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Focusing Stewardship to Help Tackle CDI · The SHEA Podcast

• 0:09
  SPEAKER_00: Welcome to the podcast series Stewardship, Practical Approaches and Applications of the Society for Healthcare Epidemiology of America, or SHAY, which promotes the prevention of healthcare associated infections and antibiotic resistance and seeks to advance the fields of healthcare epidemiology and antibiotic stewardship.
• 0:30
  SPEAKER_00: Shea is excited to launch the first podcast of this series, Stewardship Practices, with the goal of demonstrating how to impact the rates of Clostridium difficile infections using antimicrobial stewardship interventions, targeting providers in various practice settings.
• 0:46
  SPEAKER_00: Our two panelists are Libby S.
• 0:48
  SPEAKER_00: Dodds Ashley, who is a pharmacist with the Duke Antimicrobial Stewardship Outreach Network, and Dr.
• 0:54
  SPEAKER_00: Larissa May, who is an associate professor and director of emergency department antibiotic stewardship at the University of California Davis Health System.
• 1:03
  SPEAKER_02: Thank you for the introduction.
• 1:05
  SPEAKER_02: Today, as it was mentioned, we're going to talk about antibiotic stewardship interventions and how we can help drive down C deficiels through some of those interventions.
• 1:14
  SPEAKER_02: I know in the hospital setting, we're working very hard to implement the new Joint Commission requirements around educating patients and families about appropriate antibiotic use, which is such an important first step in getting patients on board with our initiatives to right-size antibiotic use in our hospitals.
• 1:29
  SPEAKER_02: Larissa, I know that this is something you must encounter all the time in the emergency department.
• 1:33
  SPEAKER_02: What strategies have you employed to educate patients and their families about appropriate and not overuse of antibiotics when they come in seeking those treatments?
• 1:42
  SPEAKER_01: Well, Libby, I think you make a very good point that patient education is paramount, but I also think that we need to educate our providers as well to really understand that there are adverse events related to these antibiotics.
• 1:52
  SPEAKER_01: And you know, we often prescribe antibiotics in the emergency department, they're the second most commonly prescribed medication beyond analgesics.
• 1:59
  SPEAKER_01: And often those antibiotics are used inappropriately because there are certain patient expectations that perhaps an acute bronchitis needs to be treated with antibiotics.
• 2:08
  SPEAKER_01: And the strategies that we employ are really emphasizing not just the public health consequences to society as a whole, which traditionally has been used by the Get Smart campaign but not so effective for patients and physicians in the moment.
• 2:21
  SPEAKER_01: What we do is we really try to emphasize that these antibiotics have potential harm and we really want to save them for when they are necessary, not just for society, but for individual patients.
• 2:31
  SPEAKER_01: And we've all had many cases where patients came back in after an unnecessary antibiotic with serious diarrhea and C.
• 2:38
  SPEAKER_01: difficile infection.
• 2:40
  SPEAKER_02: Yeah, and I know that at least when we talk to our inpatient providers, and sometimes when we work with our providers in long-term care facilities, we hear that families really help drive this.
• 2:48
  SPEAKER_02: You know, every time my loved one behaves in this way or I feel that the urine is foul smelling, they then request an antibiotic as they've sort of been trained to this behavior.
• 2:58
  SPEAKER_02: Do you see that in the ED as well?
• 3:00
  SPEAKER_02: And have you identified any strategies in working directly with patients and their families that help?
• 3:05
  SPEAKER_01: Well, I think asymptomatic bacteria is absolutely one of the syndromes that we can really use to kind of target to avoid unnecessary antibiotic use and C.
• 3:13
  SPEAKER_01: diffacile infection.
• 3:14
  SPEAKER_01: I think it's a big challenge in the emergency department.
• 3:16
  SPEAKER_01: We certainly do see many patients who come in from long-term care facilities, for example, that do end up having euroscepsis.
• 3:22
  SPEAKER_01: And I think it's very difficult when family members are conditioned to think about UTI, which is often being driven in the nursing home setting.
• 3:30
  SPEAKER_01: And yet we do know that treating these patients unnecessarily causes harm.
• 3:34
  SPEAKER_01: And I've certainly seen many patients come back with facial infection after being on antibiotics for weeks because there was a presumed catheter-associated UTI based simply on delirium.
• 3:43
  SPEAKER_01: But I think that we really need to talk to these families about the potential harms.
