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The SHEA Podcast | Vancomycin & Antimicrobial Stewardship Programs: Two Perspectives · The SHEA Podcast

• 0:07
  SPEAKER_02: Welcome to Shay's Podcast.
• 0:09
  SPEAKER_02: I'm Dr.
• 0:09
  SPEAKER_02: Mackenzie Keitz.
• 0:10
  SPEAKER_02: I'm a third-year Fellow of Infectious Disease and a clinical instructor at the University of Nebraska in Omaha, Nebraska.
• 0:17
  SPEAKER_02: I'm very pleased to serve as today's moderator as we discuss if vancomycin use is still appropriate.
• 0:22
  SPEAKER_02: Our topic is vancomycin and how antimicrobial stewardship programs should address its use.
• 0:27
  SPEAKER_02: We've tapped two experts on the topic that represent the physician and pharmacy perspective of an ASP program.
• 0:34
  SPEAKER_02: Both are leaders on this topic and have real-world expertise on this topic, especially on meaningful metrics that can be used that is applicable for other antibiotic stewardship programs addressing this issue.
• 0:45
  SPEAKER_02: Before we get started, I'd like to introduce you to today's speakers.
• 0:49
  SPEAKER_02: First, I'd like to introduce Dr.
• 0:51
  SPEAKER_02: Rebecca Moring, who is an infectious disease physician, hospital epidemiologist, and associate professor working at Duke University.
• 0:59
  SPEAKER_02: She is medical director of the Duke University Hospital Antimicrobial Stewardship and Evaluation Team and co-director for research of the Duke Antimicrobial Stewardship Outreach Network.
• 1:09
  SPEAKER_02: Her research interests include the development of meaningful metrics to guide decisions about antimicrobial stewardship program design and strategy.
• 1:17
  SPEAKER_02: She had a talk on using MRSA NARS surveillance data for vancamycin de-escalation at ID week this past fall.
• 1:24
  SPEAKER_02: So I appreciate her being here to expand on those thoughts as we think through vancomycin today.
• 1:30
  SPEAKER_02: Next we have Dr.
• 1:30
  SPEAKER_02: Kim Clays joining us, an infectious disease pharmacist and health services researcher.
• 1:36
  SPEAKER_02: She's an associate professor at the University of Maryland School of Pharmacy and co-chair of the University of Maryland Medical Systems Rapid Diagnostics Committee.
• 1:46
  SPEAKER_02: She recently completed her PhD in epidemiology with a focus on improving diagnosis of healthcare associated infections.
• 1:56
  SPEAKER_02: Welcome to the podcast, Dr.
• 1:57
  SPEAKER_02: Morings and Clays.
• 1:59
  SPEAKER_02: I'm excited to hear your opinions today.
• 2:01
  SPEAKER_02: So let's get started.
• 2:02
  SPEAKER_02: Let's start with the basics.
• 2:03
  SPEAKER_02: What is vancomycin and why is it a target for antimicrobial sewer chip programs?
• 2:08
  SPEAKER_01: Okay, so starting vancomycin is a glycopeptide antibiotic.
• 2:12
  SPEAKER_01: It works prevent the synthesis of the cell wall.
• 2:14
  SPEAKER_01: It targets gram-positive organisms.
• 2:17
  SPEAKER_01: And for the past 50 years or so, it's been one of our main empiric and definitive treatments for particular gram-positive MRSA.
• 2:24
  SPEAKER_01: With the IV form, it's one of the most prescribed antibiotics in the acute care setting.
• 2:29
  SPEAKER_01: And why this is important is because it actually still has a narrow therapeutic window, uh, has a lot of issues with nephrotoxicity with reported incidences ranging between 5 and 40% and requires extensive therapeutic monitoring to maximize its efficacy and reduce its toxicity.
• 2:44
  SPEAKER_03: I would say bank is an everyday thing for most antibiotic stewards who are reviewing cases because it is just widely used in hospital populations.
