WEBVTT 00:00:02.106 --> 00:00:03.076 A:middle >> Thank you for joining. 00:00:03.076 --> 00:00:08.336 A:middle We would, well, we would like to welcome you to our annual ÐÇ¿ÕÓéÀÖ¹ÙÍø 00:00:08.556 --> 00:00:12.046 A:middle and Federal Office of Rural Health Policy webinar, 00:00:12.316 --> 00:00:15.466 A:middle celebrating U.S. Antibiotic Awareness Week 00:00:15.626 --> 00:00:18.716 A:middle and National Rural Health Day This year, 00:00:18.716 --> 00:00:22.996 A:middle we are also partnering with the Agency for Healthcare, Research 00:00:22.996 --> 00:00:29.516 A:middle and Quality, to showcase how the AHRQ Safety Program Toolkit can 00:00:29.516 --> 00:00:33.646 A:middle be implemented in critical access hospitals. 00:00:33.646 --> 00:00:36.836 A:middle My name is Linda Neuhauser, and I am the pharmacist 00:00:37.006 --> 00:00:40.136 A:middle and acute care lead for ÐÇ¿ÕÓéÀÖ¹ÙÍø's Office 00:00:40.136 --> 00:00:47.516 A:middle of Antibiotic Stewardship, and I'll be the moderator today. 00:00:47.606 --> 00:00:53.096 A:middle And at this time, I would like to introduce our speakers. 00:00:53.096 --> 00:00:56.366 A:middle Very thrilled to be joined by Natalia Vargas, 00:00:56.366 --> 00:01:01.326 A:middle who is program lead for the Medicare Beneficiaries Quality 00:01:01.326 --> 00:01:04.426 A:middle Improvement Program in HRSA's Federal Office 00:01:04.426 --> 00:01:08.596 A:middle of Rural Health Policy, who will discuss the recent efforts 00:01:08.596 --> 00:01:10.376 A:middle to support improvements 00:01:10.376 --> 00:01:12.776 A:middle in antibiotic use in rural facilities. 00:01:12.776 --> 00:01:16.496 A:middle Next, we'll discuss the four moments 00:01:16.496 --> 00:01:20.746 A:middle of antibiotic prescribing in critical access hospitals 00:01:20.746 --> 00:01:25.026 A:middle with Dr. Melissa Miller, who is a physician in the Division 00:01:25.026 --> 00:01:28.596 A:middle of Healthcare Associated Infections in the Agency 00:01:28.596 --> 00:01:30.456 A:middle for Healthcare, Research and Quality. 00:01:30.656 --> 00:01:35.366 A:middle Dr. Pranita Tamma is an infectious disease physician 00:01:35.366 --> 00:01:39.216 A:middle and director of the Pediatric Antimicrobial Stewardship 00:01:39.216 --> 00:01:44.226 A:middle Program at the Johns Hopkins Hospital. 00:01:44.226 --> 00:01:48.836 A:middle And then Dr. Sara Cosgrove is also an infectious diseases 00:01:48.836 --> 00:01:50.896 A:middle physician and director 00:01:50.896 --> 00:01:53.816 A:middle of the adult Antimicrobial Stewardship Program 00:01:53.866 --> 00:01:56.256 A:middle at the Johns Hopkins Hospitals. 00:01:57.056 --> 00:02:00.806 A:middle At this time, I would like to introduce Natalia 00:02:00.806 --> 00:02:03.206 A:middle to provide her presentation. 00:02:05.416 --> 00:02:06.126 A:middle >> Thank you, Linda. 00:02:06.126 --> 00:02:08.846 A:middle I really appreciate the introduction. 00:02:08.846 --> 00:02:10.626 A:middle And would like to thank ÐÇ¿ÕÓéÀÖ¹ÙÍø 00:02:10.626 --> 00:02:12.346 A:middle for the opportunity to be here today. 00:02:12.846 --> 00:02:18.826 A:middle I will be presenting our recent efforts to support improvements 00:02:18.826 --> 00:02:20.996 A:middle in antibiotic use in rural facilities. 00:02:20.996 --> 00:02:23.766 A:middle So, my goal with today's presentation is to set the stage 00:02:23.766 --> 00:02:27.406 A:middle for what you will hear next from the presenters 00:02:27.406 --> 00:02:28.806 A:middle that we have lined up today. 00:02:29.336 --> 00:02:32.226 A:middle And we have three objectives to cover 00:02:32.226 --> 00:02:33.816 A:middle in this portion of the webinar. 00:02:34.086 --> 00:02:37.696 A:middle And that is first I would like to review the national reach 00:02:37.696 --> 00:02:38.726 A:middle and overarching goals 00:02:38.726 --> 00:02:42.126 A:middle of our Medicare Beneficiaries Quality Improvement Program. 00:02:42.126 --> 00:02:45.656 A:middle And then provide an overview of the healthcare delivery 00:02:45.656 --> 00:02:49.456 A:middle and quality improvement context in rural facilities. 00:02:49.456 --> 00:02:52.006 A:middle And then end with a short discussion on how we aim 00:02:52.006 --> 00:02:55.036 A:middle to collaborate across levels of the healthcare system 00:02:55.036 --> 00:02:57.106 A:middle so that we can reach these program goals 00:02:57.106 --> 00:03:01.846 A:middle and improve quality of care for rural populations. 00:03:01.846 --> 00:03:07.546 A:middle This is just to give you a snapshot of what it's 00:03:07.546 --> 00:03:11.846 A:middle like to serve the hospitals across the country, we have, 00:03:11.936 --> 00:03:15.446 A:middle where you see on the right side, all of those dots, 00:03:15.736 --> 00:03:17.036 A:middle the colored dots on the map, 00:03:17.416 --> 00:03:20.366 A:middle are the critical access hospitals that we serve. 00:03:20.366 --> 00:03:22.466 A:middle They comprise over 75% 00:03:22.846 --> 00:03:25.786 A:middle of overall hospitals in the United States. 00:03:25.786 --> 00:03:31.346 A:middle We, through, and equip, are able to support these hospitals 00:03:31.346 --> 00:03:35.126 A:middle in providing high quality care to rural populations. 00:03:35.126 --> 00:03:40.606 A:middle These small hospitals are limited to only 25 beds. 00:03:40.606 --> 00:03:43.136 A:middle So, unlike traditional hospitals pay it 00:03:43.136 --> 00:03:45.506 A:middle through the perspective payment system, 00:03:45.506 --> 00:03:49.146 A:middle Medicare pays critical access hospitals based on each 00:03:49.146 --> 00:03:50.946 A:middle of the hospitals' reported costs. 00:03:52.006 --> 00:03:57.316 A:middle Therefore, with this context, you can, you can see that, 00:03:57.316 --> 00:04:01.356 A:middle you know, we tried to really provide the support 00:04:01.356 --> 00:04:06.606 A:middle for this small rural hospitals to report measures 00:04:06.606 --> 00:04:13.036 A:middle so that we can, we can use those measures to improve quality 00:04:13.036 --> 00:04:14.666 A:middle of care for populations. 00:04:14.866 --> 00:04:19.386 A:middle The primary goal of our program is to enhance the reporting 00:04:19.386 --> 00:04:23.186 A:middle of quality data, and then have the hospitals use that data 00:04:23.416 --> 00:04:25.886 A:middle for quality improvement activities, 00:04:25.886 --> 00:04:28.906 A:middle and support quality improvement measurements 00:04:28.906 --> 00:04:30.506 A:middle and quality improvement activities 00:04:30.506 --> 00:04:32.196 A:middle across all of those hospitals. 00:04:32.436 --> 00:04:35.396 A:middle We have about 1,350 hospitals 00:04:35.396 --> 00:04:38.856 A:middle that are currently participating in our program. 00:04:38.856 --> 00:04:39.896 A:middle And through our program, 00:04:39.896 --> 00:04:42.096 A:middle we established this national tracking system 00:04:42.096 --> 00:04:44.686 A:middle for the first time so that these hospitals 00:04:44.686 --> 00:04:49.386 A:middle that are voluntarily report quality measures to CMS are able 00:04:49.386 --> 00:04:52.266 A:middle to be supported through our program, 00:04:52.266 --> 00:04:55.526 A:middle and have additional access to funds 00:04:55.526 --> 00:04:57.416 A:middle that support quality improvement activities. 00:04:57.466 --> 00:05:00.816 A:middle So, we work at the intersection of various levels 00:05:00.816 --> 00:05:02.056 A:middle of the healthcare system. 00:05:02.676 --> 00:05:05.486 A:middle The national, state, and facility levels. 00:05:05.486 --> 00:05:09.606 A:middle And antibiotic stewardship is one of those successful examples 00:05:09.606 --> 00:05:14.936 A:middle of how we have used one of the measures to enhance reporting, 00:05:14.936 --> 00:05:18.036 A:middle that then drives improvements at the local level, 00:05:18.036 --> 00:05:19.946 A:middle at the hospital level, 00:05:19.946 --> 00:05:24.096 A:middle by expanding those activities for quality. 00:05:24.096 --> 00:05:29.016 A:middle So, the healthcare delivery context in rural facilities is 00:05:29.016 --> 00:05:33.296 A:middle that essentially we have a mandate to serve 00:05:33.296 --> 00:05:36.816 A:middle over 60 million people with very little resources. 00:05:36.816 --> 00:05:39.276 A:middle And unfortunately these are competing priorities 00:05:39.276 --> 00:05:41.856 A:middle that we have access, quality and costs, 00:05:41.856 --> 00:05:43.996 A:middle are always competing in rural settings. 00:05:43.996 --> 00:05:48.816 A:middle So, what we hear most in terms of challenges 00:05:48.816 --> 00:05:51.226 A:middle from our hospitals is that there is scarcity 00:05:51.226 --> 00:05:55.036 A:middle of infectious disease physicians and pharmacists. 00:05:55.036 --> 00:05:58.536 A:middle There is a little bit of lack of provider engagement 00:05:58.536 --> 00:06:00.466 A:middle in antimicrobial stewardship due 00:06:00.466 --> 00:06:02.726 A:middle to the competing priorities that I mentioned. 00:06:03.716 --> 00:06:08.796 A:middle We have also come across deficiencies 00:06:08.796 --> 00:06:10.086 A:middle in staff understanding 00:06:10.086 --> 00:06:14.556 A:middle of antibiograms sensitivity reports, drug classes, 00:06:14.556 --> 00:06:16.886 A:middle how to use antibiotics properly. 00:06:16.886 --> 00:06:19.736 A:middle And also we have limited capabilities 00:06:19.736 --> 00:06:21.966 A:middle of EMRs to man data for QI. 00:06:21.966 --> 00:06:24.996 A:middle Despite all of these challenges, 00:06:24.996 --> 00:06:29.816 A:middle we have some real implementation come examples here 00:06:29.816 --> 00:06:32.476 A:middle that I have linked for you. 00:06:32.596 --> 00:06:35.836 A:middle We are really focused on pushing the accountability 00:06:35.836 --> 00:06:39.416 A:middle for optimizing antibiotic use in critical access hospitals 00:06:39.416 --> 00:06:41.126 A:middle and increasing the number of interventions 00:06:41.126 --> 00:06:41.976 A:middle at the hospital per week. 00:06:42.106 --> 00:06:45.156 A:middle Some hospitals have also reported 00:06:45.156 --> 00:06:47.256 A:middle that through the implementation 00:06:47.256 --> 00:06:51.246 A:middle of antibiotic use focused activities, 00:06:51.246 --> 00:06:54.096 A:middle they have reported decreases in cases, 00:06:54.496 --> 00:06:56.786 A:middle but also they have decreased the costs 00:06:56.786 --> 00:07:00.356 A:middle of purchasing antibiotics at the hospital. 00:07:00.356 --> 00:07:02.896 A:middle Underpinning all of these efforts is actually the 00:07:02.896 --> 00:07:06.176 A:middle collaboration approaches that they have used 00:07:06.176 --> 00:07:11.006 A:middle for antibiotic stewardship, such as sharing education, resources, 00:07:11.006 --> 00:07:14.496 A:middle and tools to better equip the providers. 00:07:14.496 --> 00:07:19.146 A:middle And that strategy has been one of the most successful ones 00:07:19.146 --> 00:07:23.176 A:middle to be used in critical access hospital facilities 00:07:23.796 --> 00:07:26.236 A:middle to overcome those challenges 00:07:26.236 --> 00:07:29.156 A:middle and support those implementation outcomes 00:07:29.156 --> 00:07:32.056 A:middle that I have outlined above. 00:07:32.536 --> 00:07:38.086 A:middle So, with that is of key importance to our program 00:07:38.086 --> 00:07:41.806 A:middle that we better collaborate across the levels 00:07:41.806 --> 00:07:43.826 A:middle of the healthcare system. 00:07:43.826 --> 00:07:46.106 A:middle And that is what brings this presentation today. 