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PharmToExamTable: What do we know about Etravirine for HIV?

Recently, several of our HIV pharmacist colleagues in our Division of Infectious Diseases at UNMC/Nebraska Medicine, published an invited review in Clinical Pharmacokinetics entitled: Clinical Pharmacokinetics and Pharmacodynamics of Etravirine: An Updated Review.  The first author, Dr. Josh Havens PharmD, wrote this summary describing the review article.

What prompted the review?

This was an invited review, but there was only one previously completed shortly after etravirine’s FDA approval in 2009.

What do we know about the role of etravirine in ART regimens today?

Etravirine was initially brought to market as an additional agent to be used in conjunction with ritonavir-boosted darunavir in patients who were on failing regimens.  In the phase III, DUET-1 and -2 trials, the addition of etravirine to an optimized background regimen resulted in significantly greater improvements in HIV viral suppression.

In the US, etravirine’s use has declined secondary to the advent of integrase strand transfer inhibitors and etravirine’s twice daily dosing frequency.  Further, etravirine exhibits significant potential for bi-directional drug-drug interactions with other antiretrovirals as well as concomitant medications.  In other countries, specifically in Europe, etravirine has been used with once-daily dosing.  In pharmacokinetic studies, etravirine once-daily did not significantly differ from twice daily dosing by systemic exposure (AUC), but resulted in slightly higher max concentations (Cmax) and slightly lower trough concentrations (Cmin).

Etravirine has also been studied in small populations of antiretroviral naïve patients with variable results.  In comparison to DHHS guideline recommended antiretroviral regimens, etravirine use in naïve populations was less favorable by efficacy measures.  As a result, we still see etravirine’s use in the same way it was initially approved.  Once-daily dosing may be favorable in some patients to improve adherence granted that therapeutic drug monitoring may be available to verify sufficient etravirine plasma concentrations. Additionally, etravirine is now approved for use in children down to 2 years old with weight based dosing (BID only) and offers an additional agent in the form of a dissolvable tablet for use in this population.

What are the high-level take-aways about how/when to use etravirine?

Europe uses therapeutic drug monitoring more readily for ART than the US and thus uses once daily etravirine more frequently.  Given our stance on refraining from its use in naïve populations with a regimen such as ETR + F/TAF, as was done in the UNC study (78% VS rates at week 48), we feel the most likely patient that would use etravirine would be someone with some resistance and the risk of using once daily etravirine in this type of patient would likely be greater than its benefit.

What is the biggest gap in the science/knowledge about the role of etravirine in ART?

Further studies of etravirine use once daily in both adults and children may be warranted.  Given the efficacy of INI’s, we don’t feel that ETR has a place in naïve regimens.

Read the full study here: Havens, J.P., Podany, A.T., Scarsi, K.K. et al. Clin Pharmacokinet (2019). https://doi.org/10.1007/s40262-019-00830-9

Unpacking the new IDSA Community-Acquired Pneumonia guidelines

We are always excited to have our ID fellows provide guest blog posts. Second year ID fellow Dr. Lindsey Rearigh (follow her on Twitter @LRearigh) was recently on her Antimicrobial Stewardship rotation and reviewed the latest published guidelines for Community-Acquired Pneumonia (CAP). 

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) recently released updated community-acquired pneumonia (CAP) guidelines. The first immediate implication is the healthcare-associated pneumonia (HCAP) definition is gone for good. IDSA had previously retired the term in the 2016 hospital-acquired pneumonia/ventilator-acquired pneumonia (HAP/VAP) guidelines.

HCAP was previously defined as patients with any one of the following risk factors: residence in a nursing home or other long-term care facility, hospitalization for >/= 2 days in the last 90 days, receipt of home infusion therapy, chronic dialysis, home wound care or a family member with a known antibiotic-resistant pathogen. This category would help guide empiric antibiotic therapy (before an organism is known), which could include treatment of methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and other multi-drug resistant pathogens.

