Antimicrobial resistance and the shift to shorter courses of antibiotics

On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham explore the growing challenge of antimicrobial resistance and how shorter courses of antibiotics are reshaping prescribing practices. The conversation builds on insights from the CMAJ practice article “Five things to know about shorter courses of antibiotics” co-authored by Dr. Maria Ivankovic, an emergency physician at St. Joseph’s Health Centre in Toronto.

Dr. Ivankovic explains why shorter courses of antibiotics are as effective as longer ones for many common infections and how this approach can reduce the risk of antimicrobial resistance and adverse effects for patients. She highlights key conditions with strong evidence for shorter durations and discusses practical strategies for implementing these changes in practice.

Dr. Lynora Saxinger, an infectious diseases specialist and professor of medicine at the University of Alberta, broadens the discussion by examining the current state of antimicrobial resistance in Canada and globally. She explores the drivers of resistance, including unnecessary and inappropriate antibiotic use. Dr. Saxinger introduces the concept of the antibiotic footprint as an analogue to the carbon footprint, encouraging physicians to consider the collective impact of their prescribing decisions.

This episode provides actionable advice for physicians looking to balance patient care with stewardship practices, helping to preserve the effectiveness of antibiotics for future generations.

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Transcript

Dr. Blair Bigham:
I'm Blair Bigham.

Dr. Mojola Omole:
I’m Mojola Omole. This is the CMAJ podcast.

Dr. Blair Bigham:
Jola, today we're taking a look at a practice article in CMAJ, looking at something that has been in the news a lot, but also in the news forever, it seems. And that's antimicrobial resistance. In particular, this article is looking at shifting the way we prescribe.

Dr. Mojola Omole:
So for me, probably since I was in residency, I remember our ICU pharmacist. I don't know if you remember her from McMaster. She— 

Dr. Blair Bigham:
I think I know.

Dr. Mojola Omole:
Do you? Yeah. She was just on a path to make us all do short-course antibiotics, and the minute you write something, she's like, "Do you really need that? Does it really need to be IV? Can you prescribe shorter?" So for me, I've always been a fan of doing short-course antibiotics, and the only time I would do a longer course of antibiotics is if they had quite a lot of intra-abdominal abscesses.

Dr. Blair Bigham:
I was also influenced by Mac to do shorter-course antibiotics. Mine was from a pediatric ID doc who I think I just wanted to be like. I didn't know the evidence for it at the time, but he was always around shorter-course antibiotics and drove some of the evidence that has recently sort of shifted this practice, both in the surgical world and also in the medical world.

Dr. Mojola Omole:
But it doesn't seem as if the shift to short-course antibiotics is uniform across patients, across infections. So this is a perfect time for us to dig into the evidence behind the change. So we're going to be speaking to one of the authors of a CMAJ article looking at short-course antibiotics to prevent antimicrobial resistance.

Dr. Blair Bigham:
Then we're going to take a little bit of a step back and get a status report on the state of antimicrobial resistance in Canada with Dr. Lynora Saxinger. 

Dr. Mojola Omole:
But first we'll speak to Dr. Maria Ivankovic. That's coming right up. Dr. Maria Ivankovic is the lead author of the practice article in the CMAJ entitled “Five things to know about  shorter course of antibiotics.” She's a staff emergency physician at the St. Joseph's Health Center in Toronto, and an assistant professor at the University of Toronto. Maria, thank you so much for joining us today.

Dr. Maria Ivankovic:
It's a pleasure. Hi Blair. Hi Jola.

Dr. Mojola Omole:
Hi. Hello. So when we say shorter-course antibiotics, how long are we meaning?

Dr. Maria Ivankovic:
So for most commonly treated infections, we mean five days. And that might not seem like a huge difference when a lot of the antibiotics you prescribe are for seven-day courses, but every single day matters. So even one or two days shorter makes a big difference.

Dr. Mojola Omole:
Does it matter the degree of infection they have? Let's say I was treating appendicitis with antibiotics versus treating, like, a small diverticular abscess. Does it matter the duration of treatment?

Dr. Maria Ivankovic:
Yeah, so absolutely, there are lots of different studies out there giving us guidance on how long for different conditions. So right now I think there are over 130 RCTs on over 20 different conditions.

Dr. Blair Bigham:
Oh, can you tell us about all of them?

