:12:02.259 --> 00:12:05.039 we help with this initiative? Definitely like 00:12:05.039 --> 00:12:07.240 awareness, I think, is one of the key things. 00:12:07.419 --> 00:12:10.620 But are there other ways that we can kind of 00:12:10.620 --> 00:12:14.519 join networks or maybe help with information 00:12:14.519 --> 00:12:17.820 spread with Firstline? That's a great question. 00:12:18.039 --> 00:12:21.379 And yeah, I definitely think that medicine is 00:12:21.379 --> 00:12:25.059 a team sport and we all have to work together. 00:12:25.620 --> 00:12:28.980 An IV to PO switch is just another one of those 00:12:28.980 --> 00:12:32.419 examples that requires a collaboration between 00:12:32.419 --> 00:12:37.259 all healthcare providers to ensure success. And 00:12:37.259 --> 00:12:41.220 for us at our site, we have a pharmacy policy 00:12:41.220 --> 00:12:45.139 in place that allows pharmacists to really drive 00:12:45.139 --> 00:12:48.740 this initiative. and to switch from IV to oral 00:12:48.740 --> 00:12:52.659 for highly bioavailable antimicrobials when feasible 00:12:52.659 --> 00:12:56.580 in accordance with two established criteria. 00:12:57.159 --> 00:13:00.220 So this, yeah, this can be pharmacy driven, but 00:13:00.220 --> 00:13:03.000 we really should be working together with the 00:13:03.000 --> 00:13:06.120 whole medical team to ensure the appropriate 00:13:06.120 --> 00:13:10.299 use and the delivery of medications. Also, I 00:13:10.299 --> 00:13:13.740 think nurses can play a role here. And I think 00:13:13.740 --> 00:13:16.779 that they can also advocate for their patients 00:13:16.779 --> 00:13:20.320 to switch to PO if they are tolerating oral. 00:13:20.820 --> 00:13:22.919 Yeah, that's a really good point. Yeah, especially 00:13:22.919 --> 00:13:25.179 because they're doing the daily clinical assessments. 00:13:25.279 --> 00:13:27.620 And so usually know the clinical status of the 00:13:27.620 --> 00:13:30.639 patient prior to even us kind of entering the 00:13:30.639 --> 00:13:32.899 room. So I think that's a really good point. 00:13:32.940 --> 00:13:36.080 And I think your emphasis on kind of working 00:13:36.080 --> 00:13:39.879 as a team is really important. I actually recently 00:13:39.879 --> 00:13:44.539 went to Toronto for the AMR symposium, and it 00:13:44.539 --> 00:13:47.720 was quite fascinating because it was a combined 00:13:47.720 --> 00:13:54.320 event with AMR, obviously those enthusiasts that 00:13:54.320 --> 00:13:58.039 are into AMR, and then also with Sepsis Canada. 00:13:58.320 --> 00:14:03.289 And it was really neat to see. multiple areas 00:14:03.289 --> 00:14:06.490 of medicine come together, but still fighting 00:14:06.490 --> 00:14:08.710 for the exact same thing, which is to reduce 00:14:08.710 --> 00:14:12.610 AMR. And it was nice to see that it comes in 00:14:12.610 --> 00:14:14.830 layers. And there was pharmacists, there was 00:14:14.830 --> 00:14:17.850 nursing staff there, there was other support 00:14:17.850 --> 00:14:20.549 staff, there was pharmaceutical companies. I 00:14:20.549 --> 00:14:22.730 think it was one of those things that it was 00:14:22.730 --> 00:14:25.129 really nice to see that collaboration. And I 00:14:25.129 --> 00:14:28.399 think bringing that back. home and you know bringing 00:14:28.399 --> 00:14:30.820 it to your own center is really important because 00:14:30.820 --> 00:14:33.639 this is not one person's fight. If we're going 00:14:33.639 --> 00:14:35.059 to do this we're going to have to do it as a 00:14:35.059 --> 00:14:38.320 team for sure. And so along those lines are there 00:14:38.320 --> 00:14:41.840 ongoing studies or future research like are there 00:14:41.840 --> 00:14:44.720 other audits or other areas that you guys are 00:14:44.720 --> 00:14:47.559 exploring through Aspires? Well, based on our 00:14:47.559 --> 00:14:51.120 findings from our audits, we have launched an 00:14:51.120 --> 