• 2:55
  SPEAKER_03: I've looked at hospital-level data for several facilities for many years, and I would say bank is always in the top three on your top 10 list at my institution.
• 3:06
  SPEAKER_03: It's number one.
• 3:07
  SPEAKER_03: And I think the reason that it's most commonly targeted by stewardship programs outside of being really commonly used are what Kim mentioned in terms of association with harms and you know, the number one being acute kidney injury there.
• 3:23
  SPEAKER_03: But I think also it's frequently used in really broad empiric regimens.
• 3:29
  SPEAKER_03: So uh when your patient's on two drugs, and it's also really commonly used in combination.
• 3:35
  SPEAKER_03: So, you know, either the vanc plus cefapime or vanc plus zocin combo, you're gonna see that used a lot empirically.
• 3:43
  SPEAKER_03: And so for patients that remain on vancomycin a long time, that usually represents an opportunity for antibiotic de-escalation.
• 3:51
  SPEAKER_03: So I think it's one of the more ripe drugs for stopping when you see it started.
• 3:58
  SPEAKER_03: So that's that's another reason that stewardship programs really target it because many times it's used empirically, sometimes maybe when it shouldn't be used empirically.
• 4:08
  SPEAKER_03: And then it's usually the first to go when we think about de-escalation.
• 4:13
  SPEAKER_02: Thank you.
• 4:14
  SPEAKER_02: What stewardship strategies have been proven successful in targeting bacamycin use and safety?
• 4:20
  SPEAKER_03: So I think the most common one is probably the easiest, and what most hospitals have already started to work on, or at least have some of, and that is your empiric guideline recommendation.
• 4:31
  SPEAKER_03: So if you have institution-specific guidelines, um, putting bankamycin in where it should be and not where it shouldn't be.
• 4:38
  SPEAKER_03: And I think probably if I had to give you the top two places where I think opportunity uh for stewardship are in terms of syndrome, the main one I would say is non-purulent cellulitis.
• 4:50
  SPEAKER_03: So if your institutional guideline doesn't delineate between purulent and non-purulent, um, that's often an education point in a lot of anchomycin courses that can be avoided altogether.
• 5:00
  SPEAKER_03: And then the other one, I think, with more emerging data more recently is in surgery prophylaxis, where we're overusing vincomycin.
• 5:08
  SPEAKER_03: And this is actually an area where the updated SSI prevention Shea Compendium has added a section specifically on the harms of anchomycin in the perioperative uh setting.
• 5:20
  SPEAKER_03: So I think if I had to highlight two of empiric guidelines that maybe you should take a look at, look at your soft tissue infection, diabetic feet, and surgery prophylaxis, and really question the areas where you have ancomycin.
• 5:33
  SPEAKER_03: So empiric guidelines, I think, certainly an opportunity and a strategy for stewardship programs.
• 5:40
  SPEAKER_03: And then I think the next one I'm gonna kick to Kim, and that is in dosing strategies for vancomycin, which is very much in the wheelhouse of our pharmacist colleagues.
• 5:50
  SPEAKER_01: Yeah, so I think one way that most hospitals should be at least thinking about, if they haven't already done, is switching to AUC to MIC as the referred PKPD target.
• 6:01
  SPEAKER_01: Having pharmacist dose programs where they target an AUC to MIC of about 400 or 500, it helps decrease unnecessary exposure and confers just the additional benefit of decreasing the risk of nephrotoxicity.
• 6:13
  SPEAKER_01: So we used to dose to a minimum of TOF of 15, but we found that we were actually still causing a lot of unnecessary risk for kidneys and kidney injury.
• 6:23
  SPEAKER_01: And if we go to an AUC to MIC method, whether it's done through Bayesian software or some two-level AUC-based calculations, we're able to significantly decrease our rates of nephrotoxicity secondary to vancomycin.