Dr. Maria Ivankovic:
All of them? Okay. This is going to be a long conversation. So definitely, I think we should cover some of the basic ones. But I think one of the top ones, for example, is community-acquired pneumonia. So for the longest time, we've been treating that for seven to 10 to sometimes even 14 days. And I should start by saying that these, what we call longer courses—so the seven- to 10-day courses, let's say—are very arbitrary. They're not actually based on anything. It was quite interesting. I actually came across this JAMA article from the early 1940s when antibiotics were first introduced, and at that time we were only doing two to three days of antibiotics for pneumonia. I think a couple of doses for meningitis. It was very short, and we just started prolonging these courses for no good reason. There was no evidence to suggest—

Dr. Mojola Omole:
I say big pharma.

Dr. Maria Ivankovic:
Yeah, you're probably right. Yeah.

Dr. Mojola Omole:
So why is this change being recommended now?

Dr. Maria Ivankovic:
It's because of antimicrobial resistance. So this is a huge, huge issue. Antimicrobial resistance is one of the biggest global public health threats of our time. It's estimated that by 2050, 40% of infections will be resistant to first-line antimicrobials, and that's pretty scary. So basically, antimicrobial resistance, or AMR for short, will kill more people than cancer, and it's not just the death, morbidity, and mortality, but it's a huge, huge economic hit. So it's thought that our GDP in Canada is going to be reduced by over 300 billion over the next 25 years due to AMR. So it's huge for patient mortality, morbidity, and the economic impact.

Dr. Blair Bigham:
This is the opposite of what I always remember people saying around, "Take your entire course of antibiotics because if you don't, the bugs will get resistant." When did things start to change? When did the evidence flip to shorter courses?

Dr. Maria Ivankovic:
So I'm glad you asked that, because when I was training, we were taught to ensure our patients completed the full course of antibiotics that they started, no matter what—even if it was just one dose of that penicillin they had in their cupboard that they started for a bit of a sore throat. And this was because we thought that shorter courses would promote resistance, that if we didn't kill every last bacteria, they would promote resistance, and we would actually be contributing to antimicrobial resistance. It actually wasn't until recent years that we realized that the opposite is true. So longer courses contribute to increased antimicrobial resistance. So every excess day increases your risk of AMR and increases your adverse effects from the antibiotics. So it's a huge paradigm shift. And this wasn't until recent years when more studies were coming out to show that shorter courses were better and there was a better understanding that longer courses are actually drivers of AMR.

Dr. Mojola Omole:
Was there evidence to support the longer course, or is it just what we do?

Dr. Maria Ivankovic:
It was, you know, what we do, exactly. And it is very much arbitrary. So a lot of people are saying it's the number of days of the week, so seven to 14 days, or the number of fingers on your hand, so five to 10 days, and not based on any good evidence.

Dr. Mojola Omole:
So with shorter courses of antibiotics, why doesn't this select for more resistant bacteria?

Dr. Blair Bigham:
Yeah, I feel like infectious disease doctors, who are universally smarter than me, have said things like, "Oh, that's an AmpC organism," or, "That's a SPICE organism," and that they're able to just become resistant even if they're not originally. Aren't we still concerned that a little bit of an antibiotic can cause trouble?

Dr. Maria Ivankovic:
So this is hard sometimes for people to wrap their head around. So if you just picture a Petri dish with a bunch of bacteria in it, in this Petri dish there's always going to be some naturally resistant bacteria, let's say. Now in the presence of the antibiotics, that naturally resistant bacteria is going to thrive because all the other bacteria are being killed off. And as it replicates, it is further pressured to make new mutations that are even more resistant to the antibiotic in its environment. So the longer you've got that antibiotic working, the increased pressure of selective resistance to favor resistant bacteria. Does that make sense?

Dr. Mojola Omole:
Yeah, it does to me. What types of infections have strong evidence for short courses, and what types have evidence for long courses?

Dr. Maria Ivankovic:
So that's a great question. So for shorter courses, some of the more commonly treated infections we see are community-acquired pneumonia. So five days is as good as seven days. And this is even in children. I think the studies mostly showed children down to six months of age, but a lot of infectious disease experts would say that even for kids two to six months who are immunocompetent with uncomplicated pneumonia would do just fine on a five-day course as well.

COPD—even though most of us are moving away from antibiotics for most cases of COPD—for those that do meet criteria for treatment, five days has been shown to be as good as seven days.

Cystitis is one that we've been treating for longer, for shorter courses, we know that the evidence—for example, trimethoprim-sulfamethoxazole for three days—has been around for quite some time. And nitrofurantoin, five days for cystitis, good evidence for that as well.

