85: WAAW - Being a Stewie

He works with the Duke Center for Antimicrobial Stewardship and Infection Prevention to further their mission of improving patient safety and enhancing quality of care. His research interests include implementation of anti-microbial stewardship interventions and leveraging interprofessional teams. He also has additional interest as a medical educator with a passion for curriculum development and effective assessment of educational interventions.

His responsibilities include prospective audit and feedback, policy and protocol development, implementation of stewardship initiatives, antimicrobial use tracking and reporting, and education of frontline staff on ID and anti-microbial stewardship related topics. He also precepts pharmacy residents on anti-microbial stewardship learning experiences.

Lastly, he has interest in digital medical education and is co-director of the microbiology block for the first year medical students.

Uh, it has pecans on top, not a fan of the marshmallows that some people do, uh, for that dish. So that's gonna be my pick.

So really busy time of year, but one I really enjoy.

Uh, and this episode is brought to you in collaboration with the Society of Hospital Epidemiology Antimicrobial Stewardship Committee, for which Dr. Ryder is a member.

So just to start, Jonathan, why do we need stewardship teams?

So antimicrobial resistance is a, is a growing problem of international scale, and a 2014 report estimated that if antimicrobial resistance continues on its current trajectory, that by 2050, about 10 million people would die each year as a result of antimicrobial resistance, with a global cost up to a hundred trillion US dollars. And so, while, uh, antimicrobial resistance is, is a growing issue, we also have a pretty big issue with appropriate antibiotic prescribing.

And so when you look at common reasons for antimicrobial, uh, uh, prescriptions, the, the data show that it, it was inappropriate in about 80% of patients that have community acquired pneumonia, about three quarters that have urinary tract infections, half of patients who are prescribed fluoroquinolones and about a quarter of patients who are receiving intravenous vancomycin, uh, antibiotics.

And, and the reasons why we see inappropriate antibiotics are usually due to inappropriately uh, long therapy in patients with, uh, community acquired pneumonia and in urinary tract infection, about half of patients, um, don't have any signs or symptoms of infection.

And so ultimately, antimicrobial stewardship programs are in place because as infectious disease doctors, we can't, uh, be consultants on every single patient on antibiotics, and so we need to have larger systems-based interventions that improve our utilization of antimicrobials.

And, and similarly, you have to track what you do, uh, in order to make changes and to make improvements and having a dedicated stewardship team and program really helps with tracking and reporting and, and building accountability to help drive these improvements. And ultimately, antimicrobial stewardship teams are about improving patient care. And I always want to emphasize this point because sometimes people really see these as more, uh, health system or, more societally driven, uh, programs.

And while those things are certainly true, that there are downstream benefits, uh, to society and the health system, ultimately what we do on the day-to-Day is about optimizing patient care. That we're making sure that each patient receives the right drug, for the right bug, at the right dose, for the right duration, and at the right time. And so I always think that stewardship programs really at the core of them are taking care of our patients.

And so looking at hospital leadership commitment. CMS is very clear that institutional leadership, along with quality improvement must address issues that are identified by the infection prevention and the stewardship committees. Uh, and this open communication between stewardship and hospital leaderships really helps facilitate this.

And this is really important 'cause a lot of the bigger stewardship initiatives can really flounder if you don't have that administrative support and kind of like leadership weight behind them. Hospitals can demonstrate this leadership through funding positions, and so actually having dedicated funding for salary for these positions, having dedicated FTEs for these positions.

Um, and another way that you can show leadership support is just by having some public statements of support that leadership can sign. You can display these across your institution, um, or publish them on websites, um, just to show that that leadership is, committed to supporting antimicrobial stewardship. Talking about the accountability piece, uh, is, is more centered around having a clear leadership structure within the stewardship program.

So typically that's gonna take the form of a physician leader, uh, and a pharmacist as co-leaders. Um, but you can have stewardship programs that have just a single leader. These roles should ideally be clarified, so it's always clear who's running the stewardship program and who's accountable for the metrics and outcomes with the stewardship program.

One often overlooked point, things that we've seen Or not thought about in a lot of surveys, um, is that these leaders should have some sort of education or training or experience in infectious diseases or antimicrobial stewardship, um, as outlined by Joint Commission in CMS. And so this can be your kind of classic post-graduate training with an ID fellowship or ID pharmacy residency, um, or can be through certificate courses plus ongoing continuing education kind of year to year.

