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EMR Order Set Speeds Time to Antibiotic Treatment in Musculoskeletal Infections

The UNMC contingent at the 2019 Musculoskeletal Infection Society, from right to left: Nurse Practitioners Dan Cramer and Tiffany Kalin, Dr. Angela Hewlett (Orthopedic Infectious Diseases), Dr. Curtis Hartman (Orthopedic Surgery). Dr. Hewlett moderated a scientific abstract session and served as a panelist for a prosthetic joint infection clinical case presentation session.

Dr. Angela Hewlett spends her time at UNMC not only studying Ebola but also working to prevent and manage musculoskeletal infections.  In addition to publishing this year’s update on “What’s New in Musculoskeletal Infection,” she collaborated with orthopedic surgeons, trauma surgeons, and emergency physicians to design and implement a new order set in the UNMC electronic medical record system to streamline antibiotic initiation in the setting of fractures.  Previously, physicians would have to build an antibiotic regimen for each of their patients, frequently resulting in ID consultation to determine the appropriate medication and dose.  By constructing an order set in the EMR, the authors hypothesized that providing clear and easily accessible instructions would lead to faster initiation of appropriate antibiotics in the emergency department.

The order set contains guidelines for fracture classification and recommended antibiotic strategies based on contamination, patient allergies and condition, and bacterial colonization. There are also direct links for providers to request an ID consult.

The results of their performance improvement project, published in the Journal of the American Academy of Orthopaedic Surgeons, were powerful.  Patients whose physicians used the new order set were evaluated sooner and received antibiotics faster compared to those whose physicians did not use the order set.  The order set has been rolled out at all UNMC/Nebraska Medicine sites and is available in the supplemental resources in their paper.

 


 

Medical Student Musings from #UNMCHIV2019

This year, the UNMC HIV Update for Care Providers and Educators on October 10, 2019 brought approximately 100 attendees to Omaha again to learn about new drugs, management approaches, and patient experiences with HIV. The CME conference was funded by the Nebraska AIDS Education & Training Center (AETC), [a local partner of the Midwest AETC], and the Nebraska Department of Health & Human Services. One of our medical students, Brandon Lew, attended and shared his thoughts about the conference here. 

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Every year, health professionals involved in the care for patients with HIV get together at the UNMC HIV Care Update Symposium. With the successes of antiretroviral therapy, HIV treatment has been one of the major healthcare successes of recent history. However, there is still progress to be made and the treatment for patients with HIV is continually improving.

This year the symposium took place on October 10, and I had the pleasure of attending the conference. It was a full day of talks organized by the UNMC ID healthcare professionals who staff the HIV Specialty Care Center. The talks began with UNMC physician Dr. Sara Bares, who set the stage in what’s new in HIV care. She established how HIV still impacts hundreds of thousands of lives, and discussed the hopes for making HIV a disease of the past with initiatives such as the Ending the HIV Epidemic. She then turned to the audience and asked what they thought the biggest barrier to ending the HIV epidemic in Nebraska was. Free responses were submitted through our phones and immediately a word cloud was generated using the audience’s answers. This was not only a super cool way of making the presentations interactive and engaging, but also highly impactful seeing professional consensus that 1) lack of education and 2) stigma were major barriers to HIV care.

The day went on with keynote speaker Dr. Timothy Wilkin (from Cornell) sharing about advances in antiretroviral therapies and Dr. Josh Havens speaking about the current state of Pre-exposure prophylaxis (PrEP), that is, medication for HIV prevention. In going to scientific conferences, these were the talks I was expecting and excited to see, learning about the state-of-the-art therapies and scientific studies. However, I was also pleasantly surprised by the number talks that did not revolve around the science and medical jargon.

Dr. Nada Fadul, MD, Precious Davis, MSN, RN, and Tommy Young-Dennis presented on connecting patients in a talk entitled “Meeting Them Where They Are: Strategies to Engage Black MSM in HIV Care and Prevention Services.” Their passion for not just treating, but truly caring for patients and their lives was striking. They advised to engage the patient and learn about their struggles, “keep it real,” and be mindful your own of verbal and nonverbal communication. Interestingly there were also talks which did not centrally focus on HIV, including presentations on current trends in illegal drug use in Omaha, and how to have a dialogue with refugee populations living around Omaha. These patient focused discussions and locally driven information were especially impactful because they were not jargon filled lectures, but rather topical information on subjects that are important for patient care.

