Tag Archives: antimicrobial stewardship

“Antimicrobial Stewardship and the Problem of Unsolicited Advice”

“I would stop that fluoroquinolone…”

A good proportion of my job as a clinical microbiologist is being an antimicrobial steward. i.e. giving antibiotic advice based on microbiology results. And a good chunk of this advice is “unsolicited”, in that nobody has specifically asked for it. One could argue that the advice is “semi-solicited” in that it is given under the auspices or framework of an Antimicrobial Stewardship Program.

Being on-call over the Christmas period has made me reflect on the difference between giving solicited and unsolicited antibiotic advice. When someone specifically asks for your advice, they are genuinely interested in what you have to say and for the most part listen and act on your recommendations. However, when the advice is unsolicited, regardless of whether it is given by phone or in-person, it may not always be welcomed with open arms…

It is not that the prescriber necessarily disagrees with your advice. They know it is generally correct in purist terms. It is just that there are (several) other agendas at play for the attending clinician.

Taking it from the clinician’s perspective, antibiotic advice from an antimicrobial steward on occasion may prevent early discharge and may create logistical issues in terms of organising outpatient antibiotics, arranging further investigations, or arranging clinic follow-up. Put in simpler terms, more work. Such factors are accentuated during the Christmas break where the (laser) focus is on getting patients out of hospital, and minimising any admin work that is required during the holiday season.

A classical example of this is advising on a Staphylococcus aureus bacteraemia. (2 weeks IV abx, Echocardiogram, repeat blood cultures, etc.) Sometimes the attending clinician just doesn’t want to know…

Of course, sometimes our advice can be beneficial to the patient workflow & pathway. For example, early oral switches, and promotion of short course antibiotic therapy. I think it is really important to focus on documenting & highlighting such “wins”, as a counterbalance for when “bad news” needs to be given.

Personally, I am a little fatalistic when it comes to whether my advice is accepted, whether it solicited or unsolicited. I believe in the principle that the final management decision always rests with the attending clinician and they can choose whether to take my advice or not. There is only so much that you can do…

Building up relationships and trust is key in getting people to listen to your unsolicited advice. Some prescribers are more receptive than others. And some specialties are more receptive than others.

So, is unsolicited advice more about the giver than the receiver? Is it essentially self-serving in nature? Or is it a necessary evil of being a good antimicrobial steward? These are difficult questions, and ones that I do not have the answers for.

The other approach is to have a more passive approach to antimicrobial stewardship, to only give advice when it is specifically asked for, or at least to issue clear guidelines as to when advice should be sought.

My children often complain when I give them unsolicited advice on how to live their lives. I hope that my clinician colleagues do not feel the same way!


Check out this interesting article on the psychology of antimicrobial stewardship, published in CID

“Vanquishing VRE”

I am the master of false assumptions…

When a hospital close by was affected by a VanB VRE outbreak, I suspected that my local hospital would be relatively immune, due to its smaller size, different patient cohort and relatively strict antimicrobial stewardship policies.

Of course, my assumptions were wrong! It didn’t take long for the VRE to gain a foothold locally as well. (I am simply carrying my poor form on from the COVID pandemic, where I also made several false assumptions…)

MDRO rates in NZ are relatively low compared to many parts of the world. Even though I work in a reasonably big laboratory covering a population of approximately 500,000, up until recently we could go a whole year between VRE isolates! It has therefore been a bit of a shock to see them appear on an almost daily basis over the past few months, fortunately all from rectal screening samples.

Enterococci are hardy bugs and survive well in the environment, necessitating meticulous cleaning with high-level disinfectant to minimise the risk of onward transmission. Despite our best efforts to date, we have struggled to get on top of the outbreak.

However, the news is not all gloomy. All our isolates so far have been from screening samples, and we have yet to see any clinical infections. Can you really call it an outbreak if you don’t have any clinical infections? Personally, I find it difficult to get excited about something like this unless the patients are clearly unwell.

The laboratory I work in serves secondary level care hospitals and we don’t have many of those highly immunocompromised patients with lots of lines in-situ who tend to run into problems with VRE. Our annual number of Enterococcus faecium bacteraemias is low and it may be that we will not end up with many VRE clinical infections even if it does become endemic.

VanB VREs are still amenable to several different treatment options such as linezolid, teicoplanin, daptomycin, etc. In terms of the MDRO spectrum, VanB VREs are on the milder end, at least on a population level. I would be a lot more worried about a CPE outbreak in the hospital.

It is also a good reminder to us that we cannot afford to relax in the field of antimicrobial stewardship. VREs are in particular selected out by the “3Cs”, namely (3rd generation) Cephalosporins, Ciprofloxacin and Carbapenems. We do well in controlling usage of the first two, maybe not so hot on the carbapenem front.

At the moment we are still trying to “stamp out” VRE from our local hospital. The financial cost and staff time involved in managing a VRE outbreak are not insignificant by any means. At some point, one needs to weigh up the cost-benefit analysis of an eradication approach…



Challenging the Dogma of Empirical Antibiotics

A lot of antibiotic treatment of infectious diseases is still “empirical” in nature. “Empirical” generally means “based on experience”, so to administer an empirical antibiotic means to give the antibiotic that is most likely to work based on previous experience with that infection.

Antibiotic treatment has traditionally been empirical because waiting for culture and susceptibility results was simply far too slow. Only a generation ago the average turnaround time for a microbiology culture test was 3 days and counting….

A lot of antibiotic treatment is still empirical in nature. If you go to your GP with a sore throat or a urinary tract infection, chances are high you will receive an empirical antibiotic. If you attend your local Sexual Health clinic with symptoms of gonorrhoea, you will likely be getting some empirical ceftriaxone long before the diagnosis is established. If you go to your local hospital with pneumonia, you will likely get a macrolide antibiotic (to cover atypical pathogens) as well as a beta-lactam.

However microbiology labs are improving all the time. We now have the potential in many areas to make empirical treatment redundant for certain infections. Check out the following examples:

  • Rapid antigen and PCR tests are now available for the laboratory diagnosis of sore throat, with a turnaround time of minutes to a few hours.
  • Bacteriology automation, such as Kiestra TLA, can reduce turnaround times for urine cultures to less than a day, and a day and a half for wound swabs. I suspect a lot of patients with straightforward UTIs and wound infections can wait that long for a result without outcomes being adversely affected.
  • Rapid PCR tests for atypical respiratory pathogens (Legionella spp., Mycoplasma pneumoniae, Chlamydia pneumoniae) can mean that macrolide coverage for community acquired pneumonia can be stopped early, or not even started.
  • Ultra-fast PCR tests for influenza can prevent any antibiotics being prescribed in patients who present with Upper Respiratory Tract Infection (URTI).
  • PCR tests with genotypic antimicrobial susceptibility information (e.g. Neisseria gonorrhoeae, Mycoplasma genitalium) can avoid the use of empirical antibiotics and selection pressure for antibiotic resistance.

Costing silos, resistance to change, and a lack of vision are amongst the main reasons that it takes so long for treatment protocols to move to “directed therapy” wherever possible.

There are still areas where empirical antibiotics will continue to be necessary. The acutely septic patient presenting to hospital is one such example. However large swathes of infections, particularly in the community setting are still managed by empirical antibiotic therapy. This is the way it always has been. However that doesn’t mean it is the way it always should be…

The next big revolution in clinical microbiology labs should be to challenge the dogma of empirical antibiotic treatment. This would be a huge step forward towards counteracting the development of antibiotic resistance.