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IV to PO from an Ambulatory Perspective: An Intervention Worth the Effort? · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to our podcast series, Antimicrobial Stewardship Popi, brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antimicrobial resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:27
  SPEAKER_02: This series will discuss communication techniques for antimicrobial stewardship, evaluate the opportunities and limitations of antimicrobial IB to PO conversions, and identify best practices when shortening durations of therapy.
• 0:40
  SPEAKER_02: I am Dr.
• 0:41
  SPEAKER_02: Rebecca Wren of Duke University Hospital, where I serve as the coordinator of infectious disease pharmacy programs, co-chair of the antimicrobial stewardship and evaluation team, director of the PGY2 Infectious Disease Residency Program, and adjunct associate professor for Duke University School of Medicine.
• 0:59
  SPEAKER_02: I will be your podcast moderator today.
• 1:01
  SPEAKER_02: Shay is excited to launch this episode of the podcast series, which is entitled IV to PO from an ambulatory perspective, an intervention worth the effort.
• 1:11
  SPEAKER_02: IV2PO conversion has immense potential to benefit patients by preventing unnecessary intro therapy associated with risks such as prolonged length of stay, Line-associated infections, and excess costs and inconvenience to patients.
• 1:26
  SPEAKER_02: Although it is often listed as low-hanging fruit for antimicrobial stewardship programs, there are many nuances to cover.
• 1:33
  SPEAKER_02: This podcast will discuss special cases, big successes, and gaps in our current understanding of IB2PO conversion, specifically in the ambulatory setting.
• 1:42
  SPEAKER_02: I'm happy to introduce our two speakers for today.
• 1:45
  SPEAKER_02: First, we have Dr.
• 1:46
  SPEAKER_02: Monica Mahone, Clinical Pharmacy Specialist in Infectious Diseases as Beth Israel Deaconess Medical Center, and Dr.
• 1:54
  SPEAKER_02: Neil Ritchie, Deputy Clinical Director of Medical Services at Queen Elizabeth University Hospital, an honorary senior clinical lecturer at the University of Glasgow.
• 2:04
  SPEAKER_02: Thank you both for joining us today.
• 2:06
  SPEAKER_02: Thank you for having us.
• 2:08
  SPEAKER_00: Yes, thank you very much.
• 2:09
  SPEAKER_02: All right.
• 2:10
  SPEAKER_02: So to get things started, I'd like each of you to describe your current practice setting and how you approach IV to PO specifically as patients transition out of the hospital, or perhaps when you see them in the ambulatory setting.
• 2:23
  SPEAKER_02: What's one of your biggest successes intervening to switch these patients to oral therapy?
• 2:27
  SPEAKER_02: Dr.
• 2:28
  SPEAKER_02: Maloney, we'll start with you.
• 2:30
  SPEAKER_01: Sure.
• 2:30
  SPEAKER_01: So I think it'd be good to give some background on both of our clinical practices because I know that Dr.
• 2:35
  SPEAKER_01: Richie is from outside the US and vastly different practices across the seas, vastly different practices across the US as well.
• 2:42
  SPEAKER_01: I think that's one of the biggest things that I learn as I talk to more OPET practitioners is that we all practice very differently.
• 2:49
  SPEAKER_01: There is no one standard way.
• 2:50
  SPEAKER_01: So here at Beth Israel, we are lucky that we have a multidisciplinary OPET team.
• 2:55
  SPEAKER_01: It's led by an OPAT physician.
• 2:57
  SPEAKER_01: We have a nurse practitioner who sees mostly bone and joint infections on the inpatient side, then sees them in the outpatient setting as well.
• 3:03
  SPEAKER_01: Two ID nurses, myself as an ID pharmacist, and then administrative support.
• 3:08
  SPEAKER_01: I want to point out that this is nobody's full-time job.
• 3:11
  SPEAKER_01: We all have other responsibilities that we are responsible for, but this is a common ground for all of us.
• 3:18
  SPEAKER_01: At our institution, patients have to be being sent home on two weeks or longer of IV antibiotics.
• 3:24
  SPEAKER_01: Sometimes we will take more complex oral patients as well, but that two weeks is our marker or our time marker.
• 3:30
  SPEAKER_01: And additionally, ID has to see the patient.
• 3:32
  SPEAKER_01: So they have to formally be consulted on the inpatient side.