00:07:46.106 --> 00:07:50.206 A:middle As you can see, we have joined efforts with our ÐÇ¿ÕÓéÀÖ¹ÙÍø colleagues, 00:07:50.206 --> 00:07:52.926 A:middle with our, with agency for healthcare research 00:07:52.926 --> 00:07:54.016 A:middle and quality colleagues, 00:07:54.096 --> 00:07:58.236 A:middle to really address the improvement goals that we have 00:07:58.236 --> 00:08:01.266 A:middle in our program that we see, you know, 00:08:01.266 --> 00:08:05.156 A:middle through this chart you can see there is a microlevel, 00:08:05.156 --> 00:08:07.246 A:middle a mesolevel, and a macrolevel. 00:08:07.246 --> 00:08:10.106 A:middle This is adopted from a pediatric, 00:08:10.106 --> 00:08:13.256 A:middle from an academic pediatrics journal article. 00:08:13.686 --> 00:08:17.566 A:middle And basically what it does is that it shows the connection 00:08:17.566 --> 00:08:19.686 A:middle for why it is important to have, 00:08:20.226 --> 00:08:23.266 A:middle to connect those dots across the systems. 00:08:23.266 --> 00:08:26.506 A:middle We set priorities at the federal level, but we most work together 00:08:26.506 --> 00:08:28.306 A:middle in order to reach those goals. 00:08:28.626 --> 00:08:32.796 A:middle We have to better understand the role of managed care delivery 00:08:32.796 --> 00:08:35.746 A:middle at the mesolevel in order to really impact what happens 00:08:35.746 --> 00:08:38.566 A:middle at the microlevel, to provide evidence, 00:08:38.566 --> 00:08:40.956 A:middle evidence based treatments, and services 00:08:40.956 --> 00:08:42.086 A:middle that support patient care 00:08:42.086 --> 00:08:44.936 A:middle and improve health outcomes in rural areas. 00:08:44.936 --> 00:08:50.146 A:middle So, as we look ahead in our program goals, we are hoping 00:08:50.146 --> 00:08:53.496 A:middle to identify all the rural relevant measures 00:08:53.496 --> 00:08:54.876 A:middle that establish, in order 00:08:54.876 --> 00:08:59.396 A:middle to establish a curated measure sent one 00:08:59.396 --> 00:09:01.246 A:middle of the broad priority areas 00:09:01.246 --> 00:09:03.256 A:middle that we have is actually patient safety. 00:09:03.566 --> 00:09:06.866 A:middle So, the work that we're doing in this space is very important. 00:09:07.286 --> 00:09:10.346 A:middle We also hope to continue supporting critical access 00:09:10.346 --> 00:09:15.116 A:middle hospitals to report measures that align with CMS IPP rules. 00:09:15.116 --> 00:09:20.676 A:middle And one of the priority areas will involve antibiotic use. 00:09:21.086 --> 00:09:23.796 A:middle We also hope to continue supporting the states 00:09:23.796 --> 00:09:28.116 A:middle in building capacity for conducting QI, building the work 00:09:28.116 --> 00:09:32.886 A:middle that space has completed so far as part of QI projects 00:09:32.886 --> 00:09:36.376 A:middle that they are implementing, and co designing 00:09:36.376 --> 00:09:38.726 A:middle with the critical access hospitals, 00:09:39.106 --> 00:09:41.336 A:middle including antibiotic stewardship. 00:09:41.676 --> 00:09:45.746 A:middle And also integrating a systems level approach to the work 00:09:45.746 --> 00:09:47.796 A:middle that we do to the strategies that we implement 00:09:47.796 --> 00:09:51.726 A:middle at the program level, which involves this type 00:09:51.726 --> 00:09:53.206 A:middle of collaboration today. 00:09:53.206 --> 00:09:56.856 A:middle So, today I'm just really pleased to be here 00:09:56.856 --> 00:10:02.256 A:middle in celebrating what we call National Rural Health Day, 00:10:02.476 --> 00:10:05.056 A:middle that is actually tomorrow. 00:10:05.056 --> 00:10:07.886 A:middle And the theme for this year is driving change, 00:10:07.886 --> 00:10:09.156 A:middle going the extra mile. 00:10:09.266 --> 00:10:12.436 A:middle And that's what we're hoping that this presentation brings 00:10:12.436 --> 00:10:15.416 A:middle to you today is just driving changes 00:10:15.416 --> 00:10:17.776 A:middle in critical access hospitals in a way 00:10:17.776 --> 00:10:22.106 A:middle that helps contextualize the care that we support 00:10:22.106 --> 00:10:24.026 A:middle in this rural communities. 00:10:24.026 --> 00:10:28.216 A:middle So, with that, I will leave my contact information here, 00:10:28.476 --> 00:10:31.946 A:middle and I will pass it onto my colleague at AHRQ 00:10:32.046 --> 00:10:35.986 A:middle who will be speaking and introducing herself next. 00:10:35.986 --> 00:10:37.526 A:middle So, Dr. Miller, thank you. 00:10:40.526 --> 00:10:41.306 A:middle >> Thank you, Natalia. 00:10:41.306 --> 00:10:47.826 A:middle And thank you to HRSA and to ÐÇ¿ÕÓéÀÖ¹ÙÍø for having us here today. 00:10:47.826 --> 00:10:48.546 A:middle We are looking forward 00:10:48.546 --> 00:10:52.886 A:middle to sharing our toolkit and work with you. 00:10:52.886 --> 00:10:55.726 A:middle Oh, and so today we're going to review the overarching goals 00:10:55.726 --> 00:10:58.606 A:middle of the AHRQ safety program for improving antibiotic use. 00:10:58.606 --> 00:11:01.266 A:middle We'll provide an overview of the safety program, 00:11:01.266 --> 00:11:04.606 A:middle and review the findings from the one year acute care AHRQ 00:11:04.606 --> 00:11:06.516 A:middle safety program. 00:11:06.576 --> 00:11:08.336 A:middle And discuss how to apply the four moments 00:11:08.336 --> 00:11:09.716 A:middle of antibiotic decision making 00:11:09.716 --> 00:11:12.096 A:middle in clinical practice using a case based approach 00:11:12.096 --> 00:11:16.236 A:middle for community acquired pneumonia and urinary tract infections. 00:11:16.416 --> 00:11:20.276 A:middle So, first, to review the overarching goals, next, 00:11:20.276 --> 00:11:24.276 A:middle antibiotic stewardship, or antibiotic stewardship programs, 00:11:24.276 --> 00:11:27.056 A:middle or ASPs, have traditionally used a top down approach 00:11:27.056 --> 00:11:29.446 A:middle to improve antibiotic use in acute care settings. 00:11:29.446 --> 00:11:33.246 A:middle For example, an administrative decision to use one antibiotic 00:11:33.246 --> 00:11:38.826 A:middle versus another, or a service that guides the antibiotic use, 00:11:38.826 --> 00:11:42.666 A:middle such as, you know, a traditional antibiotic stewardship program, 00:11:42.666 --> 00:11:43.766 A:middle our AHRQ safety program 00:11:43.766 --> 00:11:46.846 A:middle for improving antibiotic use challenges this approach 00:11:46.846 --> 00:11:49.376 A:middle by equipping frontline clinicians with tools 00:11:49.376 --> 00:11:51.316 A:middle to incorporate stewardship practices 00:11:51.316 --> 00:11:53.266 A:middle into their daily decision making. 00:11:56.346 --> 00:11:58.336 A:middle So, the AHRQ safety program 00:11:58.336 --> 00:12:04.076 A:middle for improving antibiotic use aimed initially 00:12:04.076 --> 00:12:07.226 A:middle to improve antibiotic use in acute care, long term care, 00:12:07.226 --> 00:12:08.976 A:middle and ambulatory care settings, in a phased approach. 00:12:09.186 --> 00:12:13.176 A:middle What we're presenting today represents the experiences 00:12:13.176 --> 00:12:16.296 A:middle of the first large cohort of over 400 acute care hospitals, 00:12:16.296 --> 00:12:18.496 A:middle including critical access hospitals. 00:12:18.496 --> 00:12:21.316 A:middle The goals were to assist facilities with establishing 00:12:21.316 --> 00:12:26.816 A:middle or strengthening ASPs to provide frontline clinicians with tools 00:12:26.816 --> 00:12:28.546 A:middle to incorporate stewardship principles 00:12:28.546 --> 00:12:31.246 A:middle into routine decision making by underscoring the importance 00:12:31.246 --> 00:12:34.566 A:middle of communication and teamwork around antibiotic prescribing, 00:12:34.566 --> 00:12:37.956 A:middle and to equip frontline clinicians with best practices 00:12:37.956 --> 00:12:41.316 A:middle in the diagnosis and treatment of common infectious processes. 00:12:41.316 --> 00:12:44.326 A:middle So, next I'm going to hand it over to my colleague, 00:12:44.326 --> 00:12:48.306 A:middle Dr. Pranita Tamma, to provide you with an overview 00:12:48.306 --> 00:12:49.226 A:middle of the safety program. 00:12:49.226 --> 00:12:51.266 A:middle >> Thanks so much, Melissa. 00:12:51.266 --> 00:12:54.356 A:middle And I'm excited to talk a little more in depth 00:12:54.356 --> 00:12:57.596 A:middle about the acute care portion of the AHRQ safety program. 00:12:57.596 --> 00:13:01.556 A:middle So, just very briefly, this was a one year program. 00:13:01.556 --> 00:13:04.776 A:middle It occurred in the calendar year 2018. 00:13:04.776 --> 00:13:09.826 A:middle And the goal was to include at least 250 acute care facilities 00:13:09.826 --> 00:13:11.606 A:middle across the United States. 00:13:11.606 --> 00:13:14.526 A:middle And recruitment efforts included social media campaigns, 00:13:14.526 --> 00:13:17.656 A:middle engagement of federal partners, including the ÐÇ¿ÕÓéÀÖ¹ÙÍø and HRSA 00:13:17.656 --> 00:13:19.786 A:middle and professional societies. 00:13:19.786 --> 00:13:22.576 A:middle And we invited either retired hospitals, 00:13:22.576 --> 00:13:25.296 A:middle which was generally the case for critical access hospitals, 00:13:25.646 --> 00:13:29.596 A:middle or individual units within a hospital, to participate. 00:13:29.596 --> 00:13:32.576 A:middle And Sara Cosgrove and I delivered all the webinars. 00:13:32.576 --> 00:13:36.116 A:middle It was usually about two webinars per month, 00:13:36.346 --> 00:13:38.256 A:middle each delivered about three times 00:13:38.256 --> 00:13:40.426 A:middle to accommodate different work schedules, 00:13:40.426 --> 00:13:42.626 A:middle and time zone differences. 00:13:42.626 --> 00:13:45.616 A:middle And we invited all members of the healthcare team 00:13:45.616 --> 00:13:48.846 A:middle to participate, including physicians, mid level providers, 00:13:48.846 --> 00:13:52.516 A:middle pharmacists, nurses, and anyone else who was involved 00:13:52.516 --> 00:13:55.076 A:middle in the process of antibiotic decision making. 00:13:55.396 --> 00:13:58.896 A:middle We also included two office hours every month 00:13:59.176 --> 00:14:02.396 A:middle where participants had the opportunity to ask questions 00:14:02.396 --> 00:14:04.986 A:middle about implementing stewardship programs, 00:14:04.986 --> 00:14:07.316 A:middle or even just management questions related 00:14:07.316 --> 00:14:09.406 A:middle to particular patients. 00:14:09.406 --> 00:14:11.036 A:middle And we were very fortunate to partner 00:14:11.036 --> 00:14:14.036 A:middle with quality improvement experts that came 00:14:14.036 --> 00:14:15.716 A:middle from health quality innovators, 00:14:15.716 --> 00:14:19.186 A:middle health services advisory group, and stratus health. 00:14:19.186 --> 00:14:21.546 A:middle And one quality improvement expert was assigned 00:14:21.546 --> 00:14:25.366 A:middle to each participating hospital to assist them with some 00:14:25.366 --> 00:14:28.796 A:middle of the day to day stewardship implementation work. 00:14:28.796 --> 00:14:31.036 A:middle So, I'm going to go a little further 00:14:31.036 --> 00:14:33.976 A:middle into what actually took place during the one year period. 00:14:34.046 --> 00:14:39.656 A:middle And fortunately, AHRQ did a very nice job on their website 00:14:39.656 --> 00:14:44.186 A:middle of developing a toolkit where the material can be accessed 00:14:44.186 --> 00:14:46.696 A:middle so that even for sites that didn't participate 00:14:46.696 --> 00:14:49.646 A:middle in this one year program, they would have the ability 00:14:49.646 --> 00:14:52.466 A:middle to access all of the content developed for the program. 00:14:52.466 --> 00:14:54.836 A:middle And on the website, there's some guidance 00:14:54.836 --> 00:14:57.926 A:middle on how you could implement the toolkit locally 00:14:57.926 --> 00:14:59.786 A:middle to emulate the one year program. 00:14:59.786 --> 00:15:03.586 A:middle So, just very briefly, there were three general domains 00:15:03.586 --> 00:15:06.176 A:middle as part of this acute care safety program. 