Latest / The SHEA Podcast / COVID-19: Involving Antimicrobial Stewardship Programs, 4/09

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COVID-19: Involving Antimicrobial Stewardship Programs, 4/09 · The SHEA Podcast

• 0:07
  SPEAKER_01: Welcome to the Rapid Response Podcast, 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.
• 0:20
  SPEAKER_01: I am Dr.
• 0:21
  SPEAKER_01: David Bannock, Associate Professor of Medicine and Hospital Epidemiologist at the University of Connecticut School of Medicine, and I'll serve as today's podcast moderator.
• 0:29
  SPEAKER_01: Discussion on the podcast doesn't necessarily reflect Shay's perspective, but facilitates communication of multiple different perspectives and experiences as we go through this challenging time together.
• 0:38
  SPEAKER_01: Shay is excited to launch the seventh episode of this podcast, COVID-19 updates, What We Need to Know.
• 0:44
  SPEAKER_01: Today's episode will focus on how to involve antimicrobial stewardship programs in the COVID-19 response.
• 0:50
  SPEAKER_01: Our speakers for today's podcast are Dr.
• 0:52
  SPEAKER_01: Jason Pogue, Clinical Professor at the University of Michigan College of Pharmacy, and Dr.
• 0:57
  SPEAKER_01: Michael Stevens, an infectious disease specialist at Virginia Commonwealth University Health System in Richmond, Virginia.
• 1:02
  SPEAKER_01: So thank you both for joining us today.
• 1:04
  SPEAKER_01: I'll now turn it over to Dr.
• 1:05
  SPEAKER_01: Pogue to get us started with some news updates for the week.
• 1:08
  SPEAKER_02: Thanks for that introduction, David.
• 1:10
  SPEAKER_02: Thanks for having me.
• 1:11
  SPEAKER_02: Pleasure to be here.
• 1:12
  SPEAKER_02: So I think first off, it's always good to see where we're at from a number of cases standpoint.
• 1:17
  SPEAKER_02: So we're just about to hit globally one and a half million cases of COVID-19.
• 1:23
  SPEAKER_02: Here in the United States, we just passed the 400,000 threshold, so huge burden of illness.
• 1:30
  SPEAKER_02: From a death standpoint, globally, there have been over 80,000 reported deaths to date, and here in the US, about 13,000.
• 1:37
  SPEAKER_02: The other thing that I always like to look at, just to kind of get an idea of the trajectory, is you know, what are the daily rates?
• 1:44
  SPEAKER_02: So are we increasing still?
• 1:46
  SPEAKER_02: Have we stabilized out?
• 1:47
  SPEAKER_02: And if you look at the data from Hopkins, the daily global rates are about 80,000 per day new cases, and it's been pretty steady for over the last week.
• 1:56
  SPEAKER_02: So it seems to be a little bit of a plateau, at least currently.
• 1:59
  SPEAKER_02: And if you look at the US, you see very similar numbers from a stability standpoint, that is.
• 2:04
  SPEAKER_02: We have about 30,000 cases per day, and it's been pretty consistent over the last week.
• 2:10
  SPEAKER_02: So again, we seem to be at a stable daily increase.
• 2:13
  SPEAKER_02: We'll see how that goes moving forward, but I think it's always good and always helpful to get an idea of where we're at from that standpoint.
• 2:19
  SPEAKER_02: And so looking back to the past week of what else has been happening from a therapeutic standpoint, you know, we're largely where we were a week ago.
• 2:28
  SPEAKER_02: No real good novel evidence has come out to help direct us in how we should be managing these patients.
• 2:34
  SPEAKER_02: We're still going off the limited information that we had since the beginning of this pandemic.
• 2:40
  SPEAKER_02: I think probably the most interesting stuff that has come out this past week has been related to masks.
• 2:46
  SPEAKER_02: The interesting study that came out from Bay and colleagues that's published in the Annals of Internal Medicine was looking at the effectiveness of both surgical and cotton masks in blocking SARS coronavirus too.
