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Antibiotic Stewardship in the Time of COVID-19 · The SHEA Podcast

• 0:09
  SPEAKER_00: Welcome back to our four-part podcast series, Challenges and Innovations in Antimicrobial Stewardship brought to you by the Society for Healthcare Epidemiology of America, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:33
  SPEAKER_00: This series will focus on applying stewardship practices in the ambulatory and emergency department setting, describing how tele stewardship can be used in resource-limited settings, analyzing innovations in diagnostic stewardship and discussing stewardship in the time of COVID-19.
• 0:55
  SPEAKER_00: I am Dr.
• 0:55
  SPEAKER_00: Jaffar Altofi, an adjunct officer of medicine at Indiana University and COVID-19 incident commander at Johns Hopkins Aramco Healthcare, and I will serve as your podcast moderator today.
• 1:19
  SPEAKER_00: This podcast will discuss antibiotic stewardship importance during and after COVID-19, including challenges faced with emerging antimicrobial stewardship program information as a result of COVID-19, lessons learned, and more.
• 1:38
  SPEAKER_00: I'm happy to introduce our two speakers for today.
• 1:42
  SPEAKER_00: First, we have Dr.
• 1:43
  SPEAKER_00: Rebecca Mohering, Associate Professor of Medicine at Duke University.
• 1:48
  SPEAKER_00: Dr.
• 1:48
  SPEAKER_00: Mohering is also the medical director of the Duke University Antimicrobial Stewardship and Evaluation Team, and co-director of research for Duke Antimicrobial Stewardship Outreach Network.
• 2:02
  SPEAKER_00: We also have Dr.
• 2:03
  SPEAKER_00: Emily Spivak, Associate Professor of Medicine at University of Utah.
• 2:09
  SPEAKER_00: Dr.
• 2:10
  SPEAKER_00: Spivak also established and serves as the co-director of the antimicrobial stewardship program at University of Utah Health and the Salt Lake City Veterans Affairs Healthcare System.
• 2:23
  SPEAKER_00: Thank you both for joining us today.
• 2:26
  SPEAKER_00: First, I am sure our listener would love to know more about your background and work in antibiotic stewardship.
• 2:34
  SPEAKER_00: So would you both share a little bit about yourselves?
• 2:38
  SPEAKER_00: Dr.
• 2:38
  SPEAKER_00: Moharing, we'll start with you.
• 2:41
  SPEAKER_02: Thanks, and Jafar, thank you so much for inviting me to be a part of this podcast.
• 2:45
  SPEAKER_02: I think this is a great topic that we've been living and breathing for a while now.
• 2:50
  SPEAKER_02: And it's important to kind of sit back and reflect a little bit and think about what we're learning and where we're going.
• 2:56
  SPEAKER_02: So thanks for setting this up.
• 2:58
  SPEAKER_02: I've been working in stewardship.
• 3:00
  SPEAKER_02: Well, I kind of got the bug when I was an ID fellow, my second or third year of ID fellowship.
• 3:07
  SPEAKER_02: At first, I thought I wanted to do only infection control, infection prevention, and had come to Duke really to learn that, to get a degree in Epi and really kind of follow that track.
• 3:17
  SPEAKER_02: But here at Duke, we have this great existing relationship with our community hospital collaborators in our outreach network.
• 3:25
  SPEAKER_02: And I just noticed that there was just a lot of need to grow the stewardship programs in a lot of our community hospitals.
• 3:32
  SPEAKER_02: And at that point, we also needed to do a lot of growth in our academic program.
• 3:37
  SPEAKER_02: So I kind of shifted my focus at that point and have been doing stewardship ever since then.
• 3:42
  SPEAKER_02: In my early career, I worked over at the Durham VA and helped formalize that program as the VA directive came through.
• 3:50
  SPEAKER_02: And then about three years ago, I shifted my focus all my service time, mostly here to Duke University Hospital to be the medical director here.
• 3:59
  SPEAKER_02: So I'm lucky because I've got to have a kind of variety of experience working in stewardship program at the VA, working with our community hospitals, and now working here at the Academic Center.
• 4:09
  SPEAKER_02: So excited to be here.
• 4:10
  SPEAKER_02: Thanks.
• 4:11
  SPEAKER_00: That's great.
• 4:12
  SPEAKER_00: We're glad that you are with us.
• 4:14
  SPEAKER_00: What about you, Dr.
• 4:15
  SPEAKER_00: Spivek?
• 4:16
  SPEAKER_01: Yes, thanks, Jafra, for having me as well.
• 4:18
  SPEAKER_01: This is fun to do these and also to kind of commiserate hopefully with Rebecca about the last year and a lot of work still to be done.
• 4:26
  SPEAKER_01: I live in Salt Lake City, of course, but I am originally from Virginia.
• 4:31
  SPEAKER_01: I did my medicine residency and fellowship at Johns Hopkins Hospital in Baltimore.
• 4:36
  SPEAKER_01: And I got interested in stewardship there.
• 4:38
  SPEAKER_01: So from probably my first hour as an intern, I heard from the stewardship program about whatever I was ordering antibiotics on somebody.
• 4:46
  SPEAKER_01: And so in early in my residency, had a lot of interaction with the stewardship team.
• 4:50
  SPEAKER_01: And then when I became an ID fellow, you know, I thought I was going to do some sort of international global health, but I latched onto Sarah Cosgrove pretty quickly as a resident and fellow and really became interested in the stewardship program and then also infection control with Trish Pearl.
• 5:04
  SPEAKER_01: And so I trained with both of them as a fellow in sort of practicalities, day-to-day stewardship and infection prevention, and also got a master's of health sciences at the Bloomberg School of Public Health and Clinical Investigation while I was there.
• 5:16
  SPEAKER_01: But when I finished fellowship, my husband and I were ready to leave the East Coast and sort of go on an adventure, I guess you could say.
• 5:23
  SPEAKER_01: And there was no stewardship program out here.