Looking at pharmacy expertise really focuses more on the pharmacy co-leader of the stewardship program, and really is another essential element of that. You know, I'm biased as a pharmacist, but I will say that because of the positioning of pharmacists within the healthcare system, kind of our roles, we can be really helpful in stewardship programs because we interface with so many different aspects of the healthcare team.

We also are situated really well to have access to antibiotic use, to help kind of track that over time and help with that reporting piece. Um, already integrated into the Pharmacy and Therapeutics committee, which really helps, uh, with integration with that for leadership and quality. They're also just very familiar with drug specific information like pharmacokinetics and dynamics and all those fun things that go into how we optimize dosing of antibiotics.

So all in all, really helpful to have a pharmacist co-leader, um, in stewardship. The action core element, um, has intervention such as prospective audit and feedback or pre-authorization, which we'll talk about here in a little bit. Um, also facility specific treatment guidelines. They're also a very key action element, and will be required by Joint Commission, uh, as of this year. having at least two of those implemented. So really important from a, a regulatory standpoint as well.

And overall action is probably the broadest and most vague of all of the core elements because there are so many things that you can do. You could have automatic protocols, uh, for renal dosing or IV to PO conversions, kinetics based dosing, antibiotic timeout processes or handshake rounds, automatic stop dates. So this is where you can really fit in a lot of the, the interventions in the day-to-Day. Like big projects in the stewardship programs.

Tracking is vital because of its utility in helping to find opportunities for improvement, for tracking progress of any interventions you've implemented, and helping to build accountability. There are tons of different metrics. We could probably have a whole hour talk on just what metrics you could track but really one of the most basic is antibiotic use.

Uh, and so actually tracking and reporting antibiotic use to NHSN, which is the National Healthcare Safety Network, is a regulatory requirement starting in 2024. Uh, and it serves as a great method of not only tracking your use, but help establish some benchmarking and comparisons to similar hospitals. It's especially helpful to track in relation to any particular initiatives you have going on. So maybe you have, you know, new guidance to help decrease use of broad spectrum hospital agents.

And then you can actually track this over time. And CDC has a ton of great examples on their website of some of these ways to actually track this data. But then you can also encompass other aspects of tracking. So, you know, number or type of audit and feedback patient interventions. And so that's really helpful 'cause it can highlight the impact of your stewardship group.

You know, how many interventions are you having, what's your acceptance rate, um, and then also helping to justify some of those continued funding and additional, uh, positions. You can also track other outcomes like c diff or MDRO infections. And so the list is really long on tracking, but what's really important is that after you track, you actually go to the next core element, which is reporting. So really reporting is your kind of actionable.

Back inside of tracking where you take the data that you've actually, uh, tracked and you've deemed most important, and then you relay that back to your frontline staff. And so that's important because it's gonna increase transparency and buy-in for those providers, especially when you pair that with the reporting and education and ongoing interventions.

It also makes the data more actionable and helps with modifying initiatives that may not be doing so well from the beginning, you look and say, you know, Hey, we implemented this a month ago and we're not seeing really any movement in our use. What can we do better? Can we educate better? Can we communicate this? Um, or maybe you highlight some early successes that you can take back immediately and say, look, we started this last month and we're having, we're seeing a huge impact.

Like keep good job, keep going, and really helps with that kind of morale and buy-in. Overall, the combination of tracking and reporting really helped drive the program forward, uh, and work as a great accountability piece. And then lastly, education. It's really kind of one of the more nebulous topics of core elements because it can take so many different forms, have so many different audiences. Education can involve prescribers or pharmacists, nurses, you can educate patients and family.

And then you could cover a whole host of topics from resistance. You know, the harms of antibiotics, optimal prescribing. Uh, it can really take the form of institutional guidelines or antibiograms, uh, hospital policies in-service presentation handouts. I mean, you name it, and you can educate on it essentially. And so because of that, usually I recommend keeping a log of education, things that you've done, you know.

Who you educated, when you educated, and then what did you actually educate about? Um, so that if you're ever asked by a surveyor, you know, prove to me what education you've done, you can have a list there. They'll say, oh yeah, we went to this session back in July. Um, and then also just to make your lives easier. 'cause there's so much going on, uh, in the day-to-Day of a stewardship program. Try to pair your education with whatever initiative you're really trying to push forward.

