Dr. Jennifer Blumenthal and Dr. Mari Nakamura - Surgery and Antimicrobial Stewardship: Partnering for Better Care

All right, thank you everyone for joining us today. So we have the distinct pleasure of a dual threat grand balance. So thank you so much, Dr. Blumenthal and Dr. Nakamura for joining us. It's always awesome to have an ID perspective on antibiotics stewardship. And we hope everyone here will find this very insightful. So for some quick intros, Dr. Blumenthal received her MD at the University of Alabama, then followed that with residency in pediatrics, as well as fellowships in pediatrics and infectious diseases and pediatric critical care here at Boston Children's. She has been served as an assistant in critical care medicine here with the Department of anesthesia, an assistant in pediatrics as well as instructor of anesthesia at the Harvard Medical School. And she leads many, many awesome discussions on antibiotic stewardship, as well as a PIDS ID on their critical care wards. So following that is Dr. Nakamura, who completed her MD at the Washington University School of Medicine, followed by residency at Vanderbilt Children's, as well as pediatric ID fellowship at Sanford. She serves as an expert in the diagnosis and management of childhood infections in as director of quality improvement of the division of ID. She strives to optimize care by studying and improving the safe and judicious use of antimicrobials and the use of IT at Children's Hospitals. She's also deeply interested in medical education and serves as the Associate Director of the BCHP's ID Fellowship Program. Thank you both for joining us today. Thanks for having us. Appreciate it. You. I'm going to share our slides. Let me know for some reason you can't see them. It looks perfect. Good morning everyone and thanks so much for this opportunity to share our work with you. And I want to start off by being sure to acknowledge that a lot of the work that I'll be presenting has been in collaboration with Strong Rangal and others in the Quality Improvement Program for Surgery and working with the various Quality Improvement Programs for each surgical department. So we really appreciate and value that partnership and much of this would not be possible without that. And we have no conflicts of interest to disclose. So our objectives today are to share some of our current initiatives to improve antibiotic use for surgical patients. And in doing so along the way we'll also highlight antimicrobial stewardship resources at BCH for care of surgical patients. Some of the topics that we'll touch on are surgical antibiotic prephylaxis, management of penicillin and cephalosporin allergies, diagnosis and treatment of trickyitis, and treatment of common infections in acute care settings. Next slide. This is our antimicrobial stewardship team. So it is led by our ASP pharmacist Sarah Jones, our Associate Medical Director, Annie Von Malloy and myself. We have an awesome analyst. We receive advice from our Director of Pharmacy and Hospital Epidemiologist. We're extremely lucky to have Jenna continue to work with us, especially focused on the area of ICU fellowship stewardship. And then we have currently three ID fellows who are pursuing formal training and antimicrobial stewardship as part of their ID fellowship. Next slide. So our mission in the antimicrobial stewardship program is to optimize antimicrobial selection, dosing, duration and monitoring to achieve the best possible clinical outcomes while minimizing antimicrobial associated adverse effects and avoiding development of antimicrobial resistance. Next slide. And a key part of how we do this is by supporting and educating clinicians to use antimicrobials only when needed for only as long as needed to help them to choose the most effective and narrow regimen and to prevent and monitor for antimicrobial associated adverse effects. And so while often when thinking about antimicrobial stewardship programs, people think about the efforts to reduce antibiotic use and that is certainly an important part of what we do. Really our goals are broader than that. We just want to optimize use whatever that might mean for a specific patient. In some cases that might actually involve using a broader regimen or a longer duration. But what we want to do is help you to tailor care for your patients to achieve the best possible outcomes. And we're always happy to help with questions. So the page for the stewardship program is BUGGBug or 2844. We're available Monday through Friday during business hours. If you have urgent questions or questions that are more complex, of course you should always feel free to page our ID fell along call. And while we are separate from infectious diseases, we work in close consultation with the ID service. Next slide. So first off, I'm going to talk about some of our work on surgical antibiotic prophylaxis. And this is an area that we have been active in pretty much since the exception of our program as a formal program back in 2014. And there are a few reasons for this. One is that evidence-based antibiotic prophylaxis is of course an important strategy for preventing surgical site infections. It also comprises one of the largest categories of antibiotic use for our hospital. Next slide. But it's also, and this is not just at BCH, but really nationwide, quite common for antibiotic prophylaxis to be overused. And we know that worldwide antibiotic resistant infections are a major public health crisis. So the most recent US statistics show that antibiotic resistant infections are responsible for about 35,000 deaths in the US annually. Antibiotic overused does in the context of surgical prophylaxis does contribute. So overused is estimated to occur in about 40% of cases. And you know with surgical prophylaxis, because overall the courses are relatively short, it's easy to wonder what difference does one more day make of antibiotic. But actually studies have shown that even one additional dose of surgical prophylaxis in a child is associated with an increased risk for adverse effects, such as sea-deficial infection. Next slide. And of course, not a question to ask is well in using antibiotic prophylaxis for surgical procedures, is there better prevention of surgical site infections, which is the overall goal, and a lot of the motivation for why there's overused. So it's not that people want overused, but that they are concerned if they use antibiotics for a shorter duration or more narrow spectrum ones that they might have more SSIs. And thankfully, Sean Rangel and other colleagues just published this study in JAMA's surgery, which was to my knowledge, the most comprehensive evaluation of the relationship between surgical prophylaxis and surgical site infections in children. So this was in kids undergoing non-emergent surgery, and the key outcomes that they looked at were hospitals of using any prophylaxis and then using any prophylaxis for