Latest / The SHEA Podcast / Innovations in Diagnostic Stewardship: A Focus on Bacteriruria & Bacterisputia

Transcript

Innovations in Diagnostic Stewardship: A Focus on Bacteriruria & Bacterisputia · The SHEA Podcast

• 0:09
  SPEAKER_01: Welcome to our new four-part podcast series, Challenges and Innovations in Antimicrobial Stewardship, brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:29
  SPEAKER_01: This series will focus on applying stewardship practices in the ambulatory and emergency department settings, describing how telestewardship can be used in resource-limited settings, analyzing innovations in diagnostic stewardship, and discussing stewardship in the time of COVID-19.
• 0:44
  SPEAKER_01: I'm Dr.
• 0:45
  SPEAKER_01: Jessica Howard Anderson, assistant professor of medicine in the Division of Infectious Diseases at Emory University School of Medicine and the Associate Hospital Epidemiologist at Emory University Hospital Midtown, and I will serve as the podcast moderator.
• 0:58
  SPEAKER_01: Today is excited to launch the third episode of the podcast series, which is entitled Innovations in Diagnostic Stewardship, a focus on bacteria urea and bacteria civedia.
• 1:08
  SPEAKER_01: This podcast will compare and contrast diagnostic stewardship strategies and interventions related to both urinary and respiratory tract culturing practices.
• 1:16
  SPEAKER_01: The speakers will discuss why diagnostic stewardship is needed in these areas and how we can continue to innovate in these areas.
• 1:23
  SPEAKER_01: I'm happy to introduce our two speakers for today.
• 1:26
  SPEAKER_01: First, we have Dr.
• 1:27
  SPEAKER_01: Sanali Advani, Assistant Professor of Medicine at Duke University School of Medicine, and co-medical director of Duke Infection Control Outreach Network.
• 1:36
  SPEAKER_01: We also have Dr.
• 1:36
  SPEAKER_01: Owen Albin, Assistant Professor of Internal Medicine in the Division of Infectious Diseases at Michigan Medicine.
• 1:43
  SPEAKER_01: Thank you both for joining today.
• 1:45
  SPEAKER_01: So, first, I'm sure our listeners would love to know more about your background and work in diagnostic stewardship.
• 1:51
  SPEAKER_01: So, would you both share a little bit about yourselves?
• 1:53
  SPEAKER_01: Dr.
• 1:53
  SPEAKER_01: Adbani, I'll start with you.
• 1:55
  SPEAKER_02: Thank you for the opportunity to discuss my work on this podcast today.
• 1:59
  SPEAKER_02: I currently serve as the co-medical director of DICON, which is a very unique outreach network of more than 60 community hospitals to whom we provide infection prevention services.
• 2:11
  SPEAKER_02: So this network allows me to evaluate data and trends from a large number of hospitals and design and implement diagnostic stewardship strategies for both community and academic medical centers.
• 2:22
  SPEAKER_02: I'm also currently funded by SHA, CDC, and NIH and IBDK to study different interventions and implementation strategies to optimize urine testing.
• 2:34
  SPEAKER_02: My prior work heavily focused on urine culture stewardship and its impact on CAUDE prevention.
• 2:40
  SPEAKER_02: However, my most recent work focuses on implementing strategies to leverage the urine analysis, to improve the diagnosis of UTIs, and support diagnostic stewardship interventions.
• 2:51
  SPEAKER_02: Thanks so much.
• 2:52
  SPEAKER_02: Dr.
• 2:52
  SPEAKER_01: Albin, how about you?
• 2:54
  SPEAKER_00: Thank you for having me today, Jessica.
• 2:56
  SPEAKER_00: I'm an ID doc at the University of Michigan, and I spend a good chunk of my time doing clinical research on pneumonia writ large, but mostly ICU pneumonia, and specifically the role of microbiologic outcomes in predicting and correlating with clinical outcomes in pneumonia and innovative techniques in antimicrobial stewardship and the approach to ventilator-associated pneumonia.
• 3:19
  SPEAKER_01: Great.
• 3:20
  SPEAKER_01: Thank you both for that introduction.
• 3:22
  SPEAKER_01: So let's get into the questions.
• 3:24
  SPEAKER_01: So, Dr.
• 3:25
  SPEAKER_01: Advani, you recently published an article in antimicrobial stewardship and healthcare epidemiology titled Deconstructing the Urinalysis: A Novel Approach to Diagnostic and Antimicrobial Stewardship.
• 3:37
  SPEAKER_01: Can you tell us a little bit more about what you describe as the misuse of the urinalysis and how you think we can optimize this process in the future?
• 3:44
  SPEAKER_02: Yeah, thank you for highlighting this article.
