 Thank you for joining us today for this 

 program. The overuse and misuse of antimicrobials is a pressing issue in the healthcare setting. Antimicrobial stewardship programs coupled with social media are poised to educate and engage the world in the appropriate and responsible use of antimicrobials to improve outcomes and mitigate an escalation in resistance to these therapeutic agents.

I’m Dr. Debbie Goff, an infectious disease clinical pharmacist at The Ohio State University Wexner Medical Center.

 Hi, I’m John Nosta. I’m a health technology strategist and a contributor for 

. My job is to look at how technologies interface with clinical medicine to provide optimal solutions to reach patients, caregivers, and clinicians around the world.

 Thank you, John. So today we’re going to have an important discussion about antimicrobial stewardship and the role of social media. Let’s get started.

You know, I look at social media. Why is it important to me, as a clinician? There are so many reasons. It gives me the opportunity to engage, educate, connect, and network, literally with experts and consumers and patients around the world. That’s an opportunity that no other vehicle provides. So John, why is it important to you?

 I have this inclination to reach into my pocket and pull out my phone and check Twitter or tweet this moment. Clearly it allows us to know what’s going on in the world with a surprising heft of content. But when I think about it, when we talk about antimicrobial stewardship, it’s such a complicated topic. It’s a life-or-death topic, in many instances. I guess for me, and we’re going to get into this, Twitter feels trivial. It’s something for the Hollywood stars.

Let’s kind of set the ground on antimicrobial stewardship in the world today. How do we do it? It’s such a complicated question. Let’s grab it.

 We’ve been doing it for years—over a decade. I always say that if it was as simple as reading a guideline or an article, the world would be successful. But we’re not. We’ve made great progress, but we don’t have everybody fully engaged. It’s so complex. It’s not just the healthcare provider that needs to be onboard. We need to have patients onboard. They pressure us for antibiotics because they think they’re feel-good medicine. They solve problems quickly. But the consumer doesn’t understand some of the basics of science, such as that antibiotics don’t work for viruses. When you see a cold, people ask us for medications, antibiotics, and it’s just not appropriate. But doctors are evaluated. We have patient-satisfaction scores, and people go on social media and make bad reviews on Yelp.

 The satisfaction score that a patient provides to a physician is often a function of getting the script.

 If I go to a dermatologist and the dermatologist says, “Just go to CVS and buy hydrocortisone,” I’m disappointed.

 So help me understand the dimensionality of appropriate use. We have the patient—and Twitter, social media, consumer empowerment&mdash;and they want to know what they’re doing. They want to have a hand in that&mdash;collaborative care, as we say.

 So if you look at this kind of broadly, where does it align? Is it an office space problem? Is it a problem in the intensive care unit with a nosocomial pneumonia? Is it a surgical scenario? Is it a little bit of everything? Does it stack up one way or another?

 So you could just keep going, and I’d say, “John, it’s all of the above.”

 That’s what makes it so hard. I work in the hospital setting, and I used to think, when I started, that if I could just get antibiotics to be used appropriately in my hospital, I’d have half of the problems solved.

? Let’s define that. Let’s start at the very beginning.

 Sure. The Centers for Disease Control and Prevention has already told us, and they’ve done amazing studies, that 30% of antibiotics prescribed in the outpatient setting are inappropriate. This means they’re not even necessary. Or we choose to prescribe an antibiotic for an uncomplicated urinary tract infection [UTI], which actually is just colonized bacteria. A patient is not truly infected, and we will just treat a culture.

 Yes. And so that’s not an appropriate use.

 But it hurts. If I’m a patient with a UTI…

 If the patient is symptomatic, that’s probably a true infection. But asymptomatic bacteriuria lead to the most common overuse and misuse of an antibiotic in the hospital setting.

 A culture. And now they feel compelled to treat a lab result, but it’s actually not that simple. You have to look at the patient and put the whole clinical scenario together. So that’s the No 1 cause of overuse in a hospital setting. But it doesn’t stop there, to get back to your point.

We know about outpatient prescribing. For respiratory tract infections, if the patient comes in sniffling and sneezing and wants an antibiotic because they think that’s what’s going to treat them, the physician is more likely going to give them that antibiotic. It’s sort of feel-good medicine. “I’m going to make you happy, and you’re going to like me. And therefore I’m going to do this.” But it’s actually inappropriate to do that if the patient does not have a bacterial infection.

 You know, it’s, “I want my MTV.” It’s “I want my Z-Pak.”

 So that is the behavior that we have to change. Antibiotic stewardship is more than just trying to teach the appropriate use of antibiotics. It’s about behavior change. For 30 years, you’ve prescribed this. Now I’m going to try to tell you that you’re potentially causing more harm because you’re helping to create antibiotic resistance. The world is running out of effective antibiotics. You have to stop doing that. I’m trying to change your behavior. I always tell antibiotic stewards that’s the psychiatry degree I forgot to get. Now I have to be able to influence and change your behavior, and that’s really hard.

Social Media Adds Value to Antimicrobial Stewardship Programs

 What’s a better tool, the carrot or the stick?

 You know how people respond to sticks—people don’t like them. If I’m talking to a surgeon, and I’m trying to tell them, “No, you can’t have this new antibiotic because you have to call me and I have to approve it,” right away you have set up a brick wall. It’s defensive medicine. “You can’t have this. You have to have me approve it.” Nobody likes to say, “I have to have your approval to do something that I think I’m an expert in.” And so we have to change the way we operate. It’s not as simple as, “Here’s a set of guidelines.” Everybody is supposed to follow them, but they don’t. You’re not going to follow a guideline if you don’t understand why you are being asked to do this.

 But one of hot button phrases we hear a lot about today is “big data.” We have so much more data to make smarter decisions. Is that helping?

