Division of Infectious Diseases

At the end of 2018, we remember and respect Influenza, 100 years after the great pandemic

The Mother of All Pandemics

In the 1918-1919 calendar year, the world experienced the worst influenza pandemic in modern times. Coming on the heels of WWI, the H1N1 pandemic occurred in three waves – in the spring of 1918, fall 1918 and spring 1919. Estimates suggest that the pandemic infected a third of the world’s population, with 50 million people dying worldwide, including 675,000 Americans. Mortality was high at extremes of ages, but what sets this particular pandemic apart was the significant mortality (over half of all deaths) in young, healthy 20-40yr olds.

Why such devastating morbidity and mortality? Perhaps a combination of war-ravaged, crowded conditions, malnourishment, inadequate healthcare resources (many doctors/nurses were deployed at war), and poor hygiene. In the early 20th century, there were no influenza vaccines to prevent flu or lessen its symptoms; no antivirals to help reduce transmission; no antibiotics to treat post-influenza bacterial pneumonia.

The Smithsonian National Museum estimated that the total death toll of the 1918 pandemic outnumbered military deaths in both World War I and II. You can watch a video created by the CDC about the 1918 pandemic here. This avian-origin H1N1 pandemic has been called “The Mother of All Pandemics”, setting the stage for all of the subsequent epidemic and pandemic strains of influenza we have experienced.

After 1918: Influenza still deadly, though not as devastating

In 1957-1958 an H2N2 avian influenza virus caused a pandemic resulting in 1.1 million deaths worldwide including 116,000 Americans. 10 years later, another avian-based virus H3N2 triggered a similar sized pandemic with 1 million deaths worldwide and 100,000 Americans. The H3N2 still circulates as a seasonal flu virus and is included in seasonal vaccines.

The next major pandemic was triggered in 2009 by a novel influenza A virus called H1N1pdm09, originating in the United States. By this time, seasonal influenza vaccines had included H1N1 but this variant was completely different from the seasonal flu vaccine, resulting in an estimated over half million deaths worldwide and up to 18,000 Americans.

Today: There is still work to be done

Since 2009’s pandemic, seasonal influenza is still prevalent, with an estimate of over 291,000-645,000 deaths from seasonal influenza worldwide. The highest mortality rates are in poorer, developing countries, with individuals at extremes of age being most vulnerable to death from seasonal influenza. We still do not have a universal influenza vaccine, though research is moving in that direction.

The 2017-2018 influenza season brought a serious influenza epidemic, with 48.8 million illnesses, 959,000 hospitalizations and 79,400 deaths estimated in the United States alone.

Recently, the Infectious Diseases Society of America (IDSA) released updated guidelines for diagnosis, and management of seasonal influenza. In the guidelines, they recommend testing for influenza in upper respiratory specimens of high risk patients, when testing can reduce unnecessary additional testing/inappropriate antibiotics, or when testing can influence chemoprophylaxis for high-risk household contacts. Vaccination is still recommended as the best way to mitigate the impact of seasonal influenza, but antiviral prophylaxis may be necessary in outbreaks or for certain at-risk populations.

More than 166.6Million influenza vaccines have been distributed in the US as of December 20, 2018. This year’s vaccine contains an influenza A H1N1pdm09-like strain, A H3N2-like, and influenza B strains from the Victoria and Yamagata lineages. Updated this year, the Advisory Committee on Immunization Practices (ACIP) also recommends the live-attenuated influenza vaccine (FluMist); however, the American Academy of Pediatrics suggests this only be used if the alternative would be no flu shot at all. The CDC can explain the types of vaccines available and who should get them.

Influenza

What it is: Influenza is a respiratory infection caused by a virus that can be easily spread from person to person by contact with respiratory droplets.

Who can get it: Anyone can get the flu, but the very young, very old, and those who are immunocompromised are at increased risk for getting the flu, or developing serious complications from the flu. The flu season usually goes from October to May but usually peaks between December and February.

How we can treat it: Symptomatic treatment is still the mainstay of management – fluids, rest, and over the counter medications targeting stuffy nose, body aches, fever, and sore throat. There are antiviral drugs available for treating influenza, but most people recover without needing antiviral treatment. People at highest risk for severe influenza or serious complications (such as infants, elderly or immunocompromised individuals) will benefit from antiviral treatment. Antibiotics are NOT used to treat influenza, although may be used to treat a serious bacterial pneumonia occurring as a complication of influenza.

