Please note that the following post was copied with permission from its original website. For more information about antimicrobial stewardship, check out the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) blog, Facebook, and Youtube page.
Are You Antibiotics Aware? U.S. Antibiotic Awareness Week is November 18-24, 2022
U.S. Antibiotic Awareness Week is an annual observance that raises awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic use. The observance is a partnership between the CDC, state-based programs (such as the Nebraska Department of Health and Human Services, Healthcare-Associated Infections/Antibiotic Resistance Team), and non-profit/for-profit partners. The goal of this national observance is to improve antibiotic stewardship practices of both healthcare providers and consumers to achieve the best outcomes while minimizing untoward effects of antibiotic therapy.
CDC examined antibiotic prescribing and factors that influence prescribing practices such as provider type, geographic location, setting, and patient age to inform targets for antibiotic stewardship. A Mortality and Morbidity Weekly Report (MMWR) published in February 2022 evaluated publicly available data to better understand how antibiotics were prescribed for older adults (>65 years) in 2019. 1 The highest 10% of antibiotic prescribers prescribed 41% of total antibiotic prescriptions.
Outpatient Antibiotic Use in Nebraska
Outpatient antibiotic prescribing rates vary widely across the United States. This variation suggests that there are stewardship opportunities for healthcare providers, facility and healthcare system leadership, and other partners to improve how antibiotics are used. Monitoring of outpatient antibiotic prescribing data is regularly conducted by CDC to better understand trends in outpatient antibiotic prescribing, identify where interventions to improve prescribing are most needed, and measure progress.
Nebraska has an opportunity to improve antibiotic prescribing across all types of practice settings, but especially in outpatient facilities. In 2021, Nebraska’s prescribing rate was reported by the CDC as 760 prescriptions per 1,000 population. This ranks Nebraska 42nd in the nation. The lowest prescribing rate in the nation was 350 antibiotic prescriptions per 1,000 population – Nebraska was more than double that rate!
Hospital Antibiotic Stewardship in Nebraska
Hospital Antibiotic Stewardship Programs use the CDC’s Core Elements of Hospital Antibiotic Stewardship as a framework for implementation. These seven Core Elements include:
Hospital Leadership Commitment
Accountability
Pharmacy Expertise
Action
Tracking
Reporting
Education
As of 2021, 86% of hospitals in Nebraska reported meeting all seven of the Core Elements on the annual National Healthcare Safety Network Hospital Survey. This may seem like a large percentage of hospitals, but it ranks Nebraska 45th in the nation!
Nursing Home Antibiotic Use
Tracking and reporting antibiotic use in nursing homes is critical to monitor trends in antibiotic prescribing, inform opportunities to guide practice change, and evaluate the impact of stewardship interventions. CDC researchers evaluated the utility of electronic health record data to monitor antibiotic use and characterized antibiotic prescribing practices. Electronic health record data can be leveraged to support nursing homes in tracking and reporting antibiotic use.
Electronic health record antibiotic orders in 1,664 U.S. nursing homes were used to describe antibiotic use at the facility and national levels.5 In 2016, 54% of residents received an antibiotic. The antibiotic use rate was 88 days of therapy (DOT) per 1,000 resident days and the median antibiotic course duration was 7 days (interquartile range, 5–10). Antibiotic use rates varied considerably across nursing homes and were only partially explained by nursing home and resident characteristics, highlighting potential opportunities for targeted improvement of prescribing practices.
How can you help?
Be Antibiotics Aware, a CDC educational effort, complements U.S. Antibiotic Awareness Week by providing partners with up-to-date information to help improve human antibiotic prescribing and use in the United States.
The CDC invites healthcare stakeholders, providers as well as consumers to share the important Be Antibiotics Aware message during this week-long observance by
Printing and sharing Handouts and Posters with healthcare providers and consumers
Playing Videos on TV screens in medical offices, waiting rooms, and pharmacy
We look forward to your participation in U.S. Antibiotic Awareness Week from November 18 to 24!