• 2:58
  SPEAKER_02: And it was a study in four patients.
• 3:00
  SPEAKER_02: So basically what they did is they had four patients, they were COVID positive, they had active disease, and what they asked them to do was basically cough, and they held a petri dish out in front of them.
• 3:10
  SPEAKER_02: And so they had them do this with no mask on, they had them do it with a surgical mask on, and they also had them do it with a cotton mask on.
• 3:19
  SPEAKER_02: And what they wanted to see was did it stop the virus from being able to be grown in the petri disc when they had one of these masks.
• 3:26
  SPEAKER_02: Unfortunately, but maybe somewhat unsurprisingly, neither of the masks really had much of an impact.
• 3:32
  SPEAKER_02: They were able to have growth in the petri discs on just a regular cough with no masks, but also if a patient had a surgical mask or cotton mask on.
• 3:41
  SPEAKER_02: And they also swabbed both the inside and outside of those masks where they found live virus there as well.
• 3:46
  SPEAKER_02: So bottom line is that they found in this study that neither were really effective at stopping the virus.
• 3:53
  SPEAKER_02: I think that it's an interesting finding, particularly in the it was almost the same time frame where the CDC, for the first time, really recommended that cloth masks be worn when we go to places where social distancing can occur.
• 4:07
  SPEAKER_02: So when we have to go to the grocery store, when we go to the pharmacy, when we have to go out, really from a thought process of trying to, you know, limit the spread of the virus.
• 4:17
  SPEAKER_02: And I think that people are maybe conflating these two things because people hear this recommendation then also see this data set, and they're like, well, does this counter that recommendation?
• 4:28
  SPEAKER_02: I think it's important for everybody to understand that really the goal of the cough mask that, for example, I have a bandana that I put on when I went out to the store.
• 4:38
  SPEAKER_02: Really, the goal there is to try to stop asymptomatic or pre-symptomatic spread from normal activities, things like breathing, things like speaking, where we're concerned we've seen evidence that we've had some pre-symptomatic or asymptomatic spread.
• 4:51
  SPEAKER_02: So again, not actively coughing in that situation, you should still stay home in that scenario.
• 4:57
  SPEAKER_02: But I think the key thing is that this was a really interesting study for how we handle patients who are symptomatic, but doesn't really apply to what we're trying to do in the community whenever we go out, in addition to social distancing, trying to wear those cloth masks so that we don't have pre-symptomatic or asymptomatic spread.
• 5:16
  SPEAKER_02: So I'd say that those are probably the highlight of what's new this week.
• 5:20
  SPEAKER_01: Thanks for that update.
• 5:21
  SPEAKER_01: I agree there's been so much focus on masks both in healthcare settings as well as in the general public.
• 5:26
  SPEAKER_01: And the messaging can be complicated.
• 5:29
  SPEAKER_01: The message that we try to promote is that we wear masks to protect others.
• 5:32
  SPEAKER_01: That's our responsibility.
• 5:34
  SPEAKER_01: And I think that you know helps support that there's a very positive sort of social responsibility to wearing a mask to protect others in case I may be an asymptomatic individual who can shed virus or pre-symptomatic, like you mentioned.
• 5:46
  SPEAKER_01: Um, that it's really sort of out of the social obligation that we're all doing this to protect each other.
• 5:51
  SPEAKER_01: So, really, thanks for that great update.
• 5:53
  SPEAKER_01: We are going to transition the podcast a little bit to talk about the role of antimicrobial stewardship programs in the COVID-19 epidemic.
• 6:01
  SPEAKER_01: With that, I want to turn the discussion over to Dr.
• 6:03
  SPEAKER_01: Stevens, who's done a lot of work in antimicrobial stewardship in general and is really a leader in this area.
• 6:08
  SPEAKER_01: Dr.
• 6:08
  SPEAKER_01: Stevens, do you want to give a little background as to your thoughts in this uh more broadly and then we'll get into some more specific details?