• 3:35
  SPEAKER_01: Either they've been following them all along for their stay, or you know, they want to enroll them in the OPAT program.
• 3:40
  SPEAKER_01: So ID sees them one time, writes a formal intake note, and then transitions to OPAT.
• 3:46
  SPEAKER_01: In my practice, half my time is in OPED, the other half is ID clinic.
• 3:50
  SPEAKER_01: So I kind of see the whole spectrum of ambulatory ID.
• 3:53
  SPEAKER_01: What is a big success?
• 3:55
  SPEAKER_01: This is the loaded question and kind of the 10,000$10 million question.
• 3:59
  SPEAKER_01: Pick your dollar amount, that's the question.
• 4:01
  SPEAKER_01: And I think the biggest success would be if we are thinking of transitioning a patient from IV to oral therapy, try to intervene prior to discharge.
• 4:10
  SPEAKER_01: Now I know that we're supposed to be focusing on the ambulatory side, but since we are talking about transitioning from IV to PO, if you look at when we have patients on IV, it's a lot of times when patients are started on the inpatient side and then being discharged, the transitions of care.
• 4:25
  SPEAKER_01: It's very rare that we have a patient that's being started on IV therapy in the outpatient setting.
• 4:31
  SPEAKER_01: It happens, but I think that's the exception rather than the rule.
• 4:34
  SPEAKER_01: So I think the biggest impact that we can have is try to intervene, switch that patient over to oral therapy prior to discharge.
• 4:42
  SPEAKER_01: Wrap it all up, top it with a bow, and have a nice complete package.
• 4:46
  SPEAKER_01: What does that mean?
• 4:46
  SPEAKER_01: That means do the benefits investigation while the patient is still in-house.
• 4:50
  SPEAKER_01: Will the insurance cover the prescription?
• 4:52
  SPEAKER_01: What is a copay?
• 4:53
  SPEAKER_01: How long will it take to get delivered?
• 4:55
  SPEAKER_01: A lot of times we're talking about some of the newer oral antibiotics and they have a limited distribution model.
• 5:00
  SPEAKER_01: So only certain pharmacies can deliver.
• 5:02
  SPEAKER_01: Sometimes it's locked into a specialty pharmacy.
• 5:05
  SPEAKER_01: See if the patient needs financial assistance.
• 5:07
  SPEAKER_01: Some of these medications are expensive, even though they are technically covered by their insurance.
• 5:12
  SPEAKER_01: And then make sure that the medication can it be delivered to the patient's bedside.
• 5:15
  SPEAKER_01: More and more institutions have med-to-bed delivery programs.
• 5:18
  SPEAKER_01: And I think getting that drug to the patient's hand before they even leave, sending them home with it, counseling them on how to take it is key to ensuring success and not delaying any care as they transition to that oral medication.
• 5:31
  SPEAKER_02: So, what is the trigger for you guys to become involved in the patient's care and the transition point of OPEC?
• 5:39
  SPEAKER_01: So I wish we had more people in OPET.
• 5:41
  SPEAKER_01: And hopefully this will plant seeds and in people's minds to expand their OPET programs.
• 5:46
  SPEAKER_01: My particular role focuses more on the outpatient side.
• 5:50
  SPEAKER_01: I would love to have an inpatient counterpart, a pharmacist that focuses on that transition aspect, a pharmacist that gets tagged in as soon as that patient is enrolled in OPET.
• 6:00
  SPEAKER_01: I did talk about that our ID colleagues, nurse practitioner and physicians, they do have to see the patient to formally enroll them in OPET.
• 6:08
  SPEAKER_01: But then getting myself involved, trying to figure out what that best oral option is, that is unfortunately not as standardized, just because, as I mentioned before, we all have different responsibilities that we are trying to take care of as well.
• 6:22
  SPEAKER_01: Exactly.
• 6:22
  SPEAKER_01: Yeah, just like everybody during the pandemic, right?
• 6:25
  SPEAKER_01: We're all an ID.
• 6:27
  SPEAKER_01: So if you are lucky enough to have a dedicated transitions of care team, I think that is a big proponent, big way to ensure success.
• 6:37
  SPEAKER_01: And I know that we'll we'll be talking about that transitions of care aspect more during the podcast.
• 6:42
  SPEAKER_02: Yeah, thank you so much for that.
• 6:43
  SPEAKER_02: That's really helpful.
• 6:44
  SPEAKER_02: And Dr.