• 3:47
  SPEAKER_02: The major driver behind this article was the fact that most UTI diagnostic stewardship efforts have focused on reducing inappropriate urine cultures, but not urine analysis.
• 3:58
  SPEAKER_02: The misuse of urine analysis can occur at all stages of testing, starting with pre-analytic or the ordering stage, the analytic stage, and the post-analytic or the reporting phase.
• 4:10
  SPEAKER_02: So when we start with the pre-analytic or the ordering phase, urine analysis can be ordered inappropriately for general screening or as a part of non-infectious disease workup.
• 4:20
  SPEAKER_02: We see this in several screening and diagnostic protocols.
• 4:24
  SPEAKER_02: You know, as you astutely mentioned, with the emergency room, different medicine pediatrics, nursing home, outpatient protocols, it is often bundled with other screening tests that we see that are not related to infectious diagnosis.
• 4:36
  SPEAKER_02: So that's the first part.
• 4:38
  SPEAKER_02: The second part is the analytic phase, where modifications to the laboratory processing of urine analysis to reduce urine cultures may paradoxically lead to the misuse of urine analysis.
• 4:50
  SPEAKER_02: So many hospitals now are using reflex urine cultures, which is when you order a urine analysis, it automatically reflexes to a urine culture when specific UA parameters are met.
• 5:02
  SPEAKER_02: Although these reflex urine cultures in general have led to a reduction in urine culture orders in patients without pi urea, an indiscriminate use of this reflex urine culture can lead to an increase in asymptomatic bacterial urea diagnosis, especially in certain populations like catheterized patients or older patients that have a high incidence of asymptomatic bacterial urea.
• 5:27
  SPEAKER_02: Additionally, there's no consensus on which parameters or cutoffs for UA we should be using, which leads to confusion and lack of standardized care.
• 5:36
  SPEAKER_02: The most interesting misuse of urine analysis is seen actually in the post-analytic or the reporting phase, which is when a screening UA is ordered for a different medical condition and it incidentally reveals an abnormal finding like pyuria or bacteriuria.
• 5:53
  SPEAKER_02: For example, when we order a urine analysis in a diabetic patient for proton urea, and it incidentally shows pyuria or bacteriuria and reflexively triggers a urine culture at that point or inappropriate antimicrobial therapy.
• 6:08
  SPEAKER_02: So now that I've discussed misuse, I want to touch a little bit on what efforts we can make to handle this misuse and overuse of urine analysis.
• 6:17
  SPEAKER_02: Firstly, we need to make a concentrated effort to ensure that urine analysis is only used when it provides significant value to manage the disease, regardless of whether it is an infection or a non-infectious condition.
• 6:32
  SPEAKER_02: Second, the value of urine analysis varies based on the patient characteristics and clinical scenario.
• 6:39
  SPEAKER_02: For example, reflex urine culture should be used when directed towards a symptomatic or non-cathedrized patient, especially in an outpatient or emergency room setting.
• 6:49
  SPEAKER_02: However, they should never be used in cathodized patients or neonates or neutropenic patients.
• 6:55
  SPEAKER_02: So really thinking about your pretest probability is very important.
• 6:59
  SPEAKER_02: And lastly, and this is the most interesting part of our paper, we start to propose a very novel diagnostic stewardship approach that starts to think about urine analysis as a compilation of several different tests put together based on the function they serve.
• 7:16
  SPEAKER_02: When we think about urine analysis, we should think about the panel and the use that each test within urine analysis provides.
• 7:23
  SPEAKER_02: So we should consider reporting the part of urine analysis that provides us the information that we need at the time.
• 7:30
  SPEAKER_02: So if you have a diabetic, you don't need information on pyuria and bacteriuria at the time.
• 7:35
  SPEAKER_02: So it would really help us to develop panels that are based on infection and panels that are based on metabolic disease or renal disease.
• 7:43
  SPEAKER_02: So that information is really targeted to the organ system that we are testing at that point in time.
• 7:50
  SPEAKER_02: Another approach would be thinking about suppressing urine analysis components at the post-analytic phase that have low positive predictive value.
• 7:59
  SPEAKER_02: That's something that we're doing at Duke.
• 8:01
  SPEAKER_02: As of August 31st, 2021, we are no longer reporting bacteria and yeast on urine analysis because of the low positive predictive value.
• 8:12
  SPEAKER_02: So I hope that was helpful.
• 8:13
  SPEAKER_02: That was a lot.
• 8:14
  SPEAKER_02: But I'll pass it on to Owen.
• 8:16
  SPEAKER_02: I think there's a question in there for him.
• 8:18
  SPEAKER_01: Yeah, thank you.
• 8:20
  SPEAKER_01: That was really helpful.