How we can prevent it: We can prevent the flu by getting the flu shot annually. The influenza vaccine may not always be a 100% match to all circulating strains, as we saw with last year’s flu season. It is true that even after getting the flu shot, a person may still develop the flu, but vaccination reduces the risk of influenza by 40-60%. Benefits of the vaccine include reducing illnesses from influenza, and preventing complications or dying from influenza.

Other ways to prevent spread include hand hygiene, limiting contact with people who have influenza-like illness, and if you have such an illness yourself, STAY HOME.

Final thoughts about the flu

Regardless of which vaccine is more appropriate, our ancestors would probably encourage us to just get ANY vaccine if it would help avoid recreating the influenza pandemic of 1918. There’s still time – it’s not too late so if you haven’t gotten your flu shot, consider getting it today!

*Dr. Marcelin published a version of this article on the HAI Controversies blog on 12/20/18*


 

Pharm To Exam Table – Candida glabrata Urinary Tract Infections

The following is a clinical review written by Allison Graner, UNMC College of Pharmacy PharmD candidate 2019, and supervised by Scott Bergman PharmD FIDSA, Clinical Pharmacy Coordinator of Nebraska Medicine Antimicrobial Stewardship Program

What is the appropriate treatment for urinary tract infection caused by Candida glabrata?

Infections caused by the fungus known as Candida, the most common fungus to be cultured in the microbiology lab encompass many different species.  Candida spp are part of the human natural flora, and just because they are detected in a sample does not mean they are pathogenic.  The most common Candida species is Candida albicans, and this organism fortunately has very low resistance rates against antifungals.  Candida glabrata, however, exhibits resistance around 30% of the time to azole antifungals.1  In many infections the inability to use a drug such as fluconazole does not pose a problem because another class of antifungals, the echinocandins, is a dependable group of medications that has strong fungicidal activity against Candida glabrata.2  However, candiduria is unlike most infections because most antifungal drugs do not reach the urine in high enough concentrations.

Candida in a urine sample does not always mean the patient needs to start therapy to eradicate the yeast.  In an asymptomatic patient, this indicates colonization and does not need to be treated.  In fact, treatment is not recommended unless the patient is neutropenic, will need urologic surgery, or is a very low-birth-weight infant, all of which meet criteria for high-risk patients.3  If Candida is present, it is suggested that the medical team look for causes of why this could be, as it is usually associated with catheter use, diabetes mellitus, or patients who are immunosuppressed.  Regardless of the cause, if the candiduria is causing symptoms, spreading to other sites of the body, or the patient is clinically worsening, appropriate treatment is necessary.1,3

Azole Antifungals

Due to its high penetration into the urine, the number one drug for Candida-associated urinary tract infections (UTI) is fluconazole for 14 days.3 Treating candiduria with amphotericin B bladder irrigation used to be a more common therapeutic option, and there was originally concern for treating a localized infection with a systemic medication such as fluconazole.  However, a randomized, double-blinded study concluded that fluconazole is at least as effective as amphotericin B irrigation, but less expensive and causes fewer side effects.4

Fluconazole is 100% bioavailable when given intravenously or orally.  It is also renally eliminated with almost 80% of the drug remaining unchanged upon excretion into the urine.  When comparing concentrations in the plasma to that in the urine, urine levels exceed plasma by 10 times the amount.5  This means that lower doses could be used to achieve eradication of the infecting organism when it is in the urine.  Fluconazole also penetrates the kidney tissue, making it even more optimal in cases of pyelonephritis.5

However, Candida glabrata exhibits fluconazole resistance rates up to 30%.  Sometimes this can be overcome with the concept of susceptible but dose-dependent therapy, but other therapeutic options may need to be considered.1 In symptomatic candiduria caused by Candida glabrata, consider requesting susceptibility testing.  The minimum inhibitory concentration (MIC) for C. glabrata to fluconazole can range from 0.25 to 256 μg/mL.  The MIC should be noted because Candida glabrata exhibits dose-dependent susceptibility at concentrations <32 μg/mL.

