The Tortured Stewards & Surgeons Department

[Music] Hello and welcome to Breakpoints, the Society of Infectious Diseases Pharmacist Podcast. My name is Jillian Hayes and I'm a part-time ID and stewardship pharmacist at Duke University Hospital and full-time medical information manager at GSK. All pertinent conflicts of interest related to this podcast have been mitigated. First off, happy, tortured poets department album release date to those who celebrate. We absolutely could not pass up the opportunity to name this episode, "Intribute to the True Leader," Breakpoints, Dr. Taylor Ellison Swift. While she was unable to join us today, understandably, we do have an absolutely stellar panel of guests to help us navigate what we are calling the tortured, steward, and surgeons department. That's right. Today's episode is a deep dive into all things surgical site infection and peri-operative antimicrobial prophylaxis. It is estimated that up to 3% of patients undergoing surgery will experience infection at or adjacent to their surgical incision site. And when you compare patients who experience SSIs with patients who don't experience a surgical site infection, those with an SSI are hospitalized approximately 7 to 11 days longer. This episode was also a listener request and I think by the end of our time together, we'll certainly understand why. So without further ado, let's get you introduced to today's panelists. First off is Professor Trish Appeal. She is an infectious diseases clinician researcher and deputy director of research in the Department of Infectious Diseases, Monash University, and Alfred Health. She was awarded her PhD at the University of Melbourne in August of 2014 and completed her post-doctoral fellowship at Mayo Clinic in Rochester, Minnesota. She's passionate about improving the outcomes of patients undergoing surgery with a particular focus on prevention of surgical site infections. She leaves large-scale randomized controlled trials and infection prevention and surgery will get into some of that today and is developing strategies to tailor and implement her research findings to a broad range of hospital settings. Trish, we're so thrilled to have you with us today. Welcome to breakpoints. Hi, Jillian. I'm very excited to be here to talk about one of my favorite topics as well. Awesome. Next we have Dr. Delainger. Dr. Delainger is a professor of surgery emeritus at the University of Washington Medical Center where he performed general and bariatric surgery and was chief of the division of general surgery from 1977 to 2018. He graduated from Swathmore College and Harvard Medical School. During surgical residency at the Beth Israel Hospital in Boston, he completed an infectious disease fellowship at Tufts. He is past president of the Surgical Infection Society, a fellow of the American College of Surgeons of the IDSA of the Society for Healthcare Epidemiology of America and of the Surgical Infection Society. I will note that the following does not include all of his notable accomplishments throughout what is only able to be described as an illustrious career, but I'll attempt to hit some of the highlights that you may be familiar with. He was on the Healthcare Infection Control Practices Advisory Committee of the CDC or HIC-BAC from 2004 to 2007, served on the WHO Working Group, which resulted in the surgical safety checklist in 2019. He has co-authored IDSA guidelines for surgical antibiotic prophylaxis, management of soft tissue infections, prevention of clapsies, treatment of intra- abdominal infections, and the clinical practice guidelines for antimicrobial prophylaxis in surgery, a joint guideline sponsored by ASHP, IDSA, Shea and Sis. He is a co-author of the new HicPAC guidelines for SSI prevention and of the WHO guideline for SSI prevention, so he needs no further justification why he's joining us for this conversation today. Patch, we are so thrilled to have you. I, it's a pleasure to be here. And last but certainly, not least is Dr. Michael Calderwood. He is an infectious diseases physician and a chief quality officer at Dartmouth Hitchcock Medical Center in New Hampshire. He earned a bachelor's degree in biology from Harvard University, followed by a medical degree from the University of Chicago Pritzker School of Medicine. He completed his residency in Internal Medicine at Brigham and Women's Hospital and a fellowship in infectious diseases in the combined Brigham and Women's Hospital, Massachusetts General Hospital Program. He also holds a master of public health degree from the Harvard School of Public Health. Dr. Calderwood started his career off at the Brigham and Women's Hospital where he directed the Hospital's antimicrobial stewardship program, was one of the hospital epidemiologists, and was a research investigator in the therapeutic research and infectious disease epidemiology group in the Harvard Medical School Department of Population Medicine. He joined Dartmouth Hitchcock Medical Center in 2016 and is an associate professor of medicine at the Geisel School of Medicine at Dartmouth. His current responsibilities include management and oversight of the integration of safety, quality, patient experience, and process improvement activities, along with oversight of quality assurance and regulatory compliance. Michael, we're so excited that you bring the quality assurance and regulatory angle to our conversation today. Thanks so much for joining us. Really excited to be here and looking forward to the conversation. Wonderful. I'm really thrilled to have all of you here as we navigate again what we're calling the Tortured Stewards and Surgeons Department, hopefully less tortured by the end of today's episode. So I figured we could dive right into one of the hotter topics around this space, especially to antimicrobial stewards, which is the duration of post-op antimicrobial profile access. The intro to the first question of each episode is where I, as the host, typically attempt to get the guest to convince the audience that our topic matters. We're going to do things a little differently today and I am going to declare or issue a proclamation that, of course, this topic matters, and we'll jump right into the controversies about duration as a group. The reason the duration of post-op antimicrobials is so important to stewards is perhaps best summarized by a 2019 publication by Dr. Branch Element and colleagues called "Association of Duration and Type of Surgical Profile Access" with antimicrobial associated adverse events in Jammis surgery. This will be linked for you in the show notes below, and this paper really gave us hard evidence that every single day a patient remains on antimicrobials absolutely does matter. This was a national cohort study, including approximately 79,000 patients undergoing surgical procedures at the VA. The authors found that increasing duration of surgical prophylaxis was not associated with additional reductions in surgical site infection, but was associated with increases in both acute kidney injury and cluster deoidy's difficile infections in a duration-dependent fashion. So we have no benefit with known harm, which is obviously not ideal. We've had historical guidelines stating that post-op antimicrobials should not continue beyond 24 hours. We now have new guidance, like the strategies to prevent surgical site infections in acute care hospitals 2022 update. Again, linked in show notes for you. Let's suggest that antimicrobial prophylaxis should be discontinued at the time of surgical closure in the operating room. We are lucky enough to have Michael with us today who's the lead author on this