• 5:26
  SPEAKER_01: And so I took a job at University of Utah to really start to work with pharmacy and start and build a stewardship program.
• 5:33
  SPEAKER_01: And I very quickly realized that I had actually had no training in how to do that because the program at Hopkins has been so well established for many, many years.
• 5:41
  SPEAKER_01: And so over the last 10 years, I've had a real crash course, real life experience and how figuring out like how you just even do this from scratch.
• 5:50
  SPEAKER_01: Started actually at the Salt Lake VA, got things up and running over there and hired a pharmacist before I then came over to the university.
• 5:56
  SPEAKER_01: And I've hired several pharmacists and expanded things over here.
• 6:00
  SPEAKER_01: And you know, work also with Dr.
• 6:02
  SPEAKER_01: Stenham and different people at Intermountain, and also with our epidemiology colleagues here at the Salt Lake VA and PEEDS ID and even Dr.
• 6:09
  SPEAKER_01: Moring on different sort of stewardship clinical research areas.
• 6:11
  SPEAKER_01: And so it's been really, really fun and every day is different than the one before.
• 6:15
  SPEAKER_01: So it's exciting.
• 6:17
  SPEAKER_00: Thank you very much, Dr.
• 6:18
  SPEAKER_00: Sabivak.
• 6:19
  SPEAKER_00: That was very informative.
• 6:21
  SPEAKER_00: And we are glad that both of you are with us.
• 6:24
  SPEAKER_00: So what is the current status of antibiotic stewardship program as we navigate through this pandemic?
• 6:31
  SPEAKER_00: I'll start with you, Dr.
• 6:32
  SPEAKER_00: Sabivak.
• 6:33
  SPEAKER_01: Yeah, well, I'll speak a little bit, I guess, from my perspective of our stewardship program here.
• 6:38
  SPEAKER_01: And I think our experience is probably similar to other places.
• 6:41
  SPEAKER_01: And I'll start first by saying, you know, this COVID has been an amazing opportunity, I think, for stewardship programs to highlight all the different expertise that we have and things that we can contribute to a health system and to the care of patients in a rapidly sort of emerging situation.
• 6:57
  SPEAKER_01: I will say that we have been stretched really thin.
• 7:00
  SPEAKER_01: For me, one of the main lessons learned from this is that, and I already knew this going into COVID, but that stewardship programs, and I think this is true around the country, are vastly under-resourced even before COVID-19 for essentially the work that we need to be doing in inpatient and outpatient settings.
• 7:15
  SPEAKER_01: And I think COVID has clearly pushed that to the limit.
• 7:19
  SPEAKER_01: That's been the case here with us for sure, as we have taken on numerous functions and had our resources and energy diverted from typical antibiotic or animal girl stewardship to a lot of COVID activities.
• 7:30
  SPEAKER_01: A lot of surgery programs in this country are stretched really thin, but I think it's a huge opportunity.
• 7:34
  SPEAKER_01: And it's one I'm sort of leveraging locally, but across the country, nationally and internationally, for us to really highlight.
• 7:41
  SPEAKER_01: And I think COVID has highlighted our expertise and our contributions, but it's time to really leverage that for increased funding, you know, locally, nationally, internationally for stewardship programs, because we have so much to contribute.
• 7:53
  SPEAKER_01: Some examples of things that we've done here.
• 7:55
  SPEAKER_01: I mean, we jumped on things as most people have pretty quickly, and of course developed guidelines and like everybody else and updated those.
• 8:01
  SPEAKER_01: But all COVID therapies from the beginning, actually outpatient as well, have been really housed within our stewardship programs.
• 8:08
  SPEAKER_01: Some of them so restricted that only myself and a few others could order them.
• 8:11
  SPEAKER_01: And we have really been the center of all novel therapeutics, not even antivirals, but everything else that has been used for COVID-19 and have been involved with clinical trials and even at a state level.
• 8:23
  SPEAKER_01: I had representation on a state scarce medication allocation committee.
• 8:28
  SPEAKER_01: It's a subgroup of our crisis standards of care group that has decided from the beginning how we were going to allocate REM desivere before it was FDA approved and how we were going to prescribe it across the entire state.
• 8:37
  SPEAKER_01: So we were all in alignment.
• 8:38
  SPEAKER_01: We've done the same thing for monoclonal antibodies as well.
• 8:41
  SPEAKER_01: So I think it's been a huge opportunity to highlight what we can contribute, but we have been stretched so, so thin that I hope the future is that we can all get a lot more resources to contribute going forward.
• 8:53
  SPEAKER_00: Thank you.
• 8:53
  SPEAKER_00: Dr.
• 8:54
  SPEAKER_00: Mori, can you share a new thoughts, please?
• 8:57
  SPEAKER_02: Yeah, I think, you know, Emily put this really well.
• 9:00
  SPEAKER_02: If I had to use one word for the state of my stewardship program right now, I would just say that we're a little bit tired of COVID, tired would be the one that I would use, just because this has continued to go on and on.
• 9:12
  SPEAKER_02: But I think what's been really interesting to me as like we have gone through this period is that with every phase of the pandemic, things have changed.
• 9:21
  SPEAKER_02: Like it's just been so dynamic.
• 9:22
  SPEAKER_02: And I think with one of the things that I've learned is like this absolute critical need to be flexible and adaptive to meet the challenges and the priorities at hand that day or that hour, even.
• 9:35
  SPEAKER_02: So I think, you know, being with our frontline providers, as they've gone through just this rapid dynamic change, a lot of good things have come from that.
• 9:44
  SPEAKER_02: I definitely have more phone numbers on my phone for folks than I did before the pandemic, being able to rapidly call them and be able to make decisions quickly.
• 9:53
  SPEAKER_02: You know, one of the things that always used to bug me prior to the pandemic was just the length of time it took to make decisions.
• 9:59
  SPEAKER_02: That has been completely squashed.