One of the recurring and most impactful discussions for me was around “U=U”. I had learned of the phrase during a preceptorship at the Specialty Care Center, and as a medical student, I immediately identified it as a great learning tool. In medical school, there is so much to memorize, and acronyms become ubiquitous for learning. So when I learned that Undetectable = Untransmittable, or U=U, I identified it as an important educational tool not only for myself, but also in patient education. I knew that this phrase was effectively helping address one of the major barriers to HIV care, the lack of education.

However, what I did not realize is how U=U also addresses that second audience-identified barrier to HIV care, the stigma surrounding HIV. This discussion was the final topic of the symposium, and was the most impactful part of the day for me. Three patients with HIV spoke about their stories with HIV and their perspectives on HIV care, and the message of U=U. The stigma they had experienced throughout their lives due to HIV was heart breaking, describing denigration and isolation due to their diagnosis. They then described how the message of U=U was freeing from that stigma. Undetectable = Untransmittable; that is, NO risk of transmitting HIV through sexual contact. And for the patients, eliminating that risk of transmission can in turn eliminate the unending concern that one might transmit HIV to someone they love, or the isolation that some patients may feel in being labeled as HIV positive. Put in much better words by one of the panelists: “I am liberated from the cloud over me.”

Ultimately the symposium opened my eyes to what it means to care for patients with HIV. I learned about the cutting-edge advances in antiretroviral therapies and the current state of PrEP for HIV prevention. But importantly, I also learned that care for patients with HIV is much more than a viral load and CD4 count. It’s also about meeting them where they’re at, overcoming barriers to care, and addressing the stigma around HIV.

Happy National Pharmacy Week!

We LOVE our UNMC ID Pharmacists! This week is National Pharmacy Week and we want to share our appreciation and thanks for the hard work and invaluable contributions of our pharmacists at UNMC ID. Our pharmacists are not only exceptional clinicians giving us the clinical advice we need on antimicrobials and drug interactions, but they are also published national experts in Antimicrobial Stewardship and HIV, experienced educators in both the College of Pharmacy and College of Medicine, and phenomenal colleagues all-around. Our division would not function as well as it does without these individuals, and we do not thank them enough.

Meet our UNMC ID Pharmacists:

(TOP ROW L-R):

Josh Havens, PharmD, BCPS: Pharmacy Coordinator of the UNMC Specialty Care (HIV) clinic, PI on several clinical studies, coordinator of our Pre-exposure Prophylaxis (PrEP) clinic, and HIV clinic pharmacy rotation preceptor.

Kimberly Scarci, PharmD, MS, FCCP, BCPS-ID: Clinical Pharmacist at UNMC Specialty Care clinic, HIV clinic pharmacy rotation preceptor, HIV principal investigator with many collaboration on AIDS Clinical Trials Group (ACTG) studies and recipient of several research awards. She is also a College of Pharmacy representative on the UNMC Faculty Senate and member of the HIV Medicine Association (HIVMA) board of directors.

Phil Chung, PharmD, MS, BCPS, BCIDP: Antimicrobial Stewardship pharmacist and Pharmacist coordinator of the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP). He coordinates the outreach stewardship programs and participates in several clinical studies relating to this.

(BOTTOM ROW L-R):

Anthony Podany, PharmD: Clinical Pharmacist at UNMC Specialty Care clinic, HIV clinic pharmacy rotation preceptor, and HIV researcher with many collaboration on AIDS Clinical Trials Group (ACTG) studies.

Andrew Watkins, PharmD: PGY2 ID Pharmacy Resident

Bryan Alexander, PharmD, BCIDP, AAHIVP: Clinical and Antimicrobial Stewardship Pharmacist and coordinator of Outpatient Parental Antimicrobial Therapy (OPAT) program.

