Welcome back to another episode of the Canadian Breakpoint, a Canadian infectious disease
podcast by Canadian infectious disease physicians.
I'm Summer Stewart, here again with Dr. Rupeena Purewal, pediatric infectious diseases specialist
from Saskatoon.
In this episode, we welcome two guests, Dr. Jason Newland, pediatric infectious disease
physician in St. Louis, Missouri, as well as Dr. Michelle Mitchell, pediatric infectious
disease physician in Milwaukee, Wisconsin.
Today we discuss the importance of antimicrobial stewardship.
Dr. Purewall.
Welcome, everyone, to another episode of our podcast at the Canadian Breakpoint.
Today we have two very special guests, and I will be introducing them shortly here.
Our topic that we'll be talking about today is regarding antimicrobial stewardship.
So as most of us are aware, as our audience are pharmacists, family doctors, nurses, medical
students and residents and fellows, all of us working with patients, we know that the
importance of an antimicrobial stewardship program, especially in a time where resistance
is developing, and we have a lot of antimicrobial resistance and a shortage probably of some
novel antibiotics, I think this is a really, really important topic.
So today we have Dr. Jason Newland and Dr. Michelle Mitchell.
So thank you so much for being on the podcast today.
Thanks for having me.
Yeah, for having us.
Perfect.
All right.
So Dr. Jason Newland is a professor of pediatrics at Washington University in St. Louis and
the director of antimicrobial stewardship program at St. Louis Children's Hospital.
His current research spotlights the use of antimicrobials and the impact of an antimicrobial
stewardship program at Children's Hospital.
He's a co-founder of the Sharing Antimicrobial Reports for Pediatric Stewardship, SHARPS
Collaborative, for improving antimicrobial use in children that is comprised of over
70 children's hospitals in the US.
He has been the chair of the Pediatric Infectious Disease Society Committee on Antimicrobial
Stewardship and served on the IDSA's Antibiotic Resistance Committee.
All right.
And then I'll introduce our second guest.
It is Dr. Michelle Mitchell, who is an assistant professor of pediatric infectious diseases
at the Medical College of Wisconsin.
She received her MD and completed a pediatric residency at St. Louis University, followed
by a fellowship in pediatric infectious diseases at University of Colorado Children's Hospital,
Colorado.
She is associate program director of the Pediatric Infectious Disease Fellowship Program at the
Medical College of Wisconsin and the medical director of the antimicrobial stewardship
program at Children's Wisconsin, where she co-led the implementation of Handshake Stewardship.
All right.
So thank you so much.
We look forward to hearing some of your expertise on antimicrobial stewardship.
Just for our listeners, we may use terms as ASP and that'll stand for Antimicrobial Stewardship
Program.
So if there's some acronyms used, that would be probably the most likely.
All right.
So I wanted to do this podcast because obviously being an infectious disease physician, it
was important for me as well.
And there's a lot of differences between Canada and the US in terms of resources and how much
and how advanced we actually are in terms of the stewardship programs.
And you guys definitely are our leading neighbors.
So I think hearing from the experts, just to let our audience know a little bit about
the role of an ASP physician.
Yeah.
I mean, this is super exciting, Rapina.
Thank you so much for having us.
I always love being on podcasts and trying to get the word out.
I just have conversations.
Obviously, we've been blessed to collaborate with people from Canada and I've been able
to meet different people like Nicole in Ottawa and Sergio, who I know you train under in
Manitoba and doing a lot of work.
There's a number of folks, obviously, and we are blessed with resource compared.
And we have hospitals that literally are mandated.
If they want to get paid by the government, they have to have stewardship programs in
place, which requires them to put money toward people like Michelle and I.
And that's been in pediatrics specifically, US News and World Report, many people are
aware of.
In the US, we like to compete on everything.
And so if there's anything that drives hospitals, it's US News and World Report.
They all care about their ranking.
And there's about 10 questions about stewardship in your hospital.
And those questions even include what sort of funding or what amount of funding do you
provide for a physician?
And I can tell you, my job here in St. Louis at WashU was largely driven by that need to
have that funding.
And so having that backup makes it a lot easier to spend days and to have funding to say,
OK, we're going to be an all in approach to antimicrobial stewardship.
Meaning, not that that's what I do now as much, but when I first arrived in St. Louis,
the only thing I had to focus on was stewardship with not as much inpatient service time so
that I could focus on that.
And so that day to day means I can round in the hospital, I can walk around and talk to
all the services, I can meet with a pharmacist, I can then do guidelines and interact with
the informatics or the electronic health record teams to try to develop the things that you
need to develop.
Because as we've all learned in stewardship, this is a full time plus job for one just
physician lead.
Right.
Yeah.