In Candida glabrata urinary tract infections, always consider fluconazole as a first line option when MIC is  <8 μg/mL.  An oral dose of 200-400 mg per day would be adequate since urine drug concentrations are substantially higher than blood levels.  Even with an MIC up to 64 ug/mL, fluconazole therapy should be considered because the urine concentration of the drug would result in levels >100 μg/mL, given its ability to easily penetrate the urine.1  With any MIC greater than this, the clinician should explore other therapeutic options since the minimum Inhibitory concentration would then exceed that of the amount of drug able to access the urine.  Drug interactions need to be monitored, along with signs of hepatotoxicity and the QT interval of the patient.  A different azole antifungal is not an option, as no other drug in this class has adequate distribution into the urine.1

Echinocandins

Echinocandins are an acceptable alternative option, though they may not penetrate the urine at high levels. To date, 10 successful case studies have been published, 6 with caspofungin and 4 with micafungin, which have laid a foundation for the use of these medications in UTIs.  The case reports with Micafungin used doses from 50 mg to 200 mg daily for 14 to 25 days, and all showed benefit. Micafungin has poor glomerular filtration and tubular secretion, however, a small percentage still makes its way into the urine as unchanged drug.6  In animal studies, micafungin was found to concentrate in the kidney tissue at 1.6 times the amount in the plasma, which could be beneficial in the case of pyelonephritis.  Studies have shown that with a dose of micafungin 100 mg, the maximum plasma concentration averages almost 6 μg/mL.  Even with only 1% of the drug reaching the urine, about 0.06 μg/mL of micafungin in the urine could exceed  the MIC of Candida glabrata to micafungin, which is usually very low (MIC ≤ 0.015 to 0.5 μg/mL).6

Caspofungin data suggests effective use despite only 2-3% of active drug reaching the urine.8  However, data from a randomized double-blind trial proved micafungin was just as effective as caspofungin and had a similar side effect profile for invasive infections.  Micafungin does not require a loading dose, is less expensive and therefore is preferred at most institutions.2  Micafungin is the most cost effective option, but in a setting where micafungin is unattainable, caspofungin would be an appropriate therapeutic option.

Other Antifungals

The Candida guidelines recommended using amphotericin B at 0.3–0.6 mg/kg daily for 1 to 7 days or flucytosine 25mg/kg 4 times daily for 7 to 10 days if unable to utilize fluconazole. For urinary tract infections, the amphotericin B deoxycholate formulation must be used as the liposomal product will not reach the urine in high enough concentrations.  Amphotericin B deoxycholate is known for the intolerablility of its adverse events.9  For UTIs caused by Candida, it is also used to directly irrigate the bladder.  This method is effective in up to 90% of patients, but long term efficacy has not been proven, as many patients have recurrent candiduria within weeks.3  If not for its side effects and cost, flucytosine would be a great option as 97% is excreted as unchanged drug into the urine, and it has low resistance rates against most Candida species.3,5  However, resistance can develop when using flucytosine alone for more than a few days.  In severe infections it is often paired with amphotericin B to prevent the resistance from developing.3

With the already mentioned therapeutic options being readily available, these agents are only used in refractory cases in the United States because of their cost and toxicities.  Flucytosine was developed as a chemotherapy agent, and can predictably cause side effects such as bone marrow suppression, hepatotoxicity, gastrointestinal problems, rash, and diarrhea.1  After a recent price hike in the US, using flucytosine would cost around $1400 per day.10  Amphotericin B also has a long list of adverse events such as renal toxicity, electrolyte abnormalities, hypotension, chills, headaches, etc., and can cost anywhere from $90 to $160 per day.9

Conclusion:

Fluconazole has established efficacy for its use in candiduria, and if following susceptibility testing the Candida species is susceptible (or dose dependent), fluconazole for 14 days should be considered the number one therapeutic option.  If the organism is resistant or fluconazole is not an option, consider antifungals from the echinocandin class, as more case reports are demonstrating efficacy despite minimal urine penetration. If all of the above options are unavailable, one could then consider therapy with amphotericin B or flucytosine knowing that more toxicities are probable and the expense will be higher.

References:

  1. Fisher JF, Sobel JD, Kauffman CA, et al. Candida Urinary Tract Infections – Treatment. Clinical Infectious Diseases. 2011;52(S6):S457-S466.
  2. Pappas PG, Rotstein CMF, Betts RF, et al. Micafungin versus Caspofungin for Treatment of Candidemia and Other Forms of Invasive Candidiasis. Clinical Infectious Diseases. 2007;45:883-893.
  3. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2015 November:1-50.
  4. Sobel JD, Kauffman CA, McKinsey D, et al. Candiduria: A Randomized, Double-Blind Study of Treatment with Fluconazole and Placebo. Clinical Infectious Diseases. 2000;30:19-24.
  5. Felton T, Troke PF, Hope WW. Tissue Penetration of Antifungal Agents. Clinical Microbiology Reviews. 2014; 27:68-88.
  6. Pieralli F, Bazzini C, Vannucchi V, et al. A case of candida glabrata severe urinary sepsis successfully treated with micafungin. Medical Mycology Case Reports. 2015;5:1-3.
  7. Fisher JF, Woeltje K, Espinel-Ingroff A, et al. Efficacy of a single intravenous dose of amphotericin B for Candida urinary tract infections: further favorable experience. Clinical Microbiology Infections. 2003;9:1024-1027.
  8. Sobel JD, Bradshaw SK, Lipka CJ, et al. Caspofungin in the Treatment of Symptomatic Candiduria. Clinical Infectious Diseases. 2007;44:e46-e49.
  9. Drew R. (2018). Pharmacology of amphotericin B. Retrieved September 14, 2018, from https://www-uptodate-com.library1.unmc.edu/contents/pharmacology-of-amphotericin-b
  10. Drew RH, Perfect JR (2018). Pharmacology of flucytosine. Retrieved September 14, 2018.

Featured image from CDC: https://www.cdc.gov/fungal/antifungal-resistance.html 

Allison Graner, UNMC College of Pharmacy PharmD candidate 2019

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Bacteriocidal versus Bacteriostatic: What Makes the Biggest Difference in VRE Bloodstream Infection?

An October 2018 publication in Critical Care Medicine by Chuang et al details a prospective study of adults in Taiwan, between 2010 -2015, aimed to assess all-cause mortality and rate of bloodstream clearance among patients with vancomycin-resistant enterococci (VRE) treated with daptomycin (bacteriocidal) versus linezolid(bacteriostatic). Patients were treated with conventional daptomycin (6 to < 9 mg/kg actual body weight), high-dose daptomycin(>9 mg/kg) or linezolid (600mg IV Q12 hours). The initial blood culture bacterial load was determined, followed by blood cultures daily for the first 4 days and then twice per week for a total of 2 weeks unless the patient was discharged or therapy discontinued prior to that. Blood cultures were assessed via traditional blood culture methodology and by a real-time quantitative PCR detecting vanA (no vanB documented in cohort).

108 patients were included in the analysis. 63(58.3%) received conventional dose daptomycin, 15 (13.9%) received high-dose daptomycin and 30(27.8%) received linezolid. There was no statistically significant difference between survivors and non-survivors in the initial bacterial load, however, survivors had a statistically significant higher rate of early bacterial clearance (p = 0.02). There was no statistically significant difference in bacterial clearance among those with empiric versus definitive treatment, however clearance was statistically significant in difference among the antimicrobial treatment arms. Early bacterial clearance was faster with high-dose daptomycin(p<0.001) and linezolid(p =0.043) as compared to conventional daptomycin, with no statistically significant difference between high-dose daptomycin and linezolid. A higher PITT bacteremia score and slower clearance of bacteremia were found to be independent predictors of mortality. PCR was more sensitive, and equally as specific, as traditional blood cultures.

The statistically significant differences in rate of bacterial clearance (and associated survivorship) between high-dose daptomycin and linezolid, compared to conventional daptomycin, suggests that higher doses of daptomycin or use of linezolid should be considered in VRE BSIs. Larger studies are needed to validate the results and validated determine clinical impact and optimal dosing.

Of note, the study is limited by smaller sample sizes, no vanB carrying VRE and the inability to report false positive PCRs. A formal RCT would be needed to determine optimal therapy. In addition, the average weight of patients was 60 kg, thus this data cannot be extrapolated necessarily to obese patients.  Further studies related to dosing weight and optimal dosing are also warranted.

Content originally written and adapted for the IDSA journal club. 


 

Saving SIRS? Discernment of Sepsis from Non-Infectious Syndromes in the ED

Upon patients’ arrival to the emergency department (ED), determining whether they do or do not have sepsis is difficult. Because of this, many patients receiving antibiotics ultimately are found to have a noninfectious cause of their syndrome. In order to try and improve detection of sepsis in the ED, Mearelli et al. completed a multicenter prospective study at five university hospitals in Italy and reported their results in a recent article in Critical Care Medicine.

The study included two cohorts: an inception cohort for the development of a predicted algorithm and a validation cohort to determine positive and negative predictive value of the algorithm based on pretest probability of infection with the aim to differentiate sepsis syndromes from noninfectious inflammatory states. Despite its faults, criteria for systemic inflammatory response syndrome (SIRS) were used to enroll patients and then categorize them based on whether an infectious diagnosis was ultimately identified. Biomarkers utilized in the algorithm included procalcitonin, soluble phospholipase A2 group IIA (sPLA2GIIA), presepsin, soluble interleukin-2 receptor α (sCD24), and soluble triggering receptor expressed on myeloid cells (sTREM-1).