Written by Jenna Preusker, Pharm.D., BCPS – Nebraska ASAP Pharmacy Coordinator
References
Gouin KA, Fleming-Dutra KE, Tsay S, Bizune D, Hicks LA, Kabbani S. Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data – United States, 2019. MMWR Morb Mortal Wkly Rep. 2022 Feb 11;71(6):202-205. doi: 10.15585/mmwr.mm7106a3. PMID: 35143465; PMCID: PMC8830623
Antibiotic Use in the United States, 2022 Update: Progress and Opportunities https://www.cdc.gov/antibiotic-use/stewardship-report/current.html
UNMC ID has a long history of not only providing extraordinary medical care for people living with HIV (PLWH), but also contributing strongly to the research that informs the future of medicine. We have even featured many such articles on this blog. Today, we summarize a few recent publications focused at improving care for for this patient population through bettering medication adherence and important health screening measures.
Dr. Josh Havens
In the first article, led by Dr. Josh Havens along with others from the UNMC community, antiretroviral medication refill history is linked to risk of HIV viremia from suboptimal medication adherence. In fact, this article showed that lower adherence to medication regimens was extremely strongly predictive of eventual virologic failure and reemergence of detectible virus. This underscores the importance of finding ways to promote adherence to antiretroviral therapy, something our next article in this digest addresses as well. Read more here.
Dr. Susan Swindells
As hinted at in the article linked above, one of the most important aspects of medical care for PLWH is maintaining adherence to antiretroviral therapy, something that is often difficult as many regimens require multiple doses per day with little room for error. This very problem is addressed by this second article, authored by Dr. Susan Swindells. The authors report success of injectable antiretroviral medication at 96 weeks into the study. This regimen is dosed every four weeks instead of orally, decreasing the burden of daily medication and improving compliance. Astoundingly, 100% (27/27) of the study participants preferred this new injectable regimen to their previous medications, and it was found to be at least as effective. Read the rest of the article here.
The last article tackles a different but equally important aspect of HIV medical care; screening for other diseases. PLWH have an increased risk of many other medical conditions, including lung cancer- the screening guidelines for which have just been updated. However, little is known about how to adjust these guidelines for specific subgroups of the PLWH population with additional risk factors. The authors, among them Drs. Fadul and Bares (pictured with the first article), identified a low rate of lung cancer screening in the PLWH population which creates an opportunity for quality improvement programs in HIV clinics. Read the full details and analysis here.
A #PharmToExamTable question about antibiotic resistance in S. aureus, answered by Feiyang Ding, PharmD, a Graduate of UNMC College of Pharmacy.
(Reviewed by Andrew Watkins, PharmD)
Background
Staphylococcus aureus has been recognized as an important cause of human diseases ranging from minor skin and soft tissue infections to fatal endocarditis, chronic osteomyelitis, or sepsis. Vancomycin has been the treatment of choice for serious infections caused by methicillin-resistant S. aureus (MRSA), and for many years, vancomycin resistance did not seem to be a problem in S. aureus. However, in 1997, a case of vancomycin-intermediate Staphylococcus aureus (VISA, MIC = 4-8) was reported in Japan. In that case, the MIC of vancomycin was 8 mcg/mL, and the patient was successfully treated with amoxicillin-clavulanate plus gentamicin. Subsequently, cases of VISA infections have been reported worldwide. Generally, the incidence of VISA is hard to estimate due to the rarity of infection and challenges related to laboratory detection.1 Shariati et al.2 performed a comprehensive systematic review of literature from 1997 to 2019 and found the overall prevalence rate was 1.7% among 22,227 S. aureus isolates. Incidence of vancomycin-resistant S. aureus (VRSA, MIC ≥ 12) was much lower, with 23 out of 5855 (0.39%) S. aureus isolates being reported as VRSA.2
Mechanism
Various studies, from morphological to molecular level studies, have been performed to determine the mechanism of S. aureus resistance to vancomycin.3 In morphological studies, VISA strains appeared to have a thickened cell wall compared to non-VISA strains, and it is believed that this could prevent the diffusion of vancomycin to its active site. Moreover, a fluorescence imaging study demonstrated that the vancomycin binding site D-Ala-D-Ala was also increased in resistant strains; however, these residues are maintained in the mature peptidoglycan due to the low carboxypeptidase activity and, therefore, they constitute potential nonlethal binding sites for vancomycin. By binding to theses inactive sites, access of vancomycin to the active sites are reduced. Another early phenotypic change observed in resistant isolates is reduced autolytic activity. Impaired acetate metabolism has also been described in very resistant strains, which could lead to altered antibiotic resistance and cell death. On the molecular level, a variety of experiments have identified mutations at genes, such as walkR, vraSR and rpoB in various resistant isolates4. In most cases, these mutations are involved with changes in the cell wall, leading to reduced vancomycin activity.