• 6:45
  SPEAKER_02: Ruchi, from your perspective, I know your practice is quite different.
• 6:48
  SPEAKER_02: So if you can describe that a little bit and then kind of talk about some of your successes as well.
• 6:53
  SPEAKER_00: Yes, thanks very much.
• 6:54
  SPEAKER_00: So obviously, working within the state-funded healthcare model in Scotland, some of the funding issues are very different that we face.
• 7:03
  SPEAKER_00: But it's interesting how the broad setup of our OPAT service sounds to be very similar.
• 7:08
  SPEAKER_00: So there are three infectious disease consultants who work as part of our OPAT service in Glasgow.
• 7:14
  SPEAKER_00: I think we have it's we're about to expand our number of specialist nurses.
• 7:17
  SPEAKER_00: I think we have four specialist nurses and an advanced nurse practitioner, but that will shortly be increasing in number.
• 7:23
  SPEAKER_00: And we have two antimicrobial specialist pharmacists who work as part of our unit.
• 7:27
  SPEAKER_00: And just as in the Beth Israel model for OPAD, it's none of our full-time jobs either.
• 7:32
  SPEAKER_00: We're all doing some other things as part of our role.
• 7:36
  SPEAKER_00: My particular area of interest is orthopedic infection.
• 7:39
  SPEAKER_00: And what I've tried to develop through my practice is a model of care for patients with complex orthopedic infection that run from the pre-operative planning phase right through to our discharge and post-discharge care for them, where we start planning what antibiotic therapy the patient might receive at the earliest possible stage.
• 8:01
  SPEAKER_00: So, for example, we might discuss a patient who is going to have a planned orthopedic implant revision and plan different scenarios for what their antibiotic therapy might be based on what we know about them, and then seek to get them out of hospital really, very quickly.
• 8:17
  SPEAKER_00: Sometimes for upper limb surgery, even manage that patient as a day case and discharge them on parental antibiotic therapy or an ambulatory basis immediately after their surgery, although that's still relatively unusual, and we'd like to increase that.
• 8:29
  SPEAKER_00: And I certainly agree that planning for oral therapy at the earliest possible stage is really important.
• 8:34
  SPEAKER_00: There are all of the logistic issues around discharge, access to medicines, suitability for ambulatory care that we've talked about.
• 8:42
  SPEAKER_00: But the other thing is the complexity of oral antibiotic therapy, I think, is really quite high.
• 8:48
  SPEAKER_00: And so, whereas sometimes putting a patient on an intravenous antibiotic, there might be lots of logistic challenges for them.
• 8:55
  SPEAKER_00: How do we deliver the antibiotic?
• 8:56
  SPEAKER_00: What's their line care like?
• 8:58
  SPEAKER_00: And so on.
• 8:59
  SPEAKER_00: It's relatively uncommon that we have to worry about drug-to-drug interactions, for example, with intravenous therapies.
• 9:04
  SPEAKER_00: So sometimes it might be a much easier option to treat an older, frailer patient actually with an intravenous lycopeptide than it would be to manage them with a quinolone ravampison combination, for example, because of the drug interactions.
• 9:17
  SPEAKER_00: And so trying to plan for that at an early stage and think about what a patient might be most suitable for is really important.
• 9:23
  SPEAKER_00: When I think about successes in terms of intervening with oral therapy, it's really through that orthopedic process that I would look back on and see as being, you know, if I've had success, then it's there.
• 9:33
  SPEAKER_00: Because what we have now is a model where we're able to discharge the vast majority of patients who might previously.
• 9:40
  SPEAKER_00: I'm going to talk about the OVA study a little bit more later on in the podcast, but before the Oviva study, we were discharging almost all of our patients on intravenous therapy who'd had major orthopedic revision surgery.
• 9:49
  SPEAKER_00: And now it's a small minority actually that are discharged on intravenous therapy, and we manage most of them by converting them to oral pre-discharge.
• 9:57
  SPEAKER_00: And I think that's a big step forward for patients.
• 10:00
  SPEAKER_00: It allows us to include patients who we wouldn't previously have been able to include and reduces things like Line infections, and I think makes a really big difference to my cohort of patients.
• 10:10
  SPEAKER_02: Yeah, that's excellent.
• 10:11
  SPEAKER_02: Can you talk to us a little bit more about kind of the COPAT term?
• 10:14
  SPEAKER_02: What does that mean and what is the success you've guys seen since you wrote about that in 2019?
