The Role of Antimicrobial Stewardship in Outpatient, Hospital Settings
In this video roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Lisa Davidson, MD, and Ryan Maves, MD, about the importance of antimicrobial and diagnostic stewardship, fighting antimicrobial resistance, minimizing toxicity, and maximizing infection control.
Additional Resources:
Satterfield J, Miesner AR, Percival KM. The role of education in antimicrobial stewardship. J Hosp Infect. 2020;105(2):130-141. doi:10.1016/j.jhin.2020.03.028
Majumder MAA, Rahman S, Cohall D, Bharatha A, Singh K, Haque M, Gittens-St Hilaire M. Antimicrobial stewardship: fighting antimicrobial resistance and protecting global public health. Infect Drug Resist. 2020;13:4713-4738. doi:10.2147/IDR.S290835
Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control. 2019;8:35. doi:10.1186/s13756-019-0471-0
Schouten J, De Waele J, Lanckohr C, Koulenti D, Haddad N, Rizk N, Sjövall F, Kanj SS; Alliance for the Prudent Use of Antibiotics (APUA). Antimicrobial stewardship in the ICU in COVID-19 times: the known unknowns. Int J Antimicrob Agents. 2021;58(4):106409. doi:10.1016/j.ijantimicag.2021.106409
For more antibiotic stewardship content, visit the resource center.
TRANSCRIPTION:
Dr Jaspal Singh:
Hi, everybody. Welcome to our next podcast series on Consultant360. I'm your host, Dr Jaspal Singh. I'm a pulmonary critical care physician, and with me today are two experts about antimicrobial stewardship, a very important topic for all of us, whether it be inpatient or outpatient medicine.
With me today, we have two distinguished guests, Dr Ryan Maves. Want to introduce yourself first?
Dr Ryan Maves:
Yeah. Sure. Thank you, Dr Singh. I'm Ryan Maves. I'm an infectious diseases and critical care physician at Wake Forest University in Winston-Salem, North Carolina, where I'm part of our antimicrobial stewardship committee, and obviously, a practicing clinician in ID consultation and the ICU.
Dr Jaspal Singh:
An ID specialist and a critical care specialist. Fantastic. All right. And then Dr Davidson?
Dr. Lisa Davidson:
Hi, I'm Lisa Davidson. I'm an infectious disease physician. I practice at Carolinas Medical Center, which is part of Atrium Health, and now Advocate Health. And I also have an appointment in the Wake Forest School of Medicine. My direct role in antimicrobial stewardship is that I'm the medical director for the Antimicrobial Stewardship Network in the Greater Charlotte Area for Atrium Health. I also work for our adult medical specialty division working on quality issues.
Dr Jaspal Singh:
Fantastic. Both of you have a lot to bring to the table today for this topic that is so important, and I understand it's Antimicrobial Stewardship Month. Is that not correct, Dr Davidson?
Dr. Lisa Davidson:
Yes. Every November, we try to get the public to focus on antimicrobial stewardship, and in particular, the third week in November, right before Thanksgiving is when there's a worldwide Antibiotic Awareness Week. And so, in that week, we try to bring the public to focus on both antibiotic stewardship, antibiotic resistance, and what the public can do to improve their use of antibiotics and also what the public can do to decrease antimicrobial resistance in the community.
Dr Jaspal Singh:
That's fantastic. And, if it's okay, I'm just going to use first names from here on out, so please use my first name. It makes it more of a conversation.
Hey, Ryan, talk to us a little about antimicrobial stewardship a little bit. Why does this matter? What's the history? What gives here?
Dr Ryan Maves:
Yeah. The big picture with antimicrobial stewardship is improving our uses of antibiotics, and I think antibiotics are unique among drugs that we use in that how we treat one patient will have a long-term effect on how we can treat other patients. If I give one patient lisinopril, that doesn't affect my ability to treat other patients with lisinopril in the future, but antibiotics are different, and we change the ecology of a health system, of a hospital, of a unit, as we use antibiotics in different amounts. I think there's a perception that antimicrobial stewardship is about using fewer antibiotics, and that is on some level true. We are trying to use antibiotics in a more focused manner, which often means shorter durations, depending on the patient and the syndrome. Still, a lot of it is about really using it in the best possible manner.