And so I guess, Michelle, in terms of like in terms of the antimicrobial stewardship
program, if you want to talk a little bit about what are the benefits of it.
So we obviously know that having a physician like Jason just mentioned, but having a team
as well is really important in a stewardship program.
And so as in the role of a physician, what can you tell us a little bit about ESP is
brought up and that you think has been beneficial?
So I think everybody knows that there's ample data that tells us that antibiotics can be
pretty harmful to a lot of people, you know, 20% serious adverse event rate for hospitalized
patients receiving antibiotics, about one in three kids that are placed on antibiotic
at some sort of adverse event.
So we know that's happening.
We know that a lot of our antibiotic use is completely unnecessary.
Those antibiotics that are considered necessary, a lot of them are either dose suboptimally
or given for the wrong duration.
So there's unfortunately a lot that we do wrong.
So that's low hanging fruit to correct that, make it better.
We know the antibiotic use is the main driver of antibiotic resistance, right?
So with 2.8 million antibiotic resistant infections in the US per year, 35,000 deaths, you know,
and on our current track record, that's only going to increase.
So unless we do something to curb that trend, you know, we're causing harm, which is exactly
what we're supposed to be avoiding as physicians.
So those are the potential benefits and we can also save the hospital a lot of money.
So there's a lot of data out there that suggests you can invest in stewardship, but you get
much more than what you invest.
I mean, let's face it as ID physicians.
We do not cost as much as a surgeon.
So, you know, I mean, we don't come all that expensive, but we can build those relationships.
We can get people to change.
And so you get a lot of return on investment.
Yeah.
No, that's fair.
I mean, I think the economic impact of inappropriate antibiotic use has not been, you know, looked
at enough.
And I think just, if you just look at the inpatient side, I mean, you know, you're preventing
a case of acute kidney injury that required, you know, an extra day or two of hospitalization
because someone continued on vancomycin and pipersilentazobactam.
I mean, there's enough stuff there.
And I think we in the antimicrobial stewardship world have failed to demonstrate value at
that level because it's hard to determine a value when something doesn't happen.
Right.
And if you don't have the negative consequence of an antibiotic, how do you value that?
And that's just going to require some other work.
And let's not, I mean, the outpatient world is that in the same boat.
I mean, we in collaboration with a woman, a great epidemiologist, Anne Butler, we were
able to publish a paper and JAMA open just this past couple of weeks that suggested,
you know, inappropriate antibiotics in the outpatient setting cost us an excess of $74
million.
I mean, that's a lot of money just from what people are like, oh, oxacillin for that, you
know, cold is probably not that big of a deal.
Well, in the end it is because the excess healthcare costs and the back to the hospital
or back to the clinic because of the adverse events.
I mean, it's a lot greater when you take the totality of excess antibiotics as it being
prescribed.
Yeah, definitely.
And I think it's one of those things like you talked about, Jason, is that it's just
so difficult when you're trying to like, you're on the preventative side, right?
So whereas like most of the time an ID, you know, we're coming in afterwards and, and
really treating like we're on the treatment side and that's usually when we get called.
So having that kind of forefront person being part of our team and ID, you know, most people
think of ID physicians as antibiotic doctors, which I usually walk in and I, you know, sometimes
the parents you say that, but then I also like kind of step back and let them know,
like I will, I'm also somebody who's probably going to pull off the antibiotics faster than
then like another team member, just because I know that there are adverse events and we
see those.
And so those are, you know, and part of having stewardship and having that role, I think,
and I think you brought up a really good point is that it's not just in the inpatient setting.
And I think when we think about ASP, we commonly think about that because that's where the
bulk of the stewardship program exists, that really having kind of that outlook that yeah,
most of the antibiotics are actually prescribed outpatient and for those colds, for those
milder, you know, ear infections that maybe would have improved in 72 hours and didn't
require antibiotics, right?
So, so I think there's definitely that now we talked a little bit about resources and
you mentioned that obviously there's a lot of funding in the US that goes to towards
this position now, unfortunately, in Canada, there, we don't have as much funding that's
well established for this role.
And so, you know, in terms of setting up a stewardship program, a lot of ID physicians
don't actually have more than 15 to 20% of their actual role that they can dedicate to
this.
And in this position, it's almost a full time position to have somebody in this role.
So can we talk a little bit about the reason I'm really interested in this is because we
are currently in our children's hospital here, you know, in the process of we've tried to
set up a program, it's just been more difficult because we don't have pharmacists support.
And so what is some advice that you would give to somebody, let's say a physician like
myself or my colleagues here to set up a program if you're in a resource limited area?
I think that can be really difficult.
I'll just say that.
First off, I mean, you're making me think about all the resources that I have that helped
me in my job and making me appreciate those resources for sure.