John, you might have access to that. Try working in a hospital with electronic healthcare records that were designed to be an efficient billing system. We’re trying to make them decision-support tools, big data. I walk into my hospital today and go, “Tell me how many patients got admitted last night for community-acquired pneumonia.” I cannot get that data. I can get it once they’re discharged, but I cannot get it in real time. So we actually don’t have great access, in real time, to data that would empower us to do better.

 So let’s get back to the notion of risk and reward. Is the mistreatment of nosocomial pneumonia, which is a high-mortality issue, more of a problem? Or is the mistreatment of a urinary tract infection that has broad consumer implications a bigger problem? How do you scale that or put that into perspective?

They are all a problem—every single misused antibiotic, such as an inappropriately prescribed antibiotic or an antibiotic that’s prescribed and actually turns out not to be the correct one&mdash;because we don’t have rapid tests to tell us what the organism is when you’re infected. So we take our best educated guess. It might be 4 days before I actually know, “Yes, I picked the right antibiotic.” Or it actually may have been the wrong antibiotic. And so that all contributes to the problem.

 But that’s with in-hospital use. Right?

 In the outpatient setting, you get your antibiotic and then the issue is, will you even take it? So is underuse sort of a reciprocal dynamic here?

Part of that is consumers or patients, when you give them an antibiotic prescription, generally stop it when they feel better. They save it for the next time. So duration of antibiotics is a big topic of discussion. We’ve actually learned that they might be right. Maybe we have just started to use antibiotics for 7, 14, or 21 days. I call them football scores. When you look at the evidence of how that duration ever came to be, there’s really not good data. So you’re correct. Patients don’t always follow the directions that we give them. Sometimes that contributes to the development of antibiotic resistance if you stop before you’ve actually eradicated the infection.

Inappropriate Prescription of Antibiotics and Other Causes of Antimicrobial Resistance

 Are pharmaceutical companies active participants in the management of misuse and overuse? Or are they financial companies trying to sell their products? Obviously, they report to investors, but they also report to clinicians and patients. How do you feel, as a clinician, about that dynamic in the marketplace?

 I see them as partners. At our institution they’ve always been an extension of what I do. I can’t be everywhere. So they come and educate our physicians, but I make sure their message is consistent with your message. Sometimes they might have an antibiotic that has 5 FDA- approved indications. At my hospital, I only want it used for this 1 indication. And so, we partner. They’re an extension of our marketing to our own physicians. “This is the way this antibiotic is going to be used at our hospital.” This is the best way because I match it with what our organisms are in our hospital, and that differs everywhere.

So we are reliant. They’re the ones who discover the drugs. Without pharmaceutical companies we have no products. That is part of the problem right now. They are companies that have to make a profit, and antibiotics are not profitable antibiotics. Actually, from a marketing perspective or a business perspective, they are really a poor drug to select.

 Most of them are off patent, right? A lot of the mainstream cephalosporins, beta lactams, and even the quinolones are not on patent. So there isn’t a lot of marketing pressure to drive use or support use or justify use.

You talked about being a psychiatrist or psychologist. To me, it’s very interesting. In the hospital there’s a bit of hegemony. There’s a control structure. How does that work?

That’s why I should have gotten that degree.

 There’s the infectious disease specialist, the general practitioner, the chief of medicine, and the pharmacist and the emerging role of the pharmacist, which is important. Do they play nice in the sandbox? Are there ways of evolving that relationship?

There is clearly a hierarchy. I work globally and see that to be even more prevalent. In the United States, we really work as partners. I work with infectious disease physicians and we’re a team. When we make patient care rounds, it’s the physician, the clinical pharmacist, the nurse, the medical student, pharmacy student, and the resident. We are one big team. We work collaboratively. But let’s be honest, the physician is legally responsible for the patient. I consult and I give them my best advice. The pharmacist is an integral part of patient care because we’re the drug therapy experts.

 Right. Collaboration in the context of antimicrobial stewardship is a little dangerous. If you want a white house and I want a red house, is the collaborative solution a pink house?

So that’s a good analogy. Antibiotic stewardship only works if there is collaboration. If I go and try to tell my surgeons, “You cannot do this any longer,” and I just give them a set of rules, I already know that’s not going to work. Nobody wants to just be told that what they’ve been doing for 20 years is not going to be done any more, unless they understand your motivation. And so, I always go in for collaboration.

I bring them to the table, whatever group I’m talking with—whether it be surgeons, the hospitalist, the critical care physician&mdash;and say, “Here’s the problem. We have this escalating antimicrobial resistance in your unit.” I bring factual data. “Here are the last 100 patients we’ve treated, and here have been their outcomes with the antibiotic you’ve been selecting. At this point in time, we have to make a change, and this is what I’m recommending.” And then I stop and listen to them.

 Just in my limited clinical experience about the surgical mentality, they do everything and know nothing. I hope I won’t get into trouble with this.

 And the medical guys know everything and do nothing. Is there a method to the madness?

There is. How I work and speak with surgeons is different. I’ve worked with a lot of surgeons and have a lot of respect for them, and it’s mutual. We work well together. But they’re very much in the moment. “Tell me right now, very quick.” They want sound bites. They don’t want a dissertation of why “this is the antibiotic I’m recommending, and here’s the mechanism of action.” They’re like, “Just tell me what I need to know, what I need to prescribe, and why.”

So they want to be educated. “Here’s what’s best for your patients and I’ve got your hand.” I’m going to come back and make sure what I recommended actually worked. When I talk to a hospitalist, they want that whole story.

They’re going to give more time. “Explain to me, Debbie, why we would use this. I’m used to using that.” So there is a different style. As an antibiotic steward, I have to know that style to be most successful. It’s not one-style-fits-all. Or, as I say, one-stop shopping. You can’t do that. Every physician has their own personality and style, and you’ve got to know that type of style to be most effective.