Scott Bergman, Pharm.D., BCPS, FIDSA: Antimicrobial Stewardship Pharmacy Coordinator, ID Pharmacy Residency Program Director, Pharmacy residency ID rotation education coordinator and preceptor, education award recipient

 

#IDWeek2019: An infectious air of inclusion, knowledge, and empowerment

This year, our ID division was well represented at IDWeek, with several residents and students attending (and presenting) for the first time. One of our third year Internal Medicine/Pediatrics residents interested in Infectious Diseases, Dr. Joe Wang, wrote about his experiences, published last week on Doximity. We are very proud of him and share his IDWeek recap below:

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IDWeek is the seminal event for Infectious Diseases (ID) occurring annually in October. During this week-long event, current and future ID specialists from all over the world converge to share their latest research, cases, experiences, and stories of the past year. This event fosters a multinational, interdisciplinary, collaborative approach and the continued dissemination of scientific and social knowledge across the world. Perhaps more importantly, this event gives the opportunity for old friends, colleagues, and mentors/mentees to reunite and for new connections to be made.

Dr. Wang with his mentors, Dr. Marcelin (top) and Dr. Cawcutt (bottom)

This year, as a third year Internal Medicine/Pediatrics resident, I had the privilege to attend my first IDWeek in Washington D.C. and presented two scientific posters to the ID community. Let me tell you, for all the hype there was beforehand, it did not disappoint. From day one, attendees could sense an infectious air of inclusivity, knowledge, and empowerment throughout the convention center. The entire community embraced all of us first-timers and support for all of us from our home institution and well beyond was unparalleled.

The knowledge and science found at ID Week was beyond anything I had imagined. Multiple lectures on challenging cases in all areas of ID as well as novel approaches and research to clinical conundrums dotted the program. There were updates on the Ebola outbreak, flanked by updates in the world of prosthetic joint infections, HIV, diarrheal illnesses, excited discussions about the new community-acquired pneumonia guidelines — the list goes on and on. Thousands of amazing posters were presented by trainees and faculty, across multiple professions, from all reaches of the world, providing insight and innovation into every conceivable area of ID and then some.

The convergence of a major scientific community on the capital of the United States was also not lost amidst the scientific rigor of the conference. From lectures on healthcare and career disparities in our field to infectious diseases amongst refugees (and how international travelers carry more risk for disease spread and transmission than refugees), to the importance of vaccination, particularly as we see resurgence of vaccine-preventable diseases, IDWeek made sure to rise as a singular voice against discrimination, prejudice, and inequality. With an ever-present voice in the Twitterverse, ID is taking up the mantle for change within the medical community.

Vaccines and vaccine-preventable diseases (particularly measles) have been making recent headlines, and IDWeek took up the cause without hesitation. The NIH director Dr. Francis Collins and TIME Magazine Person of the Year and computational genetics expert Dr. Pardis Sabeti opened up the meeting with a fantastic plenary on outbreaks and genomics. For anyone who thinks ID docs don’t know how to have fun, think again! Social media from that day was flooded with video clips and images of Dr. Collins (wearing a “Vaccines cause Adults” t-shirt) and Dr. Sabeti rocking out with Dr. Collins’ band the Affordable Rock & Roll Act. Later in the week, during a plenary on vaccine hesitancy, ID specialists flooded social media with a #WhyIVaccinate Twitterstorm. A “Plague Doctor” visited IDWeek to call attention to recent outbreaks of vaccine-preventable diseases. Almost 5,000 unique tweets about vaccination posted during IDWeek sent a loud and clear message that vaccines work, period.

I left IDWeek with a newfound sense of pride in the field of medicine that I plan to pursue and that has embraced me from day one. From cutting edge research into antimicrobial resistance to the fight against healthcare and career disparities, IDWeek has left this young physician in training with a stronger sense of purpose and affirmed that I have chosen the right career. IDWeek has left me eager to see what we as an ID community can bring to the table to change not only ID but also the world. I also left IDWeek with something I never thought I would have: a Twitter account (@JoeWangDO)! In the days since IDWeek, #IDTwitter has not disappointed and is something I look forward to checking up on every day. You could say I caught the “Twitter bug” at #IDWeek2019.

IDWeek is an amazing opportunity to meet your fellow ID enthusiasts and to connect with those across the nation and across the world. If you’re interested at all in ID, meet me in 2020 in Philly! From the way it looks, it’s going to be a great time!

Celebrating Global Handwashing Day!