But I think, you know, even before I have all these resources, I think, you know, guidelines
in general are less labor intensive, right?
If you're not able to do prospective audit and feedback, you might be able to at least
have a select group of antibiotics that you can do prior authorization on, right?
When you do have to have a person that has to be called or notified, but you could potentially
set that up through your hospital pharmacist or the ID physician that's on call, you know,
if they're willing to participate in that.
And those phone calls don't have to be super labor intensive.
But you know, if you want to protect things like Mirapenem or septariline, you know, some
of your really broad spectrum antibiotics, you know, those phone calls, I don't think
are going to get too onerous unless you're in a really large hospital system.
And again, the guidelines, I think, just building those relationships with other groups of physicians
in the hospital, they can do a lot of the bulk work behind the guideline.
But if you're able to kind of influence the antibiotic use, the dosing, the duration,
you can work with your hospital pharmacist on IV to PO protocols that they can help enforce,
standardizing dosing throughout your hospital, you know, I think those are some low hanging
fruit that don't require a whole lot of resources.
Other, you have other thoughts, Jason, those are the ones that I...
Yeah, no, I think that's all I mean, I guess the first thing is, and I like to, I know
you mentioned this, that you don't have pharmacy support.
I just, I think that if there's been anything that I would fight for is pharmacy support.
Like if someone's going to say, okay, what's a must?
I think anymore, if you can get the must to be pharmacy support, that's what I go for.
Now, people that are listening have to understand that I'm married to a ID pharmacist who does
stewardship.
And so, yes, I am very biased, but you know, you can see over time that, you know, everyone
realizes this and that's why the CDC and their, as they changed their core elements said,
look, it needs to be co-led.
It needs to be co-led by a physician and a pharmacist because pharmacists have really
driven the impact in a lot of our programs.
So I guess that's the one thing.
I think you got to do everything you can to get pharmacy support.
And then I think the second thing, and Michelle mentioned all the things that you can, these
things you can do.
I really strongly believe in in-person interactions and I think as you're limited, you know, then
you pick some spots and go talk to people.
Because then, as Michelle said, then you're trying to find your advocates within each
of these groups, right?
So there's probably someone in neonatology that actually gets the fact that antibiotics
are bad and gets the fact that, I mean, neonatologists get it better than most, right?
Because they realize that excess antibiotics leads to neck and they don't like cephalosporins.
Like I mean, these guys are, you know, they have their own, they come up with their own
early sepsis score to make it easier not to do antibiotics.
So, you know, there's these people that are there and I think they're there in neonatology,
they're in intensive care medicine and, you know, they're there in surgery and it can
you identify that because then they become your, the people that kind of get the job
done as you're moving forward.
And, you know, and then with that all being said, you're always going to have the people
that just aren't going to want to pay attention, but I always say kill them with kindness,
keep me happy around them and kill them with kindness.
And eventually like, why are these people so nice?
I just continue with other people, like working with other people too.
And then like over time they're like, well, that person's not very threatening and they're
getting resources there and then they maybe get a little bit jealous, like, well, why
don't you come help us out?
Exactly.
Yeah.
And you build small wins with the people and you're there and you're there and you're present.
I think that part of it's just having a presence.
And that's if I was in your shoes, that's probably, I'd probably pick a unit and I'd
probably go there two to three times a week.
And I would say, here on the stewardship program, I've looked at these patients, just wanted
to know this one thing.
And do you have any questions?
Right.
And even I had nothing and I would just start with that.
And I would probably make sure that I'm talking to as many people as I can.
Because I think in the end, and we've said this a lot, I think there's the medicine side
and we can argue about tracheitis and the ICU people understand where they come from.
They actually understand where we come from.
The surgeons that want to do drain prophylaxis have their reasons and we disagree and we
have our reasons.
And there's not a, I mean, you can debate it all you want, but we all know each other's
side, honestly.
But when it comes down to it, it's a social game.
And then having all the skills to be a social scientist is necessary.
How do you do conflict resolution?
How do you do communication management?
I mean, all these different things.
That's what stewardship becomes.
Great.
Yeah.
It's key about communication.
So like them being aware, knowing you, having, and I think that's where the handshake approach
comes in play when you talk about that model.
So why don't we talk a little bit about, I know Michelle obviously has co-led that initiative
there and she previously told me that she's had some training under you, Jason, for helping
establish her stewardship program there.
So why don't we hear it from Michelle first to see how setting up your program there and
when you co-led the handshake stewardship model, kind of what were some challenges and
what were some things that maybe you weren't anticipating when you started that program
out there?