 Excellent. This is a fascinating discussion.

Potential Antimicrobial Stewardship Interventions

 I think it’s interesting that we both have a relationship with Twitter. It’s such a social tool, yet it has real value to us professionally and personally. I’m going to talk a little about my relationship with Twitter. I’ve been on Twitter now for 7 or 8 years and some of the most famous people in the world follow me. I’m not going to mention their names. Of course, one of them is Debra Goff. I just find it to be an indispensable tool to know what’s going on in the world.

 It might be breaking news on a newly published clinical paper. It might be a CDC [Centers for Disease Control and Prevention] report. It might be political news. I find it first on Twitter.

 Oh, I agree. That’s my go-to. Even when things are happening around the world—you and I travel globally&mdash;it’s my go-to place. Is there something that I need to be aware of? Is there political instability in a country? Even if I want to do something for fun in the country, I go to Twitter to find it because it’s in real time. Every other vehicle I use in medicine is retrospective. It’s a journal. I wrote this article and it’s a year before it’s actually printed. There’s a lag and it’s a huge lag. In the field of infectious disease and antibiotic stewardship, when there’s an outbreak…Look at Ebola.

 Yes. So the 2014 Ebola crisis was horrible. You could actually go on Twitter and watch a video of someone, a family member, who lost a loved one to Ebola describe it. You could see these tented hospitals they were putting up. There was no other vehicle, other than Twitter, to actually connect with the people living in that horrid moment. Yes, every news station, although not too close, was reporting. But that’s what they chose to report.

 It’s antidotal. But it’s the power of that antidotal video or that person. Also, the interesting thing for me is that on Twitter you can follow key people who you’ve already built a level of trust with. So when you tweet something, or see that [C.] Michael Gibson [,MD,]—who’s got 300,000 followers&mdash;tweet something, it has a certain authority built right into it.

 Right. As a health care provider, everybody that I teach had to get on Twitter. You’re held to a higher standard because you are a healthcare provider. You must always tweet responsibly. And remember, your word is your integrity. People are going to hold you accountable. So if you have political beliefs or you feel rage about some topic going on in the world, it’s probably not the best way to talk about it.

 Have you ever deleted a tweet before you posted it?

 No, I really think through what I’m going to say before I say it, and I am not on Twitter for all of those other reasons described. I am on there as a health care provider. Very rarely will you see me tweet outside of infectious diseases.

 Yes, I think I’m more inflammatory. That’s kind of our personal brand.

 There’s no filter on Twitter. What I love, as a global antibiotic steward, is that there are no borders. Infectious disease has no borders. Antibiotic resistance travels globally. There is no other vehicle, other than Twitter, to tell me in real time that this New Delhi metallo-beta-lactamase just appeared in my New York hospital. You’re not disclosing anything that’s a HIPPA [Health Insurance Portability and Accountability Act] violation. A health care provider can tweet about it and I can say, “Oh my gosh, it’s now in the United States.”

 You said something very interesting. We’re all concerned about HIPPA and confidentiality. In the antimicrobial world, bugs are not protected by HIPPA, right?

 Yes, and it empowers me in real time. My best example is with surgeons. I can share that story a bit later—how the power of a tweet really provided real-time education.

 I want to get back to some of those key insights about Twitter. We both have insights that I think once you hear are almost transformative. We’ll get to that in a minute. When I first went on Twitter, it was a bit of a social experiment for me. I was working for a large advertising agency and I saw this thing called “social media.” I jumped on and started playing around. I kind of stumbled through it, following interesting people. And then I started tweeting some things. But to me, it’s not only about talking, but listening. How did you get involved? I was so afraid to start.

 Right. I was there too. It’s kind of a fascinating story. Again, I’ve worked very closely with surgeons. Dr Chris Ellison [,MD,] was head of surgery at Ohio State University, where I work. He actually just retired. He had a wonderful career. Several years ago, I said, “Chris, I can’t give any more lectures on antibiotic resistance.” Quite honestly, we all know if you lecture it goes in one ear and out the other. In the moment when the surgeon’s trying to prescribe an antibiotic, they don’t remember what I said a week ago. But I said, “How can I reach them in a more real-time way? I’m looking for a vehicle.” He goes, “Oh, Debbie, you need to jump on Twitter.” I was like, “Twitter?” And he goes, “No, seriously.”

 I think this was back in 2013. I’m going to quote him. This is not me. He goes, “Oh, most of us have ADHD [attention-deficit/hyperactivity disorder]. We don’t have time to read all of those articles. We like sound bites. Twitter’s the perfect [medium].” I was like, “Really?” And so, he connected me with someone who I call the king of surgery on Twitter—Dr Ben Nwomeh, [MD,] a pediatric surgeon. I never knew him. We’re a huge university and I don’t know every person working in our facility. So I meet this younger surgeon and he says, “You need to be on Twitter.” I actually still didn’t really get it. I’m like, “Well, if I have no followers, where does my tweet go? Who hears anything?” My son was in college and I knew he was on Twitter. I called him and of course he was mortified.

 He was mortified. He was like, “Oh my gosh, why would [you] be on that?” So I got no help from him. So I turned to a PharmD student who started our college of pharmacy Twitter feed. That young man sat down and tutored me. I’ll never forget this. Here we are, many years later. I said, “OK, Blake, who should I follow?” He said to look for infectious disease experts. “Let me show you how to use a hashtag to search on Twitter.” So that was new to me. I searched and found some key people.

But he goes, “Well, you want to follow others who are not in your immediate circle because that’s the power of this. You can learn from other people.” And he goes, “So you want to follow people in healthcare who are really entrepreneurs and are out-of-the-box thinkers. The No. 1 person you need to follow is John Nosta.” And I go, “Oh, I don’t know him.” So, John, you were actually one [of] the first people I followed outside of my immediate circle, and here we are. This is the power of Twitter. We’re here together.