• 6:35
  SPEAKER_01: And there are different organizations that have vancomycin AUC toolkits available online to help different help your organization with the implementation of these changes in dosing.
• 6:46
  SPEAKER_03: Another area uh where I think there's been just a ton of work and progress made has been in using lab diagnostics to help us more rapidly identify patients who are at risk for MRSA or who where MRSA has been ruled out.
• 7:01
  SPEAKER_03: And so the two that I would say that come to mind first is one, just some of our rapid blood culture technology.
• 7:08
  SPEAKER_03: Um, when you get a GPC in the blood, being able to definitively identify that quickly can help you target therapy off of bancomycin more quickly.
• 7:18
  SPEAKER_03: So I'm thinking if you get a nice group A strep or a nice strep pneumo, getting that patient over to beta lacteans is the more appropriate and effective antibiotic than bancomycin.
• 7:29
  SPEAKER_03: Similarly, for MSSA, we know that um beta-lacteans are just more effective at treating MSSA than bancomycin.
• 7:36
  SPEAKER_03: So those rapid technologies, now we can get within just a couple hours of that blood culture becoming positive, has really helped us kind of shrink down the time that our patients are on empiric bancomycin, especially for gram-positive bacteremia.
• 7:50
  SPEAKER_03: And then the other way is to try and help uh estimate who is at risk for MERSA pneumonia.
• 7:57
  SPEAKER_03: And so many stewardship programs, and mine included, over the last few years, have implemented use of MRSA NARE surveillance data to try and identify patients who can be safely de-escalated from vancomycin when they don't have colonization with mRSA.
• 8:15
  SPEAKER_03: So, this strategy, there's lots of papers that have looked at this, but it's the best use for cases where you're using vancomycin empirically for pneumonia rather than other syndromes.
• 8:26
  SPEAKER_03: And I think it is especially popular with pharmacists-driven vancomycin de-escalation um initiatives because pharmacists have a special interest in getting their patients off of vancomycin and that all that complexity of the dosing, copulating AUCs and things like that goes away if you stop the vancomycin.
• 8:47
  SPEAKER_03: So MRSA NARIS surveillance, the idea is basically if you are starting to treat your patient empirically for mRSA pneumonia, and then you get a NARI swab that shows they are not colonized with MRSA, that encomycin can safely be discontinued.
• 9:04
  SPEAKER_03: And that works with both patients coming in from the community as well as hospital-acquired pneumonia.
• 9:09
  SPEAKER_03: And there's a lot of kind of intricate implementation questions with that strategy.
• 9:13
  SPEAKER_03: And I would say the most successful strategies that I've seen have generally been where a pharmacist or someone at the bedside can actually order these when in along with the primary team.
• 9:27
  SPEAKER_03: So engaging more than just the clinician and the prescriber in making that decision and helping promote that as a team sport, I think it has been more successful.
• 9:38
  SPEAKER_03: But I don't know.
• 9:39
  SPEAKER_03: Kim also is a diagnostic steward.
• 9:42
  SPEAKER_03: She might have some more comments on that area of investigation.
• 9:46
  SPEAKER_01: Those were the two areas I wanted to talk about as well.
• 9:48
  SPEAKER_01: For sure, leveraging the negative predictive value of the MRSA nasal screen.
• 9:53
  SPEAKER_01: And yeah, definitely if you can do a collaborative practice agreement to have the pharmacist more engaged with the ordering of the screening and even the discontinuation of the antibiotic based on the results, that'll be the most effective.
• 10:03
  SPEAKER_01: But as Rebecca was saying, there's a lot of literature out there to support use of these for different types of practices.
• 10:10
  SPEAKER_01: If you can't get a collaborative practice agreement in place, you still have the option of having those tests available to help you decrease how much vancomycin you're using.
• 10:18
  SPEAKER_01: And we use them at our hospital for pneumonia, but also for other infections such as intraabdominal, skin and soft tissue, as long as the patient doesn't have other risks for MRSA.