In these new guidelines, clinicians are now recommended to empirically treat for MRSA or P. aeruginosa in adults with CAP only if locally validated risk factors for either are present. The most consistently strong individual risk factors for MRSA/P. aeruginosa include previous lower respiratory tract infection (LRTI) with MRSA or P. aeruginosa, hospitalization within last 90 days, or if the patient had received intravenous (IV) antibiotics within that time-frame. If empiric MRSA or P. aeruginosa therapy is started, the guidelines recommend de-escalation at 48hrs if cultures remain negative.

Traditional pathogens that previously accounted for CAP included Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus, Legionella species, Chlamydia pneumoniae and Moraxella catarrhalis. Now with the implementation of vaccinations, viral pathogens are thought to be more prominent causes of CAP. Streptococcus pneumoniae is still a major contributor, although declined from 90-95% to 5-15% in recent studies.

Other main updates fall into the realm of diagnostic stewardship. The guidelines do not recommend obtaining sputum and blood cultures in the outpatient or inpatient setting, except only in cases of severe CAP (admission to the ICU or intubated), or if the patient is being empirically treated for MRSA or P. aeruginosa.

Procalcitonin has previously been used to help guide clinicians in the initiation of antibiotics in LRTI, but there were concerns of varied sensitivity of the test (range 38-91%) might miss patients with bacterial causes. The guidelines recommend empiric antibiotic therapy for presumed CAP regardless of initial serum procalcitonin.

Given the rising incidence and prevalence of viral causes of CAP, more research is needed to accurately identify clinical scenarios where antibiotic therapy can be safely withheld. Overall, treatment recommendations have not significantly changed except for the de-emphasis on macrolide monotherapy, particularly in areas where macrolide resistance was >/= 25% (which is pretty much everywhere in the US).

Five days of therapy is recommended to be adequate given the patient has reached clinical stability, including normalization of vital signs, ability to eat, and returned to baseline mental status.

If you are looking for a longer play-by-play summary of the new guidelines on Twitter, including a robust discussion of the mention of ceftaroline for CAP, click here for a thorough assessment by @ASPphysician, Dr. Andrew Morris.

Following up on pharmacist-led HIV pre-exposure prophylaxis

Earlier this year we featured a study by UNMC ID Drs. Sara Bares and Susan Swindells: “Midwest pharmacists’ familiarity, experience, and willingness to provide pre-exposure prophylaxis (PrEP) for HIV.”  We’re excited to share an update on their work building inter-professional relationships to increase PrEP education and use in Nebraska that was recently published in Open Forum Infectious Diseases: “Acceptability and feasibility of a pharmacist-led HIV pre-exposure prophylaxis (PrEP) program in the Midwestern United States.”

We spoke with first author Dr. Joshua Havens, UNMC ID HIV Program Clinical Pharmacist, about this recent publication.

What is the current work about?

The uptake of HIV pre-exposure prophylaxis (PrEP) is generally highest within large urban cities on the Western and Eastern coasts of the US.  Parts of the Midwest and the South are underserved in many ways but especially for PrEP access.  A provider paradox exists in determining the optimal setting where PrEP provision should take place (i.e. HIV provider, primary care clinic, STI clinic, etc).  It would seem that the primary care setting may be the first access point for PrEP provision of high-risk individuals, but many primary care providers are uncomfortable with providing PrEP for various reasons including increased daily patient loads, discomfort with HIV antiretrovirals, stigma, etc.  Further, patients have reported that they do not feel comfortable with discussing their sexual activity with their primary care provider.

Our study investigated the feasibility of pharmacists as collaborative HIV pre-exposure prophylaxis (PrEP) providers in several different settings (HIV clinic, primary care clinic, and a community pharmacy).  We aimed to capture the number of patients that chose to participate in the study, their retention in care over a year, patient satisfaction with the program, and the pharmacist’s acceptability with the program.

What were some of your key findings?

Our study enrolled 60 patients over 6 months most of which were Caucasian, gay or bisexual men with some sort of insurance coverage. Sexually transmitted infections (STI) were present in 23% of the population at baseline. The majority of the patients chose to participate in the study with nearly all enrolling at either the HIV clinic or community pharmacy settings (only 5 patients participated at a primary care site). Over the time course of the study, retention in PrEP care at all study sites fell. Overall, there was a high rate of patient satisfaction with the pharmacist-led program. Additionally, the pharmacist providers found the program to be acceptable.

