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Tiffany Kalin, APRN-NP on Why I Love ID

Why I love ID and UNMC:

I wanted to work an UNMC/NM because of the positive experiences/education that I gained while working within the system previously (2007-2016). I truly enjoyed and am looking forward to again working in such a large operation with so many different experiences/education opportunities that are truly specific to UNMC/NM.  I am excited about ID because of the knowledge/experiences I have gained over the past 3 years while working in this specialty in a different practice. I have very much enjoyed the challenge of learning/seeing something new each and every day.

Something about me unrelated to my work:

I married my “high school sweetheart” and we now have 2 happy, healthy little girls (5 y/o and 3 y/o) who definitely keep us busy and on our toes.


 

Preparing for Measles – What You Need to Know

Measles is one of the most contagious infections and is acute respiratory viral infection currently causing an outbreak of infection through the United States. Measles was first described hundreds of years ago and became a reportable infection in the US in 1912. In 1963, the first vaccine for measles became available. Efforts focused on measles elimination starting in the late 1970’s and with increased vaccination rates, measles was declared eliminated in the US in 2000.

Illustrator: Alissa Eckert CDC/ Allison M. Maiuri, MPH, CHES

What’s the Big Deal?

As of May 17, 880 cases of measles have been confirmed in the US this year making this outbreak the largest in the US since 1994 (before elimination in 2000). The number of cases continues to rise and thus far, 24 states have reported at least 1 measles case. Thus far, Nebraska has had a confirmed case of measles, but certainly the risk remains present as neighboring states (including Iowa, Missouri, and Colorado) have reported measles.

https://www.cdc.gov/measles/cases-outbreaks.html

How did this happen?

The risk for spread of measles has existed despite US elimination as the infection can be secondary to imported cases from travel as globally, measles has not been eliminated. The risk of transition has been augmented with the increased number of parents opting to not vaccinate their children against measles (via the MMR vaccine; see more about the vaccine below), thus there are increased opportunities for nonimmune, unvaccinated persons to develop infection and subsequently spread measles. Up to 90% of nonimmune people with a close exposure to measles will develop the infection. Measles is very contagious and can spread through the air. People with measles can infect others even before the classic rash appears, increasing the possibility of spreading the infection unknowingly.

Clinical Presentation

After exposure to the measles virus, symptoms usually appear between 7 and 14 days, however, may still develop for up to 21 days.

Measles usually presents with high fever, malaise and the 3 C’s: cough, coryza (runny nose) and conjunctivitis (red and watering eyes). Two to three days after symptoms arise, tiny white spots may appear inside the mouth, known as Koplick spots. Three to five days after onset, the classic rash of measles breaks out starting as flat red spots starting on the head and face and extending downward over the rest of the body. These spots may connect to create large patches of red. When the rash appears, it may high temperatures ( even over 105 degrees F) may arise.  (images can be found here: https://www.cdc.gov/measles/about/photos.html)  Measles is contagious for 4 days before the onset of the rash to 4 days after it develops.

Complications: Measles can be very serious, resulting in hospitalization in approximately 1 in 4 patients and even death (in 1-2 of every 1000 infected children). Additional complications include: bronchitis and/or pneumonia, otitis media, diarrhea and acute encephalitis. The acute encephalitis can cause permanent brain damage at the time of infection, and those with measles can also suffer from subacute sclerosing panencephalitis (SSPE) 7 to 10 years after their initial infection. SSPE a degenerative disease of the central nervous system that is fatal, but rare.

Diagnosis: The test of choice is a PCR test before day 9, after that , serology testing is more effective. This remains a reportable disease, so testing will need to go through local public health laboratories and departments.

Treatment: There is no specific treatment to cure measles. For those who are not immune, or have weakened immune systems, vaccines and infusions of immunoglobulins may be used to prevent measles, or at least decrease the severity of infection.

Prevention Spread of Disease:

Transmission: Measles is one of the most contagious of all infectious diseases; up to 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by airborne spread, therefore in clinics or hospitals, if you present with symptoms (or care a healthcare worker caring for them) N95 masks should be used. If not available, a surgical mask should be used. Measles virus can remain in the air for up to two hours after an infected person leaves.

