1. Antimicrobial Stewardship The Adventure Continues… IM R-1 Orientation Paul Pottinger, MD, DTM&H, FIDSA June 30, 2016

2. Antimicrobial Stewardship The Adventure Continues… IM R-1 Orientation Paul Pottinger, MD, DTM&H, FIDSA June 30, 2016

3. Abx in the Hospital OBJECTIVE Increase your confidence in Prescribing Antibiotics Increase your confidence in Prescribing Antibiotics Understand your role in Antimicrobial Stewardship Understand your role in Antimicrobial StewardshipFORMAT Case-based & interactive Case-based & interactiveCONTENT Cases you will work up as an R-1 Cases you will work up as an R-1SLIDES Available on the web Available on the web

4. Another Question…. What’s the susceptibility rate for P.aeruginosa at UWMC (non-CF) DRUG % Sensitive Ceftazidime87% Cefepime85% Meropenem82% Pip/Tazo78%

5. GET HELP if you are unsure what’s best… You are NOT alone!

6. Stewardship Teams at UWMC & HMCStewardship Teams at UWMC & HMC OCCAM (in your pocket, on your phone, online)OCCAM (in your pocket, on your phone, online) Service PharmacistsService Pharmacists ID Consult ServiceID Consult Service Stewardship Resources

7. Jeannie Chan, PharmD HMC Rupali Jain, PharmD UWMC

8. https://occam.hsl.washington.edu

9. RESISTANCE is a problem here… YOUR problem (sorry)

11. A 68 y/o woman with type-2 DM & HTN recently Rx’d for CAP with cefotaximeA 68 y/o woman with type-2 DM & HTN recently Rx’d for CAP with cefotaxime Now admitted for major CVANow admitted for major CVA Febrile → Ceftazidime startedFebrile → Ceftazidime started BCx & foley cath urine grew K.pneumoniaeBCx & foley cath urine grew K.pneumoniae Two days later: Fever persists, and she becomes less responsive….Two days later: Fever persists, and she becomes less responsive…. 1) Switch to Levo or Cipro 2) Switch to Ceftriaxone 3) Switch to Cefepime 4) Switch to Meropenem 5) Everything’s groovy, make no change 1) Switch to Levo or Cipro 2) Switch to Ceftriaxone 3) Switch to Cefepime 4) Switch to Meropenem 5) Everything’s groovy, make no change Case

12. Emerging Resistance: ESBL Extended Spectrum ß-Lactamases Mutant TEM-1, SHV-1, CTX-M, or OXA ß-lactamaseMutant TEM-1, SHV-1, CTX-M, or OXA ß-lactamase Enzymes hydrolyze oxyimino-ß-lactams (includes 3 rd Gen Cephalosporins)Enzymes hydrolyze oxyimino-ß-lactams (includes 3 rd Gen Cephalosporins) Usually in Klebsiella spp. and E.coliUsually in Klebsiella spp. and E.coli Consider in all nosocomial infections with these organismsConsider in all nosocomial infections with these organisms  Risk Factor = Previous ß-lactam use  Overall prevalence may > 10%

13. ESBL Worry if resistance “skips a generation”Worry if resistance “skips a generation” Confirm with  3-fold decrease in MIC with ß –lacatmase inhibitorConfirm with  3-fold decrease in MIC with ß –lacatmase inhibitor Rx of choice:Rx of choice: Carbapenem Carbapenem Variable success: Variable success: FQ FQ Aminoglycoside Aminoglycoside TMP/SMX, Nitro, Fosfo TMP/SMX, Nitro, Fosfo

14. BROAD SPECTRUM abx will select resistant mutants

15. Catheter-Associated UTI: CAUTI Pathogenesis Colonization (universal): Endogenous flora ascends peri-catheter space or lumenColonization (universal): Endogenous flora ascends peri-catheter space or lumen Infection (rare): Systemic inflammatory response to adherent or invasive bugsInfection (rare): Systemic inflammatory response to adherent or invasive bugs Confirm Diagnosis U/A and reflexive quantitative UCxU/A and reflexive quantitative UCx

16. Diagnostic Options: UTI Leukocyte esterase: If >10 5 cfu/ml, then: sensitivity 68-98%specificity 59-96% Nitrite: If >10 5 cfu/ml, then: sensitivity 19-45%specificity 95-98% False negatives common. False negatives common. Enterobacteriaceae reduce nitrate to nitrite, but Pseudomonas, S. saprophyticus, & Enterococcus do not reduce nitrate. Enterobacteriaceae reduce nitrate to nitrite, but Pseudomonas, S. saprophyticus, & Enterococcus do not reduce nitrate. False positive tests uncommon. False positive tests uncommon. Tom Hawn, MD-PhD + LE poorly predictive of real UTI in foley patients!