The community pharmacy site for the study offered same day appointments in a private setting. All of the point of care screening and testing (HIV, creatinine, syphilis) was done by the pharmacist provider and the STI specimen collections (urine, pharyngeal, rectal) were self-collected by the patients after education was provided. All of these were free of charge during the study period and couriered delivery and processing of STI specimens were completed at a central laboratory with any incident STI’s communicated back to the study team to arrange for subsequent treatment. All of these processes pose as logistical challenges if the community pharmacy model were to be duplicated. Specifically, there is no point of care tesing for either Hepatitis B serology or rapid plasma regain (RPR). As a result, the initiation of PrEP in the community pharmacy would be challenging and the may be more appropriate for follow-up PrEP care. Further, the logistical challenges of STI specimen collection, processing, and treatment would present more challenges at the community pharmacy setting. Thus, these issues would need to be abated prior to implementing a pharmacist-led PrEP program in the community pharmacy setting.

What are some future directions for this work?

Larger scale research studies exploring ways to alleviate the logistical challenges noted in our study, PrEP persistence, and sustainability within the pharmacist-led PrEP model would help to strengthen its utility.

You can read more about this work here.

 


 

Fellowship MATCH DAY: Congratulations to our 2020 ID Fellows!

Every year our ID division is excited to welcome numerous fellowship applicants during the summer and fall months. Match Day is the culmination of these applicants’ hard work and our collective opportunities to demonstrate what we have to offer each other.  Our goal as program directors is to provide fellows with an educational experience that provides them with skills and knowledge to make them successful in whatever career path they choose.

The opportunities available to ID physicians continue to expand and this year we expanded our our fellowship program, accepting three first-year fellows for the first time. We are thrilled that Drs. Casey Zelus, Laura Selby and Jonathan Ryder chose UNMC to embark on this path to becoming ID physicians. Congratulations, and we look forward to welcoming you in July 2020!

Dr. Trevor Van Schooneveld
Program Director, Infectious Diseases Fellowship
Medical Director, Antimicrobial Stewardship Program
University of Nebraska Medical Center
985400 Nebraska Medical Center
Omaha, NE 68198-9400
Email: tvanscho@unmc.edu

Dr. Andrea J. Zimmer
Associate Program Director, Infectious Diseases Fellowship
Director, Oncology Infectious Diseases
University of Nebraska Medical Center
985400 Nebraska Medical Center
Omaha, NE 68198-9400
Email: Andreaj.zimmer@unmc.edu

Learn more about the UNMC ID fellowship here and here.

Thanks and Gratitude

This time of year is a time for reflection, gratitude, and appreciation of the blessings we have, and we are grateful for the opportunity to share our thanks from all of us at UNMC ID. 

We want to thank all of our blog subscribers, those who forward our blog on to others, and all of our Twitter followers who support and share our content.

We want to thank the generous donors to our UNMCID #SHEARoes Race Against Resistance campaign (shout out to Tara Palmore who donated even after the race was over, thank you!), which raised over $2000 and won second place in the overall race.

We want to thank our Department Chair Dr. Debra Romberger, Division Chief Dr. Mark Rupp, and COM Dean Dr. Bradley Brittigan, for their ongoing support and encouragement for our Digital Innovation & Social Media Strategy team

We want to thank every individual, group, or conference who has invited our Digital Innovation & Social Media Strategy team (Drs. Cawcutt and Marcelin) to speak and share in this digital revolution

We want to thank our faculty, fellows, residents, students and advanced practitioners for their tireless work countless hours taking care of our patients in the hospital and in our clinics

We want to thank our ID pharmacists who have been instrumental in getting key initiatives off the ground, like our outpatient parenteral antibiotic treatment program and troubleshoot when we have antibiotic shortages.

We want to thank our ID nurses who have been the glue that keeps our clinics working

We want to thank our division/clinic administrators and administrative assistants for keeping the nonclinical work on track, and generally keeping us afloat

We want to thank our trainees for allowing us the privilege of teaching them this, and every year

We want to thank our statisticians and research assistants for working so closely with us on research that has brought us again to be the 2nd most productive division in the department of Internal Medicine at UNMC

We want to thank our patients in the hospitals and clinics for the privilege to treat them and in most cases, journey with them to complete resolution of their illnesses.