Post-exposure Prophylaxis

If you have been exposed to measles, if you cannot show you have evidence of immunity against measles via documentation of vaccine or age. If these are no readily available, post-exposure prophylaxis with the vaccine (within 72 hours of exposure for healthy individuals) or immune globulin infusions (within 6 days of exposure). Of note, both of these should not be given for a single exposure event.

Outside of the healthcare setting, after receiving the MMR vaccine for a known exposure, people can return to school or work. For healthcare workers without evidence of immunity, from 5 to 21 days post-exposure they should be excluded from work.

Vaccine Specifics:

Measles vaccine is usually combined with mumps and rubella (MMR), or with mumps, rubella and varicella (MMRV).

Everyone should be assessed for immunity via documentation MMR/MMRV vaccinations or if adults are born during or after 1957 (before this assumed to have immunity UNLESS they are a healthcare worker, then immunity should be confirmed or vaccination considered).

Children – should have 2 doses of vaccine. 1 between age 12-15 months and 1 between 4-6 years.

Adults born during or after 1957 ( or currently under age 63): should have at least one documented dose of vaccine with the exception of the following, who should have a 2nd dose:

  • Postsecondary educational students
  • International travelers
  • Healthcare personnel
  • Persons with HIV and a CD4 count ≥ 200 cells/μl for at least 6 months
  • Household or close personal contacts of immunocompromised persons with no evidence of immunity.

Stay Informed:

https://www.cdc.gov/features/measles/

https://www.cdc.gov/measles/resources/parents-caregivers.html.

https://www.cdc.gov/vaccines/parents/parent-questions.html.

https://www.cdc.gov/vaccines/parents/diseases/child/measles.html.

https://www.cdc.gov/measles/index.html

https://www.who.int/immunization/diseases/measles/en/

https://www.paho.org/hq/index.php?option=com_topics&view=article&id=255&Itemid=40899&lang=en

Latest updates for Nebraska can be found here:  http://dhhs.ne.gov/Pages/Health-Alert-Network.aspx


 

UNMC IDSHEAROES Enter the Race Against Resistance – Read Their Top Ten Reasons

Life-threatening infections caused by antimicrobial resistant organisms, commonly referred to as ‘superbugs’ have taken the media by storm. MRSA, VRE, MDRO, KPC, CRE, CDI – all acronyms that put fear in our hearts that one day, we will have run out of treatment options. That one day, our patients will die from infections that we once could cure.

Sadly, what was once a threat, is predicted to be a reality by 2050. Certain experts predict that these ‘superbugs’ will be the most common cause of death globally in 2050. That is truly terrifying.

What can we do?

We can fight back with science. The Society for Healthcare Epidemiology of America (SHEA) is sponsoring the Race Against Resistance for the 4th year. Money raised is used to fund educational scholarships involved in treating, and researching, ways to prevent the 2050 predictions from coming true. This is a chance to take a stand against ‘superbugs’, to support those fighting against them today, to help change the future.

So, who is racing?

Dr. Kelly Cawcutt and Dr. Jasmine Marcelin, are faculty physicians within UNMC’s Division of Infectious Diseases and have leadership roles in Infection Prevention and Antimicrobial Stewardship, respectively. They also serve as Co-Directors for Digital Innovation & Social Media Strategy for the ID Division. Together, they are the UNMC IDSHEAroes – two social media Co-Directors, trying to do some good.

Here are their TOP TEN reasons for racing:

10 – To beat Dr. Hilary Babcock, who won last year.

9 –  Because honestly, it’s a pretty catchy title & team name.

8 –  To remind everyone that antibiotics cannot treat a ‘cold’ or the flu. Or measles.

7 – To inspire our younger colleagues in medicine that anyone can help make a difference.

6 – To focus on healthy & wellness in a profession that has been struggling with burnout.