• 10:00
  SPEAKER_02: Like we're able to make decisions quickly.
• 10:02
  SPEAKER_02: We don't have to go through a million committee reviews and we can meet the needs of our patients without those kind of bureaucratic barriers.
• 10:09
  SPEAKER_02: And then I think the other thing in terms of where I am right now is I'm really thankful for where I work.
• 10:15
  SPEAKER_02: You know, I've become closer to a lot of my coworkers during this time period.
• 10:19
  SPEAKER_02: I have the most amazing partner in pharmacy to do this job with, Rebecca Wren.
• 10:24
  SPEAKER_02: And I really rely on her, she relies on me.
• 10:27
  SPEAKER_02: We joke that we uh share a brain because we do, we not only share our first name, we share our brain.
• 10:33
  SPEAKER_02: And people just are like, okay, Rebecca's, what do you think?
• 10:35
  SPEAKER_02: And so I've just become more and more close with her.
• 10:38
  SPEAKER_02: I mean, I think it's like you get through this time period during the pandemic and like you reflect back and you realize how far you've come.
• 10:46
  SPEAKER_02: I think the other thing is that because we've shown our ability to lead, as Emily described, and like to be the experts on this, we now are getting asked to do more and more.
• 10:57
  SPEAKER_02: So one thing that happened just last week, Rebecca, my counterpart Rebecca Wren, got asked to now supervise more people in the pharmacy as their manager.
• 11:06
  SPEAKER_02: So I'm like, oh, okay, that's a promotion, right?
• 11:09
  SPEAKER_02: And she's like, well, actually, I don't know.
• 11:11
  SPEAKER_02: That's I'm not really getting paid more.
• 11:12
  SPEAKER_02: I'm just being asked to do more.
• 11:14
  SPEAKER_02: And so I think like we have to be really strategic about, yeah, we can lead, we can make decisions, we can be on the phone with our hospital leadership and you know provide support to our frontline folks during this, but we need to be really careful that we're not asked to do more and more and more without getting the resources we need to actually do a good job with stewardship and not get spread because we have been functioning spread thin for a while.
• 11:40
  SPEAKER_02: So I think that's probably the biggest challenge coming out of the pandemic is just like not having this expectation that we're gonna be able to do 150% like moving forward.
• 11:50
  SPEAKER_00: Can you both speak on the need for antimicrobial stewardship as we continue through the pandemic and what consequences we have seen because of not focusing on ASP as much as we should have during this time, as you had mentioned, because we are stretched thin.
• 12:09
  SPEAKER_00: And Dr.
• 12:09
  SPEAKER_00: Mohrang will let you answer first.
• 12:12
  SPEAKER_02: I think you know, dealing this pandemic with a viral respiratory illness kind of uncovered underlying challenges that we've been facing through stewardship for many years.
• 12:24
  SPEAKER_02: One is we suck at diagnosing pneumonia, and that just became very bacterial pneumonia.
• 12:30
  SPEAKER_02: That became very obvious when respiratory illness started showing up and we were unsure about the clinical syndrome of COVID.
• 12:38
  SPEAKER_02: And so that first wave, early pandemic, we were using a lot of antibiotics empirically for a viral illness.
• 12:45
  SPEAKER_02: So that just really elucidated how we need to have good diagnostics as well as just discipline in our diagnostic thinking, because I think when we get scared and we're dealing with new things, we often choose to use antibiotics just to have kind of something that we're doing, this act of intervention.
• 13:04
  SPEAKER_02: And so I think, you know, stewardship programs, that's what we do.
• 13:08
  SPEAKER_02: We teach clinical reasoning, diagnosis is kind of like the basis for every evaluation we do in the hospital starts with, you know, what is the diagnosis?
• 13:17
  SPEAKER_02: And I think, you know, COVID just amplified that need, especially early in the pandemic.
• 13:22
  SPEAKER_02: I think we've gotten better with the diagnosis as we've gone on.
• 13:25
  SPEAKER_02: We now have access to COVID tests, you know, whereas before, you know, first few weeks we were waiting up to a week for a COVID test.
• 13:32
  SPEAKER_02: We don't have that as much.
• 13:33
  SPEAKER_02: But I still, you know, every week I'm still talking about, okay, we don't see any bacteria evidence of bacterial pneumonia in this patient, you know, let's stop antibiotics.
• 13:43
  SPEAKER_02: We know that COVID is going on.
• 13:44
  SPEAKER_02: Let's, you know, support that this person through their COVID.
• 13:47
  SPEAKER_02: But we've gotten better.
• 13:48
  SPEAKER_02: As we look at our antibiotic use data, you know, we had kind of a big bump during the first, but each subsequent wave of COVID has not been as high of a bump.
• 13:57
  SPEAKER_02: And so we're learning, we're teaching, we're growing.
• 13:59
  SPEAKER_02: And I think that is just evidence of the work that we've been doing through stewardship.
• 14:03
  SPEAKER_00: Very good.
• 14:04
  SPEAKER_00: We'll go to the next question.
• 14:06
  SPEAKER_00: How did antibiotic stewardship program absorb the role of reviewing and providing guidance in COVID therapeutics?
• 14:15
  SPEAKER_00: Dr.
• 14:15
  SPEAKER_00: Spivak, I'll ask you to answer first, please.
• 14:18
  SPEAKER_01: Yeah, I mean, I'll speak from our experience, and I assume that Rebecca's and others is the same.
• 14:22
  SPEAKER_01: And the simple answer is we just stepped up and did it.
• 14:25
  SPEAKER_01: I have to admit, I think it was January, February maybe of 2020.
• 14:30
  SPEAKER_01: I we had a pharmacy, an ID pharmacy resident who, you know, at our stewardship meeting was like, hey, have y'all heard about this new coronavirus and something about hydroxychloroquine?
• 14:40
  SPEAKER_01: I think we need to get on top of this.