• 10:21
  SPEAKER_00: Yeah, thank you.
• 10:22
  SPEAKER_00: So we wrote that opinion piece in JEC to coincide with the publication of the Aviva study in the New England Journal of Medicine in the same month.
• 10:30
  SPEAKER_00: And for people who are listening who don't know about the AVBA study, it was a UK-based multi-center, large randomized controlled trial that was essentially a pragmatic study that looked at patients with orthopedic infection or bone and joint infection who were randomized to either receive an investigator-selected intravenous regime or an investigator-selected oral regime.
• 10:52
  SPEAKER_00: It was an open label study, so patients and investigators knew what the patient was receiving.
• 10:57
  SPEAKER_00: And staph aureus bacteria was excluded because it was felt that early oral switching was perhaps not appropriate in those cases.
• 11:04
  SPEAKER_00: And it was a it was a study which demonstrated that, or at least I believe it demonstrated that in the main, oral therapy is a reasonable choice for the majority of our patients.
• 11:14
  SPEAKER_00: Outcomes were very similar.
• 11:16
  SPEAKER_00: The study wasn't powered to look into all the subgroups, so I don't think you can exclude that there aren't subgroups that benefit from intravenous therapy, and I'm sure there are some subgroups that do benefit, but broadly speaking, it supported an approach of early intravenous switching in bone and joint infection.
• 11:29
  SPEAKER_00: And so we wrote our OPAT to COPAT article, and I should credit my colleague and much more experienced hand in antimicrobial stewardship, Andrew Seaton, for both coming up with the COPAT idea and really driving it forward in our in our institution.
• 11:42
  SPEAKER_00: The idea of OPAT to COPAT is around saying that it's the complexity of the patient and their therapy that should count for being included in an infectious diseases-led ambulatory infection service.
• 11:54
  SPEAKER_00: So we have patients on IV therapy in our OPAT, we have patients on oral therapy in our OPAT, and really that's not the criteria that we would use to judge whether they should be involved in our care.
• 12:05
  SPEAKER_00: It's the complexity of the patient.
• 12:07
  SPEAKER_00: And so I mentioned quinolone ravampicin combinations a few minutes ago.
• 12:11
  SPEAKER_00: You know, many of those are quite complicated.
• 12:13
  SPEAKER_00: Patients who need to have drug interactions monitored, maybe adjustments made to their medication.
• 12:17
  SPEAKER_00: We might need to monitor their ECG for QTC prolongation.
• 12:21
  SPEAKER_00: And so all of those things can be managed through our OPAT service, even though the patient's being discharged on orals.
• 12:27
  SPEAKER_00: Whereas some ambulatory outpatient intravenous therapy might be so straightforward that we can pass that on to other services working elsewhere, maybe with much less oversight.
• 12:38
  SPEAKER_00: And so I've probably spoken enough about that, but the main thrust of COPAT is that it's the complexity of the patient that counts for inclusion in our service, not necessarily the threshold of do they need an intravenous antibiotic?
• 12:50
  SPEAKER_02: Yeah, that was great.
• 12:51
  SPEAKER_02: And I think it kind of highlights the point that in the inpatient setting, sometimes we consider IV to PO as low-hanging fruit, but it's often more high-hanging fruit in the outpatient setting because of all those complexities that you mentioned.
• 13:04
  unknown: Dr.
• 13:05
  SPEAKER_02: Mahoney, I think you really highlighted this well in the article entitled The Role of Infectious Disease Pharmacist in the Outpatient Interbetus and Complex Oral Antimicrobial Therapies, Society for Infectious Disease Pharmacist Insights, NJP.
• 13:21
  SPEAKER_02: Do you talk about this and kind of the need for antimicrobial stewardship across the continuum of care and get into these nuances a little bit?
• 13:29
  SPEAKER_02: Can you further describe this publication and kind of what you and you, your co-authors were seeking to describe in it?
• 13:36
  SPEAKER_01: Sure.
• 13:36
  SPEAKER_01: Kudos to Christina Rivera.
• 13:38
  SPEAKER_01: She was the one that approached SIDP and said, hey, there is a huge group of pharmacists getting into this specialty, sub-specialty of OPEC, COPET, whatever you want to call this group of us that are practicing in this area.
• 13:51
  SPEAKER_01: And there is no guidance as to, you know, what are pharmacists doing?