5 – To help SHEA and our racing teammates raise more money this year than EVER before

4 – To raise awareness of ‘superbugs’ & antimicrobial resistance by publicly sharing the Race Against Resistance.

3 – To provide the funds that train the next generation in Infection Prevention & Antimicrobial Stewardship.

2– To honor those who fought the fight against resistance before us, and the ones we have lost along the way.

1 – To never lose another patient to an infection we cannot treat.

How are we racing?

With physical wellbeing through exercise! Dr. Cawcutt is recovering from a partial knee reconstruction and will be #RacingInRehab to gain independent ambulation. Dr. Marcelin is#RacingForWellness by focusing on active exercise every day as a reminder that we cannot provide excellent care for others, if we do not care for ourselves first.

If you are interested in supporting the UNMC SHEAROES in the Race Against Resistance, you can donate here.


 

Fasting around the World: A Celebration of Diversity and Culture at UNMC ID

Infectious Diseases is a specialty that is inherently diverse, if you consider our patient population and the constellation of diseases we treat.  Our UNMC ID division is a diverse and welcoming community, encompassing faculty, fellows, nurses, advanced practice providers and staff from different cultures, languages, race/ethnicities, geographic origin and faiths.

Three of our faculty, Drs. Nada Fadul, Salman Ashraf, and Razan El-Ramahi, are Muslim and have been observing Ramadan for the past month.  In celebration of the diversity of culture and traditions in our ID division, Drs. Fadul (far right), Ashraf (center) and El-Ramahi (far left) coordinated our division’s inaugural annual Ramadan Iftar (breaking the fast) event on May 24th 2019 – Fasting around the World: A Celebration of Diversity and Culture.

In this celebration, we learned about what fasting means in various faiths, from representatives of those faiths within our division and UNMC.

Pastor Joyce Miller is a Lutheran minister and chaplain at Nebraska Medicine and has been a pillar of comfort for grieving faculty, staff and patient families during illness and death. She began by acknowledging that Islam, Judaism, and Christianity share similar roots, therefore it is no surprise that there are similar customs among these faiths. Miller shared the major fasting period of Christianity – Lent – is an important 40-day period of prayer, charity and alms-giving in preparation for Easter.

Kate Tyner, an Infection Preventionist working with the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), shared about fasting specifically within the Catholic faith. She related that before the Vatican II council decision, Catholics observed strict abstinence from meat on Fridays, but that after the decision, this strict abstinence was relaxed outside of the Lenten period. Tyner also shared a beautiful quote about what fasting means: “The willingness to deny ourselves awakens in us a capacity to give ourselves in greater love to our faith.” (Adapted from Magnificat daily devotion provided by Father Donald Haggerty).

Bryan Alexander, an ID Pharmacist working with the Antimicrobial Stewardship program, shared about fasting in the Orthodox Christian faith, which we learned is a stricter fasting regimen, including fasting from meat, wine, dairy and fish with backbones on Wednesdays and Fridays, and approximately 180-200 days of limited fasting per year. Alexander related that the purpose of the limited fasting was to “simplify your diet to focus on your day”, and that the act of fasting makes feasting more joyful, especially with the communal nature of the feasts at the end of a fast.

Dr. Raj Karnatak, a senior ID fellow, shared what fasting means in the Hindu faith. The Sanskrit word for fast is Upvaas, which means “staying near God”. He shared that in his culture, different foods carry various implications. Food is divided into three categories 1) Sattvic food: fruits, vegetables and dairy. 2) Rajsic food: Spicy food, garlic, onion (Believed to create unrest in mind). 3) Tamsic food: Meat, fish, and eggs (can serve to decrease spiritual enhancement); therefore, fasting often involves abstinence from Rajsic and Tamsic foods. People can fast in different ways in Hinduism – complete abstinence from all food/water, abstinence from only food, limiting intake to just one meal per day, or even abstinence from speaking (Maunvrat). He reminded us that fasting has been used as a political/social justice tool, as Mahatma Gandhi did fasting for human rights.