more than 24 hours. And then whether or not those two things correlated with surgical site infection rates. And so on the left side of this figure, we have prophylaxis at all, and on the right side, a post-doc prophylaxis durations of greater than 24 hours. And each dot is one of the participating hospitals. And then the Y-access, excuse me, is the odds of having a surgical site infection. And so if there were fewer infections with increasing use, then we would expect a lot of the dots for the high users, meaning the far right side of the graph to cluster in the bottom right quadrant. And as you can see, that's actually not the case. So this is really almost more of a random scatterplot, and the key message of their study was that there is not a correlation between increased use and prevention of surgical site infections lower rates. So as with many uses of antibiotics, more is not better. Next slide. And this is the same data for post-doc prophylaxis use, but now broken down by the surgical specialty, so general surgery, orthopedic surgery, otolaryngology, and neurosurgery, and those four were highlighted because they contributed the highest number of cases to this cohort. But as you can see, it's a similar message, even when you look by specialty, that there is not a correlation with more use, meaning fewer infections. Next slide. So to help address this issue, which as we saw from that last study, is really a nationwide one. There's currently an ongoing trial called operatic, optimizing perioperative antibiotics and children. Sean is one of the PIs for this study, and it includes nine sites of which we are one. It's a collaboration between the pediatric and hisquep group and then the sharps collaborative, which is a national antimicrobial stewardship collaborative. Next slide. And the aims of this study are to evaluate strategies to eliminate unnecessary post-operative surgical prophylaxis. So the two key strategies that are being assessed are creating or modifying order sets for surgical prophylaxis and then use of an implementation science technique called facilitation, which is defined as interactive problem solving to implement evidence-based practices, conducted with a recognized need for improvement and a supportive interpersonal relationship among the stakeholders. Next slide. So when we started this work, we at VCH looked at our in-esquep report card for surgical antibiotic prophylaxis. So the data here are from calendar year 2021, and it was readily apparent that an issue for us is using post-operphylaxis for more than 24 hours. Just as a reminder, as many of you are probably aware, there are many procedures for which no post-operphylaxis is needed, so just a pre-incision dose. There are other procedures where some post-operphylaxis is recommended based on evidence, but for no procedure is their evidence of going longer than 24 hours after the procedure. So when we looked at our post-operphylaxis durations, our percentage of cases, excuse me, in which our post-operphylaxis duration was greater than 24 hours, we noted that compared to the overall niscop rate, which is shown in that first column, of 9% that our observed rate was about 14%, whereas our expected rate based on our case mix should be more around 10.5%. And so we had a significantly greater rate of using post-operphylaxis for that prolong duration, and we were a high outlier compared to the other niscop pediatric hospitals. Next slide. So the stuff that we've taken here as part of our participation in this trial is that we've disseminated the niscop pediatric comparative utilization data, and as many of you have hopefully seen while I had displayed the all hospital data, the report card includes data for each department, and so that was shared with each of the departments so that they could identify targets for improvement. And then we collaborated to eliminate or shorten the duration of post-operphylaxis for selected procedures and modified post-operative management order sets accordingly. Next slide. So this is very recent data that was shared by Sean and Crystal Stroh showing the improvements that we've been able to make from between 2021 and 2022. So the upper left table shows the rate of post-operphylaxis for greater than 24 hours in patients receiving any post-operphylaxis at all. So these are just patients who received any post-oper antibiotics, and you can see from 2021 to 2022. We reduced that rate from about 32% to 23%. And the upper right table, this is showing the overall rate of post-operphylaxis used for more than 24 hours for the whole cohort. So now the denominator includes patients who didn't receive any post-operphylaxis, and that we dropped from 15.3% to a little under 9%. And that is the comparable number to the rate that I showed you in that first slide. So we've definitely been able to reduce that rate. And then in the bottom two tables, we have the SSI rates for those corresponding cohorts. So there was not a significant change in the SSI rates from 2021 to 2022 despite that reduction in our use of prophylaxis for more than 24 hours. Next slide. So another area of work that has been ongoing is improving our management of penicillin and cephalosporin allergies, particularly as they affect selection of antibiotics for surgical prophylaxis. Next slide. And to understand why is this important? Why is it something that we're focused on? It's key to know a bit about penicillins and how come they are preferred agents when they can be used. So from many common infections, penicillins and related antibiotics, which collectively are referred to as beta lactams, so that includes cephalosporins, are known across many studies to be most effective for treating infections. And conversely, the alternatives, so other antibiotic classes are not only less effective, but often more toxic. Because another great feature of beta lactams is that they are among our safest class. Compared with nonallergic patients, those who do have penicillin allergy labels are significantly more likely to experience exposure to suboptimal alternative antibiotics, whether for treatment or prophylaxis. They suffer an increased prevalence of C-diff infections, an increased prevalence of colonization and infection due to multi-drug resistant organisms like MRSA and BRE, and longer hospital stays associated with all of those adverse outcomes. Next slide. And there are just a really robust number of studies that support the benefits of beta lactams, but here are just a few examples. One is that in treating MSSA Vectoremia, the mortality rate is up to 43% lower if beta lactams are used than vancomycin. Beta lactams are known to lead to improved clinical response and treatmentogram negative infections. And then especially important for our discussion today, surgical site infections are more common with non-bata lactam antibiotic prophylaxis than if penicillins or cephalosporins are used. Next slide. Despite the issues