In this article surgeon and co-investigator of the STOP-IT Trial Dr. Heather Evans is interviewed about incorporating antimicrobial stewardship into surgical care.
Interview with: Heather Evans, M.D., M.S.
Interview by: Krutika Mediwala, Pharm.D., BCPS & Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
[Last updated: 7 January 2019]
Antimicrobial stewardship has long been identified as a “team sport” with the best outcomes occurring when physicians, pharmacists, nurses, microbiologists, administrators, information technologists, and stakeholders work together towards a common goal. In developing and growing multidisciplinary teams, understanding the needs, interests, and skillsets of those involved is critical.
Surgeons are amongst the most important physician groups to engage in antimicrobial stewardship. Not only do they oversee antibiotic prescriptions for surgical prophylaxis on a daily basis, but they also manage active infections on the wards and in surgical intensive care units. Additionally surgeons serve as prominent institutional role models for medical staff and trainees.
There have been calls to action for surgeons to engage in antimicrobial stewardship (as published by Sartelli et al. here for example in 2016) and there is no doubt that stewardship in surgery has unique challenges (as noted by Tarchini et al. here in 2017). Even just two months ago in November 2018 Charani et al. reported on differences in antibiotic decision making between acute medical teams and acute surgical teams (available here), concluding that junior surgical staff play an integral role in this realm.
With numerous opportunities for antimicrobial stewardship in the care of surgical patients, it is clear that surgical teams should be engaged in patient-care conversations. Another important factor is examining the data on hot topics within this field. To target both of these avenues, we interviewed surgeon Dr. Heather Evans on her passion for antimicrobial stewardship and also took the opportunity to inquire about her perspective on the Study to Optimize Peritoneal Infection Therapy (STOP-IT) Trial for which she served as a co-investigator.
The goal of the STOP-IT trial was to investigate strategies for managing complicated intra-abdominal infection and determine if a fixed 4-day course of antibiotics after source control would reduce antibiotic exposure without worsening outcomes, as compared to a course of antibiotics through 2 days after physiological improvement (with defined criteria). The study found no difference between the experimental and control groups (p=0.92, 95% confidence interval -7.0 to 8.0). The median duration of therapy was twice that of the experimental group in the control group and no differences in the primary or secondary outcomes were detected. The study was published in the New England Journal of Medicine and has been an important asset to antimicrobial stewards seeking to reduce inappropriate antibiotic exposure. The full study can be found here for more specifics:
In this article we provide an interview with surgeon, researcher, and antimicrobial stewardship leader Dr. Heather Evans. The purpose of the interview is to gain further insights into the STOP-IT Trial and antimicrobial stewardship in surgery on the whole.
1. How did you find you passion for surgery? Could you briefly describe your path?
I went to medical school thinking I would become an obstetrician. This was back in the late 90’s, and a remarkable chief resident on my third year surgery clerkship changed my path. She stood about 5’11” and went toe to toe with all the men in the operating room. But what really surprised me about her, and challenged my preconception of surgeons, was that she warmly introduced herself to every one of her patients, sat on their bedside and looked in their eyes when she talked to them. And she listened. I did not realize that surgeons actually spent time with the people they operated on, and it hooked me.
My first month of my general surgery residency at the University of Virginia, I had an opportunity to work with Dr. Rob Sawyer, who would become my most important mentor, both as a researcher and an academic surgeon. His enthusiasm for caring for the sickest patients, as well as for data and discovery drew me into a world of clinical outcomes research focusing on surgical infections. I would go on to spend three years doing clinical research and to earn a Masters in Health Evaluation Science in the middle of my residency, so that I could have more tools to understand the data we were collecting. I was always as interested in collecting data on the process of care as the eventual outcome, however, and I think that is how my current line of investigation, building and implementing tools to bring the patient into collecting and monitoring their own data really came about.
2. What were some influences for you to take on the role of “antimicrobial steward” in the surgical world?
When I was just a second year surgery resident, I had the opportunity to present an abstract on intra-abdominal infection at the Surgical Infection Society. The focus of the study was the risk of mortality in patients who developed tertiary peritonitis (i.e., intra-abdominal infection that persisted after an attempt at source control in the operating room or recurred after source control was achieved). It was pretty clear that these patients had prolonged broad spectrum antimicrobial exposures prior to the development of these infections and it was the first time that I truly recognized the unintended impact that antibiotics had on surgical patients.