Nowairah Syed, a teacher at Noor Academy and wife of Dr. Ashraf, shared about fasting in Islam. The fasting month of Ramadan (which means dryness or scorching heat) occurs in the 9th lunar month, with daily fasts (abstaining from food and water) from sunrise to sunset. The daily breaking of fast is called Iftar. Dr. Fadul shared that in Sudan, men would sit outside in the community with food around sunset so that if someone was too weak from fasting to make it inside their homes, they could celebrate Iftar wherever they were at sunset, a testament to the strong sense of community responsibility. Because it is based on the lunar calendar, Ramadan can last for 29-30 days and is at a different time every year. Syed shared that Ramadan is a reminder for Muslims to be better people, both spiritually and physically, refraining from anger and frustration. It is a reminder to exercise patience, understand others and giving to charity. The fast is broken daily with dates and water, and at the end of Ramadan, called Eid, Muslims gather to celebrate with a big Feast.

After hearing about fasting in different faiths, there was spirted discussion and sharing as the group waited for sundown at 8:43pm on that evening, then it was time to feast. There was so much food there that everyone was filled and still had enough to take home leftovers. It was an event where after sharing this occasion with friends and colleagues, and learning about different cultures, one left feeling full both physically and spiritually, regardless of individual faith backgrounds.

Drs. Fadul and Ashraf were previously colleagues together at another institution where they created this tradition, and Dr. El-Ramahi joined them here; we are thrilled that they have shared it with us here at UNMC. We hope that in subsequent years the event is even bigger, expanding to the Department of Medicine and beyond, so that more people can share this special occasion, learn about different cultures, and recognize the impact of diversity in our lives.

Do you really need to test the poo? Diagnostic stewardship for (outpatient) diarrheal illness

Rapid molecular testing has changed the landscape of diagnostic approaches to many infectious disease syndromes, including diarrheal illnesses. These panels typically have the capacity to diagnose multiple organisms in one test. The FilmArray gastrointestinal pathogen panel (BioFire) tests 22 stool pathogens. Despite the impact of improved clinical efficiency, these tests are often expensive, especially in the outpatient setting, but the convenience of a comprehensive testing panel can lead to unnecessary testing.

Recent IDSA guidelines on management of diarrheal illness only recommends rapid diagnostic testing in patients who are immunocompromised or those with fever, severe diarrhea, abdominal pain, bloody stools. Clark et al. sought to validate these recommendations in the outpatient setting by evaluating the yield of the molecular testing, and clinical outcomes.  In this retrospective study, 629 patients were included in the analysis, and over two-thirds of patients had a duration of diarrhea greater than 14 days.

Given the possibility of asynchronous testing without face-to-face encounter, physical exam findings were not included in assessment, only documentation of patient-reported abdominal pain. Only 20% of the specimens actually had pathogens detected, and were clinically relevant in only 5% of patients (19/107 in immunocompromised patients vs 14/522 immunocompetent patients, p<0.001).

The authors validated that the IDSA guideline-based criteria had a sensitivity of 97% (95% CI 84.2-99.9), specificity of 33.9% (95% CI: 30.1-37.8), negative predictive value of 99.5% (95% CI: 97.3-100.0), and a positive predictive value of 7.5% (95% CI: 5.2-10.4). They found that application of these testing criteria would have avoided testing in 32% of patients, and avoided unnecessary antibiotics) in 23% of patients.

The authors concluded that duration—based criteria for testing stool is not warranted, however given the higher prevalence of clinically relevant pathogens in immunocompromised patients (who may demonstrate fewer systemic symptoms), broadly testing in this patient population is reasonable. C. difficile was not included in this study, and guidelines recommend two-step testing for C. difficile infections (rather than single-step PCR, as would be the case for this panel).

The retrospective nature and absence of clear physical exam findings limit the findings. Nevertheless, this study emphasizes the opportunity for diagnostic stewardship to decrease inappropriate testing without significant clinical penalty, and identifies immunocompromised patients as a valuable subgroup where less restricted use of this test for diarrhea is reasonable.