 We’re fast friends. We talk. We call. We tweet. We share information. This is really a powerful dynamic. Well, thank you for following me.

 Yes, and I learned so much. So here is a gentleman who I never even knew. And then I started reading his tweets and links and I’m like, “My gosh, he’s on 

.” Right away you build this bond. I realized, “This person has really valuable knowledge, and it’s very different knowledge from what I’m used to learning.” I’m used to learning from reading journals. It’s medical information. To really be a great steward, as I said, you’ve got to learn more than just infectious disease and matching an antibiotic with an organism. It’s way beyond that. It’s the social aspect of connecting with people to convince them that they need to change what they’re doing. So there are all of these other skills that you really have to have to be a great steward. Following your Twitter feed empowered me to learn a different type of knowledge that really helped me to become a better clinician.

 So pardon the pun, but I guess we can say that Twitter can be infectious when it comes to learning?

Twitter Is a Powerful Medium for Antimicrobial Stewardship Programs

 I’m interested in understanding a bit more about your colleagues’ reactions to Twitter. All the time, I hear, “Twitter? I don’t want to do that.” It’s almost like appropriate use of Twitter—appropriate use of antibiotics.

 We have an infectious disease conference every Wednesday. This is when our physicians and infectious disease pharmacists present interesting cases. Maybe a patient is still in our hospital with a case that is complex. We want everybody to kind of weigh in on how to manage the patient. So during one of these conferences I said, “I’d like to present a topic discussion called Twitter.” If only I could describe the reactions. “Are you serious?” I’m like, “No, no, no, this is serious. I’m not kidding.” Let’s just say that this was not real well received. They were like, “Wow.” When you don’t understand something and you don’t see any value in it, what do you do?

 And most infectious disease clinicians [who] I try to share the value of Twitter with see it as another email. We’re so inundated with emails. I can barely keep up with them. And so, who wants another email to deal with? You can’t even keep track of the ones you’ve got. So I say, “Trust me, it is not email.” And they ask me, “Debbie, how do you find time to do this?”

 And I say, “You know, you always find time for the things in your life that are valuable.”

 So with that thought, you said something earlier that I think is extraordinary and very powerful. The first is the value of a tweet and the power of an idea. And then, the utility of Twitter as a search engine. We’ve talked about that a lot. That’s a big area. I try to get that to be the cognitive tipping point, to get people to embrace Twitter, so they know how to use it.

 So that’s not well understood. Explain that in more detail.

 People say, “I have nothing to say.” That’s the first thing I hear.

 “I have nothing to say. [Whom] do I tweet to?” And then, “I’ve got no followers,” which is worse. It’s almost embarrassing.

 “I have no followers.” I want to know what’s going on in the world now, whether I’m at IDWeek or AHA [American Heart Association]. AHA is going on right now. What a wealth of information—if you want to follow some of the cardiology tweeters or just the AHA hashtag. We’ll talk a bit more about what a hashtag is and how to use it. To me, I know what’s going on in the world right now. If I google “AHA,” I’m going to get nonsense. I’m just going to get reams and reams of data that I can’t make heads or tails of. If I hashtag “AHA,” I know what’s going on right now and can even prioritize my search by not only what’s happening now but what the top-trending tweet [is]. I know they’re talking about X or Y. So for me, that is one of the most valuable tools. It’s a search engine. If you use Google, you should be using Twitter.

 World Antibiotic Awareness Week is in November. The stewards around the world are trying to reach people. The most useful vehicle is Twitter. The Centers for Disease Control [and Prevention (CDC)] is on it, as well as the Society of Infectious Disease Pharmacists, the Infectious Diseases Society of America, and the European groups. People around the world have a coordinated effort around a hashtag.

John, you’re right. If you want to become involved in Antibiotic Awareness Week.… And, oh my goodness, the CDC does an amazing job. They have educational professional artists designing posters that any doctor could put in their office, and that’s hopefully what they’re doing. I don’t have time to design that stuff, nor am I a graphic artist. They have professional people who are creating tools for us to use. You can hang them in your hospital. You can hang them in the health care clinic. We can’t forget about the veterinarians. We prescribe a lot of antibiotics to animals. While that is a whole other story, it’s a coordinated effort around the world. How many efforts take place around the world that are coordinated?

 So interestingly, you refer to Twitter as knowing what’s going on now.

 I also find Twitter to be an amazingly quick analysis of what’s going on now. I don’t need to spend a lot of time on Twitter. Through a couple of trending tweets and a couple of big ideas, I get a sense of what’s going on in a specific category.

 Well, it reveals a lot. If we’re on World Antibiotic Awareness Week, part of what we’re looking at is, who are we engaging with? Are we preaching to the choir? Are we tweeting to [one another]? Are we actually reaching consumers, patients, the noninfectious disease experts, surgeons, hospitalists, and critical care physicians? I have a strategy for how I tweet. You can tweet and say, “Well, who’s reading this?” And, “I don’t know.” But if I include you in my tweet, I know if you feel that what I tweeted to you was important and provided value if I see you tweet it to your network of people. You reach a huge amount of people.

 By knowing you, I now reach a whole different avenue of people, and a lot of them are not in health care. That’s exactly who we’re trying to reach, and you’re the one who has that voice.

, but there is a private dialogue offered through Twitter. You tweet something, include me, and include a few other people. This becomes almost a dialogue among us.

 But the point is not only to educate us but to provide the basis for broad-based dissemination. I’m honored to be followed by someone like Mark Cuban. You know, I have millions, tens of millions of followers. John Sculley from Apple follows me. You know, interesting people [who] you can…

 So your circle is totally different [from] mine.