• 13:55
  SPEAKER_01: What can pharmacists do?
• 13:57
  SPEAKER_01: So this paper kind of served as kind of an advertisement of the different roles that pharmacists could have, you know, spanning the inpatient transitions of care, complete outpatient setting that pharmacists can do, and also advertising to non-pharmacists how pharmacists can help in this area.
• 14:14
  SPEAKER_01: Kudos to Dr.
• 14:15
  SPEAKER_01: Richie's group for coining the term copet.
• 14:17
  SPEAKER_01: I've actually gotten pushback from some reviewers.
• 14:20
  SPEAKER_01: We might call them reviewer number two, saying, Can we kill that abbreviation, COPET?
• 14:25
  SPEAKER_01: And I firmly say no.
• 14:27
  SPEAKER_01: I love it.
• 14:28
  SPEAKER_01: And I think it describes exactly what you said.
• 14:31
  SPEAKER_01: Oral antibiotics are not benign, and we know that some of them need a higher level of care or follow-up.
• 14:38
  SPEAKER_01: What we're currently trying to do at Beth Israel is try to define which oral antibiotics would qualify as COPET.
• 14:46
  SPEAKER_01: And we're struggling because that's hard to do.
• 14:48
  SPEAKER_01: At first, we thought maybe we'll select antibiotics themselves, you know, long-term linasolid or todazolid.
• 14:54
  SPEAKER_01: They have the potential for thrombocytopenia or any rifampin because of drug interactions.
• 14:58
  SPEAKER_01: And then we realized that that's probably not the best way to approach things because we can, you know, go on.
• 15:04
  SPEAKER_01: All antibiotics should be followed by ID specialists.
• 15:07
  SPEAKER_01: So then we thought maybe we can start categorizing by infection types, you know, maybe endocritis or bone and joint infection should be included if they're on oral medications.
• 15:15
  SPEAKER_01: And then we realized that that's not perfect either.
• 15:17
  SPEAKER_01: So we're really struggling on how to best identify oral antibiotics that could be rolled up into our OPET program because I think whether you call it OPET, whether you call it OPET slash COPET, we're talking about the same group of patients on long-term antibiotics, oral, intravenous combination of both, but being followed in a more structured program.
• 15:36
  SPEAKER_01: So what we did in the paper is we tried to highlight all the areas a pharmacist could be involved in.
• 15:42
  SPEAKER_01: Some of it is a clinical decision making that both of us just talked about, drug interactions, selecting the appropriate drug, making sure that you have microsusceptibility results for those medications.
• 15:53
  SPEAKER_01: Others are more programmatic.
• 15:55
  SPEAKER_01: So uh follow-up, making sure that we have safety labs, calling and scheduling appointments, depending on what state you practice in, what authority pharmacists have, having follow-up appointments that pharmacists can offload volume for some of our other clinicians, and just kind of putting it out there that, hey, this is an area of medicine, pharmacy, ID that pharmacists can get more involved in in outlining more structured areas that OPEP programs can look to bring pharmacists in.
• 16:27
  SPEAKER_01: And, you know, sometimes that might mean going against some of our inpatient stewardship mantras.
• 16:34
  SPEAKER_01: We might need to go a little broader to ensure that we can come up with a regimen that the patient can complete in the outpatient setting.
• 16:42
  SPEAKER_01: So I think all of us have said start thinking early about transitioning the patient, whether you do that during their transition of care from IB to PO or, you know, a week or two in follow-up in clinics, switching them over to an oral drug.
• 16:54
  SPEAKER_01: But there are just so many areas that pharmacists can be involved in.
• 16:58
  SPEAKER_01: I think there's so many areas that also nurses, nurse practitioners, uh, physician assistants can be involved in in OPET as well.
• 17:04
  SPEAKER_01: That's one of the reasons that I love practicing in here, because it's so multidisciplinary.
• 17:08
  SPEAKER_02: Thank you so much for describing that.
• 17:09
  SPEAKER_02: So, as you're both kind of thinking about when you first started this IV to PO transition, right?
• 17:16
  SPEAKER_02: So really get people to start thinking about uh PO being appropriate for some of these deep-seated infections and for long-term care.
• 17:23
  SPEAKER_02: What are some of the pushbacks that you got?
• 17:26
  SPEAKER_02: You know, common questions perhaps that when is it appropriate and when when should we be avoiding PO therapy?
