Priya Nori, MD: Hello. I'm Dr. Priya Nori. I am current chair of the Infectious Diseases Society of America Antimicrobial Stewardship Curriculum Working Group. Welcome to the Steward's Corner. Today we are joined by Dr. David Gaston, Dr. Ahmed Babiker, and Dr. Romney Humphreys. We'll be engaged in an in-depth discussion on the crucial interaction between antimicrobial stewardship programs and the clinical microbiology lab to improve antimicrobial use and reduce antimicrobial resistance. We will also be discussing examples of successful microbiology and stewardship initiatives to improve antibiotic use such as Antibiograms, Cascades, Multiplex PCRs and the like. Welcome to our Guests.
David Gaston, MD, PhD: Thank you very much Dr. Nori. I'm David Gaston. I'm an assistant professor at Vanderbilt University Medical Center, infectious diseases and clinical microbiology trained and currently directing the Molecular Infectious Diseases Laboratory here at VUMC. I am delighted to be hosting a conversation today with Dr. Romney Humphries, who is also a Vanderbilt University Medical Center, as well as Dr. Ahmed Babiker, who is of Emory University. These two fantastic individuals have a tremendous background in microbiology and infectious diseases and in interfacing between the world of clinical microbiology and the world of antimicrobial stewardship. So, thank you two both very much for joining us here today and I look forward to our discussion. I'm starting off. Dr Humphreys… Romney, would you please introduce yourself?
Rodney Humphries, PhD: Yeah, absolutely. So, I'm thrilled to be here. Thank you so much for the invitation. As David mentioned, I'm Rodney Humphries. I'm a professor at Vanderbilt University Medical Center, where I am the division director of lab medicine and also the service director for the infectious diseases labs; and of course susceptibility testing is my passion so I'm thrilled for this whole conversation and how we tie this to our clinical patient management.
Gaston: Take it away, Ahmed.
Ahmed Babiker, MD: Great and thank you very much. I'm also thrilled to be here. I am an infectious disease physician and clinical microbiologist and I serve as the associate director of the Investigation of Clinical Microbiology Corps, as well as one of the medical directors of our clinical microbiology lab. My research interests are in the clinical and genomic epidemiology of multi-drug resistant bacteria, and capacity building of microbiology labs in low- and middle-income countries, so I'm also very pleased to be here and take part in this conversation.
Gaston: Wonderful. Thank you two so much. May I also just say as a personal anecdote, I know both of these folks personally. They're just incredible people. If you ever have a chance, when you're at a conference, to walk up to them and say hello, well worth your time to do so. So here I hope that we can have a discussion, and I hope we can have some fun, and hope you, as the listener, can join us in that. Starting off, we're going to be thinking about the interactions between clinical microbiology and antimicrobial stewardship. We're also going to be thinking about initiatives for how to make those interactions formalized, how to standardize them, how to carry them forward. All of this is going to be patient focused. As clinical microbiologists and infectious disease providers, the patient is always first. That's what we do, day to day, is help care for people who are sick, so that's going to be sort of a grounding focus in these discussions as well. Starting off, Romney, I'd like to open a question directed to you, which is just on an individual patient level, how do stewardship microbiology work together to impact care of the patient?
Humphries: Well there's lots of levels that we can do this in. I think that there's the systems based levels which talks a bit about how we do the work in the microbiology lab. How the results go out the door. How those are interpreted by the end user, the clinician, who then is making treatment decisions with the aid of stewardship team, and so at every step along the way there's opportunities for us to make a substantial impact on the individual patient level. Very, kind of almost passively honest, with the lab reporting all the way through to very active interventions where we in the lab are noticing an unusual resistance phenotype or maybe we're getting calls about asking for additional drugs to be tested that really maybe not very appropriate and so looping into our stewardship colleagues. I will say I have our ID pharmacists on speed dial here in Vanderbilt and I probably call them about a couple times a day anyways to pick their brain about different clinical cases, and so that's, you know, I think the key thing though is to build those relationships right. We want to be partners. We want to be friends and interact on a daily basis.
Gaston: Could you talk a little bit about those interactions going both ways? You have the antimicrobial stewards on speed dial. I think they have you on speed dial as well. What are the ways to be able to build those relationships so that they can best benefit patients?
Humphries: Yeah. So, I I started here at Vanderbilt a little bit over two years ago now and the first thing I did was invited myself to the antibiotic stewardship team. So they didn't necessarily know who I was or the level of Interest I had, and the first thing they said is, “well, we have our standing monthly kind of official meeting”, but I was like “no no, forget that, I want to come to the weekly working sessions to really understand what are you guys dealing with here. What are the key issues? What are your pillar goals? What are the things that you're trying to address and then how can I start to infuse the microbiology lab and what we can do into that overall program”, and it goes the other way as well. So, we have our ID Pharmacists and our ID fellows and our attendings all come and rotate through the lab at least at the beginning of their program, but usually a couple of times throughout to kind of understand what's going on on our side, like what are the things that we're struggling with, what are we implementing and how can we really find synergies where there's things that both of us are working on that can make a big impact.