Citation: Stephen D Clark, Michael Sidlak, Amy J Mathers, Melinda Poulter, James A Platts-Mills, Clinical yield of a molecular diagnostic panel for enteric pathogens in adult outpatients with diarrhea and validation of guidelines-based criteria for testing, Open Forum Infectious Diseases, ofz162, https://doi.org/10.1093/ofid/ofz162


 

 

Dr. Elizabeth Schnaubelt promoted to Lieutenant Colonel in the US Air Force

Please join us in extending congratulations to Dr. Elizabeth Schnaubelt for her promotion to Lieutenant Colonel (Lt Col).  This is a very significant achievement that is given in recognition of a military officer’s expertise, professionalism, and leadership abilities.  Here is a little bit of background on Lt Col Schnaubelt’s role here, and how she found her way to Omaha:

Dr. Schnaubelt joined the UNMC/Nebraska Medicine team last summer when she was assigned as the inaugural medical director for the U.S. Air Force Center for Sustainment of Trauma Readiness Skills (C-STARS) Omaha. C-STARS Omaha’s mission is to advance the readiness skills and competency of U.S. Air Force (USAF) medical personnel so they can provide safe and effective care for patients who have contracted or may have been exposed to highly hazardous infectious diseases.  To accomplish the C-STARS Omaha mission, Dr. Schnaubelt and her team also work closely with the Nebraska Biocontainment Unit.  In addition to her significant responsibilities as the C-STARS Omaha medical director, Dr. Schnaubelt carries a substantial clinical load, attending on the General Infectious Diseases and Orthopedic Infectious Diseases services in the UNMC ID Division, and fully participates in the clinical and educational missions of UNMC.

Lt Col Schnaubelt began her military career as a Cadet at the United States Air Force Academy with hopes of flying fighter jets.  Her focus quickly changed after a visit to Haiti where she realized that her true passion was a career in medicine.  After the academy she attend medical school at Loyola University Chicago. Dr. Schnaubelt completed her internal medicine residency at Wright State University, and infectious diseases fellowship at San Antonio Military Medical Center. Following her medical training, she was deployed to Afghanistan, and was then assigned to Landstuhl Regional Medical Center in Germany.

Landstuhl Regional Medical Center (LRMC) is the largest U.S. medical treatment facility outside of the United States.  In additional to providing medical care to U.S. personnel in Europe, LRMC is uniquely positioned to treat the most critically ill patients who are evacuated from Iraq, Afghanistan, and countries in Africa.   While at Landstuhl, Lt Col Schnaubelt was recognized as the top field-grade (e.g., senior level) physician in the USAF when she earned the USAF Clinical Excellence Award in 2015. This award recognized her work as the infectious diseases medical lead on a team that developed contingency plans for treating and managing Ebola infected patients evacuated through Europe, from Africa.

Following her assignment in Germany, Dr. Schnaubelt was selected as an Epidemic Intelligence Service (EIS) officer and served in the Global Tuberculosis Prevention and Control branch at the Centers for Disease Control and Prevention in Atlanta, GA.  As an EIS officer she traveled and worked internationally as part of an effort committed to reducing the burden of TB in the world by conducting innovative, impactful and programmatically relevant research, and by providing technical assistance to national TB programs while working directly with country-level Ministries of Health.   Her international work included projects in China, Lesotho, Malawi, Namibia, Uganda, and Vietnam.   Upon completion of her EIS assignment, Dr. Schnaubelt relocated to Omaha for her current position.

Congratulations, Dr. Schnaubelt, on a well-earned promotion, recognizing your talents and long list of accomplishments.  We appreciate you and thank you for your service, as both a military officer, and an UNMC ID faculty member.

Nadal Fadul, MD on Why I Love ID

Why I love ID and UNMC:

The strong commitment to serving the community, the great opportunities provided to faculty; and my former colleague, Salman Ashraf, who is very happy here!  I chose ID because my passion is taking care of people living with HIV, however, I enjoy all of ID and the intellectual challenge it poses.

