Mar 7, 2020
In this podcast, Dr. Elliot Francke, an infectious disease physician with Midwest Infectious Disease Consultants (Minneapolis, MN) and head of the Antimicrobial Stewardship Committee at Ridgeview Medical Center. Dr. Francke discusses antimicrobials and how the notion of antimicrobial stewardship came about. Dr. Francke also discusses where we are today with antimicrobials and the trends for the future.
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Dr. Francke joins us today to discuss antimicrobials and how the notion of stewardship came about, as well as where we are with this today, and the trends for the future. Infectious disease topics are rapidly evolving, and while this recording happened a few months ago, there are inevitably going to be many updates, so exercise due diligence and read the literature to stay current. Let's jump into antibiotic stewardship with Dr. Elliot Francke.
Good stuff have been discussed so far in this first of three chapters with Dr. Francke! Recapping up to this point...Earlier studies looked at the need for improved use and restriction of antimicrobials back in 1966 in Canada. Understandably, with the suggestion that an ID specialist sign-off on every antibiotic order was cumbersome and not well received Nearly 30 years later, however, two physicians, one name Gerding and another name McKowan were looking at the rise of C difficile, and it was discovered that this proliferation was linked to antibiotic use and misuse. Hence, he coined the term "stewardship". It was borne out of inspiration from a church sermon. Stewardship us not dictatorial, but rather suggestive and guideline oriented, which implores practitioners to "do the right thing" and find the narrowest spectrum agent that has low toxicity and cost optimization. Ultimately this was adopted by CMS and JCAHO as a requirement. The guidelines are published by IDSA and SHEA.
At the end of the 1990s, we were beginning to see resistance to multiple classes of antibiotics. Therefore, if we can limit or restrict to certain antibiotics, the theory is that we can reduce this emerging resistance. However, the literature doesn't actually support this as of yet. The literature does support the reduction of C. diff infection in the setting of limited antibiotic use, however.
The stewardship guidelines aim to educate people to make the best choices. It involves gathering information including resistance patterns, C. diff rates, use indications and cost of antimicrobials. These are reported to the institution, JCAHO and similar organizations. The aim is to be able to compare apples to apples with other facilities in the nation.
Administrative support for stewardship is equally as important as the medical staff's participation. These would include infection control, microbiology personnel, physicians, APPs and nursing staff. Currently, larger health systems are required to have antimicrobial stewardship programs, although in the future, smaller systems, hospitals and clinics will also require this. Collecting data can seem honors, however, these data (i.e. overall antibiotic use, costs, C. diff rates, formulary, resistance rates, etc.) can increasingly be collected from programs within or adapted to existing EMR systems more automatically.
Stay tuned for Part 2 with Dr. Francke, as we take a deeper dive into this issue of stewardship, how it's effectively implemented and enforced.
Time to pause and regroup. Let's summarize Chapter 2 of our antimicrobial discussion with Dr. Francke. EMR currently is a data gathering device, and not used as a decision maker and analyzer as yet, therefore, the members of stewardship committees are and will remain necessary for the foreseeable future. In terms of actual "policing" of prescribing practices, the stewardship committee is not charged with this task. Hospital and institutional P and T committees as well as administration, but also JCAHO, DNV and similar organizations are the elements that actually can and do enforce best practices. Patient education and participation is paramount as well. Employees and staff should also be recruited and "signed-off" as aware and attuned to these best practices. As far as future possible education modalities for patients, we would like to provide a web link within an institution's guest site for patients to explore what they are taking or have received in the hospital.
The head of stewardship programs tend to be infectious disease specialists, however, this tends to be costly. PharmD's now are an increasing popular option for this role. There can sometimes be conflicts of interest with ID physicians being used for this role of chart review, but also and implications of the need for physician "consultation" as well. This program was implemented at ANW and has been a success thus far.
So what happens in a chart review? The ID specialist of PharmD is actually reading the chart, looking for appropriate empiric, therapeutic and prophylactic antimicrobial use. The PharmD follows published guideline recommendations, for instance Sanford and IDSA guidelines are used at our institution, as well as from individual society guidelines. There tends to be upwards of 96% compliance with these guidelines at our institution, actually. And this happened in a short period of time.
The next steps for stewardship are to tie into outpatient centers. But also the need to spotlight the overuse of antimicrobials in agriculture and having broader support in the medical industry, but also governmental agencies and various lobbying organizations. In order to accomplish this, though, education needs to happen and data must be presented in order for big food and big Pharma to adopt better practices in antimicrobial use.
Cost of antibiotics is not quite to the level of chemotherapy or biologics that are out there. We can combat cost by deescalating our antibiotics to the one that is cheapest and most effective after the initial doses of empiric antibiotics are given.
Chapter 3 will discuss more details on stewardship and how this may all play out in the outpatient setting, as well as what looms on the horizon with this topic and infectious disease in general.
Summarizing chapter 3 with Dr. Francke, patients often ask for antibiotics by name. So how do we challenge this reality? First, ask the patient why the want a particular antibiotic. Plainly, we have to tell our patients that we're trying to reduce resistance; and actually show patients online or with educational materials which antibiotic is appropriate and why. Or, why an antibiotic is not actually indicated.
Outpatient antimicrobial stewardship will be an interesting challenge. We will need to rely on guidelines and antibiograms are updated on a yearly basis. Outpatient stewardship will need champions and drivers for this effort to have beneficial effect, and as Dr. Francke states - it will be mandatory in the coming years.
Duration of antibiotic treatment is now being looked at more and more. Will length of treatment affect potential resistance, C. diff rates, etc? Many of the durations of treatment are arbitrary and are borne out of the initial Pharma trials when drugs are at their inception and emerging. At this point, duration of treatment presumptively can lead to resistance, but we simply don't know whether this is a fact.
Candida iris is widely resistant to almost all antifungals. Middle eastern acinetobacter also have significant resistance and increased pseudomonas resistance nationwide. Not a lot of this is seen in our local/metro area, but it's likely to happen.
Testing for infectious organisms with PCR will give us faster answers and provide for rapid deescalation, but is not likely to immediately have impact on drug resistance.
Biologics are an emerging therapeutic as well in the infectious disease world. These will target specific organisms, and effectively use the human immune system to do the work of killing the organism. This is way off on the horizon, though.
Dr. Francke states that people should keep their vaccines up to date, and for the public to take an active interest in their health, use antibiotics, their own gut flora, and the public health issues that relate to antimicrobials. Ask questions of your providers, and your colleagues to help guide what to take and what to prescribe.
A huge thanks to Dr. Francke for his time with us, as well as his many years of practice and dedication to the field of infectious disease. And to all of us practicing, let's keep an eye on those guidelines and do our part in this. Buy-in essential and ambivalence is no longer an option.
Thanks for tuning into Antibiotic Stewardship, and we'll see you in a couple weeks here at Ridgeview Podcast CME Series!