Treatment Options
Currently, there are no clinical trials on VISA/VRSA treatment, and few successfully treated cases are reported in the literature. As a result, the optimal regimen for treating infections due to VISA/VRSA remains uncertain. According to the 2011 IDSA MRSA treatment guidelines,5 for infections due to S. aureus with reduced susceptibility to vancomycin and daptomycin, options may include the following: quinupristin-dalfopristin, sulfamethoxazole-trimethoprim (TMP-SMX), linezolid, and/or telavancin (C-III). These options may be given as a single agent or in combination with other antibiotics. Kullar et al.6 performed a systematic review of literature examining salvage therapy for resistant/persistent MRSA bacteremia. Their findings are summarized below:
High-dose Daptomycin
Daptomycin is approved by the FDA for the treatment of S. aureus bacteremia and right-sided IE at 6 mg/kg/day. At this dose, however, non-susceptibility may occur. As a result, the IDSA MRSAB treatment guidelines recommend daptomycin to be dosed at 10 mg/kg/day when used as monotherapy. But currently there is no randomized trial comparing high- and standard-dose daptomycin in MRSA bacteremia treatment.
Ceftaroline
Ceftaroline is distinguished from other β-lactams by its uniquely high binding affinity for PBP-2a, thus conferring its activity against MRSA. In a retrospective evaluation of 527 patients treated with ceftaroline, most patients (80%) were initiated on ceftaroline after receipt of another antimicrobial, with 48% citing disease progression as a reason for switching. A total of 271 (51%) patients were culture positive for S. aureus. The median duration of ceftaroline treatment was 6 days, with an interquartile range of 4 to 9 days.7More clinical data is needed to analyze the effect of in patients with persistent MRSA bacteremia.
Linezolid
There are several successful case reports indicating the effectiveness of treating persistent MRSA bacteremia with linezolid alone. However, linezolid is bacteriostatic and its toxicities such as thrombocytopenia may limit its use clinically.8
Telavancin
Telavancin is a lipoglycopeptide which can inhibit cell wall synthesis as well as depolarize the cell membrane. With this additional mechanism of action, it has activity against VISA/VRSA. In vitro PK/PD data has demonstrated its activity against vancomycin and daptomycin non-susceptible S. aureus.9 In vivo studies for bacteremia treatment are needed for further evaluation.
Quinupristin/dalfopristin
In an observational study by Sander et al.10, Quinupristin/dalfopristin has been used in 9 patients with MRSA infections who failed vancomycin treatment initially. Of these patients, 7 out 9 achieved bacterial clearance with quinupristin/dalfopristin therapy.10 However, the use of this medication is limited due to its substantial adverse reactions such as hepatotoxicity, risk of superinfection and need for a central catheter for administration.
Vancomycin + β-lactam
In vitro studies have shown synergistic activity between vancomycin and several β-lactams like ceftaroline and oxacillin against S. aureus, and this synergy can be extended to VISA isolates.11 As salvage therapy, vancomycin combined with a β-lactam at or near the initiation of therapy seems to yield improved results compared with vancomycin monotherapy. In a retrospective study, MRSA bacteremia microbiological eradication was achieved in 48/50 patients (96%) who received vancomycin with a β-lactam (ampicillin, nafcillin, amoxicillin/clavulanate, piperacillin-tazobactam, cephalexin and meropenem and etc.) compared with 24/30 patients (80%) (P = 0.021) who received vancomycin monotherapy.12 Another open-label, multicenter trial conducted in Australia showed a shorter duration of MRSA bacteremia in patients receiving vancomycin plus flucloxacillin (n = 31, 1.94 days) compared to vancomycin alone (n = 29, 3 days).13However, CAMERA2 trial indicated that the combination of antistaphylococcal β-lactam to vancomycin or daptomycin were associated an increased risk of acute kidney injury without an significant improvement on mortality, bacteremia, relapse or treatment failure. 14
Daptomycin + β-lactam
The combination of daptomycin and β-lactam also shows synergistic activity in in vitro studies. β-Lactams with PBP-1 binding (e.g. meropenem, ampicillin, nafcillin, cefepime and piperacillin/tazobactam) appear to enhance daptomycin anti-MRSA activity the most.15 Sakoulas et.al16 reported the results of salvage therapy with daptomycin and ceftaroline combination therapy for persistent MRSA bacteremia in 22 patients. Of these, 2 patients had vancomycin intermediate S. aureus infections and 4 patients had daptomycin non-susceptible S. aureus infections. With the initiation of daptomycin plus ceftaroline, bacteremia cleared in a median of 2 days (range 1-6 days).