Something about myself unrelated to my work:

I enjoy reading and writing poetry in Arabic.

 


 

The Antimicrobial Stewardship Program: Keeper of the S. aureus bacteremia Checklist Manifesto

Staphylococcus aureus bacteremia (SAB) is a serious and sometimes devastating infection. There are established guidelines for optimal management, and more recently, numerous studies have shown the benefits of Infectious Diseases consultation, including improving guideline-adherent management, and reducing hospital stays, 30-day readmissions, and in-hospital mortality. Pharmacist-driven initiatives embedded within the Antimicrobial Stewardship Program (ASP) have also been shown to improve quality of care for patients with SAB.

In this study, Remtulla et al. described the impact of combining unsolicited prospective audit and feedback (PAF) a standardized SAB bundle on SAB management. ASP pharmacists used the SAB bundle once per patient, to make PAF recommendations to teams whose patients developed SAB. The SAB patients were identified to the ASP by twice-daily microbiology laboratory emails, only during normal business hours on non-holiday weekdays. The SAB checklist recommendations included ID consultation, repeat blood cultures, empiric therapy recommendation (vancomycin unless MSSA known), echocardiogram, duration of therapy guidance, and source control recommendations.

In their analysis of 199 patients, PAF recommendations were accepted at a rate of 92.6%, and 44% of the recommendations were for ID consultation. SAB bundle adherence increased from 29.0% to 72.8% (p<0.001) in the intervention group, with statistically significant (p<0.001) increases in ID consultation (56.5% vs 93.4%), guideline-adherent therapy (83.9% vs 99.3%), echocardiography (72.6% vs 95.6%), and duration of therapy (87.0% vs 100%). Reductions in 30 day readmission and 30 day mortality rates were not statistically significant, likely owing to the small study size.

Implementation of this SAB bundle seemed to augment the impact of ID consultation, because even in the intervention groups without ID consultation, the adherence to the bundle elements approached that of the pre-intervention groups with ID consultation.

This is yet another study demonstrating the ease of implementation of checklists/bundles for improving quality of patient care. Other studies have shown that automatic ID consultation for SAB can lead to better patient outcomes. However, the resources needed for automatic consultation may not be available to all hospitals, and this study provides another pharmacist-driven protocol that can also improve outcomes. Further improvements in an approach like this should include a mechanism for weekend/holiday notification in the absence of pharmacist presence, or inclusion of rapid diagnostic testing such as detection of mecA gene to facilitate earlier definitive treatment during uncovered periods.

 

Citation: Shahileen Remtulla, Karen Zurek, Carlos Cervera, Cristina Hernandez, Mao-Cheng Lee, Holly L Hoang, Impact of an Unsolicited, Standardized Form–Based Antimicrobial Stewardship Intervention to Improve Guideline Adherence in the Management of Staphylococcus aureus Bacteremia, Open Forum Infectious Diseases, Volume 6, Issue 4, April 2019, ofz098, https://doi.org/10.1093/ofid/ofz098


 

Bryan Alexander, PharmD on Why I Love ID

Why I love ID:

I love academic medicine; working jointly with an interdisciplinary team of experts to sort out the most complex clinical cases excites me. There is no place in the region that fulfills each of the aspects of that statement better than Nebraska Medicine.

While more and more of the practice of medicine necessarily moves to the long-term management of chronic disease states, infectious disease is one area where we are routinely able to cure a patient’s medical condition and appreciate the satisfaction that can bring for them. Also, the pathogen-host-antimicrobial interaction is fascinating and unique in medicine from a pharmacotherapy perspective. Drug therapy can be complicated enough in other areas without the host and its associated resistance mechanisms further complicating things, which makes being an ID pharmacist very intellectually rewarding. Finally, microbes are some of the most diverse, important, and fascinating entities on our planet. There’s always so much more to appreciate and learn (or re-learn!).