00:14:55.960 educational campaign at our site to target certain 00:14:55.960 --> 00:15:00.120 medical services as well as pharmacy. And so 00:15:00.120 --> 00:15:04.419 we have presented at rounds and we've developed 00:15:04.419 --> 00:15:08.539 an infographic as well that is posted on select 00:15:08.539 --> 00:15:11.440 units throughout the hospital. The infographic 00:15:11.440 --> 00:15:15.539 is also posted on Firstline. attached to our 00:15:15.539 --> 00:15:19.639 IV to PO switch guideline as well. And we are 00:15:19.639 --> 00:15:24.779 also looking at our EMR to see where we can optimize 00:15:24.779 --> 00:15:28.000 flags in the system, which can sort of nudge 00:15:28.000 --> 00:15:30.919 providers to consider changing the route to oral 00:15:30.919 --> 00:15:34.279 if there are no contraindications to oral therapy 00:15:34.279 --> 00:15:37.600 and whether the patient is already receiving 00:15:37.600 --> 00:15:40.789 other medications orally. Yeah, I would also 00:15:40.789 --> 00:15:43.269 like to review our order sets in our electronic 00:15:43.269 --> 00:15:46.730 system to see whether there are opportunities 00:15:46.730 --> 00:15:50.429 to optimize the way that we list our antimicrobials. 00:15:50.470 --> 00:15:54.850 For example, for these highly bioavailable antimicrobials 00:15:54.850 --> 00:15:57.070 to list the oral route preferentially before 00:15:57.070 --> 00:16:02.940 the IV route in certain cases. We plan to evaluate 00:16:02.940 --> 00:16:07.240 the impact of our interventions by measuring 00:16:07.240 --> 00:16:10.799 our proportional use of IV to PO of these highly 00:16:10.799 --> 00:16:15.360 bioavailable antimicrobials over a long period 00:16:15.360 --> 00:16:17.940 of time to see whether there will be a change 00:16:17.940 --> 00:16:21.539 in prescribing behavior. And then we would like 00:16:21.539 --> 00:16:25.700 to provide that feedback back to the target medical 00:16:25.700 --> 00:16:29.919 services to let them know how their usage has 00:16:29.919 --> 00:16:32.500 changed. changed over time. It's really nice 00:16:32.500 --> 00:16:35.480 to see the kind of the overall like long term 00:16:35.480 --> 00:16:38.360 action plan that you guys have. And then I think 00:16:38.360 --> 00:16:41.000 the huge key point in there is looking at the 00:16:41.000 --> 00:16:43.720 outcomes and measuring them and providing that 00:16:43.720 --> 00:16:46.820 feedback. Because I think sometimes in our clinical 00:16:46.820 --> 00:16:49.200 world, things just, you know, you become very 00:16:49.200 --> 00:16:52.240 tunnel visioned and you kind of forget about 00:16:52.240 --> 00:16:53.879 the rest of it. And you're just worried about 00:16:53.879 --> 00:16:56.799 them being on pressers or clinical status changes, 00:16:57.039 --> 00:16:59.620 their heart rate. And so you really need other 00:16:59.620 --> 00:17:01.919 people to step in to remind you, like, is this 00:17:01.919 --> 00:17:05.480 actually a hemodynamics instability due to an 00:17:05.480 --> 00:17:08.180 antibiotic or is there something else going on? 00:17:08.259 --> 00:17:10.400 So I think it's really important to kind of have 00:17:10.400 --> 00:17:14.099 that reflection. As a clinician, for sure. I 00:17:14.099 --> 00:17:16.380 would appreciate if somebody did this for us, 00:17:16.380 --> 00:17:21.259 too. Great. That's awesome. And is there anything 00:17:21.259 --> 00:17:24.359 else that, Dr. Thalathara, you wanted to let 00:17:24.359 --> 00:17:27.420 us know about kind of the audit or the planetary 00:17:27.420 --> 00:17:29.799 health study before we move on to Dr. Pierre 00:17:29.799 --> 00:17:32.279 -Mohamed letting us know some more information 00:17:32.279 --> 00:17:35.740 about the IV to oral switch? I just want to say 00:17:35.740 --> 00:17:38.720 that it was great. experience for us. I think 00:17:38.720 --> 00:17:41.900 we've all learned a lot along the way, and it's 00:17:41.900 --> 00:17:44.359 just been really great to collaborate with all 00:17:44.359 --> 00:17:48.079 these different medical services and groups, 00:17:48.299 --> 00:17:51.980 healthcare providers, to really talk about this 00:17:51.980 --> 00:17:55.039 topic, planetary health, and to raise that awareness 00:17:55.039 --> 00:17:58.829 that is really needed. Yeah, and we're honestly 00:17:58.829 --> 00:18:01.910 so grateful to hear all about it. And I think 00:18:01.910 --> 00:18:05.069 it's encouraging to see that things like this 00:18:05.069 --> 00:18:07.930 are happening and that maybe we could bring them 00:18:07.930 --> 00:18:12.250 into our sites as well. And so we, yeah, definitely 00:18:12.250 --> 00:18:15.569 are encouraged by the work that Aspires has done. 00:18:15.650 --> 00:18:18.109 So thank you so much for discussing that today. 00:18:18.349 --> 00:18:21.950 Thanks. Awesome. And then now I think some of 00:18:21.950 --> 00:18:24.700 the... Clinicians and pharmacists and nurses 00:18:24.700 --> 00:18:27.279 are all thinking, well, how do I decide? How 00:18:27.279 --> 00:18:30.720 do I know when to go from IV to oral? And what's 00:18:30.720 --> 00:18:33.900 really the benefit or which medications are those? 00:18:34.259 --> 00:18:37.539 So Dr. Piram Mohamed is going to give us his 00:18:37.539 --> 00:18:39.940 expertise in this area and walk us through that. 00:18:40.700 --> 00:18:45.019 I think it's really interesting to reflect upon. 00:18:45.789 --> 00:18:48.950 history and where these myths come from that 00:18:48.950 --> 00:18:53.450 IV is better than oral antibiotics and a lot 00:18:53.450 --> 00:18:58.130 of that came from the 1940s and 1950s when the 00:18:58.130 --> 00:19:01.130 oral antibiotics that we had at that time were 00:19:01.130 --> 00:19:05.049 quite limited and so this culture of IV being 00:19:05.049 --> 00:19:10.349 better than oral was enshrined into us and it's 00:19:10.349 --> 00:19:12.710 really gratifying. that there are more trials 00:19:12.710 --> 00:19:15.970 coming out recently that are challenging that 00:19:15.970 --> 00:19:19.910 notion that IV antibiotics are better than oral 00:19:19.910 --> 00:19:24.150 antibiotics. So there's the OVEVA trial or the 00:19:24.150 --> 00:19:27.930 POET trial that are challenging that notion and 00:19:27.930 --> 00:19:30.890 have shown that oral antibiotics are just as 00:19:30.890 --> 00:19:33.990 good as IV antibiotics when it comes to the treatment 00:19:33.990 --> 00:19:38.430 of bone and joint infections and infective endocarditis 00:19:38.430 --> 00:19:42.210 as well. So there is certain antimicrobials that 00:19:42.210 --> 00:19:44.930 we would deem as being highly bioequivalent or 00:19:44.930 --> 00:19:48.670 having high oral bioavailability, which essentially 00:19:48.670 --> 00:19:51.190 means that whether you give them intravenously 00:19:51.190 --> 00:19:54.789 or orally, there is no difference in terms of 00:19:54.789 --> 00:19:58.470 absorption as long as your patient has a functioning 00:19:58.470 --> 00:20:03.970 gut and is able to absorb the medication. So 00:20:03.970 --> 00:20:07.630 these antibiotics include things like our fluoroquinolones. 00:20:08.160 --> 00:20:12.200 ciprofloxacin, moxifloxacin, levofloxacin, and 00:20:12.200 --> 00:20:14.720 other antimicrobials that are highly bioavailable 00:20:14.720 --> 00:20:19.400 are things like metronidazole, limesolid, clindamycin, 00:20:19.660 --> 00:20:24.420 septra, and some antifungals like gluconazole 00:20:24.420 --> 00:20:27.579 and voriconazole would be part of that list of 00:20:27.579 --> 00:20:32.079 highly bioequivalent antimicrobials. Awesome. 00:20:32.079 --> 00:20:34.819 Yeah. So a huge list of probably all of those 00:20:34.819 --> 00:20:36.339 ones that you went through right now, most of 00:20:36.339 --> 00:20:37.680 us are sitting there going like, I prescribe 00:20:37.680 --> 00:20:42.099 that all the time. And so really good to know 00:20:42.099 --> 00:20:44.759 that for those, especially that aren't as familiar 00:20:44.759 --> 00:20:47.660 with that property, I think it's really important 00:20:47.660 --> 00:20:51.440 to know that it is equivalent and as efficacious. 