All Together Now Part 2: The Role of Clinical Education in The Stewardship Movement

May 20, 2019

Education is a key part of any stewardship intervention, and the CDC lists it as one of the 7 core elements of hospital antimicrobial stewardship. Clinical education is relatively well supported in fields like nursing and medicine. If you work in a medical or health science field, you likely participate in continuing education activities throughout the year, or maybe you attend professional conferences. However, advances in technology and changes in the new generation of clinician’s learning styles, needs and experiences require novel forms of education. While traditional learning styles are still effective and supported by the greater medical community, alternative methods should be considered when implementing a stewardship team. Although efforts have been made, it is clear that antimicrobial resistance continues to stem from poor behavioral practices. Modern medicine is more complex than ever, but clinical education has not been able to keep up with these changes. In order to help clinicians make the best prescribing choices for their patients, multi-professional, global and modern techniques that match competencies and population needs are imperative.

Education Provided by the Clinical Microbiology Laboratory

Few people understand pathogens better than a clinical microbiologist. Sadly, the laboratory is often a “black hole” to those that don’t work within it. Very few members of the clinical team understand the processes that are occurring in the lab and as a result the lab-clinician relationship isn’t usually a strong one. I was involved in several lab-based education programs for years, and observed firsthand how lab education can benefit communication between clinical microbiologists and the healthcare provider team. What began as a once-a-month course for infectious disease fellows eventually became a course offered several times a month to any interested provider. Once the door was opened for providers of all kinds (nurses, physician assistants, surgeons, pharmacists, infectious disease doctors, hospitalists), we could barely keep up with the demand.

The microbiology course was offered in the laboratory, and providers attended 2 mornings back to back to fully complete the curriculum. The first day consisted of a clinical microbiology overview and day 2 was completely hands-on, allowing the providers to work through cases as a microbiologist would do in the laboratory. Each case was supplemented with an explanation of a diagnostic tool. For example, when working through the case of the child with a UTI, the providers would perform spot-testing on the organism growing on the media, evaluate a Gram stain of the organism, and finish with a lesson on automated susceptibility testing (complete with a live demo on how organisms were tested on these systems). Providers were taught how to interpret microbiology terminology that could directly impact clinical decisions, like “lancet-shaped cocci in pairs” in a Gram stain suggesting strongly that Streptococcus pneumoniae was suspected.

Course attendees were also given a tour of the laboratory and an overview of pertinent instrumentation, which included discussions about turnaround times, when appropriate indications for antimicrobial susceptibility testing, and the interpretation of PCR results. Providers were generally unaware of the processes performed daily in the laboratory, and their clinical laboratory education had only come from pathologists or other physicians. As knowledge of the program spread throughout the hospital, more clinicians signed up to participate. One of the most consistent pieces of feedback we received was that although this material was briefly taught in medical school (or other forms of medical training), it had not been revisited since. This was especially true for physicians who were not completing an infectious disease fellowship.

Infectious disease affects nearly every medical specialty, and many providers felt the need to be further educated on diagnostics, microbiology and susceptibility testing. To help those unable to attend the course in person, I created a clinical microbiology website. This website contained case studies, pages of information on organisms complete with corresponding images, a discussion board and an online version of the laboratory course.

My experience illustrates not only do clinicians need continuing microbiology education, they seek it out when available, and further suggests in-lab workshops may present a teaching opportunity for their clinical microbiologist colleagues. Clinical microbiologists can explain how diagnostics work, review best testing practices, and discuss how to interpret results and what antimicrobial susceptibility results mean. For these reasons, they are essential to the success of the antimicrobial stewardship movement. While lab results and antibiograms are key for stewardship, I argue that clinical microbiologists are able to contribute so much more. Lab education can be offered in a variety of (affordable) ways including in-person courses offered in the laboratory throughout the year, real-time case studies that can be shared with staff within the hospital, and short lab-based lectures that are focused on a stewardship topic of interest. Additionally, microbiologists can provide preanalytic guidance, which ensures that the right test is being ordered and the right specimen is being collected at the right time. Through these practices, lab staff can serve as a source of continuous and active education, which has been shown to be effective in changing provider prescribing practices.