So, you know, you're, you're implementing this new initiative that's part of the action core element. Uh, and then you, you're educating providers on that as well. You're reporting back and so you really hit a lot of these core elements all at one time with one initiative.

Now, uh, Jonathan, to pop back to you, I did want to expand a little bit on one thing that Andrew was talking about, and that's 'cause the CDC highlights as a priority intervention, two of the things that stewardship programs do that have the most evidence for efficacy, and that's prospective audit and feedback and pre-authorization. Can you tell us a little bit more about what these tools are and how they work?

And this can take place in many different formats, either by messaging or calling a team, or actually in a face-to-face format, which is known as handshake stewardship in which, uh, the recommendations actually occur in person. And so, in contrast to prospective audit and feedback is pre-authorization, also known sometimes by restriction, and this is really requiring some sort of approval, uh, by the antimicrobial stewardship team in order to use a certain antibiotic.

And this really allows for the antimicrobial stewardship team to give their input whenever a prescriber is interested in using that antibiotic. And really prevent unnecessary initiation of antibiotics as well. And so these two different forms have actually been compared, uh, directly and generally prospective audit and feedback has been shown to be more effective. However, there's really a use for both of these in stewardship programs depending on some of the different situations that pop up.

One pro when you're running a program is that prospective audit and feedback is, is primarily during, uh, daytime hours, actually almost exclusively. Uh, so not a lot of phone calls in the middle of the night. The other part of this is since you're providing education, you may actually have kind of downstream impacts on multiple components of antibiotic use throughout your hospital system.

And then you're also able to comment to that individual about both the antibiotic that's being used, but also dosing, duration, deescalation. And so . There's multiple components that can be affected. The problems with prospective audit and feedback is it can be kind of resource intensive to actually go through a, a list, for example, every day, uh, spend time in those patient charts, reviewing the indications, the dosing, the durations, et cetera, for each of those individual patients.

Another disadvantage is that the patient already receives usually at least one dose of antibiotics, if not several D doses, or even several days of antibiotics before an intervention occurs. And so some of that upfront antibiotic use, uh, when deemed inappropriate already has occurred. And then ultimately the prescribers can do what they want.

That autonomy does allow, uh, for the prescribers to disagree with the stewardship team, and that may mean that, um, the recommendations do not have a great uptake. So to, to contrast that with pre-authorization, its big advantage is it really allows more control by the stewardship team over antibiotic prescribing es, especially in that upfront empiric and initial antibiotic choice or, or choice to not initiate therapy.

And I think this is especially effective and useful when you're talking about really expensive antibiotics, newer antibiotics that people may be less familiar with. Or, antimicrobials that may be more toxic or for example, antifungal agents or certain antiviral agents. Another situation can be whenever, um, you're facing shortages and there's just a very limited supply that a few wasted doses goes a long way. So the concept pre-authorization are that there's a lot less prescriber autonomy.

There's usually some sort of phone call that has to take place, usually asking for some sort of permission for antibiotics, which can be a, a fairly adversarial interaction at some points in time, and this oftentimes will also involve some sort of overnight call. And this intervention is really limited only to the antibiotics that are on the restricted list. So it doesn't help with antibiotic durations or dosing or non-restricted antibiotics.

And of course, the, the last concern I'll bring up is that this pre-authorization process could result in delays of therapy to patients who are especially critically ill, which, uh, could be a, a downstream consequence. So my experience at my institution is that we largely use prospective audit and feedback for our daily stewardship activities, which does take a, a really dedicated stewardship team that's dedicating time to this. But we review lists of key antibiotics and diagnostic tests.

So for example, all positive blood cultures and rapid molecular diagnostic testing results and antibiotics that are higher risk for, uh, uh, Clostridoides difficile, such as, uh, fluoroquinolones and clindamycin. And then we look at broad spectrum agents like vancomycin, piperacillin-tazobactam, cefepime et cetera. And, and we provide that, uh, feedback to clinicians based on, um, the antibiotics that they've prescribed.

But we also use pre-authorization and restrictions on certain antibiotics, such as those that I mentioned that have higher adverse, uh, event profiles or, that are more expensive. And these are also reviewed as part of the, uh, prospective audit and feedback process where oftentimes clinicians may be able to access a dose overnight, but then the next day, uh, feedback is given to adjust that.