TMP-SMX + daptomycin/ceftaroline
Although guidelines suggest using TMP-SMX either alone or in combination with other recommended medications, a recent randomized controlled trial showed a greater bacteremia persistence with TMP-SMX monotherapy.17 Claeys et.al18 investigated the combination of TMP-SMX with daptomycin. For patients with persistent MRSA bacteremia, adding TMP-SMX to daptomycin could allow clearance of bacteremia in 2.5 days. Microbiological eradication was demonstrated in 24 out of 28 patients, and in vitro synergy was demonstrated in 17 of the 17 recovered isolates. For the combination of TMP-SMX with ceftaroline, a retrospective analysis studied 29 patients using ceftaroline alone, in which 23 switched to combination therapy. The median duration of bacteremia was 9.5 days (range 7-15 days) before the switch and 3 days (range 2-5 days) after the switch.19
Conclusions
Although various regimens have been suggested, trials have enrolled small numbers of patients and have yielded inconsistent results. Possible monotherapies for VISA/VRSA infection include telavancin, ceftaroline and linezolid. Possible combination therapies that have been investigated include daptomycin or vancomycin combined with a β-lactam and daptomycin or ceftaroline combined with TMP-SMX.
2 Shariati, A. et al. Global prevalence and distribution of vancomycin resistant, vancomycin intermediate and heterogeneously vancomycin intermediate Staphylococcus aureus clinical isolates: a systematic review and meta-analysis. Sci Rep10, 12689, doi:10.1038/s41598-020-69058-z (2020).
3 Howden, B. P., Davies, J. K., Johnson, P. D., Stinear, T. P. & Grayson, M. L. Reduced vancomycin susceptibility in Staphylococcus aureus, including vancomycin-intermediate and heterogeneous vancomycin-intermediate strains: resistance mechanisms, laboratory detection, and clinical implications. Clin Microbiol Rev23, 99-139, doi:10.1128/CMR.00042-09 (2010).
4 Hafer, C., Lin, Y., Kornblum, J., Lowy, F. D. & Uhlemann, A. C. Contribution of selected gene mutations to resistance in clinical isolates of vancomycin-intermediate Staphylococcus aureus. Antimicrob Agents Chemother56, 5845-5851, doi:10.1128/AAC.01139-12 (2012).
5 Liu, C. et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis52, e18-55, doi:10.1093/cid/ciq146 (2011).
6 Kullar, R., Sakoulas, G., Deresinski, S. & van Hal, S. J. When sepsis persists: a review of MRSA bacteraemia salvage therapy. J Antimicrob Chemother71, 576-586, doi:10.1093/jac/dkv368 (2016).
7 Casapao, A. M. et al. Large retrospective evaluation of the effectiveness and safety of ceftaroline fosamil therapy. Antimicrob Agents Chemother58, 2541-2546, doi:10.1128/AAC.02371-13 (2014).
8 Jang, H. C. et al. Salvage treatment for persistent methicillin-resistant Staphylococcus aureus bacteremia: efficacy of linezolid with or without carbapenem. Clin Infect Dis49, 395-401, doi:10.1086/600295 (2009).
9 Steed, M. E., Vidaillac, C. & Rybak, M. J. Evaluation of telavancin activity versus daptomycin and vancomycin against daptomycin-nonsusceptible Staphylococcus aureus in an in vitro pharmacokinetic/pharmacodynamic model. Antimicrob Agents Chemother56, 955-959, doi:10.1128/AAC.05849-11 (2012).
10 Sander, A., Beiderlinden, M., Schmid, E. N. & Peters, J. Clinical experience with quinupristin-dalfopristin as rescue treatment of critically ill patients infected with methicillin-resistant staphylococci. Intensive Care Med28, 1157-1160, doi:10.1007/s00134-002-1358-7 (2002).
11 Werth, B. J. et al. Novel combinations of vancomycin plus ceftaroline or oxacillin against methicillin-resistant vancomycin-intermediate Staphylococcus aureus (VISA) and heterogeneous VISA. Antimicrob Agents Chemother57, 2376-2379, doi:10.1128/AAC.02354-12 (2013).