00:15:06.176 --> 00:15:08.426 A:middle The first was assisting sites 00:15:08.426 --> 00:15:10.686 A:middle with developing stewardship programs. 00:15:10.796 --> 00:15:13.856 A:middle Some sites did already have a stewardship program 00:15:13.856 --> 00:15:16.616 A:middle that was maybe in its early phases, and we assisted them 00:15:16.616 --> 00:15:18.926 A:middle with how they could sort of take it to the next level. 00:15:18.926 --> 00:15:22.106 A:middle Part of this involved identifying a 00:15:22.106 --> 00:15:23.436 A:middle leadership structure. 00:15:23.766 --> 00:15:29.006 A:middle Ideally we preferred a clinician and a pharmacist lead. 00:15:29.006 --> 00:15:31.276 A:middle Not necessarily trained in infectious diseases, because, 00:15:31.276 --> 00:15:34.046 A:middle of course, that's just not feasible in many sites. 00:15:34.046 --> 00:15:36.486 A:middle And how they could identify senior leadership 00:15:36.486 --> 00:15:40.696 A:middle to Garner the support amongst other healthcare practitioners 00:15:40.696 --> 00:15:42.416 A:middle within that facility. 00:15:42.416 --> 00:15:46.106 A:middle We also assisted them with identifying how 00:15:46.466 --> 00:15:50.606 A:middle to develop metrics to collect data for metrics, 00:15:50.606 --> 00:15:52.356 A:middle which I'll talk about. 00:15:52.356 --> 00:15:55.756 A:middle And to use these metrics by tracking them over time 00:15:55.756 --> 00:15:57.196 A:middle to guide intervention. 00:15:57.196 --> 00:15:58.456 A:middle So, for example, if you notice 00:15:58.456 --> 00:16:01.986 A:middle that Vancomycin uses extremely high in an ICU, 00:16:02.206 --> 00:16:04.226 A:middle what kinds of interventions can you think 00:16:04.226 --> 00:16:06.366 A:middle about to help reduce that use. 00:16:06.366 --> 00:16:09.876 A:middle The second main domain was trying to develop a culture 00:16:09.876 --> 00:16:12.256 A:middle of safety around antibiotic prescribing. 00:16:12.346 --> 00:16:15.536 A:middle We realize that a lot of times there's a social etiquette 00:16:15.536 --> 00:16:16.776 A:middle involved around prescribing 00:16:16.776 --> 00:16:20.886 A:middle or perhaps one prescriber starts an antibiotic, 00:16:20.886 --> 00:16:22.606 A:middle and another clinician comes on 00:16:22.606 --> 00:16:25.356 A:middle and might feel strange stopping an antibiotic 00:16:25.356 --> 00:16:26.886 A:middle if a colleague started it, 00:16:26.886 --> 00:16:28.696 A:middle because it might be deemed disrespectful. 00:16:28.696 --> 00:16:34.946 A:middle Or perhaps during clinical rounds, a physician is rounding, 00:16:34.946 --> 00:16:38.386 A:middle assessing the patient, and a nurse might feel a little, 00:16:38.386 --> 00:16:39.906 A:middle might not feel as empowered to mention 00:16:39.906 --> 00:16:40.976 A:middle that the patient is still on Vancomycin. 00:16:41.076 --> 00:16:44.686 A:middle Is this really still necessary? 00:16:44.686 --> 00:16:47.236 A:middle So, we wanted to help with improving teamwork 00:16:47.236 --> 00:16:49.516 A:middle and communication between healthcare providers, 00:16:49.516 --> 00:16:52.336 A:middle as well as between healthcare providers and patients 00:16:52.336 --> 00:16:55.706 A:middle and families who might be expecting an antibiotic. 00:16:55.706 --> 00:16:58.666 A:middle And finally, the third domain dealt 00:16:58.666 --> 00:17:01.676 A:middle with teaching frontline providers 00:17:01.676 --> 00:17:05.256 A:middle with learning best practices in the management and the diagnosis 00:17:05.256 --> 00:17:08.346 A:middle and management of common infectious diseases syndromes. 00:17:08.346 --> 00:17:12.096 A:middle And we've decided to focus on syndromes and nonantibiotics 00:17:12.096 --> 00:17:14.706 A:middle because clinicians are generally much more excited 00:17:14.706 --> 00:17:19.346 A:middle if you say would you like to learn about the latest data 00:17:19.536 --> 00:17:23.246 A:middle in managing community acquired pneumonia versus would you 00:17:23.246 --> 00:17:26.786 A:middle like to learn how to use Vancomycin more appropriately. 00:17:26.786 --> 00:17:29.746 A:middle And for all of the syndrome based content, 00:17:29.826 --> 00:17:33.496 A:middle we organize the material using a framework we developed as part 00:17:33.496 --> 00:17:35.526 A:middle of this program called the four moments 00:17:35.526 --> 00:17:39.016 A:middle of antibiotic decision making, which I'll summarize. 00:17:39.016 --> 00:17:44.456 A:middle So, this is a snapshot of, from the AHRQ website. 00:17:44.456 --> 00:17:47.016 A:middle In the develop and improve stewardship content that's 00:17:47.016 --> 00:17:49.996 A:middle really targeting the stewardship leader, so, again, 00:17:49.996 --> 00:17:55.056 A:middle ideally a clinician and a pharmacist, a physician, 00:17:55.056 --> 00:17:57.646 A:middle and if a physician's not available, a mid level provider, 00:17:57.646 --> 00:18:00.226 A:middle like a nurse practitioner or physician assistant, 00:18:00.226 --> 00:18:03.306 A:middle along with a pharmacist, and we have content in how 00:18:03.306 --> 00:18:06.826 A:middle to develop the program, how to effective, 00:18:06.866 --> 00:18:09.426 A:middle make behavior /KHAEUFPBLGZ around prescribing. 00:18:09.426 --> 00:18:11.666 A:middle And after the program is developed, 00:18:11.666 --> 00:18:14.986 A:middle have a sustained stewardship activities 00:18:14.986 --> 00:18:16.946 A:middle so that this program will continue 00:18:16.946 --> 00:18:19.306 A:middle to exist and be impactful. 00:18:19.306 --> 00:18:22.746 A:middle And these content are available 00:18:22.746 --> 00:18:25.686 A:middle as PowerPoint slides on the website. 00:18:25.766 --> 00:18:27.896 A:middle There's also what we call facilitator guide, 00:18:27.896 --> 00:18:31.646 A:middle which includes a detailed script for each slide, 00:18:31.646 --> 00:18:34.436 A:middle so that the content can be used locally. 00:18:34.436 --> 00:18:38.206 A:middle In terms of the developing culture of safety 00:18:38.206 --> 00:18:43.216 A:middle around prescribing, there's four targeted PowerPoint slides 00:18:43.216 --> 00:18:43.976 A:middle with facilitator guides. 00:18:44.826 --> 00:18:48.676 A:middle For each of these, and these are targeting mostly frontline 00:18:48.676 --> 00:18:52.886 A:middle providers, for each of these, we used case based approaches, 00:18:52.936 --> 00:18:55.366 A:middle because we think that that's probably most engaging 00:18:55.366 --> 00:18:57.086 A:middle to healthcare providers. 00:18:57.086 --> 00:19:00.716 A:middle And finally, for best practices, as you can see here, 00:19:00.716 --> 00:19:02.536 A:middle we target a variety of syndromes 00:19:02.536 --> 00:19:04.946 A:middle that we think are common problems, 00:19:04.946 --> 00:19:06.926 A:middle both in large academic facilities, 00:19:06.926 --> 00:19:11.016 A:middle as well as small critical care access hospitals. 00:19:11.016 --> 00:19:13.996 A:middle And for all of these, again, we have slides available, 00:19:13.996 --> 00:19:15.886 A:middle as well as the facilitator guide. 00:19:15.886 --> 00:19:20.146 A:middle And we also have several other types of content available, 00:19:20.146 --> 00:19:21.836 A:middle which I'll show you in the next few slides. 00:19:21.836 --> 00:19:25.636 A:middle But for all of these best practices topics, 00:19:25.856 --> 00:19:27.656 A:middle we Lutz what we call the four moments 00:19:27.656 --> 00:19:29.366 A:middle of antibiotic decision making. 00:19:29.366 --> 00:19:31.806 A:middle So, these are the four moments 00:19:31.806 --> 00:19:37.056 A:middle when we think clinicians should review when deciding 00:19:37.056 --> 00:19:38.536 A:middle if a patient needs antibiotics, 00:19:38.536 --> 00:19:41.066 A:middle and if antibiotics need to be continued. 00:19:41.066 --> 00:19:44.666 A:middle So, very briefly, the first moment asks, 00:19:44.666 --> 00:19:46.546 A:middle does my patient have an infection 00:19:46.546 --> 00:19:48.006 A:middle that requires antibiotics? 00:19:48.006 --> 00:19:52.136 A:middle And this might just be stopping and thinking about the patients. 00:19:52.136 --> 00:19:54.326 A:middle Maybe the patient has a cough. 00:19:54.586 --> 00:19:56.346 A:middle Maybe they're having a little bit of chest pain. 00:19:56.346 --> 00:19:58.546 A:middle But is this a pulmonary embolism? 00:19:58.546 --> 00:20:00.116 A:middle Is this congestive heart failure? 00:20:00.116 --> 00:20:02.696 A:middle Doesn't necessarily have to be bacterial pneumonia. 00:20:02.696 --> 00:20:05.276 A:middle So, it's really asking clinicians to stop 00:20:05.276 --> 00:20:07.196 A:middle and think about, is it more likely than not 00:20:07.196 --> 00:20:10.106 A:middle that this patient has a bacterial infection. 00:20:10.416 --> 00:20:13.006 A:middle The second moment has two questions. 00:20:13.006 --> 00:20:15.306 A:middle Have I ordered appropriate cultures before 00:20:15.306 --> 00:20:16.636 A:middle starting antibiotics? 00:20:16.636 --> 00:20:19.156 A:middle For example, do I need blood cultures? 00:20:19.156 --> 00:20:20.346 A:middle Do I need urine cultures? 00:20:20.346 --> 00:20:21.856 A:middle Do I need a sputum culture? 00:20:21.856 --> 00:20:26.076 A:middle And the second question asks what empiric therapy should 00:20:26.076 --> 00:20:27.266 A:middle I initiate? 00:20:27.266 --> 00:20:32.676 A:middle And for each of the infectious syndromes, we include guidance 00:20:32.676 --> 00:20:34.976 A:middle on what we would consider empiric therapy 00:20:34.976 --> 00:20:37.316 A:middle for your routine patients. 00:20:37.316 --> 00:20:38.606 A:middle And then what about patients 00:20:38.606 --> 00:20:41.916 A:middle who might have a severe Penicillin allergy, who might, 00:20:41.916 --> 00:20:46.116 A:middle maybe there's concerns for MRSA or concerns for pseudomonas. 00:20:46.116 --> 00:20:47.326 A:middle And in those patients, 00:20:47.326 --> 00:20:49.976 A:middle the empiric therapy regimens might be different. 00:20:50.026 --> 00:20:52.416 A:middle The third moments has three questions. 00:20:52.416 --> 00:20:55.836 A:middle After more clinical and diagnostic data are available. 00:20:55.836 --> 00:20:58.816 A:middle And these include can I stop antibiotics, particularly 00:20:58.816 --> 00:21:00.286 A:middle if cultures are negative, 00:21:00.286 --> 00:21:03.116 A:middle and an alternative diagnosis has been established. 00:21:03.186 --> 00:21:05.146 A:middle Can I narrow therapy or change 00:21:05.146 --> 00:21:08.456 A:middle from an intravenous to an oral agent? 00:21:08.456 --> 00:21:11.426 A:middle And finally, the fourth question asks about the duration 00:21:11.426 --> 00:21:12.866 A:middle of antibiotic therapy. 00:21:12.866 --> 00:21:17.896 A:middle For all of the best practices topics, we include evidence 00:21:17.896 --> 00:21:21.886 A:middle that supports what the available data suggests in terms 00:21:21.886 --> 00:21:24.866 A:middle of effective durations of antibiotic therapy. 00:21:24.866 --> 00:21:29.916 A:middle And then, again, for each of the topics as an example, 00:21:29.916 --> 00:21:32.786 A:middle we have what we call a one page document 00:21:32.836 --> 00:21:35.196 A:middle that summarizes some of the data. 00:21:35.306 --> 00:21:38.206 A:middle These are editable on the website 00:21:38.546 --> 00:21:43.186 A:middle so that local sites can include recommendations here 00:21:43.286 --> 00:21:44.976 A:middle and make these their local treatment guidelines. 00:21:45.046 --> 00:21:47.766 A:middle Alternatively, you could delete these sort 00:21:47.766 --> 00:21:52.006 A:middle of place local recommendations here sections and post these 00:21:52.006 --> 00:21:55.786 A:middle in common work areas, send them as e mails or other ways 00:21:55.786 --> 00:21:57.246 A:middle to disseminate this knowledge 00:21:57.406 --> 00:22:00.206 A:middle between the healthcare providers in your facility. 