He was seen by cardiothoracic surgery as an outpatient, and he has planned for coronary artery bypass grafting tomorrow. The cardiothoracic surgery team has the practice of collecting a urine culture on all patients as part of their routine preoperative labs. He has not reported any fever, dysuria, frequency, urgency, or other urinary symptoms of note. His allergy history is significant for a listed penicillin allergy.

Patient's mother reportedly told him in childhood around seven, he developed a rash after being given penicillin for a sore throat. He does not believe that it required treatment at that time. He has avoided repeat exposure since then. His labs are fairly unremarkable. His CBC had a white blood cell count of 7.6 with a normal differential, a hemoglobin of 12.7 and platelets of 256. His complete metabolic panel showed normal electrolytes and normal liver transaminases.

A serum glucose of 183 and a serum creatinine of 1.2, which was his baseline. His urinalysis had an unremarkable dipstick and on microscopic analysis showed five white blood cells per high powered field, one red blood cell per high powered field, and 10 squamous epithelial cells per high powered field without any cast visualized. His urine culture grew Enterococcus faecium that was susceptible to ampicillin and resistant to vancomycin.

As mentioned earlier, you are on the antimicrobial stewardship pager. And you get a call for linezolid, a drug that requires pre-authorization at your institution. So Jonathan, to go back to you, you know, as you think about this case, I know that for me, being in the pre-authorization role as a fellow was sometimes awkward. Uh, unlike a consult where you're being asked for help by the team, you're kind of inserting yourself and sometimes perceived as the antibiotic police.

So how do you frame your role, or what other techniques do you use when having to give this unsolicited advice?

I print this off and I hang it on my wall and, anytime I am, uh, facing a case or working with a trainee in stewardship, I always kind of review this and take a deep breath and really make sure I'm in the right place to kind of have this, um, conversation because sometimes there is a little bit of negotiation that happens through this process. So just gonna go through this mnemonic briefly and use this case as an example. But the first part of, uh, NARROWS is n and that's to name the issue.

And so, you know, this is the patient, whoever that we're talking about. And, um, you're, you're calling asking about linezolid for, uh, treating a urinary tract infection is basically what you're calling me. And so I, I then go to a, which is to ask, what, what is the reason why, why do you want to use linezolid? What about this patient's uh, urinalysis and urine culture make you concerned? Um, and then r is to reflect their emotion. And so.

I, I always try to empathize with the team and say, yeah, this patient's really sick, or in this situation, yeah, this patient's going for a big surgery tomorrow. I understand that we want to make sure this patient is optimized for this, uh, surgical intervention and they don't develop any sort of postoperative complications, uh, as a result. so the next r in narrows is to relate with personal experience.

And so saying something like . Yeah, I remember, um, whenever I, uh, worked in the ICU and I was worried about a patient, um, uh, something to really kind of show that you care about that individual patient, you know, whatever your personal story or, or memory is, that's relevant for that particular situation. The O in narrows is to orient to the suggested management. So, um, I would say something like, in this case that you could use linezolid.

It's a, it's, it actually is a really good option for treating someone with a true, uh, VRE, uh, urinary tract infection. However, in this situation, it, it doesn't seem like there's a lot of inflammation. I. Uh, on the urine culture, and, and the patient doesn't sound like they have any symptoms, and so this seems more like asymptomatic bacteruria. And so w then is working together on a plan.

And so I then make a suggestion like, you know, do you feel . Comfortable, like, uh, discontinuing antibiotic therapy in this case and, and monitoring for, uh, the development of further urinary symptoms. And this is where sometimes there's a little negotiation that takes place. Maybe they're concerned for another reason. Maybe, maybe they tell me that they actually do have urinary symptoms and that, um, they're actually symptomatic.

And that maybe what I understand from what they first told me or what I read in the chart actually isn't the case. And then s is to set follow up. And so, um, it, it can always be reassuring to say, Hey, call me back if, if the patient develops symptoms, or I'll keep an eye on the chart and wait on the susceptibilities or, the next set of labs or whatever the next marker is to really figure out, you know, how can I help this patient?

We could dive into this penicillin allergy that may or may not be real, and talk about opportunities for de labeling penicillin allergies. Andrew, to jump to you this time, how do you decide on the priority of these interventions? When you have lots of things on the menu in front of you, how do you decide what to focus on?