Established by the Global Handwashing Partnership in 2008, Global Handwashing Day is celebrated each year on October 15 as a way to increase awareness and understanding of the benefits of handwashing with soap. Global Handwashing Day is an opportunity to get involved in creative ways to encourage people to wash their hands with soap at critical times.

The Infection Control & Epidemiology team took the opportunity to promote hand hygiene with our front line staff.  We prepared bags of cheery stickers saying “I cleaned my hands” and life saver candies.  The CDC “Life is better with clean hands” picture was enclosed in each sticker/candy bag with the following phrase:  Thank you for being a “Life Saver” at Nebraska Medicine”.

We asked our Leadership team to round in clinical areas and catch our front line staff/providers performing hand hygiene.  Our Dr. Linder, our CEO and Mr. Cory Shaw, COO also took bags of stickers and vowed to round in clinical areas.  When caught in the act, leaders thanked the staff member for being a “lifesaver” by performing hand hygiene, gave them a sticker and a life saver candy.  Many managers captured fun poses of their staff and shared them with Infection Control.

 

It was gratifying to see the teams have fun with it.  It was such a simple way to have fun at work but raise awareness about the importance of hand hygiene.

Written by Terry Micheels, MSN, RN, CIC; Manager of Infection Control & Epidemiology, UNMC/NM

Why I Love ID – Dr. Nicolas Cortes-Penfield

What about ID makes you excited?

I love a good medical mystery or diagnostic challenge.  Infectious disease specialists are often the experts other physicians turn to when they’re stumped by a patient’s seemingly inexplicable symptoms – a persistent fever, a perplexing rash, abnormal bloodwork that hints at inflammation in the body no one can seem to track down.  As a kid who grew up listening to Car Talk on NPR and wondering at how the two hosts could make diagnoses over the phone that other mechanics had missed in person just by getting a good story, that aspect of the job really resonates with me. I still find making tough diagnoses that have frustrated patients and their doctors immensely satisfying.

I also appreciate that Infectious Diseases gives me the opportunity to move though all of the different domains of medicine.  By that, I mean that the ID team may be called to see patients in the Emergency Room, on the post-operative surgical ward, in the ICUs, in Labor & Delivery, or anywhere else, sometimes all in the same day.  We get to interact with all of the various other types of clinicians – hospitalist, medical and surgical specialists, radiologists, pathologists, laboratory microbiologists, pharmacists, nurses, etc – and rather than focusing on a single organ system and a handful of diseases we’re challenged to consider the whole patient and the full spectrum of medical illness.

Finally, I love that the keys to challenging ID cases are often in the social history – that is, in asking the patient the sorts of questions about their lives that are too often curtailed in the bustle of modern medicine. That means that part of doing my job well is spending the time to uncover the unique and more interesting sides of my patients and having the opportunity to develop a bit of a relationship.  Do you volunteer at the zoo and clean the cages in the rodent house?  Did you live in the Middle East for a year overseeing an oil pipeline construction project? Did you vacation in the rainforests of Borneo and sleep outside on the dirt?  Did you eat raw bear meat, unpasteurized cheese, or a live snail?  Please, tell me all about it!

Pharm2Exam Table: Does methenamine prevent recurrent urinary tract infections (UTIs)?

The following is a clinical review written by Lauren Hoeft, PharmD, a recent graduate of the UNMC College of Pharmacy, and supervised by Scott Bergman PharmD FIDSA, Clinical Pharmacy Coordinator of Nebraska Medicine Antimicrobial Stewardship Program

Does methenamine prevent recurrent urinary tract infections (UTIs)?

Urinary tract infections (UTIs) are one of the most common indications for the use of antibiotics. A UTI is diagnosed not only based on the presence of bacteria in the urine, but also requires the presence of symptoms. Common symptoms of UTI include, but are not limited to, dysuria, pain or burning sensation with urination, increased frequency, and urgency. Asymptomatic bacteriuria is primarily treated in pregnant women, immunocompromised individuals, or those with a planned invasive urological procedure scheduled. Recurrent UTI is defined as 2 or more infections within 6 months or 3 or more infections within 1 year. These are often a reinfection, not a relapse of the previous infection.