00:22:01.086 --> 00:22:04.496 A:middle We also include commitments posters on the website. 00:22:04.496 --> 00:22:08.956 A:middle And we suggest that people put the pictures of providers, 00:22:08.956 --> 00:22:12.656 A:middle their signatures, maybe pictures and signatures of leadership. 00:22:12.656 --> 00:22:15.066 A:middle And this is meant to show that to patients, 00:22:15.066 --> 00:22:17.356 A:middle as well as to just all healthcare providers 00:22:17.356 --> 00:22:20.116 A:middle within the institution, that your facility committed 00:22:20.116 --> 00:22:22.736 A:middle to the judicious use of antibiotics. 00:22:22.736 --> 00:22:25.956 A:middle And similar to this commitment poster, we also have posters 00:22:25.956 --> 00:22:28.276 A:middle with the four moments, screensavers 00:22:28.276 --> 00:22:32.536 A:middle for the four moments that are available on the AHRQ websites. 00:22:32.536 --> 00:22:35.186 A:middle And then another document we developed 00:22:35.186 --> 00:22:37.996 A:middle that we thought was particularly helpful in settings a lot 00:22:37.996 --> 00:22:41.776 A:middle of critical access hospitals are what we call the team antibiotic 00:22:41.776 --> 00:22:42.606 A:middle review forum. 00:22:42.606 --> 00:22:45.926 A:middle So, the goal of these forums would be every month we would 00:22:45.926 --> 00:22:50.146 A:middle ask sites to retrospectively pick five, ten patients 00:22:50.426 --> 00:22:53.706 A:middle who are receiving antibiotics, and as a group to go 00:22:53.706 --> 00:22:57.236 A:middle through these questions that use the format of the four moments, 00:22:57.236 --> 00:22:59.366 A:middle so that you can look for areas for maybe 00:22:59.366 --> 00:23:02.466 A:middle where there should be improvement for the next patient 00:23:02.466 --> 00:23:03.706 A:middle who started antibiotics. 00:23:03.706 --> 00:23:07.056 A:middle So, it might be caught that perhaps Vancomycin was continued 00:23:07.056 --> 00:23:09.386 A:middle for too long, or a duration longer 00:23:09.386 --> 00:23:11.716 A:middle than the evidence suggests is necessary might have 00:23:11.716 --> 00:23:12.396 A:middle been prescribed. 00:23:12.396 --> 00:23:16.896 A:middle And the hope would be that as a group, again, including nursing, 00:23:16.896 --> 00:23:20.426 A:middle pharmacists, physicians, and anyone at a team meeting, 00:23:20.426 --> 00:23:22.306 A:middle that lessons could be learned 00:23:22.306 --> 00:23:24.196 A:middle to improve care for the next patient. 00:23:24.196 --> 00:23:27.256 A:middle So, for the sites that participated 00:23:27.256 --> 00:23:29.526 A:middle in this one year program. 00:23:29.876 --> 00:23:34.276 A:middle We requested that they submitted antibiotic use data as days 00:23:34.276 --> 00:23:37.086 A:middle of antibiotic therapy for per thousands patient days, 00:23:37.086 --> 00:23:39.836 A:middle and they submitted these data on a monthly basis. 00:23:40.286 --> 00:23:46.806 A:middle We also requested the submitted C difficile lab ID event per 00:23:46.806 --> 00:23:48.216 A:middle 10,000 patient days. 00:23:48.216 --> 00:23:49.696 A:middle So, basically this is looking 00:23:49.696 --> 00:23:53.556 A:middle for if a lab test indicated positive C difficile testing, 00:23:53.556 --> 00:23:56.036 A:middle of course this is not a perfect proxy 00:23:56.036 --> 00:23:58.016 A:middle for clinical C difficile infections, 00:23:58.016 --> 00:24:00.926 A:middle because some patients might be colonized, but we thought 00:24:00.926 --> 00:24:03.006 A:middle that this would still be helpful to get a sense 00:24:03.006 --> 00:24:05.706 A:middle of if we could impact C difficile rates 00:24:05.756 --> 00:24:07.976 A:middle by reducing antibiotic use, 00:24:07.976 --> 00:24:10.936 A:middle or really optimizing antibiotic use, I should say. 00:24:10.936 --> 00:24:15.566 A:middle And then we requested up to 10 team antibiotic review forums 00:24:15.566 --> 00:24:16.186 A:middle per month. 00:24:16.406 --> 00:24:19.266 A:middle For some hospitals, particularly critical access hospitals, 00:24:19.386 --> 00:24:20.756 A:middle they might have actually had less 00:24:20.756 --> 00:24:21.976 A:middle than 10 patients a month on antibiotics. 00:24:22.176 --> 00:24:26.016 A:middle And, of course, that was perfectly acceptable too. 00:24:26.016 --> 00:24:31.106 A:middle And for all sites, and we talk a lot about on the website how 00:24:31.106 --> 00:24:34.516 A:middle to collect the data, how to report data to clinicians 00:24:34.516 --> 00:24:38.446 A:middle within your institution, but we, what we would do 00:24:38.446 --> 00:24:42.266 A:middle with the program was feedback quarterly reports 00:24:42.356 --> 00:24:44.746 A:middle so you could compare yourself over time, 00:24:44.746 --> 00:24:47.616 A:middle and also compare yourself to like facilities. 00:24:47.616 --> 00:24:50.156 A:middle So, for example, for critical access hospitals, 00:24:50.156 --> 00:24:53.356 A:middle we compared them to other critical access hospitals. 00:24:53.356 --> 00:24:56.796 A:middle And, of course, not large academic medical centers. 00:24:57.036 --> 00:25:00.446 A:middle I'll move on to very briefly summarized findings 00:25:00.446 --> 00:25:03.676 A:middle of the project before I hand it over to Sara Cosgrove. 00:25:03.676 --> 00:25:06.216 A:middle But there were 402 hospitals 00:25:06.216 --> 00:25:08.636 A:middle that completed the one year safety program. 00:25:08.836 --> 00:25:12.176 A:middle Over 90% of facilities that started the program, 00:25:12.176 --> 00:25:14.206 A:middle which we were very happy to see. 00:25:14.206 --> 00:25:17.076 A:middle And for those that weren't able to complete it was often 00:25:17.076 --> 00:25:19.556 A:middle because they had staff turnover, 00:25:19.556 --> 00:25:21.796 A:middle didn't have the resources to stay engaged. 00:25:21.796 --> 00:25:26.056 A:middle In terms of the types of hospitals that participated, 00:25:26.056 --> 00:25:28.856 A:middle about 20% were critical access hospitals. 00:25:28.856 --> 00:25:32.706 A:middle And about 40% of hospitals had less than 100 beds. 00:25:32.706 --> 00:25:36.676 A:middle So, it was really a variety of types of hospitals 00:25:36.676 --> 00:25:38.326 A:middle that participated in the program. 00:25:38.576 --> 00:25:42.986 A:middle And what we saw was that antibiotic use decreased 00:25:42.986 --> 00:25:44.366 A:middle in that, in that first quarter, 00:25:44.366 --> 00:25:46.876 A:middle and then this first quarter we were actually relatively 00:25:46.876 --> 00:25:49.026 A:middle aggressive with the number of webinars 00:25:49.026 --> 00:25:51.246 A:middle and engagement we had with sites. 00:25:51.246 --> 00:25:54.486 A:middle And then after that antibiotic use plateaued, 00:25:54.486 --> 00:25:57.676 A:middle and basically stayed relatively consistent. 00:25:57.676 --> 00:26:01.026 A:middle We actually were able to compare these data with data 00:26:01.026 --> 00:26:03.126 A:middle from premier, which included large number 00:26:03.126 --> 00:26:05.446 A:middle of hospitals not participating in the program. 00:26:05.446 --> 00:26:09.776 A:middle And basically that data suggested that antibiotic use 00:26:09.776 --> 00:26:13.386 A:middle in nonparticipating programs started off high 00:26:13.386 --> 00:26:16.956 A:middle and remained relatively consistent [inaudible] the 00:26:16.956 --> 00:26:17.436 A:middle one year. 00:26:17.436 --> 00:26:20.906 A:middle So, they didn't have this sort of drop in that first quarter. 00:26:20.906 --> 00:26:22.726 A:middle Now, obviously it's not a perfect comparison, 00:26:22.726 --> 00:26:26.006 A:middle but it just gives you a sense of what was happening nationally 00:26:26.186 --> 00:26:28.166 A:middle in other institutions at the same time. 00:26:28.166 --> 00:26:32.856 A:middle We did find that antibiotic use significantly decreased 00:26:32.856 --> 00:26:37.076 A:middle when we looked at the data in various subgroups. 00:26:37.076 --> 00:26:39.726 A:middle And I highlighted in red here critical access hospitals 00:26:39.726 --> 00:26:43.266 A:middle where we did see a significant reduction in antibiotic use. 00:26:43.266 --> 00:26:46.566 A:middle And also across the cohort, we saw significant reduction 00:26:46.566 --> 00:26:48.836 A:middle in C difficile lab ID rates. 00:26:48.836 --> 00:26:50.956 A:middle So, I'll hand is over to Sara. 00:26:51.106 --> 00:26:54.726 A:middle And before I do so, again, I just want to stress 00:26:54.726 --> 00:26:59.706 A:middle that we really do encourage people to go to the AHRQ website 00:26:59.976 --> 00:27:02.316 A:middle to look at the content of this program, 00:27:02.316 --> 00:27:05.616 A:middle because I really do think that there's, this can be sizeable, 00:27:05.616 --> 00:27:07.316 A:middle scalable for all institutions, 00:27:07.316 --> 00:27:09.356 A:middle including critical access hospitals. 00:27:09.716 --> 00:27:10.826 A:middle So, thank you very much. 00:27:12.276 --> 00:27:14.186 A:middle >> Thanks, Pranita. 00:27:14.286 --> 00:27:17.706 A:middle We'll start the last portion of this with a clinical case. 00:27:18.026 --> 00:27:21.246 A:middle And then basically go through this case, 00:27:21.246 --> 00:27:24.036 A:middle showing how you could apply the four moments 00:27:24.196 --> 00:27:28.396 A:middle in everyday decision making around antibiotics. 00:27:28.456 --> 00:27:31.926 A:middle So, this is a case in a 54 year old man with diabetes 00:27:31.926 --> 00:27:36.436 A:middle and hypertension who presents with two days of fever, a cough, 00:27:36.506 --> 00:27:38.366 A:middle and left sided chest pain. 00:27:38.366 --> 00:27:40.176 A:middle He's febrile. 00:27:40.356 --> 00:27:42.216 A:middle His blood pressure is fairly normal. 00:27:42.396 --> 00:27:44.546 A:middle But his heart rate is elevated. 00:27:44.546 --> 00:27:48.716 A:middle And his respiratory rate at 24 is certainly elevated. 00:27:48.896 --> 00:27:53.446 A:middle He has a normal oxygen saturation of 95% [inaudible]. 00:27:53.876 --> 00:27:58.936 A:middle And on other [inaudible] exam, he's tired, appearing, 00:27:59.166 --> 00:28:03.226 A:middle and has crackles over the lower left lung field. 00:28:04.166 --> 00:28:07.366 A:middle So, going through the four moments, 00:28:07.366 --> 00:28:10.056 A:middle remember that the first moment is does my patient have an 00:28:10.056 --> 00:28:12.396 A:middle infection that requires antibiotics. 00:28:12.496 --> 00:28:18.116 A:middle So, thinking about this patient, he needs a lot of criteria 00:28:18.116 --> 00:28:19.736 A:middle for community acquired pneumonia. 00:28:19.736 --> 00:28:23.156 A:middle And, therefore, in him, CAP is likely. 00:28:23.156 --> 00:28:27.466 A:middle But if some of this presentation were slightly different, 00:28:27.656 --> 00:28:29.486 A:middle he might actually have something 00:28:29.486 --> 00:28:34.306 A:middle that is not community acquired pneumonia, and may mimic some 00:28:34.306 --> 00:28:36.686 A:middle of the signs and symptoms of community acquired pneumonia, 00:28:36.686 --> 00:28:38.486 A:middle so we always say, you know, 00:28:38.486 --> 00:28:40.256 A:middle think about other potential causes 00:28:40.256 --> 00:28:42.016 A:middle of someone's presentation. 00:28:42.246 --> 00:28:44.246 A:middle And just some examples of things 00:28:44.246 --> 00:28:47.316 A:middle that would also be considerations 00:28:47.316 --> 00:28:50.046 A:middle on the differential here are viral respiratory tract 00:28:50.046 --> 00:28:52.936 A:middle infections, aspiration, pneumonitis, 00:28:53.076 --> 00:28:56.666 A:middle chronic obstructive pulmonary disease exacerbation, 00:28:56.666 --> 00:28:58.886 A:middle asthma exacerbation, congestive heart failure, 00:28:58.886 --> 00:29:00.086 A:middle and pulmonary embolism. 