• 3:47
  SPEAKER_01: And it's, as I mentioned, a big challenge.
• 3:49
  SPEAKER_01: It's not, it's not just an avoidance of antibiotics.
• 3:51
  SPEAKER_01: I think we're also over-ordering urinalyses, and it would be beneficial if we could also come up with some strategies to make the right diagnosis as well as prescribe the right antibiotic and only when necessary.
• 4:02
  SPEAKER_02: Yeah, I I agree that that is a huge problem.
• 4:05
  SPEAKER_02: We've had some success with some altered mental status protocols, specifically around asymptomatic bacteria, that encourage, I mean, some people call it watchful waiting.
• 4:14
  SPEAKER_02: I know there are others that are advocates of different terminology around that.
• 4:17
  SPEAKER_02: And that can really be a strategy that helps us to withhold therapy but still provide a treatment, you know, often with more aggressive fluids or other strategies with patients to increase the likelihood of resolution of symptoms and then not obtain the culture.
• 4:32
  SPEAKER_02: Or if a culture is obtained, be sure that symptoms are reassessed before any therapy might be started.
• 4:38
  SPEAKER_01: I think you you make a really good point, Libby, that you know, really working with families to reduce the incidence of C.
• 4:43
  SPEAKER_01: diffacyl based on these unnecessary antibiotics is important.
• 4:46
  SPEAKER_01: It sounds like you've had some successful innovative strategies.
• 4:49
  SPEAKER_01: I think in the emergency department, we're always sort of in a difficult situation because oftentimes the long-term care facility, for example, has ordered the urine culture.
• 4:58
  SPEAKER_01: You know, they have not empirically treated the patient, so to my eyes, it seems that they haven't been that concerned that the patient actually had a UTI.
• 5:04
  SPEAKER_01: And then all of a sudden the culture comes back and they decide to send the patient to the emergency department, and it's very difficult for us as ED clinicians to not act on that.
• 5:12
  SPEAKER_01: And I think there are also many important healthcare system limitations that really affect how we practice.
• 5:17
  SPEAKER_01: So when you talk to providers in the ED, you know, a lot of times you're concerned about a patient, you think they might need to be admitted to the hospital just because you have a concern about a poor outcome or maybe they don't have great follow-up, or you're not really too sure what's causing this delirium, and yet you're looking for a reason to admit the patient, and it's just all too easy to get that urinalysis that you know may or may not be the cause of the patient's symptoms, and then to act on that in order just to get the patient admitted to the hospital.
• 5:44
  SPEAKER_01: So I think we have a lot of work to do, you know, in educating patients, to really think about perhaps an antibiotic timeout.
• 5:50
  SPEAKER_01: Do we really need this antibiotic?
• 5:51
  SPEAKER_01: And then also finding alternative strategies to address the concerns that we have for which we're really using antibiotics inappropriately as a patch.
• 6:00
  SPEAKER_02: Yeah, it's interesting that you bring up the antibiotic timeout.
• 6:02
  SPEAKER_02: That's kind of an interesting place to employ it.
• 6:04
  SPEAKER_02: So you know a lot of hospitals that I've worked with on the inpatient side, specifically to target fetophacillion problems, have been trying to use the antibiotic timeout at 72 to 96 hours of therapy when they have more data available to guide their decision.
• 6:17
  SPEAKER_02: It sounds like you're also advocating what might work better in the ED where you don't have 96 hours of contact with your patients if they are either moving to inpatient status or going back to the community.
• 6:27
  SPEAKER_02: Is an antibiotic timeout at the time of prescribing, you know, more as it's employed in the OR right at the time something's about to happen.
• 6:33
  SPEAKER_02: Talk to me about what you consider as part of your antibiotic timeout when initiating antibiotics.
• 6:38
  SPEAKER_01: Well, I think the the first question is really have we made the right diagnosis?
• 6:41
  SPEAKER_01: And you know, I work in a teaching institution and we do try to train our trainees, so to speak, you know, to really think wisely about whether the patient needs an antibiotic, what's the risk benefit to giving this patient antibiotic, and then do you really know what antibiotic is best in that situation?
• 6:56
  SPEAKER_01: Because we have problems with starting an antibiotic inappropriately and also selecting the wrong antibiotic, for example, selecting broad spectrum antibiotics where they might not be necessary, or just sort of our go-to, you know, what's considered broad spectrum antibiotic, for example, and considering vancomycin a broad spectrum antibiotic, which clearly it's not, but you know, sort of having our go-to, you know, in some institutions, you know, it might be vancomycin and zosin, and in other places, you know, it might be vancomycin or cefapine.
