Last week, I attended the Illinois Summit on Antimicrobial Stewardship at Northwestern Memorial Hospital. While the target audience was physicians, nurses, pharmacists, and administrators, as a clinical laboratory scientist I found the presentations (with a few caveats, which I’ll get to in a moment) quite informative.
The morning sessions covered the relationship between antibiotic use and resistance patterns; interpretations and implementation of the national guideless for stewardship; and using behavioral science to increase compliance with stewardship programs. Participants spent part of the afternoon in small groups to discuss designing and implementing a stewardship program.
A few notes:
-50% of antibiotics for upper respiratory infections aren’t needed; 50% of antibiotics for inpatients aren’t needed, either
-antibiotics are the only drug where use in one person impacts it effectiveness in another
-based on the literature, antibiotic stewardship programs have at least a transient effect on antibiotic effectiveness—eventually, resistance numbers begin to climb again
-hospital antibiograms are the most widely available measure of resistant organisms, but we aren’t using them as effectively as we could. For example, we typically report that, say, “62.5% of E. coli isolates are resistant to ciprofloxacin,” but we don’t say where those isolates come from. Are they urinary tract infections or upper respiratory infections? What’s the rate of resistance for infected wounds?
-a weighted antibiogram might make empirical treatments for effective. For example, “what % of urinary tract infections are resistant to ciprofloxacin?”
-it’s important to note that the IT department, hospital information systems, and laboratory information systems play a huge role in stewardship programs
-stewardship programs depend on the “5 D’s” Diagnosis, drug selection, dose, duration, and de-escalation of use
-diagnostic uncertainty—driven by lack of early organism identification—drives a significant amount of antibiotic use
-when combined with stewardship, rapid bacterial identification methods such as MALDI-ToF platforms decrease parameters such as length of patient say, time to treatment, etc.
-we can use peer pressure to drive improvements. No one wants to perform worse than the doctor next door
-our efforts might be moot, anyway; other countries take a much laxer stance on antibiotic use
While the laboratory in general and clinical microbiology departments specifically were mentioned during the presentations, I must say they were only mentioned in the context of how little perceived impact we have on stewardship. (“Well, we know the laboratory isn’t going to give us any useful information for another three days…”) It wasn’t until I participated in the small group sessions in the afternoon that attendees at my table admitted that the laboratory is an important piece of the stewardship puzzle. We have mountains of data we can assimilate (antibiogram creation, anyone?). We can bring in new technologies to make identifications faster. We can work closely with the infectious disease doctors to help guide treatment. That brings up a good point—if microbiology labs aren’t in-house, then creating an antibiotic stewardship program becomes that much harder because results can be delayed.
If you’d like to see the powerpoints from the presentations, you can do so by clicking the “downloadable content” tab at Northwestern Memorial Hospital’s antibiotic stewardship page.
–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.
Happy New Year! I hope that everyone has been having a great holiday season so far. I just wanted to share some brief musings I recently had as we start our new year…
Most of us have heard of the famous 1910 Flexner Report but for those who are unfamiliar, it is not exaggerating to state that it transformed and birthed the modern concept of biomedical education that we know today. Originally entitled “Medical Education in the United States and Canada”, it was study commissioned by the Carnegie Foundation for the Advancement of Teaching (CFAT), an American educational policy and research “think tank” founded in 1905. The report’s author, a former secondary school teacher and principal and not a physician, toured all the existing medical schools in both the U.S. and Canada and recommended reforms that would result in the standardization of the structure of medical curricula with Johns Hopkins as their ideal model. Medical education went from for-profit apprenticeships, varying in quality, to an academic model of basic science study followed by practical hands-on training in patient care. Eventually with standardized accreditation requirements, most medical school curricula, despite their differences in implementation, had their core foundation in common: didactic years to learn and clinical years to apply (under supervision).
Like the proprietary “medical” training institutions of yesteryear that existed prior to the Flexner report, do our pathology training programs need a global re-evaluation and an overhaul? Despite the existence of ACGME accreditation criteria and visits, do we have programs that need serious reform or termination to meet an ideal? Do our accreditation standards need to change to create a new ideal? And must we come together now to adapt our expectations and training objectives to meet the challenges of our rapidly evolving health care landscape? What is and should be the role of the pathologist on the interdisciplinary clinical health care team? And so the core question becomes, what are the most important things that we need to teach our trainees and how do we go best about it? I’d love to hear your thoughts…
And to encourage scholarship in the Flexner tradition that also emphasized the role of research in our education…for those who would like to submit an abstract for resident poster and platform presentations, submission periods for these conferences are currently open (except for CAP) with the following deadlines (I’ll try to update with more later but these are the most immediate in terms of deadlines in the next quarter):
- American Society for Investigative Pathology (ASIP), for more basic science research minded trainees: March 28-Apr 1, 2015 in Boston, MA; late breaker abstract deadline Jan 21, 2015; http://www.asip.org/meetings/2015/abstracts.cfm
- Society for Hematopathology/European Association of Hematopathology (SH-EAHP): October 29-31, 2015 in Long Beach, CA (with ASCP); workshop case submission (topic: immunodeficiency and dysregulation) deadline Jan 31, 2015; http://www.ascp.org/2015shmeeting
- American Society of Clinical Oncology (ASCO): May 9-June 2, 2015 in Chicago, IL; abstract deadline Feb 3, 2015; http://am.asco.org/abstracts
- American Association of Clinical Chemistry (AACC): July 26-30, 2015 in Atlanta, GA; abstract deadline Feb 26, 2015; https://www.aacc.org/meetings-and-events/annual-meeting/2015-annual-meeting-and-expo/abstracts
- Academy of Clinical Laboratory Physicians and Scientists (ACLPS), for CP minded trainees: May 29-30, 2015 in Minneapolis, MN; abstract deadline Feb 27, 2015; http://www.aclps.org/meeting_current.html
- American Society for Clinical Pathology (ASCP): October 28-30, 2015 in Long Beach, CA; abstract deadline March 31, 2015; http://www.ascp.org/ascp2015
- College of American Pathologists (CAP): October 4-7, 2015 in Nashville, TN; abstract period Feb 9- Apr 10, 2015; http://www.thepathologistsmeeting.org/pdf/CAP15AbstractProgram.pdf
-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.
Do you want to present your research at a national meeting? The American Society for Clinical Pathology is currently accepting abstract submissions for their Annual Meeting. This year it’s in October in Tampa, Florida. Soak up the sun while presenting your work and networking with your peers.