Well, so for better or for worse, we, you know, Tracy Zumbels, who's the, you know,
my pharmacist co-lead, you know, we just decided we picked a date and said, we're just going
to start going out there and just doing this.
We didn't really give anybody a whole lot of warning because we thought, well, if we
give them warning, then, you know, then they have an opportunity to push back.
So we'll just kind of see what happens and you'll have to gauge your center and if that's
a worthy approach or not, but, you know, fortunately it worked out, but we did have to survive a
year of, you know, sort of rehashing kind of who we are, what we're doing.
You know, we're not the antibiotic police.
We're just, you know, we're just trying to optimize care for patients.
We're on the same side.
We got a lot of like deer in headlight looks of like, you know, what am I doing wrong?
Like what are these people doing here?
And we still get a little bit of that every July, right?
And the new residents come in and, and so they're a little bit scared when they see
us, but, you know, we bring around candy and pass it out and, you know, try and do like
nice things.
You know, we, we read a room, so things look really busy and chaotic, like in the ICU workroom,
we just, you know, back off.
So we're really looking at the long game.
We're trying to change the culture, make our visibility, you know, have a positive connotation
with it.
So, so yeah, we just went out there and we started giving feedback and we stopped by
all the workrooms, regardless if we have an intervention or not.
Do you have any questions?
You know, is there anything we can help you out with?
And a lot of the times it's the questions that then they ask us that were totally not
on our radar.
Right.
That ended up being some of the best things that we can help with, you know, you know,
it may turn out that the patient, you know, they had it like a suspected CNS infection.
It's like, well, the drug you're on doesn't even penetrate there or, you know, maybe they
weren't even thinking about a certain diagnosis or something that touches like in the ID world.
And so I can recommend an ID consultant, you know, could completely change the management
of a patient.
And I know other hospitals have similar examples to that, but, but it's really been a door
opener for a lot of that, like relationship building.
So again, if you want to change the culture, like Jason had mentioned before, you got to
start just building those relationships with different people, building that trust.
And over time, you know, you sort of, yeah, you kill them with kindness or you wear on
them, you know, nudges are good, but you don't want to get pushy.
You know, you don't want to burn any bridges.
So we just try and stay positive.
Like we get a door slammed in our face, so to speak, we haven't actually had any doors
slammed in our faces, but you know, figuratively, if that happens, then we just kind of back
off and, you know, we may approach it from a more global standpoint of like looking at,
you know, can we, can we get on the same page maybe with a guideline or, or, you know, we
just give it, give it some time and then we kind of circle back.
So, you know, I wish I had a minor or major in psychology after doing this for a while.
Yeah, it sounds like it.
Well, I mean, Michelle trained at Colorado, right?
So she trained where they, where they actually developed Handshake Stewardship under Sarah
Parker.
I mean, she's the one that coined it.
And so, I mean, I think she hit on it.
I think, and Michelle mentioned it, right?
I mean, what ends up happening is you develop the relationships.
And I think, I think for the people listening, I mean, the person to actually read stuff
about her, try to listen to is Julie Simczak.
And the way you spell her last name is S-Z-Y-M-C-Z-A-K.
I mean, her work is really fascinating in the number of quotes and stuff.
And she's followed stewardship teams around and done a lot of stuff on communication.
And she now has developed kind of a communication model that suggests, you know, you have to
understand the context, then you have to have your communication strategies and you have
to have your collaboration.
And these are the three C's of kind of the important thing.
And I think that's exactly what Michelle just mentioned, right?
I mean, you understand the context.
You mentioned that like sometimes you don't, when the ICU is in the middle of rounding
on an ECMO patient, like talking about the ANSA, if they're on for the two, well, you
might not agree with this, probably like the last thing they want to hear about.
Right?
That's the content.
You have to understand that content.
That's the social part of this versus the kids on ECMO and they don't have them on vancomycin
because they, and they have MRSA and they have horrible pneumonia.
And you're like, guys, why aren't you, you know, like that's another side of stewardship
people don't talk about.
But when you have that relationship, you can have that conversation because they know you're
only going to talk when, or you're going to speak when it's really important in that regard.
So I mean, I think that's the part of this.
That's why to me, as Michelle mentioned, like a psychology or social science degree, all
of these things, these social, the social game of stewardship, I think is the most important
thing in what you do as you move forward in it.
Right?
No, that's, that's a really good point.
And I think, you know, bringing up, you know, the type, the communication, I mean, it just
goes back to medicine, right?
Like that is what we are trained to do.
We are, you know, working in a collaboration.
And I think sometimes, you know, and Michelle mentioned that antibiotic police, the policing,
you know, role.
And so I think sometimes it's taken as like, we're, you know, somebody who'd be walking
in and having that role, but really it's more working as a team.