00:20:52.160 --> 00:20:55.480 And so kind of what are the benefits of using? 00:20:55.519 --> 00:20:58.200 So obviously, one of the benefits is that we've 00:20:58.200 --> 00:21:00.519 already talked about, which was cost effectiveness. 00:21:00.980 --> 00:21:03.799 But what are some of the other benefits of using 00:21:03.799 --> 00:21:07.240 oral antibiotics versus IV? So I like to think 00:21:07.240 --> 00:21:10.420 about benefits in three different groups. I think 00:21:10.420 --> 00:21:13.880 switching from IV antibiotics to oral antibiotics 00:21:13.880 --> 00:21:17.279 has benefits to our patients, as well as benefits 00:21:17.279 --> 00:21:20.930 to the health care system and the planet. I think 00:21:20.930 --> 00:21:24.250 ultimately in medicine, our priority should be 00:21:24.250 --> 00:21:27.470 optimizing patient care and improving outcomes, 00:21:27.750 --> 00:21:30.910 but we can also see these co -benefits to the 00:21:30.910 --> 00:21:33.430 healthcare system with reductions in costs and 00:21:33.430 --> 00:21:37.150 co -benefits to the planet with reduction in 00:21:37.150 --> 00:21:41.650 carbon footprint. So switching from IV antibiotics 00:21:41.650 --> 00:21:44.549 to oral antibiotics has lots of benefits to our 00:21:44.549 --> 00:21:48.789 patients. We can see reductions in adverse events, 00:21:49.009 --> 00:21:51.690 especially if patients have an intravenous catheter 00:21:51.690 --> 00:21:54.769 in place. So having a line can increase risk 00:21:54.769 --> 00:21:58.650 of infection and clots. And we can also see from 00:21:58.650 --> 00:22:01.369 literature that switching from IV antibiotics 00:22:01.369 --> 00:22:04.609 to oral antibiotics also leads to earlier discharge 00:22:04.609 --> 00:22:07.529 from the hospital. So less risk of acquiring 00:22:07.529 --> 00:22:09.730 different infections while you're admitted to 00:22:09.730 --> 00:22:14.069 the hospital. Switching from IV to oral antibiotics 00:22:14.069 --> 00:22:18.009 can also benefit our healthcare system by decreasing 00:22:18.009 --> 00:22:22.329 healthcare resources and decreasing costs. There 00:22:22.329 --> 00:22:24.670 was a really interesting study that showed the 00:22:24.670 --> 00:22:27.430 amount of time it takes a nurse to administer 00:22:27.430 --> 00:22:31.150 an IV dose of an antibiotic is about 22 minutes. 00:22:31.819 --> 00:22:34.480 Whereas the amount of time it takes to administer 00:22:34.480 --> 00:22:37.140 an oral antibiotic for a patient in the hospital 00:22:37.140 --> 00:22:40.480 is about 80 seconds. So you can see significant 00:22:40.480 --> 00:22:43.839 reductions in nursing time and health care resources 00:22:43.839 --> 00:22:48.380 from switching from IV antibiotics to oral. And 00:22:48.380 --> 00:22:51.220 then, like Roseanne mentioned, we can also see 00:22:51.220 --> 00:22:55.119 lots of benefits to our planet by reducing unnecessary 00:22:55.119 --> 00:22:58.599 environmental waste. I do want to emphasize again 00:22:58.599 --> 00:23:01.660 that patient safety and patient quality of care 00:23:01.660 --> 00:23:03.920 will always and should always be our primary 00:23:03.920 --> 00:23:06.740 goal in health care. But it's nice to see that 00:23:06.740 --> 00:23:09.700 these additional co -benefits can also occur 00:23:09.700 --> 00:23:13.660 to our health care system and to our planet by 00:23:13.660 --> 00:23:16.759 switching from IV to oral, especially for those 00:23:16.759 --> 00:23:20.829 highly bioavailable antibiotics. In terms of 00:23:20.829 --> 00:23:23.069 obviously like the harms, the benefits and the 00:23:23.069 --> 00:23:26.309 harms will be opposite of each other. But