Thread by @ErinMcCreary

my grandpa has been in the hospital for the past week w/ Acinetobacter baumannii bacteremia.

I keep deleting this, but I think I need to share what I learned about antibiotics and fear, and reinforce the life-saving nature of stewardship [thread] 1/

First, I just want to say my grandpa is the best human. From a tiny town in WV. He started the cable company back in the day bc "people deserved to know the news" Sold it for a song once it was established because he had achieved his goal. Help people, at no personal gain. 2/

He stopped driving ~1 yr ago. Sometimes he’s frustrated by this.

“I am sure people in town would drive you, Grandpa”

Grandpa, sincerely, “I’d rather give than take.”

He’s the kind of selfless we don’t deserve.

He is also hilarious and a great drinking buddy. 3/

Okay, so I really love my grandpa. You guys would too, he is the best.

Anyway-- last week, I get a call from my dad that they called the ambulance because grandpa was “shaking” and “can’t walk”.

AFib, doctor says. 4/

Later my dad texts me he also has an infection in his leg and he is getting ceftriaxone in the ED.

My ID pharmacist stewardship heart sighs so deeply.

Grandpa has CHF w/ bilateral leg swelling (known, chronic).

Stop the ABX!

Feeling GOOD about this move, y’all. Boom. 5/

Next morning I get this: 6/

Huh? That’s not AFib and edema.

Cefepime?

How’d we get here? What the hell?

Here’s how: 7/

(lesson learned: asking for dose optimization over text to your dad who’s then trying to communicate that recommendation to an on-call ID specialist who covers multiple rural hospitals in OH and WV doesn’t go so well, but don’t worry we got there. 2g q8h over 3h, baby) 8/

Also, WTF GNR BSI? Discover source is likely a leg wound that he’s had for weeks & been covering up (lol so stubborn). But he hasn’t been in the hospital since March (before that, not since 2017), only a few days of ABX in past 6 months, lives at home, no real risk factors. 9/

Drive to WV as soon as I can. Not much in the way of rapid diagnostics, so ~2 days until organism identification and 3-4 for sensis. Woof.

He looks sick, but not horrible.

The ceftriaxone probably worked. He’ll be fine. 10/

Go back to work Thursday.

ID MD calls me at 3p and says bug is Acinetobacter.

Grandpa is worse.

At this point, I forget everything I know about treating infections. I think meropenem but is that enough? What do I do? 11/

I phone a friend. Land on mero (1g q6h over 3h) + mino (200mg BID). Call ID MD back.
Come to find out 1) this hospital doesn’t have mino and 2) Ab is send-out for susceptibility testing
We’re at >48h inactive therapy. Thursday before a holiday weekend. Send-out. Wooooooof. 12/

I am so scared driving back to WV on Thursday. Fear heightens when I walk in his room. Grandpa is sick. Can’t speak. Rigoring. Trouble breathing (and DNI). I start crying silent tears. My mom hugs me and looks at my dad: “This is worse than we thought if Erin’s crying.” 13/

Mom: “Why are they changing his medicine?”

“Because the one he’s on doesn’t work”

Mom: “But they told us they started really broadly”

We did. 14/

Rapid diagnostics (&micro lab collab) are essential. Grandpa suffered days longer than needed (w/all the collateral damage of that like ↑ LOS) bc of delayed results. We need to be better in our health care systems & get all patients/providers access to these technologies 15/

But some good news: I call the micro lab and after discussing turns out they didn’t need to send out for sensis (yay) and hospital found some minocycline (double yay). I have no idea where, but hooray. 16/

Side note: I learned this week that what we think we communicate or explain about medical care and what patients/families/caregivers hear and perceive are two completely different things. But that’s another thread for another day. 17/

I sleep zero minutes on Thursday. As the night progresses I legit debate giving him colistin. Risk factors for carbapenem-resistant organisms (in this case—lack thereof) are seemingly irrelevant when you are watching someone suffer. 18/

I want to give him anything that’s possibly active. But he’s only received 1-2 doses of (likely) active therapy now. Chill Erin. Chill. But what if we’re wrong again? 19/

I am now the provider I spend most of my time educating on judicious antibiotic use. I get it now. I totally get it. This is hard. I have dedicated my life to optimizing antibiotic use and I feel like I have no idea what the best thing to do for my patient is. 20/

Friday finally comes. He is improving.
We get susceptibilities late that afternoon.
Cefepime 8 (worthwhile to note that is considered susceptible but at 2g q8h over 3h infusion my grandpa was still SICK).
Mero 0.5.
Unasyn 2.
21/

This was my second moment of fear (and shame) that’s worth sharing: I legit want him to stay on meropenem. He was dying 12 hours ago. He is barely turning a corner. I know it says susceptible to uasyn….. but he got better on meropenem. 22/

Oh my goodness. There it is. “But the patient got better on [broad spectrum therapy]” SIGH. I hate myself but I also don’t care because my grandpa is better. But I know better. Discuss deescalating to unasyn w/friend. Okay, logical. I can do this. Unasyn it is (q4h). 23/

.@julieszymczak speaks about social determinants of abx rx: relationships btwn clinicians, (mis)perception of problem, risk/fear/emotion. To “do stewardship” we *must* think sociologically & build trust; address data but also things that drive prescribing outside of data. 24/

@JulieSzymczak I really get that now. When stewie teams make recs to optimize abx use (escalation or other) & providers hesitate to change rx, it’s probably bc there’s a lot going on, including fear. we need to build trust while showing data to do the best thing for the patient, together. 25/

@JulieSzymczak I worked at my hospital this weekend too, and so for the past three days I’ve split time between Theradoc alerts for many patients and visiting my grandpa. So I was intimate with both sides of the spectrum. 26/

@JulieSzymczak It is easier to be objective from outside looking in (duh).
Stewards need to keep fighting the good fight: nudging on therapy optimization (drug and DOSE), putting systems in place to ensure prompt action on results and abx administration, assessing durations, etc etc 27/

@JulieSzymczak Because my grandpa may have died if meropenem hadn’t been active therapy.

Antibiotics are freaking amazing—when they work.

And we must protect them so they can keep saving patients lives.

28/

@JulieSzymczak Stewardship is tough, but early, active antibiotic therapy & optimal use absolutely saves lives. We have to continue to work together to marry data and clinical gestalt in order to take calculated risks, overcome fear, and practice medicine to the best of our abilities. 29/

@JulieSzymczak As for my grandpa—slow but steady improvement, rocking along on unasyn, prayers still appreciated 😊 /end