And the interest at the end of the day is the best interest for the patient, right?
Because as all of us know, the ASP programs, you know, we're changing inappropriate use
of antibiotics, but also modifying so that there is appropriate use of antibiotics.
And there has been great studies out there letting us know that there's decreased morbidity
and mortality with when you're working on all aspects of it.
And so, and so that's, I think most of our listeners probably are aware of all of that.
And so I think the next kind of thing I want to talk about is highlighting.
So we talked about this handshake model.
Maybe we can touch a little bit about, is this the same model like currently that you
guys are using in ASP?
Is this pretty much been a bit modified since the beginning?
And I wonder if Jason, since you've been in this a little bit longer than the rest of
us in ASP and you're kind of, you know, on and by a lot of the committees, and if there's
ongoing talk about what is the best kind of model.
Well, yeah, you know, so I trained all age myself.
I trained from 2003 to 2006 and trained at Children's Hospital of Philadelphia, where
we just did prior approval, right?
So we held a pager if you wanted ceftriaxone, Amsobactam, you know, you got to call us to
get it.
Now you can imagine getting a call for ceftriaxone like at seven o'clock at night, you know,
like that, you're like, man, really, especially now.
But that was what we did.
That was fine.
I mean, I stopped a lot of ceftriaxone for community acquired pneumonia back in 2003.
And I know you can do ampicillin, you're fine, right?
But that was there.
So that was why one of your first papers was on that, right?
You're so sick of getting that call.
That is exactly right.
Switch to the ampicillin, please.
So and so when I first, so when I took, when I moved to Kansas City, my first 10 years
of my career was in Kansas City.
And I was like, I'm not coming to Kansas City, gonna make them call me because I don't think
that's going to go well.
And so we, so we started a prospective audit, but we only looked at those people who had,
you know, we only went and talked to those that we had a recommendation.
And then Sarah came along, right, and did a handshake stewardship.
And it and that made sense to me, right?
I mean, the reality of it is, is communication and collaboration is what sustains a program.
The more you can communicate, the more you can collaborate, the better you're going to
be.
And we kind of talked about that.
And so it then has become clear that you need, I think you need to have some sort of in person
conversation relationship building time.
And that's what handshake stewardship allows you.
I'm on the side of the fence.
So that still thinks there needs to be some, I still think there needs to be some prior
approval.
Now, some places don't, some people still don't do it.
And probably because they have the ability that they're not going to use the Ceptaz AV
Bactams or Ceptola Zantazo Bactams or the Daptomycin in a inappropriate use that where you only
find out about it after they started it.
Because I do think that there are some things, right?
Like when do you ever really need to start empirically, you know, Ceptazenem AV Bactams?
Not very often.
And if you do need to start it, you probably need to have an ID console because there's
probably something really bad in some highly resistant that's going to take a lot more
than just a stewardship conversation.
So I still am thinking that prior approval needs to be a part of our programs.
And that's how we have it.
So we now, so when I moved to St. Louis in 2016, the program started here was really
based off of handshake stewardship.
So we do the rounding with the pharmacist.
We now have trainees that join us, which is always fun because it's a, because handshake
stewardship is a perfect opportunity to educate, right?
Like you get to chat with people.
You can quiz the residents.
You can have fun in that.
You can also learn everything about them, which is also, as Michelle can tell you, I
usually like to do a lot of chit chatting about all kinds of things.
It might be the latest Netflix show or something else, but I think that builds relationship.
And so I think that's the way, but I think those are like your core features on a day
to day thing.
But what often gets missed is that while that might be your morning, your afternoons are
trying to develop a guideline because it gets kind of old to go by the same surgeon over
and over saying, you don't need the post-op drains because that's kind of annoying to
them and for you.
So that's a different, right?
That's working on something else or trying to get the set tracks on the ampicillin switch
without having to have the conversation every time.
Well, that's a big guideline.
And so I think those are the other parts.
Oh, that's fair.
Yeah.
And then I guess just touching on, because we talked a little bit about guidelines and
developing, I guess, like order sets or guidelines that have helped clinical pathways basically
that can assist.
So when I just for my own knowledge, locally on our adult side, we do have a more well
established stewardship program because funding is obviously at larger hospitals, more patients.
And so funding is kind of shifted there.
In our pediatric side, there's a couple of things lacking.
We are just kind of moving into more of a proper EMR system.
So we don't actually have a lot of order sets to begin with.
And so kind of even implementing clinical pathways in your guys' experience to get approved,
like get them hospital approved or authority approved, once you have an established ASD
program, is it much easier, do you feel, to kind of be able to, I guess, have more clinical
pathways introduced at a quicker pace than because there's times when I've had to.