• 8:21
  SPEAKER_01: And I think the concept of splitting up the urinalysis is a really unique one and one I like.
• 8:27
  SPEAKER_01: So thanks for breaking that down for us.
• 8:29
  SPEAKER_01: I'm now going to turn it over to Dr.
• 8:31
  SPEAKER_01: Albin, because you also recently published an article in infection control and hospital epidemiology, where I believe you coined a new term called asymptomatic bacterisputia.
• 8:41
  SPEAKER_01: So can you explain to us what this is and what you think the main issues are with diagnostic stewardship and pneumonia?
• 8:48
  SPEAKER_00: Yeah, thanks, Jessica.
• 8:49
  SPEAKER_00: Yeah, the genesis behind the term asymptomatic bacterispudia is really just the recognition that there are differences, but real parallels between the stewardship approaches that have thus far been successful for urinary stewardship and those for respiratory infections.
• 9:10
  SPEAKER_00: And the idea that we've tried to advance is that urinary stewardship approaches are kind of an untapped resource to a certain extent in approaching the respiratory tract in general.
• 9:21
  SPEAKER_00: So, you know, I remember when I was in medical school, there there was kind of the idea that, like, well, anything can be a UTI, right?
• 9:28
  SPEAKER_00: You have a cognitively or functionally impaired older adult who's admitted with confusion, that's that's like a UTI, right?
• 9:36
  SPEAKER_00: And increasingly what we know is that, you know, the urine is not a sterile site, and that bacteriuria is often kind of a clinically inconsequential finding in patients with other drivers for organic disease.
• 9:50
  SPEAKER_00: And what we realize is there's really similar parallels to the lungs.
• 9:54
  SPEAKER_00: The lungs, you know, we've always kind of considered a sterile space, but what we are increasingly learning is that, you know, the lung microbiome is really its own thing, and the relative composition of that can influence health and disease states.
• 10:07
  SPEAKER_00: We also know that colonization of the respiratory tract with pathogenic bacteria is really not uncommon.
• 10:14
  SPEAKER_00: There's not anywhere near as much data on this as there is for asymptomatic bacteriuria, but you know, upwards of a quarter of hospitalized patients and about half of critically ill patients, particularly those with indwelling endotracheal material, are colonized at least in the proximal respiratory tract with pathogenic bacteria.
• 10:37
  SPEAKER_00: And so if you get a test in a patient that has a relatively low pretest probability of infection, recovery of bacteria from that test is not synonymous with infection.
• 10:47
  SPEAKER_00: And the basic idea that we have is that the majority of stewardship efforts, particularly for nosocomial pneumonia, have been focused on therapeutic processes to date, procalcitonin or other biomarkers to try and truncate antibiotic treatment durations or innovative ways to de-escalate antibiotics, either with MERSA and NERI swabs or rapid molecular multiplex testing.
• 11:11
  SPEAKER_00: But the diagnostic stewardship approach that has been, to a certain extent, successful for urinary infections has a lot to teach us about ways in which we can innovate and improve antibiotic over-treatment within the hospital and within our ICUs in particular.
• 11:29
  SPEAKER_01: It sounds like, Dr.
• 11:30
  SPEAKER_01: Albin, you're making the argument here that we should apply lessons from the asymptomatic bacteria or ASV framework, which most clinicians I think are quite familiar with, and figure out how we can apply this to respiratory stewardship practices.
• 11:44
  SPEAKER_01: So, Dr.
• 11:44
  SPEAKER_01: Advani, I want to turn it to you and ask do you think first that the term asymptomatic bacteria has been helpful for urine culture stewardship overall?
• 11:53
  SPEAKER_01: And do you think this framework could be adapted for respiratory cultures?
• 11:57
  SPEAKER_02: So I'll answer the question in two parts.
• 11:59
  SPEAKER_02: I think this is a really good question.
• 12:02
  SPEAKER_02: The first question is whether asymptomatic bacteriuria has been helpful for stewardship.
• 12:08
  SPEAKER_02: I have mixed feelings about the definition, and I hope I don't get in trouble with my ID and stewardship crew, and I can explain the reasons behind my mixed feelings.
• 12:17
  SPEAKER_02: I think the definition itself is described as the presence of one or more species of bacteria growing in urine at specified quantitative counts of greater than 100,000 colony forming units, irrespective of the presence of pyuria.
• 12:32
  SPEAKER_02: And here's the most important point in the absence of signs or symptoms attributable to a urinary tract infection, where the challenge, and this is a challenge that I face, and I'd like to know how you guys handle this.
• 12:44
  SPEAKER_02: When I speak to someone who is in infectious diseases or is a pharmacist, even urologists and some medicine specialties, most clinicians understand what is signs and symptoms attributable to urinary tract infections, which is sopropubic pain, blank pain, dysturia, urgency, frequency, genital urinary signs and symptoms.
