57. Antimicrobial stewardship begins at home

Jame and Callum are together in person to talk about the importance of keeping your house in order. Being an infection specialist does not automatically make you an antimicrobial steward. We reflect on some challenges to being an antimicrobial steward  when practising infection medicine

The choosing wisely campaign mentioned by Jame:
https://www.choosingwisely.org/

A course on Antimicrobial Stewardship which is a good starting point:
https://www.futurelearn.com/courses/antimicrobial-stewardship

The IDSA guidance on AmpC production risk organisms mentioned by Jame:
https://www.idsociety.org/practice-guideline/amr-guidance/#AmpC%CE%B2-Lactamase-ProducingEnterobacterales

Transcript

Jame: 0:00

Hi everyone, welcome to the Idiot's podcast that's Infectious Disease Insight of two specialists. I'm Jame, that's Callum. We're going to tell you everything you need to know about Infectious Disease. Soon may the ID team come to discontinue The tazocin , one day, CRPs done, we'll take our leave and go. Callum, how you doing? You getting used to recording, like staring me in the eye.

Callum: 0:24

Yeah, I can't just turn off my camera and ignore you. No, do you normally do that?

Jame: 0:30

I've never done that Okay, you never do that.

Callum: 0:33

Well, I was just thinking, jame, about how nice it is to be in your home, because when you're at home, you're obviously the best version of yourself. You follow all the rules that you've laid out for other people and you definitely don't just do your own thing. You know, make things up as you go along. Where you going with this, maj? Where am I going with this? Well, I think you know the topic of this show and you know where.

Jame: 1:05

I'm going with this. Well, I brought it up, so this is another rant. Who knows when we'll put this in, probably when we've got a lot, but it is the following Stewardship begins at home. And when I say begins at home, what I mean is infection doctors should be anti-microbial stewards. First, because there's nothing more frustrating to me, Callum, than an infection doctor turning round to me and saying something like I don't trust this drug, or I quite like this drug, or why don't we just put them on Meropenem or Tazasyn and then think about the diagnosis later?

Callum: 1:50

Or even lower level than that which is someone's on Meropenem and we add in Vancomycin because they have to be Vancomycin. They go together like a horse and carrot.

Jame: 2:01

What if?

Callum: 2:01

it's MRSC, well then, don't have MRSC. The MRSC screen is negative. The clinical syndrome doesn't really fit with MRSC, or what's the secret, mrsc?

Jame: 2:11

Enterococcal cover.

Callum: 2:12

And it's like well, actually probably Meropenem maybe does Enterococci or or does it not open that kind of worm?

Jame: 2:17

Well no. But I mean, if you gave that much of a crap about it, you would put them on an MRSC. Oh, I'm not really used to that. I don't like that. I don't like that drug. I really hate that phrase. I don't like MRSC, I prefer.

Callum: 2:30

Meropenem. Do you think that the issue is that because infection specialists know more about infection and antibiotics and spectra of activity and bacteria, is that we don't look at our own guidelines? Because I've been caught a cropper a couple of times? So there was a recent case where I think in my head I looked at the guidelines for a catheter social UTI long time ago, used to recommend amoxicillin gentamicin and at some point it changed to just being give a dose of gentamicin and change the catheter and that's fine. Now I didn't look at that guidance for a while because I advise a lot and you know, you know a bit of taste of my own medicine. I was talking to someone and I said something and they said that's not what the guidelines say. Actually, today at work it was hilarious One of the consultants phoned Pharmacy for advice about a tetanus vaccine and then Pharmacy said have you looked at the antimicrobial guidelines? Because it's in there and it was just like. Like you, obviously we hadn't looked there, so it was a bit embarrassing, but you know it is.

Jame: 3:47

Well, now I've realised, callum, that you are part of the problem, because I'm the one that dropped a moxie salon from those guidelines.

Callum: 3:54

I am bothered by them.

Jame: 3:56

With my boss, my sort of mentor that I was doing that antimicrobial stewardship with when I was in NATO North, we'd sort of realise that when you look at what was causing CAUTIs, Enterococcus was this vanishing tiny number. I forget what it was, but it was certainly not enough to justify a moxie salon going in with every dosage. So he said, what about just giving them gentemising? It's got staff cover, it's got gram negative cover, you don't need to worry about any robes. Intracoccus doesn't really matter. You know, and I fought tooth and nail to get it stripped out because I kind of like why use tooth when you can just want it? I just like simplicity. And eventually we put in some gum for about if they're at risk for Intracoccal colonisation, like as if they had an Intracoccus infection in the past year or they've had recent, you know, intracrobdomal surgery to add in a moxie salon, but otherwise to drop it.

