Canadian health-care services have a significant environmental footprint, which contributes to an increasing global burden of disease. A quarter of health-care admissions in Canada come from medications. That was the jumping off point for our most recent Lunch and Learn session, which was held just before World Antimicrobial Resistance Awareness Week.

The session, which was hosted by the Vancouver Acute/Vancouver Community Medical Staff Planetary Health Committee, featured pharmacist and ASPIRES VGH team member Dr. Rosanne Thalakada and Infectious Diseases Specialist and Regional Medical Director for ASPIRES Dr. Shaqil Peermohamed. The full session can be seen here.

Dr. Thalakada was quick to point out the different carbon footprint for highly bioavailable antimicrobials administered orally (PO) rather than intravenously (IV). She used the example of ciprofloxacin 400 mg IV Q12H for one week versus ciprofloxacin 500 mg PO BID. The intravenous regimen has a greater than 100 times higher carbon footprint. She added that oral antimicrobials are easier for patients to take, have fewer adverse effects, reduce a patient’s length of hospital stay, and have reduced health-care costs. However, there are contraindications to oral therapy, so each patient must be assessed individually to determine if they meet criteria to switch from IV to oral antimicrobials. Antimicrobials that are administered parenterally also carry risks of line infections and thromboses.

To establish a baseline antimicrobial prescribing pattern, ASPIRES did five spot audits of highly bioavailable antimicrobials that were being administered parenterally. These patients were reviewed for contraindications to oral therapy to determine what proportion could have received oral rather than intravenous antimicrobials. Over 60 per cent of these patients were eligible for oral switch. ASPIRES also partnered with UBC researchers to analyze the carbon footprint of IV versus PO formulations. The carbon footprint associated with intravenously administered antimicrobials ranged from 60 to 170 times higher their oral equivalents. These findings encouraged the ASPIRES team to create an educational initiative to reduce the unnecessary reliance of IV highly bioavailable antimicrobials to reduce their carbon footprint and costs.

Dr. Thalakada pointed to the sculpture that ASPIRES commissioned to represent the daily waste generated by IV administration of antimicrobials at VGH. More than a Drip that will be on display in the VMDAS Hub for Engagement and Wellness until early December. Tofino artist Pete Clarkson said in a statement,

“Creating this installation was very revealing to me regarding the tremendous quantity of medical waste produced every day. The proliferation of single-use disposable materials in health care is particularly difficult to address given their many positive benefits. However, the consumption and disposal of these products comes with a real cost to the environment—our collective life support system. Ultimately we must ensure both are cared for.”

Mobilizing to defeat antimicrobial resistance

Dr. Peermohamed then spoke about the antimicrobial stewardship mobile app, Firstline, that ASPIRES has just launched. The app provides health-care professionals quick access to local infectious diseases guidance and antimicrobial dosing information directly at the point of care, at no cost to users. It helps health-care professionals make informed treatment decisions, reduces the burden of antibiotic-resistant infections on the health system, minimizes adverse events, health-associated infections and long-term complications associated with unnecessary antibiotic use, and health-care providers can receive instant notifications on drug shortages and updated guidance through the app.

Dr. Peermohamed referred to VCH’s goal to spark a culture of antimicrobial stewardship to safeguard health in our community. The Firstline app provides access to local guidelines, which are based upon local resistance patterns. Dr. Peermohamed guided the audience through the app’s functions, including information on pathogens and antimicrobials. Firstline also includes useful tools and games. The app is free and is available to download from the Apple store or Google Play. A web-based version is also available.

The goals for Firstline are for health-care providers to make better decisions for better patient outcomes as well as to reduce the burden of antibiotic-resistant infections on our health system. The ASPIRES team hopes using the app will minimize adverse events, hospital-acquired infections, and long-term complications associated with unnecessary antibiotic use.

Firstline includes an IV to PO conversion guideline, including criteria to determine when it may be safe to transition patients to oral antimicrobials. The ASPIRES team is keen to hear feedback about the app, whether that be changes or additions you think should be made; ASPIRES is keen to collaborate and build upon the app.

Session feedback

Fourteen of the 36 people who attended the session completed the post-event survey. Their responses to the question of what resonated with them most from the session included the following:

• That some IV antibiotics are being used with their PO versions are just as good.
• New concepts for sustainability in medicine are very important. This one is a no brainer and needs broad application.
• The amount of waste that comes from using IV Abx is astonishing.
• Aspect of how much waste is produced in the procedure of putting in an IV line.
• We have a great group of engaged physicians working to improve practices for patients and the environment.
• I did not realize the environmental impact of IV antibiotics until today.
• Huge opportunity to improve impacts for the environment as well as the health-care system.