More recently, I would say what we call complicated male UTIs, so pyelonephritis and complicated UTIs in men—I say that, quote-unquote because that might be changing—seven days has been shown to be as good as 10 to 14 days. So that's a big practice changer.

And I think another very common infection that we see is cellulitis, and studies are showing that five to six days are as good as seven days. And it's funny, when I say six days, I don't know if you guys have ever written a prescription for six days or would be comfortable doing so.

Dr. Mojola Omole:
I like odd numbers.

Dr. Maria Ivankovic:
Yes, it just feels naturally wrong, but yes, so five to six days. And there are caveats to a lot of these, so it's important to know. For example, cellulitis, the studies didn't include patients who had freshwater infections, patients who had abscesses, for example, and human or animal bites, or neutropenic patients, or periorbital cellulitis. So those are some exceptions that are important to know, but for most standard cellulitis that we see, five to six days is adequate.

Dr. Blair Bigham:
Maria, even if we can keep track of what needs shorter, what needs longer—3, 5, 6, 7, 10—what about patients? I'll give the example of cellulitis. A patient comes back seven days later, and they say, "I've completed my course; my leg still looks funny."

Dr. Mojola Omole:
Yeah, I was about to ask that. Or you don't feel better.

Dr. Blair Bigham:
Someone says, "Oh, this x-ray still looks funny," but there just hasn't been radiographic resolution or the tissue is still inflamed, but we don't think it's infected anymore. How can we help patients understand that a shorter course is in their best interest? I feel like a lot of people just say, "I get that you're trying to protect society and avoid antimicrobial resistance, but it's my leg, it's my health. I want the longer course."

Dr. Maria Ivankovic:
Yeah, that's a great question. You definitely want to get patient buy-in to their treatment. And I have noticed—and I'm curious what your experience is—but I think patients are getting the message that antibiotics aren't always good, and there is this better understanding of the growing resistance.

So I found that when I do have a conversation with patients explaining that we used to think we had to treat for longer, now we're realizing that shorter is just as good and you're going to have less side effects, less risk of these opportunistic infections—whether it's a yeast infection, whether it's a very bad diarrhea. So it's good news all around.

I think there tends to be pretty good buy-in, but you do have to take that time to educate patients, just like you do when they don't need antibiotics for a common cold or a viral pharyngitis.

But I would say, if somebody's come back and the infection has not resolved, then definitely you'll have to consider prolonging the antibiotic. And that's in the guidelines specifically for cellulitis as well. If somebody is not significantly improved by that five-day mark, they actually say you should extend it to 10 days. So something to keep in mind. If the patient is not clinically improving, then absolutely at that time, it does make sense to prolong it. But we shouldn't be doing these unnecessarily long antibiotics routinely on everybody at the outset.

Dr. Mojola Omole:
So this is practice changing for—and it's a culture shift in what we know about antibiotics—do you think that physicians would feel comfortable making these changes?

Dr. Maria Ivankovic:
That's a great point. I think we know that knowledge translation is a very slow process. So a lot of these studies have been out for years now. I think it does. Practice changing is very, very slow.

I think given these shorter courses have made their way into guidelines, a lot more practitioners are prescribing shorter courses. But definitely there are a lot of us that are still routinely prescribing the longer courses. And this was shown in a study that actually came out in recent years in Canada, showing that most doctors are still prescribing seven- to 10-day courses of antibiotics for a lot of the routine infections that would require just five days.

Dr. Blair Bigham:
I want to go back to the start of our conversation when we were talking about taking that full course. What about with the shorter courses? Can people just stop when they feel better and take an ultra-short course, or should they complete that shorter course? Has the guidance changed around "take every last pill"?

Dr. Maria Ivankovic:
That's a really, really good point because there is this mentality that we should be moving towards clinical cure. However, it is hard to let the patient decide if they're cured. So I think for now, the recommendation is still, if you're going to give them a five-day course, you ask them to complete that course, unless there are patients that you feel like you'd have a conversation with and say, look at three days, if you're quite confident, you're feeling much better, you can stop it. But I think for the most part, as clinicians, we probably should be asking them to complete their course and not putting the onus on them to know when they are better.

Dr. Mojola Omole:
I remember I had strep throat last year, and I felt better at five days, so I stopped it.