with penicillin allergies, we also have a dual problem that many penicillin allergies labels are erroneous. And so penicillin is the most commonly recorded drug allergy, it's documented in 15 to 20% of hospitalized patients, but in reality less than 1% of the US population has a true serious penicillin allergy that would preclude treatment with beta lactam. And so as shown in this snapshot of a New York Times column about this problem, many of the labels are erroneous. And why is this? How come there are so many patients who are erroneously labeled with beta lactam allergy? One common reason is that parents will report an allergy for a child because of a history of allergy and a family member. So while the child may have never received penicillins or not had a reaction because of a fear that they may also have an allergy that child is reported to be allergic, a couple of other common reasons are that symptoms or signs are attributed to an antibiotic that are really due to the infection that the antibiotic is intended to treat. So for example, delayed viral rashes are often mistaken for a moxicillin rashes. Another common reason is that common medication side effects such as diarrhea, arnazia are attributed to an antibiotic allergy rather than to just known effects of the medication that are not allergy mediated. Next slide. So with all this information is background. We've been collaborating with Sean, representatives from allergy and from pharmacy to improve our first of all documentation of penicillin allergy reaction history among patients undergoing surgery and to improve the assessment of the reaction history and increased use of beta lactams when feasible. And the reason for the focus on improving documentation of penicillin allergy reactions is that we've learned from this work as well as our initiatives and other patient populations that it's very common at BCH to have a penicillin allergy recorded. So to have allergy to say a moxicillin in a patient's chart, but to have no information as far as what the reaction was. And that makes it therefore impossible to determine if it was a true allergy and what the risk would be of giving either the same drug or related drug again. Next slide. So as part of this effort, we all worked on creating an algorithm to help patients to help providers determine whether patients could receive the Vaseline for surgical prophylaxis. And the reason we focused on that particular antibiotic is one of our most common for surgical prophylaxis that's really an overcourse. And so this algorithm guides the provider through assessing based on what the patient's history was and what the inciting drug was, whether they could receive the Vaseline or should receive an alternative. And this algorithm once we finalized it was widely disseminated or across the surgical departments and made accessible so that it could help with clinical decision making at the point of antibiotic selection. Next slide. So when we looked at whether we were able to improve the rate of documentation of the reaction, we found that there was some initial improvement that seemed encouraging, but overall as we've continued to track it, we see that this is definitely an area for further improvement and something that we'll continue to work on and are working on in other patient populations. So this has also been a focus of initiatives on some of the medical units. There are multiple challenges here including the fact that our documentation process in power chart is pretty clunky and non-intuitive and so that in its self-acidab area. Also, we continue to spread the word about what sorts of details need to be collected and how those will be used to assess the patient's allergy. And then a third barrier for sure is just that our staff are extremely busy especially with recent staffing shortages and so adding this to their long list of other things that they have to do is definitely an ongoing challenge. But we have not given up and we'll continue to work on this. Next slide. That said though, for patients who do have a documented reaction showing what happened when they received a penicillin or cephalensporn before, we've been able to make substantial progress. So this control chart shows the initial rate of appropriate prophylaxis use for patients who had a complete documentation of their penicillin allergy. And so you can see that we started out somewhere only around 25 percent. And then with dissemination of that algorithm and a lot of surrounding education and messaging, we were able to increase that rate of appropriate antibiotic selection for prophylaxis to sum around 50 percent. And then a few months after that, we collaborated with Pharmacy IT to update the main OR medication power plan which contains all of the antibiotic orders for prophylaxis to include guidance right there in the power plan around allergies. And with that change, we've more recently been seeing appropriate selection of antibiotics based on history, somewhere in the neighborhood of 70 to even 80 percent. So it's been really exciting to see this progress. Next slide. And these improvements really have occurred for each department. So the run chart or the control chart that I showed you were for all departments combined. But you can see here on this bar graph where the pre is the green bar and then the post is the blue bar that for every department there has been improvement in appropriate selection of the antibiotic for prophylaxis in kids who have a penicillin allergy. Next slide. So I'm going to close out my part of this talk by telling you about some of the tools available for you for surgical prophylaxis. And as I'll explain, as we've worked on the initiatives that I've described, we've made sure to incorporate information from them into these tools so that they're there for you right at your fingertips. So next slide. First of all, hopefully you're all aware, but Boston Children's Hospital has its own local guideline for surgical prophylaxis. And this is based on national consensus guidelines as well as our local antibiotic resistance data and historical practice. The Animal Corp. Search for Program first developed this back in 2016 working closely with representatives from every surgical specialty. And we continue to update it over time quite frequently. So as recently as last Friday, in fact, based on changes in prophylaxis recommendations as well as QI initiatives like those I described. So the beginning of the document includes guidance about pre-optiming of antibiotics, interoperative redosing next slide. And then post-opteration. So the fact that for noncardiac procedures that all prophylaxis should be discontinued within 24 hours. As we worked on the penicillin allergy issues, we incorporated more nuanced and detailed allergy guidance shown here in this table. And there is a link under the table to that, so the phasaline algorithm that I shared. And so one can get to it from here