• 13:06
  SPEAKER_02: When I start to delve into other specialties, it starts to become, like we highlighted earlier, altered mental status, fever, you know, and anything can become a sign or symptom of UTI.
• 13:18
  SPEAKER_02: And it starts to become vague.
• 13:20
  SPEAKER_02: And that's where I struggle with explaining to them that asymptomatic bacteria urea is not that.
• 13:26
  SPEAKER_02: It's not fever plus a positive urine culture.
• 13:29
  SPEAKER_02: It's not altered mental status plus a positive urine culture.
• 13:32
  SPEAKER_02: So that's where I'm I struggle a little bit.
• 13:35
  SPEAKER_02: And I think we need to do a better job of disseminating information about asymptomatic bacteria urea to all medical specialties and correlating it better with bladder colonization and bladder microbiome.
• 13:48
  SPEAKER_02: So that's that's my answer related to asymptomatic bacteria urea.
• 13:52
  SPEAKER_02: The framework, however, and the work that has been done in the field of ASB is phenomenal.
• 13:59
  SPEAKER_02: I think we have had remarkable success, and some of it has been tied to financial incentives.
• 14:04
  SPEAKER_02: You know, if you don't monitor something and you don't tie it to financial incentives, you don't really see results.
• 14:10
  SPEAKER_02: But I think some of that has driven an extensive amount of work in the field of urine culture stewardship.
• 14:16
  SPEAKER_02: We have seen phenomenal success with our cow D rates and decrease in unnecessary urine cultures.
• 14:23
  SPEAKER_02: And why the framework can be applied to respiratory cultures, the most important reason is something that Dr.
• 14:29
  SPEAKER_02: Albin highlighted is that both urine and respiratory cultures have the most have one thing in common is that they're non-sterile sites, that we can always highlight the fact that there's a high incidence of colonization in these sites and that the positive predictive value of a positive urine culture or a positive respiratory culture is going to be low in most cases, especially just for fever or just for altered mental status.
• 14:54
  SPEAKER_02: One of the other things that I find, which is again unique to urine and sputum, is that it is easy to collect them as compared to blood.
• 15:04
  SPEAKER_02: So that's another reason why these cultures get collected.
• 15:07
  SPEAKER_02: There is a higher likelihood of anchoring the positive urine cultures and positive respiratory cultures and missing other diagnoses.
• 15:15
  SPEAKER_02: So I think because of the similar principles of the pretest probability, we can apply the same framework of ASB to respiratory cultures.
• 15:24
  SPEAKER_02: I will say that we are at an advantage of applying this framework to respiratory cultures because there are more markers within the respiratory realm, especially with procalcitonin, to be able to rule out pneumonia as compared to UTI.
• 15:40
  SPEAKER_02: We have struggled with UTI to not have any markers to be able to tell, especially with catheter associated UTI, where patients are completely asymptomatic when it comes to the catheter itself and genital urinary symptoms.
• 15:53
  SPEAKER_02: I think we are in the dark there, whereas with ventilated patients, there's still a drop in oxygenation, there's still an increase in secretion.
• 16:01
  SPEAKER_02: So I think there's more room for diagnostic stewardship interventions when it comes to pneumonia.
• 16:06
  SPEAKER_00: I'd echo what Dr.
• 16:08
  SPEAKER_00: Advani said.
• 16:09
  SPEAKER_00: You know, so first of all, asymptomatic, the word there is a little loaded, right?
• 16:14
  SPEAKER_00: Because particularly when you're talking about reasons for respiratory culture procurement, particularly among critically ill patients, not many places, some places do, but not many places routinely just do surveillance cultures.
• 16:29
  SPEAKER_00: There are there are institutions that do this for ECMO patients, and there are some places in ICUs that do it regularly across the globe, but it's not an incredibly common practice.
• 16:39
  SPEAKER_00: More often than not, no, it's it's the idea that a particular symptom, in the absence of localizing features to the respiratory tract, be those clinical or radiographic, it's the idea that that somehow is indicative of an infection when it's paired with bacteria spudia.
• 16:58
  SPEAKER_00: For an example, we know that treatment of VAP drives the majority of antibiotic use within ICUs.
• 17:05
  SPEAKER_00: Anywhere between 50 to 70% of antibiotics that are used within ICUs are for the purpose of treating pneumonia.
• 17:12
  SPEAKER_00: And we also know that if you look at either autopsy studies as a reference gold standard or multidisciplinary case review studies, of which there have been a couple now, that a large chunk of what is diagnosed and treated as VAP is very likely misdiagnosed.