We want to thank our families who have supported all of us in our medical careers

THANK YOU, THANK YOU, THANK YOU, and keep following us for more amazing work in the future!

qOlrhcTpoC c GyEuWnR t E

Antimicrobial Resistance is a Global Problem: Notes from the World Health Summit

From the World Health Summit, Berlin: Panel on Antimicrobial Resistance (AMR), October 27, 2019.

The 2019 World Health Summit (#WHS2019) opened with a panel discussion about the accelerating problem of global antimicrobial resistance (AMR). Dr. Peter Beyer, an intellectual property law expert working with the WHO on global health applications, led a panel of international experts to discuss current challenges of AMR – mostly focusing on what is widely recognized as a systemic market failure for R&D for new antimicrobials.

A number of international organizations, including the WHO and the UK Government, have issued reports citing the threat of AMR and issuing strong calls for action. (The CDC recently released their updated Antibiotic Resistant Threat Report earlier this November). The WHS panel began its conversation reviewing several recent reports of outbreaks of virtually untreatable bacterial infections. These reports highlight the current state of global emerging AMR. Many experts fear that we are approaching a tipping point in the 80-year “Antibiotic Era” in medicine and moving into a post-antibiotic era where definitive cures for bacterial (and other pathogen) infections are no longer a given.

A central theme of the WHS discussion was the alarmingly small pipeline of candidate antimicrobial therapeutics. Dr. Beyer relayed a current assessment by WHO that estimated in the range of 50 novel antimicrobials in the development pipeline across the entire pharmaceutical industry. This was contrasted with the thousands of candidate anti-cancer drugs currently in development. The lone industry representative on the panel, Julia Spencer from Merck, acknowledged the sentiments of the entire panel that the current economic market for antimicrobials coupled with the high development costs create an insurmountable disincentive for the capital and opportunity cost investments necessary to create new drugs under our present-day model of pharmaceutical R&D.

Panel members acknowledged the critical need for policy and regulation to reduce inappropriate antimicrobial use and advocated for more programs dedicated to improved infection prevention and control practices and antimicrobial stewardship. These interventions are particularly relevant for low and middle-income countries, and they represent a foundational element of actions to combat AMR.

Much of the discussion focused on the need for innovation, both in the technological space (where rapid, accessible, and affordable diagnostics could dramatically reduce inappropriate use of antimicrobials) and in the collaboration, finance, and market spaces. Dr. Elmar Nimmesgern, the head of the G20 initiative Global AMR R&D Hub, discussed opportunities to improve international collaboration and joint public-private efforts in antimicrobial development.

Some of the most interesting ideas came from the representative of the European Investment Bank, Felicitas Riedl. The Bank is exploring new financial instruments that could be used to incentivize investment in new antimicrobial candidates. The role of “impact investment” is acutely promising as a new trend where traditional venture capital mechanisms are used to achieve lower returns on investment in exchange for social impact that is important to investors. Variations on this theme, for example where impact investors may take “first loss” risk in investments, promise to expand dramatically the available capital for specific products or diseases.

The audience for the AMR panel was intently engaged, and the session ended with many hands still raised with questions and comments. The interest level from this international gathering of global health experts illustrates the importance of AMR in global health– what was termed “a silent pandemic” by one of the panelists. Dr. Lothar Wieler, President of Germany’s Robert Koch Institute ended the session on an optimistic note. He proposed that while similar to climate change in complexity and potential impact, AMR differs in that it is “100% anthropogenic” and therefore also resolvable by human action.

Although technically arguable – microorganisms have been producing and evolving to evade antimicrobial compounds for over a billion years – his point is relevant in directing immediate action that can counter this growing threat to global health security.