• 6:14
  SPEAKER_00: Yeah, David, thank you for that kind introduction.
• 6:17
  SPEAKER_00: This really came about early March.
• 6:20
  SPEAKER_00: I put a poll on Twitter.
• 6:21
  SPEAKER_00: The antibiotic stewardship community is actually pretty active on Twitter.
• 6:25
  SPEAKER_00: I put a poll there asking what other programs have done or have they been involved in COVID-19 preparation or response efforts.
• 6:32
  SPEAKER_00: I think all of us can agree March 1st in the United States feels very different than April 8th.
• 6:37
  SPEAKER_00: And sort of back on March 1st, about 58% of people who responded to that poll indicated they had been involved in response efforts, but a large portion of people had not.
• 6:47
  SPEAKER_00: And so there were some crowdsourcing of potential ideas, and ultimately I want to acknowledge Drs.
• 6:53
  SPEAKER_00: Kyle Patel, who's up at University of Michigan, working at the VA up there, and Prionori up at Albert Einstein Montgori in New York City.
• 7:02
  SPEAKER_00: We all put our heads together and came up with some ideas around how we could involve stewardship programs in the COVID-19 response efforts.
• 7:09
  SPEAKER_00: And this led to a letter to the editor in Infection Control Hospital Epi that was published on March 13th.
• 7:16
  SPEAKER_00: The title of that is Involving Antibiotic Stewardship Programs in COVID-19 response efforts all hands on deck.
• 7:22
  SPEAKER_00: I'll briefly just mention a couple of things we found.
• 7:25
  SPEAKER_00: It was very interesting because really we could find almost nothing about involving stewardship programs in disaster response planning.
• 7:34
  SPEAKER_00: We could find almost nothing anywhere where stewardship programs had been mentioned as sort of key players in response efforts.
• 7:42
  SPEAKER_00: So we we said this is a population of folks that have really specialized knowledge and skills, and really when we're talking about response to the COVID-19 pandemic, it's an all-hands-on-deck scenario, and we need to engage these talented individuals.
• 7:58
  SPEAKER_00: And we identified numerous potential opportunities, including utilizing some of the day-to-day techniques that stewardship programs use for case identification, especially folks that aren't captured on entry into the health system.
• 8:11
  SPEAKER_00: Diagnostic stewardship, responding in real time when testing results come back, guideline creation, and this ended up being a huge area where I think a lot of stewardship programs have been engaged.
• 8:22
  SPEAKER_00: And then also anticipating and managing drug shortages, often now in creative ways involving drugs that we don't typically look at from the stewardship perspective.
• 8:32
  SPEAKER_00: And then the other thing was assisting with often complex paperwork related to obtaining medication like from Death Severe via compassionate use back when the compassionate use program was open.
• 8:42
  SPEAKER_00: I can say locally, this was enormously valuable.
• 8:46
  SPEAKER_00: This exercise in thinking about how stewardship programs could become involved, led us to stand up guidelines early, three to four weeks before we started seeing activity here in Virginia, and then also putting restrictions in place and doing planning around potential issues with medication supply, three or four weeks again before things really um started to ramp up here in Virginia.
• 9:07
  SPEAKER_00: And I know in communications with Pyle and PRIA, even as late as today, that they found it useful to sort of go through this and think about this.
• 9:15
  SPEAKER_01: Great.
• 9:15
  SPEAKER_01: That's a really terrific overview on the topic.
• 9:18
  SPEAKER_01: You've highlighted a few specific areas that I want to get into a little bit more depth with both you and Dr.
• 9:22
  SPEAKER_01: Pogue on your roles that you've had at your institution from an antimicrobial stewardship perspective.
• 9:27
  SPEAKER_01: So the first area that you mentioned was really looking at post-prescriptive review or prospective auditing and feedback to providers.