incredibly helpful document. So listeners, if you haven't, take a moment to check it out. Please do. Thank you, first off to you and your team, for work on this beauty. So we'll come to you first. In clinical practice, we so often see these agents continued for longer. So our post-operative antibiotics needed for prophylaxis and if not, which types of procedures do you think are maybe easy to start with when we're thinking about removing those from order sets, things like that. So, Jillian, thank you for leading us off in that discussion. This is actually one of the recommendations that we were most excited to update in the most recent compendium. And the reason for that is there's actually a fair bit of data that's come out between the prior-shake compendium in 2014 and the one that just came out this past year, really showing that antibiotics that are administered after the patient's incision has been closed, even in cases such as when drains are left in place. Don't do much to prevent surgical site infection, but instead, and you had highlighted Dr. Branch Elements paper, increase things like C. difficile infection, acute kidney injury, antimicrobial resistance. And this is actually in line with a number of other national and international guidelines that have come out since 2014. And so just to remind folks, there are a number of guidelines that are out there. And so the American College of Surgeons came out with guidelines in 2016. And they really kind of emphasized stopping antibiotics at the time of skin closure. They did highlight some exceptions and they didn't have enough data at that time around implant-based breast reconstruction, joint arthroplasty, and cardiac procedures. And so there was still some debate about the optimal duration in those. And then as you go forward, the CDC publishes guidelines in 2017, WHO publishes them in 2018, really getting to the point where we have firm recommendations and support that antibiotics be discontinued immediately after a patient's incision is closed. And there's actually a perspective written from the angle of a surgeon in the Journal of the American College of Surgeons in 2020. And it was entitled Surgeons as antimicrobial stewards. I love the title. It just kind of realized that we're all stewards. We all have a role to play here. We all believe that. All your listeners do as well. But what the authors wrote is that for clean and clean contaminated incisions, antibiotics given after incision closure have no impact on further reducing SSI risk. Therefore, they should not be administered after skin closure in these surgical cases. And they provided a number of references. Main one that you mentioned is the 2019 paper in JAMA surgery. There's another one that's often referenced in 2022 paper in the Journal of Arthroplasty by Lee at all. And the benefit there is that it really highlights a number of the areas that had been called exceptions in the ACS document that was put out in 2016 and show data that even in those areas there was no benefit in preventing surgical site infection. I'll end by just saying that, you know, we still have areas where we don't have evidence, but the absence of evidence is not evidence of absence. And so we need to think about why are we doing it when we know there's harm, study after study that has been shown, has not shown a benefit. And I will say at my own institution, we had an opportunity to study this. And so one paper that people are often asking about is, well, what happens in orthopedic surgery? And the answer is we had a national shortage of sephazelum that people will remember. And that gave us an opportunity to say, we don't have enough sephazelum to treat all the infections and the prophylaxis and everything else we use this medicine for. And so we worked with orthopedic surgeons to actually study before and after. They stopped at the time of skin closure and studied it. And for a year after that showed no increase in surgical site infection. And now other institutions are using that to say, this is safe in orthopedic surgery. In general, if we're taking a blanked statement, no evidence that continuing antibiotics after skin closure have a benefit and clear evidence that they have harm. Just wanting to add, I guess, and firstly to congratulate Michael and his team on such a great guideline. It's really lovely to have some clear data and clear statements to support practice. I guess I just wanted to, and you've sort of highlighted it in your conversation. I think one of the questions is still around cardiac surgery and the potential benefit of giving postoperative or whether there's potential harms. And I think that's an area we haven't quite teased out. And it's one that's been highlighted in the WHO guidelines and the CDC to highlight there is potential evidence. And when you do look into the guidelines and you're looking to the trials that inform those recommendations, in cardiac surgery, there are actually three randomized controlled trials, which when you pull them together suggests there is a benefit with giving postoperative doses, but there is a poorly designed trials, small trials and low quality trials. So I think there is still a question over cardiac surgery. And I don't know about other stewards, but we've had some difficulty convincing our cardiac surgery colleagues to stop the antibiotics following completion of surgery. And actually, we're trying to answer that question actually in a large randomized controlled trial ourselves. So we've got an adaptive randomized control trial looking at postoperative durations of antibiotics in cardiac surgery. So we're randomizing patients to intraoperative only compared to 24 and 48 hours. Part of the reason we did this was it was really informed by a cardiac surgeon colleagues who said they were reluctant to change until there was some definitive answers for them. But again, interested in others, the what's on this issue. That's great, Trisha. I'm glad to hear that that trial is going because we certainly need this in areas of controversy. Just thinking about the evidence, which Michael has covered pretty well, but I just looked at some things recently and there's a large study out of the Dutch Arferplasty Registry in 2020 looking at a mere 242,000 patients where they found no benefit whatsoever to any prolongation of prophylaxis beyond incision closure. And then there's the young meta-analysis that was published in Lancet ID 2020, which formed the basis for the WHO recommendation. And in that one, interestingly, what they showed is that they had 24 studies that had best practices, that is, give the first dose within the appropriate time before incision, repeat for long operations. And in those 24 studies with over 9,000 patients, there was no benefit whatsoever to post up. But they also looked at 28 studies that did not follow best practices like on-time preoperative dosing and redosing during long operations. And in that group of 28 studies with 19,000 patients not following best practice, they saw the implication of a possible benefit to prolonged prophylaxis. But the odds ratio was 0.79 to 1.0. So basically did not really show a benefit. Awesome. I think this is an excellent way to kick things off. And I noticed, Trish, when you started talking about the fact that you and your team were working on this trial, patch hit us with a thumbs up. And I think a lot of us would feel the exact same way. A thumbs up for that, that'll be really highly anticipated work. Like you said, to sort of give a definitive answer to these questions with the zones of uncertainty that still exists. Okay, so I think I heard the word