antibiotic appropriatness

Alan Sanders amsidp at AOL.COM
Tue Nov 12 17:49:29 UTC 2013


That's exactly how these sepsis protocol requirements came to be. Now we have to be on guard for potential antibiotic overuse and then C diff....  Order sets and protocols are needed but can't replace case by case judgement
Alan

Sent from my iPhone

> On Nov 12, 2013, at 8:15 AM, "Kuhn, Gloria" <gkuhn at MED.WAYNE.EDU> wrote:
> 
> Janet what you are reporting regarding blood cultures is, in my opinion, long overdue.  They are expensive, often negative or contaminated, and extremely expensive.  We really need to think hard about when and who to culture rather than culturing everyone.
>  
> Alan when I was a resident every medication/lab/x-ray order had to be renewed every 3 days.  It was more work but we had to do some thinking.  I do like the idea of stewardship but I agree with you regarding protocols.  I honestly believe that in the US we put in place rules so we don’t miss the outliers and that changes what we do dramatically.  When we do miss an infection the wrath of society falls on our heads with everyone yelling how could you miss that? 
> Gloria
>  
> From: Janel Hopper [mailto:janelhopper at COMCAST.NET] 
> Sent: Monday, November 11, 2013 11:17 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] antibiotic appropriatness
>  
> Sutter Health, a very large US clinic practice will not culture (or send out for culture). They report that cultures are problematic.
> 
> Sent from my iPhone
> 
> On Nov 10, 2013, at 6:59 PM, Alan Sanders <amsidp at AOL.COM> wrote:
> 
> Gloria
> When we went from a 7 day auto stop for antibiotics to a 4 day stop many providers balked because they had to renew their orders too quickly. We were forced to go back to a 7 day minimum and found ourselves stewarding on more cases and finding more unnecessary prolonged orders without a diagnosis of infection.  By 4 days, a good clinician should be able to rule in/out an infection and have culture/sensitivity results to guide them. That is the ideal, but it is becoming more difficult - I dread the onset of these emerging sepsis protocols mandated in New York State that will require broad regimens for presumed sepsis (many times not an infection after all)' that may continue for days , especially in facilities without a mature stewardship program.
> Alan
> 
> Sent from my iPad
> 
> On Nov 10, 2013, at 4:03 PM, amsidp at aol.com wrote:
> 
> Gloria
> It has been amazing how many "bodies" one finds on antibiotic stewardship rounds. The collateral savings that institutions can experience by these "mini ID consults" may be enormous. It remains a major teaching opportunity as long as those prescribers get the message  but I am also becoming concerned that having a stewardship program may be leading to prescribing laziness ( no different than my kids knowing one if their parents will pick it up!). We all have out challenges
> Alan
> 
> Sent from my iPhone
> 
> On Nov 10, 2013, at 3:36 PM, "Kuhn, Gloria" <gkuhn at MED.WAYNE.EDU> wrote:
> 
> Dear Alan,
> I sense and share your frustration.  Please remember that in the ED we are often operating with incomplete information coupled with demands of making decisions under time constraints imposed by CMS.  I know that many of us are frustrated that the concept that decisions made in the ED "clearly misdirects the whole team from what is really the correct diagnosis" implies that the team is incapable of looking at new evidence and making decisions that will put the team and the patient on the correct course. Clearly all of us within medicine need to be aware of the biases of premature closure and anchoring.  
> I have followed our discussions regarding 90 biases and still finding more with a sense of wonder.  After reading your impressive e-mail I am convinced if we would tackle and decrease the biases of premature closure and anchoring we would be doing countless patients a true service.
> Add to this concept the requirement to actually look at the tests we order and mandatory stoppage of orders after a pre agreed number of days unless renewed by a physician or midlevel provider and we could really make an impact on error rates.
> I wonder if as a group we could put together a program to do just that and see if it makes an impact.  
> Certainly not as grand as other research but I do believe we could do this and really help patients.
> Gloria Kuhn
> From: Sanders, Alan [Alan.Sanders at SPHP.COM]
> Sent: Friday, November 08, 2013 2:54 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: [IMPROVEDX] antibiotic appropriatness
> 
> I have been involved intimately with two antibiotic stewardship programs for the past seven years, and it is remarkable how many inappropriate course of antimicrobials are prescribed, for days, when no infection is ever documented.  Most commonly, these  antimicrobials are initiated in the ED and continued on the hospital ward, often on a hospitalist service, for  a “urosepsis”  which never exists.  This makes up a major part of our daily stewardship rounds which we do on the wards, with the charts, and EMR.  Going down the wrong road with this and other diagnoses (often CAP) leads to enormous antimicrobial costs, and clearly misdirects the whole team from what is really the correct diagnosis.
> Alan Sanders, MD
> Chief of Medicine
> St.Peter’s  Hospital , Albany NY
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