as well next slide. And then a little later in the document, we have a multi-page table that shows what the standard prophylaxis meaning for patients who do not have a beta-lactim allergy. And then the non-beta-lactim alternative are for each procedure type organized by surgical specialty so that you can quickly find the procedures relevant for your department and be able to see what the recommendations are. And then in some cases, if no prophylaxis is recommended, then we've noted that too. Next slide. So how you can find this, one way is by going to the Animal Acrobiostrowardship Program Internal Website, which you can find under department and programs under A. Next slide. If you go to the practice sidelines section, then the surgical antibiotic prophylaxis guideline is linked right there. Next slide. And then another convenient place to find it is if you find any antibiotic in lexicon par formulary that's used for surgical prophylaxis. One of the Boston Children's Hospital Web links will be to the surgical prophylaxis guideline. So I have a screenshot for our Syphazoline shown here as an example. Next slide. And then next slide. We also, as I mentioned, have incorporated all these recommendations into the main OR medication plan. So you can find that by searching for main OR. Next slide. And then once you open that plan, you will find nested within plan for each department by, that's organized by the standard prophylaxis antibiotics and then the non-beta lactam alternatives. And the text in the green bands is allergy guidelines for when patients should receive non-beta lactam prophylaxis versus when they could safely receive a cephalosporine. Next slide. If you then open a nested plan for a particular specialty, so just an example I've shown here the orthopedic standard prophylaxis plan. You'll find orders for every antibiotic that is recommended in the surgical prophylaxis guideline with the procedure label for which it is recommended and then specific allergy guidance within that plan in the green band. So our hope with this is to make it really easy at the point when you're ordering antibiotics to be able to know which one to choose. Next slide. And with that, I am going to turn the presentation over to Jenna and she's going to talk about some exciting work that has been happening focused on management of common infections in surgical patients and acute care settings. Perfect. Thanks, Murray. So yes, we'll definitely go through some more practical guidance. So I think a lot of what we're trying to do from the antimicrobial stewardship standpoint is teach people about the resources and about ways that they can protect their patients and we have lots and lots of those. So we'll keep going through those. But in addition to that, talking a little bit about some of the different initiatives that we've been doing in the ICU and beyond. So one of which that I wanted to highlight was a trigegous diagnosis and treatment and it's more of a sort of opportunity for people to see how we're able to make some of these algorithms that help us manage patients. And so in pediatric trikegous is a difficult concept. There's no clear guidance on diagnostics. There's no clear guidance on treatment. Certainly in adults in the infectious disease society of America and the American thoracic society guidelines. There's no treatment recommendation at all. They actually recommend do not treat whatever is considered trigegous. And so trying to sort of come out of that mire from patients who are likely over treated for trigegous is sort of where we started. And so we recently published sort of a pilot study about this or the pediatric quality and safety journal that I as I was going to get this little symbol for noticed that Sean Regal is on the editorial board of another shout out to Sean. But we were working to approve the standardization of evaluation and management of trigegous in our ICU patients, many of which you guys interact with or are your patients to start with in the MSICU. We made our own algorithm sort of homegrown out of children's of what we sort of had best practices as much as we could from the scarce literature that exists in pediatrics. And I'll go through this a little bit more data detail in a minute. But we sort of made a how to get into the algorithm and sort of how to interpret the the trigolaspere findings and then how to treat. And what we saw as we put this into into this pilot study into the medical ICU was that the number of trikyl and indistricular aspirate cultures per 100 in to trikyl 2 over trikyl 70 days was able to actually come down in our centerline to have a nice shift, which is what we were going for. And more importantly to me, we were able to see that the antibiotic days or antibiotic utilization was actually able to come down as well. And we had a pretty good centerline shift there as well. We ultimately took out things like antimicrobial prophylaxis or patients that had a positive blood culture or things that would sort of alter the amount of antibiotics that they'd be getting otherwise and tried to hone in as best we could, although it's a sort of fraught metric. And on the number of antibiotic days that we thought were sort of addressing these endotrykyl 2 days, but or in these respiratory cultures, but ultimately we're able to bring that down. And in doing so, we decided to collaborate with a bigger group and try to get this sort of more traction nationally. And so we've been collaborating with a group called BrightStar with the 21 pediatric hospital quality improvement initiative based out of Johns Hopkins. And they are sort of aimed at diagnostic stewardship. And anytime we are improving the way that we diagnose and manage pediatric infections, we can decrease the amount of antibiotics we utilize. And so we saw that with our initial project with this group, our blood culture project. We ultimately had this sort of same algorithm each hospital did their own quality improvement. Algorithm, we all changed the way that we were doing blood cultures. And ultimately we saw a pretty significant decrease in the amount of antibiotics used in blood cultures done. And we're able to publish national guidelines on blood culture, blood culture and practices and pediatrics. And but now we're still working with that pilot based on that pilot study with the respiratory, um, culture and data and how to culture how to interpret and treat my guidance. And so this is our MSICU algorithm. This is an ongoing active study right now. There's a few points that I wanted to highlight in here that are interesting. So a few things that will probably come up for this group and other groups clinically, when to not obtain a tracheal culture. One of the times is within 72 hours of the last tracheal culture. Realistically that does not allow the microbiology lab time to process the sample appropriately. It takes three days just to grow the different bacteria from the