Dr. Maria Ivankovic:
And you know what? There's just so much controversy around strep throat, something that's been around for so long, it's crazy. So one of the exceptions to shorter-course antibiotics is actually for the treatment of strep pharyngitis. And this is a little bit controversial. So in the Canadian guidelines, the recommendation for both adults and for children is for a full 10-day course, and 10 days has been shown to be better for eradication than five days. But the question is, do we need eradication? Is that actually significant?

Dr. Mojola Omole:
I needed eradication.

Dr. Maria Ivankovic:
You weren't better until that every little last, strep was gone—

Dr. Mojola Omole:
You know what? I felt great at five days. I was like, oh, I feel great. And I was like, I'm just going to stop it. This is all, this 10-day thing is a little too much for me. And then I was good for four days and then I was like, oh my God, I thought I perforated my trachea. I'm dramatic. But that is literally how I think. I called Blair, I was like, oh my God, what is going on? I'm like, did I perforate my trachea?

Dr. Blair Bigham:
Take some Tylenol, get over it.

Dr. Mojola Omole:
No, I was bagging. I had to get a CT to make sure there wasn't an abscess and all this other stuff.

Dr. Maria Ivankovic:
Wow. Okay. So most cases of pharyngitis, I should start by saying, we know is viral. And I think a lot of us over-test and over treat for strep pharyngitis, and in fact, some countries don't even test and treat adults with strep pharyngitis anymore at all. Because the reason we were doing that is to prevent rheumatic fever, which is very rare in developed countries in immunocompetent individuals.

So I think, like, Australia, some countries in Europe, they don't actually test and treat patients for strep routinely. Now in Canada, we are a little bit more conservative. For children, the recommendation definitely is to test and treat. Rheumatic fever is certainly more common in children. In areas of Canada where people don't have as good access to healthcare or they may be on First Nations reserves, for example, a recommendation is definitely to test and treat because they do have a higher rate of rheumatic fever.

But for adults that are, let's say, in urban centers that are immunocompetent, it is a bit of a controversy whether or not we should bother treating them given that the rates of rheumatic fever are so low, and the downside of putting them on antibiotics probably outweighs that tiny, tiny risk.

Now, there is evidence that it can improve your symptoms for, I think it was like 12 to 14 hours. But really, if you manage your symptoms well with some ibuprofen, some Tylenol, some lozenges, some throat coat tea, and maybe a dose of dex, do you really need that antibiotic?

Do you even antibiotic? Okay, you're not alone. You're not alone. And you know what? If you asked a bunch of ID doctors, they would say a hundred percent, this is something that we can easily treat. I am a big advocate of shared decision-making around strep in adults.

So I tell them why we don't need to routinely treat anymore in developed countries if they're a healthy, immunocompetent person. But if they are very adamant, they want the antibiotics, and they're like, "I don't care, doctor, even if it gives me one hour less pain, I want it. I am not worried about the diarrhea or the risk or having to come back to the emerg with an allergic reaction. I want the antibiotic," then okay, I'm okay with that.

But I think it's important to know that we don't have to treat these patients. The other thing is, if we are going to treat, the guidelines say you should only treat if there's culture-proven. So gone are the days where we do the Toronto Throat Score, the Centor Score, and treat on spec for a higher score. Now the recommendation is you only treat once that strep is proven positive. And again, you have to make sure they have a high enough score to even do the swab because a lot of us are just carriers, and we'll always test positive.

Dr. Blair Bigham:
From a broader sense, not just around strep throat, but around the many infections that we see either in family clinics, walk-in clinics, or emergency departments, how do we better communicate this with physicians? Because it's not super amenable to a flashcard or a quick bit of education. What's the best way to help clinicians nail this down?

Dr. Mojola Omole:
Listening to the CMAJ podcast every day?

Dr. Blair Bigham:

I love it.

Dr. Maria Ivankovic:
So that would be number one. Yes.

I actually think that order sets are great. If you have an EMR or if you have Epic or whatever it might be, and you put the default to five days or to three days depending on what the infection is, what the antibiotic is, that will make people have to switch consciously to say, "Oh no, I need seven days for this," or "I need 10 days." So I think those things help.

I think having the guidelines available and accessible to remind people. But I think a lot of it is just CME and teaching our learners and teaching each other. At my hospital, we had rounds on shorter-course antibiotics. A lot of our group is on board. So I think you really have to work on it with your community of practice, whether it's order sets, rounds, or a journal club discussion.

These practice changes are very important to put into practice. It does take time. And again, it's really hard to get into a new habit when you've been prescribing the same antibiotic, let's say for 20 years, to suddenly switch to shorter course.