 But imagine that I tweet something really responsible about, let’s say, [an] MRSA infection. That’s methicillin-resistant Staphylococcus (Staph) aureus. You know, anybody can get that. You may cut yourself. Staph is on our skin. You can get an infection with MRSA, and there are only a handful of effective antibiotics to treat it. So let’s say I tweet something about that, and Mark Cuban’s son happens to have MRSA.

 Exactly, and all of the athletes he is connected to.

 Exactly. Athletes get MRSA [methicillin-resistant 

]. We can name so many athletes—football players, basketball players&mdash;whose careers have been ended because of MRSA infections, or they were certainly sidelined. All of a sudden, Mark Cuban, [whom I have] never met and don’t know, might retweet my tweet because it’s personal to him. His best player got sidelined [because of] MRSA. There’s a personal connection now. I probably would never have him retweet it, but I tweet it to you, [whom] he has that personal connection with. That’s so powerful.

 There are networks, broad-based networks, but there are also clusters of tweeters—people who know [one another]. I’ll often ask for people to retweet things. I’ll say, “This is important. Please retweet this.” They may not be an expert, but they may have a really interesting audience. So it’s really the diffusion of innovations, and the diffusion of timely…

 I love the fact that people don’t think the topic of antibiotic resistance is important to them because they’ve never had an infection. I tell them, “I’m going to guarantee that if it’s not you, it’ll be a family member—your grandparent, your parent, or your child. Then this topic’s going to become personal.” When your loved one is in the hospital and does not have an effective antibiotic because we’ve overused them and none of them work, you’re like, “What do you mean there’s nothing to treat them with?” You know, that’s kind of the mind-set of cancer. Society values cancer because everybody feels sorry for somebody with cancer because we know the outcome. Cancer is generally going to come back. In many scenarios, there’s nothing to treat it with.

And so, we want all of the stops pulled out. But in infectious disease, society doesn’t have that perspective. There is not that value. It’s like, “Oh, there will always be antibiotics. Antibiotics treat everything.” When I see a patient, sometimes it [is] as simple as a 23-year-old college student at [The] Ohio State [University] who is coming in with her first urinary tract infection. This isn’t grandma who is age 95 with 20 different diseases and is dying in a nursing home. This is a 23-year-old who has never even been in a hospital. I have to tell the patient, “We actually have no oral effective agents to treat you with, so we’ve got to admit you to get IV [intravenous] therapy.”

 You should see the look on their face. And then their parents are going, “What? How did my daughter get this?” That’s the moment we’re living in right now. And so, to me, Twitter provides me a voice to get that story out there. You are a vehicle to help me spread that story.

 Yes. You talk about our connections to cancer. Almost 1 in 3 are touched with cancer, either personally or through family. Who has not had a course of an antibiotic?

 That’s the 1 drug that touches all of our lives.

infections. I mean, they’re rich in emotion.

 For decades, the biggest challenge in my field was keeping up with all of the new antibiotics. There was 1 every 2 months. It seemed like there was a new cephalosporin every day.

 That was a challenge early in my career—trying to keep up with every new antibiotic. Pharma is a smart business and bacteria are real smart. You know, bacteria live to mutate and overcome antibiotics. That’s their sole purpose. The minute you start using an antibiotic and expose the bacteria to that antibiotic, they’re sitting there going, “OK, we’ve got to fight this. This is a new class.”

 You get the idea. It’s like their job is to finish fighting antibiotics and mutating. So pharmaceutical companies quickly realized that this class of drugs, from a business perspective, is not a smart class to discover. As fast as they get them out to market, they render useless [because of] antibiotic resistance.

 It’s a very complex problem. So bacteria are smart and they’re doing their job. They’re resisting antibiotics.

The Relationship Between Clinicians and Twitter

 Sometimes you have to be a little poetic on Twitter. Sometimes you just can’t transfer the title of the article. You’ve got to say, “Hey, look at this.” You know, there was an interesting study that looked at emerging resistant trends in MRSA [methicillin-resistant 

]. What the study did was put it on the shuttle on the space station. Under a zero-gravity situation, or microgravity, they thought maybe it would mutate more quickly and that we could get ahead of mutation patterns. Fascinating, right?

So I wrote a story about that. Most people didn’t want to read that. So I said, “Elon Musk just launched a lethal pathogen into space, and it might save your life.” All of a sudden, everybody wanted to know about the mutation patterns of MRSA. So I think language is effective.

 You’re right. That’s part of the art of tweeting.

 So you’re exactly right. People in medicine generally aren’t the most creative people. We’re scientific. We’re analytical. And so being creative is not our strength. So this topic title is boring. No one’s going to read that tweet. Now you tweak it and make it…

 That’s exactly what you have to learn. That’s the other degree I forgot to mention—the creative part, right?

 We write. We publish studies, but they’re scientific. You need to create a tweet that would engage the reader. When I am tweeting to surgeons I’ve got to find a way to make it engaging: “Duodenoscopes contaminated with…” I’m telling them something that I know they probably don’t know. With this gram-negative bacteria called KPC, I don’t expect them to even know what it stands for. They’re not an infectious disease expert. As a steward, it’s my job to say, “KPC [

] means that none of these antibiotics will work. And then I link it to a PubMed abstract that’s scientific and factual. But my tweet has got to engage them or they’re never going to click on that link.

 And there’s the duality, right? The dissemination of scientific information from the professional should sound professional. It has to stick to the roof of your customer’s brain. When you can link it to a reference, that’s another duality that I think is important.

I want to go back to Ebola and talk about someone on another continent who touches us with an individual story that is not supported by data. That was a fascinating thing that you were telling me about.