There are many approaches to prevention of recurrent UTI’s. The most commonly used approach and current standard of care is the use of antibiotics such as sulfamethoxazole/trimethoprim or nitrofurantoin as suppressive therapy. They are typically dosed once daily and used for long periods of time. The major concerns with this are a risk of selecting out resistant organisms that must be treated with a broader spectrum antibiotic if the infection recurs as well as side effects.

With the increasing amount of antibiotic resistance, methenamine seems to be a promising strategy for prevention of recurrent UTIs. Methenamine is an oral antiseptic agent that is converted to formaldehyde in acidified urine, and as a result has general antibacterial activity. There are two different salt forms of methenamine available via prescription, as well as several over the counter products containing methenamine. Methenamine hippurate is dosed 1000 mg twice daily and methenamine mandelate is dosed 1000 mg four times daily. The over-the-counter products, such as Cystex and AZO Antibacterial Protection, contain 162 mg of methenamine per tablet with recommended dosing of 2 tablets three times a day. Methenamine can be taken with food (or without) to reduce upset stomach. It should also be taken with plenty of water to avoid bladder irritation due to increased formaldehyde concentration. Methenamine should not be crushed or chewed because it is enteric coated and would otherwise form formaldehyde in the stomach.8

The available data regarding efficacy of methenamine in prevention of UTIs is insufficient.2 A Cochrane review in 2012 assessed the findings of 13 studies (n=2032) that tested the use of methenamine for treatment of UTIs. Overall the results were not significant. Subgroup analysis of 4 studies (n=456) showed some benefit compared to placebo in treatment of patients without renal tract abnormalities (RR 0.24, 95% CI 0.07-0.89). Further analysis of 3 studies (n=319) demonstrated that treatment for 7 days or less in patients without upper renal tract abnormalities is also more effective than placebo (RR 0.14, 95% CI 0.05-0.38). Limitations in the Cochrane review were the lack of consistency in defining UTI among studies, many of the studies were unblinded, and significant heterogenicity among studies (I2 = 71.8%).7

One of the studies compared methenamine, trimethoprim, nitrofurantoin, and placebo. The UTI recurred in 34.2% of the patients taking methenamine compared to 63.2% with placebo. Recurrence was also observed in 10.4% of those taking trimethoprim and in 25.0% of those taking nitrofurantoin. All three treatment options were superior to placebo in this study with trimethoprim being significantly better that the others. This study also looked at the rate of recurrence with trimethoprim-resistant organisms, and there was no difference in the incidence among the groups. The major limitations to this study are that it was unblinded and was conducted in 1981 when bacterial resistance was less common.6 A second study comparing methenamine to sulfamethoxazole/trimethoprim (SMZ/TMP) in 1975 found that there were significantly less bacteriuria and pyuria in the SMZ/TMP group compared to methenamine as well as fewer acute clinical episodes of UTI.5

Based on the Cochrane Review and other studies, the use of methenamine for a short duration (7 days or less) in patients without renal tract abnormalities may be effective and is likely better than no intervention to prevent recurrence. Because methenamine is only converted to formaldehyde inside the bladder, it should not be used to prevent or aid in treatment of UTIs outside of the lower urinary tract.

Overall methenamine is safe to use and generally well tolerated. The most common side effects are nausea, vomiting, dyspepsia, pruritus, or skin rash. Taking larger doses than recommended can result in bladder irritation, frequent/painful urination, albuminuria, or hematuria. Methenamine should be used with caution in patients who also have gout due to an increased risk of urate crystal precipitation in the urine. Methenamine should not be used in patients with renal impairment due to increased risk of side effects and little data on its effects in these patients. It should also not be used in severe hepatic impairment because there is a higher risk of reversible increases in liver function tests. Methenamine should not be used in combination with sulfonamide antibiotics due to the risk of insoluble precipitate formation. Other drug-drug-interactions with methenamine exist but are less severe – check for medication interactions before prescribing or dispensing.8

Methenamine will be most useful in preventing UTIs caused by E. coli, which is the most common pathogen. Some bacteria have the intrinsic ability to split urea and make the urine more alkaline, which will prevent the release of formaldehyde from methenamine making it routinely ineffective. Typical pathogens causing UTIs with this capability are Proteus, Klebsiella, Pseudomonas, Staphylococcus. Methenamine may also be rendered less effective if the patient’s diet is high in most fruits, vegetables, milk, or other dairy products that alkalinize the urine. It is recommended to eat more protein and fruits such as cranberries, oranges, plums, or prunes to make the urine more acidic.