Screenshot of book text on dynamic education.
Figure 1. A passage from Barlam et al. emphasizing the importance of dynamic education in AST.

With microbiology laboratories turning to full automation, lab scientists are struggling to find their place in patient sample analysis. Allowing clinical microbiologists to assume more of an interpretive and educational role utilizes their unique knowledge base and could improve patient care.

Screenshot of an information table showing education activities.
Fig 2. Types of education that can be implemented with a stewardship program and associated efficacy

Education-based Stewardship Interventions

What types of person-to-person contact can clinical microbiologists use for teaching? Figure 2 shows an example of the variability within teaching methods and how efficacious these various educational interventions are. There are many options, and here I'll discuss 3 important ways: rounding, social media, and digital technologies.

Rounding Increases Antibiotic Stewardship Efforts and Education

Microbiology laboratories should regularly round with clinicians . This allows the microbiology team to discuss relevant culture results and stewardship concerns with the clinical team. Attendance by the infection control team at clinical rounds is also ideal, as they are critical members of an antimicrobial stewardship team. Interdisciplinary rounding is effective and has a high rate of acceptance among both providers and microbiologists.

Rounding is a wonderful educational process for everyone, and I have seen amazing things develop from it in our own team practice. I was present at rounds when both an Enterovirus D68 and Bacillus cereus outbreak were discovered using information presented by microbiologists, and saw effective solutions come from bringing problems to the clinical team’s attention that only the laboratory staff could have detected. Communication in rounds gets everyone on the same page! It works!

Three clinical microbiologists in discussion.
Figure 3. Clinical microbiologists and healthcare professionals rounding together provides opportunity to share knowledge.

Social Media Is an Education Method for Antimicrobial Stewardship

Twitter has become an amazing resource for research and the sharing of very valuable opinions. Science Twitter is currently one of the most effective platforms you can use to disseminate important information to many diverse audiences. Articles shared in twitter journal clubs are much more widely read than those shared in institutional journal clubs, allowing for broader dissemination of the research findings. The ability to spread information on Twitter has inspired many institutions, including the World Health Organization, Centers for Disease Control and Prevention, and universities (like Duke University, shown here) to use the medium to conduct public health awareness campaigns.

Promotion poster of a campaign to stop 'Superbugs.'
Figure 4. Example of an AST social media campaign by Duke Center for Antimicrobial Stewardship and Infection Prevention
Source: Duke Center for Antimicrobial Stewardship and Infection Prevention.

For those who prefer longer form communications, creating websites or blogs that contain useful information for those in medicine is a great way to share information at a minimal cost to the writer and the user. Creating online material is also a great way to collaborate with other experts in a field of interest without having to do so in person.

Digital Technology as an Education Method for Antibiotic Stewardship

Although some groups are actively pursuing the development of digital technology to support stewardship education programs, this is an area in need of more research and development. These tools might include applications that can be accessed by a cell phone, tablet or computer that provide information on how to appropriately dose and prescribe antimicrobials based on the infection at hand. Other tools may offer easy-to-understand infectious disease education in local languages, or provide infection prevention reminders in facilities where they are most needed. Empowering community leaders with digital tools that could help them make appropriate antibiotic choices or help them educate community members about medication adherence and infection prevention could prove to be highly impactful.

Check out some examples of digital technology currently available:

Antibiotic Stewardship Education: The Take-Home Message

If we plan to change practices surrounding antibiotic use, we need creative ways to educate and empower healthcare providers to make better, more informed choices. Enlisting the help of the education techniques discussed in this article will ensure a broadly educated workforce who will collaborate to not only extend the useful life of antimicrobials, but find new ways to prevent the spread of deadly resistant infections and encourage others to evaluate and change their behavior around antimicrobial prescription and use.

Be sure to check out my previous article discussing the need for cohesiveness in antimicrobial stewardship!

The above represents the views of the author and does not necessarily reflect the opinion of the American Society for Microbiology.

Author: Andrea Prinzi, Ph.D., MPH, SM(ASCP)

Andrea Prinzi, Ph.D., MPH, SM(ASCP)
Andrea Prinzi, Ph.D., MPH, SM(ASCP) is a field medical director of U.S. medical affairs and works to bridge the gap between clinical diagnostics and clinical practice.