• 17:33
  SPEAKER_02: On the inpatient side, you know, we have this myth sometimes that IV therapy is required for those that are admitted.
• 17:40
  SPEAKER_02: And I'm just wondering if you guys ever get these pushbacks when you're going ahead and making that long-term plan across the continuum for the patient that they need to stay on IV just a little bit longer.
• 17:52
  SPEAKER_01: And Dr.
• 17:52
  SPEAKER_01: Moni, can you start us off?
• 17:54
  SPEAKER_01: Sure.
• 17:55
  SPEAKER_01: That is a loaded question.
• 17:57
  SPEAKER_01: Um, all of your questions are loaded.
• 17:59
  SPEAKER_01: Excellent question.
• 18:00
  SPEAKER_01: I think probably the biggest one that encompasses a lot of the minor details that go into it is will it work?
• 18:07
  SPEAKER_01: You know, particularly when we're dealing with things like multi-drug resistant organisms, we might not have as many options available.
• 18:15
  SPEAKER_01: We might be using newer medications.
• 18:17
  SPEAKER_01: We're most likely using them off label.
• 18:19
  SPEAKER_01: So do we have the data to drive the practice?
• 18:22
  SPEAKER_01: Somebody once said that it takes 17 years for new guidelines to be incorporated into clinical practice.
• 18:28
  SPEAKER_01: I don't think we're even there yet because I don't think we have guidelines saying that oral works for all of these infections.
• 18:34
  SPEAKER_01: We have great papers that say that it does, but I don't think it's been adopted across the board.
• 18:39
  SPEAKER_01: So we might be 20 years away from adopting it.
• 18:42
  SPEAKER_01: Hopefully sooner, this podcast can shift the thinking.
• 18:45
  SPEAKER_01: So it's trying to find the clinical data to support this.
• 18:49
  SPEAKER_01: Is there a case series?
• 18:50
  SPEAKER_01: Is there something that you can extrapolate that shows that this particular medication works in a patient population similar to yours?
• 18:58
  SPEAKER_01: And then there's a lot of variables, you know, was there surgical involvement?
• 19:02
  SPEAKER_01: Is there retained hardware?
• 19:04
  SPEAKER_01: All of those can change how, I mean, to be honest, it changes how the IV medication could work in the patient as well.
• 19:10
  SPEAKER_01: And then my biggest complaint, wish list, I want more data on is what dose do we use?
• 19:16
  SPEAKER_01: Oftentimes I feel like we're just making this up because there isn't a lot of data to drive it.
• 19:22
  SPEAKER_01: Oviva and Poet were fantastic, but I think they were more proof of concepts.
• 19:28
  SPEAKER_01: They were studying whether oral therapy in general can work rather than does this one specific regimen work.
• 19:35
  SPEAKER_01: And because of that, we don't really have great guidance on what particular dose to use, in particular beta lacteams.
• 19:41
  SPEAKER_01: How much oral beta-lacteam are you going to wallop your patient with to make sure that you have adequate levels, but at the same time, they don't have adverse effects that would cause them to stop taking the medication.
• 19:51
  SPEAKER_01: The other area is medications, oral medications that need loading doses.
• 19:55
  SPEAKER_01: Do we need to give that loading dose or can we skip it?
• 19:58
  SPEAKER_01: The one that I encounter this most frequently in is omatocycline.
• 20:02
  SPEAKER_01: I think it's a fantastic gram-positive drug.
• 20:04
  SPEAKER_01: It's active against some resistant gram-positive organisms.
• 20:08
  SPEAKER_01: We know from the FDA labeled indications you should be doing a loading dose.
• 20:13
  SPEAKER_01: That is related to higher rates of GI upset.
• 20:17
  SPEAKER_01: Can you skip the loading dose, prevent that GI upset because we're treating these infections for more longer term?
• 20:23
  SPEAKER_01: And I don't think we have definitive data to guide us.
• 20:27
  SPEAKER_01: I know what I do and recommend in my practice, but that might not be what others do.
• 20:31
  SPEAKER_01: So the data and the dosing are big questions.
• 20:35
  unknown: Dr.
• 20:35
  SPEAKER_02: Uji, how about from your perspective and your practice?
• 20:38
  SPEAKER_00: Yes, I certainly agree that all of those things are big issues.
• 20:41
  SPEAKER_00: And I'm endlessly grateful to my antimicrobial pharmacy colleagues for helping with some of those, you know, what are often theoretical questions because we simply don't have the data.