 You know, the CDC actually studied this. They were really the epicenter of trying to coordinate the containment of Ebola. Of course, it went to a different level when Ebola arrived in the United States. I’m going to go back to my surgeon colleague, Dr. Ben Nwomeh, who is the king of tweeting for surgeons. He happens to be Nigerian, and he still returns to Nigeria several times a year. He has an amazing mentoring program that teaches surgeons in Nigeria how to be even better surgeons.

But he had family members right at the epicenter of Ebola. He made a tweet when it arrived in the United States. I can’t quote it exactly, but his tweet said something similar to: “Thousands have died in western Africa, and the world didn’t take notice or sort of ignored it. But 1 [case] in the United States, and the world stopped.”

 monitors the top 15 health care tweets each year. His Ebola tweet was 1 ahead of Bill Gates’. You know that Ben Nwomeh has a lot of followers, but not the number that Bill Gates had.

Think of the power of Dr. Ben Nwomeh’s tweet on Ebola. The CDC actually studied it. It was their most effective communication tool. Why? Because it was real time. They could update the numbers. The other way to do it, you had to log on to the CDC website. That’s just not an efficient way. If you’re a surgeon sitting between cases, you can jump on Twitter from your phone and get an Ebola update. Honestly, the CDC’s website is phenomenal, but navigating it is a little complex. You can’t find stuff.

 The CDC is 10 lb of information in a 5-lb paper bag.

 Right. If you can find it, it’s there. The CDC actually published data. Their most effective communication tool was to teach the world about Ebola facts because there was so much misinformation going on. As soon as it uninformed, people were tweeting on treatment for Ebola. They were tweeting about things that were actually going to harm people.

 The CDC monitored all of those tweets and would quickly put that to rest. “This is not accurate. This is not correct.” People can tweet on anything, but it doesn’t have to be right.

Hook Your Twitter Reader With Creative and Poetic Headlines

 Isn’t there a lot of nonsense on Twitter?

 What’s the pushback that you get? For example, “I’m a clinician, show me the data.”

 “Show me a peer-reviewed clinical journal, and then I’ll read up on it on Twitter.”

 Right. I knew that would be a barrier. When I met Dr. [Benedict] Nwomeh, [MD,] I said, “Look, I’m going to try to start using Twitter to reach surgeons, and I need you to help me because you have this network of over 5000 surgeons. You’re my voice because they don’t know me. I’m not a surgeon, so I’m not going to have that instant credibility. Yes, I’m a health care provider, but I’m not a surgeon. I’m not in your circle. I need you to help me. Knowing people in medicine are evidence-based, we’re going to do this as a study. We’re not just going to do it and say, ‘We feel this works.’ That doesn’t work in medicine. We’re going to do it as a study.”

So we actually set it up as a study and published on it. It was fascinating. We actually did medical grand rounds at The Ohio State University Department of Surgery on Twitter. Those are coveted lectures planned 1 year in advance. But Dr. [E, Christopher] Ellison, head of surgery, understood the value. He understood what I was trying to accomplish. Surgeons need to use antibiotics. If a surgical procedure is done and no prophylactic antibiotic was given, your patient has a high probability of getting an infection that they can die from.

So surgeons are one of the highest users of antibiotics, [and] rightfully so. Antibiotic resistance is a moving target. When KPC [

 carbapenemase] occurs, which was nothing they learned about in medical school because it never existed back then, what is their vehicle to learn about this? I can’t give a lecture to 100 surgeons in real time. Twitter is the vehicle. So it’s not the end-all, it’s just another communication tool that reaches them in a very different way.

 Let’s keep going because this is so fascinating.

 So there’s a method to the madness. It’s not just your word or anecdotal data. You actually did a study on this?

 We did. We set it up as a study. We had our surgeons volunteer to participate in active tweeting. I, as an infectious disease expert, along with our surgical and clinical pharmacists who had that network of surgeons, tweeted relevant infectious disease topics to a surgeon. There are a lot of infectious disease topics, but a lot of them don’t really apply to a surgeon.

 Before you go there, I’m going to do the eye roll for you.

 You recruited surgeons to do active tweeting?

 Let’s talk about recruitment. We know that trial recruitment for patients is hard. Trial recruitment for physicians on Twitter must have been brutal. Was there a take?

 Absolutely. Well, remember that the chair of [the] Surgery [Department] was my advocate. There’s a lot of power.

 When the head of surgery says, “You all need to participate in this,” there’s a hierarchy. But actually, many of the surgeons at Ohio State University were already on Twitter.

 Did you find that it was younger surgeons, older surgeons, women, men?

 I constantly hear, “I’m not 20. This is for the younger generation.” Yes, they grew up with these tools. We did not. But my head of surgery is age 71. He realized this was a vehicle that he could learn and engage with others in a different setting. But yes, this included one of the younger surgeons who would never be asked to do surgical grand rounds. That’s a very prestigious role at a university, and that’s exactly what he stated. He was the most active and really got the division on it. Christian Jones is probably in his 30s. He was a brand-new surgical attending. He would never be asked to do surgical grand rounds. But our grand rounds at Ohio State University included Christian Jones, Dr. Ben Nwomeh, myself—as a pharmacist, which is sort of unheard of&mdash;and Dr. Chris Ellison, who is head of surgery. In essence, we had 4 generations to dispel….

 Did you kind of do that, or did it just happen?

 It really was. But they all understood the power of using Twitter as a communication tool in real time. If you have a bone marrow transplant, and you’re in my hospital for 30 to 60 days recovering, people unfortunately acquire infections in hospitals. This is not because we’re doing bad things but because people don’t wash their hands.