And so that means not just, in many cases, shorter courses, but also appropriate dosing, appropriate spectrum, minimizing the toxicity to patients, because antibiotics or drugs and drugs have toxicity while maximizing benefit to the greatest possible way. Usually, in the current milieu, that means earlier targeting of pathogens, earlier adoption of narrower spectrum agents, and shorter courses, but in some cases, it may not mean that. In some cases, it may mean the deliberate use of broader spectrum drugs, depending on the patient, the setting, the syndrome, and such.
Dr Jaspal Singh:
That's important. So let me just reframe. You're saying it's not just about using less, it's about using it smarter, using all the diagnostic tools to approach this strategically and looking at it as antibiotic stewardship as more of a philosophy towards a smarter use of antimicrobials, both for the public health good, but also for the individual patient's benefit. Is that correct?
Dr Ryan Maves:
Exactly. Exactly.
Dr Jaspal Singh:
All right. Lisa, anything to add to that?
Dr. Lisa Davidson:
I think Ryan summed it up well. It's really about appropriate use, and I think often, when we started in the field of antimicrobial stewardship, we focused on the hospital setting, but now the concepts of antimicrobial stewardship of appropriately using antibiotics extend through all areas of healthcare, so whether it's babies in the NICU getting appropriate antibiotics for sepsis or how we treat older individuals who may live in skilled nursing facilities or long-term care facilities, treating their infections appropriately. It's an entire spectrum across healthcare.
And why I think it's important is people often ask what the harms are, and Ryan spoke to some of those harms, but it can be adverse events. Antibiotics are one of the most common types of drugs that have adverse events. That could be nausea, vomiting, diarrhea, rashes, or interactions with other medications. And it could also be what we are the most concerned about is the development of resistance. One of the reasons we want to have awareness around antibiotic use is that we're seeing this resistance not just in the hospital anymore, but really in our community, so in the communities that all of us live in every day.
Dr Jaspal Singh:
And I think that's important. Now this sounds great in theory, we've been hearing about this forever, but it's one of those things. I have a number of areas I work in. One is the office and one is in the ICU, and so in that spectrum of the healthcare continuum, we always have these patients that, we think about antimicrobial stewardship, but then you get this patient, whether in the office calling you, "I need antibiotics," or whether it be ... heck, even family members call you to say, "Hey, I'm sick, can you send some antibiotics in for me?" And that up to the ICU, where someone's in multi-system organ failure, and then you're trying to figure out can you be smart about this, and you're racing between what's practical and what's realizable.
Help us everyday clinicians navigate that maze a little bit. Ryan?
Dr Ryan Maves:
Oh, yes, I agree. And I'm in a similar situation as you are that I have a clinic and I have an office, and my clinic is ... I largely care for patients with solid organ transplant hematologic malignancies, so obviously, a very high-risk group in my outpatient practice, and balancing my ID brain with my intensivist brain a little bit, or my ID brain and my intensivist soul and what do I do with these people clearly when they're very sick? And the way that I've come to approach this is, first of all, appreciating that really what you do in the first 48 hours is a giveaway. It's a freebie. And I'm watching Lisa very nervously on the camera to see if I'm going to be reported for betraying my ID people. But I think this is broadly true.
If you get good cultures, if you get good specimens, if we leverage these emerging molecular technologies, then the first 48 hours of a critically ill patient ... I'm not talking about an ambulatory patient, I'm not talking about someone who is admitted to the ward with cellulitis, who's hemodynamically stable and alert and talking to you and on room air. I'm talking about the person in multi-organ failure and shock. With that person, our margin for error is extremely narrow. It is extremely narrow. And our selection of antibiotics and our institutional protocols largely reflect that. Here at Atrium Health Wake Forest Baptist, the default regimen is a vancomycin-cefepime or a vancomycin-piperacillin-tazobactam depending on the site of infection.
Dr Jaspal Singh:
For shock, for a patient with septic shock you can do what you need to do.