17. Diagnostic Options: UTI Microscopic analysis Pyuria: Majority of symptomatic UTIs have pyuria… but lower PPV among catheterized pts Gram stain for bacteria: >1 organism per hpf on uncentrifuged urine is >10 5 on culture Culture Method: collect from sterilized tube port, not bag Inoculate 1 to 10  l onto agar plate Criteria for Enterobacteriaceae UTI if NO foley Symptomatic women Symptomatic women 10 2 : sensitivity 95%, specificity 85% for cystitis Asymptomatic women Asymptomatic women 10 5 : used in high risk clinical settings & research + WBC poorly predictive in foley patients!

18. Diagnostic Options: UTI Summary Test judiciously! (Death, Taxes, and Foley Colonization)Test judiciously! (Death, Taxes, and Foley Colonization) If NOT immunosuppressed: Order “UA with reflexive culture.”If NOT immunosuppressed: Order “UA with reflexive culture.” Immunosuppressed: Order both UA and UCx.Immunosuppressed: Order both UA and UCx.

19. Treatment Options: CAUTI Empiric coverage depends on gram stain: GNR’s: Ceftazidime (vs. Meropenem if MDRO hx or heavy recent cephalosporin exposure) GPC’s: add Vancomycin (cover Staph) Total Length of Therapy: Usually 7 days; longer may be needed for pyelo Definitive Treatment: Focus spectrum based on C&S results…

20. CAUTI Other Management Change or remove the catheter if UTI detectedChange or remove the catheter if UTI detected Colonization virtually universal… No need for routine surveillance cultures!Colonization virtually universal… No need for routine surveillance cultures! Appreciate difference between asymptomatic bacteriuria and UTI!Appreciate difference between asymptomatic bacteriuria and UTI!

21. CAUTIPrevention Use foley only when necessary!Use foley only when necessary! Aseptic insertion techniqueAseptic insertion technique Maintain securely, proper bag placementMaintain securely, proper bag placement Know who has a FoleyKnow who has a Foley Condom caths when feasibleCondom caths when feasible Pull them ASAPPull them ASAP

22. TIME + TUBE = TROUBLE Disinvade your pt ASAP

24. Case A 58 y/o man in MVC 9 days ago sustained CHI → remains comatose, intubated to protect airway. New onset fever,  WBC, rising FiO 2 requirements.A 58 y/o man in MVC 9 days ago sustained CHI → remains comatose, intubated to protect airway. New onset fever,  WBC, rising FiO 2 requirements. Unresponsive w/o sedation, on vent, febrile, HR 112, BP fine, POX 92% on 40% FiO 2. B/L ronchi.Unresponsive w/o sedation, on vent, febrile, HR 112, BP fine, POX 92% on 40% FiO 2. B/L ronchi. CXR:CXR: Working Diagnosis Ventilator-Associated Pneumonia Ventilator-Associated Pneumonia B/L Infiltrates

25. Case: VAP A 58 y/o man in MVC 9 days ago sustained CHI → remains comatose, intubated to protect airway. New onset fever,  WBC, rising FiO 2 requirements.A 58 y/o man in MVC 9 days ago sustained CHI → remains comatose, intubated to protect airway. New onset fever,  WBC, rising FiO 2 requirements. Unresponsive w/o sedation, on vent, febrile, HR 112, POX 92% on 40% FiO2. B/L ronchi.Unresponsive w/o sedation, on vent, febrile, HR 112, POX 92% on 40% FiO2. B/L ronchi. CXR: B/L InfiltratesCXR: B/L Infiltrates 1) Meropenem + Gent + Linezolid 2) Ceftazidime + Ertapenem + Cipro 3) Pip/Tazo + Cipro + Tigecycline 4) Cefepime + Gent + Daptomycin 5) Cefepime + Vancomycin 1) Meropenem + Gent + Linezolid 2) Ceftazidime + Ertapenem + Cipro 3) Pip/Tazo + Cipro + Tigecycline 4) Cefepime + Gent + Daptomycin 5) Cefepime + Vancomycin