• 17:29
  SPEAKER_00: And it's in people with incredibly low pretest probabilities.
• 17:33
  SPEAKER_00: In our institution, probably the major driver of that is the concept of a reflexive pan culture, so-called, which is you know a packaged microbiologic search for an infection, blood, urine, sputum in response to a fever or a new white count in a mechanically ventilated patient.
• 17:53
  SPEAKER_00: And the problem is if you take an ICU patient, you know, the differential diagnosis for fever is exhaustive.
• 18:00
  SPEAKER_00: And if you take a patient who has bacteros spudia and a fever, but has no new convincing radiographic infiltrates on chest x-ray, no meaningful worsening and ventilator requirements, and no purulent sputum production, you know, the pretest probability of infection is incredibly low.
• 18:19
  SPEAKER_00: And the reality is that respiratory cultures really in that setting tell you how to treat pneumonia, not whether to treat pneumonia.
• 18:27
  SPEAKER_00: So the whole concept of something being asymptomatic to begin with, I agree, is a really, really challenging concept to convey to kind of frontline providers.
• 18:37
  SPEAKER_01: Thank you both.
• 18:38
  SPEAKER_01: I think that was a really great discussion.
• 18:40
  SPEAKER_01: So I'm going to switch now to ask you both what interventions have worked well or what you would recommend to improve diagnostic stewardship for both urine and respiratory tract cultures.
• 18:51
  SPEAKER_01: And I'm also curious to see if there's any been in any concerns about patient safety with implementing any of the interventions at your respective institutions.
• 19:00
  SPEAKER_01: So, Dr.
• 19:00
  SPEAKER_01: Radvani, I'll start with you.
• 19:02
  SPEAKER_02: That is an excellent question.
• 19:03
  SPEAKER_02: So, successful diagnostic stewardship interventions are based on the assessment of the underlying key drivers at your institution and use complementary approaches.
• 19:14
  SPEAKER_02: I actually discussed this in depth in one of my recent manuscripts published in current infectious disease reports, quality improvement interventions, and implementation strategies for urine culture stewardship in the acute care setting, advances and challenges.
• 19:30
  SPEAKER_02: What I focus on is the fact that systems-based changes like forced functions, automation within the electronic medical record or laboratory, and standardization of processes and order sets are generally considered to be stronger interventions.
• 19:45
  SPEAKER_02: For example, interventions like suppressing urine culture results or using reflex urine cultures are considered to be strong interventions, but combining systems-based interventions like forced functions and automations with persons-based approaches like coaching and education are more likely to yield long-term success.
• 20:06
  SPEAKER_02: And part of the reason behind this is because you want to combine the technical aspect, which is changing the electronic medical record, with the socio-adaptive component of the intervention.
• 20:21
  SPEAKER_02: And this will lead to sustainability of the intervention.
• 20:24
  SPEAKER_02: This was actually discussed in one of the previous Shay podcasts by Julia Simzek.
• 20:29
  SPEAKER_02: And it's very important that initiatives align with the organizational culture.
• 20:34
  SPEAKER_02: One example from my own experience was at my prior institution, where we incorporated a urine culture algorithm for categorized patients into the electronic medical record, but combined this with a large-scale education program for nurses, physicians, trainees with cognitive aids all over the hospital, in addition to leadership support for a gatekeeper to stop inappropriate urine cultures.
• 21:01
  SPEAKER_02: When I say gatekeeper, what I mean is if you tried to order a urine culture outside of the algorithm, then you would have to page me.
• 21:10
  SPEAKER_02: And just having a gatekeeper reduced urine cultures by 60%.
• 21:15
  SPEAKER_02: The real driver of this intervention was the fact that we had organizational support.
• 21:22
  SPEAKER_02: And this led to a change in the culture.
• 21:25
  SPEAKER_02: And if you ever want a successful intervention at your hospital and you want it to be successful over time, it has to start with changing the culture.
• 21:34
  SPEAKER_02: So I'll pause there and pass it on to Dr.
• 21:37
  SPEAKER_02: Albin.
• 21:38
  SPEAKER_00: Thank you.
• 21:38
  SPEAKER_00: So in comparison to urinary stewardship, specifically diagnostic stewardship, we're a couple laps behind in the respiratory tract.
• 21:47
  SPEAKER_00: And I think a lot of the work that needs to be done or has been done so far is kind of repurposing to a certain extent the concepts that have been successful within diagnostic stewardship strategies for the urinary tract.
• 22:00
  SPEAKER_00: And as Dr.
• 22:01
  SPEAKER_00: Advani, I think, broke down earlier, these can really just be partitioned into the three phases of the diagnostic testing pathway: the ordering phase, the collection phase, and the post-analytic or reporting phase.