And so in this case, you know, if you're looking big picture, I think asymptomatic bacteruria really stands out as the greatest opportunity for a targeted initiative because of how often it's treated unnecessarily and how widespread the issue is. I mean, I know where I practice and where I've practiced in the past. You see antibiotics started for asymptomatic bacteruria numerous times every day. It's clearly a driver of antibiotic use.

and so it's also a great example because it can be tackled from numerous angles. So a lot of the things that you mentioned are kind of pieces that we can target for asymptomatic bacteruria. So, you know, first and most importantly, you can roll out education and some targeted messaging to really highlight the lack of benefit and frankly, risk of harm, of giving unnecessary antibiotics. Uh, when you're talking about treating an asymptomatic bacteruria.

Uh, this education and the targeted messaging pairs really nicely with reinforcing these concepts through some patient review, audit and feedback practices, reaching out to providers so you're providing overarching education, and then you're also reaching out on a patient by patient case to kind of discuss this with providers. Uh, it's also a really great chance to include some of this information in local treatment guidance.

Um, so again, circling back that helps with your action core element and with some of those regulatory requirements we mentioned. Then aside from education about just appropriate non-treatment of asymptomatic bacteruria, there's also really a great opportunity for some diagnostic stewardship.

So there's a growing amount of literature highlighting some great strategies to really help leverage the electronic health record to help with appropriate urine culturing, uh, through different algorithms, alerts, order questions. To be sure that, you know, we're steering providers to only order urine cultures when it's appropriate.

Because if you never have the urine culture that grew something, you can never really have that prompt of, oh, I really need to treat that and, and you can prevent the whole cascade from occurring by just not sending the inappropriate, uh, test. Studies have shown that a lot of these practices can have positive impacts on antibiotic use as well as lab and nursing workflow due to decreasing the amount of inappropriate cultures actually being ordered.

And I'd say that this also ties into the case really well because of the patient's routine, preoperative, uh, quote unquote urine culture that kicked off the whole decision tree, uh, in, in this case. So I know surgical teams can often get really nervous about asymptomatic bacteruria, uh, in particular, especially when you're talking about hardware being implanted. and I actually just had an example of this happen in a patient a few weeks ago that I saw. So this, this case really hit home there.

Um, you know, obviously we empathize with providers who see a positive urine culture. You know, they wanna do what's best for the patient. They wanna treat that, um, because especially when they're gonna be placed in hardware, they don't wanna put patients at increased risk of post-op infections. Um, there was a really large study done a few years ago in JAMA surgery that actually found that in patients who are undergoing cardiac, orthopedic, or

vascular surgery, . Giving antibiotics that were active against the urinary bacteria, uh, in those patients with asymptomatic bacteruria had no effect on the incidence of surgical site infection. And then a step further, the study actually found that when surgical site infections did occur, the causative organisms were actually different than what grew in the pre-surgical urine culture.

So really highlighting the practice of widespread pre-surgical urine culturing that should likely be discontinued because there's just not a lot of, uh, additional benefit, um, in the decision making process that it provides. It also highlights a really good opportunity to work collaboratively with surgical leadership, with pre-op teams to educate and optimize some of those screening practices.

and then in general, just wanna put a plug that diagnostic stewardship can really have large impacts across the board, not just in, uh, the surgical patient population. And it's gonna be even more important as more complex and sensitive molecular tests come out. I just heard the other day about a urinary PCR test that is gonna wake me up at night and with nightmares, um, because just all of the, um, potential overuse of antibiotics it may cause.

And so this diagnostic stewardship, uh, is a really important piece.

And so you're talking about increased risk of acute kidney injury and that's could lead to patient worse patient outcomes, increased cost. Uh, and so this patient had a listed allergy of rash 60 years ago, um, that didn't require any intervention or treatment. Um, so he is a really great candidate to receive an agent that has minimal risk of allergy cross reactivity. And so with penicillin allergies, the reaction occurs based on the drug side chain.

So if we pick agents that have a different side chain to penicillin, we can generally give them because of the low risk of cross reactivity. Cefazolin is one of those first line surgical prophylaxis options that has a completely different side chain to penicillin. So it's usually a safe option, uh, in this patients and is in this patient for the case.

Um, the allergy and immunology expert community actually just updated guidelines last year to recommend that even in patients who have a history of anaphylaxis to penicillin, a non cross-reactive cephalosporin like cefazolin can be administered without prior testing. And I also wanna put a plug that another stewardship intervention related to surgical pro prophylaxis is to eliminate prolonged courses postoperatively.