The area under the curve (AUC) for the algorithm in the validation cohort was an impressive 0.95 (95 percent confidence interval [CI] 0.82-0.90). The primary impact of this study may be for ruling out sepsis and septic shock given that only five of 700 (0.7 percent) patients were misclassified when having sepsis or septic shock compared to the usual approach of clinical concern for infection, fever, leukocytosis, and increased C-reactive protein.

Although imperfect, the algorithm does appear to be better than current diagnostics used for determining if a patient has sepsis or septic shock. Primary concerns for future implementation of this are the few patients that had sepsis or septic shock with a negative SIRS screen, the feasibility of rapid multimodal test results for screening versus potential delay of therapy, and the overall cost of obtaining such labs.

(Mearelli et al. Crit Care Med. 2018;46(9):1421-1429.)

Content written by Dr. Kelly Cawcutt; originally posted for the IDSA journal club.


 

 

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Skin Deep: A Closer Look at Treatment of Skin and Soft Tissue Infections

Current guidelines for management of Skin/Soft Tissue Infections (SSTIs) were published in 20141.  Nevertheless, management of SSTIs is variable, likely driven by the fact that culture data is often unavailable to direct clinical decision making. Treatment variability results in inappropriate antimicrobial use, highlighting the need for antimicrobial stewardship. Consequently, management of SSTIs is one area where more research has identified easy targets for improvement. This review describes two such studies.

The first, a systematic review conducted by Bowen et al.2, sought to answer the question: For which SSTIs should we use sulfamethoxazole-trimethoprim (SXT)? After identifying 196 potential studies, 10 randomized controlled trials (RCTs) and 5 observational studies underwent full-text review. The largest RCT of impetigo with 90% of isolates cultured as group A streptococci (GAS), found a nonsignificant difference in treatment success with 3-5 days of SXT vs benzathine penicillin. The authors therefore recommended a short course of SXT as treatment of choice for impetigo (when clinical situation dictates systemic therapy). The 2014 SSTI guidelines recommend covering S. aureus in impetigo, but only recommended it for situations where MRSA is suspected or confirmed.  The systematic review also highlighted newer RCTs demonstrating high grade evidence in favor of adding SXT to incision and drainage for abscesses vs incision and drainage alone.  The authors concluded that there was high grade evidence to support use of SXT monotherapy for SSTIs caused by GAS and S. aureus, including impetigo, purulent SSTIs and abscess (coupled with incision and drainage), and agreed that beta-lactams are treatment of choice for nonpurulent cellulitis, as MRSA coverage provides no additional benefit.

The second study conducted by Kamath et al.3, discovered that the majority of SSTI management was not compliant with guidelines. Their retrospective analysis looked at 240 patients who were diagnosed with purulent or nonpurulent SSTIs in a large VA Emergency Department. Patients seen in the ED for SSTI were either admitted to the hospital inappropriately (20%) or discharged from the ED inappropriately (34%). Patients were more likely to be hospitalized if they were alcoholics (OR 3.4, CI 1.3-8.5, p0.01), had SIRS (OR 3.98, CI 1.4-11, p 0.008), or had redness (OR 2.9, CI 1.06-4.2, p0.03).

More recent RCTs have again supported guideline recommendations to use beta-lactams for treatment of non-purulent cellulitis. Remarkably, (but unfortunately not surprisingly) only 30% of the time did treatment of nonpurulent cellulitis follow guidelines; most patients received some agent covering CA-MRSA. Compliance with guidelines improved slightly with management of purulent SSTIs (44% compliance). 88% of patients received antibiotics for management of mild skin abscess, and half of these underwent concurrent incision/drainage (I&D). Current guidelines indeed recommend I&D without antibiotics for mild abscess, however we do not know the size of the abscesses included in the study, and since the guidelines were published, new RCT data support adjunctive SXT after I&D for abscesses >2cm4, so perhaps these “noncompliant” clinicians were simply ahead of their time.   Finally, the authors looked at diagnostic testing. Current guidelines only recommend blood cultures in patients with severe nonpurulent infection, but 29% of patients with mild cellulitis had blood cultures obtained (only 1 positive).