00:29:00.086 --> 00:29:02.856 A:middle I'm not saying that that's what I think he has. 00:29:03.106 --> 00:29:05.796 A:middle But a lot of times people present with symptoms 00:29:05.796 --> 00:29:08.776 A:middle that are a little more nonspecific than what he has. 00:29:08.986 --> 00:29:12.156 A:middle And so these other items should certainly be 00:29:12.156 --> 00:29:14.916 A:middle on the differential, and the majority 00:29:14.916 --> 00:29:19.976 A:middle of them do not require antibiotic therapy. 00:29:20.226 --> 00:29:22.176 A:middle You know, and I think our next [inaudible] management 00:29:22.176 --> 00:29:24.816 A:middle of this patient would be to obtain a chest x ray. 00:29:24.816 --> 00:29:27.776 A:middle And it's also important to know while you're thinking 00:29:27.776 --> 00:29:30.426 A:middle about does the patient need antibiotics or not 00:29:30.426 --> 00:29:34.336 A:middle that if there's no infiltrate on a chest x ray, with the patient 00:29:34.336 --> 00:29:36.916 A:middle in general, it's much less likely 00:29:36.916 --> 00:29:38.426 A:middle to have community acquired pneumonia. 00:29:38.736 --> 00:29:40.956 A:middle So, moving on to moment two, 00:29:40.956 --> 00:29:43.246 A:middle remember moment two has two questions. 00:29:43.246 --> 00:29:45.346 A:middle Have I ordered appropriate cultures before 00:29:45.346 --> 00:29:47.146 A:middle starting antibiotics? 00:29:47.276 --> 00:29:50.496 A:middle And what empiric therapy should I initiate? 00:29:50.656 --> 00:29:51.816 A:middle Remembering, of course, 00:29:51.816 --> 00:29:55.156 A:middle that empiric therapy ideally should be based 00:29:55.156 --> 00:29:58.436 A:middle on local empiric treatment guidelines 00:29:58.436 --> 00:30:00.966 A:middle that have been developed by the stewardship program 00:30:00.966 --> 00:30:03.536 A:middle in conjunction with frontline providers. 00:30:03.536 --> 00:30:06.416 A:middle So, first with diagnostic testing 00:30:06.416 --> 00:30:07.966 A:middle in community acquired pneumonia. 00:30:07.966 --> 00:30:11.656 A:middle A sputum gram stain and culture is recommended 00:30:11.656 --> 00:30:15.026 A:middle if the patient is able to produce sputum. 00:30:15.496 --> 00:30:18.006 A:middle And blood cultures are really 00:30:18.006 --> 00:30:21.036 A:middle at this point not recommended for all patients. 00:30:21.826 --> 00:30:25.296 A:middle They used to be part of a core measure that led 00:30:25.506 --> 00:30:28.256 A:middle to people getting blood cultures all the time in patients 00:30:28.256 --> 00:30:29.686 A:middle with community acquired pneumonia. 00:30:29.686 --> 00:30:32.546 A:middle That is no longer a requirement. 00:30:32.546 --> 00:30:35.416 A:middle However, if the patient is quite ill, 00:30:35.416 --> 00:30:38.966 A:middle or they have any abnormal chest imaging findings, 00:30:38.966 --> 00:30:41.506 A:middle such as a long abscess or a parapneumonic infusion, 00:30:41.506 --> 00:30:42.976 A:middle then it's reasonable to consider blood cultures. 00:30:43.046 --> 00:30:46.616 A:middle But in the average patient presenting with CAP, 00:30:46.766 --> 00:30:49.286 A:middle blood cultures are likely to be a very low yield. 00:30:49.286 --> 00:30:54.156 A:middle It also can be useful to obtain a respiratory virus panel, 00:30:54.426 --> 00:30:57.496 A:middle because that can be an alternative explanation 00:30:57.496 --> 00:30:59.186 A:middle for our patient's clinical symptoms, 00:30:59.186 --> 00:31:02.016 A:middle particularly during respiratory virus season. 00:31:02.696 --> 00:31:04.266 A:middle And, you know, in institutions 00:31:04.266 --> 00:31:07.966 A:middle that have the strep pneumourinary antigen test, 00:31:08.226 --> 00:31:09.726 A:middle that can be considered. 00:31:09.896 --> 00:31:12.356 A:middle Many institutions don't have this available. 00:31:12.356 --> 00:31:16.956 A:middle We actually do use it in our institution, because we find 00:31:16.956 --> 00:31:19.956 A:middle that it can be helpful if positive to say 00:31:19.956 --> 00:31:22.526 A:middle that the patient has pneumococcal pneumonia 00:31:22.656 --> 00:31:25.346 A:middle and not some other kind of pneumonia, and that allows us 00:31:25.346 --> 00:31:29.856 A:middle to comfortably narrow antibiotic therapy to Amoxicillin. 00:31:29.856 --> 00:31:33.556 A:middle And then, again, on the, on the theme of urinary antigen tests, 00:31:33.556 --> 00:31:37.066 A:middle if Legionella urinary antigen testing is available, 00:31:37.066 --> 00:31:39.676 A:middle it can be considered for patients with moderate 00:31:39.676 --> 00:31:43.076 A:middle to severe symptoms, people who smoke, 00:31:43.236 --> 00:31:47.676 A:middle immunocompromised patients, or patients over 50 years of age. 00:31:48.856 --> 00:31:52.046 A:middle So, remember the other part of moment two is empiric therapy. 00:31:52.046 --> 00:31:54.806 A:middle Empiric therapy for community acquired pneumonia 00:31:54.806 --> 00:31:59.916 A:middle in the United States is largely driven by existing guidelines 00:31:59.916 --> 00:32:02.436 A:middle from the American Thoracic Society 00:32:02.436 --> 00:32:05.256 A:middle and the Infectious Diseases Society of America. 00:32:05.256 --> 00:32:10.786 A:middle And these recommend coverage for typical bacterial pathogens 00:32:10.786 --> 00:32:14.876 A:middle such as streptococcus pneumoniae and haemophilus influenzae. 00:32:14.876 --> 00:32:18.756 A:middle And the U.S. guidelines also suggests a coverage 00:32:18.756 --> 00:32:22.526 A:middle for atypical organisms, such as Legionella. 00:32:22.696 --> 00:32:29.886 A:middle So, regimens to consider are Ampicillin or Ceftriaxone, 00:32:30.096 --> 00:32:33.076 A:middle as your beta lactam agents. 00:32:33.076 --> 00:32:36.926 A:middle Plus, either Azithromycin or Doxycycline. 00:32:36.926 --> 00:32:39.846 A:middle The guidelines will tell us that there is more evidence 00:32:39.846 --> 00:32:43.786 A:middle for Azithromycin than there is for Doxycycline. 00:32:43.786 --> 00:32:49.126 A:middle However, many institutions preferentially use Doxycycline 00:32:49.126 --> 00:32:52.136 A:middle because it is less commonly associated 00:32:52.136 --> 00:32:54.726 A:middle with Clostridium difficile infection 00:32:54.896 --> 00:32:58.346 A:middle than other antibiotics. 00:32:58.456 --> 00:33:01.716 A:middle In general, and as part of the safety program, 00:33:01.846 --> 00:33:06.506 A:middle we discouraged use of fluroquinolones for the majority 00:33:06.506 --> 00:33:07.856 A:middle of patients, not just for patients 00:33:07.856 --> 00:33:10.246 A:middle with community acquired pneumonia. 00:33:10.246 --> 00:33:12.946 A:middle And one of the findings in our safety program was 00:33:12.946 --> 00:33:17.046 A:middle that decreases in antibiotic use were driven 00:33:17.046 --> 00:33:19.526 A:middle by reductions in fluroquinolones. 00:33:19.526 --> 00:33:21.366 A:middle So, for community acquired pneumonia, 00:33:21.486 --> 00:33:24.976 A:middle even though historically I think many providers have reached 00:33:24.976 --> 00:33:28.546 A:middle for fluroquinolones, because they think, oh, it's easier, 00:33:28.546 --> 00:33:34.476 A:middle it's just one agent, we really recommend, as do the guidelines 00:33:34.476 --> 00:33:37.556 A:middle against these being first line agents, 00:33:37.696 --> 00:33:42.436 A:middle and instead limiting them to patients 00:33:42.436 --> 00:33:44.886 A:middle with severe Penicillin allergies. 00:33:44.886 --> 00:33:48.816 A:middle And as I mentioned, you know, most antibiotics are associated 00:33:48.816 --> 00:33:53.526 A:middle with C diff, but fluroquinolones in particular can be associated 00:33:53.526 --> 00:33:55.246 A:middle with C diff infections. 00:33:55.466 --> 00:33:59.836 A:middle And other side effects, such as prolonged QTC intervals, 00:33:59.836 --> 00:34:02.566 A:middle tendinopathies, altered mental status changes. 00:34:02.566 --> 00:34:06.766 A:middle And this is particularly an issue in the elderly population, 00:34:06.766 --> 00:34:11.116 A:middle so I really do try to avoid quinolones in that population. 00:34:11.686 --> 00:34:15.676 A:middle I think a common question that comes up is is it, 00:34:15.676 --> 00:34:17.576 A:middle is it okay to cover patients 00:34:17.576 --> 00:34:19.946 A:middle with community acquired pneumonia with all those agents 00:34:19.946 --> 00:34:21.986 A:middle that we just discussed? 00:34:22.156 --> 00:34:24.646 A:middle Should we be concerned about patients' risk 00:34:24.716 --> 00:34:27.736 A:middle for Methicillin resistant staph aureus? 00:34:27.806 --> 00:34:31.656 A:middle Or risk for pseudomonas aeruginosa? 00:34:31.656 --> 00:34:35.346 A:middle And I just want to say, for both of these organisms, 00:34:35.456 --> 00:34:38.986 A:middle which are the source of much handwringing and worrying 00:34:38.986 --> 00:34:45.466 A:middle in the hospital, as we all know, that CAP is very unlikely 00:34:45.466 --> 00:34:49.386 A:middle to be caused by MRSA, and very unlikely to be caused 00:34:49.386 --> 00:34:51.576 A:middle by pseudomonas aeruginosa. 00:34:51.726 --> 00:34:53.596 A:middle And frankly, patients 00:34:53.596 --> 00:34:58.326 A:middle who ultimately do have these organisms isolated probably 00:34:58.326 --> 00:35:01.366 A:middle didn't have what we would call community acquired pneumonia. 00:35:02.056 --> 00:35:05.776 A:middle They probably had pneumonia that was associated with contact 00:35:05.776 --> 00:35:08.136 A:middle with some kind of healthcare facility. 00:35:08.136 --> 00:35:12.066 A:middle I think another interesting point for MRSA is 00:35:12.066 --> 00:35:16.246 A:middle that there have been many studies 00:35:16.246 --> 00:35:20.026 A:middle that both tell us it is uncommon as a cause of CAP, 00:35:20.156 --> 00:35:21.756 A:middle and then a large study that showed 00:35:21.756 --> 00:35:25.676 A:middle that empiric anti MRSA therapy was not associated 00:35:25.676 --> 00:35:28.646 A:middle with reduced mortality in patients with CAP. 00:35:28.766 --> 00:35:31.146 A:middle So, I think there's just a couple of considerations 00:35:31.146 --> 00:35:33.426 A:middle for when you might use this agent. 00:35:33.726 --> 00:35:37.816 A:middle And they include patients who present fairly ill 00:35:37.816 --> 00:35:40.356 A:middle and have a cavitary or a necrotizing pneumonia 00:35:40.816 --> 00:35:43.236 A:middle on chest x ray or chest CT. 00:35:43.396 --> 00:35:46.586 A:middle And in patients that have MRSA risk factors, 00:35:46.636 --> 00:35:49.836 A:middle perhaps if the sputum gram stain has gram positive cocci 00:35:49.836 --> 00:35:51.576 A:middle and clusters on it. 00:35:51.736 --> 00:35:55.556 A:middle You know, the standard CAP regimens don't include coverage 00:35:55.556 --> 00:35:59.016 A:middle for MRSA, so, you know, if MRSA coverage is indicated, 00:35:59.016 --> 00:36:01.486 A:middle this would be Vancomycin, Manazalib [phonetic], 00:36:01.486 --> 00:36:03.676 A:middle or Trimethyl [inaudible] Mathoxazole [phonetic]. 00:36:03.676 --> 00:36:06.226 A:middle And then for pseudomonas, again, 00:36:06.226 --> 00:36:08.836 A:middle I think I've mentioned now several times 00:36:08.836 --> 00:36:11.036 A:middle that pseudomonas CAP is very rare. 00:36:11.576 --> 00:36:14.406 A:middle In general, you would think about it in patients 00:36:14.546 --> 00:36:18.176 A:middle who had a fairly severe underlying lung disease, 00:36:18.176 --> 00:36:21.546 A:middle such as Bronchiectasis, or severe COPD, 00:36:21.636 --> 00:36:24.406 A:middle where they have likely been exposed to multiple courses 00:36:24.406 --> 00:36:27.156 A:middle of different antibiotics over several years. 