Dr Ryan Maves:
For a patient with septic shock, in the absence of some known other resistance profile, known ESBLs, known carbapenemases, and the like. In that setting, you get blood cultures, respiratory cultures, urine cultures, whatever is appropriate for that patient, treat them broadly, but what you have to do is, on some level, you got to believe, you got to believe the culture data, or the absence of culture data. For example, a thing I tell my residents and my fellows a lot is, "Listen, if staph aureus is present, Staph aureus will grow. And if Staph aureus doesn't grow, Staph aureus almost certainly is not there." That is a tool that we can use in the first 48 to 72 hours to, for example, get people off of vancomycin.
That kind of strategy of acting not only on the positive data, but the negative data after the first 48 to 72 hours helps you narrow things down in an appropriate manner, and I find that is a useful first step.
Dr Jaspal Singh:
Perfect. In the ICU, what you're saying, with a critically ill patient, don't be shy about using what you think is appropriate, but then have the discipline and the rigor to check the cultures, check the data, check what's going on, and somewhat have faith in that. And, in 48 to 72 hours, really scale back what you think is reasonably safe and then follow that patient clinically.
Dr Ryan Maves:
Precisely, precisely.
Dr Jaspal Singh:
Perfect. Lisa, how do you approach this?
Dr. Lisa Davidson:
I approach it in the same way, and one of the teaching points or the learning points that I try to emphasize to physicians, whether they're medical students and residents or they've been practicing a long time, is you have to take a step back and look at the severity of illness in the patient and their risk factors. It's not just all or none. And so, for instance, as Ryan said, 100%, first 48 hours, someone comes in in septic shock or someone comes into the ICU, you want to treat them broadly and appropriately. We want to emphasize that you have to look back at their cultural history, and Ryan referenced that because that will help guide us to the appropriate therapy. The flip side of that is someone who's maybe in the emergency room, but not getting admitted, or pretty stable or someone who's in the outpatient setting, and to understand that, if someone is clinically stable, especially if their vital signs are pretty normal, we have time.
The most common example that I could give is a person who's 85 and comes into the emergency room with altered mental status. And we've gotten in the habit of saying that the patient has a UTI until proven otherwise, and we start antibiotics, often sometimes broad-spectrum antibiotics. But the truth is that the vast majority, close to 90% or 100%, of patients over the age of 80 are going to have abnormal urinalysis. If that patient's hemodynamically stable, we have time. We can wait. If their vital signs are normal, we can wait. And you need to be able to think of the differential diagnosis and the workup and put this in the context of that.
Same thing, I think, where we even see more interesting patterns is in the outpatient space when someone comes in and says, "I've got a cough for two weeks, I feel terrible, I need my antibiotics." And you have to be able to have I call it a courageous conversation with them to say, "Yes, you are sick, and I'm sorry you're not feeling well, but I think you have a viral infection," or, "I think we need to do some testing before we diagnose you and then I'll follow up with you," or "Here's the plan."
And there's a lot of good qualitative research out there that shows that it's the conversation that's critical in these times. People are vulnerable, people are feeling sick, and we latch onto antibiotics as the, "We're doing something," but that doing something can potentially be harmful. Again, we're not talking about the patient in the ICU, or even the patient that's been hospitalized for a clear infection who may have sepsis or severe septic shock. We're talking about when infection is the differential or a patient's not admitted and we have more time to evaluate them. It is a spectrum.
Go ahead.
Dr Jaspal Singh:
Walk me through this a bit.Wee're running into cold season or flu season or RSV or COVID, whatever this might be this coming winter, for example. In the outpatient arena, how do you know? I deal with patients who have advanced lung disease, many of our listeners might as well, or cardiovascular diseases, or other things that chronically put them susceptible to high risk of potentially, if you guess wrong ... their perception, whether that be data-driven or not, is that, if they don't get the antibiotics, they're going to have a serious problem. And walk me through that a little bit, your logic, on how you counsel or appropriately manage those conundrums.