• 22:13
  SPEAKER_00: There's a variety of interventions that can be trialed at the ordering phase, systems or direct persons-based, in a manner that Dr.
• 22:20
  SPEAKER_00: Advani kind of spoke about.
• 22:22
  SPEAKER_00: But I think key to this is really identifying situations that are incredibly low yield.
• 22:30
  SPEAKER_00: For example, you know, fever or leukocytosis in mechanically ventilated patients without convincing features to localize an infection to the respiratory tract.
• 22:40
  SPEAKER_00: Patients with chronic tracheostomies or structural lung disease who have a mucus plugging incident or a clear aspiration pneumonitis that rapidly improves, those are situations, so to speak, low-hanging fruit, in which respiratory cultures might successfully be deferred.
• 22:58
  SPEAKER_00: From a collection phase, I want to be careful that I don't land myself in hot water.
• 23:02
  SPEAKER_00: But the reality is in prospective trials that have compared invasive to non-invasive sampling of the lung for VAP diagnosis, there really haven't been meaningful clinical differences in terms of mortality and rates of ventilator or length of ventilator dependence in a number of trials that have been done.
• 23:21
  SPEAKER_00: But what has been consistently shown is that antibiotic use is consistently lower when an invasive lung sampling approach is taken.
• 23:29
  SPEAKER_00: And so we are actually moving at our institution towards a kind of BAL for all approach, not necessarily done by physicians, but non-bronchoscopic BALs done by respiratory therapists.
• 23:41
  SPEAKER_00: And then, you know, something that I think to a certain extent, the kind of respiratory stewardship efforts have not repurposed enough from urinary stewardship purposes, is we don't really have the equivalent of a urinalysis for the respiratory tract.
• 23:57
  SPEAKER_00: We do, but we don't really pay attention to it the same way.
• 24:00
  SPEAKER_00: And what we know is that, you know, especially for ventilator-associated pneumonia, a negative gram stain, even with recovery of an organism, actually has a really high negative predictive value for ruling out pneumonia.
• 24:12
  SPEAKER_00: So there's a variety of things from a respiratory specimen or respiratory cultures in general that oftentimes providers and even ID physicians are not really paying attention to when interpreting the clinical picture and the microbiologic results in trying to discern whether or not there's a pneumonia.
• 24:29
  SPEAKER_00: So at our institution, we're actually conducting a pilot feasibility trial of a VAP diagnostic stewardship bundle, which actually has structured interventions at each of the three phases of the diagnostic testing pathway in an effort to lower antibiotic overuse.
• 24:45
  SPEAKER_00: I think the safety question is a really important one.
• 24:48
  SPEAKER_00: We know that inappropriate empiric antibiotic therapy for pneumonia is one of the primary determinants of outcomes.
• 24:55
  SPEAKER_00: And so any kind of advances in the diagnostic stewardship field for pneumonia really have to be done with a careful attention to safety.
• 25:04
  SPEAKER_00: And that's one of the things we're looking at in our pilot study.
• 25:07
  SPEAKER_01: Thank you both.
• 25:08
  SPEAKER_01: Those are both really great interventions and ideas.
• 25:12
  SPEAKER_01: So I'm curious now, have there been any interventions that maybe did not go as planned or were not as successful as you would have liked?
• 25:19
  SPEAKER_01: And can you share any lessons learned from these experiences with our audience?
• 25:23
  SPEAKER_01: So, Dr.
• 25:24
  SPEAKER_01: Albin, I'll start with you.
• 25:26
  SPEAKER_00: You know, I would say one of the most important things when you're dealing with pneumonia is you know, a lot of the culture-positive pneumonia cases come from ICUs.
• 25:36
  SPEAKER_00: And it's very, very, very challenging to be on the same page as our intensivist colleagues just because they have a completely different set of priorities with training and experiences.
• 25:47
  SPEAKER_00: And so I think less so interventions that you know didn't go as planned, but more so lessons that can be kind of learned from work in this area is the importance of partnering, particularly with intensivists and hospitalists, to make sure that you're getting all stakeholders' perspectives.
• 26:05
  SPEAKER_00: And I think particularly in ICUs, a crucial piece of this that I know Dr.
• 26:09
  SPEAKER_00: Advani actually mentioned a little bit before is nursing support.
• 26:13
  SPEAKER_00: So ICU care is increasingly a team sport nowadays.
• 26:18
  SPEAKER_00: And getting buy-in from your respiratory therapists, your intensivists, and particularly ICU nursing staff is vitally important in implementing really any of these kind of interventions.
• 26:29
  SPEAKER_01: Great.
• 26:29
  SPEAKER_01: And Dr.