Dr. Mojola Omole:
For sure. Thank you so much for joining us today.

Dr. Blair Bigham:
Yeah, thank you. That was awesome. 

Dr. Maria Ivankovic:

Thank you. It was a pleasure.

Dr. Mojola Omole:
Dr. Maria Ivankovic is the lead author of the practice article in CMAJ, entitled “Five things to know about shorter courses of antibiotic.”

Okay, let's take a step back and explore the current state of antimicrobial resistance in Canada and just generally around the world, and most importantly, what we as physicians can do to help reduce it.

Dr. Lynora Saxinger is an infectious diseases specialist and associate professor of medicine at the University of Alberta. Thank you so much for joining us today.

Dr. Lynora Saxinger:
Oh, thanks for having me. And actually, I was promoted, so I'm full professor now.

Dr. Mojola Omole:
I am so sorry.

Dr. Lynora Saxinger:
No, that's fine.

Dr. Mojola Omole:
Dr. Lynora Saxinger is an infectious disease specialist and a full professor of medicine at the University of Alberta. We have to celebrate all the wins.

Dr. Lynora Saxinger:
Yeah, we do.

Dr. Mojola Omole:
So what's the broader picture of antimicrobial resistance? Is it accelerating on a linear curve, or is there an exponential curve to it? And is it really bad?

Dr. Lynora Saxinger:
I'll start with the "it's really bad" part. It is really bad. I mean, even just reflecting back on my own time in medicine, when I was in training, an MRSA infection was big news, and I'm not that old. And the things that we see just on a kind of daily—you'll see this in the community basis—are this hugely increasing rate of ESBL urinary tract infections, which come to emerg a lot because they generally need intravenous antibiotic therapy.

And so just the kind of "where the rubber hits the road" part of antimicrobial resistance has clearly changed a lot over the decades. And then there are some areas within antimicrobial resistance where we're really seeing things move along more quickly. So, like resistance in gram-negatives, it's becoming harder and harder—whack-a-mole, trying to find an antibiotic for some of these hospital selected strains.

So it really has changed radically. It is worldwide. And it's interesting because some countries that have kept a tighter lid on antimicrobial use—they've had a more cohesive approach and they're more restrained—do not have the same problems as countries where there's been really unfettered and unregulated antibiotic use, including a lot of places that actually let people buy antibiotics over the counter.

Dr. Mojola Omole:
OK—

Dr. Lynora Saxinger:
And so you can see really significant geographic variation. Like, resistance is going up everywhere, but in some places it's actually really severe.

Dr. Mojola Omole:
So where in the world is it growing most significantly?

Dr. Lynora Saxinger:
I would point to—there's some European Union countries that have pretty unregulated antibiotic use. So Greece and some Eastern European countries. There's actually quite a few placesI think when you start to look a little bit more deeply into places that don't often publish antibiotic resistance rates, when they actually do that work, you can find a lot in Global South countries where there's also unregulated antimicrobial use, but it's just not being tracked the same way. So there's a lot of non-reassuring signals there.

And then, of course, places where we're keeping a bit of a better eye on it, you still tend to see those increasing trends in some major areas of resistance.

Because I do need to differentiate the notion of resistance that we create by giving antibiotics and how we give antibiotics and how we select for those bugs. And then there are also antibiotic-resistant organisms that are just basically carrying the resistance already that we select for when we use antibiotics. And those things are a little bit different. So that's your MRSA, your VRE that are already resistant, and because of all the antibiotic use, they become predominant.

Dr. Mojola Omole:
Okay. So you had mentioned that unfettered use of antibiotics—is that the driving force where you see some areas having more resistance and others less?

Dr. Lynora Saxinger:
When you're looking at changes between places, that's probably the biggest thing. I mean, there also is a phenomenon within hospitals. You might see a strain that becomes more transmissible, and you see outbreaks of a specific kind of resistance.

But across the board, the worst resistance that we see in medicine has generally been selected by what we have done in medicine. And so even in a hospital, if you look at community isolates of bacteria, like your E. coli patterns in the community, show some resistance. But as you kind of move up—if you start looking at hospital-wide selection—you see more resistance.

If you look at a nursing home selection of E. coli in the urine, often hugely you'll see the most resistant isolates just because of the intensity of antibiotic use in those settings. The ICU can be different than the hospital. So it kind of builds—as you select your population and use more antibiotics, you see a change in the pattern of what we get on resistance testing.