12 Dilworth, T. J. et al. beta-Lactams enhance vancomycin activity against methicillin-resistant Staphylococcus aureus bacteremia compared to vancomycin alone. Antimicrob Agents Chemother58, 102-109, doi:10.1128/AAC.01204-13 (2014).
13 Davis, J. S. et al. Combination of Vancomycin and beta-Lactam Therapy for Methicillin-Resistant Staphylococcus aureus Bacteremia: A Pilot Multicenter Randomized Controlled Trial. Clin Infect Dis62, 173-180, doi:10.1093/cid/civ808 (2016).
14 Tong, S. Y. C. et al. Effect of Vancomycin or Daptomycin With vs Without an Antistaphylococcal beta-Lactam on Mortality, Bacteremia, Relapse, or Treatment Failure in Patients With MRSA Bacteremia: A Randomized Clinical Trial. JAMA323, 527-537, doi:10.1001/jama.2020.0103 (2020).
15 Berti, A. D., Sakoulas, G., Nizet, V., Tewhey, R. & Rose, W. E. beta-Lactam antibiotics targeting PBP1 selectively enhance daptomycin activity against methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother57, 5005-5012, doi:10.1128/AAC.00594-13 (2013).
16 Sakoulas, G. et al. Antimicrobial salvage therapy for persistent staphylococcal bacteremia using daptomycin plus ceftaroline. Clin Ther36, 1317-1333, doi:10.1016/j.clinthera.2014.05.061 (2014).
17 Paul, M. et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin resistant Staphylococcus aureus: randomised controlled trial. BMJ350, h2219, doi:10.1136/bmj.h2219 (2015).
18 Claeys, K. C. et al. Impact of the combination of daptomycin and trimethoprim-sulfamethoxazole on clinical outcomes in methicillin-resistant Staphylococcus aureus infections. Antimicrob Agents Chemother59, 1969-1976, doi:10.1128/AAC.04141-14 (2015).
19 Fabre, V., Ferrada, M., Buckel, W. R., Avdic, E. & Cosgrove, S. E. Ceftaroline in Combination With Trimethoprim-Sulfamethoxazole for Salvage Therapy of Methicillin-Resistant Staphylococcus aureus Bacteremia and Endocarditis. Open Forum Infect Dis1, ofu046, doi:10.1093/ofid/ofu046 (2014).
The following content was provided by Dr. Jonathan Ryder who, along with Dr. Cortés-Penfield, recently authored a fantastic article on this content in the journal Clinical Infectious Diseases.
Infectious diseases clinicians have nightmares when thinking about necrotizing fasciitis and toxic shock syndrome from group A streptococcus (GAS), given the rapid progression and high mortality. Since the 1950s, evidence emerged that penicillin alone was inadequate for these infections.[1] Clindamycin, which has antitoxin effects against GAS, emerged as a potential adjunctive antibiotic in the 1980s with clinical evidence of benefit being published in the late 1990s.[2, 3] However, the rising rates of clindamycin resistance in GAS, as high as 29.2% in 2020 in the US (Figure 1), bring to question whether clindamycin remains effective for the treatment of these severe infections.[4]
Recently, Dr. Nicolás Cortés-Penfield and I published a viewpoint article in Clinical Infectious Diseases critically analyzing the existing literature to determine the pros and cons of using clindamycin versus linezolid for necrotizing soft tissue infections and toxic shock syndrome due to GAS.[5] I outline the salient points of this debate below:
Pros of Clindamycin:
Preponderance of clinical data demonstrating the benefit of adjunctive clindamycin in our meta-analysis, demonstrating an odds ratio of 0.45 favoring clindamycin compared to no clindamycin across 8 retrospective studies
Resistance to clindamycin, when used with penicillin as a primary treatment, is not definitively correlated with worse clinical outcomes, although this area warrants further study given low-quality evidence
Cons of Clindamycin:
Rising resistance rates are highly concerning for a decrease in the effectiveness of clindamycin, including one study showing an increased risk of amputation with clindamycin-resistant isolates
Associated with a high risk for Clostridioides difficile infection
Pros of Linezolid:
GAS remains universally susceptible to linezolid, so there are no concerns with resistance to this treatment
Linezolid can replace empiric use of vancomycin for methicillin-resistance Staphylococcus aureus. This may decrease risk of acute kidney injury associated with vancomycin
Linezolid has a low risk of C. difficile infection and may even be protective
Cons of Linezolid:
There is minimal comparative literature between clindamycin and linezolid. Two small studies have not demonstrated a difference in mortality between the two drugs
Linezolid is slightly more expensive than clindamycin, but the net benefits of linezolid may outweigh these cost differences
In summary, the rise of antimicrobial resistance necessitates re-evaluation of our current therapies. Local resistance rates of clindamycin for GAS should be evaluated and may warrant re-consideration of the optimal antibiotic regimen for these serious infections, as linezolid retains its effectiveness. Further studies comparing clindamycin and linezolid are highly desirable, as we adjust to threats from antimicrobial resistance.