00:36:27.246 --> 00:36:31.036 A:middle And then the other groups of people who have this, 00:36:31.126 --> 00:36:34.276 A:middle in general, they don't have CAP, they have some kind 00:36:34.276 --> 00:36:36.036 A:middle of healthcare associated pneumonia, 00:36:36.036 --> 00:36:39.206 A:middle so recent received a broad spectrum antibiotic therapy, 00:36:39.206 --> 00:36:40.916 A:middle recent full on hospitalization, 00:36:40.916 --> 00:36:44.836 A:middle admission from a skilled nursing facility or nursing home, 00:36:45.386 --> 00:36:48.036 A:middle or people with significant immunocompromise. 00:36:48.176 --> 00:36:51.766 A:middle And, of course, coverage for pseudomonas would be 00:36:51.766 --> 00:36:55.046 A:middle with Sethapime [phonetic] or Piperacillin and Tazobactam. 00:36:56.736 --> 00:36:58.956 A:middle So, we'll move on to moment three. 00:36:59.016 --> 00:37:02.386 A:middle And so this is a moment that should happen every day 00:37:02.386 --> 00:37:04.476 A:middle that a patient is on antibiotics. 00:37:04.666 --> 00:37:08.056 A:middle So, a day or moment has passed, can I stop, can I narrow, 00:37:08.326 --> 00:37:10.506 A:middle or can I change from IV to oral therapy. 00:37:10.546 --> 00:37:17.996 A:middle And so for community acquired pneumonia, here we go, 00:37:17.996 --> 00:37:23.746 A:middle transitioning to oral therapy is recommended as soon 00:37:23.746 --> 00:37:26.376 A:middle as the patient is starting to have clinical improvement, 00:37:26.376 --> 00:37:27.976 A:middle and able to tolerate oral medications. 00:37:28.046 --> 00:37:30.566 A:middle So, in community acquired pneumonia, 00:37:30.566 --> 00:37:33.266 A:middle there's no requirement for prolonged IV therapy. 00:37:33.266 --> 00:37:37.606 A:middle So, when, you know, when their vital signs parameters are 00:37:37.716 --> 00:37:43.936 A:middle starting to normalize, it's perfectly reasonable 00:37:43.936 --> 00:37:46.146 A:middle to transition to oral therapy. 00:37:46.196 --> 00:37:47.056 A:middle We, in general, transition 00:37:47.136 --> 00:37:50.346 A:middle to an oral third generation Cephalosporin, or, 00:37:50.346 --> 00:37:53.256 A:middle as I mentioned, if you know that the patient has pneumococcus 00:37:53.256 --> 00:37:56.246 A:middle in general, it's safe to transition to Amoxycillin. 00:37:56.246 --> 00:38:00.996 A:middle If the I think we've covered that. 00:38:01.146 --> 00:38:03.616 A:middle So, now we can move on to moment four. 00:38:03.616 --> 00:38:05.826 A:middle What is the duration of antibiotic therapy 00:38:05.826 --> 00:38:07.786 A:middle for my patient's diagnosis? 00:38:07.786 --> 00:38:10.626 A:middle And fortunately for community acquired pneumonia, 00:38:11.046 --> 00:38:15.806 A:middle we now have multiple randomized control trials, 00:38:15.996 --> 00:38:18.876 A:middle and observational trials that indicate that five days 00:38:18.876 --> 00:38:21.396 A:middle of antibiotic therapy is sufficient for most patients 00:38:21.396 --> 00:38:22.936 A:middle with community acquired pneumonia. 00:38:22.936 --> 00:38:27.286 A:middle And, you know, and this should really be the standard, 00:38:27.416 --> 00:38:29.746 A:middle five days, we should drill 00:38:29.746 --> 00:38:32.686 A:middle that into everyone's head, five days of therapy. 00:38:32.686 --> 00:38:35.206 A:middle There are, you know, occasionally cases 00:38:35.206 --> 00:38:37.876 A:middle where someone has severely immunocompromised, has severe 00:38:37.876 --> 00:38:40.156 A:middle or underlying structural lung disease, 00:38:40.686 --> 00:38:44.006 A:middle or had inadequate clinical response, 00:38:44.006 --> 00:38:46.416 A:middle or ended up growing an organism that you weren't covering 00:38:46.416 --> 00:38:48.846 A:middle where you might prolong therapy to seven days. 00:38:48.846 --> 00:38:51.216 A:middle But the vast majority of patients 00:38:51.216 --> 00:38:54.476 A:middle with CAP should be treated for five days. 00:38:54.476 --> 00:38:57.286 A:middle If you started a combination regimen 00:38:57.286 --> 00:38:59.286 A:middle with the beta lactam and Azithromycin. 00:38:59.596 --> 00:39:01.816 A:middle Remember that you don't need to give more 00:39:01.816 --> 00:39:02.976 A:middle than three days of Azithromycin. 00:39:03.086 --> 00:39:05.536 A:middle It has an incredibly long half life. 00:39:05.536 --> 00:39:09.906 A:middle And so it's actually, you know, three days, sticking around in 00:39:09.906 --> 00:39:12.926 A:middle that person's body for probably 10 days. 00:39:13.506 --> 00:39:17.936 A:middle So, remember to encourage discontinuation of Azithromycin 00:39:17.936 --> 00:39:21.576 A:middle after three days if it was part of the empiric regimen, 00:39:21.576 --> 00:39:23.616 A:middle unless the patient is diagnosed with Legionella, 00:39:23.776 --> 00:39:27.696 A:middle in which case longer courses of Azithromycin would be indicated. 00:39:27.856 --> 00:39:33.776 A:middle Also, you know, remember, and remember to remind patients 00:39:33.776 --> 00:39:37.216 A:middle that they may feel tired, they may have a cough that goes 00:39:37.216 --> 00:39:41.066 A:middle on for, you know, quite a few days after a bout 00:39:41.066 --> 00:39:42.646 A:middle with community acquired pneumonia. 00:39:42.646 --> 00:39:45.526 A:middle And it's going to take a while for them to get better. 00:39:45.826 --> 00:39:50.786 A:middle But don't rework them up for this, you know, 00:39:50.786 --> 00:39:53.776 A:middle by getting chest x rays and more sputum, 00:39:53.776 --> 00:39:57.686 A:middle because chest x rays can take a long time to improve. 00:39:57.946 --> 00:40:02.786 A:middle And, you know, so it should be considered as part 00:40:02.786 --> 00:40:05.766 A:middle of the natural history that cough and fatigue can go 00:40:05.766 --> 00:40:09.276 A:middle on for a few weeks after a patient has community acquired 00:40:09.276 --> 00:40:12.236 A:middle pneumonia, and is not a reason to prolong antibiotics. 00:40:12.896 --> 00:40:18.216 A:middle So, I think we have time to one through quickly a second case, 00:40:18.736 --> 00:40:25.536 A:middle just to give another idea of how you can use the four moments. 00:40:25.646 --> 00:40:30.126 A:middle This is a case of a 31 year old woman who is healthy 00:40:30.126 --> 00:40:32.886 A:middle and presents with dysuria, fever, rigors, 00:40:32.886 --> 00:40:35.096 A:middle and left sided flank pain. 00:40:35.096 --> 00:40:39.216 A:middle She, you know, also has evidence of being infected 00:40:39.216 --> 00:40:42.556 A:middle with a temperature of 101, low blood pressure, 00:40:42.556 --> 00:40:47.376 A:middle elevated heart rate, and is standing normally 00:40:47.376 --> 00:40:48.276 A:middle and breathing normally. 00:40:48.276 --> 00:40:52.416 A:middle On exam, she is ill appearing, but able to carry 00:40:52.416 --> 00:40:54.316 A:middle on a normal conversation. 00:40:54.596 --> 00:40:57.646 A:middle So, for this patient, the first question is does my patient have 00:40:57.646 --> 00:41:00.916 A:middle an infection that requires antibiotics? 00:41:00.916 --> 00:41:03.216 A:middle In this case, the patient has signs and symptoms 00:41:03.216 --> 00:41:05.846 A:middle that are concerning for pyelonephritis. 00:41:06.076 --> 00:41:08.626 A:middle So, in this particular case, the answer is yes. 00:41:08.626 --> 00:41:12.076 A:middle But, in general, for urinary tract infections, 00:41:12.306 --> 00:41:14.046 A:middle there are many situations 00:41:14.046 --> 00:41:18.586 A:middle where patients do not necessarily have an infection, 00:41:18.586 --> 00:41:21.936 A:middle even if they have abnormalities with their urine. 00:41:21.936 --> 00:41:25.966 A:middle So, remember that foul smelling urine, cloudy urine, 00:41:26.746 --> 00:41:30.976 A:middle or isolated mental status changes, in the absence 00:41:30.976 --> 00:41:34.376 A:middle of other clinical symptoms of a urinary tract infection, 00:41:34.586 --> 00:41:38.056 A:middle are not indications to obtain urine cultures. 00:41:38.326 --> 00:41:42.916 A:middle And if a urine culture is obtained, 00:41:42.916 --> 00:41:47.176 A:middle and comes back positive, it's always important to go back 00:41:47.296 --> 00:41:51.046 A:middle to the patient and ask about symptoms, because a lot of time 00:41:51.046 --> 00:41:53.796 A:middle in medical care, urine cultures get sent all the time, 00:41:54.026 --> 00:41:57.956 A:middle and then no one remembers why that urine culture was sent, 00:41:58.126 --> 00:42:00.416 A:middle and, you know, positive urine cultures can trigger antibiotic 00:42:00.416 --> 00:42:03.306 A:middle therapy, when antibiotic therapy is not needed at all. 00:42:03.406 --> 00:42:06.316 A:middle So, moving on to moment two. 00:42:06.316 --> 00:42:08.096 A:middle Have I ordered appropriate cultures before 00:42:08.096 --> 00:42:09.376 A:middle starting antibiotics? 00:42:09.376 --> 00:42:12.226 A:middle And what empiric therapy should I initiate? 00:42:13.296 --> 00:42:17.276 A:middle You know, just some more information about interpreting, 00:42:17.276 --> 00:42:22.196 A:middle sending and interpreting urinalysis and urine cultures, 00:42:22.196 --> 00:42:25.326 A:middle you know, there are, in general, in labs, 00:42:25.326 --> 00:42:28.606 A:middle cut offs for positive UAs, you know, 00:42:28.606 --> 00:42:30.926 A:middle and so your lab might differ. 00:42:30.926 --> 00:42:33.596 A:middle But, you know, in general, this is usually considered greater 00:42:33.596 --> 00:42:37.446 A:middle than or equal to 10 white cells per high powered field. 00:42:38.016 --> 00:42:41.066 A:middle In patients with very small numbers of white cells 00:42:41.066 --> 00:42:45.326 A:middle in their urine, a UTI is, in general, unlikely. 00:42:46.506 --> 00:42:48.896 A:middle In our patient with pyelonephritis, 00:42:48.896 --> 00:42:52.286 A:middle a urine culture should be obtained. 00:42:52.286 --> 00:42:57.516 A:middle But a lot of patients get urine cultures as I, as I mentioned, 00:42:57.516 --> 00:43:00.866 A:middle and, you know, it's really important to look 00:43:00.866 --> 00:43:03.196 A:middle at colony counts in these urine cultures 00:43:03.506 --> 00:43:08.056 A:middle when assessing whether they are clinically significant. 00:43:08.756 --> 00:43:11.626 A:middle If patients do not have symptoms, 00:43:11.626 --> 00:43:15.496 A:middle and have low colony counts, again, highly unlikely 00:43:15.496 --> 00:43:18.656 A:middle to be a urinary tract infection. 00:43:18.656 --> 00:43:20.936 A:middle And then with regard to blood cultures, 00:43:21.086 --> 00:43:26.986 A:middle most patients do not need blood cultures. 00:43:26.986 --> 00:43:28.366 A:middle Certainly patients with concern 00:43:28.366 --> 00:43:30.866 A:middle for cystitis don't need blood cultures. 00:43:31.076 --> 00:43:32.926 A:middle And patients being treated for pyelonephritis 00:43:32.926 --> 00:43:35.776 A:middle as outpatients don't need blood cultures. 00:43:35.986 --> 00:43:39.256 A:middle If patients are hospitalized for pyelonephritis, 00:43:39.256 --> 00:43:41.606 A:middle a urine culture is still the most useful culture. 00:43:41.606 --> 00:43:44.746 A:middle But if there's any concern about getting that urine culture, 00:43:44.746 --> 00:43:46.416 A:middle difficult to getting that urine culture, 00:43:46.416 --> 00:43:48.496 A:middle or if the patient has evidence of sepsis, 00:43:48.526 --> 00:43:50.836 A:middle then blood culture should be obtained. 