Gaston: That's fantastic. So, crash the party. Find out where it is and invite yourself in. Great.
Humphries: It's pretty much a good way to run your life, actually. If you want to get involved, just join on in.
Gaston: Totally agree. I like it. Very good. Ahmed, how about at Emory and particularly in your role both as an infectious disease provider and as a clinical microbiologist, because you're interfacing with patient-facing teams in different ways at different times and you're also interacting with the antimicrobial stewards in different ways at different times, depending upon which hat you're wearing. So how does that look for you?
Babiker: Well, I just want to Echo what Romney was saying, and I'm all about crashing parties. I love to party and I love wearing different hats, as you mentioned.
Gaston: Your hats are always fantastic by the way
Babiker: Thank you very much, and I agree with what Romney said, that antimicrobial stewardship at the patient level is sort of like an invisible kind of caretaker or hand that's making sure that everything is being done and high quality care is being provided, kind of surreptitiously in the background, but for that to happen systems need to be put into place and for the systems to be put into place, as Romney was saying, relationships and understanding need to happen, and I just want to highlight one great example from my current institution that I think really helps foster these relationships between infectious disease physicians, trainees, pharmacists and microbiologists. Which is, our daily microbiology rounds. So, every day at about one o'clock we, the clinical infectious diseases teams which includes our fellow-led team, our attending only team, and our transplant team and at any point in time there could be Internal Medicine rotators, people from the medical school, pharmacists, infection preventionists also frequently come, emergency medicine docs, and just a whole bunch of other sub-specialty fellows, and so we take it as a real moment to teach about the microbiology processes that are occurring, and of course, a lot of these microbiology processes that occur are integral to stewardship. They're integral to the right test being ordered on the right patient at the right time. They're integral to results coming out that are high quality and coming out an appropriate time, so the front-facing teams can act on those results, to make sure that patients are getting the right dose/the right drug so they can de-escalate, but I think a lot of the clinical teams or even maybe some of our stewardship colleagues don't understand everything that happens to make all of that run smoothly, and so we take micro rounds as an opportunity to do that, through a focused didactic session.
So, we usually have the fellow give a small didactic session, but then we walk through the lab and then it's an opportunity for the clinical teams to ask us questions about, so for example, “Hey we have a pseudomonas, but we haven't received the antimicrobial susceptibility results yet. What's going on?”, and that can be an opportunity for us to talk about some of the difficulties in doing antimicrobial susceptibility testing on pseudomonas and talking about it needing to reflex to some e-tests or maybe talk about cascading, such as, “well it's carbapenem resistant and in the background we are now doing additional susceptibility testing for some novel agents and that'll be done in a day or two or sooner, hopefully”. So, I think, to me, the relationship building is super important, and this has been a real informal way, I think, a formalized informal way that is sort of outside of the boardroom, outside of the weekly meetings that has helped strengthen relationships at my Institution.
Gaston: That's fantastic. So, what I'm hearing from Romney is “crash the party”, and what I'm hearing from Ahmed is “bring your friends”, and doing that together we'll be able to really work for good. That's great. If you find yourself in Atlanta at one o'clock in the afternoon eastern time, stop by the microbiology lab for walk rounds. If you find yourself in Nashville at 10 o'clock Central Standard Time, come by the microbiology lab for our walk arounds. We'd be happy to have you and then go out and get some Nashville Hot Chicken afterwards.
Humphries: Can I add something? One thing I think that we often do is round in the micro lab, and we have our fellows round with the ID teams as well, our microbiology fellows, and I think that it's a really nice opportunity to see both sides of it, right? So, where they add value on rounds with the ID teams is those on-the-fly conversations about developing the differential. understanding the testing, the nuances, even kind of being the line to the lab to understand what's going on in the background, like you said, on-the-fly. So, for those of us in the lab, I mean listen a lot of people, we're not exactly extroverts. Sometimes we don't like to leave the walls of the lab, but it's a really good thing to do because it first off really helps you kind of see what's actually going on out there on the floors, and then also it can provide a really nice interplay between more on-the-fly interventions for the patient as the team is seeing that patient.
Gaston: That's wonderful. An important topic that you both brought up is relationships and how important relationships are to building trust, so that the interactions between microbiology and antimicrobial stewardship programs actually work. When that's done at an Institutional level, it's great and it can work really well. So, on the on the second question here.
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