initial sample. What you pull from a respiratory culture tends to be relatively messy data. And so they have to sort of subdivide each plate. It takes another day. Then they have to identify what they have found and then get sensitivity data on that. So it's a little bit more complicated than just a routine blood culture. In doing so, you really need to give the lab the time to find that information. So if you send a tracheal culture every single day for three days, you're not going to have the information that you've wanted from that first culture. It's in that way it's not like a blood culture, which I think people are more used to doing. And therefore we're trying to teach people how this works. The microbiology lab has helped us out, intermittently, with being able to reject cultures without an MD override that are sent within that 72 hour timeframe. And that's been really impactful. Another thing we did for this particular group is pull out the significantly immunocompromised patients, particularly the nutrient patients, because as you interpret a tracheal aspirate stain, you're trying to see how many neutrophils that patient has in that stain. And if you don't have any neutrophils to start with, that's an impossible place to go. And then ultimately our guidance is around treatment. And so trying to reduce the amount of antibiotics these patients are getting for infection that's unclear for antibiotics ultimately make it a difference anyway. And so trying to sort of treat a true tracheitis with no, not in ammonia, but a true tracheitis with no other findings for three days. Adjusting the antibiotics to respiratory cultures as necessary, although you're unlikely to have pretty significant information in that three days. And then dropping your vagumized synch if you don't think you have that in Marseille, which you would probably have around the 48 hour mark. And then working on empiric antibiotic choices, which we'll go through in more detail. And what we've been able to see, and again active data so we don't have to subversity at, but this is June of November, and as when we started this intervention in the MSIC, we were able to shift our center line down, and we've been able to keep it down, although not as far down as we'd like. Ultimately, the lab order rejections had to stop in the midst of the Omicron spike in the lab being incredibly busy and just not having the bandwidth to keep that going. But we have re-installed that and re-initiated that culture rejection. And I think our universal continued to turn back down, but we'll watch it over time. And then looking at those number of cultures that were sent within that 72 hour time frame, again, this is where the lab has been rejecting things, and we definitely saw a spike right back up when they stopped being able to do that for us. So hopefully, over time that will improve. We don't have our antibiotic data yet, but I am hopeful that even with, even with the guidance that we have of just this three days we'll be able to see those improvements over time. So we'll see. And with the collaborative with 21 hospitals, these are thousands and thousands of patients that have been affected by these changes. And so we're hoping to see a pretty significant change in the antibiotic use. Some more to come. What we want to provide you guys with is lots of strategies for success and to sort of continue to highlight some of those resources for clinical care. So, Marie, you know, went through a lot of the perioperative antibiotics to prevent surgical site infections, but there are so many more opportunities that you guys have when you're taking care of patients on the wards or in the ICU. And so we just wanted to highlight the clinical pathways for formerly known as CPGs or clinical practice guidelines. We wanted to highlight our antibiotic plus and our antimicrobial stewardship teams activities. And so I'll go through the antibiotic and more detail. But I think many of you probably know that antimicrobial stewardship team is going through patient charts in the background. We have certain reports that come to us. So, for example, if your patient is on double adorovic coverage, so for example, you're on flagellant marapanum. You might get a call from the antimicrobial stewardship team saying, you know, there's only a couple of situations where it's appropriate to be on double adorovic coverage. You probably don't need it. Let's talk through what you really need. And provide some general guidance on that kind of thing. We watch positive blood cultures in the hospital. We are monitoring certain antibiotic use and can reach out with things that are sort of out of the variation of normal on our sort of run charts. And then when things get more complicated, we're both infectious disease actors. We have a nice robust infectious disease team. And we definitely encourage you guys to consult us on the ID side so that we can provide sort of more specific guidance and help you help you all and help our patients when things get very complicated, which they often do. And we know that. And then I just wanted to highlight the fact that realistically for strategies for antimicrobial stewardship and prevention of incredibly long durations, antibiotics. We encourage people to consult you all as well. Because, you know, source control is one of the most important tenets of antibiotic and anti-infection medicine. And so in order not to need an incredibly prolonged duration of antibiotics or even to help the antibiotics work or ultimately save a patient, the source control can be one of the most important things that we encourage people to consult you all all the time on the ID surface. So looking at those clinical pathways, just to highlight this, you get to this through the main clinical resources tab in the Children's Hospital website. And Interweb. So there are 126 clinical pathways currently. I think that number is growing. Lots of people apply for these all the time. They're very complicated to actually get sort of put forth. And so it takes multiple stakeholders. It's incredibly rigorous. So these are, you know, well thought out pathways that take a lot of time and that are updated every two years. Currently of the 126 total, there are 47 that sort of touch our antimicrobial stewardship team. Either they recommend an answer microbial or an infectious disease consult or have infectious disease content. And as it stands right now, we review all of those. And so over time, we are in the process of going through them and we'll go through them every couple of years, incorporate new data, incorporate new guidelines, our antibiotic, gram data, which I'll show you in a second. And so this is just an example of one of the CPGs, sorry, the clinical pathways. And this is bloodstream infections and patients with the central venous catheter. I'm sure something that you all have seen frequently. I certainly see in sort of the treatment guidelines differ for a short term catheter versus long term catheter, but they're very detailed. Sort of give you great guidance on sort of what to do with your patients in these scenarios. They change by different pathogens. They change by different clinical scenarios. So, you know, it's really nice to know that these are available to us and have sort of best practices available. And then I wanted to show you our antibiotic gram plus website. And so an antibiotic which we'll go through first is the hospitals matrix, so a local matrix, bug drug sensitivity patterns. And so like highlighting acid need a bactore just along the top line here, you can see that there are 47 isolates that takes a certain number to even make it on the chart. 