Patrick Bafuma is back for the second part of his EM ID interview with Dr. Valerie Vaughn. She is internal medicine trained and a hospitalist with a special interest in infectious disease. Go back to Podcast #182 to hear her discussion with nudges as it comes back to play in this post.
As with the last EM ID post, we are only going to hit some of the highlights here, so make sure to check out the rest in the podcast.
How does prolonged use of antibiotics cause problems? Dr. Vaughn recently published a study regarding the excess antibiotic treatment duration and how it negatively impacted patients due to increasing adverse events. The study, done through the Michigan Hospital Medicine Safety Consortium, was able to obtain data of over 6000 patients from 17 centers. They found that 2/3 of patients received an excessive duration of antibiotics outside of guidelines. Her study found that each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Treatment was expected to last 5 days and potentially longer if clinically indicated following ATS/IDSA guidelines. Did the prolonged treatment help reduce adverse outcomes? In Dr. Vaughn's study, excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Can these concepts be applied to other conditions? Dr. Vaughn indicates there have been studies on skin and soft tissue infections as well as urinary tract infections, but the latter can be harder to study due to subjective issues such as distinguishing cystitis from pyelonephritis. How do we fix this issue? The key is education and recognition. Going back to the previous podcast, nudges could be one way to do this easily. At one of the lower performing hospitals, Dr. Vaughn's team changed the default length of antibiotics to a shorter period. This resulted in immediate decrease of antibiotic prescription duration, but the prescriber still had the option to extend the antibiotic length to what was previously the default. This was a nudge and it did not remove the option, but simply changed the default. We could help by doing the same or something similar in our own institutions. There are many more examples but listen to the podcast to find them and other pearls. Also, make sure to check out a project that Dr. Vaughn has been helping, the Michigan Hospital Medicine Safety Consortium. There is a lot of great information there and it is worth checking out. Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere. 
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