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Nate Shively Profile picture
@NateShivelyMD
Oct 21, 2022 • 8 tweets • 6 min read • Read on X
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What's better for reducing unnecessary treatment of asymptomatic bacteriuria? Diagnostic stewardship or antibiotic stewardship?

@ValerieVaughnMD presenting the @SHEA_Epi featured oral abstract.

#IDWeek2022 ImageImage
Pathway to overuse and opportunities to intervene.

#IDWeek2022 Image
Diagnostic stewardship metric was ASB (treated or not) / +UCx

#IDWeek2022 ImageImage
Antibiotic stewardship metric was ASB treated with abx / ASB and ASB treatment duration.

#IDWeek2022 ImageImageImage
Treatment of ASB went down over time.

#IDWeek2022 Image
Diagnostic stewardship metric went down over time.

#IDWeek2022 Image
Antibiotic stewardship metric did not for the collective of hospitals, but did for some hospitals.

I'd be curious about how stewardship programs at these hospitals differed and whether that may have had a role.

#IDWeek2022 Image
Conclusion

Diagnostic stewardship > antibiotic stewardship for ASB.

There's likely value in work at any stage along the pathway above, but appears preventing the UCx from happening in the first place is the best bang for your buck.

Great work, @ValerieVaughnMD!

#IDWeek2022 ImageImageImage

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More from @NateShivelyMD

Nate Shively Profile picture
Apr 20
Getting my own talk from yesterday up late.

Also presented at the Big Beasts session on Community-Acquired Pneumonia.

Focused at stewardship folks but something in here for everyone 👇

#SHEASpring2024

#IDTwitter
#MedTwitter

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First up, quick definition:
➡️ Since HCAP is now dead, CAP is basically all pneumonia acquired outside of a hospital.

Lots of stuff can cause CAP, but viruses cause a LOT. Any virus that can cause an upper respiratory infection can also cause pneumonia.

#SHEASpring2024

2/


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Check out this CDC study: when a pathogen was found, #1 cause?

Rhinovirus.

Flu was #2.

Strep pneumo is #3, then 4 more viruses before you hit another bacteria.

(This study is well pre-COVID, but rest assured it would be well represented now).

#SHEASpring2024

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Read 23 tweets
Nate Shively Profile picture
Apr 19
Next up is Dr. Will Allegria to talk about stewardship in Immunocompromised patients.

This is a complicated patient population.

#SHEASpring2024

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Many challenges in this patient population, with limited guidelines and data.

Note the specialists (hematology, oncology, transplant) unique to this setting that should be part of the stewardship team. Definitely include transplant ID docs when you have them

#SHEASpring2024

2/

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Limited data, but does exist.

Covering ASB in renal transplant patients.

Don't treat it! 4 RCTs done, two showed harm.

2021 trial highlighted below, more resistance.

#SHEASpring2024

3/


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Read 7 tweets
Nate Shively Profile picture
Apr 18
Next up is the Dogmas of stewardship!

Bookmark this thread folks, some great stuff below.

First up is Dr. Jim Lewis.

#SHEASpring2024

1/

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First up is busting the "cidal vs static" myth. Jim says he is "quoting Noah to Noah" with @IDwithNWD standing by for the next talk, and an author on this excellent paper with @BradSpellberg.

56 Trials!

#SHEASpring2024

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What about MRSA pneumonia?

Linezolid and Vancomycin on equal footing.

The "cidal" definition is completely arbitrary, lab based, and irrelevant clinically.

#SHEASpring2024

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Read 20 tweets
Nate Shively Profile picture
Apr 16
To get my thumbs warmed up for #SHEASpring2024, figured I'd share this talk I forgot to share last month.

Was asked to talk about antibiotic prophylaxis in primary care.

Here's what I came up with:

🧵

#IDTwitter
#MedTwitter

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First, one that comes up a lot - should we give antibiotic ppx to prevent recurrent UTIs?

Will first cover older adults - important here: is it truly recurrent UTI?

A lot gets called "UTI" that isn't.

2/
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Here's the evidence.

I like the study here from @BRxAD.

Older patients on antibiotic prophylaxis have more side effects, more C diff, more resistance, and go to the hospital MORE than patients on no ppx.

3/

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Read 14 tweets
Nate Shively Profile picture
Mar 24, 2023
Just got done presenting at the 31st Annual Clinical Update in Geriatric Medicine, put on by @AHNtoday and @UPMC. Awesome attendees, as usual!

Was asked to talk about "Controversies in Antimicrobial Therapy"

Figured would share here.

#IDTwitter #MedTwitter

🧵

1/
With a Geriatric audience, had to take the opportunity to focus first on the urine.

But also get into SSTI, Bactrim for Group A strep, if you need IV antibiotics for Lyme, dental prophylaxis for prosthetic joints, and duration of therapy.

First up - does +UA/UCx=UTI?

2/
Emphatic NO on that one.

Need SYMPTOMS to diagnose a UTI.

I tell patients they need to tell us, we can't tell them.

Positive UCx without symptoms = asymptomatic bacteriuria.

3/
Read 38 tweets
Nate Shively Profile picture
Oct 22, 2022
What drives physicians refusing ASP recommendations?

We looked into it.

Just got done presenting our #IDWeek2022 oral abstract.
#IDTwitter

🧵

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First, there are a bunch of ways to do TeleASP, but especially the more "intense" models have shown success and can be as good as on-site programs.

Our prior work: academic.oup.com/cid/article/71…

SCORE trial from @E_Stenehjem et al.: academic.oup.com/cid/article/67…

#IDWeek2022

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What do we know already about what influences rec acceptance?

Summary of prior work, including great work from @BRxAD - surgeons tend to be less accepting, and recs that reduce antibiotic exposure refused more.

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Read 16 tweets

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