• 7:24
  SPEAKER_01: But really there's a a lack of comfort around antibiotic prescribing by our providers and you know, and also assumed expectations about what the patient might want or need at the time.
• 7:34
  SPEAKER_01: I I think having more of a shared decision-making process and really having everybody kind of working towards figuring out whether we need these antibiotics is important because as I mentioned, it's the second most commonly prescribed medication in the emergency department.
• 7:46
  SPEAKER_01: That we have at least a 10% rate of adverse events.
• 7:49
  SPEAKER_01: It might be as simple as diarrhea, but perhaps one out of ten of those are going to end up having C.
• 7:53
  SPEAKER_01: diffacil infection.
• 7:54
  SPEAKER_01: And then we know that that is a big cause of return visits to the ED are adverse events to antibiotics.
• 7:59
  SPEAKER_01: So I think oftentimes both providers and patients and their families downplay the potential harm and they really just don't see the risk of using these antibiotics and kind of think, why not?
• 8:10
  SPEAKER_02: Yeah, I know we we do hear that quite a bit.
• 8:13
  SPEAKER_02: I I feel like one of the elephants in the room when we talk about stewardship and when we sit and meet about ways to decrease C-tificile has to do with these handoffs in care.
• 8:22
  SPEAKER_02: And so, you know, I tend to practice more on the inpatient side, and you're clearly in the emergency department.
• 8:26
  SPEAKER_02: And I think people look at the handoffs between your area of practice and my area of practice as one place where there can often be confusion about antibiotics.
• 8:34
  SPEAKER_02: So I feel like the the blame game goes in both directions.
• 8:38
  SPEAKER_02: So, you know, in the emergency department, there's a lot of pressure to make a rapid decision and decide whether or not to treat.
• 8:44
  SPEAKER_02: And then sometimes on the inpatient side, and I don't always understand this, providers don't necessarily feel empowered to change what was started because maybe the patient responded.
• 8:52
  SPEAKER_02: What are your thoughts on that?
• 8:53
  SPEAKER_02: What are some ways that we could help stimulate conversation and better have the handoff for patients on antibiotics so that the ED providers are doing what's necessary and appropriate to treat the patient that's in front of them, but also that we empower the providers receiving the patients on the inpatient side or for patients not admitted back in the community to change and modify therapy.
• 9:14
  SPEAKER_02: I hear so often I wasn't there to see the patient, and I heard you say that about the nursing home patients.
• 9:19
  SPEAKER_02: How do we tackle that together to better steward our antibiotics so that we can start what's necessary and stop what's no longer necessary, and everybody feels empowered to make those changes.
• 9:29
  SPEAKER_01: Well, I think you bring up another excellent point, which is really the work that needs to be done around the transitions of care.
• 9:34
  SPEAKER_01: And you know, certainly in the emergency department, I think honestly that the bigger and lower hanging fruit for us is really the prescribed medications for those patients that are being discharged home, where it really is kind of the Wild West.
• 9:45
  SPEAKER_01: But on the inpatient side, you know, I think the ED has an important role in getting the appropriate cultures and starting appropriate empiric therapy.
• 9:52
  SPEAKER_01: And I do also hear this sort of blaming, well, the ED, you know, started this inappropriate antibiotic, but then it just gets continued in the inpatient setting.
• 10:00
  SPEAKER_01: And for some reason there's not that communication or or the uh inpatient team doesn't feel empowered to change it.
• 10:06
  SPEAKER_01: Whereas as an ED provider, we just assume that that uh antibiotic is going to get changed or narrowed based on the additional information that's available during the inpatient stay.
• 10:13
  SPEAKER_01: So I think perhaps more research and more efforts need to go towards communicating better at the transitions of care.
• 10:20
  SPEAKER_01: And then also perhaps, you know, more multidisciplinary rounds or discussions about you know what is impro appropriate empiric therapy and you know, how can we improve care for these patients once they're admitted to the hospital?
• 10:31
  SPEAKER_01: Because my perception is that the inpatient stewardship team is going to take care of that.
• 10:36
  SPEAKER_01: And for some reason, in reality, that doesn't happen.
• 10:39
  SPEAKER_02: Yeah, I agree.