Cranberry herbal supplements are another option for the prevention of recurrent UTIs. There is some evidence that cranberry may be effective, but the data is similar to that of methenamine. A randomized controlled trial comparing the use of cranberry capsule to placebo showed no difference in the rate of recurrent UTI among premenopausal women (25.9% vs. 29.5% respectively).4 Other non-pharmacologic strategies include increasing fluid intake3, voiding after sexual intercourse, and avoiding spermicides as a method of contraception.1

Currently the standard of care for patients with recurrent UTIs is the use of antibiotic suppressive therapy due to its known efficacy. Unfortunately, the use of antibiotics long-term increases the risk of bacterial resistance and puts the patient at risk for experiencing medication side effects. With the increased risk of resistance, the use of methenamine may become more common practice or at least better studied in the future.

References

1. Barclay J, Veeratterapillay R, Harding C. Non-antibiotic options for recurrent urinary tract infections in women. BMJ. 2017.

2. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases. 2010;50(5):625–663.

3. Hooton TM, Vecchio M, Iroz A, et al. Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial. JAMA Intern Med. 2018;178(11):1509–1515. doi:10.1001/jamainternmed.2018.4204

4. Juthani-Mehta M, Van Ness PH, Bianco L, et al. Effect of Cranberry Capsules on Bacteriuria Plus Pyuria Among Older Women in Nursing Homes: A Randomized Clinical Trial. JAMA. 2016;316(18):1879–1887. doi:10.1001/jama.2016.16141

5. Kalowski S, Nanra RS, Friedman A, Radford N, Standish H, Kincaid-Smith P. Controlled Trial Comparing Co-Trimoxazole and Methenamine Hippurate in the Prevention of Recurrent Urinary Tract Infections. Med J Aust. 1975;1:585–9.

6. Kasanen A, Junnila SYT, Kaarsalo E, Hajba A, Sundquist H. Secondary Prevention of Recurrent Urinary Tract Infections: Comparison of the Effect of Placebo, Methenamine Hippurate, Nitrofurantoin, and Trimethoprim Alone. Scand J Infect Dis. 1982;14:293–6.

7. Lee BSB, Bhuta T, Simpson JM, Craig JC. Methenamine hippurate for preventing urinary tract infections (Review). Cochrane Database of Systematic Reviews. 2012;(10).

8. VATRING PHARMACEUTICALS, INC. Urex™ (methenamine hippurate) [Internet]. FDA Access Data. FDA; 2006. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/016151s025lbl.pdf

Strong, Smart, and Bold: UNMC ID Faculty Empower Young Women at Girls, Inc.

Dr. Caitlin Murphy presents to girls at Girls, Inc. Omaha.

Strep, pneumonia, microbiome, oh my! ID physicians Dr. Alison Freifeld, Dr. Andrea Zimmer, and Dr. Erica Stohs and Dr. Caitlin Murphy, Assistant Director of the Clinical Microbiology Laboratory, recently brought the world of infectious disease medicine to young women at Girls Inc. Omaha.  Girls learned about common infections and the bugs that cause them, the bacteria that inhabits the world around them, and careers in microbiology and infectious disease.

Dr. Andrea Zimmer shows girls cultures grown from dirty and clean hands and household locations

This event is one of many connections between UNMC and Girls Inc., a national nonprofit dedicated to “inspiring girls to be ‘strong, smart, and bold.’”  Dr. Freifeld started working with the Omaha chapter when she came to UNMC almost 20 years ago, when the chapter operated out of a church basement.  Since then, Girls, Inc. Omaha has grown to two dedicated locations that provide after-school enrichment activities, homework help, mentorship, and career advising to girls across the city.

Dr. Alison Freifeld is excited to talk to the girls about oral flora!

In 2016, Dr. Freifeld was instrumental in forging a partnership between UNMC/Nebraska Medicine and Girls, Inc. to open a primary care clinic at one of the chapters. The clinic is open after school and provides annual physicals, longitudinal care, well woman visits, reproductive health education, and urgent care.