47 isolates over the course of a couple of years, two or three years. It's always the first isolates. So not not when they've seen a ton of antibiotics and the sensitivity patterns have changed with the first isolates. And then what they're sensitive to. And so you see that most of our isolates are sensitive to amacacines, sensitive to sephapines, sensitive to syphiroagent. And then it has this for the vast majority of the common pathogens that comes out of our micro lab. We generate this data for what it's worth. The state has one of these as well. Each hospital has one of these as well. All long-term care facilities are required to have them. And they're made for clinicians, but realistically, you know, when I'm in the ICU at night, and I'm, you know, even as an ID doctor and I have a new patient, this is sort of not my go-to for what I go to to think about for a parent coverage. I don't think, oh, my patient could have E. coli from, you know, this neonate was supposed to say, could have E. coli and go through it this way. That is a fact of the job of the antimicrobial stewardship team and the microbiology team to go through this level of detail and put things into recommendations. But just so you know where some of this data is coming from, we take the antibiotic ramp data from the state, from local, and we take that IDSA recommendations, we take you know, the American College of Gyrochology recommendations for pediatrics, we take sort of everything that goes together and bring it into antibiotic recommendations. And so this is something that I would hope that people are using. And if not, just wanted to let you know it exists. You can click the antibiotic recommendation. It's been specialized to our hospital, so it's you know, in some ways it's a little bit better than like up to date for like a general patient that's at children's because it incorporates our antibiotic ramp data. And you would click on gastrointestinal, intradammal abscess, or secondary parasympathitis. And it comes to this antibiotic recommendation page. And you see the common pathogens that are listed there for you, their comments and alerts. So if there was a clinical pathway, it would be highlighted there. If there were something specific to know like, oh, we're going to recommend Maripena, Maripena is restricted in a microbial at children, so please make sure and consult ID. This is you know, the pageant report. And then it tells you the first slide drug recommendations down at the bottom. And I think very importantly, it gives you a duration recommendation. And I think durations tend to be one of the harder things to do and to know what to do in infections. It's a something to really highlight. Here's just been a lot of work putting into trying to make reasonable durations for these things. And obviously not all patients are the same, but definitely a nice resource to have to utilize. It also offers second-line treatments for those allergic patients. And then down below it, it would give you the matrix of the antibiotic ramp and these different common pathogens, but shorthand version is this. And then looking back at the main page, we also have a quick dosing reference. And so I think that's important to see as well. Redone to see been built into any system is a safety mechanism. And so this is obviously redundant. You could certainly look on lexiconp in the hospital formularies, but if you wanted a quick guidance for standardized dosing for our hospital, what you'll see here is sort of pulled up three in alphabetical order, a moxacillin, an apotericin, an ampacillin. And you could get a sense of comparative and level of expense. So one to four, four being the max. And you could see dosing guidelines for an ampazole here, but it's given only IV formulation. It's given every 24 hours. And then it gives you some comments and alerts, for example, or renalto's adjustment for a moxacillin. If you're pregnant, clearance is less than 30. And so this could be a very useful piece of technology as well. And we're hoping to incorporate more of this into the new systems. And so what I often hear from clinicians with this and so I want to address it. And I think it's very important to address is, oh my patient is very unique. Like empiric antibiotic choices are really difficult. And I agree with empiric antibiotic choices are really difficult. And many of our very unique patients who spend a lot of time in the hospital and are not sort of, you know, coming in off the street with a urinary drafted infection. And so I wanted to highlight how to go through some unique patient pieces. And so looking at a personal antibiotic ram, which is available in Power Chart. This is a patient who's actively in the MSICU right now, being cared for by Farook, who if you go into their microbiology viewer right here, you'll see this come up. And so you can see all of their culture and data, essentially. There's a few non-cultur-based things that come into here, but not all infectious disease information is in this view. It's mostly culture data. And so if you change the dates here, you can get sort of narrowing on what you're looking for. So let's say that we change this patient's date to the last six months of their life or something like that. And we want to see all their culture data then. And then you hit this little var across the bottom that does not look like a button, but actually is. It's called personal antimicram. And what you can do then is select different pathogens that the patient has had. So different positive cultures that they've had. And I couldn't show this slide because I have too many dates that have protected. But ultimately, you click every suit of bonus from the last three weeks that the patient has grown suit of bonus. And you can see that they all have the same sensitivity pattern. It sort of run the charts across. But in the last three weeks, the patient has also grown equal life. And so if you click all of their gram negatives, you can instead see what you could utilize in an empiric fashion. So if they were off antibiotics, and they had new fever, and you know they've grown all these things in the past, you can see that if you follow the yellow line across that seven people