• 14:41
  SPEAKER_01: I remember being like, oh, you know, I don't think we need to dedicate time right now to that.
• 14:44
  SPEAKER_01: We're talking about penicillin allergies or whatever, whatever.
• 14:47
  SPEAKER_01: And of course, I was totally wrong.
• 14:48
  SPEAKER_01: And then we quickly pivoted, you know, as I alluded to, like everybody else, we developed the first sort of inpatient guidance around COVID-19 and treatment.
• 14:59
  SPEAKER_01: And then we've again modified that probably 20 times.
• 15:02
  SPEAKER_01: And as everything has been sort of evolving and new things came out and other things retired or went away.
• 15:06
  SPEAKER_01: I just was going to send an email before this podcast to talk to our ICU colleagues and everybody about actually cutting down on REM desivere even more than we already have.
• 15:14
  SPEAKER_01: So, like as Rebecca said, things continually change.
• 15:17
  SPEAKER_01: The other thing I'd point out that myself and another physician, Dr.
• 15:20
  SPEAKER_01: Hannah Emily, who works with me in our stewardship program, did is that she and I got involved with COVID clinical trials on the inpatient side pretty quickly for many reasons.
• 15:29
  SPEAKER_01: But I actually think that helped with stewardship a lot because basically, you know, our guidelines were always from the beginning coordinated with, hey, first, this person needs to be evaluated for ongoing clinical trials.
• 15:39
  SPEAKER_01: And we helped coordinate that by being PIs on some of these trials, but also honestly performing, and we did it for 17 months until I ran out of steam and just said, I'm not doing this anymore.
• 15:49
  SPEAKER_01: But we reviewed all of our inpatients with COVID every day for 17 months and helped coordinate, okay, this person is eligible for this trial, this person's going to get remdesivir index.
• 15:59
  SPEAKER_01: And we went through every one to do that over a long time without extra support, I will point out, which I have pointed out to many people and hopefully we'll leverage for things going forward.
• 16:10
  SPEAKER_01: But what I think is interesting from it again is that once we were, we did that for, you know, the usual stuff at the beginning, hydroxychloroquine, which fell away, and then remdesivir, pharmacy and everyone turned to us to do that for everything for tocalismab.
• 16:21
  SPEAKER_01: For then when we didn't have to salismap for cerulumab and barasitinib, and we absorbed all of it.
• 16:26
  SPEAKER_01: And I mentioned the stuff on the outpatient side too.
• 16:28
  SPEAKER_01: And I think it's given a lot of, it's turned a lot of heads as far as the stewardships team's ability to, as Rebecca again was pointing out, like rapidly assimilate information and condense it in a very clinically sort of common sense, meaningful way as to okay, how we should diagnose and treat these patients and put people into different categories.
• 16:48
  SPEAKER_01: And I think people have gained an appreciation.
• 16:50
  SPEAKER_01: I mean, that's what we've always done, right?
• 16:52
  SPEAKER_01: For CAT, for UTI and other things.
• 16:54
  SPEAKER_01: But to do it in such a rapidly evolving environment, I think is a really important skill of stewardship programs that we can harness, you know, moving forward.
• 17:05
  SPEAKER_01: And I've had multiple people come and just thank me and thank our team for like, you know, I didn't have to read or keep up with half this stuff because I knew that you guys were on top of it and were constantly updating the entire institution.
• 17:18
  SPEAKER_01: So, you know, I think that's a huge role for stewardship moving forward.
• 17:22
  SPEAKER_01: So we just jumped on it from the beginning and got involved, which I suspect is the same at Duke.
• 17:26
  SPEAKER_02: Emily, I cannot believe that you did that for so long.
• 17:30
  SPEAKER_01: It required Dr.
• 17:32
  SPEAKER_01: Emily going on maternity leave.
• 17:33
  SPEAKER_01: And three weeks into her maternity leave, I was like, I'm done.
• 17:38
  SPEAKER_01: And sometimes, I'm not sure why I'm doing this anymore, other than I'm really obsessive.
• 17:42
  SPEAKER_02: But okay, wow.
• 17:44
  SPEAKER_02: Well, I mentioned before that I'm very thankful for where I work.
• 17:47
  SPEAKER_02: You just made me feel even more thankful, Emily.
• 17:50
  SPEAKER_02: But oh no.
• 17:52
  SPEAKER_02: I'm just really lucky because there are a bunch of people within the division of ID here at Duke that just jumped on the research part of COVID.
• 18:02
  SPEAKER_02: So Susanna and Nagy in my division basically started a COVID research task force to evaluate any like COVID-related research project, help prioritize and decide like what as an institution it was the best strategy to use.
• 18:17
  SPEAKER_02: Because, you know, when the pandemic first broke, like everybody wanted to do a COVID research.
• 18:22
  SPEAKER_02: And so we had to kind of set up this group that could like help manage from an institution level.
• 18:28
  SPEAKER_02: And so I am on that group as a as a voting member, but have not been a PI or a site PI for any study, really kept my view as you know, being able to integrate our clinical enterprise with the research enterprise.
• 18:43
  SPEAKER_02: And so I think stewardship actually is perfect to kind of bridge that gap, both because we have our hand on what's going on with like individual people just like sweating it out on the first line, as well as understanding like where, you know, are we getting these data?
• 18:57
  SPEAKER_02: Are we learning?
• 18:58
  SPEAKER_02: Are we, you know, turning this learning back into active decision making?
• 19:02
  SPEAKER_02: So I'm I'm really lucky to have other leaders to kind of like take on that role as well.
• 19:07
  SPEAKER_02: In terms of like how we made our policy decisions, and you know, Emily alluded to this, but I think we've updated our, you know, kind of institutional COVID guideline upwards of 25 times now.
• 19:19
  SPEAKER_02: And that's taking it through a committee review as well, expedited committee review.