• 9:33
  SPEAKER_01: We think about that most commonly with antibacterials, but in the COVID-19 era, we're looking at maybe different drugs that don't typically fall within the usual context of antimicrobial stewardship.
• 9:45
  SPEAKER_01: And I think there's a great opportunity for ASP programs to get involved.
• 9:48
  SPEAKER_01: So maybe I'll first I'll turn to Dr.
• 9:50
  SPEAKER_01: Pogue.
• 9:51
  SPEAKER_01: Can you share some of your experiences and sort of what your vision is like as far as the antimicrobial stewardship role in helping with auditing and providing feedback on some medications that are now being used for patients with COVID-19 infection?
• 10:04
  SPEAKER_02: Yeah, I mean that's a great question.
• 10:06
  SPEAKER_02: I think that there are two parts to that.
• 10:08
  SPEAKER_02: So the first is with regards to trying to figure out treatment pathways and paradigms.
• 10:13
  SPEAKER_02: And I think that this is really where stewardship's niche in this space is because, again, as you start to see these patients come in, they start to come in by the bucket full, right?
• 10:24
  SPEAKER_02: You see more and more patients coming in.
• 10:27
  SPEAKER_02: The frontline providers are not going to be aware of all the latest publications that come out.
• 10:32
  SPEAKER_02: There seems to be 20 preprints a day, there seems to be 300 new entries on PubMed a day, and really being able to sift through that, critically analyze that literature and helping to inform therapeutic decisions, if any, with regards to any potential antivirals.
• 10:49
  SPEAKER_02: I think it's a it's critically important to do.
• 10:51
  SPEAKER_02: I think it's a natural role for stewardship because that's what we do normally.
• 10:56
  SPEAKER_02: And certainly, again, the ED providers, the ID docs who are on service, the ICU teams, they're managing all of these patients.
• 11:03
  SPEAKER_02: So they really need that assistance, and it's where we can kind of help out.
• 11:07
  SPEAKER_02: So the second part of you know, how does that fit in with post-prescriptive review?
• 11:12
  SPEAKER_02: I think that post-prescriptive review probably isn't the most important thing right now because, again, I will tell you that as these cases started to take off at our institution, you now kind of get to that place where it's COVID or unless ruled out or otherwise know that it's not in that situation.
• 11:30
  SPEAKER_02: And so you're really seeing the empiric therapy in these patients being driven towards the management of that, which may or may not be the use of some antivirals.
• 11:40
  SPEAKER_02: What the response to that should be, the normal course of the disease state is really unclear in a lot of ways.
• 11:46
  SPEAKER_02: And so there isn't necessarily a starting or escalation type piece that comes to it.
• 11:52
  SPEAKER_02: With that being said, I do think that you know, for institutions that maybe aren't seeing a lot of patients yet, ASVs can actually be very helpful in maybe identifying these patients or practitioners.
• 12:04
  SPEAKER_02: It might not be on the radar for institutions where they're still only seeing a smattering of cases, or maybe they haven't even seen a patient come in yet.
• 12:11
  SPEAKER_02: And they might be getting started empirically for the management of community car pneumonia or hospital car pneumonia.
• 12:17
  SPEAKER_02: And so as part of the prescription review, you know, the normal prospective audit and feedback that you might be doing for your patients, I think there's a great opportunity for stewardship programs to be aware of what these patients look like.
• 12:30
  SPEAKER_02: If you have those kind of typical presentations where you're seeing, you know, loss of smell, loss of taste, potential gastrointestinal manifestations, worsening shortness of breath, fever, cough, and that positive CT scan, you know, certainly as part of your review, if it's not as kind of commonplace at the institution that you're at, you can certainly be bringing that to the primary teams of saying, you know what, this could be what's going on here.
• 12:55
  SPEAKER_02: Should we look into this as a potential etiology of this infection?
• 12:59
  SPEAKER_02: And I think that even more so as we move forward, whenever we get out of just this mass amount of cases, it's gonna always be keeping this on our radar.