Figure 1: Clindamycin Resistance in Group A Streptococcus (GAS) Isolates in the United States per the Centers for Disease Control’s Active Bacterial Core surveillance (ABCs)[4]
References
1. Eagle H. Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice. Am J Med 1952; 13(4): 389-99.
2. Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle Effect Revisited: Efficacy of Clindamycin, Erythromycin, and Penicillin in the Treatment of Streptococcal Myositis. Journal of Infectious Diseases 1988; 158(1): 23-8.
3. Zimbelman J, Palmer A, Todd J. Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J 1999; 18(12): 1096-100.
5. Cortés-Penfield N, Ryder JH. Should Linezolid Replace Clindamycin as the Adjunctive Antimicrobial of Choice in Group A Streptococcal Necrotizing Soft Tissue Infection and Toxic Shock Syndrome? A Focused Debate. Clin Infect Dis 2022.
Today is the final day of IDWeek 2022. If you happen to be at the conference and missed our posts last week, here is a quick guide to UNMC members presenting today, October 23rd.
Sunday, October 23rd, 2022
8:30-9:00am – Nada Fadul, MD – Speaking on “Disparities of Post/Long COVID-19 Syndrome in Women and Young Adults”
Today is the fourth day of IDWeek 2022. If you happen to be at the conference and missed our posts last week, here is a quick guide to UNMC members presenting today, October 22nd.
Saturday, October 22nd, 2022
10:30-11:45am – Erica Stohs, MD, MPH – Panelist on ” Challenging Cases in Transplant Infectious Diseases”
12:15-12:45pm – Riley Ostdiek, Medical Student – Rapid Fire presenter on “A Highly Effective ID Physician and Infection Preventionist-led Interactive Webinar Series for Infection Prevention and Control Training Among Frontline Healthcare Workers”
12:15pm-1:30pm – Poster Presentations
Shawnalyn Sunagawa, PharmD – Sexually Transmitted Infection (STI) Therapy Compliance Pre and Post Centers for Disease Control and Prevention (CDC) STI Treatment Guideline Update
Jon Freese, Medical Student – Perceptions of the COVID-19 Vaccine within the Sudanese American Community
Salman Ashraf, MBBS – A Highly Effective ID Physician and Infection Preventionist-led Interactive Webinar Series for Infection Prevention and Control Training Among Frontline Healthcare Workers
Laura Fischer, MPH – Impact of Asymptomatic Upper Respiratory Viral Shedding in Pediatric Cardiothoracic Surgical Patients
Mackenzie Keintz, MD – Outcomes in Intravenous to Oral Antimicrobial Therapy in Beta-Streptococcus Species
Oliva Paetz, Medical Student – Missed Opportunities for Confirmatory HIV Testing at a Midwestern Medical Center
3:15-3:30pm – Jonathan Ryder, MD, and Clayton Mowrer, DO, MBA – Speaking on “Adoption and Utilization of Social Media among Adult and Pediatric Infectious Diseases Divisions and Fellowship Programs in the United States and Canada
4:05-4:30pm – M. Salman Ashraf, MBBS – Speaking on “Antibiotic Stewardship in Long-Term Care Facilities – We’re Doing It!
Today is the third day of IDWeek 2022. If you happen to be at the conference and missed our posts last week, here is a quick guide to UNMC members presenting today, October 21st.