Dr. Lisa Davidson:
Yeah. This is something that I think, nationally, there's a lot of attention working on this, and it's not really in the ID space. It really is in the urgent care and primary care and pediatric space, and it's not for the patients that you treat or Ryan treats or the immunocompromised or the chronic lung disease patients. They're a very different population. You have to evaluate them very differently. But, for the vast majority of patients that come in during flu and cold season, or upper respiratory viral season, 80 to 90% of those infections are not going to be bacterial.
And it is a very different conversation now than five years ago. COVID has changed that. I like to say that, before COVID, every time I told someone I was an infectious disease doctor, they'd be like, "What's that?" or they'd walk to the other side of the room because they think I'm contagious, and post-COVID, now everybody thinks they're an infectious disease doctor. The one benefit, I would say, of COVID is that people understand now a little bit more what a virus is. That doesn't mean they don't want treatment. You have to really, I think, walk the patient through what their symptoms are and then explain to them what makes you think this is a virus versus a bacteria, and then why an antibiotic would not help, but here's what can help.
There's great work from Rita Mangione-Smith, who has done amazing research on this, and her methods of talking to patients have become some of the foundations of how we train primary care doctors to have this conversation. But then we get to the point about testing. I think one of the things that's going to become really different in the next couple of months is now tests are going to be charged for by insurance companies, and the treatments for some of our viral infections, our COVID infections, are going to become very expensive. It's not just you have a virus, it's do we need to do a potentially expensive test for this virus or what are the other treatment options? Giving an antibiotic is easy, but it is very rarely the right thing to do.
Dr Jaspal Singh:
Wow, that sounds challenging. Ryan, any thoughts on that?
Dr Ryan Maves:
Yeah, I think something Lisa's alluding to is a concept that's paired with antimicrobial stewardship, which is that of diagnostic stewardship. The two go hand in hand. However, the idea is to use diagnostic tests in a way that will affect patient care in a beneficial way. And so a common way that I think we've probably all seen in the last few years has been changes in Clostridioides difficile testing in hospitals. I think some of those protocols can be a little heavy-handed sometimes. There is some flexibility, and I'd say that Lisa and I occasionally have the benefits of just being able to override the protocols, because I can say, "I'm an ID doctor, I can do what I want," but there is a wisdom to it, like checking an afebrile patient. Sending off a C. diff assay for an afebrile patient who has diarrhea while on tube feeds is unlikely to be a useful test. It's going to lead to some degree of overdiagnosis.
Comparable to that would be something like multiplex PCR-based viral testing for respiratory infections. I'm lucky. I'm a pretty healthy guy. I don't have a lot of medical problems. If I have an upper respiratory infection, the benefit to testing me nowadays, setting aside issues of COVID isolation obviously, is relatively low. I am probably not going to benefit tremendously from oseltamivir. I am probably not going to benefit tremendously from some emerging RSV antiviral, which are, interestingly, just as a side note, moving into clinical trials. But, when I'm 65 when I'm 70, that picture changes. I may be at greater risk and there may be a benefit to testing me because there may be a therapy that will benefit me in the future.
How do I deploy those tests, taking into mind what am I going to do with the results? If I have a respiratory infection now, I should stay home, I should isolate myself until I get better because I shouldn't give all of my patients with leukemia whatever virus I'm walking around with, again, setting aside issues of COVID testing. That test has relatively limited utility for someone like myself. But, for many of our higher-risk patients, your patients in the clinic, my patients in the clinic, and Lisa's patients in the clinic, that math is very different. There may be something we could do. Influenza testing would be kind of the classic one, and nowadays, COVID testing. But, if I'm someone who's not going to benefit from Paxlovid because I am at very low risk, then maybe that test is of different utility, for the third time, setting aside issues of public health isolation and the like.
Dr Jaspal Singh:
No, that's great. Just to summarize, it sounds like the combination of antimicrobial stewardship and diagnostic stewardship go hand in hand, particularly in the ambulatory and probably the inpatient space as well, trying to think through who we're going to test, be mindful of looking at the patient, looking at the overall clinical picture, and then helping make a nuanced decision, and the idea that not an indiscriminate use of antibiotics, but also not indiscriminate holding back, depending on where we are, and then trying to use some of the additional diagnostic tests, but also, with a caveat that Lisa pointed out earlier, is, for the outpatients, is we've added additional considerations in terms of cost, logistics, and other constraints that we not have been that mindful about before, but we just have to be mindful about today. Is that pretty accurate?