As a student, I am both impressed and excited by the community outreach and impact of our physicians.  I’m proud to be at an institution with such compassionate, innovative, and altruistic clinicians, and I am hopeful, seeing their examples, that my future career can include meaningful service.

 


 

Special contributor: Dr. Shipra Goel

Dr. Shipra Goel joined us for the summer as an observer in the Infectious Disease Department.  We’re excited to include her contributions to our blog during the month she was with us!

My journey to an exciting observership at UNMC was enabled by my passion for infectious diseases (ID) which was virulent enough to infect Dr. Marcelin from 8000 miles away. Thanks to social media, which has made the world much more connected and interactions with mentors much easier, I could follow and reach out to people who inspired me. Social media in its various forms provides a means to young physicians to voice their opinions, showcase their mettle, and follow and learn from leading figures in their fields.

On one of these social media websites, when I was looking for like-minded people and luminaries in ID, a field I am extremely passionate about, I happened upon the UNMC ID Twitter account. Through this, I came across one of the most incredible and enthusiastic group of doctors working in ID.

I devoured every post and discussed and debated them with my peers. I followed Dr. Marcelin religiously while working in a land far far away. Over time, I longed for more direct learning, and I worked up the courage to reach out to her. I wrote to her that I aspire to pursue an ID fellowship in the United States and do substantial research in the field. She was enthusiastic and provided invaluable guidance, telling me about the observership opportunity, and helping me with the application process.  I could not have had this experience without her.

I have always been someone who gets really excited about opportunities to learn, and I am so glad to have the opportunity to come to UNMC for an observership.  The ID department at UNMC has gained recognition worldwide, and I have often been part of discussions of scientific papers where UNMC-ID research was referenced or referred to back in India as well.

My passion for ID has been chiefly driven by my ardent love for peace and harmony in the world and the aspiration to alleviate preventable suffering to work towards these lofty goals. I believe a better, healthier world can only be created if we recognise the multiple facets of microbes and understand that humans need not fight them but instead need to find better ways to live in harmony with them. I see this as a way to combat antibiotic resistance and prevent major outbreaks that the world faces every so often.

This is one of my favorite quotes about microbes from one of my favorite books – “Missing Microbes” by Martin Blaser:

“Microbes are invisible to our naked eye, with a few exceptions that reinforce the rule. Millions can fit into the eye of a needle. But if you were to gather them all up, not only would they outnumber all the mice, whales, humans, birds, insects, worms, and trees combined- indeed all of the visible life- forms we are familiar with on Earth- they would outweigh them as well. Think about that for a moment. Invisible microbes comprise the sheer bulk of the Earth’s biomass, more than the mammals and reptiles, all the fish in the sea, the forests. “

Here’s a brief introduction to my credentials:

I received my MBBS (equivalent to an MD in the US) from Lady Hardinge Medical College, New Delhi, one of the oldest and most prestigious medical schools in India. During my studies I discovered and developed my aptitude for ID and research by working on projects under the aegis of Indian Council of Medical Research (ICMR) . Under the tutelage of professors from my medical school I received my initial training in research methodology and had an enriching experience.

After medical school, I pursued Post Graduation training in Clinical Microbiology and ID from Maulana Azad Medical College, New Delhi, where Dr. Anita Chakravarti, a luminary in the field of virology, served as my guide and mentor over 3 years. This cemented my interest in research on infections, their diagnosis, and their management. I have experience in hepatic viruses, arboviruses, encephalitis causing viruses, and transplant virology, and I have published several research papers in these fields (you can find some of my publications here). I am keen to take on further challenges in ID, and I am really excited for my time at UNMC and looking forward to this wonderful month of opportunity and growth.


 

Journal Club – Stewardship in Community Hospitals: How should we spend our limited resources? 

Stewardship in Community Hospitals: How should we spend our limited resources? 

The following is a review by our ID Fellowship Program Director Dr. Trevor Van Schooneveld from our last Infection Control/Antimicrobial Stewardship Journal Club. He discussed the article by Anderson et al: Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals. JAMA Network Open.  2019;2(8):e199369.  