• 26:30
  SPEAKER_01: Advani, anything you want to share?
• 26:32
  SPEAKER_02: Yeah, no, I think that was really helpful.
• 26:34
  SPEAKER_02: Everything that was mentioned.
• 26:36
  SPEAKER_02: What I'd like to add to that, what we've noticed, especially with urine cultures, for a while, a lot of hospitals focused on either education rules or policies as interventions to try to counter excessive urine culture orders.
• 26:52
  SPEAKER_02: And we know from prior experience, relying on education rules or policies alone will not be successful.
• 27:00
  SPEAKER_02: You know, they're weak interventions, they're focused merely on people, but without any systems focus.
• 27:07
  SPEAKER_02: So trying to implement them without identifying champions can actually lead to a failure of adoption.
• 27:14
  SPEAKER_02: One of the other reasons that's actually been mentioned in the past is not identifying what's in it for different service lines.
• 27:22
  SPEAKER_02: So anytime you're rolling out an intervention, say you're rolling out a urine culture stewardship intervention or even a urine analysis stewardship intervention for your ICU docs, or say a respiratory stewardship intervention.
• 27:34
  SPEAKER_02: So what's in it for them?
• 27:36
  SPEAKER_02: And this was mentioned in the previous podcast.
• 27:38
  SPEAKER_02: And this is why I love our Sh podcast, because you can tie them all together is C diff.
• 27:43
  SPEAKER_02: That's something that ties everyone together.
• 27:46
  SPEAKER_02: Everyone wants to prevent C diff.
• 27:47
  SPEAKER_02: Everyone wants to prevent anchoring to a diagnosis that doesn't exist and you're missing something more important.
• 27:54
  SPEAKER_02: What I have learned from prior experience is just being on the units and spending time on the units.
• 28:00
  SPEAKER_02: I found cases and stories to share with people that have driven people away from urine cultures more than data.
• 28:09
  SPEAKER_02: And it's stories that surprisingly drive even our scientists away from their, you know, their preconceived notions.
• 28:16
  SPEAKER_02: And you know, we've seen stories of uh retained foreign bodies that were almost missed because someone wanted to get a urine culture.
• 28:23
  SPEAKER_02: So, you know, I think it's important to realize the power of champions.
• 28:27
  SPEAKER_02: And that's what we've focused on.
• 28:29
  SPEAKER_02: And then the other aspect of it, which is very important, is you can have a successful intervention in the beginning, and then you don't have a plan for sustainability.
• 28:39
  SPEAKER_02: So if you don't have a plan for sustainability, your intervention will probably last six months to one year.
• 28:45
  SPEAKER_02: It's on the shoulders of one or two people, those people leave the organization and your intervention falls apart.
• 28:51
  SPEAKER_02: So it's very important to engage your staff, make sure you have enough resources and stakeholder buy-in.
• 28:58
  SPEAKER_02: And this is where the culture is important, champions are important, and making sure that people actually care about the changes you're making so that when you suppress the urine culture result, they don't just give more antibiotics.
• 29:11
  SPEAKER_02: They actually care about the changes that you're making.
• 29:14
  SPEAKER_02: So I think it's it's really important to address organizational culture.
• 29:18
  SPEAKER_01: Thank you.
• 29:18
  SPEAKER_01: Yeah, I agree.
• 29:20
  SPEAKER_01: Organizational culture is extremely important.
• 29:23
  SPEAKER_01: So for our last question, I want to ask both of you what further research do you think is needed in your respective areas of work?
• 29:30
  SPEAKER_01: So, Dr.
• 29:31
  SPEAKER_01: Ravani, can you start with any research needs for stewardship and diagnosing UTIs?
• 29:36
  SPEAKER_01: Yeah, definitely.
• 29:37
  SPEAKER_02: I think the first area I would start with is, you know, the approach to reflex urine cultures needs further validation in the inpatient setting.
• 29:46
  SPEAKER_02: We do need to identify ideal urine analysis parameters and specific populations.
• 29:52
  SPEAKER_02: And when it comes to diagnostic interventions, we also need to think about precursor tests like urine analysis, consider uncoupling them from urine cultures and interpreting urine analysis results in the context of pretest probability, and ideally consider selective reporting of UA criteria.
• 30:11
  SPEAKER_01: Great.
• 30:11
  SPEAKER_01: And Dr.
• 30:11
  SPEAKER_01: Albin, what do you see as major areas of need for pneumonia stewardship?
• 30:15
  SPEAKER_00: I think we really need to position some of these novel multiplex molecular panels, which are increasingly available for clinical use in a stewardship context, number one.
• 30:29
  SPEAKER_00: And number two, we're gonna be seeing a lot more of these kind of PCR-positive culture-negative cases, and determining the clinical significance and management of what to do in situations like that is gonna be important.