26. Case: VAP ATS/IDSA Guidelines MDR Pathogen Risks Hospitalized ≥ 5 days Hospitalized ≥ 5 days Abx in last 90 days Abx in last 90 days High ward MDR prevalence High ward MDR prevalence SNF resident SNF resident Contact with MDR patient Contact with MDR patient Chronic Dialysis Chronic Dialysis Chronic Infusions Chronic Infusions Immunosuppressed Immunosuppressed

27. Anti-Pseudomonal cephalosporin Anti-Pseudomonal cephalosporin (Ceftaz, Cefepime) or Anti-Pseudomonal carbapenem Anti-Pseudomonal carbapenem (Meropenem, Imipenem) or  -lactam with lactamase inhibitor  -lactam with lactamase inhibitor(Piperacillin/tazobactam)+ Anti-Pseudomonal FQ Anti-Pseudomonal FQ (Cipro, Levo) or Aminoglycoside Aminoglycoside (Gent, tobra) + Linezolid or Vancomycin Linezolid or Vancomycin Case: VAP MDR Pathogen Risks Hospitalized ≥ 5 days Hospitalized ≥ 5 days Abx in last 90 days Abx in last 90 days High ward MDR prevalence High ward MDR prevalence SNF resident SNF resident Contact with MDR patient Contact with MDR patient Chronic Dialysis Chronic Dialysis Chronic Infusions Chronic Infusions Immunosuppressed Immunosuppressed Pseudomonas aeruginosa Pseudomonas aeruginosa Burkholderia Burkholderia Stenotrophomonas Stenotrophomonas Klebsiella Klebsiella Citrobacter Citrobacter Acinetobacter Acinetobacter MRSA MRSA ATS/IDSA Guidelines OUR APPROACH: Second GNR Agent (cipro or tobra) NOT routinely recommended at HMC or UWMC

28. + Only Vanco used more often by IM.Only Vanco used more often by IM. Covers PsA, enterobacteriaciae, strep, anaerobes.Covers PsA, enterobacteriaciae, strep, anaerobes. Concern: Heavy use → Resistance.Concern: Heavy use → Resistance. Solutions:Solutions: Seek Empiric Alternatives… Use OCCAM! Seek Empiric Alternatives… Use OCCAM! Establish a Diagnosis (BAL or “mini-BAL”) and de-escalate ASAP. Establish a Diagnosis (BAL or “mini-BAL”) and de-escalate ASAP. Prolonged Infusion Prolonged Infusion Case: VAP Zosyn: Too Much of a Good Thing?

29. VANCOMYCIN

30.  Methods - Retrospective analysis 1999-2005 - University Hospital (Washington U) - N =102 Adults - Nosocomial MRSA pneumonia - MRSA established by BAL - Monotherapy with vancomycin > 72 hrs  Measurements - Vancomycin trough levels - Clinical outcome Study Design Patient Outcomes From: Isakow W, et al. ICAAC 2006. DHS/PP MRSA VAP: Vancomycin Levels? Case: VAP

31. MRSA: Van comycin MIC Creep? Soriano CID 2008 Not all VSSA created alike.Not all VSSA created alike. Published reports of rising vanco MIC’s in last 5 years.Published reports of rising vanco MIC’s in last 5 years. Presumed MOR: increased cell wall thickness.Presumed MOR: increased cell wall thickness. Retrospective case series: higher MIC’s associated with higher liklihood of clinical failure on vanco.Retrospective case series: higher MIC’s associated with higher liklihood of clinical failure on vanco.

32. MRSA: Vancomycin MIC Creep? MIC ≤ 2 still considered susceptible (VSSA)… Concern: clinical failures with vanco.MIC ≤ 2 still considered susceptible (VSSA)… Concern: clinical failures with vanco. Recommend you routinely check vanco MIC, certainly if pt fails to clear bacteremia or clinically improve after 7 days of therapy.Recommend you routinely check vanco MIC, certainly if pt fails to clear bacteremia or clinically improve after 7 days of therapy. “Consider” switch to alternative agent if MIC = 2, and if pt is failing vanco.“Consider” switch to alternative agent if MIC = 2, and if pt is failing vanco.