in 00:23:26.309 --> 00:23:30.150 terms of the carbon footprint, can you give us 00:23:30.150 --> 00:23:32.930 some more information in terms of like what you 00:23:32.930 --> 00:23:35.410 guys found and maybe some more details around 00:23:35.410 --> 00:23:39.269 that? Kind of outline the direct harms that were 00:23:39.269 --> 00:23:44.460 related to kind of IV versus the oral. So the 00:23:44.460 --> 00:23:47.640 carbon footprint difference between IV and oral 00:23:47.640 --> 00:23:51.740 antibiotics is predominantly driven by the amount 00:23:51.740 --> 00:23:54.920 of plastic that's being used. So tubing, syringes, 00:23:54.980 --> 00:23:59.180 IV bags. There was one prior study that looked 00:23:59.180 --> 00:24:03.960 at a one -week course of oral ciprofloxacin compared 00:24:03.960 --> 00:24:08.359 to IV ciprofloxacin for a one -week course. And 00:24:08.359 --> 00:24:13.059 they found that a one -week course of oral ciprofloxacin 00:24:13.599 --> 00:24:18.700 was associated with 1 .4 kilograms of carbon 00:24:18.700 --> 00:24:23.500 dioxide equivalent, whereas IV ciprofloxacin 00:24:23.500 --> 00:24:28.160 was associated with more than 100 kilograms of 00:24:28.160 --> 00:24:32.299 carbon dioxide equivalent, which is a difference, 00:24:32.380 --> 00:24:36.700 you know, if we use the example that Roseanne 00:24:36.700 --> 00:24:39.480 gave with driving a gas -powered vehicle. We're 00:24:39.480 --> 00:24:43.500 looking at 6 .8 kilometers driving your gas -powered 00:24:43.500 --> 00:24:46.480 vehicle with an oral dose of ciprofloxacin for 00:24:46.480 --> 00:24:50.579 a week versus nearly 500 kilometers. If you're 00:24:50.579 --> 00:24:53.140 driving a gas -powered vehicle, that would be 00:24:53.140 --> 00:24:56.079 kind of along the lines of a one -week course 00:24:56.079 --> 00:24:59.500 of IV ciprofloxacin. huge differences there. 00:24:59.680 --> 00:25:02.680 And we can see huge reductions in greenhouse 00:25:02.680 --> 00:25:05.480 gas emissions and carbon footprint when we when 00:25:05.480 --> 00:25:08.180 we switch from oral antibiotics, or when we switch 00:25:08.180 --> 00:25:12.440 from IV antibiotics to oral antibiotics. Yeah, 00:25:12.559 --> 00:25:16.180 and I honestly, as I think I've discussed this 00:25:16.180 --> 00:25:17.900 with you guys before, I don't think that I've 00:25:17.900 --> 00:25:21.240 ever thought about it in that terms when I'm 00:25:21.240 --> 00:25:23.119 like prescribing the antibiotics. And I always 00:25:23.119 --> 00:25:27.200 feel after I came across your guys's work, I 00:25:27.799 --> 00:25:30.180 I almost had to think like do I ever think about 00:25:30.180 --> 00:25:32.599 this and I should probably be thinking about 00:25:32.599 --> 00:25:34.640 it and I think a lot of my listeners out there 00:25:34.640 --> 00:25:36.460 are probably thinking the exact same thing because 00:25:36.460 --> 00:25:39.000 sometimes again you just get that tunnel vision 00:25:39.000 --> 00:25:42.619 right you don't think about how the effects are. 00:25:43.919 --> 00:25:46.660 uh, not directly to the patient, but to the, 00:25:46.660 --> 00:25:49.119 to the planet. And, and like you mentioned, Jack, 00:25:49.259 --> 00:25:52.200 that's, I think a huge component of the work 00:25:52.200 --> 00:25:54.200 that you guys have done is to kind of look at 00:25:54.200 --> 00:25:57.119 those multiple factors and, and, and areas that 00:25:57.119 --> 00:26:00.299 it's been affecting, which is really interesting 00:26:00.299 --> 00:26:03.619 to hear, especially I've been in this field for 00:26:03.619 --> 00:26:06.059 a while now. So I feel like I haven't ever thought 00:26:06.059 --> 00:26:08.359 about it that way. And so it's really eyeopening 00:26:08.359 --> 00:26:11.420 to even think about that. I mean, I think a lot 00:26:11.420 --> 00:26:14.339 of us are probably thinking, well, I mean, sure, 00:26:14.579 --> 00:26:18.720 like the patients