• 19:23
  SPEAKER_02: And it continues to change, you know, at one point, like ID was evaluating every patient with COVID that was a short-term thing, you know, because we just couldn't do that surge-wise, numbers-wise.
• 19:36
  SPEAKER_02: And, you know, our hospital medicine colleagues quickly became experts on COVID.
• 19:41
  SPEAKER_02: So we've been able to just like really run the gamut of, you know, very intensive reviews to stepping back like piece by piece by piece, so that we don't have to have such tight reins on some of these therapeutics.
• 19:53
  SPEAKER_02: But just the rapidity, say, you know, Rimdesavir, for example, it started out as only available through studies, then through the EUA process with very specific documentation and counseling needs for patients, to being on allocation through the state, where every day we had to report how much we used and how much we needed the following week, to finally being FDA approved.
• 20:14
  SPEAKER_02: So the stewardship team really just like took that by the horns and coordinated between the pharmacy, the state, and the folks that were making the decisions on the front line.
• 20:23
  SPEAKER_02: So I think we just kind of like took it soup to nuts.
• 20:26
  SPEAKER_02: I mean, I don't know that I've ever seen another agent come through like so fast and things have to rapidly change like that.
• 20:33
  SPEAKER_02: I also was supported by other members of my division for reviewing the literature.
• 20:37
  SPEAKER_02: We took on, we made like a therapeutics work group where every kind of like Blockbuster thing that came out of Friday at 4 30 p.m.
• 20:45
  SPEAKER_02: in New England, we reviewed it in kind of a journal club format to really not only kind of like critically review the literature, but also think about like our local policy and how how that should adjust and do that.
• 20:58
  SPEAKER_02: So I had actually, you know, early on the pandemic, people wanted to volunteer, they wanted to weigh in and help with that.
• 21:04
  SPEAKER_02: So we were meeting weekly at the time when the like the fire hose was extremely rapid and then kind of like have cut that back now that we have guidelines, you know, things aren't moving quite as fast.
• 21:16
  SPEAKER_02: But I don't know what the deal is with Fridays of uh journals only dropping studies then and FDA only make decisions on Fridays, but that's how it always seemed to happen for us.
• 21:28
  SPEAKER_00: Thank you.
• 21:29
  SPEAKER_00: Let's move on to another question.
• 21:31
  SPEAKER_00: What antibiotic stewardship programs have emerged as a result of the COVID-19 pandemic?
• 21:38
  SPEAKER_00: Dr.
• 21:39
  SPEAKER_00: Moharing, can you share your thoughts, please?
• 21:42
  SPEAKER_02: Yeah, in terms of new programs, I don't know that we've had kind of like new resource investment, at least for me, but our role has certainly changed as we've been talking through the whole discussion today.
• 21:54
  SPEAKER_02: So I think like this is the kind of pivot point where we really need to jump onto all this work that we've done.
• 22:00
  SPEAKER_02: Done and then make that turn into resources to build our programs.
• 22:04
  SPEAKER_02: Certainly one area where we had to learn and grow is in making kind of these allocation decisions.
• 22:11
  SPEAKER_02: I never knew or kind of personally interacted with a lot of our ethics groups, but we had to come up with allocation plans for therapeutics if we ran out and had a supply.
• 22:22
  SPEAKER_02: So that's certainly kind of something new that I had to learn as a steward.
• 22:27
  SPEAKER_02: I think the other area that was new is trying to get through the logistics of monoclonal antibody treatment and therapeutics, and that's in this kind of like in-between place of not really just being clinic-based and not really being hospital-based, but being kind of an infusion clinic emergency department.
• 22:46
  SPEAKER_02: Getting through those types of plans for our institution was certainly new people that I hadn't really worked directly with as much in the past and in my inpatient steward background.
• 22:57
  SPEAKER_02: That is certainly a new area where, you know, I had to learn a lot about patient flow, where we do infusions in my health system and things like that.
• 23:05
  SPEAKER_02: So that certainly was a new area as well that our program hadn't really been in the past.
• 23:10
  SPEAKER_02: Emily, I know y'all did this in Utah and the Inner Mountain group as well.
• 23:14
  SPEAKER_02: Yeah.
• 23:15
  SPEAKER_01: Yeah.
• 23:15
  SPEAKER_01: I mean, I think I don't know if I'd call us a stewardship program, although Intermountain and I have talked about it.
• 23:20
  SPEAKER_01: I'm like, this is actually like stewardship at a state level applied to novel therapeutics.
• 23:25
  SPEAKER_01: Yeah.
• 23:25
  SPEAKER_01: So we have this, it's called Scarce Medication Allocation Resource Committee or something like that.
• 23:31
  SPEAKER_01: But we're a subgroup of our crisis standards of care.
• 23:34
  SPEAKER_01: And we were convened when Rimdesivir was first coming out and obviously, you know, allocated by HHS.
• 23:41
  SPEAKER_01: And that group got together to figure out, okay, like what's the most equitable way to distribute it across the state.
• 23:49
  SPEAKER_01: But also we went a step further and said, how do we want to prescribe it?
• 23:53
  SPEAKER_01: And can we prescribe it similarly with the same criteria across all of our health systems so that people also are not doctor shopping?
• 24:00
  SPEAKER_01: And then that group reconvened around monoclonal antibodies, which had its own other set of issues, right?
• 24:05
  SPEAKER_01: It's like, who wants to do it, who's going to do it?
• 24:08
  SPEAKER_01: The allocation was very different because it's based obviously on the outpatient side and infusion capacity versus inpatient.
• 24:15
  SPEAKER_01: But then we also, under the leadership of Brina Webb at Inter Mountain, you know, actually decided as a group, like we don't really, well, we we did the numbers.
• 24:21
  SPEAKER_01: We're like the EUA criteria is vastly going to identify way more people than we'll have drug to get.
• 24:26
  SPEAKER_01: So we wanted to look in our state, what are risk factors.
• 24:29
  SPEAKER_01: And we also had a very frank conversation about equity and that the original EUA does not account for equity.