• 10:40
  SPEAKER_02: I mean I've never completely been able to wrap my head around that.
• 10:43
  SPEAKER_02: And I think, you know, it's it's exciting and I think more people are starting to work on these initiatives to try to have better handoffs of care on antibiotics.
• 10:50
  SPEAKER_02: But I would like everyone to feel empowered.
• 10:52
  SPEAKER_02: You know, we should always be reassessing the sort of like a constant timeout, right?
• 10:55
  SPEAKER_02: Anytime you encounter a patient on an antibiotic to ask yourself the questions.
• 10:58
  SPEAKER_02: I've been reading a little bit in the pediatric literature, and they have a proposal of sort of they they talk about a transitions of care and discharge stewardship, making sure that you have the four D's correct.
• 11:09
  SPEAKER_02: So the diagnosis, as you said, that's so important, the drug, the duration are all clearly important characteristics to identify up front for these patients when you're prescribing and you're about to transition patients.
• 11:22
  SPEAKER_02: I'm wondering if we couldn't em embrace doing that more across the board.
• 11:27
  SPEAKER_01: Absolutely.
• 11:27
  SPEAKER_01: And I you know I think a lot of these solutions just seem very simple to those of us who are in the field, but the reality is, you know, everyone is expected to prescribe these antibiotics.
• 11:35
  SPEAKER_01: I think most people, both patients and providers, have, at least in the past, underestimated the potential harm from these.
• 11:42
  SPEAKER_01: And it requires a lot of continuing education and and a lot of assessing expectations and time spent with the patient and their families and public service announcements to really make an impact.
• 11:54
  SPEAKER_01: And I think, you know, we have a whole generational change that needs to occur in order to make sure we're making the right diagnosis and then having the right drug at the right time, which I think is difficult because it's very hard to keep up with everything we need to keep up with, for example, in the emergency department or the outpatient setting.
• 12:10
  SPEAKER_01: But you know, all it takes is, you know, you see a few of these patients coming back.
• 12:13
  SPEAKER_01: You know, I had a lady that was a young woman in her mid-twenties, and she presented with recurrent C.
• 12:18
  SPEAKER_01: deficiel colitis.
• 12:19
  SPEAKER_01: She had been previously healthy, and you know, she was started on amoxicillin for a presumed dental infection.
• 12:25
  SPEAKER_01: Had the dental procedure, was on ten days of amoxicillin, then later got a sinus infection, was on another course of ammoxicillin, and then was on Zitramax and wasn't getting better, presumably because it was viral, and then ultimately ended up with this terrible course of C.
• 12:40
  SPEAKER_01: difficile colitis that really could have been completely avoided by not prescribing those antibiotics that she probably didn't need to start with.
• 12:47
  SPEAKER_02: That sounds like a terrible case.
• 12:48
  SPEAKER_02: And you you bring up an excellent point about who's prescribing it.
• 12:52
  SPEAKER_02: One innovative idea people have talked about, but I've never seen practice, and I want to get your thoughts on this.
• 12:57
  SPEAKER_02: Some people have proposed a notification system, not meant to be punitive in any way, but so often we hear from people, well, I prescribe a lot of antibiotics.
• 13:05
  SPEAKER_02: And in your example, it was the dentist, and when we've tried to talk to some providers where patients may not represent with their C.
• 13:11
  SPEAKER_02: difficile symptoms, and I think a dentist is a perfect example, you know, they'll say, Well, we don't, our patients have never called us back with C.
• 13:17
  SPEAKER_02: difficile.
• 13:18
  SPEAKER_02: I'm wondering if there shouldn't be some interesting collaborative we could have where we would just provide that feedback.
• 13:24
  SPEAKER_02: I wonder if if a lot of the problem or part of the problem is that the people prescribing the antibiotics, whether they be an emergency physician who doesn't see the patient in follow-up, whether they present back to the ED or whether they go into the hospital, or someone on the hospital team who continues antibiotics unnecessarily at discharge, or primary care provider who doesn't see the patient who developed C-tificile because they present to an urgent care.
• 13:45
  SPEAKER_02: I'm wondering if there couldn't be some innovative practice on notifying the prescriber of all antibiotics prescribed to that patient in the last two weeks, that that patient ended up developing C-tificile, just to start having that feedback loop, because I don't know that people appreciate the adverse events from antibiotics because they don't see them all the time.
• 14:02
  SPEAKER_02: What are your thoughts on that?