Friday, October 21st, 2022
7:30-9:00am – Jasmine Marcelin, MD – Panelist on ” Women in ID”
10:30-11:45am – Sara Bares, MD – Panelist on “Challenging HIV Clinical Cases”
12:15pm-1:30pm – Poster Presentations
Bryan Alexander, PharmD – Clinical Outcomes and Cost Savings of Dalbavancin Use in OPAT: Focus on Complicated Staphylococcus aureus Infections
Anum Abbas, MD– Cerebrospinal Fluid Findings of Solid Organ Transplant Recipients with West Nile Virus Infections
Nikki Regan, APRN– Telehealth Utilization and 2-year Outcomes among People with HIV at a Midwestern Clinic
Ryan Boyland, Medical Student– Curbsiding Twitter: Potential Value and Patient Confidentiality Implications of Infectious Diseases Clinician Peer Consultations via Social Media
Riley Ostdiek, Medical Student– A Highly Effective ID Physician and Infection Preventionist-led Interactive Webinar Series for Infection Prevention and Control Training Among Frontline Healthcare Workers
Titilola Labisi, MHA, MPH– Telehealth Utilization and 2-year Outcomes among People with HIV at a Midwestern Clinic
Josh Havens, PharmD– Patient perspectives on pharmacy experiences for antiretroviral refills
Timothy McElroy, MD – Local Antibiogram for Mycobacterium abscessus Shows Variability from Previously Published Susceptibility Data
Josh Havens, PharmD– B/F/TAF in HIV-Infected Adults with Substance Use Disorders: BASE Week 48 Results
Jeremy Tigh, PharmD– Acute Kidney Injury Rates Before and After Implementation of Integrated Bayesian Software for Vancomycin Dosing
3:15-3:40pm – Scott Bergman, PharmD – Speaking on “Influential Publications in Antimicrobial Stewardship From the Past Year”
Today is the second day of IDWeek 2022. If you happen to be at the conference and missed our posts last week, here is a quick guide to UNMC members presenting today, October 20th.
Thursday, October 20th, 2022
Poster Presentations: 12:15pm-1:30pm
12:15pm-1:30pm – Poster Presentations
Erica Stohs, MD, MPH – Biofire pneumonia panel use in severe pneumonia and antibiotic treatment in COVID-19 patients
Casey Zelus, MD – BioFire FilmArray Pneumonia Panel Implementation: Examining Appropriate Usage and Opportunities for Diagnostic Stewardship
12:15-1:00pm – Trevor Van Schooneveld, MD – Speaking on “Pneumonia Panel Implementation Lessons”
1:45-3:00pm – David Brett-Major, MD, MPH – Panelist on “Unforgettable Cases in Tropical Medicine”
2:10-2:35pm – Kimberly Scarsi, PharmD – Speaking on “New Drugs and Delivery Systems”
3:15-3:50pm – Sara Bares, MD – Speaking on “LA ART: Ready for Use in High-Risk Populations? Pro/Con
Today is the first day of IDWeek 2022. If you happen to be at the conference and missed our posts last week, here is a quick guide to UNMC members presenting today, October 19th.
Wednesday, October 19th, 2022
9:45-10:45am – Nada Fadul, MD – Panelist on “Putting Quality into Practice
10:45-12:00pm – Trevor Van Schooneveld, MD – Speaking on “Careers in Antimicrobial Stewardship” as part of Fellows’ Day Workshop
7:30-9:30pm – Kimberly Scarsi, PharmD – Speaking as part of “State of the Science in HIV: Clinical Applications Across the Care Continuum”
In early September, the Nebraska Infectious Disease Society (NIDS) held its first meeting. Read on below for a fantastic recap of this meeting provided by UNMC ID’s Dr. Clayton Mowrer.
The NIDS annual inaugural meeting in the books, with a really great turnout of ID and public health providers from across the state. Here’s a brief recap of the morning:
The meeting started off with Dr. Maureen Tierney recapping our achievements in our first year, highlighting quite a bit of work that has already been done and emphasizing all that is still to be done.
Drs. Schnaubelt, Fadul, Lawler, and McClain sitting on a panel discussion.
Next, Dr. Angela Hewlett discussed the current multinational monkeypox outbreak. She relayed the situation update, noting some improvement seen in incidence here in NE. She also emphasized the differences in clinical presentations in this current outbreak compared with our previous understanding of the disease, reviewed the diagnosis, and noted the currently available treatment options as well as challenges to follow up. Dr. Hewlett’s discussion was followed by a panel discussion with Lt. Col. Elizabeth Schnaubelt, MD, Nada Fadul, MD, James Lawler, MD, MPH, and Kimmai McClain, PharmD. The panel took questions from the audience, generating some fascinating and important discussions regarding the processes for obtaining therapies and vaccines (improving, but still much to do on this front), the efficacy of TPOXX (which seems to speed clinical recovery and resolution of the lesions), and that there are many more opportunities to engage with our patients and make efforts to reduce stigmatization.