 Exactly, that’s their home. So you might acquire one of these multidrug-resistant gram negatives. I’ve got a handful of effective antibiotics to select from. That handful is dwindling every day. It’s fewer and fewer. How am I going to teach oncologists in real time about any new antibiotic that comes to the market? They’re controlled by antibiotic stewardship programs. We tell them, “You can’t use these.” We’re going to control them. That’s good, but we want to make sure they’re used responsibly. It’s a little unsettling when you’re calling a physician stating, “Your patient has 

 carbapenamase.” Or “Your patient has this gram-negative 

.” Or I say, “You’ve got this drug-resistant pseudomonas infection.” And they’re like, “I don’t understand. I’m going to recommend that you use this new antibiotic that you know zero information about.”

 All I know is about beta-lactamase. Carbapenemase is not even on my radar, right?

 But the point is, some of our physicians don’t read 

. That’s not their expertise, just [as] I’m not a surgeon. I’m not going to read journals on the latest surgical tools.

 I don’t use it. But every physician, every nurse practitioner, and every clinical pharmacist that prescribes an antibiotic has to have knowledge to prescribe them responsibly.

 And how do you convey knowledge in real time, as we have outbreaks literally occurring that we’ve never seen before?

 Well, it’s funny. We talk about the diffusion of innovation. We often call them “viral.”

 There you have it. It just seems to be such an interesting connection.

Studies Dispel the Myth That Twitter Is a Waste of Time for Busy Clinicians

 Tell me more about the study and the grand rounds and the insights around that? What happened with that?

 Sure. Again, the surgeons have the rapport with the surgeons, and so it was actually a very easy opportunity to recruit them. We had several of all ages. There really wasn’t a specific gender or age. Across the board, we had young and old participants.

 Female, male, young, middle age, and older patients.

 Wow. It wasn’t the excuse of, “I’m too old to be on Twitter”?

 But you know what? You are correct. The majority of people my age do not embrace learning something new. We’re so busy and are so overwhelmed with emails. I don’t want 1 more thing on my plate, nor do I want to learn 1 more thing. It’s another thing to learn. So there are barriers. That’s part of the reason why I am on social media. I am trying to break down that barrier. People who know me and trust me can say, “What is it that she feels is valuable? Maybe I should get on it [Twitter] and look.” I tell them, “You can be what we call a lurker. You actually don’t tweet anything. You don’t even have to sign up. You can look and test it out and see what you think.”

 I have lots of friends who talk about technology—using this and using that. I ask them, “Have you ever done a telemedicine visit?” They haven’t. When they do it, they find that it works. It makes a lot of sense. I think finding that value…

 Regarding value from antibiotic stewardship, one of the most brilliant ways I’ve seen it used was in a big global study that tried to answer a question we’ve struggled with in the management of gram-negative infections—2 different classes of antibiotics. One is a carbapenem, which we call our last-resort antibiotic. You never want to overuse it, but in certain infections it is the drug of choice versus a beta-lactam antibiotic. There are 2 antibiotics that we use routinely in the hospital. Which one is better? This trial was called the MERINO trial. In the trial, investigators actually used Twitter. They started a MERINO trial Twitter handle for investigators to be able to follow the trial in real time, because the investigators who were enrolling patients in this study were all over the world. How do you coordinate that? Emails, conference calls? It’s so much time and effort. Everybody is on a different time zone. You could jump on Twitter. Even as someone who wasn’t a participant in the study, I could look and see how many patients were already enrolled and what countries were enrolling.

They learned that from the oncologists. Again, society values people with cancer more than antibiotic resistance. Oncologists have learned that you can go on Twitter and search for a hashtag on melanoma. You can search for information on melanoma and find academic medical centers like my own that are a part of a clinical trial for a new, novel agent for melanoma. To patients infected with this cancer, it’s advertising that there is a clinical trial at this hospital. People will go anywhere to find the best of care to possibly survive.

 We all struggle with recruitment in clinical trials and how to find the right patient.

 ASCO, the American Society of Clinical Oncology, has absolutely embraced Twitter as a vehicle to improve enrollment.

 I’ve argued and have gotten into a bit of trouble with this. Parents whose kids have cancer—the collective intelligence of that group is amazing.

It’s sometimes even better than the physician because they know the labs, they know the trials, and they know their kids.

 No one is going to advocate more than a parent.

 Yes, exactly. There really isn’t that kind of advocacy in antimicrobial stewardship.

I don’t know if it’s a deficiency or a way of looking at it?

 When we started this discussion, you asked what is working and what is not. What’s clearly not working is that connection of the gravity of the situation right now with society. I think people feel that we’re crying wolf. They may think, “Oh, there are always antibiotics. We’re never going to really run out.” The United Kingdom commissioned a world economist who published a report in 2016. I think it was predicted that if we just stay on course, where we have a few pharmaceutical companies who are discovering an antibiotic here and there, antibiotic resistance will continue to win the game. Where will we be in 2050? The number of deaths from antibiotic resistance worldwide will exceed the combination of deaths from cancer, HIV, and traffic accidents.

 So we think of that, but it’s not resonating. That report has been out for a couple of years. It’s just not resonating. That’s the psychiatry and behavior changes. That’s the sociology degree I forgot to get. It’s just not working. We struggle. We have world congresses talking about why this does not seem to have the connection that cancer has. It’s just as bad. If you survive cancer, but you acquire an infection and it kills you, you’re not any further ahead. Dead is dead.

 about fighting the next world war with a musket. That next war, as you know so well, is with infection. It’s with Ebola. We have tools at our disposal, but it just doesn’t seem to click, in many ways.

Transferring Social Media Best Practices From Oncology to Antimicrobial Stewardship

 What other data, as we talk about the work that you’ve done, is compelling? Is Twitter an epidemiological tool, too?