• 13:09
  SPEAKER_02: When patients are starting on community-acquired pneumonia antibiotics down the road in three, six months, this is still something that's gonna be have to be on our radar.
• 13:18
  SPEAKER_02: And I think that because we will, as a nature of stewardship programs, reviewing these patients who are on antibiotics, it can be another set of eyes to try to direct people to consider this as a diagnosis in these patients.
• 13:31
  SPEAKER_01: Yeah, I think that's terrific.
• 13:32
  SPEAKER_01: I like how you're really emphasizing the collaborative model, which has really now become almost universal with antimicrobial stewardship programs, and then also thinking about the future and the role that antimicrobial stewardship may have in identifying patients with COVID-19 and collaboratively managing them.
• 13:48
  SPEAKER_01: So, Dr.
• 13:49
  SPEAKER_01: Stevens, anything else to add from this perspective?
• 13:51
  SPEAKER_00: Jason did a really good job summarizing it.
• 13:54
  SPEAKER_00: I would just throw in there from a you know simple post-antibiotic order review with feedback to providers' standpoint, a lot of these patients coming in look really sick.
• 14:03
  SPEAKER_00: They've got profound hypoxic respiratory failure, they've got really abnormal imaging, and I think everybody knows it can be difficult to tease out who's got a bacterial superinfection.
• 14:14
  SPEAKER_00: A major role for stewardship programs in that setting, I think, is helping folks craft the best regimens with a narrow spectrum that can be de-escalated as rapidly as possible and used for the shortest duration.
• 14:26
  SPEAKER_00: So for instance, you know, oftentimes people can get away with, say, septiraxone as opposed to traditional healthcare associated pneumonia coverage, that sort of stuff.
• 14:35
  SPEAKER_00: So from that standpoint, I think stewardship programs are very experienced.
• 14:39
  SPEAKER_00: They've got the knowledge, skills, and tools to be able to inform management there and just sort of a natural fit.
• 14:45
  SPEAKER_02: Yeah, Mike, I just want to comment on that.
• 14:47
  SPEAKER_02: I think you're spot on.
• 14:48
  SPEAKER_02: And just in looking at these patients, they're super sick and they have pneumonia, right?
• 14:52
  SPEAKER_02: And so whether or not there's a bacterial component or not is often a concern.
• 14:56
  SPEAKER_02: Procalcitonins in these patients can be all over the map, super high, even without having a bacterial infection.
• 15:03
  SPEAKER_02: So I agree with you that strategies to limit the use of antibiotics in those patients are certainly within our wheelhouse, certainly something we should be looking at.
• 15:12
  SPEAKER_02: Again, as you know, this can be challenging because you can't get a respiratory sample in these patients because it might not be safe to do so, right?
• 15:19
  SPEAKER_02: And so things like mRSA nasal swabs, those general things that we can do to try to get them to the simplest, shortest regimen, as you kind of just talked about, I think become really important.
• 15:30
  SPEAKER_02: And then just educating, right, on the fact that, yeah, procalcitonin probably isn't informative.
• 15:35
  SPEAKER_02: And if you don't have another reason to think there's a bacterial component to this infection, you should consider stopping the antibiotics because if you look at the published data, you don't see a lot of co-infections with bacteria in these patients.
• 15:48
  SPEAKER_02: You might see bacterial superinfections down the road, particularly in the ventilated population.
• 15:53
  SPEAKER_02: But really, again, as we talked about a little bit before, it's a huge opportunity, I think, for stewardship programs to stay abreast of the literature and really help educate and inform those end users of what people are seeing.
• 16:07
  SPEAKER_01: These are terrific points.
• 16:08
  SPEAKER_01: You know, I think the importance of ASPs in staying on top of the literature, which is evolving so quickly, is really critical.
• 16:15
  SPEAKER_01: And that actually takes me to the next topic I wanted to talk about, which was sort of the development of institutional guidelines.