• 10:28
  SPEAKER_01: We feel fairly confident about having our clinical pharmacists reach out to the team to request de-escalatation.
• 10:33
  SPEAKER_01: And then for bloodstream infections, I was just going to add with the gram positives, we've got over a decade of data to support the use of these gram positives and bloodstream infections in conjunction with stewardship as improving clinical outcomes.
• 10:46
  SPEAKER_01: We have an RCT that has shown that we can actually decrease vancomycin use if we have RDTs available.
• 10:52
  SPEAKER_01: So if a hospital stewardship program hasn't worked with their clinical microlab to discuss how they can leverage the results of their rapid diagnostics for bloodstream infections, I think that's really low-hanging fruit for them to help decrease uh vancomycin use.
• 11:06
  SPEAKER_02: I think those are all excellent recommendations.
• 11:09
  SPEAKER_02: If an antimicrobial stewardship program perceives bancomycin as an area of need, what are key questions or data they should look at collecting?
• 11:17
  SPEAKER_03: So this is a good question.
• 11:19
  SPEAKER_03: I think there's several ways to go about it.
• 11:21
  SPEAKER_03: I think I would say that most hospitals, this is an area of need to some degree, but you do need to prioritize it with your other initiatives that you have going on with stewardship and make this something that is uh something that you can scope along with all the other work that you have going on in stewardship.
• 11:41
  SPEAKER_03: In terms of data to look at, certainly in general, just looking at bank bison use trends within your own institution and comparing that with an external benchmark can give you an idea of kind of like where you're starting.
• 11:54
  SPEAKER_03: You may actually be closer to what other institutions are doing than you realize.
• 11:59
  SPEAKER_03: And that that can be a good thing.
• 12:01
  SPEAKER_03: Uh, I think we all have, even if you're like comparing to the mean and looking pretty good as compared to an NHSN benchmark, I think there's probably some more fat to go there.
• 12:10
  SPEAKER_03: So that doesn't mean necessarily that you should sit back, even if you're doing pretty well on an anti-MRSA SAR.
• 12:17
  SPEAKER_03: Um, I think there's there's more to learn there.
• 12:20
  SPEAKER_03: And then I think it is more about trying to define the problem.
• 12:24
  SPEAKER_03: So if you're seeing dosing errors and AKI and super therapeutic vancomycin troughs, I think that is an area to really partner with your pharmacists to identify the types of outcomes and processes that may be worth measuring to help pharmacists feel more supported.
• 12:43
  SPEAKER_03: It could be that your pharmacy staff is just completely overworked.
• 12:46
  SPEAKER_03: There could be uh many things going on there, or maybe there's physicians that are not taking the recommendations of their pharmacists.
• 12:55
  SPEAKER_03: There's a lot that you can get into once you just start asking some open-ended questions.
• 13:00
  SPEAKER_03: In terms of data for vancomycin, in addition to grades in comparison to a benchmark, I think what is really helpful for me is to actually look at a syndrome or indication.
• 13:12
  SPEAKER_03: So if you have the ability to do a medication use evaluation and just understand where vancomycin is being used, guess would be a lot of it is an empiric in the empiric sepsis setting.
• 13:24
  SPEAKER_03: But you may find some other specific syndrome areas where educational interventions or order sets or things like that in terms of your empiric guideline implementation could help.
• 13:34
  SPEAKER_03: So looking by indication, I think is really helpful.
• 13:37
  SPEAKER_03: At my institution, we've been able to actually get indication upon order entry and get that data stratified.
• 13:43
  SPEAKER_03: And so we can actually look at that pretty quickly and dive down by syndrome, which is nice if you have access to that data.
• 13:51
  SPEAKER_03: But I'd say you can get at that also just by doing a quick cross-section prevalence or MUE assessment.