brains come up. This does bring us to sort of a rapid fire around. I do want to ask about some commonly encountered scenarios where surgical prophylaxis is often extended. Y'all can go with a simple yes or no. I know there's probably more detail. So add as much detail as you feel. We'll start with drains in place. Does the presence of a drain warrant longer antibiotic prophylaxis? Yes, absolutely not. There are quite a few studies on this and my response to this is, pro long prophylaxis is what you should do if you want resistant bacteria in your drain. I don't think anyone disagree with that statement. At least a amongst your panel, although we do continue to have this dialogue with many in the surgical community. I have found a convincing argument is the paper by Harbour Thedale in circulation where they looked at your extending prophylaxis greater than 48 hours actually increased your risk of surgical site infections due to resistant organisms. And I think that was a really key message for our surgeons that it wasn't achieving what they wanted and in fact was making things worse. So that helped us with our arguments with them. I couldn't have asked for a better response and Pat, you'll have to confirm that I didn't plant this response from our representative of surgeons on this panel. Okay, that was emphatic and it was organic and I did not plant it. Excellent. Okay, next set of patients, the next circumstance that we see come up is nasal packing, longer prophylaxis. Yes, no. I can't cite any data, but I still say no. Yeah, I agree. I wouldn't be giving postoperative doses. You know, I think this always comes into what is prophylaxis and what is treatment. And so there are times where you have associated sinusitis, but that is an indication for the antibiotic. That's not prophylaxis. A beautiful clarification. Perfect. Next up is open chest. This may be a prophylaxis versus treatment clarification like Michael just alluded to, but I'll open the floor. Yeah, thank you. You're right. We have to know what exactly your, what your aim of giving the antibiotics is is it because you're wanting to prevent infection or are you worried that there is an established infection that you're treating? So knowing that is the thing that will actually guide your antibiotic duration decisions. Okay. And grand finale for the rapid fire round will be orthopedic procedures post-op antibiotics longer than 24 hours needed. This is one where there's actually a fair bit of literature, but it tends to be single center. Cohort studies small in number, not randomized control. There are some data on patients who have had recurrent prosthetic joint infections commonly with the same organism where there is an argument made to treat with an oral antibiotic for as long as three months after the surgical procedure. We will do this at times, particularly if someone has an implant that has no possibility of being removed. And we are targeting something that has grown a number of times before. And the idea here is there may have been something left on the cement. It was present at the time of surgery. And we're during the healing process using an oral antibiotic for suppression. We are not intending that to be long term like we do at times with an infected joint, but it is a phylactic, suppressive treatment. You could phrase it a number of different ways, but there are data behind that. The other thing that has come up recently with orthopedic surgery is patients who have poorly controlled diabetes or who have morbid obesity, not general obesity, but truly morbid obesity that have difficulty with wound closure, high risk of facial dehycens and should a prolonged oral antibiotic be used. I'm going to go back to the next slide. not convinced that we need to make that standard of care, but you will see some arguing for that in this area where we need better data. Yeah, when you're talking about operating on patients who've had prior infections, I think you're talking about treatment, not prophylaxis. And if you're talking about diabetic patients, what you need to do is control perioperative glucose, but that's another whole discussion. You've done some great work on that patch. Yeah, I totally agree. It comes back to the point that we should be looking at all our processes, looking at optimization of the patient, looking at what we're doing for infection prevention, not just solely relying on an antibiotic to try to do all the heavy lifting. We have to think about everything that we're doing to try to improve the outcomes for the patients. That brings me up to something that a slide I use in some of my presentations in another area. What is the purpose of an antibiotic? Is it to kill bacteria or is it an anti-pyretic or is it a tranquilizer and is it a tranquilizer for the surgeon or the patient or the patient's family or the nursing staff? I think I speak for many us to word when I say I could not agree more. That's a sermon that'll preach seven days a week. And biotics are miracles and they are certainly not good anxiolidics. They come with a lot of side effects, unfortunately. The person whose anxiety they're usually treating often doesn't have to pay price of those adverse effects, which is the real downside. You guys crushed rapid fire around. Thanks again for getting through those difficult topics. And again, patches not being held hostage. These were his genuine opinions and he just couldn't have said it better. The next question and the next portion that we'll talk about, we'll first get into screening for MRSA and then some excellent new data from Trisha's team about use of Vinc for prophylaxis. So we'll start with with preoperative screening for MRSA first, which then often leads to the Vinc. Where does the evidence actually support us screening? Are we over screening and then over giving Vinc? Trisha will come to you first. Thanks, Gillian. Yeah, I think it's important to have a look at what the evidence does say in this. First of all, the evidence does support using a bundled approach in patients, which includes Vinc amycin, if you have MRSA colonisation at the time of surgery. But I think there's an important thing we need to really consider with that. When you look at the evidence for screening and decolonisation, it's actually for screening and decolonisation of both methamethasyl and resistance staff worries, but also methamethasyl and susceptible staff worries. I think sometimes that message gets lost in interpretation and implementation into practice. So why this is important is I know in my population of patients, about 2% will have methamethasyl and resistance staff on their skin at the time of surgery. But about 30% will have methamethasyl and susceptible staff worries on their skin. So if we screen only for MRSA, I'm going to miss a sizable proportion of patients that have staff worries on their skin and therefore miss the benefits potentially of decolonisation and removal of staff worries from their skin. So I think we always need to go back and remember it's for both MRSA and MSSA. There's a couple of other things we need to think about. And where is the strength of the evidence or where does most evidence lie? And most of the evidence lies for cardiac and orthopedic surgery. There are some data for other surgeries but I don't think it's quite as strong. And we also need to think about the practicalities of decolonisation. So do we decolonise everyone, which is universal decolonisation, which is easier, but that means we're treating a lot of people when they didn't necessarily need it or do we do targeted, which is a little bit more difficult. There's some logistic issues