• 16:21
  SPEAKER_01: I mean, each facility, I think, is trying to develop their own guidelines for managing patients with COVID-19.
• 16:27
  SPEAKER_01: We've done that, and I'd imagine your institutions have as well.
• 16:29
  SPEAKER_01: And antimicrobial stewardship, physicians and pharmacists have been really instrumental at that.
• 16:34
  SPEAKER_01: In my institution, our ID pharmacist Jeff Aichelman has really taken the lead in developing our own institutional guidelines.
• 16:40
  SPEAKER_01: So maybe you could reflect on your respective experiences on the role of ASPs in developing institutional guidelines for managing patients with COVID-19, both in terms of COVID-19 specific therapies as well as sort of the broader context of administration of antibacterials.
• 16:56
  SPEAKER_01: Maybe I'll turn to Jason first.
• 16:58
  SPEAKER_02: Yeah, so again, I think this is a great opportunity for stewardship programs, really what we should be doing.
• 17:04
  SPEAKER_02: And I guess the again, it's it's a very interesting guideline to develop too, right?
• 17:10
  SPEAKER_02: Because of the fact that you just you don't know a lot and you're learning more every day.
• 17:14
  SPEAKER_02: And so one of the things that we did, again, kind of as that first go-around, was just as we kind of started to take in on the literature, we were learning about new agents, right?
• 17:26
  SPEAKER_02: Things that we certainly aren't used to giving to patients, trying to interpret a small amount of literature, making best case decisions for your institution.
• 17:35
  SPEAKER_02: A couple of lessons that I would say that I've learned from it from that standpoint is one, the importance of transparency.
• 17:41
  SPEAKER_02: We're recommending this in this scenario, and here's why, here's how we're weighing and balancing these different things.
• 17:48
  SPEAKER_02: We're preferring patients get enrolled into clinical trials, here's why we're trying to do that.
• 17:54
  SPEAKER_02: And then also being straightforward upfront and saying that this is what our best interpretation of what we know now is.
• 18:02
  SPEAKER_02: And then I will tell you that particularly for the last two weeks and really in that first kind of week and a half where things started to take off in the US, it felt like every day at least once we were making slight modifications to what we were recommending, when we were recommending it, was there a dose change that we were looking at in that situation?
• 18:21
  SPEAKER_02: And so again, I think just making sure that you're informing people surrounding that.
• 18:26
  SPEAKER_02: And then to your point, though, is that there's that other piece of it, right?
• 18:30
  SPEAKER_02: Is that it's it might be a COVID-19 management guideline, but there's also the do I need antibiotics?
• 18:38
  SPEAKER_02: If so, what antibiotics?
• 18:39
  SPEAKER_02: And so you can use the opportunity to reinforce, and that's what we did, was really, you know, the community acquired pneumonia guideline changes that we had done.
• 18:47
  SPEAKER_02: If you are suspecting this, here's what you should be using in this situation, limiting the use of MRSA drugs, pseudomonal drugs, things of that nature.
• 18:57
  SPEAKER_02: And so that that's kind of how we attacked it at Michigan.
• 19:01
  SPEAKER_02: But like I said, it's a daily conversation with our group and modifications are made frequently.
• 19:07
  SPEAKER_01: And how about Dr.
• 19:08
  SPEAKER_01: Stevens?
• 19:08
  SPEAKER_01: Do you have any additional comments on guideline development?
• 19:11
  SPEAKER_01: Can you speak to your experience?
• 19:12
  SPEAKER_00: Yeah, so you know, I think this is definitely an area where in the future, when we think about outbreak response, this is going to be a natural fit for stewardship programs.
• 19:21
  SPEAKER_00: I think none of us knew that before this pandemic, not really, but we all have experience with guideline development locally and we're looked to as a source for that, at least many programs are.
• 19:31
  SPEAKER_00: And so there's a couple things I will highlight.
• 19:33
  SPEAKER_00: One is I have been so humbled and impressed by our community nationally and globally in terms of sharing guidelines on the flight and what people think are best practice.