33. MRSA: Vancomycin MIC Creep? “Consider” switch to alternative agent if MIC = 2, and if pt is failing vanco.“Consider” switch to alternative agent if MIC = 2, and if pt is failing vanco. What, pray tell, shall I use instead of “Vitamin V?”

34. Abx Stewardship: Linezolid “It’s An Anti-Depressant!” Oxazolidinone, targets gram-positive ribosomes (no GNR coverage)Oxazolidinone, targets gram-positive ribosomes (no GNR coverage) IV or POIV or PO Bacteriostatic, but inhibits toxin productionBacteriostatic, but inhibits toxin production Toxicities: Neuropathy, myelo- suppression, serotonin syndrome, costToxicities: Neuropathy, myelo- suppression, serotonin syndrome, cost

35. Study Design  Methods - Retrospective analysis of 2 prospective, randomized, case-control studies - N =1019 Adults - Nosocomial pneumonia - Suspected gram-positive pneumonia - 339 with documented S. aureus - 160 with documented MRSA  Regimens - Vancomycin + Aztreonam - Linezolid + Aztreonam Clinical Cure From: Wunderink RG, et al. Chest 2003;124:1789-97. DHS/PP P = 0.009 P = 0.182 Vancomycin vs. Linezolid Round One: VAP Wunderink et al. CHEST / 124 (5) 2003

36.  Methods - Blinded, Randomized prospective non-inferiority trial of pneumonia - Nosocomial pneumonia - N =1225 Adults Randomized - 339 with documented MRSA - Well-matched… except 9% more ventilated pts in vanco arm  Regimens - Vancomycin 15mg/kg IV Q 12 H - Linezolid 600mg IV Q 12 H - Both arms treated 7-14 days Study Design Outcomes From: Chastre J et al, 2010 IDSA Conference and CID January 2012 “Not significantly different” P = 0.042 CI = 0.5-21.6 Vancomycin vs. Linezolid Round Two: VAP

38. Vancomycin vs. Linezolid Jury Still Out.. At least for meJury Still Out.. At least for me Trend to survival benefit with Linezolid in meta-analysis Trend to survival benefit with Linezolid in meta-analysis Trend to better “clinical response” in large prospective trial sponsored by industry… no mortality difference Trend to better “clinical response” in large prospective trial sponsored by industry… no mortality difference Adverse events comparable Adverse events comparable Many intensivists now favor linezolid for MRSA VAP… at UW we start with vanco Many intensivists now favor linezolid for MRSA VAP… at UW we start with vanco

39. Newer, Fancier, Pricier ≠ Better! LinezolidVancomycin For empiric MRSA VAP coverage…

40. Methods (N = 401) - Microbiologically-Proven VAP* - Received initial appropriate therapy - Randomized, double-blinded - Performed 1999-2002 Methods (N = 401) - Microbiologically-Proven VAP* - Received initial appropriate therapy - Randomized, double-blinded - Performed 1999-2002 Regimens* - 8 days of therapy - 15 days of therapy Regimens* - 8 days of therapy - 15 days of therapy Methods (N = 401) - Microbiologically-Proven VAP* - Received initial appropriate therapy - Randomized, double-blinded - Performed 1999-2002 Methods (N = 401) - Microbiologically-Proven VAP* - Received initial appropriate therapy - Randomized, double-blinded - Performed 1999-2002 Regimens* - 8 days of therapy - 15 days of therapy Regimens* - 8 days of therapy - 15 days of therapy Study Design ResultsResults From: Chastre J, et al. JAMA 2003;290:2588-98. * All patients had quantitative cultures from bronchoscopy DHS/PP Case: VAP How Long to Treat? (Less is More)

41. Prevention: VAP What Works? “VAP Bundle!” Elevate head of bed to 30°Elevate head of bed to 30° Sterile technique with hand hygiene & ETT suctioning. Oral care.Sterile technique with hand hygiene & ETT suctioning. Oral care. Daily sedation holiday…Daily sedation holiday… Get the tube out ASAP!!Get the tube out ASAP!! Small added benefit: Silver tube or continuous suctionSmall added benefit: Silver tube or continuous suction