• 20:50
  SPEAKER_00: And I think there's a huge amount of variety.
• 20:52
  SPEAKER_00: As someone who spends a lot of time going and reviewing these patients, I think one of the real challenges I come up against is just that mythic quality that intravenous antibiotics have to treat infections that are really bad.
• 21:03
  SPEAKER_00: That's something that we see a lot.
• 21:04
  SPEAKER_00: It's a really bad infection, therefore it's a mantra that intravenous antibiotics are going to be better.
• 21:09
  SPEAKER_00: And trying to overcome that is really a question of trust for people.
• 21:13
  SPEAKER_00: I think that actually it's an investment of time with the services that we're working with around kind of getting alongside them and just spending time explaining to them why we think this profound change in practice works.
• 21:26
  SPEAKER_00: And also offering the follow-up of our OPAT, our COPAT service to try and give them some reassurance that we're going to be following these patients up just as closely as we would if they were on intravenous therapy.
• 21:38
  SPEAKER_00: And because I think it's the follow up that often reassures people around discharge, this idea that yes, we're going to send the patient home, but because they're getting the intravenous antibiotic, there's going to be someone checking their alright.
• 21:50
  SPEAKER_00: And so we need to provide that reassurance that you know someone's still going to be checking their patients alright, even once we've discharged them on oral therapy.
• 21:57
  SPEAKER_00: We've all probably experienced that word.
• 22:00
  SPEAKER_00: Round phenomenon where you're watching a ward round play out, and the senior clinician says to the trainee, Oh, you've treated the patient with antibiotics, what have you used?
• 22:08
  SPEAKER_00: And they say, Oh, intravenous ones.
• 22:10
  SPEAKER_00: And the clinician says, Oh, that's great, super, and moves on.
• 22:14
  SPEAKER_00: It's just really trying to get behind that and showing that what we're choosing are individualized antibiotics for our patient based on our understanding of what's going on and how best to treat them.
• 22:23
  SPEAKER_00: And obviously, in the converse, that sometimes we might choose intravenous antibiotics for an infection that isn't that bad.
• 22:28
  SPEAKER_00: And a really obvious example, I think, would be in those multidrug resistant UTIs where the patient's got a simple cystitis, but their organism is resistant to everything.
• 22:36
  SPEAKER_00: And so we have no choice but to choose an intravenous agent in order to manage that.
• 22:40
  SPEAKER_00: And so it's that, you know, we're data driven, we're doing our best to follow where the data goes, and we're providing an individualized treatment that will hopefully suit our patient and importantly following it up to reassure people that that treatment's working and we can change course if it doesn't.
• 22:54
  SPEAKER_02: All right.
• 22:54
  SPEAKER_02: So really great information from both of you.
• 22:56
  SPEAKER_02: And both of you have practices that are well advanced of many of the OPAD or COPAT programs that are here in the United States, especially.
• 23:06
  SPEAKER_02: And so are there any last general tips or best practices as folks are thinking about converting from IV to PO, either in that transition from inpatient to outpatient, or the patient's already discharged and it's it's a good time point to convert their therapy from IV over to PO.
• 23:26
  unknown: Dr.
• 23:26
  SPEAKER_02: Mahoney, do you have any general tips or best practices that you found in your time in this space?
• 23:32
  SPEAKER_01: Yeah, we touched upon it a little bit, but getting that collaboration with microbiology and getting all the susceptibility tests that you want for any potential oral antibiotic you think you might use, get those tests run while you still have that isolate in the lab, because after a couple of days or after a couple of weeks, that isolate's going to be tossed.
• 23:52
  SPEAKER_01: And once it's gone, you can't do any additional susceptibility testing.
• 23:56
  SPEAKER_01: So it's fairly common to have the patient come back a week, two weeks later in an outpatient setting.
• 24:01
  SPEAKER_01: And then my clinicians are asking, okay, what can we convert them to or what can we put them on suppression for?
• 24:05
  SPEAKER_01: And I'm like, I don't know, I don't have any susceptibilities.
• 24:08
  SPEAKER_01: The only oral uh agent that was run was fluoroquinolones, and either it's resistant or you know, the patient can't be on it because of XYZ.
• 24:15
  SPEAKER_01: So unless we're thinking outside the box and proactively, what potential oral options could I be using?