• 24:35
  SPEAKER_01: And we knew or thought and looked.
• 24:37
  SPEAKER_01: And of course, non-white race ethnicity was a huge risk factor for hospitalization, death, and COVID.
• 24:42
  SPEAKER_01: So we we again did the allocation, the operations of monoclonal antibody, but also I think the most important thing we've done is figure out who's qualifying for it.
• 24:50
  SPEAKER_01: And we and that group has adapted over time, even with vaccinations, if you're vaccinated or not, there's different criteria, et cetera.
• 24:56
  SPEAKER_01: So I would call that stewardship.
• 24:58
  SPEAKER_01: I think it's a stewardship around novel therapeutics and delivery at a state level, which has been really interesting.
• 25:04
  SPEAKER_01: And then, like internally, again, we were never doing outpatient, well, I don't know if you call it stewardship, but I think our delivery of monoclonal antibody and the oversight within University of Utah Health by the stewardship team, again, of who does it, who gets it, all based on our interactions with the state.
• 25:21
  SPEAKER_01: But it's our team that is overseeing that.
• 25:23
  SPEAKER_01: And then I have worked with, I mean, again, like you said, Rebecca, people, I never knew existed, all these nurses in the background who are actually monitoring all our COVID patients, they're outreaching to them and essentially scheduling all this stuff under my sort of direction and leadership.
• 25:37
  SPEAKER_01: I think that's a novel use of stewardship that has been really, really impactful, right?
• 25:42
  SPEAKER_01: Because we've probably saved a fair number of hospitalizations by doing that, which is a huge bang for your buck.
• 25:47
  SPEAKER_01: The other thing I would just say, I mean, it's not novel stewardship or like new stewardship, but I think a new appreciation maybe for restrictions here.
• 25:55
  SPEAKER_01: So I trained in a place where restrictions were incredibly heavy.
• 25:58
  SPEAKER_01: And that's what I did as a fellow was a lot of antibiotic approvals.
• 26:02
  SPEAKER_01: When I came here, there aren't weren't that many drugs restricted.
• 26:04
  SPEAKER_01: And over time, I get whatever.
• 26:06
  SPEAKER_01: There's pros and cons clearly about all this stuff, but I'm less inclined to try and bring on a ton of restrictions.
• 26:11
  SPEAKER_01: However, I will say this rapidly evolving novel therapeutics and getting on top of it ahead of time and like really guiding people as to how this stuff should be used with input, of course, of you know, all this team that we have, it's interesting.
• 26:25
  SPEAKER_01: I don't know that there'll be a situation like this, but it's it created such buy-in for restrictions and trust of the way that we have crafted all of the guidelines and the criteria by which we approve them, that it's made them seamless.
• 26:38
  SPEAKER_01: Like, no, when we say, no, I don't think this person needs room desktop everybody's like, okay, like there's no controversy.
• 26:44
  SPEAKER_01: And so I think it's an interesting just way to think about restrictions and kind of when novel drugs come out, getting ahead of them and really being the one to lead and know and have the expertise about how they should be used really creates a seamless role and way to implement restrictions.
• 27:01
  SPEAKER_02: So yeah, I would echo that, Emily.
• 27:04
  SPEAKER_02: I also think that like the stewardship team now gets recognized for like supporting kind of like the cognitive burden of evaluating patients.
• 27:13
  SPEAKER_02: So not only the cognitive burden of having to like read every paper, critically appraise it, and then make clinical decisions, just is a lot for somebody who's tired and is like having you know decisions with family members and in really intense, emotionally charged conversations every day.
• 27:29
  SPEAKER_02: And to really be like, okay, look, I looked at your patient, they meet these criteria, they don't meet these criteria, and being able to summarize that quickly for somebody on the front line, that just I think that only adds to kind of the trust and rapport that you're just like when somebody's just exhausted and emotionally drained, and you can be like, Look, you're making the right choice, or do it this way, and then they're like, Oh, thank you.
• 27:53
  SPEAKER_02: I didn't have to like spend my effort to think through that.
• 27:56
  SPEAKER_01: Right.
• 27:56
  SPEAKER_01: And you can mention all the phone numbers, yeah.
• 27:58
  SPEAKER_01: Like I have some more people on my cell phone and they'll text me, like, can I just ask you real quick about this COVID patient?
• 28:02
  SPEAKER_01: What do you think, you know?
• 28:03
  SPEAKER_01: But it's it's like it's not that, you know, once you and I've done it a million times, it's not that hard, but it's like a huge resource.
• 28:09
  SPEAKER_01: And I'm sure you've done the same too, but it's been really good, extremely tiring.
• 28:13
  SPEAKER_01: You know, I've been asked, you probably have some sort of similar way.
• 28:16
  SPEAKER_01: We have these like it's called a live stream where like every week, it used to be two or three times a week, there's like all this updating that was broadcast to the health system about COVID and anything therapeutic related, our team is asked to go and you know, explain to everybody.
• 28:30
  SPEAKER_01: Well, last week it was Ivermectin, and of course, I like my head almost exploded.
• 28:34
  SPEAKER_01: But everyone's like, we need your voice on this.
• 28:37
  SPEAKER_01: Can you please just like, you know, because there were some outpatia docs that were reporting each other or prescribing it.
• 28:43
  SPEAKER_01: And can you help us review the outpatient scripts and also like tell us what we should be doing on this?
• 28:49
  SPEAKER_01: And I think, you know, I wasn't asked to go and do this kind of like stuff as frequently as I am now, and it's huge visibility for our group.
• 28:58
  SPEAKER_01: And I just, yeah, it's just a I think we're gonna be much more appreciated after this.
• 29:01
  SPEAKER_01: Hopefully that comes with some dollars, but right.
• 29:05
  SPEAKER_00: It's a wonderful discussion.
• 29:07
  SPEAKER_00: Dr.