• 13:58
  SPEAKER_03: And then I think the other thing to think about measurement is just duration.
• 14:02
  SPEAKER_03: So looking at your averages and your median duration of therapy for bankamycin.
• 14:08
  SPEAKER_03: I also think if you can get a comparison from other hospitals, that's also a really nice way to get at am I using bank longer than other uh institutions do?
• 14:19
  SPEAKER_03: Because that is really, I think, the opportunity with a lot of the strategies we have from stewardship, uh, the de-escalation, the stopping the bank early when you get the data back, those are the areas to really shave off a couple of days of therapy here and there.
• 14:32
  SPEAKER_01: That's my take.
• 14:33
  SPEAKER_01: Kim, what do you think?
• 14:34
  SPEAKER_01: No, I agree with everything you said.
• 14:36
  SPEAKER_01: That's pretty much what I had as well.
• 14:37
  SPEAKER_01: If you go with NHSN and have a SAR available to start there, look at your gram positives, uh, agents.
• 14:44
  SPEAKER_01: If you see you're a little bit elevated there, go ahead and look at your DOTs, then start doing them.
• 14:50
  SPEAKER_01: Maybe, like you said, look at your process metrics.
• 14:52
  SPEAKER_01: What's the dose, what's happening with dosing, monitoring, documentation?
• 14:55
  SPEAKER_01: Are you having those occur properly throughout your hospital?
• 14:59
  SPEAKER_01: Are there specific units where you're worried about dosing being done improperly or monitoring not being done completely?
• 15:06
  SPEAKER_01: If you're able to pull the vancomycin levels, see how often you're getting elevated levels and try and target those providers or those pharmacists or those units as well to help kind of decrease the rates risk of toxicity there as well.
• 15:18
  SPEAKER_01: So I think there's a lot of different ways to go about looking at the vancomycin use within your hospital, and I think Rebecca covered them really well.
• 15:24
  SPEAKER_02: Thank you.
• 15:25
  SPEAKER_02: As we're talking about decreasing vancomycin usage, uh, what are the alternatives that are available and how do they fit into our current medical practice?
• 15:34
  SPEAKER_01: So many alternatives.
• 15:35
  SPEAKER_02: There's so many.
• 15:38
  SPEAKER_01: I think when you think about the alternatives to vancomycin, that's I think about starting with what targets MRSA has we've been talking primarily about.
• 15:45
  SPEAKER_01: But when you think about those, you kind of have to think about within your guidelines and your institution and your formulary where they would fit to offset vancomycin use because you don't just want to squeeze the balloon and say, okay, we're going to stop using vancomycin, but now we're using pretty much just daptomycin.
• 15:59
  SPEAKER_01: Uh we want to try and fit each thing to the particular area of particular need.
• 16:03
  SPEAKER_01: So we have long-acting lycoglycoptides, aridovansin, delvivancin, they're increasingly used.
• 16:09
  SPEAKER_01: Either OPEP programs or really to assist in early discharge, and we still might require IV therapy.
• 16:14
  SPEAKER_01: Daptomycin is becoming more commonly used as like a first lineogen for MRC bloodstream infection when pneumonia is not a source because the FDA recently approved that generic form.
• 16:24
  SPEAKER_01: Uh Linazolid, and I if Rebecca, if I want if you want to interrupt me at any point, I'll just keep going otherwise.
• 16:31
  SPEAKER_01: But I have a whole list of things off that I can go off of.
• 16:34
  SPEAKER_03: No, I mean, I think there's pros and cons to each of the alternatives, right?
• 16:39
  SPEAKER_03: So I think that's kind of what Kim is getting at.
• 16:41
  SPEAKER_03: Um and there's certainly uh clinical scenarios where one may be preferred over the other.
• 16:47
  SPEAKER_03: I think turning Bencomycin days into days of zero when it's not indicated is probably the first goal.