when we do that. I guess the concern with universal decolonisation is we always potentially have the downstream effects of muperison resistance, which is a real concern I think for us. I think the other issue is what do we decolonise with? And again, most of the data like I hinted is from muperison. But we've been thinking about other agents, whether we can use things such as pivoting for decolonisation. And I thought that might be a reasonable alternative, but just highlighting the recent publication by Susan Hwang and her group in Jarmour in the ICU population, which showed that pivoting was inferior to muperison. So I think for me that's made me step back and have a little rethink of what the best approach is. I guess the other thing, which is always something that I like to highlight when we're looking at our evidence, is most of this evidence is actually from high-income countries. And really, we need to think about, well, what's the efficacy in low-middle income countries, what's the cost effectiveness? Is it important in those countries as well? And think about generating evidence in that. So I think just to summarise, I think screening and decolonisation is an really important part of our infection prevention approaches, but we need to remember it's full MRSA as well as MSSA. So it's really important points. And we actually highlighted that in the compendium document around SSI prevention, and specifically the point that was just made, it is not decolonisation of MRSA. It's decolonisation for staff-oriented and inclusive about methamethosolens susceptible and methamethosolens resistant. And so the focus was not as much on the vancomycin, but it is on how are you preoperatively decolonising the skin and the nerves, a common source of colonisation in adults and pediatric patients we often have to think about other sites, the axilla and the groin that the chloroxine will be addressing. And looking at that, as was mentioned, the standard has been up to five days of intranasaline purison, twice per day bathing with chloroxidine daily. That's hard to get people to do. Some people have just screened and if you're colonised with MSSA or MRSA, they would do that. It's easiest just to give everyone who comes into your clinic, the materials and have them do it. But what about if they're coming in urgently? So the benefit of the pulpitone iodine is that the protocols are more, what can you do in the two hours before surgery, what can you do the night before surgery, day of surgery, when you don't have that five day lead in. And there are some other things people have been looking at, ultraviolet, but therapy within that within the nerves. I'd say the data is best for orthopedic and cardiothoracic procedures. There's some that have also thought about other procedures involving prosthetic material although the quality of the evidence in those areas is fairly low. But I would say particularly if you're thinking about hip arthroplasty, knee arthroplasty, shoulder arthroplasty, cardiothoracic procedures, I would recommend doing it and we kind of went through a number of different ways you could operationalize it. And I'm not sure there is a one size fits all that is best. It really comes down to what your providers can really implement and get patients to follow. Yeah, I have to agree with what you've both said. I think that is important. And the point that Michael brought up that, you know, the standard with new Pearson is five days pre-op, which a lot of patients find difficult to do. And to my knowledge, I don't know that it's ever been studied as to whether less than five days pre-op would be valuable. There was an interesting prospect of randomized trial of muperous inverses, pogodon iodine done at NYU Langoni a number of years ago. And when you looked at the patients that really followed all the protocols, the pogodon iodine actually came out slightly ahead. And the reason was probably because the muperous and wasn't done properly in those patients. It's true that the pogodon iodine clearly does not result in decolonization that lasts as long as muperous. But if you give it just in the pre-op time, you do eliminate it during the time the patient is in the OR, which is the highest risk period. There's also a great study out of England quite a few years ago. I can't remember the author's names, but it was an orthopedic study where they screened people. And if they had MRSA, they treated them with muperousin. And then they did their orthopedic operation within two months. And they gave their patients a sephalus born for prophylaxis. And they had a high rate of MRSA infections in the patients. And the reason was because we know that people who have staff and their nose have a tendency to get recolonized after being decolonized. And if you're going to decolonize them, you need to operate in the immediate period afterwards. And if they ever had MRSA, you need to give vancomycin. The other thing, I guess, is also the paper by Stefan Haabath from a number of you. years ago, which was a cohort study where they looked at MRSA and interestingly they had a low rate of MRSA on the skin at the time of surgery. But I think that it was 57% of the patients who developed a MRSA infection actually didn't have MRSA on the skin at the time of screening. So we think about these infection prevention strategies but we've got to look at them as a whole and what we're doing in regards to our hospital, cleaning our healthcare, our work as hand hygiene and so on. So we can't look at things just in isolation. We've got to look at all of our processes and make sure they're all according to evidence and up to par. Absolutely. I couldn't agree more. My sister is actually an infection preventionist. So I have a special passion and appreciation for the holistic work that goes into these infection prevention strategies. And I'm sure that that's a whole separate episode that we could probably dissect all day. I will move us into the sort of second half of this conversation. So the branch elements study also found that the type of regimen, not only the duration but also the type of regimen was an important driver of these post-operative adverse events. So again, vankemeysen is going to be our focus here. Was a significant risk factor for acute kidney injury. The authors directly state that limiting the use of vankemeysen may improve clinical outcomes. As a general rule, I don't like to pick on vankemeysen as a drug because I feel like it's a loyal drug. It's hung in there with us. But I think that we can all agree that vankemeysen has a time and a place where she can shine. And this is not it. So Trish, you recently served as the primary author on the ASAP trial. So this was a multi-center double blind superiority placebo controlled trial comparing profile access with either cifazolin plus vankemeysen or placebo in adults without known MRSA colonization who were undergoing arthroplasty. So first off, thank you so much for all the work that I know goes into these studies. And congratulations. This was published in the New England Journal. This past October will have the article linked down below for y'all listening. I would love for you to sort of walk us through what you and your group found as well as learn how it's changed practice. Thanks, Jillian. Yes, this paper in this study was really a labour of love for us over quite a few years. So I guess as a bit of a background to this, we were observing in our patients undergoing hip and knee replacement that we were seeing a significant proportion of patients who were having methamethicillin resistant stuff, or is and stuff epi isolated from