What's working: How this made-in-Canada solution helps more than 400 hospitals worldwide improve prescribing for infections and reduce antibiotic resistance

Sick Kids Hospital saw the future of antimicrobial stewardship five years ago, when it met with the founders of Firstline, a Vancouver-based health technology company that had built an online clinical decision support platform for infectious disease specialists and antimicrobial prescribers.The Toronto-based children’s hospital has had antimicrobial management guidelines in place for several decades, explained Kathryn Timberlake, clinical pharmacy specialist at SickKids. But in addition to the challenges of having these guidelines easily accessible to prescribers at point of care, there were also gaps in information within the guidelines.“For example, the total duration of treatment was not something we had recommendations for and when we did a survey among prescribers at SickKids, treatment duration came out as something they always wanted,” said. “When we met with Firstline and saw how agile their platform was and how easy it was to update, we decided to do something with them.”The idea behind Firstline’s platform was simple: To ensure proper antimicrobial prescribing and minimize antibiotics resistance by making it easier for prescribers and other healthcare providers to look up diagnostic, pathogen and treatment information for dozens of infections ranging from bacterial meningitis and COVID to tick bites and urinary tract infection.Having local information is critical because infections and the recommended interventions often vary by region, said Firstline co-founder Michael Long. This is why the company works directly with antimicrobial stewardship teams at each of its client hospitals, and the guidelines on the platform—viewable by anyone with the app on their phone—are labelled by hospital.Read: The dos and don’ts of managing bronchiolitis in infants in primary care settings“So imagine a situation in a pediatric hospital where the healthcare professional is interacting with a patient and trying to diagnose and treat that patient according to the best available evidence—that is actually quite a difficult task,” said Long. “That healthcare provider will need to integrate a lot of different sources of information: They'll need to take information about that patient, but they also need to integrate that with the drugs that they have available in the hospital, the local resistance of the pathogens in the community and the cost of those therapies. In many cases, these healthcare providers are not infectious disease experts and they also need to work without diagnostic results at the beginning of the therapy, sometimes in a medical emergency. So they need help, right?”Without access to comprehensive and location-specific antimicrobial management information, prescribers often turn to “overly broad-spectrum” antimicrobials or, in some cases, unnecessary antimicrobials “just to be safe,” said Long. “And while that is genuinely motivated by a desire to do the right thing for the patient, it can do more harm than good,” he added. “It can lead to adverse drug reactions, it can lead to associated infections and, of course, overuse of antimicrobials which drives antimicrobial resistance. So healthcare providers need help to integrate all of that information and make an evidence-based prescribing decision to choose the most appropriate antimicrobial to treat that patient in front of them. That's what Firstline does—it's effectively like putting an infectious disease expert in their pocket.”The Firstline platform, which is also available as a mobile app, organizes antimicrobial management information by type of pathogen, drug and anatomical site—such as central nervous system, respiratory system or skin and soft tissue. Users can drill deeper into each category. For example, each pathogen type includes information on routine practices, susceptibilities, epidemiology and associated syndromes.Read: Amoxicillin preferred for acute sinusitis in childrenIn the antimicrobial section, every drug includes information on susceptible isolates—expressed in percentages—dosing for particular patient groups, restricted indications, adverse effects and drug monitoring recommendations.Firstline is now used by about 400 hospitals in 13 countries. In Canada, about one in two pediatric hospitals have their guidelines on Firstline, said Long.One hospital, IWK Health in Halifax, reported an immediate improvement of almost 16% in antimicrobial prescribing after it rolled out the Firstline app to its prescribers. Another hospital saw, in its first year using Firstline, a 10% reduction in the aggregate number of days its patients were on antimicrobial therapy.Within the Eastern Health hospital system in St. John’s, N.L., the adoption of Firstline led to antimicrobial use reduction of more than 10% from January 2019 to March 2020.While SickKids was not able to share any metrics to illustrate the impact of Firstline on its organization, Timberlake did point to the high number of SickKids physicians, medical residents and pharmacists—about 650 in total—who are active users of the platform.In January, many of these users looked up information on urinary tract infections, to a total of 113 search queries.“We do plan to have some additional guidelines around antibiotic-resistant urinary tract infections,” said Timberlake. “We’re doing some work to identify how best to treat those patients with antimicrobial resistance.”Given how well-received—and valuable—Firstline has been at SickKids, Timberlake said she would like to see more prescribers and healthcare providers in the community putting the app on their phones and referring to it when caring for patients with infections.“I would like to see more pharmacy community pharmacists using this to access the right information and even to check the right dose when they’re tweaking dosing guidelines,” she said. “When we had the drug shortages in 2022, we were able to push out notifications to prescribers about the amoxicillin shortage and recommend solid oral dosage forms. That's another opportunity where pharmacists may be able to modify a prescription to ensure that whatever they have available can be an alternative to whatever is not available.”Read: Calgary researchers develop new tool to diagnose genetic mutations within hours

What's working: How this made-in-Canada solution helps more than 400 hospitals worldwide improve prescribing for infections and reduce antibiotic resistance

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