Dr. Mojola Omole:
In Canada, do we have the same variability across the country, or is it setting-specific?

Dr. Lynora Saxinger:
I wish that was easier to answer, but there's a Canadian situation with the data that we have, and so we don't have real-time, easily comparative data across Canada.

And I will just say that even though I have access to Albertan data, even if you look at antibiotic use and some resistance patterns, it can vary between health regions and cities. And so there is a fair amount of variability. But I would say that the span of resistance patterns tends to be fairly similar where we can look at it directly across Canada, with the exception of where there are regional trends in how antibiotics are prescribed. If the first-line treatment or the habitual treatment for certain conditions is different between places, we might actually see that reflected in higher resistance to the first-line agents between some areas. So that's an interesting phenomenon.

Dr. Mojola Omole:
So when we're talking about antibiotic resistance and focusing on Canada, is this community settings, or is it in hospital and long-term care settings? Is there a pattern that emerges in those different settings?

Dr. Lynora Saxinger:
Yeah, I think from a practical point of view, what we would see is that across communities, we generally have seen increasing resistance in gram-negative urinary isolates because that's high-volume testing at the community level.

And we've also seen a real shift towards more predominant MRSA in skin and soft tissue infections in the community. And the community strains of MRSA are a little different than the hospital strains.

Dr. Mojola Omole:
I didn't know that.

Dr. Lynora Saxinger:
At least they were initially. Now they've moved into the hospital, so it's not as different. But even, say, five to ten years ago, you would have community MRSA strains that were more likely to cause nasty infections—clinically important infections, purulent infections. So if it was like an ulcer or crusted or had pus, you'd think it was a community MRSA.

And they often are doxycycline- and Septra-susceptible, less often clinda-susceptible. So clinda bumped down our list. And then the hospital strains, for a long time, were dominantly only susceptible to vancomycin. But now it feels like the community strains have supplanted the hospital strains, which is good news, bad news—there's too much MRSA around, but you can often use oral agents for it, which is a big change from our gram-negative resistance, where really we're backing ourselves into this corner of having to use carbapenems more often.

Dr. Mojola Omole:
So beyond the duration of antibiotics that we're prescribing, what are other main drivers of AMR?

Dr. Lynora Saxinger:
So, as you've mentioned, unnecessary or inappropriate or extended antibiotic use is a big driver. Then the other thing is the antibiotic selection, because some—and this is an area where I think the science needs to help us more—there are some antibiotics that do seem to be more talented at selecting for resistance.

So the barrier to the threshold for development of resistance is lower for some antibiotic-bacteria combinations than others. And some antibiotics can actually select for resistance to other classes of antibiotics, which is a bit of a scary phenomenon. So, Cipro can actually tend to promote more widespread gram-negative resistance in some bacteria.

So it is actually more complicated. We have to make sure that we're staying on top of evolving knowledge and making sure that we're providing antibiograms and providing good treatment guidance for people because it is pretty complicated, honestly.

Dr. Mojola Omole:
So I feel like sometimes, as physicians, we are not exactly sure, so we just give antibiotics. Are there strategies or diagnostic tools that can help to better differentiate between bacterial and viral infections?

Dr. Lynora Saxinger:
This is kind of a loaded question. We always try to do this. And then at the actual decision-making point, a lot of the tools that are theoretically useful aren't necessarily always available.

So people using things like CRP, procalcitonin, and clinical decision rules would be common examples of trying to sort out, "Does this patient need an antibiotic?" And at the end of the day, I think point-of-care testing and optimizing that and optimizing turnaround time of diagnostic tests will end up helping us a lot more.

Because as a clinician, when you're facing a patient, you don't necessarily remember all the times where you made the right call and didn't give an antibiotic, but you sure remember the times where you made the wrong call.

Dr. Mojola Omole:
For sure.

Dr. Lynora Saxinger:
And so there's a psychological bias and a certain kind of tension that goes into that decision because the greater good and reducing theoretic risk is kind of hazy when you're looking at someone who doesn't feel well and wants your help. And so there's some real challenge there, I think, for people.

And anything that we can do to support you doing what you think the right thing to do is helpful. And the problem is a lot of these tools are also imperfect, and so they end up adding to clinical judgment, not replacing it. So CRP or procalcitonin can add to your clinical judgment, but they're not perfect. Rapid testing, antigen testing, seems like it would be great, but these tests, especially if they haven't been validated where you're using them, can have problems too.