Both of these studies identify clear targets for antibiotic (and diagnostic) stewardship with respect to SSTIs. Utilization of SXT in cases of impetigo could lead to more monotherapy and reduction of unnecessary “double coverage” antibiotic use; reinforcement of the need for only beta-lactams for non-purulent cellulitis is an important area for improvement; and avoidance of unnecessary blood cultures reduces the need for inappropriate antibiotic therapy for contaminants.

The preceding was previously posted by Dr. Marcelin to SHEA Journal Club published online in March 2018, and published on Medscape in June 2018. 

References:  

    1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10-e52.
    2. Bowen AC Carapetis JR, Currie BJ, Fowler V Jr, Chambers HF, Tong SY. Sulfamethoxazole-trimethoprim (cotrimoxazole) for skin and soft tissue infections including impetigo, cellulitis, and abscess. Open Forum Infect Dis. 2017;4:ofx232.
    3. Kamath RS, Sudhakar D, Gardner JG, Hemmige V, Safar H, Musher DM. Guidelines vs actual management of skin and soft tissue infections in the emergency department. Open Forum Infect Dis. 2018;5:ofx188.
    4. Daum RS, Miller LG, Immergluck L, et al; DMID 07-0051 Team. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017;376:2545-2555.

Top 10 Things We Are Thankful for in ID – Letterman Style

Life is better with gratitude. Today, whether or not you celebrate Thanksgiving, we want to continue to show our gratitude and thankfulness to be able to help diagnose, prevent, treat, cure and even advance, the science of medicine. Now, let’s have a little fun!

We are grateful for:

10. Hand washing with those cute seasonal soaps – No one needs a real-life learning experience about Typhoid Mary.

9. Well-cooked Turkey – Salmonella was not invited to this dinner party.

8. Antibiotic-Free Agriculture  – This is not a rise of resistance anyone wants to endorse.

7. Improved monitoring and safety of herbicides – Did you know about The Great Cranberry Scare of 1959?

6. Separate cutting boards, so our spinach salad does not get introduced to Ecoli. Safety First, Food Safety!

5. Research & outbreak investigations that have taught us so many lessons about infections & foodborne pathogens like Listeria.

4. The potential antimicrobial effect of the honey on our roasted carrots – perhaps it is extra healthy?

3. The cinnamon in your pumpkin pie, may also have antimicrobial impact against. S. aureus & E. Coli.

2. Influenza vaccinations– saving lives every year during this season of celebrations and rising cases of influenza infection. It’s not too late you get yours!

  1. Finally, YOU! Colleague, patient, educator, advocate, researcher, funder, supporter. Without all of you, we simply would not be able to continue to provide the extraordinary care and education we strive to. Thank you! May you find your day full of gratitude and thankfulness.

 


 

Earrings In Healthcare Workers: Friend or Foe?

Ear piercing among people, including healthcare workers, is a common trend.

Katsuse et al, attempted to make a correlation between ear piercings and healthcare-associated infections. In order to prove this relationship, researchers sampled the earlobes and fingers of 200 nurses working at a university hospital. 128 of those nurses had pierced earlobes and 72 of the nurses sampled did not. When sampling the fingers, the fingers on the dominant hand were used for all nurses. The results are in the table below.

Pierced earlobes (128 nurses) Not Pierced (72 nurses)
Staphylococcus aureus on ears 24 7
Staphylococcus aureus on fingers and earlobes 12 3
MRSA isolates from earlobes 6 2
MRSA from fingers 5 1
MRSA from earlobes and fingers 3 1
Enterococcus faecalis 1 (earlobe and finger)
Morganella morganii 1 (ear lobe)
Pseudomonas aeruginosa 6 (fingers)
Acinetobacter species 6 (fingers)

 

The results showed that nurses with pierced ears were more likely to test positive for Staphylococcus aureus and MRSA on both their ears and fingers. The study concludes, based on these non-statistically significant numbers, that contamination and cross transmission can occur when fingers contact the earlobes. Since the same S aureus PFGE type was found on the earlobes and fingers, the authors deduced that pierced earlobes can be a source of hospital acquired infections.

They also concluded, that since more nurses with pierced ears also had MRSA isolates recovered, that pierced earlobes are a risk factor for MRSA carriage. The researches then used this information to determine that indirect transmission can occur when health care workers wear a name badge strap because removal of the strap may lead to contact with the earlobe and result in the spread of bacterial, although they could not prove this association.