would be a good choice or septazoping would be a good choice because it would cover the things that this patient has grown in the recent past. And that's how you can sort of utilize some of that more unique information about utilized power charge to come up with an empiric antibiotic plan for that sort of more unique patient, which we have somebody. And so hopefully we've been able to share some of these current initiatives about improving antibiotic use for surgical patients both perioperatively and afterwards and highlight some of our resources at children's. We have a lot of future directions and we're always happy to collaborate if anybody has interest in this and please reach out to us or certainly Sean, I'm sure we'd be happy to collaborate to that speaker. I just have right now, but he's obviously very vested in this. We'd love to roll out some of our antimicrobial stewardship directors into the cardiac ICU. After they've had a little chance of settling to hail, we'd like to roll out a few of our known initiatives. We'd like to help improve the documentation of duration and indications for antibiotics and people's notes and hopefully this will be able to incorporate some of this into epic, but realistically our guiding groups, so CMS and HSN would really prefer us to document these things appropriately to ensure that over transitions of care, that providers know what the patient needs. And so continuing to do that more effectively is definitely something that's on our radar. And then continuing these educations throughout the hospital about best antibiotic practices because that's what we're here to do is educate other groups and try to make this process easier for everyone. So thank you for having us. We're happy to have questions and appreciate the time. Thank you guys for here. Well, Marien and Jen, I want to thank you guys so much for this really educational information and ask everybody who is joining us to use the, I guess the Q&A is which open for questions that I'm sure Jen and Mar will be happy to take in the few minutes we have left. There's lots of mentions by both of them, Sean and I will point out that Sean is not present right now. These people don't think he is and the reason he's not present is just by, oh he just showed up, it looks like, by Mason Quinson, Sean was asked to go here somewhere to talk to the ORL conference this morning and so he was carrying the antibiotic stewardship flag. We are quite fortunate to have a low-val<|ro|> expert yet as you point out, we're still not always perfect in our performance despite all of your guys' best efforts and I wonder how much of that is system related and I'm hoping they have some opportunity in front of us. From my perspective, the ability to show out of text from the chat is disabled. I think Q&A is open to try that. I can open up the chat, you guys want me to open up the chat? Okay, yeah, I'll open up both of them, that'd be great. Yeah, yeah, I just kind of let everyone know that I opened it up to everybody they should know. Great. So from my perspective, the thing that's been most helpful is the order sets, the plans. Plans in PowerChart are not just smooth things to use or probably to create for those of you who could create them but it really, really does help to not have to sort of look things up or remember them because most of us who don't do it every day can remember so I'm curious if you guys have had experience or had a look into into Epic to see if this is going to be a little bit more user-friendly than it has been in PowerChart and maybe we as the department and the institution in general will be better performers. I'll say also in from my perspective, you showed great tools. Yeah, I think some of us don't know how to find them as you point out, it's a button but it doesn't look like a button, right? So how do we know and push that? Again, that is a certain thing, hopefully that will be better with Epic. And the other important thing is you showed us, it was really nice to show the screenshots on our intranet, how to find this information. And an incredibly frustrating thing for all of us in intranet, most of us are using websites and you go to the search bar and you type in what you're looking for and of course on our intranet. That is not a useful thing, it's just searches children's today, news articles that have been posted. But if you do go under the departments and programs, despite its incredible disorganization, it's a pleasure to see that you have such good information there and we'll look for that. I will tell you many people don't know this but with the recent transition to Microsoft 365, although the focus on that has been on our email and calendars, it's a true outlook. We, the institution did by the entire Microsoft 365 suite which is going to include teams and it's going to hold new development of our intranet. So I hope you guys will be early on in access to give us information. Is this something of practical and important clinical utility? So I don't know if you guys have a chance to look at those tools to see if it's going to make your lives in our lives easier. Yeah, so I can speak a bit about what I know and then Jenna, you may have other knowledge too. So I have not myself had a chance to see what order sets are like in Epic. We have many trainees who come to us from other institutions who have used Epic and they at least say that it is more intuitive and straightforward. And this includes both the order sets and the allergy documentation which I mentioned is just really, I would say not a shining part of our our assertor system and not intuitive to use. So I do have hopes that all of this will be easier, more intuitive in Epic. On that front, I am representing the antimicrobial search program and also ID for the Epic implementation and so we'll have a voice to advocate for these features that we know are so valuable for a clinical decision support. And one thing I can say because a lot of our peer hospitals have shared screenshots and tools from Epic that they've used in stewardship is that there is great potential for best practice alerts and decision support in that way that I think we'll be able to really make good use of so that we can, just as you're saying, Dr. Fisherman, make this information just more accessible and obvious to people. Because right now one of the struggles is indeed we create these resources but then to help people know that they exist and know how to find them. And why to be able to achieve that is by having appropriate alerts that guide you to them at the point when you need them. Whether triggered by a diagnosis that you enter or the fact that you open one clinical pathway and that you probably therefore have a patient who has that condition that could lead you to the order set for that patient. So I think those tools will be more available and fully featured in Epic. So I think that there is exciting stuff to come. The only