This content was written by Dr. James Lawler, Director, International Programs and Innovation, Global Center for Health Security and Director, Clinical and Biodefense Research, National Strategic Research Institute

Nebraska Medicine receives IDSA Antimicrobial Stewardship Center of Excellence Designation

In 2018, the Infectious Diseases Society of America (IDSA) began recognizing “Antimicrobial Stewardship Centers of Excellence” at hospitals that meet or exceed best practice standards. 

We are pleased to announce that Nebraska Medicine has recently been designated as an Antimicrobial Stewardship Center of Excellence effective October 2019. 

As we celebrate #AntibioticAwarenessWeek for 2019, we are reminded of the importance of antimicrobial stewardship as antimicrobial resistance is one of the most urgent global health threats. Everyone has a role to play in improving antibiotic use to help fight antibiotic resistance, and at University of Nebraska Medicine/Nebraska Medicine, we take that role seriously. 

The antimicrobial stewardship program (ASP) at Nebraska Medicine has been considered a leader in the field since becoming active and launching our website to guide clinicians on best practices in 2004. In fact, our ASP is one of thirteen hospitals highlighted by the Centers for Disease Control & Prevention (CDC) as examples of successful hospital antimicrobial stewardship programs. This has been increasingly demonstrated through institutional clinical care excellence, regional promotion of stewardship through programmatic support and training, research scholarship, and universal outreach through website and digital media resources.

The goal of the program is to optimize antimicrobial use, limit the spread of antibiotic resistance, and reduce adverse events of antibiotics such as C. difficile. Our ASP, now consisting of three physician directors and two pharmacist coordinators, is a multi-disciplinary collaboration between the UNMC Division of Infectious Diseases, Nebraska Medicine Departments of Pharmaceutical and Nutrition Care, and Infection Control and Hospital Epidemiology. The Nebraska Medicine ASP shares expertise with the Nebraska biocontainment unit the Davis Center for Global Health Security.

The program promotes standardization in patient care and high-reliability processes for clinical practice while taking into account patient-specific factors in the treatment of infection. Leveraging this experience and national recognition, the Nebraska Medicine ASP has been able to acquire multiple external grants in the last several years. The program also works with the Nebraska Department of Health and Human Services in securing funding annually from the CDC contracted with Nebraska Medicine for antimicrobial stewardship outreach in the state, through the Nebraska Antimicrobial Assessment and Promotion Program (ASAP).

We are grateful to the leadership of Nebraska Medicine, especially Dr. James Linder, CEO of Nebraska Medicine, Dr. Julie Fedderson, Chief Patient Safety and Compliance Officer, and Pharmacy leadership Lori Murante and Colleen Malashock for their support of the Nebraska Medicine ASP which was instrumental in attaining this Center of Excellence designation. We would also like to thank the members of our Antimicrobial Stewardship Program team (Salman Ashraf MD, Bryan Alexander PharmD, Scott Bergman PharmD, Phil Chung PharmD, Richard Hankins MD, Jasmine Marcelin MD, Erica Stohs MD, Trevor Van Schooneveld MD, Andrew Watkins PharmD), and our ID Division Chief Dr. Mark Rupp (who has led and been involved with the Nebraska Medicine ASP from the beginning), for all of their hard work in building our program at Nebraska Medicine.

Antimicrobial Stewardship efforts in the state of Nebraska

Content provided courtesy Dr. Salman Ashraf: Associate Medical Director, Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) & Medical Director, Nebraska Infection Control Assessment and Promotion Program (ICAP)

CDC’s most recent (2019) report on Antibiotic Resistance Threats in the United States describes 2.8 million infections due to antibiotic resistant organisms in the US resulting in over 35,000 deaths annually. The Division of Infectious Diseases at University of Nebraska Medical Center (UNMC) and Nebraska Medicine (NM) is collaborating with Nebraska DHHS Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) program via a CDC grant to decrease the prevalence of antibiotic resistance throughout Nebraska, through the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP).