joint infections. And it raised a question about, well, cifazolin which is our standard antiprotate that we use wouldn't necessarily prevent these infections. And the question came up was, should we be broadening our prophylaxis to include vancomycin to better cover these organisms? And we had observed this, but there were other groups also publishing cohort studies where they added vancomycin and were reporting that there was a potential reduction in surgical site infections in their hip and knee replacements. So we were very keen to conduct this pragmatic trial to really see if there was a clear benefit or whether there was potential harms with adding vancomycin to our standard antipotent prophylaxis, prior to it being well and truly embedded and quite hard then to divest groups of using it. So this was really a great collaboration we had with orthopedic surgeons and ID physicians in Australia. And we randomized just over 4,000 patients to either receive standard prophylaxis with kevazolin and a placebo or kevazolin plus vancomycin. And so we recruited 4,000 patients and to our surprise we found that the addition of vancomycin did not reduce the risk of surgical site infection in our patients undergoing hip and knee replacement. And importantly, as you highlighted, these were patients who were not colonised with MRSA at the time of their surgery. What we did also observe on our secondary analysis was in the knee cohort, we actually observed an increased risk of infection when we added vancomycin. So the risk of infection in our knees was 5.7% in the vancomycin group compared to 3.7 in the kevazolin group alone. So really highlighting to us that there wasn't a benefit but potentially a harm to our patients. And again, this is a really important paper because it answered a question that our surgeons have been posing to us for a number of years. And the great thing is, as soon as the results were available, our surgeons stopped using vancomycin in hip and knee joint replacements for patients who weren't colonised with MRSA. So demonstrating a potential harm actually made them rethink their practice and they were very happy to stop using vancomycin in that setting. Really, important conversation. It recall a similar, what we call an outbreak or just an increase in SSIs from MRSA and co-agnegative staff that we were dealing with in the same population. North of Peter, back in 2008 to 2010 when I was at Brigham and Women's. And we had made the decision to add vancomycin in addition to the siphazolin and saw a decline, although lots of other things were done at the same time. And one of them was the staff worries pretty up screening. And so really targeting to those that are known to be colonised is probably the most important part of that intervention. Yeah, I think that's an important thing Michael. With the cohort studies that they had published, they were often done within a broader bundle of care. So looking at infection prevention approaches, looking at screening and decolonisation. So I think it's really hard in those cohort studies to tease out whether it was the addition of vancomycin or whether it was a general approach. I tend to think that it was probably the latter that taking, you know, paying attention to your infection prevention approaches is probably the key thing rather than just relying on an antibiotic align. You know, there was another study that we had referenced in the compendium document, which was the VA study. This one was Judy Strymesh, but branch element and the Calgupta were also involved. But the study was looking at the perception that your institution has a high MRSA rate and using that to target vancomycin. We weren't very good, or at least the individuals that study were not very good in determining who actually was colonised and who would benefit from vancomycin. So this idea of, well, I think we see a lot of MRSA and we're just going to throw vancomycin at it, was just proved in the study very nicely. I think bacteria have a way of humbling us when it comes to our perceptions and feelings. So it's an important point that data is going to help us a little bit more than sometimes even the most powerful anecdotes do. Trish, thank you so much for sharing that information and Michael for chiming in. I think the combination, like we've said, of screening the appropriate patients and then acting on that data seems to be an excellent one, two punch in terms of moving forward. Awesome. This brings us to our third big topic of the day. And as we were putting this episode together, I realised we are in a way hitting the stewards trifecta. We've talked about duration. We've talked about vancomycin use. And now we're going to talk about penicillin allergies. So historically, patients with penicillin allergies have received these alternative surgical prophylaxis options, whether that includes, depending on surgery type agents like gentemysin, clindemysin, fluoroquine loans, we've talked about, we know that these regimens are often sub-optimal whether it's an outcome-based situation or administration concerns. So we ideally would love to give patients regimens containing beta lactamps for surgical site prophylaxis whenever possible, knowing what we know now about cross-reactivity of syphazolin to penicillin and also knowing what we've learned about how rarely a penicillin allergy is truly legitimate. Many sites have begun to move towards a syphazolin for all approach. You'll sometimes hear that referred to as the ANSF for all approach. I know we have listeners that feel very passionately about this. In 2022, this move was actually supported by a joint task force on practice parameter updates. Just 2022 updates states we suggest that for patients with a history of an unverified, non-anaphylactic penicillin allergy, any syphilosporin can be administered routinely without testing or additional precautions. For those rare patients with a history of anaphylaxis to penicillin, a non-cross-reactive syphilosporin, they give the example of syphazolin, can be administered routinely without prior testing. This really gave even more support, I think having an official guidance document, you know, with this ANSF for all strategy. I will come to you first for this one. How can surgery and antimicrobial stewardship collaborate on this if you have any best practices and really best practices for the whole team? Anesthesia, surgery, pharmacy, nursing to ensure that first-line antibiotics are being administered? This is an important area. There are quite a few publications showing that looking at historical data that patients with recorded penicillin allergies had higher SSI rates because of the use of these inferior prophylactic agents as you mentioned in your introduction. And we looked at this at my own institution a number of years ago and a few of us, a joint authorship from pharmacy, ID and surgery presented our data at ID week. And we showed that we had, I forget now, the exact numbers, but many hundreds of patients listed as having penicillin allergies who got cephalosolin with no problem. And we did have of all the patients receiving cephalosolin over a several year period. We had two allergic responses to cephalosolin and neither of those patients listed as having penicillin allergies or cephalosolin allergies. So you know, you can't get rid of everything. But we've done in our electronic medical record ordering system is basically set up something that makes you go through a process if you want to choose something other than cephalosolin for the procedures where that is indicated. And so far that seems to be working very well for us. That sounds