thing I'll add is that it's a privilege to be here and we're really grateful to be invited. And I think part of that is specifically because the governing bodies that be know that antimicrobial stewardship groups have trouble getting sort of their tools and their information and their level of knowledge out to the groups and they have made it a mandate that we continue to educate throughout the hospital. So I think this is part of the way that we will continue to do those things and provide groups with those sort of more practical tools as well as the information that we're gathering in the background. So hopefully we'll maybe we'll come back when Epic starts to roll out and we can provide more guidance to this group. Yeah, we're certainly appreciative of it and actually I feel a little sorry that you guys have such great work in the background and some people probably don't access it just because the difficulty systems and I'm very enthusiastic about the possibly that's going to get much better soon. There's a question here from Alex Quinka. Does as a transplant I always struggle with anomyosis in the immunosuppressed or soon to be? What sort of projects and resources are currently available here to guide our course? The due tendency is almost always to overtreat. Sure, so one thing that I can definitely make a plug for that. Jenna mentioned earlier is for our solid organ transplant recipients. We have a great process in place that all of them receive a pre transplant consult and then a post-transplant consult and a six month post-transplant follow-up in outpatient infectious diseases to so that our immunocompromised host ID providers can help with these questions. Whether it's what proflacists make sense for the transplant procedure itself and what needs to be done after the transplant to make sure that there's appropriate surveillance for infectious diseases complications and then management of those. So that's one resource that can help for each individual patient. For more sort of general guidance, there's ongoing work to create additional internal clinical pathways and guidelines. So for example, we've had a more long standing one around CMV and HSV management, but I know that our immunocompromised host ID group is also wanting to expand that to management of other post-transplant infections and surveillance and treatment of those. So keep an eye out for those and we'll do our best to advertise those as well and make people aware. And then, you know, for sure, our great national guidelines that come out from both the sort of main national transplant societies as well as individual organ groups and so those can be helpful sources of information too. And what we try to do is to take those and interpret them locally, you know, based on things like what our local antibiotic susceptibility patterns are. But I agree that our immunocompromised patients are often especially challenging because they come to us already with a lot of antibiotic exposure. They may not have typical flora to begin with and then of course there's a great deal of appropriate concern if they were to get an infection given their immunocompromised status. And then I don't know Jennifer, have other thoughts to you? The only thing I would say, and I know Alex knows this, but just to sort of put it out of the group, it's a very small group of the infectious diseases attendings that cover the immunocompromised service. And so you do get quite a bit of continuity within that, within that consult team. And so when you consult infectious diseases, there's a general side and there's an immunocompromised side, but the immunocompromised side is like a close knit community. And so it's not as general of a project that Mari was talking about, but you'll sort of get a group of people who are very dedicated to this patient group and have lots of information and we're always happy to consult and often are consulted. Just to say that. It's perfect. I don't I do want to remind people as Andrea is typed in before before we signs up. Don't forget to text in your attendance to record your CV credit. And I'm sure everybody has seen the kind comment that Sean has made about collaboration with you guys. One last question that I think something I like to think about with regard to tracheitis and maybe the sort of over testing or treating. We obviously have some sort of patients who have extensive operations on their trachea. And is that a different population for which there should be maybe a different look at how aggressive to be? I think it's possible. I think a tracheitis postoperative infection is not the same as a tracheitis in a patient who has a tracheostomy tube in place in Kaden from seven hills with a tracheitis type infection. And we don't look at them the same. They're actually excluded. They've had recent airway work on our algorithm, but that doesn't mean that they should get indefinite antibiotic plans. And that's what we are trying to figure out where they fall into that. That's why we took them off the algorithm ultimately. Because we couldn't figure out a way to create a duration. They certainly probably have earned more than three days of antibiotics. But at some point you range into the more harm than good. And we have a totally figured out where that point is. But it could be a next step of the collaborative. Because other people ask the same question and these sort of same safety balancing markers in our collaborative meetings. So we're still working on it. And I can briefly add that for surgical prophylaxis in that population, there is a different approach of taking into account the patient's known colonization because many of these patients do have no colonizers that are more antibiotic resistant. And in the past we had a tendency to probably go too broad with everybody. And so once and we've worked on, and this is reflected in the order sets for that patient group, is to more tailored to what their known susceptibilities are for their colonizing flora. And so as a result, while some patients still end up on very broad agents, others are able to use relatively narrower ones like unison, for example, rather than going straight to Zosen or broad agents. Your own version of personalized mask. But we're at time, I want to thank both of you for not only doing us a terrific and funerable talk, but for your great expertise and the generally and helping us with this broad set of patients knowing what to do, how often do it, and when I'm not to do it all of this importantly. So thanks so much for your continuing guidance. I also want to remind everybody in the surgical department that today we have our new schedule for academic activities. So immediately following this in the surgical lab where we'll be pressurized and then we'll see everybody have been premonent followed by an indications conference. We'll be active for the day with the words in here, but I think again, Marian John. Thanks so much.