So I feel like that whole area is a little under-supported and really would be good to expand because it would take away some of the difficulties of the decision in a way that feels more comfortable for the prescriber. Because I know it's tough. I also prescribe antibiotics.

Dr. Mojola Omole:
Sure. Are there any antibiotics that physicians should avoid altogether? Please don't say clinda, and don't say Flagyl or Cipro. As a general surgeon, those are my three faves.

Dr. Lynora Saxinger:
I'm pro-clavulin.

I think that the one thing that's floated to the top as being, "This really isn't first-line treatment for things anymore," is the entire class of quinolones. They were the wonder drug when quinolones came out it was like, "Oh, we don't have to use aminoglycosides anymore. We have this gram-negative drug." It was fantastic, and it was super over-marketed and overused for all sorts of vaguely inappropriate things like skin and soft tissue infections, and then settled into this kind of comfortable place as being an excellent drug for urinary tract infection. To the point where resistance to Cipro in urinary isolates is usually in the 20% range in many places.

Dr. Mojola Omole:
Oh, wow.

Dr. Lynora Saxinger:
Okay, which is where you start to go, "Maybe that's not good empiric treatment anymore."

The other thing about that class of antibiotics is that there are warnings associated with collagen diseases—so both tendon diseases and potentially arterial collagen-related diseases like abdominal aortic aneurysms and things like that—and QT changes, which is a feature that we pay more attention to now than we used to, although I'm not sure if we should, but we do.

So those three things make it a little bit more dodgy. And so I usually reserve quinolones for culture-directed therapy where they're clearly the best choice. So still useful, but not the first empiric choice necessarily.

Dr. Mojola Omole:
I'll continue with my Clavulin.

What is the most effective antimicrobial stewardship practice that Canadian physicians should be adopting, let's say right now in their daily practice? If you could wave a wand and make everyone do what you want them to do.

Dr. Lynora Saxinger:
Oh, you just blew my mind. I'm like, I have a lot of things I'd like to wave my wand at.

Dr. Mojola Omole:

What about antimicrobials?

Dr. Lynora Saxinger:

I think it's important to think about shortening duration. That’s one thing that I think is becoming a lot more doable. So trying to go on the low end of the duration, and with that, just counseling patients that all the inflammation and all the manifestations of infection are not going to be magically gone at the end of the antibiotics—and they don't have to be.

What else would I wave my wand about? In hospitals I think that we should have better support for antibiotic stewardship programs because audit and feedback is a really good way to support people in decision-making. It's meant to be supportive, but you feel better doing it when a group has come by and said, "No, we think you should do this."

And so I think that that's something that's been underutilized in a lot of places as well.

One nice analogy, actually, is the notion of not a carbon footprint, but an antibiotic footprint. So if you just think about, "What is your antibiotic footprint?" A couple of colleagues of mine wrote about this in CMAJ, I think in 2009—what's your antibiotic footprint? Because everyone has one: the prescribers, the users, the dispensers, how you dispose of your antibiotics—all these things actually have an antibiotic footprint.

So thinking about that might be another way to just keep it in the back of your mind as you're going about your daily decision-making. But yeah, it's definitely something that I think needs to be more front of mind over the long term for physicians.

Dr. Mojola Omole:
I actually think—I was just thinking in my head—that it would be such a nice project for medical learners in community hospitals if they're doing rotations there, looking at antibiotic stewardship. At least I can say for general surgery, everyone just writes for seven days. Then we just—that's what we do. But actually maybe doing some work around that to help practice change, at least starting from the hospital level, would be helpful.

Dr. Lynora Saxinger:
Absolutely. I mean, one thing is because everything is so stressed and strained, it's easier to have a "set and forget" than something where you're like, "We're going to go on the low side, but we might need to check in with you to make sure it's going okay." Do you know what I mean?

So whenever I do something that I feel is more restrained, I also feel obligated to check to make sure that worked—for my own peace of mind. And so it becomes a workflow issue until you adjust to the experience of doing it. And then once you get used to it, you say, "You know what? This works." I think that's how you can change your practice.

Dr. Mojola Omole:
For sure. Thank you so very much for joining us today.

Dr. Lynora Saxinger:
It was very much my pleasure. Thanks for having me.

Dr. Mojola Omole:
Dr. Lynora Saxinger is an infectious disease specialist and a full professor of medicine at the University of Alberta.