great. I agree that where you can use cephalon, you should be using cephalon. Our team's actually set up with a collaboration with Jason Tribiano, who's an exceptional steward and supportive, all things are, would use of antibiotics. He and his PhD student, Joseph Duluka actually started a screening process in our elective surgery pre-admission clinic. And we were recruiting patients with a documented penicillin allergy and then actually delabeling them in our pre-admission clinic. And then these people were able to go on and have cephalosolin as part of their surgical prophylaxis. And I think it was important for two things, firstly, so they're getting the best possible antibody at their time of surgery. But the other thing is we found that people who are told that they're not allergic and they've taken an oral challenge are much more likely to believe that process and therefore down the track, they're happy to not be relabelled as a penicillin allergy. So we thought this was really quite a neat trial to show that we can give it, but also to sort of the downstream consequences to make sure these people were also getting appropriate therapy if they needed to come back into hospital down the track. I think this is another one where we need to look at how it's operationalized. And so we have a large percentage of the U.S. population, and this is true in other countries as well that are labeled as having a penicillin allergy. And so when you look at this, it's been reported as about 10% of the U.S. population as a list of penicillin allergy, but overall less than 1% are truly allergic. And we can't get all of that 10% in to see an allergy clinic with skin testing or all those challenges. So a lot of groups are actually just skipping the skin testing and going straight to a simple oral dose challenge. Obviously, you're not going to do this in someone in the history of Steve's Johnson and severe allergic reaction, but you can give a low dose 250 milligrams of a moxasillin and monitor and clinic to kind of see how someone is doing. And surgeons and anesthesiologists are also kind of really beginning to say what is a real severe allergy. And it was a nice paper out of Emory that was published in Journal of Surgery in 2019, where they actually, even for people that had hives or non-discommating rashes, just gave them suffasible without any testing, periodically, and showed really good outcomes. Similar to what Patch was describing, not having adverse outcomes in these surgeries. The other ones were the unknown childhood reactions that typically were someone who had a virus and had a rash from the virus, but was given a moxasillin, verin, ear infection, or something of the sort. Yeah, Michael. Also, the other thing is I've always found out, and need to just a great allies for a lot of these things. I think they prefer to give Kephazole and then agents such as Bank of Mice. So if you support them in that, I think they're really, they'll get on board and be really great advocates for us. Absolutely. Especially after the publication of the Palace study, anyone that we can get excited about using a pin-fast score, and then, you know, I think the combination of the detailed history taking, whether that's empowering nurses to help with those questions, pharmacists, of course, pre-operative clinics for elective surgeries so that all that information is sorted out before the time of surgery. Lots of, as Michael said, operational things and lots of options, I think, to choose from, but multifaceted approaches is likely best. And, Pat, I love what you mentioned about the two patients with allergic reactions are the two that didn't have penicillin or, you know, cephalosporin allergies even listed. So try as we might to proceed safely, of course. Life can be unpredictable. I think the other point, we always have the mantra, we're all stewards. You know, we do this a lot in infectious diseases clinic where we give a lot of challenge, monitor and clinic and D-level, primary care physicians can do this. Anyone really can do this. Given the large number with a list of penicillin allergy, it's really out of beyond everyone's radar. I think lots of stewards would say yes and amen to that. So Michael, thank you so much for throwing that in there. One more related question about logistics here. We know administration time can be quite important, especially in the perioperative space. I know some institutions have begun administering to phasal and via IV push for time and potential cost savings. Has anyone on the call had experience with that? We frequently do IV sivasalin on call to the OR as a push. The bigger issue we run into is what do we do with things that require prolonged infusion like vancomycin and how much needs to be infused by the time of incision, particularly when you've got furtikits and things of that sort. There's a lot of data and how much is enough. It's a phasal and really the push has been quite effective for us, particularly when we don't always know when someone's going to get called and we don't want to start too early. Yeah, we don't do push, but it comes in a bag, a very small bag and it goes in within five minutes or less and that works just fine. Yes, I think we've got the same experience as you patch. I think it fits into the inithetus workflow. They have very clear steps that they do and that's one of the key things that they do. I think they set up and almost get ready to get the antibiotic as soon as they set up. Another value of rapid administration of the phasal and is you can give it just a few minutes before incision. You've got the whole dose in and that means it's a longer time for your long operations before you need your intraoperative redose as opposed to giving it 60 minutes before and then the time for redose comes earlier in the case. Yeah, I think there was the paper from Weber at Al from it was a cohort study which suggested that you should be giving it within that 60 to 30 minutes prior to knife to skin. But I really commend that group because then they went back to do the randomized control trial and showed that there was no difference whether you gave it with the zero to 30 minutes versus the 30 to 60 minutes. So I think there was some confusion for a little while until we were able to get the trial data. I'm really glad you called that out because that had been an ongoing debate about should we really be pushing for 30 minutes and data are important here. I don't know if others experienced the issue we had with vankemeyerson where there was some confusion about whether the infusion had to finish prior to knife to skin. So we had an experience where people were actually sort of giving the vankemeyerson quite rapid rates and experiencing high-potention. But when you actually look into the evidence and it's a paper by Gary at Al, they were actually running the infusion throughout surgery. It didn't have to stop before surgery but just had to start within sort of the 50 to 60 minutes prior to surgery. So I don't know if that's a confusion that was unique to us or whether other side experience as well. They were data particularly in cardiothoracic that you wanted at least 15 minutes of the infusion to have started prior to incision but the rest of it could go in assuming no alternative kind of after that point. It is interesting because in those procedures you have anesthesiologists who are quite adept in handling high-potention so their general feeling is just push it we can manage that. Perfect. Thanks all for adding in those points there. This next topic also honestly ranks highly in the stewards' hall of fame so we're going for it