• 30:40
  SPEAKER_00: I think a big area of focus that we're going to also need to pay attention to in respiratory stewardship is the increasing recognition that pneumonia is probably, at least in a portion of cases, more of a dysbiosis of the lung microbiome than necessarily invasion of a monomicrobial pathogen.
• 31:02
  SPEAKER_00: And so, you know, the more that we learn about the pulmonary microbiome, the more we can integrate it with clinically meaningful stewardship interventions that hopefully will kind of yield lower antibiotic overuse.
• 31:15
  SPEAKER_00: I think the biggest thing we need, though, is we just need to catch up to where urinary stewardship is.
• 31:21
  SPEAKER_00: We need to pilot interventions that apply some of these diagnostic stewardship principles in the ordering, collection, and reporting phases that have been at least modestly successful in the urinary realm and start to try them on appropriately selected patients.
• 31:39
  SPEAKER_00: One, to determine, you know, whether or not it's effective, but two, also, like you mentioned, Jessica, to ensure that there's real safety, particularly among the sickest patients.
• 31:50
  SPEAKER_00: And that way you can also get buy-in from it, your intensivist colleagues as well.
• 31:54
  SPEAKER_02: Yeah, I agree.
• 31:55
  SPEAKER_02: I just wanted to add to that that it would be a good avenue to think about deconstructing pan culture.
• 32:01
  SPEAKER_02: Like you don't need respiratory urine, blood in every situation and C diff.
• 32:06
  SPEAKER_02: You just need to test based on what's going on at the moment and examine your patient.
• 32:11
  SPEAKER_00: I completely agree.
• 32:12
  SPEAKER_00: We we have some work coming out on this actually, but you know, it never fails to kind of surprise me that if a floor patient who can tell you that they're not having a cough, for example, doesn't get a sputum culture obtained.
• 32:25
  SPEAKER_00: But just because you have a conduit into someone's lungs and they can't tell you anything, you know, that's a reason to culture the lungs.
• 32:32
  SPEAKER_00: So completely agree.
• 32:34
  SPEAKER_00: The whole kind of concept of a reflexive pan culture really needs to be reevaluated.
• 32:39
  SPEAKER_01: I completely agree.
• 32:41
  SPEAKER_01: Thank you both so much for joining our podcast today.
• 32:44
  SPEAKER_01: Before we end, I want to ask if either of you have any additional thoughts you'd like to share with our audience.
• 32:50
  SPEAKER_01: Dr.
• 32:50
  SPEAKER_01: Advani?
• 32:51
  SPEAKER_02: Yeah, the only thing I would add is the importance to focus on organizational behavior and implementation science as we think about implementing successful interventions in large-scale systems, especially our systems now that include hospitals, nursing homes, outpatient settings.
• 33:08
  SPEAKER_02: And this is going to require us to understand the underlying drivers, addressing organizational culture, managing competing initiatives as we struggle with all these sepsis initiatives that are coming out that are not in line with what we are doing, and at the same time having a plan for sustainability.
• 33:26
  SPEAKER_00: I agree with Dr.
• 33:27
  SPEAKER_00: Advani.
• 33:28
  SPEAKER_00: You know, I would just re-emphasize the concept of multidisciplinary approaches to these kind of things.
• 33:34
  SPEAKER_00: You know, the more that we learn about medicine, the more that I think we can increasingly become kind of siloed into our own specialties.
• 33:41
  SPEAKER_00: And so the entire overriding concept of organizational culture kind of requires or necessitates multi-interdisciplinary interactions and collaboration to surmount some of these issues.
• 33:53
  SPEAKER_01: Thank you, Dr.
• 33:54
  SPEAKER_01: Advani and Dr.
• 33:55
  SPEAKER_01: Albin, for such a great conversation.
• 33:57
  SPEAKER_01: It was really a pleasure having you both here today.
• 34:00
  SPEAKER_02: Well, thank you, Dr.
• 34:01
  SPEAKER_02: Anderson, and thank you, Shay, for inviting us to speak on this podcast.
• 34:06
  SPEAKER_00: Thank you.
• 34:07
  SPEAKER_01: And as a reminder, this is episode three in our four-part series.
• 34:11
  SPEAKER_01: Be on the lookout for our remaining episode, Antibiotic Stewardship in the Time of COVID-19.
• 34:16
  SPEAKER_01: You can find more educational content like the podcast on Shay's Online Education Center, Learning CE, at www.learningce.shayonline.org.
• 34:27
  SPEAKER_01: This concludes this episode of the Challenges and Innovations in Antimicrobial Stewardship series.
• 34:32
  SPEAKER_01: Thank you for tuning in.