43. Apparent Paradox

44. MAKE A DIAGNOSIS whenever you can… Be ready to react to results

45. START BROAD, BUT DE-ESCALATE ASAP (based on micro)

46. P2P2P2P2 I WANT YOU… To keep MDR bugs under control!

47. Ignac Philipp Semmelweis (1818-65) “Clean Your *&^%@! Hands” Hand Hygiene Remains Cornerstone of ICHand Hygiene Remains Cornerstone of IC Biggest Cost:Benefit Ratio AroundBiggest Cost:Benefit Ratio Around Patients Will Thank (or Chastise) You!Patients Will Thank (or Chastise) You! Obey Precaution PlacardsObey Precaution Placards Prevent Infection

49. 1656 2008

50. ANTIBIOTICS:UNIQUEIMPLICATIONS (clinical medicine and public health, every time) Antimicrobial Stewardship

51. The UTI patient is treated with a 5 day course of TMP/SMX. Discharged home after two days. Calls you after six days reporting severe watery diarrhea, six-ten BM’s / day, crampy abdominal pain…. Just when you thought she was cured…. A) Check O&P, C&S B) Empiric ciprofloxacin C) Empiric rifaximin D) Send C.difficile fecal analysis E) Start antimotility drugs F) Let it flow….

52. C.Difficile Infection (CDI) Risk Factors:Risk Factors: Recent abx use Recent abx use Contact with SNF or Hospital Contact with SNF or Hospital Inflammatory Colitis Inflammatory Colitis Diagnosis:Diagnosis: Send Toxin B PCR (run BID at UW/HMC) Send Toxin B PCR (run BID at UW/HMC) One and done! NPV ~99%! One and done! NPV ~99%! Treatment: Depends on severityTreatment: Depends on severity Abx Stewardship: CDI

53. Acute Diarrhea: CDI Treatment Options based on Clinical Course Disease Severity DefinitionDrug/DoseDurationComments Initial episode mild- moderate WBC <15-20,000 WBC <15-20,000 Age <65 Age <65Metronidazole 500mg PO TID* 10 days * Consider changing to oral vancomycin in 5 days if lack of clinical response noted. Severe Any 2 or more of the following: Age > 65 Age > 65 WBC count > 20,000 cells/mm 3 WBC count > 20,000 cells/mm 3 Fever >38.3°C Fever >38.3°C Albumin <2.5mg/dL Albumin <2.5mg/dL Vancomycin 125mg PO QID 10 days Vancomycin is recommended as the initial antibiotic for pregnant women. Severe with complications Direct admission to ICU for CDAD Direct admission to ICU for CDAD Toxic megacolon Toxic megacolon perforation perforation severe colitis on CT Scan severe colitis on CT Scan Ileus or unable to take PO: metronidazole 500mg IV Q8H +/- intracolonic vancomycin** 10 days min.** ** Recommend Infectious Diseases consultation for vancomycin dosing & duration of therapy.

54. Acute Diarrhea: CDI Treatment Options based on Clinical Course Disease Severity DefinitionDrug/DoseDurationComments Initial episode mild- moderate WBC <15-20,000 WBC <15-20,000 Age <65 Age <65Metronidazole 500mg PO TID* 10 days * Consider changing to oral vancomycin in 5 days if lack of clinical response noted. Severe Any 2 or more of the following: Age > 65 Age > 65 WBC count > 20,000 cells/mm 3 WBC count > 20,000 cells/mm 3 Fever >38.3°C Fever >38.3°C Albumin <2.5mg/dL Albumin <2.5mg/dL Vancomycin 125mg PO QID 10 days Vancomycin is recommended as the initial antibiotic for pregnant women. Severe with complications Direct admission to ICU for CDAD Direct admission to ICU for CDAD Toxic megacolon Toxic megacolon perforation perforation severe colitis on CT Scan severe colitis on CT Scan Ileus or unable to take PO: metronidazole 500mg IV Q8H +/- intracolonic vancomycin** 10 days min.** ** Recommend Infectious Diseases consultation for vancomycin dosing & duration of therapy.