Antimicrobial stewardship is important to improving patient care and outcomes and numerous entities recommend that hospitals implement an Antimicrobial Stewardship Program (ASP).  Joint Commission requires ASPs in all settings and CMS is considering requiring all acute care facilities to have ASP.  While ASP are common at large medical centers, smaller facilities including both community hospitals (CH) and critical access hospitals (CAH) are much less likely to have an active ASP.  Additionally, the utility of strategies commonly employed in large facilities such as pre-authorization of antimicrobials (PA) and post-prescription review of antimicrobials (PPR) have not been evaluated in these smaller facilities who often lack ID trained personnel to support their program.

Anderson and colleagues set out to evaluate the feasibility and impact of implementing these two common strategies (PA and PPR) in four community hospitals.  They enrolled 4 moderately sized CH (median 305 beds) who did not previously have an ASP and trained at least one pharmacist at each location in appropriate antibiotic use and conflict resolution.  They implemented PA at 2 facilities and PPR at the other 2 for 6 months with both strategies focusing only on use of vancomycin, piperacillin/tazobactam (PT), and carbapenems.  There was then a one month washout period followed by implementation of the alternative strategy.  The local pharmacists has their stewardship time financially supported by the study site and received bimonthly feedback from the study center which has regional expertise in stewardship.  Clinical guidelines were available to assist evaluation of antibiotic appropriateness.  Local ID clinicians were only available routinely at one site and were not involved the ASP.

The primary outcome was to determine if ASP implementation was feasible which it was in each facility.  Although it should be noted that strict PA where an antibiotic is not distributed until approved was not feasible at any site and a modified PA was implemented where the first dose was distributed and then the appropriateness reviewed by local pharmacists.  Both pharmacists and physicians were somewhat skeptical about the improvement to patient care in post-implementation surveys.  While nearly 50% of clinicians said they didn’t make any changes to antibiotics based on pharmacist recommendations over 30% admitted to choosing a non-study antibiotic to avoid a pharmacist call.  The intervention was limited in scope as it only captured 30% of all study drug prescriptions.  There were significant differences in the PA and PPR group with more antibiotics judged “appropriate” in the PA group and fewer interventions.  The PPR group judged 41% of all study antibiotics inappropriate and intervened much more frequently, often with recommendations to de-escalate.  Study antibiotic use did not significantly change although this was likely confounded by a PT shortage and increases in vancomycin use at all facilities the authors hypothesized was due to the introduction of the SEP-1 quality measures.  Overall antibiotic use did not decrease during the PA portion but declined significantly with PPR.  It should be noted that while statistically significant the decline represented a 5% decrease in use.

What lessons can we take from this study?

  • Antibiotic use in CH is as high as many large facilities and there is a great opportunity to improve antibiotic use in these facilities.
  • Implementation of stewardship strategies is feasible in CH but the mechanisms used in this study did not generate major improvements in antibiotic use.
  • Pre-authorization seemed to be less effective in CH. This may be due to lack of empowerment of local pharmacists, early diagnostic and clinical uncertainty, or lack of ID involvement in PA support.  Better support for PA, particularly from ID experts, should be present if it is to be employed.
  • PPR, while showing some utility, could be improved in its effectiveness. Nearly 70% of study medications had no intervention likely due to availability factors with a single trained pharmacist at most sites, only operating during business days, and targeting PPR to 72 hours post-prescription when the median LOS was only 2 days.
  • In review of individual facility data some facilities were successful at decreasing antibiotic use while others saw only small decreases or even increases. This is likely due to local factors which may include pharmacist comfort with interventions, pharmacist communication effectiveness, clinician willingness to accept advice, and institutional prescribing culture.
  • It is likely that team-based stewardship activities supported by ID experts may be more successful. The local pharmacists received feedback from the study site but it is unclear how instructive and supportive this feedback was.  Additionally, it does not appear a local stewardship team was develop.  Multidisciplinary involvement with strong support from local leadership is essential to successful ASP development and implementation.

The authors of this study should be complimented for both addressing an oft neglected areas of ASP implementation (smaller facilities) and attempting to delineate which primary stewardship strategy is most effective in these settings.  For those who participate in ASP in CH and CAH this study provides much to learn from.

Anderson DJ, Watson S, Moehring RW, et al.  Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals.  JAMA Network Open.  2019;2(8):e199369.  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2748048

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