are, you know, sick. So how 00:26:18.720 --> 00:26:20.920 do I figure out, like, how am I going to make 00:26:20.920 --> 00:26:23.819 this IV to oral switch? Or like, what are the 00:26:23.819 --> 00:26:26.539 general recommendations? And I think it's difficult 00:26:26.539 --> 00:26:30.099 because it's not an umbrella answer. And it's 00:26:30.099 --> 00:26:32.339 probably case by case. But are there some... 00:26:32.680 --> 00:26:36.859 basic recommendations when kind of a very kind 00:26:36.859 --> 00:26:39.619 of black and white where yes like switch to oral 00:26:39.619 --> 00:26:42.079 antibiotics is great and like you mentioned like 00:26:42.079 --> 00:26:46.019 IV is not better than oral in all circumstances 00:26:46.019 --> 00:26:49.359 and so are there some general recommendations 00:26:49.359 --> 00:26:52.660 or can this always be done or is there situations 00:26:52.660 --> 00:26:55.920 where we should kind of step back and probably 00:26:56.359 --> 00:26:59.539 Very broad question, but if we just kind of get 00:26:59.539 --> 00:27:03.640 a few words on your experience. I think it's 00:27:03.640 --> 00:27:06.200 always important to think about the patient in 00:27:06.200 --> 00:27:09.400 front of you and what type of infection are you 00:27:09.400 --> 00:27:12.619 treating. There's emerging evidence that shows 00:27:12.619 --> 00:27:15.319 no difference between using oral antibiotics 00:27:15.319 --> 00:27:19.119 versus IV antibiotics for bone and joint infections, 00:27:19.400 --> 00:27:22.980 bloodstream infections, and even infective endocarditis, 00:27:23.160 --> 00:27:27.319 which is really interesting. You could always 00:27:27.319 --> 00:27:31.380 use criteria to really know if your patient could 00:27:31.380 --> 00:27:34.160 be switched from IV to PO in general terms. Are 00:27:34.160 --> 00:27:37.400 they hemodynamically stable? Are they able to 00:27:37.400 --> 00:27:42.400 take medications orally? And is there any reason 00:27:42.400 --> 00:27:46.700 for them not to absorb the medication? And as 00:27:46.700 --> 00:27:48.740 long as they're able to take other medications 00:27:48.740 --> 00:27:51.440 orally and there's no concerns about absorbing 00:27:51.440 --> 00:27:54.980 the drug, then... I think there's a strong case 00:27:54.980 --> 00:27:57.599 that you could make switch to oral, especially 00:27:57.599 --> 00:28:01.440 for the highly bioequivalent antibiotics where 00:28:01.440 --> 00:28:04.119 there's no difference giving them intravenously 00:28:04.119 --> 00:28:07.940 versus orally. There may be certain syndromes 00:28:07.940 --> 00:28:12.039 where you might prefer an IV antibiotic. So I 00:28:12.039 --> 00:28:14.859 think I would always encourage clinicians to 00:28:14.859 --> 00:28:18.259 work with their local infectious disease specialists 00:28:18.259 --> 00:28:21.920 and antimicrobial stewardship specialists. that 00:28:21.920 --> 00:28:26.079 might have guidelines and tools and more information 00:28:26.079 --> 00:28:30.099 at a local scale about when to use an IV antibiotic 00:28:30.099 --> 00:28:34.220 versus an oral. That's great advice. And so we 00:28:34.220 --> 00:28:37.519 talked a little bit about the tools. Roseanne 00:28:37.519 --> 00:28:40.920 mentioned Firstline, and I think some of my listeners 00:28:40.920 --> 00:28:44.059 might be familiar with it. So I think it would 00:28:44.059 --> 00:28:46.059 be nice for us to kind of have an overview of. 00:28:46.539 --> 00:28:49.259 How can they use that tool? What are the specific, 00:28:49.440 --> 00:28:53.539 I guess, key points or when can they resort to 00:28:53.539 --> 00:28:55.359 that tool? If you want to just kind of highlight 00:28:55.359 --> 00:28:57.299 some of those features and then if there's other 00:28:57.299 --> 00:29:01.079 specific guidelines that you support or encourage 00:29:01.079 --> 00:29:04.579 physicians and pharmacists and other health care 00:29:04.579 --> 00:29:07.740 providers to review when taking care of patients. 