55. Acute Diarrhea: CDI Treatment Options based on Clinical Course Disease Severity DefinitionDrug/DoseDurationComments Initial episode mild- moderate WBC <15-20,000 WBC <15-20,000 Age <65 Age <65Metronidazole 500mg PO TID* 10 days * Consider changing to oral vancomycin in 5 days if lack of clinical response noted. Severe Any 2 or more of the following: Age > 65 Age > 65 WBC count > 20,000 cells/mm 3 WBC count > 20,000 cells/mm 3 Fever >38.3°C Fever >38.3°C Albumin <2.5mg/dL Albumin <2.5mg/dL Vancomycin 125mg PO QID 10 days Vancomycin is recommended as the initial antibiotic for pregnant women. Severe with complications Direct admission to ICU for CDAD Direct admission to ICU for CDAD Toxic megacolon Toxic megacolon perforation perforation severe colitis on CT Scan severe colitis on CT Scan Ileus or unable to take PO: metronidazole 500mg IV Q8H +/- intracolonic vancomycin** 10 days min.** ** Recommend Infectious Diseases consultation for vancomycin dosing & duration of therapy.

56. Fidaxomicin New macrocyclic antibioticNew macrocyclic antibiotic 200mg PO BID, not absorbed200mg PO BID, not absorbed Cost: $2,800 / 10 day course (-$875 rebate)Cost: $2,800 / 10 day course (-$875 rebate) Abx Stewardship: C.difficile Louie NEJM 2011 You will probably never use this drug

57. Fecal Microbiota Transplant The Ultimate Pro-Biotic experience!The Ultimate Pro-Biotic experience! ~ 90% cure rate in case series and reports~ 90% cure rate in case series and reports Small N’s to dateSmall N’s to date Patients much less squeamish than MDsPatients much less squeamish than MDs Unresolved Issues:Unresolved Issues: Donor selection & screening Donor selection & screening Stool Prep & Delivery Stool Prep & Delivery Reimbursement Reimbursement Abx Stewardship: C.difficile Bakken Clin Gastro Hepatol 2011

58. PREVENTION RULES! Alcohol hand rub will not do itAlcohol hand rub will not do it Spores very hardy… and yes, they flySpores very hardy… and yes, they fly Gown, Glove, and wash with soap & waterGown, Glove, and wash with soap & water Continue precautions for rest of admissionContinue precautions for rest of admission No need for “test of cure”No need for “test of cure” Abx Stewardship: C.difficile

59. YOUR WISE USE of abx really DOES make a difference (for your pt & for everyone)

60. CA-UTI… Stop the Insanity UTI ≠ ABU! Test when appropriate, usually via “U/A with reflexive culture”UTI ≠ ABU! Test when appropriate, usually via “U/A with reflexive culture” Prevention is King:Prevention is King: Does your pt really need that foley? Does your pt really need that foley? Tubes & drains part of daily rounding Tubes & drains part of daily rounding RN-driven foley removal protocol can save your bacon! RN-driven foley removal protocol can save your bacon! Ensure appropriate care when it’s in Ensure appropriate care when it’s in Abx Stewardship: Summary

61. VAP… Nosocomial Nightmare A Clinical Dx: Please send a BAL (or Mini-BAL)A Clinical Dx: Please send a BAL (or Mini-BAL) Empiric Abx per OCCAMEmpiric Abx per OCCAM De-Escalate per BAL!De-Escalate per BAL! Prevention is King! Bundle of best practices: Daily SBT, HOB at 30°, meticulous hand hygiene with suctioning, limit use of PPIsPrevention is King! Bundle of best practices: Daily SBT, HOB at 30°, meticulous hand hygiene with suctioning, limit use of PPIs

62. Abx Stewardship: Summary Diarrhea… A Big Bowl of Bad Prevent with judicious abx use!Prevent with judicious abx use! CDI:CDI: Minority of AAD… but rising, especially in FQ use. Minority of AAD… but rising, especially in FQ use. Low threshold to test… Once is enough! Low threshold to test… Once is enough! STOP offending abx if possible STOP offending abx if possible Rx oral metro vs. oral vanco based on severity Rx oral metro vs. oral vanco based on severity Wash yer dang hands! Wash yer dang hands!

63. http://depts.washington.edu/uwabx/ Stewardship Primer

64. Welcome to your new life…. JUDICIOUS use of abxJUDICIOUS use of abx Critically-important need… and rising!Critically-important need… and rising! YOU are on the front linesYOU are on the front lines OCCAM: Your Friend OnlineOCCAM: Your Friend Online ID CONSULT: ANY TIME! No ? too small…ID CONSULT: ANY TIME! No ? too small… We are eager to help! Please contact us any time: abx@uw.eduWe are eager to help! Please contact us any time: abx@uw.edu Abx Stewardship: Summary