Dr. Lisa Davidson:
Yeah.
Dr Ryan Maves:
Yeah.
Dr. Lisa Davidson:
And I would say that diagnostic stewardship on the inpatient side is something that we are going to see grow and we need to do a little bit more education about. We already have quite a bit of diagnostic stewardship happening, we just are not always using it correctly. I think Ryan alluded to Staph aureus growing and now it's become pretty standard in most hospitals that, if your MRSA nasal swab is negative, you can discontinue vancomycin for empiric treatment of pneumonia. We are using rapid diagnostic tests on a lot of our sterile fluids, for instance, blood cultures and CSF cultures that allow us to discontinue therapy earlier. And I think often where our stewardship team comes in is, A, helping clinicians interpret those tests, because there's resistance markers on them now, but a lot of clinicians aren't familiar with that, so it's the alphabet soup of resistance, and it's often our stewardship team working with the providers to say, "No, you don't have a CTX-M resistance marker, so you can use ceftriaxone," and familiarizing those advanced diagnostic stewardship concepts with our teams.
Ryan mentioned C. Diff is another big one. I think one of the ones we struggle with, getting back to respiratory season, is now we see, from COVID, we all got in the habit of just doing the rapid, in the ED PCR for influenza and COVID and then admit, admit for pneumonia, but what we need to be doing is the larger respiratory panel, so because we need to look at, is it RSV, is it adenovirus, is it parainfluenza? Because that's where often it can delay the hospitalization. When we're not screening people appropriately, we're not diagnosing them appropriately. We're going to see big changes in urines, and joint testing. It's going to be one of the big changes that comes over the next few years.
Dr Jaspal Singh:
That's interesting. That's very fascinating. I'm going to go back a second, you mentioned the team. Most of our listeners might be practicing independently, for example, or might not understand. What does the antimicrobial stewardship team do? And I don't know if you want to comment on that or we can talk about what the CDC recommends, whatever your thoughts are, Lisa.
Dr. Lisa Davidson:
Yeah. I'll talk a little bit about both. Published back in 2015, '16, was the first iteration of the CDC core elements for stewardship. That was taken from the literature and expert opinion on what it takes to implement an antibiotic stewardship program and the standards for antibiotic stewardship. Those have now been incorporated into Joint Commission requirements, DNV requirements, if you use DNV, and even CMS oversight recommendations. What do you need for a stewardship program? You need a pharmacist and a physician leader at the very least, and you need buy-in from your leadership to support that work. You need a committee that's going to be involved, including microbiology, nursing, quality, our critical care colleagues, and ED colleagues, to set policy for the system.
And then, beyond that, every hospital is going to be a little bit different. Some hospitals have a lot of their regular pharmacists doing some stewardship work. Some have specific infectious diseases or stewardship pharmacists doing stewardship work. And that work means identifying interventions for decreasing inappropriate stewardship work. There are a lot of different models for doing this. I'll talk about our model for a second, which is that we're really lucky in that we have a robust stewardship team, but we also cover 15 acute care hospitals and rehabs and a pediatric hospital.
Every day we look at opportunities that are identified in our EHR for interventions for appropriate antibiotics. We look at blood cultures, we look at sterile cultures, we look at restricted antibiotics, we look at people who've been on certain antibiotics for a certain length of time to make sure those are appropriate, and we also look at opportunities to what we call narrow antibiotics, so to change people from an IV antibiotic to a PO antibiotic to facilitate getting patients out of the hospital. And some of the really exciting work happens at that transition of care. That's a big focus for us now, making sure patients aren't getting antibiotics longer than they need to.
Dr Jaspal Singh:
I'm sorry to interrupt you. Transition of care meaning from one facility to the next facility, or one team to another team.
Dr. Lisa Davidson:
Exactly. Outpatient to inpatient, inpatient to skilled nursing facility, and sometimes skilled nursing facility to outpatient. We have a hospital at home, which is a unique model where patients are getting hospital-level care in their homes. Well, we're still working with those providers to make sure they're on the appropriate antibiotics. A lot of different work, and everybody does it a little bit differently, but we're all basing our work on those core elements of stewardship.