Some notable activities of Nebraska ASAP initiative include:

  • Assisting over 30 healthcare facilities in the state in developing or improving their antimicrobial stewardship program
  • Creating a website focused on promoting ASP in healthcare facilities by providing tools and templates specific to the different healthcare settings. Since its inception in August 2017, the Nebraska ASAP website has been visited by over 12000 users both nationally and internationally and has earned the reputation of a national resource for facilities looking into developing or improving their ASP.
  • Organizing Antimicrobial Stewardship Summits for the state of Nebraska in 2018 and 2019 to provide education to over 250 ASP program professional, and four smaller sessions were held in different cities to reach out to those who were not able to attend the main summit.
  • Establishing the Nebraska ASAP YouTube Channel in February 2018 hosting all of the educational videos developed by the team, with over 20,000 views so far.   
  • Sharing our experience with healthcare community at various national meetings. (Available at https://asap.nebraskamed.com/about/selected-publications-and-presentations/)
  • Collaborating with Nebraska Medicine ASP to reduce antibiotic prescribing in outpatient clinics for acute bronchitis by 10%.
  • Launching a free online educational training on management of acute respiratory infections in outpatient setting which includes a presentation on communication strategies with patients. [CME credits available until 2020]
  • Initiating a collaborative project to decrease Clostridioides difficile infections in acute and long-term care facilities in the state.

As ASAP team members, UNMC/NM subject matter experts are supporting DHHS HAI/AR team’s fight against antimicrobial resistance. In addition to the ASAP activities, Nebraska DHHS HAI/AR team has launched several other initiatives focused on promoting appropriate antimicrobial use in the state. The DHHS HAI/AR team is committed to the CDC AMR challenge and have developed an antimicrobial susceptibility registry that can detect resistant organisms early so facilities can be assisted in containing the spread of multi-drug resistant organisms. The DHHS HAI/AR program also works closely with relevant stakeholders in the state such as Great Plains QIN/QIO, various healthcare associations, Nebraska Pharmacist association and other healthcare systems and organizations to achieve the common goal of promoting appropriate antibiotic prescribing and decrease antimicrobial resistance. They are also collaborating with Nebraska One Health to prevent misuse of antibiotics in livestock industry and agriculture.

Source: Antibiotic Resistance & Patient Safety Portal

The statewide efforts of DHHS HAI/AR program including Nebraska ASAP along with the amazing work done by our partner organizations, healthcare facilities and healthcare professionals have had positive impact on antimicrobial stewardship programs and antimicrobial resistance in Nebraska. Our MRSA bacteremia and C. difficile rates are 58% and 17%,  lower than the national baseline, respectively. The number of hospitals meeting all 7 CDC-recommended core elements of antimicrobial stewardship program have been on the rise in the last few years with 81% of the hospitals reporting to NHSN meeting all core elements in 2018 as compared to 31% in 2015.

While these findings are very encouraging there is still opportunity for improvement. Nebraska is still in the Top 10 rates of outpatient antibiotic prescribing and is significantly above the national average of 821 prescriptions per 1000 population.  An encouraging finding has been a recent decline to 986 prescriptions per 1,000 population in 2017 which was the first time the rate had dropped below 1000. We are committed to build on this success and are planning to roll out new initiatives focused on improving outpatient antibiotic prescribing practices.

In a nutshell, the unique model of public health department (NE DHHS HAI/AR program) and academia (UNMC/NM) partnership has facilitated antimicrobial stewardship efforts in Nebraska. This model has been very effective in making antimicrobial stewardship experts available to resource limited healthcare settings (such as critical access hospitals and long-term care facilities), which otherwise lack access to such expertise. Other states may also benefit from developing such partnerships in order to fight antimicrobial resistance and raising awareness of the risk of inappropriate antibiotic use.

#BeAntibioticsAware in the Community Hospital Setting

Bellevue Medical Center (BMC) is a community hospital campus of Nebraska Medicine. In 2017, our Nebraska Medicine Antimicrobial Stewardship Program expanded to include BMC with the expansion of our ASP expertise at our main campus. Danny Schroeder, a pharmacist at BMC, was recruited to lead the stewardship activities on that campus, with expertise provided by Dr. Jasmine Marcelin. In celebrating #AntibioticAwarenessWeek, Danny shares his thoughts on community stewardship. Danny can be found on Twitter at @dkschroePharmD

Antimicrobial stewardship is becoming more important every day. The CDC just released Antibiotic Resistance Threats in the United States, 2019 in which the Director of the CDC warns that we are now in the post antibiotic era. Antimicrobial stewardship needs to be a global effort, and everyone in every health care setting can help.