• 29:07
  SPEAKER_00: Speaker, what did we learn about antiviral stewardship during COVID-19?
• 29:13
  SPEAKER_01: We're incredibly important, we're incredibly adaptable, and uh we have huge, I think, clinical insight to provide it's like all of ID, but it's like great.
• 29:24
  SPEAKER_01: We're able to help with from you know the beginning to end of a patient, like the diagnostics, clinically assessing them and sort of beginning to end and wrapping up the whole case and sort of how to treat it, that we're leaders and we're able to, you know, really speak, you know, to like I was mentioning, to sort of leading the institution or the system through how to sort of treat and think about these patients.
• 29:47
  SPEAKER_01: I'm sure Rebecca's the same.
• 29:48
  SPEAKER_01: I've also been asked to do a lot of, I guess you call it advocacy and community education, which I think speaks to people recognizing that stewardship, physicians and pharmacists can really have a 40,000-foot view about things and can speak to that and our leaders.
• 30:02
  SPEAKER_01: The other thing I hope that we've really learned is that these programs are vastly under-resourced again across the country and around the world, and that we really need to focus on uh investments in people and technology to help us do stewardship everywhere to prepare for the next time.
• 30:18
  SPEAKER_00: Do you have anything else to add, Dr.
• 30:20
  SPEAKER_00: Moharing?
• 30:21
  SPEAKER_02: Yeah, I mean, I think the other kind of learning point for me over the last year and a half is, you know, my job has mostly focused on inpatient medicine.
• 30:32
  SPEAKER_02: And this pandemic has really just highlighted for me the need for outpatient stewardship programs that are well funded.
• 30:40
  SPEAKER_02: Because in a crisis situation, you know, if your duty is to really care for the hospitalized patients, there's all these outpatients that aren't getting your attention as a steward with equally as important needs to be met.
• 30:56
  SPEAKER_02: You know, with the monoclonal antibodies and potentially with, you know, oral antivirals coming soon.
• 31:03
  SPEAKER_02: That same need, all this work that we've been doing on the inpatient, it's needed equally in the outpatient setting.
• 31:08
  SPEAKER_02: Trying to do it all and putting it all on an inpatient stewardship team is just completely ineffective to me.
• 31:16
  SPEAKER_02: I mean, that the outpatient world is a different animal.
• 31:19
  SPEAKER_02: The ED is a different animal.
• 31:21
  SPEAKER_02: It needs an equal amount of brain power focused in that practice setting.
• 31:25
  SPEAKER_02: You know, I've long had on my list of wanting to really expand our work in the outpatient setting here at Duke and have been advocating for those types of resources.
• 31:33
  SPEAKER_02: But I think this experience through the pandemic has made that even more acutely obvious to me.
• 31:39
  SPEAKER_00: Thank you.
• 31:39
  SPEAKER_00: Based on what we did learn, what lessons could we carry forward in the future?
• 31:45
  SPEAKER_00: And I will stay with you, Dr.
• 31:47
  SPEAKER_00: Maharang, if you could answer this first.
• 31:50
  SPEAKER_02: Yeah, one thing that I am hopeful for is that we did learn a little bit from some of the mistakes we made early on, but I think we're still suffering from some of them.
• 32:00
  SPEAKER_02: So, I mean, the hydroxychloroquine story is one.
• 32:05
  SPEAKER_02: And then, you know, as Emily mentioned, it seems like we're reliving it now with Ivor Mactin and it's kind of like replaying, you know, some of the challenges of just having such cognitive dissonance and the decisions that we make, of you know, clinging to therapeutics that are unproven, whereas we don't want to accept vaccines that have good scientific data.
• 32:25
  SPEAKER_02: Dealing with some of those kind of social behavioral drivers of those types of decisions is certainly an area and a big challenge that not just stewardship, but like science as a whole, we need to deal with that.
• 32:37
  SPEAKER_02: And so I think that's certainly an area for us to learn.
• 32:41
  SPEAKER_02: But I think the other thing that's like a good thing is just like we are making it through this.
• 32:46
  SPEAKER_02: We're coming together, we're able to adapt change to rapidly dynamic situation.
• 32:52
  SPEAKER_02: That's just been an amazing thing.
• 32:53
  SPEAKER_02: And not just like kind of like on the micro level, you know, at our institutions, on the macro level as well, like the FDA being able to move quickly, getting drugs under EUA.
• 33:04
  SPEAKER_02: I don't know, Emily.
• 33:05
  SPEAKER_02: I had this slide early on that was just I had to explain what an EUA was to people.
• 33:10
  SPEAKER_02: So uh the top of my slide is just WTF is an EUA.
• 33:15
  SPEAKER_02: So I had to use that early on, but like, you know, people weren't really used to this mechanism.
• 33:21
  SPEAKER_02: And it was one thing that we had to learn.
• 33:23
  SPEAKER_02: And so, like, you know, we think the government like moves so slowly, but really in retrospect, like these decisions were being made rapidly.
• 33:30
  SPEAKER_02: I think, you know, the team approach is the only way to do this is support each other through it and the adaptive flexibility.
• 33:37
  SPEAKER_02: I think those are some of the main lessons that I learned.
• 33:40
  SPEAKER_00: And to sort of speak back.
• 33:42
  SPEAKER_01: Yeah, I mean, I would just echo everything Rebecca said on a personal note.
• 33:46
  SPEAKER_01: I have learned to try and like let it go, not to channel Elsa, but like, sorry, I have three girls, but like I've also been getting so wrapped up in all this over the last year that I'm learning to also kind of take a step back and do what just realize what I can and can't do.
• 34:00
  SPEAKER_01: On a sort of bigger picture, I you know, I think Rebecca said it in regards to your last question, but one thing that I think, I honestly don't know that we're gonna learn this and carry it forward because our health system is just sort of messed up.
• 34:13
  SPEAKER_01: But the focus on outpatient, you could say an outpatient prevention.