There was a recent SHEA compendium that recommended against extending prophylaxis past closure in the OR, and now there's numerous other guidelines that have come out recommended to really limit surgical prophylaxis to pre and intraoperatively only. Extending prophylaxis after closure really provides no additional benefit in patient outcomes, and so just another great low hanging fruit stewardship intervention that can really help cut back on some inappropriate use.

And so, as an internist myself, uh, who works with medical teams quite a bit, it's really important to kind of have some perspective on how we interact with each other and ourselves, um, as well. But medical teams tend to have kind of a collectivist approach in, in decision making. Everyone wants to work together and want to come to a consensus and an agreed upon plan really as a group. And this is usually quite interdisciplinary. We involve pharmacists and our consultant colleagues.

Um, and this is kind of unique to the, to the medical team. And in contrast to this, surgical teams are often more individualistic where residents are often kind of left making their own decisions as the senior surgeons are in the operating room or in the clinic and are not necessarily on rounds with them when these decisions are being made.

Surgical teams are also less likely to have pharmacists available, and there was really less time, um, spent dedicated to reviewing and stopping antibiotics by surgeons, which often led to these prolonged antibiotic courses. The surgeons were primarily focused on preventing poor surgical outcomes, and so they started, um, antibiotics to try to prevent those things, but then didn't review them later on.

Medical teams, however, really focused more on not disrupting their team dynamics or were disagreeing with other consultants. And so, um, medical teams really struggled when it came to antibiotics when there was a transition from the emergency department to the ward, as there was kind of a hesitancy to question the decision that was already made in the emergency department to start antibiotics, um, which led to antibiotics being continued for longer periods of time.

And so the key when communicating with colleagues as a steward is to really know who are you dealing with? What are the, what are the cultural factors at your institution, on that team, um, what are their methods of communication and what is important to them? Um, and so a lot of the keys when interacting with surgical colleagues is to focus on the issues that are really important to them. They, they care a lot about their surgical outcomes.

They care a lot about preventing surgical site infections, things like length of stay, um, and, and then trying to find ways to communicate with them. Uh, via the methods that work best for them. And sometimes this means, you know, that uh, rather than talking, um, necessarily with the intern that is on the team, uh, on the wards, talk to the attending that might be making the decisions about antibiotics.

Or if they do have a pharmacist that works, uh, closely with their team and that they trust, um, for example, I know our, our transplant team has a pharmacist that does a lot of their antibiotics. Uh, really communicating with that pharmacist might be the most effective way, um, because that pharmacist already knows that team and those dynamics even better than, uh, I do as an individual.

I also say that for anybody who's interested in more information or if they're feeling like they're at a standstill at their site, you know, they just feel like they need kinda a breath of, uh, new life, uh, in their stewardship program and want some inspiration. Look into some of the antimicrobial stewardship certificate programs that we've mentioned throughout this. So I know SIDP, the Society for Infectious Diseases Pharmacist has a great one.

Um, IDSA and SHEA, and I know Making a Difference in ID, you know, a lot. There are numerous programs and certificate classes, courses that can help with that. Um, sometimes it just takes some outside education or perspectives or expertise to really prompt ideas, bring some new direction in life in the clinical stewardship practice. And then lastly, I, I'm gonna get deep and, and say, you know, . As, as a stewardship clinician, give yourself grace.

You're not always gonna have your recommendations accepted. You know, there's gonna be times where you have to compromise or maybe you even lose out on a compromise and you've got situations where what's happening is completely against what you would've liked to have happened and recommended. Um, but at the end of the day, you know, you're still trying to doing your best. And if at the worst, you at least planted a seed for what you think is optimal therapy.

Uh, and so just give yourself some grace.

But, also antimicrobial stewardship has a wealth of opportunities for doing quality improvement. There's a lot of opportunities for scholarship in this regard, and really it's just an amazing community within infectious diseases. As a member and participant of SHEA, it's really been just, uh, incredibly welcoming and really getting to know everyone within this community, has been amazing as a, as a young, uh, faculty member.

and then I'll mention personally, I really love data tracking and analytics. Antimicrobial stewardship really allows me to have a lot of opportunities for this, and there's really scratch that itch. You know, pairing QI processes, uh, with data analytics and tracking to allow you to make changes and then evaluate your impact is just something I find really fulfilling as well.