In a recent JAMA article, the feasibility of antimicrobial stewardship interventions in community hospitals was evaluated. Local pharmacists were trained on how to address common stewardship questions and anticipated arguments. They utilized two different mechanisms: pre-authorization of antimicrobials (PA) and post prescription review of antimicrobials (PPR). Pharmacists received bimonthly feedback from the study site during the trial period. They found that while feasible, the mechanisms used in the study did not result in major improvements in antibiotic use. PA was found to be ineffective, while PPR resulted in a statistically significant reduction in antibiotic use, however, the absolute reduction in use was only about 5%.

At the Bellevue Medical Center, I employ the PPR mechanism when performing antimicrobial stewardship. This leads to more discussions with clinicians and allows me to create stronger relationships with them. With stronger relationships comes more trust that my recommendations are appropriate and that they follow guideline-based therapy. To aide me in my stewardship endeavors, I have the privilege to discuss complex patients with an ID expert at Nebraska Medicine, Dr. Jasmine Marcelin, twice a week. I learn something new almost every week and am able to take that knowledge forward to continue to improve my stewardship practice. In addition, I can contact expert antimicrobial stewardship pharmacists at Nebraska Medicine for assistance if needed.

Having local expertise and leadership support is something the pharmacists did not have in the JAMA article mentioned above. The pharmacists also only received bimonthly feedback while I get assistance twice a week. I believe stewardship activities supported by ID experts is a crucial step a successful stewardship program at a community hospital where pharmacy staff may not be formally trained in infectious disease and antimicrobial stewardship. Having this expertise readily available is invaluable. It increases my confidence with my recommendations and I know the interventions I make are making a positive impact on patient care.

One last item I would like to mention is #IDTwitter. I was reluctant to join Twitter for quite some time, thinking it was another “time-suck” like Facebook. I was very wrong. I have learned many great pieces of information from multiple ID experts in the US and around the world on Twitter. In community hospital settings where ID expertise may not be readily available, knowing where to find information is key. #IDTwitter is a great place to start as there are a multitude of ID experts sharing their pearls of wisdom and analysis of newly released studies every day.

We are in the post antibiotic era. No matter which healthcare setting you are a part of, you can help. Join me and the countless others in the US and around the world in the fight against antimicrobial resistance. #BeAntibiocisAware.

Celebrating Antibiotic Awareness Week in Nebraska!

Antibiotic Awareness Week Proclamation Signing Ceremony

CDC has designated November 18 to 24 as US Antibiotic Awareness Week.  Antibiotic Awareness Week is an annual observance in the United States and around the world to promote the importance of using antibiotic appropriately as a mean to minimize unwanted effects from antibiotic therapy (e.g., adverse reactions, Clostridioides difficile infections) and antibiotic resistance.

In recognition of this annual observance, Governor Pete Ricketts signed a proclamation on November 4, 2009 in the State Capitol designating November 18 to 24 Antibiotic Awareness Week in Nebraska.  Dr. Maureen Tierney, the head of the Healthcare Associated Infections and Antimicrobial Resistance (HAI-AR) Team within Public Health at the Nebraska DHHS, delivered a brief statement during the signing ceremony.  She remarked that antibiotics are critical and life-saving tools for combating common and serious infections but at least 30% of outpatient antibiotics are prescribed unnecessarily (contemporary estimates suggest that more than half of antibiotics prescribed in the outpatient setting are inappropriate).

Dr. Tierney explained that a number of different partners in Nebraska are improving the way healthcare professionals, farmers, veterinarians and other professionals in the livestock and agricultural industries are using antibiotics.  These partners include the Nebraska Infection Control Assessment and Promotion Program (ICAP), Nebraska Medicine, CHI, Great Plains Quality Innovation Network, Nebraska Pharmacist Association, Nebraska One Health, and the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP).

Follow us for more content throughout this week celebrating Antibiotic Awareness!

Content courtesy Phil Chung, PharmD

Photos courtesy Sue Beach

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