today. I do want to chat briefly about collection of pre-operative urine cultures. So as a disclaimer for this section we are talking about non-eurological procedures, non-eurological procedures only for this section. This is something that I think many people see in common clinical practice, obtainment of a urine culture pre-operatively. One that I've seen in a totally lead to a whole lot of treatment of ASB that I fear was both unnecessary and then later became not without consequence. A few weeks ago a study was published on this topic in JAMA Network Open titled "Prepensity Score Weighted Analysis of Postoperative Infection in Patients with and Without Pre-operative of your own culture. This was a cohort study examining patients undergoing major elective, noncardiac, non-eurological procedures at any of the 112 VA's here in the States. Machine learning and inverse probability of treatment waiting were used to balance characteristics between those who did and did not have a urine culture obtained. Investigators found no association between performance of a pre-up urine culture and lower risk of post-op UTI or surgical site infection. The authors go so far as to directly state that the results support the de-implementation of urine cultures and associated antibiotic treatment prior to surgery even when using prosthetic implants. So I would love to dive into this. Should anyone, again, other than patients undergoing urological procedures have a pre-operative urine culture obtained, I will open it to the whole group? We think the data continued to really argue that routine urinalysis with or without reflex urine cultures are not recommended for most surgical procedures. It was done because of the perceived risk of bacteria and soci particularly in patients that were getting prosthetic material. But we do have studies that actually have shown that the treatment of the asymptomatic bacteria does not reduce post-operative infection, nor does it reduce post-operative catheter associated UTI in patients who are hospitalized. So unless it's a urologic procedure, this is not part of the standard of care. Yeah, I agree that unless you're undergoing a urological surgery, you don't need to be screened. I think a lot of this data was derived from the orthopedic populations where there was an association between if you had a symptomatic bacteria detected preoperatively, those patients did have an increased risk of prosthetic joint infection in cohort studies. But actually there was no link between the organism that they isolated from the bacteria and what they subsequently isolated in their joint infection. And you looked at these patients and there were certain markers about these patients. So they were older patients. They had a higher rate of diabetes. So I think there was probably other comorbidities that were increasing the risk of infection rather than the asymptomatic bacteria itself. And again highlighting that there's been a randomized, a small randomized controlled trial by called Dera and Pua from Spain where they randomized those patients who had asymptomatic bacteria to be treated or not. And there was no difference in the risk of prosthetic joint infection in those. So again, I don't think the data supports doing preoperative urine screening. Yeah, an important laboratory stewardship issue, nothing to add to the good statements already made. I think what we see so often patch to your point laboratory stewardship, diagnostic stewardship, whatever you want to call it, so quickly becomes antimicrobial stewardship. Because once you have that result, it is so tempting to want to do something with it. Well, it's beyond the scope of today's conversation. I think there is a really interesting dialogue around rectal cultures for patients who are undergoing transurethal prostate biopsy and how to handle those and what antibiotics are best utilized in those settings. So that might be worth another discussion. You know, it's one that we have begun to do in a subset of patients and really trying to understand what the risk factors are for multi drug resistant pathogens, particularly gram negative pathogens and herbacteria. Once you get these results back, you often need an infectious diseases positioned to weigh in on what the best antibiotic is. And so having that partnership between an ID colleague and urology, it has led to a number of phone calls. We believe better outcomes, but it is one that I'd like to see better data. Yeah, similarly on that topic is also those patients undergoing colorectal surgery, what to do if they're colonized with an ESBL or a CPE organism. And again, there's some cohort studies to suggest potentially targeting your prophylaxis to those organisms may reduce their risk of infection. But I agree with Michael, we need good quality data before we start broadly using agents such as a cover penems for surgical prophylaxis. I think the phrase cover penems for surgical prophylaxis will make some people break out into hives immediately. So I absolutely agree we're going to need some better data before we can do something like that routinely. All right, as we work towards concluding today's episode, we've talked a lot about possible interventions, possible ways to optimize care in the pariop antimicrobial space. We know and we've identified throughout the episode many challenges still await. So I want to wrap up today with some brainstorming on how we can work as a whole team to optimize patient care. We've identified and mentioned different team members. Logistically, what issues do you all see still remain a challenge for institutions with higher SSI rates? And how can we leverage relationships with key partners? Be that surgeon stewards, quality and safety, infection prevention and control, nurses, pharmacy, anyone I missed. How can we leverage those relationships to improve patient care even more? I think that again, it's not just about antibiotics is what are the other things that we are doing preoperatively and tropatively and postoperatively. And Patch had mentioned glucose management and it's a real good evidence for the use of insulin drips within the OR strict glucose control with actually lower targets than kind of previously have been set. You can overshoot it and you want to be a little careful about not running into hypoglycemia but there are some things that are worth discussion. And so for instance, one that comes up is the use of dexamethasone as a medicine to prevent postoperative nausea but it also then leads to hyperglycemia and the complications of that. And so understanding where that is beneficial and where it may be causing harm as we try and find that balance knowing that normal glycemia is really important in terms of preventive infection. The other thing that I just like to touch on is that we've got a whole group of people who we could actually enlist to help and that's the surgical patients, the surgical consumers and their families. And I think involving and empowering our patients in this process is also critical. So having them along and having them informing the research we're doing, having them informing the information that we're giving I think is also really, really important. One thing we did at the University of Washington was we formed a subcommittee of the Hospital Infection Control Committee. We called it the surgical infection prevention committee. And the membership was surgeons representing different specialties, anesthesiologists, infectious disease, the infection control practitioners, the sterile supply people in the operating room, very operative nursing. And we proposed a number of things that we thought