Jame: 4:54

But then I thought to myself none of our law are going to look at that, because all of our law saying that they know everything about antibiotics. You know.

Callum: 5:02

Yeah, and you know, there's a big part of infection management that is, you know, this is what we usually do and that's a big part of every part of life, isn't it that sort of type two reasoning where it's just you know, you, just you get to a pattern of recognition. You're like okay, after those UTI he goes on moxie and gent, without really examining why you need the moxie salon or looking at the guidelines. And yeah, I think you're right that. You know. I've certainly had experiences where we've been on the infectious diseases ward. We're doing a ward round and someone's got, you know, say you're a new check infection, and the consultant gives a plan which is you know, let's give them some fossil license because they trust that they've got experience with it, they know it's a good antibiotic, it's, you know the pharmaconexics is, you know it's, it's going to be great, right, but in our you know so, in our guidelines, we recommend using natural free and towing. And the patient has an organism and it was sensitive to natural free and towing that's our first line drug and take quite a lot of courage to speak up and say why don't we use natural fear in tone?

Callum: 6:01

That's first line of the guidelines and they were sort of like oh, you know, and I don't think it was, it's not willful lack of you know we're not setting up and you know people sign up to be antibiotics jurors. So what is? What is it that you see as the issue Because I think that's for me as part of it is that we don't look at the guidelines and so we go off piece a lot and so we'll say, like our guidelines, for you know, penal, allergic, this might be vancomycin. And then we're all like vancomycin rubbish. So what, I'm going to use deptomycin instead. I've got to use the letters instead. But that's.

Jame: 6:31

that's not what I mean, because that, I would argue, is part of our job, where the guideline says one thing, and we realize that because we are looking at more up to date evidence and we change the guideline if it's a local guide systematic reviews and all that sort of stuff, then that's not the right drug for that patient, and so we then deviate from the guidance using our expertise.

Jame: 6:58

That's kind of what we're for. That's not what I mean. What I mean is when infection specialists have developed a predilection for using some anti microbial over others and then continue to do so despite the fact that new evidence has come out stating that that's not a good idea.

Callum: 7:19

So case in point James got a consultant appointment and I was like really laying your legs yeah now I've got a job lockdown.

Jame: 7:27

I'm off the bloody chain, okay, nobody's safe. Nados Dost, noda Seth, I'm coming for you both. No, it's not like that, but like. It's just like, say, say, the recent IDSA guidance. So I've just taught the local registrars on this. The IDSA guidance is for AMPSEE in particular, and I know this is just about to be updated. If hasn't already, it will have been by the time this has come out. It's going to be updated in the next month and those two documents are going to be amalgamated into one. But for AMPSEE it says so. For citrobacter frundii, entrobacter cloacche and clebsi laerogenes it says you know, basically based on the result of the Merino trial, don't trust stuff like PIPTAZ. We recommend a carbon payment, and those are the high probability AMPSEE producers. So their risk of producing AMPSEE Chromosome lampsy Chromosome lampsy is between 8 and 40%, and so that's your high risk AMPSEE. They're your HECCES organisms, them and a couple of others.

Callum: 8:32

So we've talked about that before, Because obviously if someone is producing and expressing AMPSEE or has got it on a plasmid or something, then it will come up in reports and you recognize a pattern, maybe covoxin resistant, comoxiclav resistant, you know.

Callum: 8:46

Yeah, but even if you don't see that on the end of the back IDSA are saying it doesn't matter, Because I think anybody that you like in the lab results, you think, or if you do a test for AMPSEE, even if you see that then you wouldn't use PIPTAZ because you're like, oh, that looks like an AMPSEE, I'm not going to use it. But these organisms, even if it looks sensitive, they're saying don't use them.

Jame: 9:03

Yes, but for non those three organisms, they're saying that you should just prescribe antibiotics according to the anti-biogram that you have in front of you, Because they're lower risk. So low risk they define is like less than 5%. So that would be things like you know, seracea and esteracea, more seracea than this particular Stuff that was in the old enomenclature.

Callum: 9:30

Yeah, like escape or scaphing.

Jame: 9:32

Escape them, Morganella.

Callum: 9:33

Morgani was in there.

Jame: 9:34

Yeah, so they're all much lower risk. So the IDSA have taken that evidence that there's actually high risk AMPSEE producers and low risk AMPSEE producers chromosomal AMPSEE and said, okay, you don't need to treat these the same. And they've done that based on some pretty good epidemiological data. But I have had consultants turn around and say to me I just don't trust that data, so I'm going to give a carapapen to everyone. That's what I mean, Cal. And that's infuriating because if you're going to look at the evidence base and say this evidence base, which may have its flaws but may actually be pretty good data, I'm going to ignore it and go with the dogma of yesteryear, just because I'm used to it. That's what I mean, Steward, you should start yeah, no, yeah, that's If you're interested in your penicillinalgae delaying. To give another example, how many times have you run into roadblocks where people don't trust the data that you're presenting? We've talked about this before, but what was that episode? Well, we were talking about I think it was the penicillinalgae, episode 13 or whatever.