00:29:08.730 --> 00:29:11.269 Firstline is an awesome tool. We were really 00:29:11.269 --> 00:29:14.430 excited to launch it for Vancouver Coastal Health 00:29:14.430 --> 00:29:17.750 in November of last year during World Antimicrobial 00:29:17.750 --> 00:29:22.390 Resistance Awareness Week. We've seen great metrics 00:29:22.390 --> 00:29:25.349 and high usage of the app in our center. So we 00:29:25.349 --> 00:29:28.509 created an IV to PO switch guideline in Firstline 00:29:28.509 --> 00:29:32.589 and have seen lots of uptake. It's a great tool 00:29:32.589 --> 00:29:35.640 for clinicians to know. about how to switch from 00:29:35.640 --> 00:29:39.279 an IV to oral antibiotic and dosing information, 00:29:39.680 --> 00:29:43.099 as well as what criteria they can use to ensure 00:29:43.099 --> 00:29:45.880 that there's no concerns with malabsorption of 00:29:45.880 --> 00:29:50.079 the drug. And also, it's a free tool. It's very 00:29:50.079 --> 00:29:52.619 accessible on your mobile device, which makes 00:29:52.619 --> 00:29:55.599 it really easy to adopt into clinical practice 00:29:55.599 --> 00:30:00.140 and access while at the bedside and making these 00:30:00.140 --> 00:30:02.829 clinical decisions throughout the day. There's 00:30:02.829 --> 00:30:05.609 also other resources out there like bugs and 00:30:05.609 --> 00:30:09.769 drugs. And there's lots of organizations that 00:30:09.769 --> 00:30:14.670 are championing IV to PO switching, as well as 00:30:14.670 --> 00:30:18.329 trials coming out that are challenging that dogma 00:30:18.329 --> 00:30:21.730 and stigma that IV antibiotics are better than 00:30:21.730 --> 00:30:25.529 oral. So that's also very gratifying to see. 00:30:25.710 --> 00:30:29.799 And I think we can all... play a role in challenging 00:30:29.799 --> 00:30:34.720 that dogma and breaking that culture and creating 00:30:34.720 --> 00:30:39.480 a new dogma that IV antibiotics are not necessarily 00:30:39.480 --> 00:30:43.440 better than oral. Yeah. I think that if anybody 00:30:43.440 --> 00:30:45.619 does take something home from today's episode, 00:30:45.700 --> 00:30:48.279 I think that's one of the highlighted points. 00:30:49.079 --> 00:30:51.599 Because like you mentioned, I think it's been 00:30:51.599 --> 00:30:54.380 like ever since we've been in school, it's always 00:30:54.380 --> 00:30:57.480 been, you know, IV, IV, IV if the patient's sick 00:30:57.480 --> 00:31:00.480 and in certain circumstances that they can't 00:31:00.480 --> 00:31:02.960 take oral or they're unable to tolerate it. Like 00:31:02.960 --> 00:31:05.160 we mentioned, that would be the case, but it 00:31:05.160 --> 00:31:08.400 doesn't have to be kind of a, it doesn't have 00:31:08.400 --> 00:31:10.539 to be thought about if it's more of like an efficacy. 00:31:11.369 --> 00:31:14.450 type of approach so so I definitely think that's 00:31:14.450 --> 00:31:17.309 some of one of the highlights from today's episode 00:31:17.309 --> 00:31:21.289 and we would like to emphasize that and to be 00:31:21.289 --> 00:31:24.089 honest I think bringing up that we have so many 00:31:24.089 --> 00:31:27.970 tools I think we are practicing in a very good 00:31:27.970 --> 00:31:30.589 time because we do have a lot of these tools 00:31:30.589 --> 00:31:33.910 at our fingertips which is makes our day -to 00:31:33.910 --> 00:31:37.440 -day practice easier I think it's there's So 00:31:37.440 --> 00:31:39.920 many approaches that you can do while you're 00:31:39.920 --> 00:31:44.059 seeing consults or even teaching. I think it's 00:31:44.059 --> 00:31:46.539 really important to emphasize that these tools 00:31:46.539 --> 00:31:50.339 exist so that even our learners or younger trainees 00:31:50.339 --> 00:31:54.240 can really familiarize themselves with these 00:31:54.240 --> 00:31:57.660 tools. And so when they are in that