• 19:45
  SPEAKER_00: So when we were creating our local guidelines, they were informed by no fewer than five other medical centers where we were all exchanging ideas about potential best practice where there is really a positive data to guide anything.
• 19:57
  SPEAKER_00: And I think that really has been an impressive element of this, and I know other folks at other places share that sentiment.
• 20:04
  SPEAKER_00: And the other thing is I agree with what Jason was mentioning, our guidelines are frequently updated, and we include things that help message best practice around things, say, for instance, hydroxychloroquine plus azothromycin.
• 20:17
  SPEAKER_00: The data for that are really hypothesis generating at best, and that is not something we're recommending.
• 20:24
  SPEAKER_00: But in our guidelines, we link to the evidence and the reasoning behind that, just like Jason had mentioned.
• 20:30
  SPEAKER_00: Other things that I'll mention, I think really locally, we've become the stewardship program, the quarterback for the guidelines, and that's helped a lot because we really have to look at a number of different groups that are doing different things in terms of several clinical trials, trying to fit what's going to be the best therapy to offer patients at different time points in their disease course, and we've really helped folks navigate that so it's collaborative, and patients are getting sort of the best options at any given point in their disease course.
• 20:58
  SPEAKER_00: I think stewards naturally are able to do this because we have had to lead through collaboration and influence, positive influence, as sort of our normal work.
• 21:07
  SPEAKER_00: And so I think that's a natural role for us as stewards.
• 21:11
  SPEAKER_01: I think you raised a lot of great points.
• 21:13
  SPEAKER_01: It just seems like such a natural fit for intimacopas stewardship programs to be involved in this aspect of the COVID-19 epidemic.
• 21:19
  SPEAKER_01: Lastly, I want to close with uh a question about new therapeutics.
• 21:23
  SPEAKER_01: This is something that we all get excited about, particularly in light of the very limited options and the very, very limited data that supports existing options.
• 21:31
  SPEAKER_01: So you know, I was hoping you could speak a little bit on to the role of ASPs in uh evaluating new therapeutics for COVID-19.
• 21:39
  SPEAKER_01: First, I'll turn to Dr.
• 21:40
  SPEAKER_01: Stevens.
• 21:41
  SPEAKER_00: David, I appreciate the question.
• 21:42
  SPEAKER_00: And I'll speak to it in two parts.
• 21:44
  SPEAKER_00: One is clinical trials.
• 21:46
  SPEAKER_00: Certainly, I think Stewardship has a role here, again, quarterbacking with the guidelines, collaborating very closely with the research groups that are investigating things like novel IELTS inhibitors or remdesivir or other things that people are looking at.
• 22:00
  SPEAKER_00: of which there are sort of numerous things people are looking at.
• 22:03
  SPEAKER_00: It makes a lot of sense for us to help quarterback that because we can make sure that patients are being approached in a fashion that makes sense in terms of the benefits to them from the different therapeutic options in a way that all the different groups are collaborating in the most optimal fashion.
• 22:20
  SPEAKER_00: In terms of other therapeutics, things that have emergency use authorization like chloroquine, hydroxychloroquine, we have a natural role there and I think one of the primary roles is through um antibiotic restrictions.
• 22:32
  SPEAKER_00: So for instance we locked down chloroquine, hydroxychloroquine, lopinivir, ritonavir, therunavir, cobi cystat early on.
• 22:41
  SPEAKER_00: I'm not saying that we really are using lopinavir, ritonavir and certainly not using thirunavir or cobicystat, but we restricted everything early in March just to say, well we don't know where things are going.
• 22:52
  SPEAKER_00: Let's use that tool in our toolbox and then make sure that we're monitoring the stock of these different medications closely so that we will have them if and when we need them for our patients.
• 23:02
  SPEAKER_00: Messaging around drug availability is also critical and we include those data in our guidelines actually so people have a sense of where we are, what the targets are for the total number of patients we anticipate wanting to treat.