Callum: 10:48

But how many times was that?

Jame: 10:51

somebody on the core team or a nurse or somebody like that no Other infection doctors who didn't trust it, people who wanted to ignore that information and keep on going with what they were doing.

Callum: 11:05

We are a specialty or group of specialties, I guess, that for a long time has had a dearth of data and so it has been acceptable to rely on dogma because there's been nothing better. And everybody's doing this. Nobody's maliciously setting out to do the wrong thing for the patients. Everyone believes. I believe that they're doing the right thing. People are turning up to work to do the best thing that they can. People are saying this based on their training and the practices they've come up with, which has been dogmatic, based on opinion, expert opinion.

Callum: 11:39

Yeah, I think the real sin here is that we as humans, when we make decisions, weigh it's like that thing with biases that you look for evidence that supports your existing. That's human nature, there's nothing like. But you need to be aware of that and when people challenge you, accepting and willing to change your practice based on updated evidence and that is the issue when someone is presented with data and it's not just like here's a paper at Journal Club. This is, if not the biggest, one of the biggest infection societies in the world and I've gone through all the data who have carefully considered it and come up with. I don't know what the strength of the recommendation is. Do they give strengths of recommendation?

Jame: 12:31

Yeah, they did, but I didn't memorise the strength of recommendations. But that's a world-renowned infection organisation probably the biggest one that we've got, that has recommended this course of action. And you know, I'm sitting in front of consultants that are just saying I just, you know, don't want to do that and because they're consultants, they that's. You know that's what happens. But now I'm the consultant Callum. So that's my first example of you know, anti-microbial stewardship begins at home. Do you have one so many?

Callum: 13:09

examples, but and some of those examples could be me, I think.

Jame: 13:14

I think a bunch of them are me earlier versions of me, but yeah now you're perfect, but I'm, and I still struggle with this.

Callum: 13:23

Yeah, I think diagnostics stewardship is another way of looking at this. So, you know, making sure that we only send the tests that are strictly necessary, that will change patient management, and we sometimes talk about tests being academic. You know that's an academic test and in our pursuit of diagnosis which I think is the right thing to do, and I think that's what we do in our specialty well often is say, be the people saying, okay, but what's the diagnosis? You know, pushing for diagnostic tests, pushing for tissue, pushing for interventions, pushing for, you know, trying to try and actually figure out what's wrong, because then we can predict other things, rather than just saying like we don't know whether the sepsis says but their own answer, but it's getting better and that's good enough. But maybe sometimes that is good enough and maybe sometimes we do push too hard or we do test that aren't maybe going to change that much.

Jame: 14:20

Have you heard of the choosing wisely campaign? I?

Callum: 14:23

have heard it's going on in America.

Jame: 14:25

And it's. It's sort of like emergency medicine and sort of front door focus, but it's things like you know, don't order CTP in people with a negative D dimer, you know, like stuff, stuff like that, and you know it's. Initially it was, I can't remember I think it was like six recommendations of stuff not to do in circumstances and they were all pretty low on foods and I don't know what's happened to the campaign more recently. But you know, we as infection specialists, I think we're we're biased towards looking for stuff to an extent. That's maybe not true in other medical specialties, just because we the you know infections can be anywhere. So the test that we employ have to be quite broad.

Callum: 15:13

I imagine if we ask this question of other specialties that have lots of examples like, oh, you know, infection, they're always coming along and saying do you have a bowel on this patient? And I see you if it lowers pretty much an infection, but we don't need to do that. And that balance between getting a diagnosis when you really need to and sometimes it's accepting that you don't have one, that balance of getting the deep samples but if the patient's getting better on your antibiotics, do you really want to put them free on a basis of tests that might mean that you know you put them at risk? Is that definitely beneficial? And also just like the way in which we approach serological tests. You know people that are trying to trap, but I think I guess you know to come to what might be the solution is that I think the SMIs quite could do this.

Callum: 16:04

The standards for micro-balladrone investigations they lay out, like in the flow charts. At the end of each of them they lay out like what's your routine tests and what to do in addition in certain circumstances and also thinking about tests. So you know, say you've got someone presenting with a syndrome like respiratory tract infection. You know rating it by lots of things. So severity can be quite useful. So if they've got a non-severe pneumonia you're not really recommended to do sputum, whereas I think often we would say like send sputum, send blood cultures, send Well the NATO South. They don't.