So we have more than just, I guess, certain infectious diseases, but a lot of congenital
infections, some things that could be more protocolized and things like that.
So just my experience with that, it's been a little bit tough to release some of these
clinical pathways.
So do you think that comes along with having the funding for a stewardship program?
Is it much easier?
I think the time commitment certainly helps.
I mean, at least before there was physician support in our institution, you're sort of
asking one of the ID physicians to kind of, you know, for a little bit more altruistic
behavior, you know, it's sort of on their own personal time.
They didn't have dedicated time.
So at least, you know, those guidelines are probably still getting formed, from what I
can tell, but they weren't having input from people that were the most knowledgeable about
the antibiotics, which includes a pharmacist and an ID physician.
So I think that was the thing that at least in our institution was lacking before there
was that dedicated time for both the pharmacist and physician.
Yeah, I think when it comes to the, I think from an approval process, you still have to
have the stakeholders and all the buy-in.
And so whether that having a formal stewardship program kind of allows that to be easier,
and they know that this is what it's coming from.
But you know, like for pneumonia, you're still going to need pulmonology to have some way
the hospitalists, you know, are going to have to have some way in this, because they're
going to be the ones really executing the actual guideline and wanting to follow what
you're saying should be the appropriate piece.
I think one of the biggest challenges we have is that we can develop these guidelines.
The problem is, is version control?
And then where do they all land?
And so, right, you can have neonatology, they might already have some guidelines on neck
and early onset sepsis and HSV and all kinds of stuff, and you might not even realize it.
And then over time, you might have actually developed a couple and forgot about them.
And then you get a new colleague that comes in trying to make things better.
Not that this has ever happened, by the way.
And then they're like, oh, what about this?
Like, oh, yeah, totally forgot about that, right?
Because we get really good about developing a guideline and then like, okay, we're good,
we got it, here you go.
And then we forget that a guideline is only a guideline.
Once you get in the guideline business, you need to be in the business for good, which
means updating it, reviewing it, making sure people can see it.
And that is so much, that's so hard.
I just want to say that is a real hard side of it, but is a necessary side to keep a guideline
relevant.
That's fair.
That's a really good point.
I think definitely over the years and things change, right?
So there's obviously a management, more research comes out.
And so definitely remembering that if you have the guideline and also not having to
reinvent the wheel, right?
So important to, and this goes back to, I think what we're talking about today is collaboration,
right?
So reach out to your colleagues, reach out to areas where they may already have something
in the unit that's functioning and you can just modify.
I'd say we know one of the biggest opportunities we have in antibiotic use, right?
Is limiting durations.
And those studies are just coming out, right?
Pneumonia, right?
Like our national guideline or national, so in the U S right, the IDSA guideline for pediatrics
still says 10 days and it actually flat out says expert opinion based.
What there has been papers, Dr. Rebecca same, who now I get to work with, who is at Hopkins
show that five days is fine.
The adults have been doing five days for inpatient pneumonia for ages.
Right.
Like you, we need to be updating that.
And we need to get ourselves to those sorts of durations.
And that's, that's why I think that update is so key because there's so much opportunity
from a stewardship perspective to limit durations that we haven't done yet.
Yeah.
And that's a really key point.
I mean, to be honest, there's a lot of variance within even different ID specialists.
Oh yeah.
So we might be the worst offenders.
Yeah.
In many cases.
Yeah.
I mean, I, all right.
So here's like, so one of my, we had a fellow Jason, like fabulous a PID ID person.
Michelle, do you know Jason?
I don't think so.
Okay.
So Jason, like he went off to Utah and he did a survey and we, we surveyed people on
the emerging infestation network and we, we divided it.
It was just ID people and, and it was, and it was mainly just physicians because the
EIN doesn't have as many pharmacists, which I would wish we had pharmacists in this, but
essentially we divided the group into whether you do stewardship or you don't do stewardship,
they self-selected.
And then we, one of the questions we asked was, should you steward your ID colleagues?
Oh yeah.
Right.
That's an elephant in the room.
Like everyone on this call should be like, oh, Jason, that's really fascinating.
And I mean, I have this strong belief that we should be stewarding each other.
Like when you're on service, you should actually have someone kind of saying, are you sure
you really need that mural pin them?
Do you think you need that for culture negative sepsis?
And interestingly, we, even in the stewardship group, it was like 45% said we should steward
each other.
Like most of us won't steward our own colleagues because we're worried about what that's going
to happen.
But I, but I think as a, and I'm going to use this as a platform to say, look, if we're
going to do this and expect our ICU colleagues to stop antibiotics for tracheitis, well,
then we should, they should have the also know that, well, the only reason they're using
is because your colleagues recommended it.
Like we got to be able to do it with each other.
Right.