Dr Jaspal Singh:
That's fantastic. Ryan, anything to add to that?
Dr Ryan Maves:
No. I think one of the challenges that we've seen in this space is a lot of the initial drivers behind new programs in antimicrobial stewardship are, at large, often tertiary facilities like we work in, well-resourced, where there's a dedicated team. And, of course, the majority of antimicrobial use in the United States, and the world, is in both smaller hospitals, where there may not even be an infectious disease physician, much less a team of them, and of course, in the outpatient world, and that's setting aside just entirely issues of, for example, agricultural use of antibiotics, which is, pound for pound, the largest use of antimicrobial drugs worldwide.
The challenge is reaching into these other spaces, finding ways to make programs work for smaller community hospitals, and advances in telemedicine and other things have made some of that possible. But finding a practical way that doesn't require you to work at a 900-bed monolith like we work at is going to be probably one of our next big steps.
And I think also, although our goal is to create systems that help people make intelligent antimicrobial decisions, we also have to recognize a lot of our colleagues are flying solo out there and finding ways to have cultural changes within our specialties at the bedside to make this work and to sympathize with the people who are in that situation who have to decide on the fly for a sick patient saying, "I get it. I understand why we're using drugs in this way. You've got that window period early on where you do what you have to do, let's find a way to pull you back from that so that we can target your particular patient's care more narrowly." There's an emotional aspect of this that we can't overstate, and I think those are going to be probably our next big challenges as we move forward with this.
Dr Jaspal Singh:
No, I think that's well said, I think, both of you. I think, Lisa, you did a great job outlining the programs, what it takes, the team, the infrastructure, the commitment, the leadership, the accountability, and all the processes that go into a robust program. And I think, Ryan, you did a nice job of saying, "Well, that's great, and it's meant to help the patients, the public, the future generations," because antimicrobial resistance, unfortunately, the future, at least today, doesn't look that great in terms of future antibiotics, future bugs, how, if we don't get a handle of stewardship, both diagnostic and antimicrobial stewardship, that we are investing in the future, and we are trying to think through that.
All of us have young children or younger children, and all of us are thinking about their generation too. How are we going to take care of them? And, as we all age, as our colleagues age, and others age, how are we going to manage all the emerging pathogens and other things like that? And I think you did a very nice job of also summarizing at the end, Ryan, about how we got to do it with an empathetic lens, as you will, the idea of we're here to help people, not necessarily to be prescriptive. It's very nuanced, it gets emotional, but it's important for the public and us in our future. Is that about right?
Dr. Lisa Davidson:
Excellent.
Dr Ryan Maves:
Beautifully phrased,
Dr Jaspal Singh:
And I know we could talk about this forever, but I know we start thinking about other things, including international and global stewardship, as I'm thinking about, Ryan, some of the work you're doing as well, internationally, globally, this is becoming a global phenomenon. And, Lisa, and the stuff that you outlined in terms of the CMS. You mentioned DNV. I don't know what DMV is, besides the Department of Motor Vehicles, so I'll assume that's something related to your work. But-
Dr. Lisa Davidson:
DNV, it's like the Joint Commission.
Dr Jaspal Singh:
The Joint Commission, got it, okay, because I thought, "Department of Motor Vehicles, wow, they're into this stuff too," and I was wondering about that. But, anyways, rather than get sidetracked, let's talk about stewardship programs. I think what you described is what the team and the core elements are, and I think this is being looked at globally, from what I understand, through the WHO and other organizations. I think feeling a little bit of hope that we are working through this with leaders like yourselves who are trying to make this work for all the moving pieces and the teams involved.
On behalf of Consultant360, I wanted to thank you both for your time today and look forward to working with you some more on this.
Dr Ryan Maves:
Thank you so much, Jaspal.
Dr. Lisa Davidson:
Bye.
Dr Ryan Maves:
Thanks for having us. Great to see you all.
Dr Jaspal Singh:
Bye-Bye.