 It can be. There is some fascinating work. I’ll just share 1 story about what we identified in our study that I did with surgeons. Are we connecting with them? Would they retweet, based on not knowing me personally? Clearly, I’m not a surgeon. Would they retweet something from me because Dr. Nwomeh liked it or tweeted it? If it was attached to something like a link to a PubMed abstract—the evidence-based, scientific analytical part of being in health care&mdash;that I provided on an article that described this drug-resistant infection in surgical wounds? Again, keeping it relevant to them or this antibiotic class that causes a high prevalence of 

 Right. So the one tweet that resonated the most was this KPC [

] outbreak. KPC is a resistance to a gram-negative bacteria. At the time I am recalling, it was fairly new. Surgeons use duodenoscopes for procedures and clean them according to the manufacturer’s directions. KPCs weren’t around when the tools were developed, so the sterile technique could not kill a KPC. So the University of California, Los Angeles, had this outbreak. Patients actually died from the untreatable KPC gram-negative infection caused by contaminated duodenoscopes. So, an elective surgical procedure actually killed patients. As a surgeon, you could imagine the liability you’ve now got and how horrid you would feel.

 As that outbreak was occurring, it was on the front page of the 

. It was happening in real time. I knew they may not even know what KPC stands for, nor what antibiotic you should give to someone who acquired this from a procedure.

 So I linked it to a medical article on the management of KPC infections. For gram-negatives, it reviewed appropriate antibiotics. That was the most retweeted tweet. That one tweet that was retweeted by Dr. Ben Nwomeh reached 15,800 people, most of whom were surgeons. That’s the power of Twitter. That was in real time, John. If I waited for the outbreak to be published…

 Exactly. It was 1 year later. So that was the value of it.

 What about the value of Twitter as a tool in academic institutions, congresses, meetings, or at IDWeek?

 I think that people completely miss that.

 You’re correct. I was at IDWeek, and I was a power tweeter because I have a bigger network, and I enjoy tweeting. Everybody can’t be at the meeting. Maybe there’s no funding to send you. Maybe the timing isn’t right. Maybe you’re on service, taking care of patients, and you can’t leave. So there are many reasons. But wouldn’t you like to know what’s happening at your national meeting? Tweeting allows you to disseminate outside of the walls of the meeting. You reach a much bigger audience, globally.

 And it’s not only inside-out, but it’s outside-in.

 So I can attend IDWeek virtually, right? I’ve got power tweeters like you doing all of the hard work to consolidate 2 or 3 hours of talks into 1, 2, or 3 key points. And once you build the trust with that individual, you really want them to….

 Right. Again, I learned that from my surgical colleagues. The American College of Surgeons… I think 20,000 surgeons attend that meeting. Surgery is very siloed. You’re a gastrointestinal surgeon or you’re a heart surgeon. They don’t even cross paths. But at the American College of Surgeons, it’s everybody. So they have power tweeters who are tweeting galore. If I’m presenting breaking work, I want my work to be known and recognized. I’m not presenting it just for the audience that is there. It allows me to have someone tweet my work. All of a sudden, a much bigger audience is seeing my research, not just the attendees.

 It’s like publishing a paper and having that paper referenced a lot. That’s the basis for a Google search. That’s how they structured search relevance. To me, it’s really interesting. If you publish a paper, you want it to go in a prestigious journal. You don’t want it to disappear into academia. So that’s a publication channel or a dissemination channel.

 It is so powerful. You know, journals now keep metrics. A journal is a business. They’re in the business of publishing. They want those articles requested, they want reprints purchased, and they want the work disseminated. The abstract is like a little teaser. You get to see a little bit of the information. If I’m reading a study and I read the abstract, I may say, “Oh, I need to know more details because I’m actually going to do this for my patient.” I need to know all of the facts, not just the little teaser. And if I don’t have the subscription to that journal, I’m going to purchase it.

 So, journals have now realized the value of Twitter.

 But also, hospitals promote good stewardship as a reason for why you should go to that hospital.

 Exactly. It’s self-promotion. We’re in the business of running a hospital.

 I think that some clinicians might cringe when they hear the words “power tweeter.” “Oh my god, a power tweeter.” What is a power tweeter? Is it gamification? Isn’t it nice to have your tweet become a top tweet?

 Absolutely, and especially when people with influence pick up your tweet. I’d like to tell you about one of my most exciting moments on Twitter. At the American Society of Microbiology conference 2 years ago, Bill Gates was the keynote speaker. So, Bill Gates put out a tweet: “Tweet me a question. If selected, you’re going to have a one-on-one dialogue with me.” Well, I jumped on that. I sat with my physician who is not on Twitter.

 I am working hard on that. I said, “In 140 characters, help me language a compelling question.” We literally spent 40 minutes trying to get what we wanted to ask down to 140 characters. And she’s like, “Why is it 140 characters?” And I said, “That’s a different discussion.” And guess whose tweet was selected by Bill Gates? I had the opportunity to have Bill Gates speak to my name.

 What’s the likelihood of you getting a call to Bill Gates? It’s pretty tough, right?

 E-mail bgates@micro... Or whatever it is— the Gates Foundation. It’s almost impossible.

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Social Media Adds Value to Antimicrobial Stewardship Programs

Inappropriate Prescription of Antibiotics and Other Causes of Antimicrobial Resistance

Potential Antimicrobial Stewardship Interventions

Twitter Is a Powerful Medium for Antimicrobial Stewardship Programs

The Relationship Between Clinicians and Twitter

Hook Your Twitter Reader With Creative and Poetic Headlines

Studies Dispel the Myth That Twitter Is a Waste of Time for Busy Clinicians

Transferring Social Media Best Practices From Oncology to Antimicrobial Stewardship

Case Studies of Effective Twitter Use in Medicine

Use of Twitter to Educate and Engage Surgeons in Antimicrobial Stewardship

Nuts and Bolts of Twitter for Antimicrobial Stewardship

Using Twitter to Disseminate Journal Visual Abstracts to Clinicians

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