Dr. Sawyer kept a comprehensive database of all the surgical patients who had infections on admission or developed healthcare associated infections during their hospitalization, so we were able to monitor the effects of antibiotic treatment durations and choices on our patients over time. We were among the first groups to study antibiotic rotation by class in a closed ICU (i.e., antimicrobial cycling) and demonstrated that withdrawal of a certain class of antibiotics was associated with decreased resistance to that class over time, to the point where that class of antibiotics became effective again as per the antibiogram of the unit. The three years I spent in Dr. Sawyer’s lab were absolutely formative – through his sponsorship in the Surgical Infection Society, I was exposed to a group of highly motivated and incredibly smart surgeon scientists. I grew to understand that surgeons are high utilizers of broad spectrum antibiotics, and it is our responsibility to not only understand their power, but also to carefully limit their use as possible.
3. Can you describe the culmination of the STOP-IT trial? What was some of the feedback that you received?
There was almost a direct line from the antibiotic rotation work and the conception of the STOP-IT trial. The membership of the Surgical Infection Society recognized that more is not necessarily better, but there was no consensus on what the appropriate duration of antibiotics for intra-abdominal infection should be, some basing our decisions on clinical response (e.g., stop the antibiotics when the leukocytosis resolved) and others choosing empiric courses based on football scores (e.g., 7, 14, 21 days).
It had been my experience, both as a trainee and then as a faculty member at the University of Washington, that our infectious disease consultants would often extend courses of antibiotics beyond 14 days. We were all looking for guidance without evidence, and there truly was equipoise, so thankfully, the trial was funded and executed. There was some concern that the trial was stopped early because we failed to show improved outcomes over conventional duration of therapy, and that the study was not designed as a non-inferiority trial from the outset. However, the discovery that there was no detrimental effect to limiting antibiotics to 4 days after source control was important, and when the site investigators pushed their individual institutions to change practice immediately, we got very little pushback.
4. What are some stewardship-specific interventions that you practice on your service?
You might ask my partners how they feel about me, because I am most definitely the antibiotic police in our division!
I think the most important thing that I do when I round in the ICU is to ask on every single patient receiving antimicrobials the following questions:
1) Are these the right antibiotics for this patient?
2) Is there a designated end date for these antibiotics?
If the answer to either of these question is “no,” then we have a decision to make right then and there to change or stop the therapy.
5. What are some “Take Action Now” interventions that surgeons, in conjunction with infectious diseases and antimicrobial stewardship participate in? How do you motivate and engage your colleagues?
Well, I volunteered to be on the infection control committee because I think surgical representation in these initiatives is so important. I recognize that not all surgeons have an interest in surgical infections like I do, but all surgeons should be aware of the guidelines from the CDC on preventing surgical site infection, for example. There are some newer recommendations based in evidence that challenge dogma, and change is hard. I’m happy to sit at the table with anyone and hear their concerns, because at the end of the day, we all want to preserve effective antibiotic therapies. Not to be too pessimistic, but without stewardship, we will head even faster into the post-antibiotic era.
6. If you could have 3 wishes to optimize antibiotics in patient care, what would they be?
1) Build multidisciplinary consensus across procedural specialties and infectious disease to:
a) Stop unnecessary antibiotic prophylaxis
b) Evaluate antibiotic usage every day and strive for less is more
7. Communication is an important aspect of antimicrobial stewardship. How can we open up avenues between our stewardship and surgical colleagues?
Invite surgeons to the table. Demonstrate the impact of our antimicrobial choices on our patients by showing us selection, duration, and healthcare associated infection data. We need to build trust so that surgeons do not perceive that stewardship is punitive or dangerous. All of us are responsible.
We would like to express our utmost gratitude to Dr. Evans for taking the time to share her insights and experiences.
ABOUT THE INTERVIEWEE
Dr. Heather Evans is a general surgeon who specializes in trauma and critical care. She joined the MUSC Department of Surgery in September 2018 as Professor in the division of General and Acute Care Surgery, and Vice Chair of Clinical Research and Applied Informatics. Prior to joining MUSC, Dr. Evans served the University of Washington (UW) as Associate Professor of Surgery and was primarily appointed at Harborview Medical Center where she was Director of Surgical Infectious Disease and a member of the Infection Control Committee. In the last 5 years, Dr. Evans assembled a multidisciplinary research team with investigators in Biomedical Health Informatics and the School of Nursing, leveraging mobile health (mHealth) solutions to improve the early diagnosis and treatment of surgical site infections (www.mpowercare.org). She is currently co-principal investigator on a CDC-funded health technology assessment of the current use of mHealth and patient generated health data to detect and monitor post-operative wound infections (https://assisthta.wixsite.com/project).
Dr. Evans earned her medical degree from the University of Rochester and completed her general surgery residency at the University of Virginia. She attended UW to finish her training in surgical critical care and trauma at Harborview Medical Center where she joined the faculty in 2008. She is a fellow of the American College of Surgeons and is board certified in general surgery, with additional qualifications in surgical critical care. She is also a fellow of the American Association of the Surgery of Trauma and chairs the program committee as Recorder for the Surgical Infection Society.
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