should always be done for a patient having an operation. We started with the right antibiotic on time and worked on that and got it better. And then we started with patient getting to the recovery room warm. And then we started with controlling perioperative glucose. And what we did is we had our infection control practitioner bring all the cases that she had found, all the surgical infections that she had found and tell us whether the items that we put should be done for everyone had been done. And if they had all been done, it was a quote apparently unavoidable infection. But if any of them had been missed, it was a potentially preventable infection. And what we did is over time, as we increase the number of things that have to be done to prevent infection, are potentially preventable infection numbers when up and down, up and down as we increase the number of items. But our total infection rate gradually decreased over a couple of years as we worked on all of these different elements. I think that's a key point, isn't it? You collect the data and feed back the data to the end user and then you iterate always and try to improve. So that's really great. And I think it really does speak to the importance of process measures. We focus a lot on outcome measures, but understanding what are the things we know prevent infections and are we hitting those 100% of the time and if not, what are the barriers? That was one benefit of the surgical care improvement project, although everyone was getting up in the high 90s. But it had people at the table looking at those measures, thinking how do we remove those barriers, how do we have all the teams working together? And clearly I have an interesting clinical trial, so I've got to plug this. I think where there are gaps in the evidence, we really need to work with our surgical colleagues, with our infection prevention colleagues, with our NETIA. in need that us and our patients to try to answer those questions and change practice. I think just this episode alone, we've brainstormed about five to ten questions that there should be plenty of inspiration for anyone wishing to join Trish. Wonderful. All right. This brings us to our last segment called I Feel Nurtie. I Feel Nurtie is meant to be a safe place for our panelists to nerd out over their favorite ID topics, quirks, fun facts. For today's edition, it is a two-parter. I mentioned Taylor Swift's album is now out on the same day that our podcast is releasing, which is why we have named it after her new album. So you get a bonus nerdy point today if you would like to throw in your favorite Taylor Swift song. If you don't have a favorite Taylor Swift song, it's okay. You've already made it on the episode. We're not going to kick you off now. So the other portion of I Feel Nurtie is we would love to know favorite thing either. A surgeon has taught you or favorite thing ID has taught you that you want others to know. So clinical, pearl, sharing time, Trish, you're at the top of my screen. So I'll come to you first, but we will round Robyn. I feel nerdy. So when I was a junior consultant, I then actually joined the orthopedic team and I would go on their rounds and sit in their meetings. And I think I learned something from the surgeons, which was being forthright, but being confident in your knowledge and your convictions and being able to express yourself. So that was something that I found a little bit confronting the way that surgeons communicate compared to ID doctors was very different. And sometimes as a junior doctor, I felt, oh, they're potentially attacking me, but I learned to shake it off and be able to become a more confident and more articulate doctor. Taylor Swift reference and an answer to I feel nerdy all in one fell swoop. So well done. Patch you are next on my screen. So I'll come to you second. Who is Taylor Swift? You've had too many good answers for me to be upset at you now. Okay. You get to say we'll talk after. All right. I don't know. A career in medicine means you learn things from all the people around you. And I can't come up with any one thing. That's fair. I think that we've we've had plenty of one liners from you that might be someone else's I feel nerdy fact today. So I think you've you've done your work. And again, we'll touch base about Taylor Swift afterwards. So Michael, I'll come to you next. So I believe Taylor Swift has a song I knew you were trouble. And so you know, part of this is the partnership. You know, the infectious disease consultant comes along and says, Oh, we need to reopen that wound. We need to get a scan. We need we need to get cultures. And it really is a partnership. It is understanding what procedure has been done, what the complications of that were, what can be done. And so, you know, we can't always remove something that's infected that we have to partner and think about, you know, is it better to leave them on antibiotics and weigh the risks and benefits of that? And it really is a dialogue. And I have learned that we cannot get to the right answer unless we are open to kind of everyone being part of that dialogue, including the patient and at times their family and understanding of what the various options are. And so you want to kind of come in and say, how can we work together to drive best care and not be seen as I'm coming into the surgical ICU? I knew you were trouble. You know, you don't want to be that person. The last thing I would say is that, you know, we oftentimes have opportunities to learn about wound management. And we haven't had an opportunity to talk about kind of postoperative care. But there's a lot in terms of wound management that is independent of antibiotics. We have a lot of wounds that look like they aren't going to heal, but need to breathe, that need wound vag need other things that will get them to heal antibiotics completely out of the picture. And so understanding what we have in our aromatherium around postoperative wound management is really important. Beautifully said, and if I misattributed the song to Taylor Swift, I apologize to my daughter. You sure did not. You are spot on. So you can proceed with confidence. And well said, I think we've touched on the multidisciplinary importance, not only having the right people at the table, but also including the patient and their caregivers when appropriate and looking at this holistically beyond just antibiotics is really an excellent set of takeaways. So I will give an ode to my favorite song from the midnight's album Mastermind because I feel just really thankful that I've been able to hang out with you three masterminds in this space today. So thank you all for joining today's episode of Breakpoints. Thank you. It's a pleasure. All right. And thank you to our loyal listeners for listening to Breakpoints, the Society of Infectious Diseases Pharmacist podcast. I have been your host, Jillian Hayes. And our featured speakers have been Dr. Strasch appeal, patched-dellinger and Michael Calderwood. Breakpoints was created by Julie Ann Jesto, Aaron McCreary and Jason Pogue. This episode was produced by Jeanette Bouchard and Megan Clap. It was edited by Amanda Roy, transcribed by Sarah Grume, and peer-reviewed by Christian Gale and Zara Kossamali Escobar. Our production team includes Justin Moore and Mary Hutton. The executive producer of Breakpoints is Aaron McCreary. Our theme song was recorded by SADP member Steve Spoke. You can subscribe to Breakpoints on Apple podcasts, Spotify, or wherever you get your podcasts. Thanks for listening and helping SADP achieve our vision of safe and effective antimicrobials for now and the future.