• 14:04
  SPEAKER_01: That's a great idea.
• 14:05
  SPEAKER_01: I mean, I think in practice it would be pretty difficult to do, you know, but I think a lot of, you know, now with the focus on the opioid crisis, you know, we have many states have um databases where you can look up your patients' records and see what narcotic prescriptions they've received and how many over the past six months.
• 14:19
  SPEAKER_01: And if we even had something like that for antibiotics, I mean we could see that the patient had, you know, received, I'm sure we'd be shocked for some patients, how many courses of antibiotics they've received in the last uh six months or twelve months.
• 14:31
  SPEAKER_01: And just having that information as well as you know any potential adverse events like C.
• 14:35
  SPEAKER_01: deficiel colitis would be really great feedback.
• 14:38
  SPEAKER_01: I I do think it's a problem in emergency medicine that after years of practice, we sometimes get some of this, but we really don't know what happens to patients, either good or bad.
• 14:46
  SPEAKER_01: Although we do, you know, often hear about adverse events, but typically we don't hear about adverse events to antibiotics like allergic reactions or C.
• 14:53
  SPEAKER_01: difficile colitis because the outcomes you know are not mortality and we tend to only hear about the mortalities.
• 14:59
  SPEAKER_01: I think it would be very innovative if institutions could consider within the health system perhaps a way to let providers know of their feedback on their practices and also you know how patients did.
• 15:09
  SPEAKER_01: It's it's always good to see that other side of things.
• 15:12
  SPEAKER_01: And you know, I think also educating the patient sometimes, it's it's amazing to me that patients also don't really perceive any harm from these antibiotics.
• 15:19
  SPEAKER_01: You know, they go see their primary care provider, they get a prescription for their acute bronchitis or a common cold for an antibiotic.
• 15:25
  SPEAKER_01: You know, they may or may not have an adverse event, although a lot of them have obviously you know had some adverse events like rashes and and diarrhea and things like that, but they still kind of have this expectation that the antibiotic is going to fix things.
• 15:36
  SPEAKER_01: And I think just even having you know educational materials, having that discussion with parents, with patients about adverse events related to antibiotics, about the potential harm, and then just assessing expectations.
• 15:48
  SPEAKER_01: You know, like I said, we sometimes have this assumption that the patient wants an antibiotic.
• 15:52
  SPEAKER_01: And oftentimes a patient doesn't want an antibiotic.
• 15:54
  SPEAKER_01: Maybe they want a work note because they just feel too lousy to go to work, but we never really asked that question.
• 15:59
  SPEAKER_01: Some communication tools for patients and providers would also be really helpful in terms of assessing and managing expectations and also providing some alternatives because when people come to the doctor and they're sick, they don't necessarily want an antibiotic, they want to feel better.
• 16:12
  SPEAKER_01: And so there are some alternatives you know that we perhaps could help patients with, like for example, a work note or some symptomatic relief that they're looking for, or even sometimes just reassurance, I think would go a long way.
• 16:25
  SPEAKER_02: And it's and it's interesting.
• 16:26
  SPEAKER_02: I I'm curious, in your experience, what is the most compelling adverse event that you when you tell patients about that seems to resonate with them and wanting to avoid antibiotics?
• 16:37
  SPEAKER_01: Unfortunately, it is the rare event, but that one does resonate the most.
• 16:40
  SPEAKER_01: I think a lot of these adverse events are a little bit removed from patients, but they think that's not going to happen to me.
• 16:46
  SPEAKER_01: So, you know, I think everybody can appreciate, for example, in a pediatric patient, your child is, you know, they might vomit, they might have diarrhea, you know, this this might lead to more resistant ear infections in the future.
• 16:56
  SPEAKER_01: You know, I think that's been much more successful in the pediatric setting.
• 16:59
  SPEAKER_01: I think for for adults it's harder.
• 17:00
  SPEAKER_01: I mean, the ones that really scare me, honestly, as a provider and that I've shared with patients is, you know, for example, the the new FDA warning on equinolones.
• 17:08
  SPEAKER_01: I've had a case where a patient presented in sudden cardiac arrest, a healthy 30-something-year-old, and no previous medical history except she had been started on acquinolone within the past few days.
• 17:20
  SPEAKER_01: Not sure if that quinolone was necessary or not, but the patient basically had a sudden cardiac arrest because of probably a prolonged QT, you know, and that was just not identified.