And if we're really going to push forward, but I think it's an elephant in the room that
we, I mean, right.
Like, oh yeah.
Yeah.
I know, I know who we work with.
Sometimes you're like, really?
I got to talk to that person.
But I think it's how we have to move forward.
It's all about those communications, psychology.
Yeah, that's right.
Sorry.
Had to jump on that soapbox for a second.
Sorry, Rukina.
No, I think, you know, it's a great point that you bring that up because there's times
even in our center when, you know, I'm on call and I do get a call from my ESP colleague
and I actually appreciate it.
I'm not actually against it because sometimes you do get a bit of tunnel vision once you're,
you know, been following somebody, especially if you're on service for a few days or two
weeks at a time, you know, occasionally you will have like this kind of two week run.
And there's times when you're, you're just kind of, you know, doing the day to day and
nobody even have a time to step back.
And I think that's the bedside too, right?
When you're caring for the patient, the fear factor is different.
Objectivity can leave the room sometimes, you know, like, you just got to be willing
to be questioned.
I think that's right.
You have to be willing to be questioned.
That's how you make medicine better.
And you don't have to agree.
Like we know that, but have the conversation and that's the key.
And I feel like we're just too into, I'm not allowed to question my colleague because then
they're going to be mad at me and then they're not going to support me.
Well, we got to get over that.
I mean, I think that's, and I think, I think stewardship programs will be better off if
we're willing to steward each other.
Each other being ID people.
Right.
Yeah.
I think, I mean, there should be no different, right?
Like we are just like the rest of our colleagues.
So, and sometimes like, and what Michelle was saying right now is like, you're at bedside
and, and there are times when, you know, if, if you have somebody kind of question your
antibiotic approach, but you've kind of thought about the process and just explaining that,
I think sometimes just going through the thought process with, with another colleague, an ID
colleague, it's just what you need.
Right.
And so, and it shouldn't be that, you know, we shouldn't, and again, we should always
remember for our listeners as well, is that ASP is not designed to say that you're doing
something wrong.
It's actually designed to look at what we're doing and if it's the best thing that we're
doing at that time.
And maybe it's different in every scenario, right?
That's why it's not a blanket kind of approach.
You have to have a case by case approach.
And, and I think just highlighting that point is really important today.
Yeah.
Love it.
Perfect.
So we have a few more minutes and I want to talk a little bit about what does the future
hold?
So, you know, there is there a lot of ongoing research and ASP, is there other models that
are, you know, and, and, and are there older models that, you know, how you mentioned Jason,
like we're bringing in some, you know, different types of approaches and, and what is the research
like saying right now?
Are there newer technologies for us physicians to kind of use in ASP?
I think the future holds.
So I think technology will always be looked at in regards to can we automate things?
Can we use guidelines for the better?
Excuse me.
I think that some of the big stuff is implementation science.
What are the implementation strategies that seem to be most effective at different phases
of stewardship or different issues you're trying to address?
For example, we're trying to address post-op antibiotic prescribing and trying to eliminate
unnecessary antibiotics.
So we're utilizing facilitation training versus just changing your order sets or, you know,
or using facilitation to get orders set change.
I mean, these sorts of things I think are the future.
I also think the future is value.
I mean, if people in stewardship should, we should all be thinking about how we're going
to demonstrate our value.
We talk about it all the time.
We got it, we have to try to hone that in as best we can because that's going to sustain
our programs.
I mean, I think about you, Rapina, and where you are, like, you need to have someone that's
saying to your hospital administrators and everyone to say, look, this is the value in
the Canadian system.
This is why this is important.
This is why we need to have a pharmacist to be a part of that.
And stewardship is not, I mean, I'd say we're in our toddlerhood, right?
Like, if you look back, I mean, people are doing some sort of stewardship in the 80s and
some would say in the 70s when they had some initial antibiotics.
So we're, but we're, I feel like we're beyond, we need to be starting to really push things
forward.
And that also means metrics.
Metrics have to improve.
I mean, days of therapy is fine, whatever.
But it's not like a central line infection where you're trying to go to zero.
You're not trying to go to zero antibiotics.
You're trying to go to zero inappropriate use.
We don't have a good way of determining that.
And mind you, we tried and it was painstaking to quarterly review every patient in your
hospital to see how, what percentage of inappropriate use was.
Oh my gosh.
It was hours and hours of work that seemed like, I'm not even sure it was the best use
of our time.
So to me, I guess in summary, then his future is best implementation strategy, value, and
then better metrics.
And one of those metrics needs to be a quick and easy ability to assess your hospital or
your outpatient appropriateness.
Right.
That's fair.