Some comments from our journal club discussion included:

  1. There is no data to differentiate persons who are colonized vs transient carriage.
  2. There is also no consideration of other variables such as recent antibiotic use, current hygiene practices(including adequate hand hygiene with patient care, which should negate the risk of hand carriage), and frequency of earring changes and cleaning or a multitude of other factors that may affect isolation of organisms from body parts.
  3. The authors in this article drew conclusions, with inadequate evidence, that:
    1. Pierced ears may cause transmission when they come into contact with name badges
    2. Pierced ears may cause hospital associated infections.

Will we be changing policies regarding earrings based on this study – not at all. Earrings and piercings may have a relationship to MRSA coverage, but this study falls quite short of proving that. It also is unable to provide a clear increased risk of healthcare-associated infections relating to earring use.

Article chosen, presented and reported in this blog by Alisha Dorn, Infection Preventionist. Edited by Dr. Kelly Cawcutt. 


 

UNMC Infectious Diseases Fellows are Antibiotics Aware

The following was written by Dr. Raj Karnatak, 2nd year ID fellow at UNMC; a reflection of his current Antimicrobial Stewardship/Infection Control rotation:

The UNMC Infectious Diseases fellowship antimicrobial stewardship and infection control rotation provides robust training for fellows in both antimicrobial stewardship and infection control. Training is well designed with education in all the core elements of stewardship and infection control. Fellows attend dedicated lectures from the experts in the field of infection control and antimicrobial stewardship. Throughout the rotation fellows actively participate in hospital acquired infections (HAI) surveillance and infection prevention, and antimicrobial stewardship interventions. In the Infection control training, we learn about the role of healthcare epidemiology, surveillance and prevention of healthcare-associated infections including C. difficile, central-line associated bloodstream infections, multidrug-resistant organisms, ventilator-associated events, and surgical site infections.

Our antimicrobial stewardship training is concentrated on learning the CDC core elements of antimicrobial stewardship and implementing principles of antimicrobial stewardship in healthcare settings (Inpatient, outpatient, long-term care facility). Fellows actively engage in quality improvement in the infection control and antimicrobial stewardship and also work closely with our Stewardship Pharmacy Coordinator. Learning stewardship core elements present you to principles that can very well be applied to a wide variety of QI efforts. As fellows we are fully integrated into the stewardship team during our rotation, and besides attending key meetings where brainstorming stewardship issues occur and decisions are made, we actively participate in daily telephone audit-and-feedback. This gives us needed practice with communicating with prescribers, troubleshooting common problems and helps us to be better Infectious Disease Doctors.  We are also participating in the IDSA Antimicrobial Stewardship Curriculum pilot. In this formal training, our curriculum Directors Drs. Van Schooneveld and Marcelin meet with us regularly for case-studies, role playing and module reviews, where we discuss approaches to handling difficult situations as #Stewies.

As a part of my stewardship project, I am working on developing an institutional guidance document for antibiotic management of acute rhinosinusitis and pharyngitis in the outpatient setting. My other project is in infection control for the prevention of ventilator-associated events. I also had the opportunity to work with a larger multidisciplinary sepsis group for the development and implementation of institutional sepsis protocol. As a budding Infectious Diseases physician with particular interest in Critical Care Medicine, I know that Antimicrobial Stewardship is essential to any job I take post-fellowship, and I am thrilled to be at an institution that values it so highly.

How Nebraska ASAP is Making Everyone Antibiotic Aware

The following was written by Dr. Salman Ashraf, co-Medical Director of the Nebraska Antimicrobial Stewardship Assessment & Promotion Program (ASAP):

Antibiotic Resistance is one of the most urgent threats to the public health. Overuse and misuse of antibiotics allows the development of antibiotic-resistant bacteria. Unfortunately, a significant proportion of antibiotic use in various healthcare settings continues to be unnecessary or inappropriate. About a third (30%) of all antibiotic use in hospitals and outpatient setting and up to 75% of antibiotic use in long-term care facilities have been found to be inappropriate. Antimicrobial stewardship programs (ASP) have been shown to be effective in decreasing inappropriate antibiotic use in all of these settings. However, there is a shortage of infectious diseases (ID) trained physicians and pharmacists who can assist healthcare facilities in such efforts, especially in heavily rural states such as Nebraska. Additionally, many of these facilities may lack the resources necessary to effectively implement an ASP.