• 34:17
  SPEAKER_01: I mean, we just miss the boat, right?
• 34:19
  SPEAKER_01: On like studying any of these therapeutics up front on the outpatient side.
• 34:23
  SPEAKER_01: And that's just simply because of the way our health system focused and the operate, the logistics of doing clinical trials, right?
• 34:30
  SPEAKER_01: There's huge, it's easier on the inpatient side than the outpatient side.
• 34:33
  SPEAKER_01: But I think it's interesting to me that, right, this has been what, 15, 16, 17 months or something, and we're now having all these amazing outpatient therapies, and it took this long to get them versus we had a lot of this other stuff faster.
• 34:47
  SPEAKER_01: We've spent so much money focused on the inpatient side for COVID when really, you know, I think most people would have said it clearly a year ago.
• 34:56
  SPEAKER_01: We were doing vaccine, of course, but like focusing on other things for prevention, even if it's not preventing infection, preventing progression to severe disease.
• 35:04
  SPEAKER_01: I hope that we can take somewhat from this that we need really need to change some of our healthcare system into being really, really focused on prevention and equity and less have our eyes on the inpatient side.
• 35:14
  SPEAKER_01: And that obviously, as Rebecca said, I think is very true for stewardship as well, right?
• 35:19
  SPEAKER_01: Like we're focusing on the very, very tip of the iceberg in the inpatient setting when all the antibiotics are being used on the outpatient setting and not really trying to prevent the impacts of that large volume of use.
• 35:29
  SPEAKER_01: The other thing, I think a lesson clearly learned, again, for me and for the world is like communication is key, right?
• 35:37
  SPEAKER_01: I mean, things have been incredibly polarized and a lot of that is out of most of our control.
• 35:42
  SPEAKER_01: But I think there have been a fair number of communication missteps.
• 35:45
  SPEAKER_01: You can think of it, I can think of it locally, you can think of it, you know, sort of like at a state level, nationally.
• 35:50
  SPEAKER_01: And I just think, you know, if you think about working in healthcare, the way that we communicate with the public, with other providers, I mean, it's so, so important.
• 36:00
  SPEAKER_01: And it's like we all need a huge communications crash course or something to make sure that we are being really transparent and not too science-y going forward as we communicate with the public.
• 36:11
  SPEAKER_00: Thank you so much for joining our uh podcast today.
• 36:15
  SPEAKER_00: I mean, this is very informative.
• 36:17
  SPEAKER_00: But before we uh come to the end of the podcast, I just want to ask if either of you have any additional thoughts you would like to share with our audience.
• 36:28
  SPEAKER_00: Dr.
• 36:28
  SPEAKER_00: Spivak, I will let you go first.
• 36:31
  SPEAKER_01: I guess I just say I'm really grateful for what I do and I really, really love my job.
• 36:34
  SPEAKER_01: But I hope people also realize, and I'll just say it out loud, like I'm incredibly burned out, and I think a lot of people are burned out and tired.
• 36:41
  SPEAKER_01: And if you think Rebecca and I aren't, we are just acknowledging that.
• 36:45
  SPEAKER_01: I think some days I'm like, gosh, how do people keeping doing all this or do that?
• 36:50
  SPEAKER_01: But again, it's sort of taking time off or relying on other people, relying on a team, and trying to have the long view that has really sort of kept me going.
• 36:58
  SPEAKER_01: But I just want to acknowledge that I'm sure everyone is really, really tired, stretched way too thin.
• 37:03
  SPEAKER_01: I do think people are recognizing what we do and that it's incredibly important.
• 37:06
  SPEAKER_01: And I'm optimistic that stewardship is only gonna sort of continue to grow and grow faster after this pandemic.
• 37:13
  SPEAKER_00: Dr.
• 37:13
  SPEAKER_00: Maher, can you close out with your final thoughts?
• 37:17
  SPEAKER_02: Yeah, I think this has been a great discussion, Emily.
• 37:20
  SPEAKER_02: I think I want to like call you in a month and check in again.
• 37:23
  SPEAKER_02: But I I would just say like one of the things that Shay gives us is this network of folks that are like highly functioning, working so hard.
• 37:33
  SPEAKER_02: And so reaching out and checking in and just understanding, you know, what we've been through and where we're going.
• 37:39
  SPEAKER_02: You know, I think this podcast just kind of exemplifies like what we can do to support each other as we're going through this.
• 37:46
  SPEAKER_02: You know, reach out to your folks, become more involved in Shay.
• 37:50
  SPEAKER_02: I know that I have benefited greatly by folks sending me their thoughts and sharing stuff through email, text and our, you know, as a field, you know, I think that's one of the strengths of working and stewardship as well, is everyone is just trying to make the right decision, right?
• 38:06
  SPEAKER_02: Everyone just wants to do the best for our patients.
• 38:08
  SPEAKER_02: So kind of keeping that at our core and supporting each other through the challenging times, I think, is where we have to go from that, what we have been doing, and where we'll go forward and how we'll get stronger.
• 38:19
  SPEAKER_02: Thanks for having us here, Shafar.
• 38:21
  SPEAKER_02: Thank you.
• 38:22
  SPEAKER_00: Thank you, Dr.
• 38:23
  SPEAKER_00: Maharing and Dr.
• 38:24
  SPEAKER_00: Speavak, for such a great conversation.
• 38:28
  SPEAKER_00: It was really a pleasure having you both here today.
• 38:32
  SPEAKER_01: Thank you for having us.
• 38:33
  SPEAKER_01: Take care.
• 38:34
  SPEAKER_00: As a reminder, this is the final episode in our four-part series.
• 38:39
  SPEAKER_00: You can find more educational content like this podcast on Shay's online education center learningce at www.learningce.shay slash online.org.
• 38:54
  SPEAKER_00: This concludes this episode of the challenges and innovations in antimicround stewardship series.
• 39:00
  SPEAKER_00: Thank you for tuning in.