• 17:28
  SPEAKER_01: But the more public information we have on this, you know, for example, if celebrities would come out who might have had adverse events to antibiotics and really start talking about this important issue, but I I think it's just until it becomes really real to the patient and scary as opposed to the perceived benefits, it's it's going to be a difficult sell to not want the antibiotic.
• 17:45
  SPEAKER_01: But I think the more that we highlight these adverse events and really focus more on the individual patient, because when people are sick and they come see the doctor or they, you know, they want care, they're not interested in the public health benefits.
• 17:57
  SPEAKER_01: And and nor should the patient and provider really be considering public health benefits when they're in that individual encounter.
• 18:03
  SPEAKER_01: But what I really do think is really underestimated by everyone are these the harms from these antibiotics.
• 18:08
  SPEAKER_01: And people really should be asking Did my doctor wash their hands?
• 18:12
  SPEAKER_01: Do I need this antibiotic?
• 18:13
  SPEAKER_01: Do I really need this pain prescription?
• 18:15
  SPEAKER_01: And I I think we really just need to have an informed discussion with patients and with families.
• 18:20
  SPEAKER_01: And also really educate the people who've had C.
• 18:22
  SPEAKER_01: difficile infection because I know some of them come back, they've already had C.
• 18:25
  SPEAKER_01: difficile infection, but they've been on another antibiotic.
• 18:27
  SPEAKER_01: And for some reason the message, you know, isn't getting across.
• 18:30
  SPEAKER_01: But I'm hoping with some of the new tools and campaigns that we have that hopefully we'll get it across soon.
• 18:35
  SPEAKER_02: Great.
• 18:36
  SPEAKER_02: Well, thank you.
• 18:36
  SPEAKER_02: So this has been valuable to me.
• 18:38
  SPEAKER_02: I've learned a lot of new great strategies that we can hopefully share with others.
• 18:41
  SPEAKER_02: You know, particularly we do tend to talk a lot to patients about avoiding antibiotics for resistance, but I think you're right, bringing up the issues around adverse drug events that could affect them in the near future as a result of them taking this individual course of antibiotics is probably a more meaningful discussion to have with a patient in that setting when they're acutely ill.
• 19:00
  SPEAKER_02: And then also working to better educate across the continuum of care about what our needs are and that nobody starts an antibiotic in the especially emergency department setting anticipating that it continues.
• 19:12
  SPEAKER_02: So really helping share that message, I think, would help us on the inpatient side.
• 19:15
  SPEAKER_02: You know, we we have those conversations all the time.
• 19:18
  SPEAKER_02: So those are two great strategies that I think we can help deploy to minimize our antibiotic use and hopefully drive down some of our C.
• 19:24
  SPEAKER_02: difficile risks because it really is wherever we're seeing the antibiotic use, it's resulting in C.
• 19:29
  SPEAKER_02: difficile in other settings.
• 19:30
  SPEAKER_02: And so we need to across the board work to drive down use and stop it when it's no longer needed.
• 19:35
  SPEAKER_02: So thanks for taking some time to talk today.
• 19:36
  SPEAKER_02: I appreciate it.
• 19:37
  SPEAKER_02: Yeah, absolutely, Libby.
• 19:38
  SPEAKER_01: I think it's so important that we we consider this a community problem.
• 19:41
  SPEAKER_01: And it's, you know, it's not an outpatient problem or an inpatient problem.
• 19:44
  SPEAKER_01: It really impacts everyone, you know, even those persons that are not contacting the healthcare system.
• 19:49
  SPEAKER_01: You know, it affects families, and I think you've really highlighted some important things and ways that we might be able to collaborate even amongst our different settings.
• 19:57
  SPEAKER_01: And I know now I believe that patient education is now a requirement at discharge regarding antibiotic use.
• 20:02
  SPEAKER_01: So I'd be interested to see some innovative strategies as to how we can inform patients as they're leaving healthcare settings in order to affect the next encounter.
• 20:10
  SPEAKER_02: Absolutely.
• 20:14
  SPEAKER_00: Looking to extend your knowledge in antibiotic stewardship and infection prevention?
• 20:19
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• 20:22
  SPEAKER_00: This conference provides the latest science-based education related to healthcare epidemiology and antibiotic stewardship, building on the education of this podcast and providing in-person networking opportunities.
• 20:35
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• 20:41
  SPEAKER_00: www.shea s p r I n G.org.