• 16:54
  SPEAKER_03: And then looking at alternatives that may fit your patient's scenario the best.
• 16:59
  SPEAKER_03: And in those, I think there are areas for considering alternatives.
• 17:04
  SPEAKER_03: So yeah, we can continue with the list though.
• 17:06
  SPEAKER_03: I think you got through daptamycin and then you started linazolid, but you didn't get very far.
• 17:11
  SPEAKER_01: Well, deptomycin, yeah, for bloodstream infections where you're not thinking of pneumonia.
• 17:14
  SPEAKER_01: I think an early switch to daptamycin from vancomycin has been shown to improve patient outcomes in MRSA BSI.
• 17:19
  SPEAKER_01: So that's a good option there.
• 17:21
  SPEAKER_01: Linazolid's a great option for MRSA skin and soft tissue infections, especially given it's 100% bioavailable.
• 17:26
  SPEAKER_01: So IV to PO switches are good there.
• 17:28
  SPEAKER_01: Um obviously you have to watch out for adverse drug events, especially given for prolonged time periods or being co-administered with other medications.
• 17:35
  SPEAKER_01: So there are some pros and cons with lanazolid as well.
• 17:38
  SPEAKER_01: And then ceftarline or bailactam with mRSA activity, uh, so it's an alternative for deep-seated MRSA infections.
• 17:45
  SPEAKER_01: But from a stewardship standpoint, we do kind of want to reserve it a bit because it does have broad spectrum activity.
• 17:50
  SPEAKER_01: It covers gram negatives, unlike the other agents I have been talking about on this list.
• 17:53
  SPEAKER_01: So it covers some of our organisms in the interbacterialis family, so we don't want to use, overuse that one because we don't want to cause too much collateral damage.
• 18:01
  SPEAKER_01: Then there's a lot of oral options for mRSA as well, kind of depending on susceptibilities of bactrum, doxycycline, minocycline, lunazolid, as I mentioned above, newer agents, amatocycline, pedazolid.
• 18:12
  SPEAKER_01: There's a lot of options for MRSA when you're thinking about uh what you could use instead of vancomycin.
• 18:17
  SPEAKER_01: It's just figuring out where they fit relative to the pros and cons of their agents and the disease states you're looking at.
• 18:23
  SPEAKER_02: How do you target prescribers who are over prescribers of vancomycin?
• 18:27
  SPEAKER_03: Yeah, I think that's a tough question because Venc just has a lot of different disease states.
• 18:33
  SPEAKER_03: And so I think the most important thing when you're actually gonna have a proscriber level uh discussion is to try and like meet them where they are.
• 18:43
  SPEAKER_03: So I feel like these are best done informally on the wards while you're there doing stewardship rounds, and especially within the context of a specific case where they can understand their decision making and what is gonna impact an individual.
• 18:59
  SPEAKER_03: So that's that's the way that I typically try to approach a prescriber, especially if I'm starting to see a pattern.
• 19:06
  SPEAKER_03: I have that case in front of me, just like talking through the details of that case and the rationales for that particular case can then open up those opportunities to do some education or share a paper or try to go through the pro-cons of the alternatives in addition to bancomycin.
• 19:23
  SPEAKER_03: I think I haven't done a lot of kind of like formalized audit and feedback specifically for bancomycin, but I know some programs have.
• 19:32
  SPEAKER_03: And I think in looking at that, if you have comparative data and peer comparisons, that could be a really powerful tool, especially if you have some clear outliers as compared to the bulk of your prescribers.
• 19:46
  SPEAKER_03: Just you know, sharing that information in and of itself can provide some level of introspection and like a wow, I didn't know type of thing, instead of just it being a rumor like around in the back of the pharmacy that Dr.
• 19:59
  SPEAKER_03: So-and-so is a high prescriber.
• 20:01
  SPEAKER_03: I always try to give people the benefit of the doubt and try to go case-based approach whenever I'm trying to um approach a prescriber that way.
