Stewardship Considerations


In this conversation, Jones discussed concerns around empirical antimicrobial treatment and opportunities to narrow down therapies.

Contagion: What are the concerns and challenges around empirical antimicrobial treatment?

Jones: I work in a community health system. Many places have their protocols and pathways, but that’s something we struggle with. To be honest, our physicians haven't fully adapted to or embraced these practices. As a result, many patients are started on broad-spectrum agents, often multiple agents, covering gram-positive, gram-negative, and anaerobic bacteria, which is frequently unnecessary.

The second issue is MRSA coverage. One of the first things to determine, whether you're working in inpatient or outpatient settings, is the MRSA rate in your area. If you're on the outpatient side, you should be able to contact your local hospital to obtain a copy of their antibiogram. I encourage you to do this, as it’s a valuable way to track MRSA rates.

For example, when I first arrived in Savannah about 14 years ago, our MRSA rate was 58%, which was quite high. Over the years, we've seen a steady decline. For the last few years, we've been at 50%, and in 2023, it was the first year we dipped below 50%. It's interesting to track these trends. In our health system, given our MRSA rates, we treat for MRSA until proven otherwise when dealing with Staphylococcus aureus infections. Knowing your local MRSA rate is crucial.

Finally, let's talk about vancomycin use. We've seen a decline in vancomycin use over the past year and a half to 2 years. This is partly due to the availability of alternatives like daptomycin and the generic version of linezolid. Vancomycin use remains a topic of interest. We switched to AUC-based dosing and monitoring about four years ago, which has helped address some nephrotoxicity issues associated with vancomycin and its combination with other agents. We continue to monitor vancomycin use closely.

Contagion: What do you need to see from a clinical standpoint in terms of narrowing down therapies?

Jones: I think clinical improvement is a significant aspect of patient management. When we admit patients, many times, unless they have comorbidities or acute exacerbations, they aren't particularly ill aside from their infection. Often, the primary reason for their admission is the need for IV antibiotics, which keeps them in the hospital. This becomes our focus: determining if we need to discharge them with IV antibiotics or if we can convert them to oral medication.

We also take many cultures, and depending on your institution, the time it takes for cultures to mature and the information they provide can be very valuable. Reflecting on previous cases, I often tell my students that cultures can predict future behavior much like past behavior can predict future actions. In other words, the results from previous cultures can inform us about likely outcomes for current patients.

When considering all these factors, our goal is to evaluate if the patient is stable and to plan the next steps in their care transition. How can we safely discharge these patients? Can they switch to oral antibiotics? These are the key questions we need to address to facilitate their discharge.

The conversation was edited for grammar and clarity.

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