00:43:52.046 --> 00:43:55.696 A:middle So, moving onto the empiric therapy part of moment two, 00:43:55.696 --> 00:43:59.316 A:middle you know, for patients being hospitalized 00:43:59.416 --> 00:44:03.186 A:middle with pyelonephritis, you know, currently, we recommend use 00:44:03.186 --> 00:44:12.036 A:middle of Ceftriaxone if a patient has risk factors for pseudomonas 00:44:12.036 --> 00:44:15.206 A:middle or structural or functional urologic abnormalities, 00:44:15.206 --> 00:44:15.996 A:middle then Sethapime [phonetic]. 00:44:15.996 --> 00:44:19.186 A:middle And if patients have histories 00:44:19.186 --> 00:44:22.356 A:middle of extended spectrum beta lactamase producing organisms, 00:44:22.356 --> 00:44:26.496 A:middle particularly E. Coli, then recommend use of a Carbapenem. 00:44:27.346 --> 00:44:29.426 A:middle For severe Penicillin allergy, 00:44:29.426 --> 00:44:34.436 A:middle it can be either Aztreonam or Gentamicin. 00:44:34.436 --> 00:44:37.426 A:middle If you look at national guidelines 00:44:37.426 --> 00:44:40.336 A:middle for urinary tract infections, quinolones 00:44:40.336 --> 00:44:43.276 A:middle and Trimethoprim sulfamethoxazole are still high 00:44:43.276 --> 00:44:45.696 A:middle on the list for empiric treatment. 00:44:45.896 --> 00:44:50.396 A:middle These guidelines are now over 10 years out of date. 00:44:50.616 --> 00:44:52.686 A:middle And while fluroquinolones 00:44:52.686 --> 00:44:55.316 A:middle and Trimethoprim sulfamethoxazole have excellent 00:44:55.316 --> 00:45:00.166 A:middle kidney and urine penetration, the big issue with them is 00:45:00.166 --> 00:45:03.676 A:middle that we have seen increasing resistance, particularly 00:45:03.676 --> 00:45:05.846 A:middle in E. Coli, over the past decade. 00:45:06.136 --> 00:45:10.176 A:middle And this is in many parts of the United States, although not 00:45:10.176 --> 00:45:12.336 A:middle in all of the United States. 00:45:12.636 --> 00:45:16.796 A:middle So, if resistance rates are known to be low, ideally less 00:45:16.796 --> 00:45:20.386 A:middle than 10%, then these agents can certainly be considered 00:45:20.386 --> 00:45:21.536 A:middle for empiric therapy. 00:45:21.536 --> 00:45:26.206 A:middle The problem is many parts of the country, the resistance rates 00:45:26.206 --> 00:45:29.276 A:middle for fluroquinolones and Trimethoprim sulfamethoxazole 00:45:29.276 --> 00:45:34.036 A:middle for E. Coli are now, you know, 30 to 40%. 00:45:34.126 --> 00:45:36.656 A:middle So, moving onto the third moment, 00:45:36.656 --> 00:45:37.556 A:middle a day or more has passed. 00:45:37.656 --> 00:45:38.226 A:middle Can I stop? 00:45:38.226 --> 00:45:38.856 A:middle Can I narrow? 00:45:38.856 --> 00:45:40.186 A:middle Can I change to oral? 00:45:40.186 --> 00:45:46.616 A:middle So, in patients admitted with pyelonephritis, 00:45:46.616 --> 00:45:50.286 A:middle therapy should be transitioned to oral therapy, again, 00:45:50.286 --> 00:45:52.376 A:middle as soon as the patient is feeling better, 00:45:52.376 --> 00:45:56.016 A:middle and whenever the patient can tolerate oral therapy. 00:45:56.376 --> 00:46:02.236 A:middle This is one situation where we actually favor use 00:46:02.236 --> 00:46:02.956 A:middle of quinolones. 00:46:02.956 --> 00:46:05.616 A:middle I know I always talk about not using quinolones. 00:46:05.616 --> 00:46:09.406 A:middle But because of their outstanding urinary penetration, 00:46:09.616 --> 00:46:13.476 A:middle I think they are very reasonable to use in stepdown therapy 00:46:13.476 --> 00:46:15.546 A:middle for patients with pyelonephritis, 00:46:15.616 --> 00:46:20.336 A:middle because you can give a pretty short duration of therapy. 00:46:20.336 --> 00:46:22.266 A:middle But it's important. 00:46:22.266 --> 00:46:26.216 A:middle Whether using quinolones or Trim sulfa to make sure 00:46:26.216 --> 00:46:28.196 A:middle that the organism is susceptible. 00:46:28.196 --> 00:46:31.536 A:middle If you can't use these agents 00:46:31.536 --> 00:46:35.336 A:middle because of susceptibility issues, then, in general, 00:46:35.336 --> 00:46:37.196 A:middle we use oral cephalosporins. 00:46:37.676 --> 00:46:42.136 A:middle And then finally, the fourth moment is what duration 00:46:42.136 --> 00:46:44.016 A:middle of therapy is needed? 00:46:44.166 --> 00:46:46.486 A:middle In this case, durations for pyelonephritis, 00:46:46.486 --> 00:46:48.586 A:middle and as I mentioned, quinolones can be attractive 00:46:48.586 --> 00:46:51.696 A:middle in these situations, because patients can be treated 00:46:51.916 --> 00:46:53.876 A:middle with five to seven days of therapy. 00:46:53.876 --> 00:46:57.166 A:middle In contrast, we don't have clinical studies 00:46:57.166 --> 00:47:01.096 A:middle that support these short courses of therapy for other agents. 00:47:01.326 --> 00:47:03.306 A:middle So, even for Trim sulfa, which, again, 00:47:03.306 --> 00:47:05.486 A:middle has excellent urinary penetration, 00:47:05.486 --> 00:47:07.486 A:middle we unfortunately don't have a lot of studies 00:47:07.486 --> 00:47:10.106 A:middle that say we can use these shorter courses of therapy. 00:47:10.106 --> 00:47:12.636 A:middle And then for oral cephalosporins, 00:47:12.826 --> 00:47:15.146 A:middle there probably is a bit higher failure rate 00:47:15.146 --> 00:47:15.976 A:middle for oral cephalosporins. 00:47:16.266 --> 00:47:21.106 A:middle And so if you're using them, again, 10 to 14 days 00:47:21.106 --> 00:47:24.516 A:middle of total therapy, of course including the days 00:47:24.516 --> 00:47:28.636 A:middle that the patient received in the hospital. 00:47:28.636 --> 00:47:33.446 A:middle And, you know, much like not repeating chest x rays 00:47:33.446 --> 00:47:36.406 A:middle and sputum cultures in patients with CAP, 00:47:36.666 --> 00:47:39.416 A:middle in patients who are recovering from urinary tract infections, 00:47:39.416 --> 00:47:42.436 A:middle they also do not need repeat urine cultures. 00:47:44.506 --> 00:47:49.186 A:middle So, I'm going to sum up the presentation 00:47:49.186 --> 00:47:51.546 A:middle for all three of the speakers. 00:47:51.596 --> 00:47:54.366 A:middle And I hope that we have convinced you 00:47:54.366 --> 00:47:56.956 A:middle that implementation of the AHRQ safety program 00:47:56.956 --> 00:48:02.316 A:middle for improving antibiotic use was, was valuable and useful 00:48:02.316 --> 00:48:05.376 A:middle and associated with enhancing antibiotic stewardship programs 00:48:05.376 --> 00:48:09.256 A:middle and improving antibiotic prescribing, and I want to point 00:48:09.256 --> 00:48:13.336 A:middle out that, you know, 20% 00:48:13.336 --> 00:48:15.976 A:middle of the participating hospitals were critical access hospitals. 00:48:16.046 --> 00:48:19.856 A:middle And we did see reductions in antibiotic use 00:48:19.856 --> 00:48:24.726 A:middle in these hospitals, you know, because overall the amount 00:48:24.726 --> 00:48:29.376 A:middle of use is not as high compared to larger hospitals. 00:48:29.446 --> 00:48:34.346 A:middle This was not a significant finding, but the magnitude 00:48:34.346 --> 00:48:36.526 A:middle of reduction was actually greatest 00:48:36.526 --> 00:48:38.606 A:middle in critical access hospitals. 00:48:38.776 --> 00:48:41.596 A:middle So, I think if we'd have more critical access hospitals, 00:48:41.696 --> 00:48:44.966 A:middle ultimately I think that finding would have been significant. 00:48:45.146 --> 00:48:48.076 A:middle And then finally, you've heard before, but I'll say it again, 00:48:48.076 --> 00:48:49.586 A:middle that the AHRQ safety program 00:48:49.586 --> 00:48:53.226 A:middle for improving antibiotic use toolkits is available 00:48:53.226 --> 00:48:55.126 A:middle at the AHRQ website. 00:48:55.366 --> 00:48:58.016 A:middle And, you know, all the materials 00:48:58.016 --> 00:49:00.506 A:middle that we've discussed today are available for download. 00:49:00.626 --> 00:49:02.796 A:middle Most of them are editable 00:49:02.796 --> 00:49:05.376 A:middle so that you can customize them for your site. 00:49:05.746 --> 00:49:10.306 A:middle And if you're somehow also looking for materials 00:49:10.306 --> 00:49:14.056 A:middle for nursing homes and materials for outpatient care, 00:49:14.056 --> 00:49:17.276 A:middle we have toolkits with all these same features available 00:49:17.276 --> 00:49:19.906 A:middle for those settings also on the website. 00:49:20.096 --> 00:49:24.636 A:middle So, thank you for your attention. 00:49:24.636 --> 00:49:26.466 A:middle And I think we have some time for questions. 00:49:26.936 --> 00:49:30.936 A:middle >> Yes, thank you so much for all our speakers. 00:49:30.936 --> 00:49:35.256 A:middle And I could just listen to Sara all day talking 00:49:35.256 --> 00:49:38.296 A:middle about clinical pearls for infections. 00:49:38.616 --> 00:49:42.566 A:middle So, I'll actually maybe start with you, Dr. Cosgrove. 00:49:42.566 --> 00:49:45.886 A:middle In terms of there's a question about the three day course 00:49:45.886 --> 00:49:48.566 A:middle of Azithromycin for CAP. 00:49:48.566 --> 00:49:51.226 A:middle What dose is used? 00:49:51.996 --> 00:49:55.966 A:middle >> It would be 500 for three days. 00:49:56.206 --> 00:49:58.886 A:middle >> Okay. Great. 00:49:59.076 --> 00:50:03.746 A:middle And in terms of the engagement for the office hours, 00:50:03.876 --> 00:50:06.096 A:middle one of our audience members was curious 00:50:06.096 --> 00:50:10.246 A:middle of what the engagement was like for the office hours. 00:50:10.456 --> 00:50:12.606 A:middle >> We had a good time on the office hours. 00:50:12.606 --> 00:50:19.916 A:middle It was actually, it was really fun to do the office hours. 00:50:19.916 --> 00:50:22.656 A:middle I think that, and I don't mean to like toot our own horn 00:50:22.656 --> 00:50:26.226 A:middle or something, but I think that people were excited 00:50:26.226 --> 00:50:30.096 A:middle to have access to infectious disease stewardship positions. 00:50:30.096 --> 00:50:34.416 A:middle And, you know, I know that there are, you know, are many places 00:50:34.416 --> 00:50:38.056 A:middle in the country that really don't have that access. 00:50:38.056 --> 00:50:41.646 A:middle And so it was really just a treat to be able to, you know, 00:50:41.646 --> 00:50:44.816 A:middle just be there to answer anyone's question, 00:50:44.816 --> 00:50:46.106 A:middle because it could be anything. 00:50:46.106 --> 00:50:48.396 A:middle It could be programmatic stewardship stuff, 00:50:48.506 --> 00:50:51.186 A:middle it could be I'm having this problem with this person, 00:50:51.186 --> 00:50:53.886 A:middle can you help me solve this problem with this person, or, 00:50:53.886 --> 00:50:57.966 A:middle you know, just stuff about the evidence behind recommendations 00:50:57.966 --> 00:50:59.436 A:middle and so forth. 00:51:00.766 --> 00:51:01.746 A:middle >> Yeah, absolutely. 00:51:01.746 --> 00:51:07.766 A:middle And getting some questions about using days 00:51:07.766 --> 00:51:12.786 A:middle of therapy per a thousand patient days, particularly 00:51:12.786 --> 00:51:14.246 A:middle in the context of a small hospital 00:51:14.246 --> 00:51:17.096 A:middle or critical access hospital, and some of the limitations, 00:51:17.376 --> 00:51:20.216 A:middle for example, one of our audience members is saying 00:51:20.346 --> 00:51:24.886 A:middle that one patient could really impact your days of therapy. 00:51:25.086 --> 00:51:29.306 A:middle And they were wondering if you had thought about other measures 00:51:29.306 --> 00:51:33.436 A:middle that might better capture this excellent work that you've done. 00:51:33.956 --> 00:51:37.116 A:middle >> So, I completely agree that I think 00:51:37.116 --> 00:51:39.906 A:middle that that is a very challenging metric. 