I think there are some cool diagnostics that are going to come our way too that, you know,
like I think over time, you know, rapid direct identification through PCR, next gen sequencing
through sterilized fluid is going to become a little more like accessible and mainstream.
But the trick is we're going to have to be able to figure out how to utilize it.
Right.
Cause like everything else, we're going to get some of it's going to be information that
we have to cut through the noise and, and find the signal.
So, so I don't know.
Yeah.
I'm glad you brought that up.
Cause the other thing I should have said, and people should yell at me for not saying
this earlier is the fact diagnostic stewardship is definitely an impactful thing.
I think if you look at the work that done out of Hopkins with, with my Charlie Woods
Hill, her paper on eliminating unnecessary blood cultures that was just published recently
is fantastic.
The same Hopkins group now under the leadership of Anna six Samuels is doing some on respiratory
cultures in the ICU about, you know, not dealing so many respiratory cultures, these sort of
diagnostic stewardship on the side of let's not do all this testing that leads to a lot
of unnecessary use.
Cause yeah, the results don't make any sense.
I think as it is a definitely future focus for many people that it's going to impact
antibiotic use tremendously.
And it has, has been shown to value too.
I mean, all of that leads to waste, right?
So I think the waste factor is going to increasingly be looked at, you know, what, what is the
hospital having to dispose of the environmental effects of all of that and all the, all the
diagnostic tools, like the actual like physical, you know, material that we're using and having
to dispose of from doing all of these tests and, you know, disposing of all these antibiotics.
I think that's going to be looked at a lot more too.
Yeah.
That's a great point, Michelle.
Right.
And I think, you know, Preeti Jaggi from, from Emory down at Children's Hospital of Atlanta,
talk about all her work around, and she's big into climate change and sustainability.
And I mean, some amazing work about just dose waste dosage, right?
Like not using it.
And I think we think of it on a sense of, oh my gosh, we've charged people.
It's no, no, no.
I mean, this has impact because now that's going to impact, cause that's waste.
Instead of it being used.
Now you just had something you never used and you've added to waste that's unnecessary.
And I mean, it has a larger impact than just our patients.
I think if we, if you think beyond, and I think that's what Preeti has shown us a lot
with some of her conversations.
She'd be a good conversation for a podcast.
I'm just saying, that would be a good one.
That's what we like.
We like when people recommend others.
She'd be fantastic.
Trust me.
Nice.
No, I would definitely reach out to her.
So I think that's, you know, looking at the approach and having so many different angles,
you know, for an ASP or just in general in medicine, I think things have changed.
You know, we have to look at it that way.
We have to look at kind of what, what are we doing initially?
What are the investigations comes back to like choosing wisely, right?
So there's a lot of initiatives around that as well.
And I think overall, you know, huge impacts on costs, like we've known for years, but
also looking at it in the environment.
I think that's a key factor to, to know.
So that's great.
I'm honestly so appreciative to have both of you on our podcast today.
It's been great.
Just have nice conversation with some nice colleagues and just see from the expert side,
you know, what are things that maybe we could change here?
We're always reaching out to our US colleagues for, you know, it's kind of our, it's almost
foreshadowing for us.
So it's nice.
We're a little bit behind on certain things in Canada sometimes.
And so it's nice to see what others are doing.
But also nice to share kind of what we have done locally here.
And, and, and I think everybody has a lot to learn in terms of stewardship.
And like you mentioned, we're kind of in that toddler herd times of this.
So so what's one thing we have a few minutes, what's one kind of key point that or highlight
that you would want to give us, I think each of you like a tip or anything that you would
think that would be a take home message from a stewardship standpoint?
Communication and collaboration are essential.
I'd focus on that and things, things go well.
Perfect.
I say it's a, it's a marathon, not a sprint, you know, like, kind of like politics, right?
You want to make culture change.
You got to look at the long game.
Yeah.
Everything that Jason said about collaboration and communication, building relationships.
That's great.
Yeah.
And I think the other key point is for smaller centers like us, I think starting, right?
So having the initiative to start somewhere is where I would say is what I learned from
this all because obviously everybody's in a different stage.
Everybody has different resources, but really looking at what you can do for your center
and having a starting point and then slowly kind of going from there, whether it's one
unit that you start in and then go from there and make it a hospital wide approach.
So right.
Just do something.
Do something.
Yeah.
No, that's fair.
Awesome.
Well, thank you so much.
I really appreciate both of you being on the podcast.
Is there any kind of last words that anybody's itching to share with our audience?
I love Canada and I'm glad we could do this together.
And you guys are way far ahead, much further ahead than you might think, because you guys
have taught us a ton.
So I appreciate us being able to continue to collaborate.
That's great.
Thanks so much.
Thank you to Dr. Newland and Dr. Mitchell for joining us.
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