I also love:

I’ve always loved music, but developed an particular appreciation for opera in high school, which I was able to foster while living in Chicago and Baltimore/D.C. during my university years. I then lived away from a city without access to live performances for about a decade and had two small children. Now having moved here and with children that are a bit older (7 and 4), my wife and I have been excited to attend Opera Omaha and share more aspects of our love for music with them.

 


 

When you see CRE: Add Equal Parts Antimicrobial Stewardship and Infection Control

The following was previously posted by Dr. Marcelin to SHEA Journal Club published online in April 2019.

Dealing with carbapenem resistant organisms presents both an antimicrobial stewardship and infection control problem. Richter et al. aimed to predict risk factors for carbapenem resistance among Gram-negative rods (CR-GNR). The authors were particularly interested in whether differences exist in risk factors for development of ertapenem-resistance (ER-GNR), versus resistance to antipseudomonal carbapenems (ACR-GNR). This was a retrospective study over a 6-year period (2011-2016) evaluating cultures from any source from a mixed patient population of patients with malignancy, transplant patients, and those in the ICU.  The final analysis included 14292 GNR isolates, with 274 ER-GNR (majority Klebsiella species) and 618 ACR-GNR (mostly Pseudomonas species), and both groups of CRE were more common in respiratory cultures.

Multivariate analysis identified predictors of ER-GNR including renal disease, admission from another healthcare facility, mechanical ventilation prior to culture, receipt of any anti-MRSA agents within 30 days, and receipt of carbapenems within 30 days. Both test and validation models had a reliable c-statistic of 0.74 and 0.73 respectively. Predictors of ACR-GNR were similar. However, instead of renal disease, male sex was another predictor of ACR-GNR, and the test and validation models had reliable c-statistics of 0.76 and 0.77 respectively. They then assigned points to these models to predict likelihood of development of resistance.

Despite limitations including missing data, the authors suggest their risk scores may be more accurate at predicting carbapenem resistance than antibiograms since they are dynamic and can be automated. Carbapenem resistance was effectively ruled out (<5% likelihood) at scores of <6 in the ER-GNR model and <4 in the ACR-GNR model. This scoring system could be useful in guiding empiric antimicrobial therapy when patients present with sepsis, but may be less useful for locations where resistant GNRs are less prevalent.

Little is known about clinical outcomes in patients colonized with carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) who develop CP-CRE of a different genotype. Chen et al. conducted a retrospective cohort study of patients colonized with CP-CRE who went on to develop clinical infection. Of the 73 CP-CRE carriers who went on to develop infection, 65 developed clinical infection with the same CP-CRE genotype with which they were colonized. Eight developed clinical infection with a different genotype. After adjusting for age, severe clinical presentation and clinical isolate genotype, the authors found that patients whose clinical CP-CRE isolate was different from that with which they were colonized, had significantly increased mortality at 14 days (aRR, 6.36; 95% CI, 1.75–23.06; P = .005) and 30 days (aRR, 3.29; 95% CI, 1.22–8.90; P = .019).

This is a very small study in an area where the authors state the general prevalence of CP-CRE carriage is low, and clinical infection with a different genotype of CP-CRE was not common. However, it generates questions about current isolation practices for patients with CRE. Geographically cohorting patients with CP-CRE may help to reduce transmission to uncolonized patients, but this study raises the questions as to whether this practice may have unintended consequences of transmission of different CP-CRE genotypes between colonized patients, leading to worse outcomes.

References:
Stefan E Richter, Loren Miller, Jack Needleman, Daniel Z Uslan, Douglas Bell, Karol Watson, Romney Humphries, James A McKinnell; Risk Factors for Development of Carbapenem Resistance Among Gram-Negative Rods, Open Forum Infectious Diseases, Volume 6, Issue 3, 1 March 2019, ofz027, https://doi.org/10.1093/ofid/ofz027

 

Wen Kai Chen, Yong Yang, Ban Hock Tan; Increased Mortality Among Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae Carriers Who Developed Clinical Isolates of Another Genotype, Open Forum Infectious Diseases, Volume 6, Issue 2, 1 February 2019, ofz006, https://doi.org/10.1093/ofid/ofz006

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