Daniel Cramer, APRN, FNP-c spoke on the experience UNMC’s Specialty Care Clinic has had with the implementation of and the implications following the administration long-acting ART (cabotegravir/rilpivirine). He began by reviewing the dosing, reviewed the eligibility criteria, and had a wonderful discussion of how they approach patient education about this new medication, which includes the use of patient liaisons. He wrapped up his talk with looking forward to the future and the hope of making this more available to our patients.
Arthur Chang, MD – pediatric ID faculty at CHMC – had a fantastic presentation of congenital syphilis, where he focused on a brief review with some highlighted discussion points. Important takeaways: 1) there are increasing rates nationwide, and the reasons are multifactorial; 2) the diagnosis and recognition of disease is complicated by varying testing requirements and methods within practices and among different specialties; 3) it is absolutely critical that there needs to be specific documentation about the diagnosis and treatment of the pregnant person during the pregnancy to avoid uncertainty when the baby is born.
Several individuals provided COVID-19 updates.
-David Quimby, MD, talked about the data behind some of the therapies used currently with acute COVID infections – particularly noting Paxlovid. He reviewed some of the studies behind the data: namely, EPIC-HR and the unpublished EPIC-SR, and how these data might be interpreted in real world management, suggesting that the highest benefit appears to be in our patients >60 years of age and high-risk.
-Maureen Tierney, MD, MS, presented an excellent review of what we know thus far regarding Long COVID (PASC). She notes that it is strikingly commonly reported in the US: 1 in 13 adults (7.5%) have with symptoms for more than 3 months. This syndrome seems most commonly reported in young persons, females > males, with Hispanic persons (9%) among the highest reported population. There does, however, seem to be some regional differences in prevalence.
– Alice Sato, MD, PhD, had a fantastic and thorough review on vaccinations, with a focus on the pediatric population, reminding us that kids do get sick and are hospitalized with COVID, and that long COVID can have a significant impact on the well-being of children (e.g., missing school or other activities due to their symptoms). She further highlighted some of the benefits of vaccination in children, noting the significantly reduced rate of MIS-C after vaccination, the excellent efficacy, while also highlighting the great safety profile, even in young (6 month-5 year old) persons noting that zero cases of myocarditis have been reported in this population. She wrapped up her discussion by noting the excellent efficacy of COVID vaccinations in early trials but that it is important to realize that the newer variants (BA.4/5) are the most antigenically distinct variants, thus the need for the newer bivalent boosters.
Dr. Jonathan Ryder reviewing vector-borne diseases in Nebraska at the NIDS meeting
Jonathan Ryder, MD, spoke in place of Jeff Hamik (the NE state vector-borne epidemiologist, who was unable to make the talk), and he provided a fascinating review of the epidemiologic data of vector-borne illnesses in NE. He reviewed: the rise in neuroinvasive cases of West Nile Virus; the appearance of invasive Aedes mosquitos (A. aegypti, A. albopictus) in SE NE, though providing reassurance that A. aegypti eggs cannot survive the winter here and are likely single events; the establishment of Ixodes ticks in NE as of 2019, with now a couple cases of Lyme disease and the isolation of B. burgdorferi from ticks here in NE; a rise in tick vectors for SFGR, Ehrlichia, and Tularemia. Because of these data, NE DHHS has received funding for further tick surveillance and testing. Lastly, he emphasized the important role that climate change is likely playing on the spread of such vectors and the rise in incidence of these diseases.
Finally, several trainees presented some fun cases:
Anne Lentino – a medical student with Creighton School of Medicine – presented a case of a child with Bartonella henselae infection, initially presenting as FUO.
Annie Nguyen – another medical student at Creighton – presented an impressive study reviewing the incidence of fungal infections in patients hospitalized with acute SARS-CoV-2 infection.
Stephen Cooper, MD, MPH – an internal medicine resident at Creighton School of Medicine – presented a really great QI study on improved awareness and usage of local antibiograms among resident trainees, providing excellent implementation protocol and follow up. The results were promising.
Mackenzie Keintz, MD – an infectious diseases fellow at UNMC – presented her research asking the question if or when it is appropriate for transition to PO antibiotics in uncomplicated beta-hemolytic streptococcal bloodstream infection. Early data suggests PO transition can reduce length of stay in stable patients.
And with that, our successful first meeting was brought to a close!
(Note: Photos of this meeting were taken from ID Nebraska’s Twitter page. Check them out here: @IdNebraska)
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