• 20:10
  SPEAKER_03: I don't know.
• 20:11
  SPEAKER_03: I'm interested to hear Ken's take from a pharmacist's perspective on that question.
• 20:15
  SPEAKER_01: So I actually had the same answers about audit and feedback, providing peer comparisons and doing clinical detailing.
• 20:23
  SPEAKER_01: I do a lot with diagnostic stewardship, and we do a lot of that for like urine culturing.
• 20:29
  SPEAKER_01: I mean, we do a lot of that antibiotic stewardship too because it is work-intensive, but it does help actually decrease those numbers and help educate our providers about appropriate use.
• 20:38
  SPEAKER_01: Other ways to target them, if they're prescribing a lot on a certain unit, we like to often reach out to the clinical specialist on that unit as well to talk to them about what's going on and to try and get an idea of how Vancomice is being used on their unit before we, you know, go over their heads and talk to the providers.
• 20:55
  SPEAKER_01: So we try to use our clinical specialists, kind of an extension of our stewardship team, to try and figure out what's going on before we reach out directly to the physician because they can work with their team.
• 21:05
  SPEAKER_01: They're on rounds every day, and we're not working mostly behind the computer, maybe with the ID team, but we're not there with those particular teams every single day while they are, and they'll be able to provide that clinical detailing and feedback better than we can from behind the computer.
• 21:20
  SPEAKER_03: Yeah.
• 21:21
  SPEAKER_03: I'm gonna ask you, Mackenzie, how about from an ID fellow's perspective?
• 21:26
  SPEAKER_03: How do you kind of like talk to your primary teams as a consultant when they're hesitant to take off the bank or they want to use it?
• 21:33
  SPEAKER_03: What do you think?
• 21:33
  SPEAKER_03: Maybe it's not necessary.
• 21:35
  SPEAKER_02: So here we do real-time audit and feedback.
• 21:37
  SPEAKER_02: And so we will have kind of those case based discussions like you're talking about.
• 21:42
  SPEAKER_02: We don't really look at our prescribers by the volume they prescribe.
• 21:45
  SPEAKER_02: It's more of looking at a list that's flagged in a certain way.
• 21:49
  SPEAKER_02: Um, so I actually don't have the data on who is prescribing what.
• 21:53
  SPEAKER_03: I think that you know, this is an area where we should learn more.
• 21:57
  SPEAKER_03: I think there certainly can be case mix differences.
• 21:59
  SPEAKER_03: So So at my institution, we have a couple of medicine teams that really uh specialize in medsych.
• 22:07
  SPEAKER_03: And so that team many times will take our population of persons who use drugs.
• 22:13
  SPEAKER_03: And so if you're just kind of like looking across the board, you wouldn't see that like they really are getting folks that have endocarditis and osteomyelitis and really have those risks for longer vancomycin courses.
• 22:24
  SPEAKER_03: So there always has to be taken within context of the types of patients as well.
• 22:30
  SPEAKER_03: And you know, I always feel like it's better to focus on the positives of what folks are doing well as well.
• 22:37
  SPEAKER_03: So when you see somebody de-escalate, I had actually somebody today in the CCU came in really sick, heart attack, also had pretty decent sized cellulitis on one leg, came in hypotensive, lactic acidosis, broad spectrum.
• 22:53
  SPEAKER_03: Within two days, had them back down to a nice narrow cephazolin as things evened out.
• 22:59
  SPEAKER_03: And so I had to give props to the team today, first seeing that good de-escalation within two days after the patient kind of evened out and they had their blood culture specs.
• 23:07
  SPEAKER_03: I also think that's the best approach as well, is just to reinforce that good behavior or what you're seeing out there.
• 23:13
  SPEAKER_02: I agree on stewardship.
• 23:14
  SPEAKER_02: I love handing out gold stars when I see the good things happening.