So, Blair, what is your takeaway? I mean, as someone who deals with antimicrobials all the time in the ICU, what do you think the broader message to all physicians is regarding antimicrobial resistance?

Dr. Blair Bigham:
Well, I think it's a little bit confounding, and I think we hear this from antibiotic fellowship or stewardship people quite a lot, and we certainly heard it from Dr. Saxinger, which is this idea that there's a lot of sympathy for frontline providers who may be in the ICU, looking at someone in septic shock, or in the ER, we’re looking at somebody differentiated. Or post-op we’re worried about certain complications.

And people just want to make sure that our patients are protected. And we see that protection as being an order for an antibiotic. And until we know what bug we're after, we tend to just say, "Okay, do we think it's in the brain? Do we think it's in the gut? Do we think it's in the lung?" And then we just pick something broad.

And we do that because we don't want people to fall behind and get sick and die of sepsis, or to end up needing to go back to an operating room, or to end up with this complication that makes them weaker or delirious or in hospital forever.

And at the same time, we're always told basically—and I'll summarize what I feel the message is—it's that although we're sympathetic towards your need to save people's lives, please stop ordering antibiotics.

And so I think something along the lines of, "Well, you can order an antibiotic, but for a shorter duration," is kind of a helpful tool. It gives me a sense that I'm being responsible to both the greater good and the patient. I'm still able to treat you, but I'm going to treat you for the shortest time.

And as we have better and better technologies coming out, we'll be able to treat you broadly but for a lesser duration of time because we're going to know your bugs sooner—because we're either looking at its DNA instead of waiting for it to culture, or something like that, or because we're going to use something like an inflammatory marker, a CRP, a procalcitonin, something other than your white blood cell count and a left shift to be able to say, "You know what? We're on the right track here. You are getting better. We can breathe a sigh of relief."

So it sounds like there's a lot coming through the pipeline that's going to make this easier for us. I don't know that we're quite there yet.

And until we're at the place where I have a diagnostic turnaround in an hour instead of 48 hours and then another 12 hours to get my sensitivities, something like shortening the duration seems like an easy step that all of us can comfortably take.

Dr. Mojola Omole:
I agree with you. I do think a lot of these diagnostic tests are for those who are practicing in hospital versus family physicians who have to treat based on their own clinical diagnosis. I do think that makes it challenging. And I do think there's a lot of pressure from patients themselves—they want to do something, right? They want you to do something.

Dr. Blair Bigham:
Yeah, we should not forget about that. In the ER or in the clinic, when somebody's been waiting to see you for a couple of hours or a week or two, they expect to leave with a piece of paper. And maybe that piece of paper doesn't have to be an antibiotic. Maybe it can be an analgesic, maybe it can be a steroid.

Dr. Mojola Omole:
But I do think that that's really challenging for people. And I think that's also challenging for family physicians who don't want to miss something, right? Someone's coming in to see you, and you don't want this person to end up in ER with something worse because you have undertreated them or not recognized something's going on.

So I do think that this is very challenging, but I think we have to weigh that—from the individualism to the collective—is that the more antibiotics we're giving people, the more we're turning this into, similar to a climate disaster, right? From the microbial perspective. And so we have to treat both the individual and the collective when we view antimicrobial resistance.

Dr. Blair Bigham:
Yeah, and it's helpful, rather than viewing it as, "You're damned if you do, you're damned if you don't," to know that you can just reduce that idea of your antibiotic footprint by maybe saying, "Okay, I'm going to go ahead with a thoughtful prescription for an antibiotic."

But at least now we have a fair amount of robust research that says we can usually limit the time course much more so than we used to be able to.

Dr. Mojola Omole:
For sure. This has been a really great episode.

Dr. Blair Bigham:
I disagree. I think this episode has been really, really great.

Dr. Mojola Omole:
Such a nerd.

That's it for this episode of the CMAJ podcast. If you like what you heard, please give us—I think more than a five-star, at least a ten-star rating—where you get your podcasts. Share it with your networks, leave a comment, reach out on—don’t reach out on X, just reach out somewhere, on LinkedIn.

Dr. Blair Bigham:
X is so, I don’t know. Just email us. Email us something good. We need some good news. Tell us you like us.

Dr. Mojola Omole:
Fair enough. Our handles are in the show notes. The CMAJ podcast is produced for CMAJ by PodCraft Productions. Thank you so much for listening. I'm Mojola Omole.

Dr. Blair Bigham:
I'm Blair Bigham. Until next time, be well.