00:51:40.046 --> 00:51:44.166 A:middle It's actually a challenging metric for all hospitals, 00:51:44.166 --> 00:51:47.626 A:middle because even if you have tons of antibiotic use, 00:51:47.716 --> 00:51:51.526 A:middle it's actually hard for clinicians to understand. 00:51:51.526 --> 00:51:55.626 A:middle You know, we've had this experience in our institution. 00:51:55.626 --> 00:51:58.296 A:middle Well, your Vanco increased from this to this. 00:51:58.296 --> 00:52:00.696 A:middle And they're like, what does that mean? 00:52:00.696 --> 00:52:02.716 A:middle Why do I care if my Vanco increased 00:52:02.716 --> 00:52:05.866 A:middle from 500 days to 600 days? 00:52:05.866 --> 00:52:07.216 A:middle What does that mean? 00:52:07.216 --> 00:52:08.956 A:middle And so I think we all should be thinking 00:52:08.956 --> 00:52:13.976 A:middle about alternative metrics, you know, obviously those kind 00:52:13.976 --> 00:52:16.316 A:middle of metrics are helpful to stewardship programs 00:52:16.316 --> 00:52:16.976 A:middle to track things over time. 00:52:17.046 --> 00:52:22.416 A:middle But when we are trying to engage providers, 00:52:22.496 --> 00:52:26.476 A:middle I think it can be more challenging. 00:52:26.576 --> 00:52:30.316 A:middle I actually think that what providers respond 00:52:30.316 --> 00:52:35.766 A:middle to more is assessments of appropriate decision making. 00:52:35.766 --> 00:52:37.776 A:middle Or adverse events. 00:52:38.196 --> 00:52:44.706 A:middle And so if you have the bandwidth to look at a sample of cases, 00:52:44.706 --> 00:52:46.416 A:middle you know, kind of like we did 00:52:46.416 --> 00:52:49.676 A:middle with the team antibiotic review form, or, you know, 00:52:49.676 --> 00:52:54.826 A:middle even if you say every Friday I'm going to look at everyone 00:52:54.826 --> 00:52:58.566 A:middle on antibiotics and like just do an assessment, you know, 00:52:58.566 --> 00:53:01.306 A:middle 30% of people were guideline noncompliant, 00:53:01.306 --> 00:53:03.496 A:middle 60% of people were guideline compliant. 00:53:03.496 --> 00:53:06.076 A:middle Here's some of the, you know, things I found. 00:53:06.076 --> 00:53:09.526 A:middle But that, I think, is actually more valuable feedback 00:53:09.526 --> 00:53:14.266 A:middle to the frontline than days of therapy per 1,000 patient days. 00:53:14.266 --> 00:53:18.396 A:middle And apologies to ÐÇ¿ÕÓéÀÖ¹ÙÍø, because obviously, you know, 00:53:18.396 --> 00:53:20.646 A:middle that is the approach for large scale surveillance. 00:53:20.646 --> 00:53:22.926 A:middle But when we're talking to frontline, 00:53:23.136 --> 00:53:25.676 A:middle they need something they can wrap their head around. 00:53:25.676 --> 00:53:28.456 A:middle And, you know, and another thing is 00:53:28.456 --> 00:53:31.826 A:middle that if you do have C diff cases that you can review, 00:53:31.886 --> 00:53:36.386 A:middle we find that our focus really kind of like to hear about, 00:53:36.386 --> 00:53:37.366 A:middle you know, assessments 00:53:37.366 --> 00:53:39.166 A:middle of how well they did with managing C diff. 00:53:39.166 --> 00:53:42.566 A:middle And that covers both the diagnostic stewardship parts 00:53:42.566 --> 00:53:44.856 A:middle of the C diff, like should the patient have been tested 00:53:44.856 --> 00:53:45.806 A:middle in the first place. 00:53:45.806 --> 00:53:51.216 A:middle It covers, you know, were the antibiotics non C diff related 00:53:51.216 --> 00:53:53.426 A:middle that the patient was on appropriate? 00:53:53.426 --> 00:53:55.136 A:middle Or did they contribute to the C diff? 00:53:55.136 --> 00:53:57.216 A:middle Once they found out about C diff, 00:53:57.216 --> 00:54:00.736 A:middle did they modify the antibiotics or stop them? 00:54:00.736 --> 00:54:02.736 A:middle And then even did they use the right approach 00:54:02.736 --> 00:54:04.276 A:middle with the treatment of the C diff? 00:54:04.276 --> 00:54:08.186 A:middle So, lots of stewardship stuff around C diff. 00:54:08.466 --> 00:54:09.096 A:middle >> Absolutely. 00:54:09.286 --> 00:54:10.656 A:middle Thank you. 00:54:10.656 --> 00:54:15.876 A:middle Along similar lines about really tracking antimicrobial use, 00:54:15.876 --> 00:54:19.336 A:middle we had an audience member ask if there's a comprehensive list 00:54:19.336 --> 00:54:23.226 A:middle of antibiotics on a spectrum of broad to narrow 00:54:24.026 --> 00:54:27.406 A:middle when this individual is doing audits, 00:54:27.406 --> 00:54:31.046 A:middle and if a physician changes the antibiotic, not a clear guidance 00:54:31.046 --> 00:54:33.606 A:middle in terms of if that was a deliberate move 00:54:33.606 --> 00:54:35.556 A:middle to more narrow spectrum. 00:54:36.906 --> 00:54:38.766 A:middle Do you want to [inaudible]? 00:54:38.986 --> 00:54:42.876 A:middle >> I can comment real quick. 00:54:42.876 --> 00:54:42.966 A:middle >> Yes. 00:54:42.966 --> 00:54:45.816 A:middle >> You know, I think this is like the question of the century 00:54:45.816 --> 00:54:49.696 A:middle in some ways, because we talk about, you know, narrowing. 00:54:49.696 --> 00:54:52.606 A:middle And it is like a core component of stewardship. 00:54:52.606 --> 00:54:56.646 A:middle But most of the antibiotics we use are pretty broad. 00:54:56.946 --> 00:54:59.256 A:middle You know, when you think of what their potential impact is 00:54:59.256 --> 00:55:00.286 A:middle on the human microbiome. 00:55:00.286 --> 00:55:05.606 A:middle But, in general, you can, I think, have your class of agents 00:55:05.606 --> 00:55:09.196 A:middle that have anti pseudomonal coverage and have a goal 00:55:09.366 --> 00:55:13.016 A:middle to not be on those, and to narrow to something else 00:55:13.016 --> 00:55:15.326 A:middle that doesn't have anti pseudomonal coverage, 00:55:15.326 --> 00:55:17.346 A:middle if they don't have pseudomonas. 00:55:17.346 --> 00:55:20.856 A:middle I think that, you know, for Vancomycin, you know, 00:55:20.856 --> 00:55:26.686 A:middle most of narrowing of Vancomycin is stopping Vancomycin. 00:55:26.686 --> 00:55:30.066 A:middle So, if they don't end up having an indication to be 00:55:30.066 --> 00:55:33.426 A:middle on Vancomycin, no MRSA isolated, no other thing 00:55:33.426 --> 00:55:36.006 A:middle that might be Vanco, narrowing 00:55:36.006 --> 00:55:39.016 A:middle of Vancomycin means stopping Vancomycin. 00:55:39.016 --> 00:55:41.826 A:middle And, you know, if you can get people on Penicillin, 00:55:41.826 --> 00:55:46.256 A:middle that is truly a pretty narrow spectrum drug relative 00:55:46.256 --> 00:55:47.596 A:middle to everything else. 00:55:47.776 --> 00:55:52.466 A:middle Amoxicillin is narrower than late generation Cephalosporin. 00:55:52.466 --> 00:55:53.976 A:middle So, if you can get people on Amoxicillin, that's good. 00:55:54.196 --> 00:55:58.946 A:middle But it's not crazy narrow, you know, it kills plenty 00:55:58.946 --> 00:56:00.566 A:middle of gram positives and gram negatives. 00:56:00.566 --> 00:56:02.786 A:middle So, [inaudible] to any other thoughts? 00:56:02.886 --> 00:56:05.456 A:middle >> No, that's good. 00:56:05.686 --> 00:56:10.986 A:middle Okay, we have like a technical question here. 00:56:10.986 --> 00:56:14.746 A:middle What is the recommendation for the duration of Azithromycin 00:56:14.746 --> 00:56:17.846 A:middle if a urine Legionella is positive? 00:56:17.956 --> 00:56:22.796 A:middle >> Yeah, so there's not actually a recommendation, 00:56:22.796 --> 00:56:25.426 A:middle because there's not been studies performed on the duration. 00:56:25.426 --> 00:56:30.706 A:middle What's kind of suggested and up to date and some other sort 00:56:30.706 --> 00:56:34.706 A:middle of review articles is somewhere in the range of 7 to 14 days. 00:56:34.706 --> 00:56:37.266 A:middle I think most people would probably treat, 00:56:37.436 --> 00:56:39.466 A:middle until the patient's better, maybe a couple 00:56:39.466 --> 00:56:40.526 A:middle of days more and stop. 00:56:41.006 --> 00:56:44.136 A:middle Like Sara, I always favor shorter durations 00:56:44.136 --> 00:56:45.316 A:middle whenever possible. 00:56:45.316 --> 00:56:48.666 A:middle So, certainly if the patient is responding to therapy, 00:56:48.666 --> 00:56:50.286 A:middle I think a week is probably fine. 00:56:50.286 --> 00:56:53.916 A:middle If the patient is critically ill in the ICU, then maybe going 00:56:53.916 --> 00:56:55.806 A:middle to like 10 days or so might make sense. 00:56:55.806 --> 00:56:59.566 A:middle But there's not actually like traditional CAP where the large, 00:56:59.806 --> 00:57:04.396 A:middle very nicely done RCTs, that data is just not available 00:57:04.396 --> 00:57:05.146 A:middle with Legionella. 00:57:06.256 --> 00:57:11.056 A:middle >> That you don't have to switch someone to a quinolone, 00:57:11.056 --> 00:57:12.966 A:middle just because they have Legionella. 00:57:12.966 --> 00:57:13.416 A:middle >> Correct. 00:57:13.416 --> 00:57:15.946 A:middle >> Quinolones pretty much have the same activity. 00:57:15.946 --> 00:57:19.056 A:middle And so if you already have them on the Azithro, 00:57:19.056 --> 00:57:21.466 A:middle you can stop the Ceftriaxone or the [inaudible] 00:57:21.556 --> 00:57:24.896 A:middle and just keep going with the Azithro. 00:57:25.116 --> 00:57:25.316 A:middle >> Yeah. 00:57:25.316 --> 00:57:27.736 A:middle >> Which is, that's one of my CAP pet peeves, 00:57:27.736 --> 00:57:29.766 A:middle when people switch to quinolones. 00:57:29.946 --> 00:57:36.516 A:middle Then they don't need to switch to quinolones. 00:57:36.516 --> 00:57:36.583 A:middle [ Inaudible ] 00:57:36.583 --> 00:57:40.376 A:middle >> We do, for the acute care program, you know, 00:57:40.376 --> 00:57:44.606 A:middle I'm a pediatrician, we definitely, the guidance that's 00:57:44.606 --> 00:57:48.206 A:middle in there is very generalizable to both children and adults. 00:57:48.206 --> 00:57:51.406 A:middle And if there are exceptions, we make note of it. 00:57:51.406 --> 00:57:54.006 A:middle So, I would say that certainly for the acute care content, 00:57:54.006 --> 00:57:56.636 A:middle it is very generalizable to children as well. 00:57:56.806 --> 00:57:58.846 A:middle Maybe not babies, because they're always a 00:57:58.846 --> 00:57:59.876 A:middle little [inaudible]. 00:57:59.876 --> 00:58:02.696 A:middle >> Ambulatory is also for both. 00:58:02.986 --> 00:58:03.596 A:middle >> Correct, yeah. 00:58:03.596 --> 00:58:05.976 A:middle >> And nursing home one, not so much. 00:58:09.506 --> 00:58:12.896 A:middle >> Yes, and we, just to address a housekeeping question. 00:58:12.936 --> 00:58:15.096 A:middle This presentation will be available, 00:58:15.096 --> 00:58:19.846 A:middle along with the recorded webinar on ÐÇ¿ÕÓéÀÖ¹ÙÍø's tune 00:58:19.846 --> 00:58:22.146 A:middle into safe healthcare website. 00:58:22.386 --> 00:58:25.576 A:middle And you'll be notified when that is available. 00:58:25.576 --> 00:58:27.636 A:middle Typically takes a couple of weeks. 00:58:27.636 --> 00:58:32.986 A:middle And then we also have it linked to the ÐÇ¿ÕÓéÀÖ¹ÙÍø's antibiotic use 00:58:32.986 --> 00:58:35.236 A:middle and stewardship websites, specifically in the [inaudible] 00:58:35.236 --> 00:58:39.846 A:middle and healthcare professionals website for resources. 00:58:39.846 --> 00:58:42.626 A:middle At this time, we're at the top of the hour. 00:58:42.626 --> 00:58:46.356 A:middle And once again, want to really thank our speakers. 00:58:46.356 --> 00:58:49.626 A:middle I enjoyed every aspect of this presentation. 00:58:49.726 --> 00:58:52.606 A:middle And look forward to hearing 00:58:52.606 --> 00:58:54.366 A:middle about U.S. Antibiotic Awareness Week 00:58:54.366 --> 00:58:55.956 A:middle and National Rural Health Day 00:58:55.956 --> 00:58:58.526 A:middle from everyone this upcoming week. 00:58:58.526 --> 00:58:59.226 A:middle Thanks again.