• 23:18
  SPEAKER_03: Yeah, that's the fun part.
• 23:20
  SPEAKER_02: So wrapping up with our final question, uh, what is the biggest lesson that you've learned as you've targeted vancomycin at your institution?
• 23:28
  SPEAKER_01: I think one of the biggest lessons I've learned is how there's a lot of opportunities to target vancomycin by using your clinical pharmacist and your clinical pharmacy specialists as extenders of your stewardship program.
• 23:40
  SPEAKER_01: So we move to pharmacist to dose and two-level AUC-based dosing at the exact same time.
• 23:47
  SPEAKER_01: Um, just get the band-aid right off, right?
• 23:49
  SPEAKER_01: Just do it both.
• 23:50
  SPEAKER_01: And having the pharmacists engage with the dosing uh combined with some of the other stewardship initiatives we talked about here, like the MRSA nasal screening, really helps our stewardship team in terms of finding those patients who probably don't need 72 hours because the clinical pharmacist or the clinical pharmacy specialist has already seen that the nasal uh swab is negative, they don't have other risk factors, they DC'd it.
• 24:13
  SPEAKER_01: So there's ways to use your CLIN specs as extenders of your stewardship program, which I think is really important when you're thinking about limited resource settings, which neither of us are from.
• 24:23
  SPEAKER_01: So it's hard for us to exactly speak of that.
• 24:25
  SPEAKER_01: But when you don't have maybe like four FTEs of ID pharmacists running around helping you out, you can have your other uh pharmacy team members who are doing the pharmacist of dose of anchomycin help you with your stewardship initiatives.
• 24:37
  SPEAKER_03: Absolutely.
• 24:38
  SPEAKER_03: I think that that's actually really important is that this is very much a team-based um multidisciplinary um approach with uh lots of people that have like key stakes in what patients are getting, and um, you know, are biggest promoters for de-escalation many times that are clinical pharmacists there on the floor with the team, knowing exactly what a thought process is and responding to data quickly and in more real time than necessarily you would be able to with a centralized um stewardship team.
• 25:10
  SPEAKER_03: I also feel like vancomycin is one of these drugs that we have kind of like a love-hate relationship with.
• 25:15
  SPEAKER_03: It's like uh you feel obligated that you have to use it because you have maybe a little bit of anxiety about what's going on with your patients, but at the same time, you have to dose it and there's toxicity risk.
• 25:26
  SPEAKER_03: And so I feel like people are already feeling a bit annoyed with vancomycin.
• 25:31
  SPEAKER_03: So give them that little bit of more of a nudge, uh, just to give them that reassurance that they're making the right choice.
• 25:37
  SPEAKER_03: And also I think having that team approach to say, look, you're far my pharmacist bought so I was worried about this, but we're gonna we're gonna make this decision together.
• 25:45
  SPEAKER_03: I think that also really provides a lot of reassurance for being able to make the right choice.
• 25:50
  SPEAKER_02: Well, thank you very much, Drs.
• 25:51
  SPEAKER_02: Moring and Clays, for sharing your perspective and your experiences.
• 25:55
  SPEAKER_03: Thank you for having us.
• 25:57
  SPEAKER_03: I'm so glad Shay is doing this podcast for stewards, and I'm excited for this one and all of the future pods that are about to come from this effort.
• 26:07
  SPEAKER_02: Yes, thank you.
• 26:07
  SPEAKER_02: Looking forward to it.
• 26:09
  SPEAKER_02: That concludes this episode of the Shea Podcast.
• 26:11
  SPEAKER_02: Thank you for tuning in.
• 26:13
  SPEAKER_00: Thanks for listening to today's episode of the Shay Podcast.
• 26:17
  SPEAKER_00: Don't forget to register for the 2024 Shea Spring Conference, taking place April 16th to the 19th in Houston, Texas.
• 26:25
  SPEAKER_00: For more information and to register, visit Shayspring.org.