• 24:23
  SPEAKER_01: And then working with your microlab because they're probably going to be very odd requests, right?
• 24:27
  SPEAKER_01: I want tetracycline, I want doxycycline, I want augmentin.
• 24:32
  SPEAKER_01: These aren't common drugs that maybe the microlab is running susceptibilities on inpatient.
• 24:37
  SPEAKER_01: So having that conversation, prepping them, making sure that they are able to do those susceptibility tests.
• 24:43
  SPEAKER_01: I know some institutions they have syndrome-specific micro testing.
• 24:48
  SPEAKER_01: If the microlab knows that this is a patient with a prosthetic joint infection and it's a staph aureus, they will automatically run your fluoroquinolones, your tetracyclines, your refampin, anything that you might be using in that second stage of treatment with the oral options.
• 25:02
  SPEAKER_01: So having that forethought to run those additional tests when you actually have that isolate in the lab.
• 25:07
  SPEAKER_02: That is a great point.
• 25:08
  SPEAKER_02: There's nothing worse than getting 10 days down the road and realizing you don't have the data and won't be able to get it.
• 25:14
  SPEAKER_02: All right, Dr.
• 25:14
  SPEAKER_02: Rachi, any general practices or best practices that you have to offer?
• 25:19
  SPEAKER_00: Yeah, the collaborative working is really important to emphasize.
• 25:22
  SPEAKER_00: Our orthopedic MDT comprises obviously orthopedic surgeons, infectious diseases, microbiology, pharmacy, sometimes radiology.
• 25:30
  SPEAKER_00: So it's by working together that we make the best choices and we can be accountable for the choices that we make through the MDT.
• 25:36
  SPEAKER_00: I think that's really important.
• 25:38
  SPEAKER_00: And trying to make those decisions early.
• 25:41
  SPEAKER_00: One of the things that really encouraged our orthopedic surgeons in trying in engaging with the MDT was this idea that we could help them not just after the operation, but to plan before it and to think about how we could get their patient home sooner.
• 25:53
  SPEAKER_00: The economics of OPAT in the UK really only work if you're getting patients out of hospital and shortening stay, because the economics is all about shortened length of stay and reducing the size of your inpatient footprint.
• 26:05
  SPEAKER_00: And so it's by providing compelling data that we can do that, that we really get buy-in from those other specialties who obviously have pressure on their practice, particularly in our post-pandemic era, the waits for treatment are longer than they've been.
• 26:17
  SPEAKER_00: And so by cleaning people out of hospital quickly, obviously, and safely, then you know we can really get traction with that.
• 26:23
  SPEAKER_00: So I think it's collaborative working, I think it's planning early and really using the different specialists that you have available.
• 26:29
  SPEAKER_00: Antimicrobial pharmacy being a particular linchpin of that, and the oral therapy is so much more complicated.
• 26:35
  SPEAKER_00: We unfortunately it was the ECMID that was disrupted by the pandemic, but we we had a poster in the ECMID in 2020 that looked at the drug interactions between our commonly used intravenous regimes and our oral regimes.
• 26:47
  SPEAKER_00: And there were about a hundred times more drug interactions with our oral regimes.
• 26:50
  SPEAKER_00: So if you don't have pharmacy buy-in, it's probably going to be quite difficult to pursue those approaches.
• 26:55
  SPEAKER_02: Wonderful.
• 26:56
  SPEAKER_02: It's been such a delightful conversation and really kind of hit home the point of we need multidisciplinary care in this area, and the IVDPO may be a little bit more complex, but certainly is better for many of our patients.
• 27:09
  SPEAKER_02: But it takes a lot of teamwork and a lot of forethoughts to pull that off.
• 27:13
  SPEAKER_02: So thank you so much, Dr.
• 27:14
  SPEAKER_02: Mahoney and Dr.
• 27:15
  SPEAKER_02: Richie, for such a great conversation.
• 27:17
  SPEAKER_02: It was a pleasure to have you both here today.
• 27:19
  SPEAKER_00: Thanks very much.
• 27:20
  SPEAKER_02: Thank you.
• 27:21
  SPEAKER_02: You can find more educational content like this podcast on Shay's online education center, learning CE at www.learningce.shay dash online.org.
• 27:33
  SPEAKER_02: This concludes today's episode of the antimicrobial stewardship potpourri series.
• 27:38
  SPEAKER_02: Thank you for tuning in.