Jame: 16:40

So NATO South, they've got this um at sort of time that goes at the end of all sputum samples. That says outside of you know, tb testing for sputum is low yield or something. I forget the way that they phrase it. You know, when I came down from NATO North I thought that was a really kind of odd thing and I'd not seen it before. But then if you look at the nice guidance for pneumonia, it sort of says that you know if you're not, if it's a non-severe pneumonia, that you know there's probably not the main thing you want really to test for Legionella, isn't it? But and yet even there that's a kind of worms, isn't it? Because down here they're still using the Legionella antigen, whereas they're still using that on the map as well. Well, but restricted, and you need permission from micro to do it and they'd much rather that you did a sputum PCR for Legionella.

Callum: 17:33

Yeah, send more blood cultures, send more, you know, send more tests and cultures. Sometimes I catch myself trying to say you know the patients on broad spectrum antimicrobials or they've got urine tract infection and then you send them out, we'll send them out culture. Or they've got slightly loose stools and they say send the C diff test. Now well, they don't diarrhea, like it's only like two bell motions a day. Or they're on meropenin in my V. Like how likely is a blood culture actually going to be positive here? Very, very low. They've already had three sets and they're all negative.

Callum: 18:02

Like why are we still? Why are we still doing this? Yeah, and so I think there's a good aspect of antimicrobial and stewardship in general for for for any specialty, and I think you're right that, in terms of closer to home, that we we maybe do and I maybe do have a tendency to over investigate and over test and try and really find that diagnosis, because you're that you I guess it's. Maybe one of the reasons is that we are biased in her, in our case, mix, so we see the more complicated people, we see that you know the intra-abdominal infection which didn't have pus and then they got a complication, but we don't see all the other patients at the surgeons are seen with appendicectomies and completely uncomplicated and they don't send pus and there's no problems. True, true, yeah. So, james, we're sitting in your home and you said that antimicrobial stewardship begins at home. So what? What do you think your takeaway or your message to the loyal listener would be about? Getting antimicrobial stewardship right.

Jame: 19:07

As an infection specialist, I think that if you are sort of early to mid or even late stage trainee and you, you know, read something that's you know, made it made it to guideline level and you know that it's not being implemented in your trust, I think that that would be a reason to speak up and ask like, why are we not doing this, you know? Why are we not, you know, implementing the IDSA, difficult to treat, gram negative guidance? Why are we not using kefadere colin instead of colosin for carbapen and resistant asthenetobacter, baminini, that that kind of stuff where the trials have come out and the evidence is, you know, clearly in the favor of something else? Are you just using or just doing an old work pattern because that's what everybody's used to like? Have people just not kept up to date with the data? Or is there a desire to continue to use an existing dogma? And when it is an existing dogma, I think we should challenge that, like you and me have taken quite big steps in challenging penisone algae, delaying dogmas in nadoch north, and I think that it's been you know nothing about being a small part of well we both have, we both have, but like it's been a bit of us, a bit a bit of our training that we've really taken on.

Callum: 20:33

And I can't think of a downside, you know, to doing that, given the state of the evidence base yeah, yeah, if we're talking about home, I think my idea there would be that and this speaks to me because I've certainly postgraduate they really just practice in the same centre for like ten years and you get used to the dogma and you accept the dogma of that area. So if you're wanting to look at what antimicrobial sturgia about home looks like, go to your friend's house and see what they do there. Because if you visit a different health board centre, hospital country, or you go to a conference and you go to a talk and you hear what other people are doing or you just read their guidelines, I think it's really eye-opening to be like oh, this thing that we do, that we are so committed to and believe in so strongly, and really go out there and advocate for someone else who is a competent person, who is trying to do their best for their patient, is saying something completely different.

Jame: 21:43

And they're doing it differently.

Callum: 21:45

And then you're like they're not stupid, so why are they doing that and why are we not doing that? And if the guidelines say it and someone you know, there's evidence out there and there's not evidence for the way we do it. Maybe your friend's house is better and you should steal their stuff.

Jame: 22:02

Alright, we'll go and strap everything down. See you later.

Callum: 22:06

Kelly.

Jame: 22:06

Thanks for this. Wissie Went off the rails there. Questions, comments, suggestions. Why don't you send them into idiotspodcastingcom? Have a five-star review in your pocket, callum, and I would love to have it. Please drop it in your podcast player of choice. We tweet at the idiotsunderscorepodcom, and if you want to donate to support the show, there's a link to do so in the description. But until next time, I'm James, I'm Callum. See you then.