1. I started my fellowship @MayoClinicINFD in July 2017. My fellowship research project was published today https://rb.gy/ffkjgs  in CID. Currently there exist NO guidelines for prophylaxis of infections in pts on ECMO. We attempted an evidence based approach to tackle this.
2. A đŸ§”on how mentorship/communication was important in this antimicrobial stewardship project. Read time: 8-10 mins.
3. I did my residency at @ACMCIMRes where we saw a large number of ICU pts, many on ECMO who are at a high risk for HAIs. 20.5% of adults acquire HAIs while on ECMO but ELSO says no additional antimicrobial coverage is recommended for patients on ECMO https://rb.gy/afzjto 
4. Despite this, depending on style/location of practice, acuity of pts, wide variety exists for prophylaxis of infections while on ECMO, with strategies ranging from broad spectrum antimicrobial use to no antimicrobials at all.
5. In my pre fellowship interview dinner I discussed this w @jcohoro who told me @MayoClinicINFD had a protocol for abx prophylaxis while on ECMO as our tertiary care center got many complicated pts. After matching we quickly started working on evaluating impact of this protocol
6. We evaluated the impact of an initial consensus opinion ECMO antimicrobial prophylaxis protocol, implemented in 2014 (pic), on antimicrobial use (primary analysis) and National Healthcare Safety Network (NHSN) reportable infection rates (secondary analysis).
7. Antimicrobial utilization was compared using the metric of days of therapy/day of ECMO. Nosocomial infection rates were also analyzed. In a brief washout period from July 2017 to November 2018, we analyzed the 6 years of data.
8. We noticed that antibiotic utilization actually INCREASED after implementation of the protocol
- Early trends of improved stewardship, were quickly off set when time frame and number of patients were increased
9. Why did this happen?
- Inconsistent compliance with the protocol.
- Inconsistent stake holder engagement.
- Lack of prospective audit and feedback.
- Lack of active ID involvement.
10. We then presented our results at various academic conferences including ELSO, ID week 2018 and 2019 and garnered suggestions for improvement. Special thanks here to @TMcCarty2010 @DoctorRachael who stopped at my posted in ID week 2019 and gave some awesome suggestions!
11. Well, we used more antibiotics, despite a protocol designed to promote rational antibiotic use, did we at least see less infections? Better outcomes?
- NO
- Despite more antibiotic use we saw no improvement in these metrics.
12. Herein came Dr @kyle_bohman Dr @pkguru10 who helped us communicate with all colleagues in surgery. After several meetings and valuable discussion/feedback, we decided to change the protocol and have more active ID involvement with active and prospective audit and feedback.
13. The new protocol had:
- Active communication with surgical colleagues with addressing of all queries with data
- Active ID review and consultation
- Active stakeholder assessment, feedback, review, meetings
14. This resulted in:
- Reduction of broad spectrum antimicrobial use for prophylaxis to almost ZERO
- No impact on HAIs, outcomes
- Improved communication and satisfaction amongst stakeholders
15. ECMO patients are medically fragile, have multiple co-morbidities, incisions and medical devices and therefore at high risk of HAIs. There is every incentive to empirically cover for potential infections, and little objective data on which to guide de-escalation
16. Expert opinion/consensus drove the initial protocol, which was not consistently followed, but helped establish ID presence with the ECMO team. The second iteration was more restrictive and consistent with an approach to antimicrobial use.
17. The protocol was also built into an order set to ‘hard wire’ it into routine practice. When then compared with the refined protocol, in the second phase of this study we managed to essentially eliminate usage of broad spectrum antimicrobials ECMO prophylaxis.
18. Limitations are the bandwidth needed to accomplish this, and the unblinded nature of the study being the inherent bias of the design. Strength is the large nature of the study, design, implementation.
19. A multidisciplinary team-based approach to antimicrobial stewardship can significantly reduce antimicrobial prophylaxis and overuse in ECMO patients without increased risk of nosocomial infection. These data can be used to assist other institutions in developing protocols.
20. Lessons learnt for stewardship:
- Know your customer (stakeholders)
- Collaboration/discussion >> Rigid enforcement
- Learn the point of view of the primary team
- Identify a problem-Do lit review-Review available data with stakeholders-suggest improvement-implement-analyze
21. Mentorship is critical and so is collaboration as evidenced by invaluable guidance by @jcohoro @PSampathkumarMD @kyle_bohman @Stevens_AK
Full article: https://rb.gy/ffkjgs 
PS: Pre interview dinner gave rise to a mentor relationship with @jcohoro, this project/completion!
Reducing Broad Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation (ECMO): Reduce...

AbstractBackground. The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicr

https://rb.gy/ffkjgs
You can follow @IDdocAdi.
Tip: mention @twtextapp on a Twitter thread with the keyword “unroll” to get a link to it.

Latest Threads Unrolled:
Those who think consciousness raising & movement building are disconnected, or even a distraction from electoral politics have not paid attention to the history of social change.In this thread, we
Read more
The 2020s will be known as the Remote Work decadeA few predictions of what is likely to emerge[ a thread ] Third Space: Office and Working from Home will
Read more
1/29: Have you ever had a concept explained to you that helps frame complex issues you’ve been wrestling with and opens your eyes to new possibilities? A concept that I
Read more
By continuing to use the site, you are consenting to the use of cookies as explained in our Cookie Policy to improve your experience.