bind of, 00:31:57.839 --> 00:32:00.019 you know, can I start oral for this? This is 00:32:00.019 --> 00:32:03.160 like a severe and complicated pneumonia. They 00:32:03.160 --> 00:32:08.579 might make that decision. But my one of my motives 00:32:08.579 --> 00:32:10.819 to bring you guys on to the podcast was to have 00:32:10.819 --> 00:32:14.700 this discussion today because I want to make 00:32:14.700 --> 00:32:17.640 others be aware that they're, you know, a huge 00:32:17.640 --> 00:32:19.519 part of it is awareness and just not knowing 00:32:19.519 --> 00:32:24.339 that these tools exist, how to utilize them and 00:32:24.339 --> 00:32:27.460 where to look for them. Right. And so I think 00:32:27.460 --> 00:32:30.759 it's important. It's important to see trials 00:32:30.759 --> 00:32:33.039 that are happening. And so we're excited to see 00:32:33.039 --> 00:32:35.740 kind of what that evidence shows as well. But 00:32:35.740 --> 00:32:38.839 yeah. Definitely huge learning point for me today. 00:32:39.000 --> 00:32:41.140 And I'm sure a lot of our listeners today feel 00:32:41.140 --> 00:32:43.480 grateful that they tuned in. So thank you so 00:32:43.480 --> 00:32:46.680 much. Are there any kind of key points that you 00:32:46.680 --> 00:32:50.180 guys wanted to really hone in on for our audience 00:32:50.180 --> 00:32:53.900 today? Besides what we've talked about? I think 00:32:53.900 --> 00:32:57.240 my take home message would be that switching 00:32:57.240 --> 00:33:01.859 from IV antibiotics to oral has benefits to our 00:33:01.859 --> 00:33:05.799 patients, healthcare system and our planet. And 00:33:05.799 --> 00:33:08.700 it's really gratifying to see more and more evidence 00:33:08.700 --> 00:33:13.359 coming out that supports switching from IV to 00:33:13.359 --> 00:33:17.059 oral antibiotics to break that stigma that IV 00:33:17.059 --> 00:33:20.500 antibiotics are better than oral. And I just 00:33:20.500 --> 00:33:24.359 wanted to say that we had a slogan for our initiative 00:33:24.359 --> 00:33:28.880 and it's let's go PO. So keep that in mind. Nice. 00:33:28.880 --> 00:33:32.369 I like that. Let's go PO. Perfect. Well, thank 00:33:32.369 --> 00:33:34.490 you so much. I really appreciate both of you 00:33:34.490 --> 00:33:37.089 taking the time out to come and speak about such 00:33:37.089 --> 00:33:40.690 an important or important topics. And I hope 00:33:40.690 --> 00:33:43.609 to have you guys back on the podcast for other 00:33:43.609 --> 00:33:46.430 work that you guys do through Aspires or any 00:33:46.430 --> 00:33:49.190 kind of work that you've done in the antimicrobial 00:33:49.190 --> 00:33:51.569 resistance and stewardship area because it's 00:33:51.569 --> 00:33:54.589 fascinating. And I think a lot of centers don't 00:33:54.589 --> 00:33:58.769 have. a lot of the resources. And so it's always 00:33:58.769 --> 00:34:00.890 a good way to kind of spread this information 00:34:00.890 --> 00:34:03.490 and for us to kind of bring this information 00:34:03.490 --> 00:34:06.930 back to our colleagues, some of our local smaller 00:34:06.930 --> 00:34:11.210 centers or even centers that have. a well -tuned 00:34:11.210 --> 00:34:14.150 stewardship program. Sometimes you just need 00:34:14.150 --> 00:34:18.289 kind of that outside look and see what other 00:34:18.289 --> 00:34:20.210 people are doing. So it's fantastic. So thank 00:34:20.210 --> 00:34:22.289 you so much for doing such great work in this 00:34:22.289 --> 00:34:25.989 area and giving us more information about such 00:34:25.989 --> 00:34:29.530 an important topic. Thanks for having us. Thanks. 00:34:30.110 --> 00:34:34.429 Take care. Have an episode suggestion? Email 00:34:34.429 --> 00:34:39.539 us at thecanadianbreakpoint at gmail .com. And 00:34:39.539 --> 00:34:42.239 be sure to follow us on X at CAA Breakpoint. 00:34:42.739 --> 00:34:45.519 See you again soon at the Canadian Breakpoint.