• 23:15
  SPEAKER_02: I'm going to jump in there because in addition to agreeing with what Mike said, I feel like one of the most important roles that stewardship has played or does play in this whole story is critically assessing when someone says a new therapy is going to be effective, really thinking through that and stopping that if it needs to be stopped.
• 23:38
  SPEAKER_02: And again I want to use the example of ivermectin just because that was the latest fad drug for about 24 hours and you know that stems from in vitro activity at some micromolar concentration and it looks like a low number and people start to get excited and I understand that because we all want therapeutic hope for our patients.
• 23:59
  SPEAKER_02: But it's it's a simple three calculations until you realize that that concentration is one one hundredth of the concentration that you get of that drug in a patient.
• 24:09
  SPEAKER_02: And so I think that there's a super important role for for stewardship programs in asking the critical questions, even though there are still a lot of unknowns that we don't know the answers to, at least asking them and if a therapy does not even make sense on the surface level moving on from that so that we're not unnecessarily giving these to patients and we're not potentially withholding therapies that might work.
• 24:33
  SPEAKER_01: Great.
• 24:33
  SPEAKER_01: No I think those are really all critical perspectives on evaluating new therapies.
• 24:38
  SPEAKER_01: So I got to close with one last question you guys are two of the best in the game when it comes to social media and Twitter and antimicrobial stewardship.
• 24:45
  SPEAKER_01: Can you just share briefly your thoughts on sharing information through Twitter and the potential value in sharing antimicrobial stewardship related information in the COVID-19 era?
• 24:55
  SPEAKER_00: Yeah so you know I think it's a really powerful platform.
• 24:59
  SPEAKER_00: The stewardship community is very active and it's pretty amazing how quickly you can see new studies being posted.
• 25:06
  SPEAKER_00: It's a great way to connect quickly with colleagues.
• 25:09
  SPEAKER_00: You know obviously there are a lot of potential pitfalls with social media people should be aware of but if used correctly it can be a powerful and collaborative tool.
• 25:19
  SPEAKER_02: Yeah that is a loaded question there's a lot of good and there's a lot of bad right I think it has been really great to one there are certain accounts that are really on top of the literature and and when something new comes out you know you learn about it right away you can start to have that discussion with colleagues.
• 25:37
  SPEAKER_02: Mike and I have chatted about things over there before it's a great opportunity to do that in that situation.
• 25:43
  SPEAKER_02: You do have to realize that there are some issues with social media particularly in something that is as politically charged as the management of these patients so you do have to tread a little bit lightly from that standpoint.
• 25:54
  SPEAKER_02: But I'm going to focus on the good here and say that it's really a good chance to you know crowdsource to get information.
• 26:01
  SPEAKER_02: As Mike said this community has been amazingly transparent, collaborative of sharing this information with one another and social media does offer the opportunity to do that in real time pretty quickly.
• 26:14
  SPEAKER_01: Well thanks for that perspective I agree there's a lot of great information out there that needs to be evaluated carefully but I'm always grateful of information that you both provide in social media.
• 26:24
  SPEAKER_01: So with that I want to thank you both for joining our podcast and sharing your perspectives and your experiences and a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID 19.
• 26:36
  SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE under the Rapid Response Program.
• 26:42
  SPEAKER_01: You'll also find additional resources such as the recording webinars healthcare facility outbreak preparedness and the SHA COVID 19 town halls.
• 26:50
  SPEAKER_01: Additional resources available on Learning CE pertinent to this pandemic include the SHA CDC Outbreak Response Training Program, the ORTP and the prevention course in HAI knowledge and control prevention check.
• 27:03
  SPEAKER_01: Thank you again Dr.
• 27:04
  SPEAKER_01: Pogue Dr.
• 27:05
  SPEAKER_01: Stevens this was terrific I really appreciate you coming on.
• 27:08
  SPEAKER_02: Thanks for having us and take care everybody take care thank you.