The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is funded by the Nebraska Department of Health and Human Services, Healthcare-Associated Infection Team through a CDC grant. It is closely affiliated with the nationally recognized ASP at Nebraska Medicine. The ASAP program employs ID trained pharmacists, ID trained medical directors and infection preventionists with extensive experience in establishing and running successful infection control and antimicrobial stewardship programs. The goal of ASAP is to promote effective use of antimicrobials and improve patient outcomes throughout the state of Nebraska by collaborating with local clinicians, pharmacists, infection preventionists and other health care workers. The team is working diligently to establish effective ASP in all healthcare facilities, especially those that lack the expertise to develop or improve these programs on their own.

The highlights of Nebraska ASAP initiative include:

• Assessment of ASP in various health care facilities
• Identification of facility-specific gaps along with provision of recommendations for improvement
• Provision of ongoing support for antimicrobial stewardship efforts in recruited acute and long-term facilities through an innovative model of remote coaching (utilizing video-conferencing service)
• Development of tools and templates to facilitate implementation of ASP in various healthcare settings
• Development of patient and provider educational resources related to appropriate antibiotic use
• Collaboration with regional organizations and healthcare facilities on educational efforts to improve antibiotic prescribing practices in outpatient setting
• Provision of expert guidance related to ASP development and maintenance for all healthcare facilities that reach out with questions (in addition to assisting healthcare facilities in Nebraska, the team also answer questions sent to us by facilities and organizations from neighboring states or other parts of the country).

Notable achievements of Nebraska ASAP initiative include:

• Currently providing expert guidance to 24 facilities in the state (10 acute-care Hospitals and 14 long-term care facilities)
• Created 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 5000 users both nationally and internationally and has earned the reputation of a national resource for facilities looking into developing or improving their ASP
• Organized the inaugural “Antimicrobial Stewardship Summit” for the state of Nebraska on June 1st 2018 to provide education to ASP program leaders (over 250 healthcare workers attended the summit)
• Established the Nebraska ASAP YouTube Channel in February 2018 that hosts all the educational videos developed by the team (almost 2500 views of the videos have been reported in this short time frame).
• Shared our findings and experience with healthcare community at various national meetings (these presentations are available online here
• Piloted an educational intervention in 10 primary care clinics that resulted in a 25% decrease in antibiotic prescribing for acute bronchitis (further analysis is ongoing and the results will be shared with healthcare community soon)

Upcoming activities of Nebraska ASAP initiative include:
• Introducing a CME educational activity for providers of outpatient clinics and urgent care centers. The course will be launched in the next couple of months. Outpatient clinics and urgent care centers who want to partner with ASAP can reach out to us in advance to make sure they have a guaranteed spot when the activity goes live: Further information can be found at online here
• Organizing the 2019 Antimicrobial Stewardship Summit that will focus on the needs of acute-care, long-term care and ambulatory-care settings. The summit will not only provide guidance on how to establish ASP but also provide education on evidence-based management of common infections in various healthcare settings. To receive news on important new website contents or upcoming events sign up for updates here
• Continue to recruit for remote coaching on antimicrobial stewardship (only a few spots left). Healthcare facilities that are interested in partnering with antimicrobial stewardship experts to assist their local ASP team can find more information on the following link:

The Nebraska ASAP team

Nebraska Medicine is Proud to #BeAntibioticsAware

Our Antimicrobial Stewardship Program (ASP) at Nebraska Medicine has been in place since 2004. Over the years our program has changed and improved sought to expand and improve its approach with the goal of providing extraordinary care to our patients. Rather than an overly restrictive practice, our program has we have emphasized constant regular communication with our clinicians through a robust audit-and-feedback program. Physician medical directors are Drs. Trevor Van Schooneveld, Jasmine Marcelin and Erica Stohs, (who recently joined our program this summer). Our Pharmacy Coordinator is Scott Bergman PharmD.

Over the last year, our ASP team has collaborated with the microbiology laboratory, hospital clinical effectiveness team and sepsis taskforce to implement some changes with goals of improved patient care.  In June 2018, we hosted the inaugural Nebraska Antimicrobial Stewardship Summit, where experts spoke on various aspects of ASP.  This has led to multiple outreach conferences where members of our ASP team have been invited to speak and counsel medical centers on their ASP development.

Diagnostic stewardship has become an integral part of our ASP. We implemented a hard stop in the electronic medical record to prevent inappropriate ordering of the gastrointestinal pathogen panel and saw significant decreases in inappropriate use with associated cost savings (Presented at #IDWeek2018). Similar interventions are underway for decreasing inappropriate respiratory pathogen panel ordering and C. difficile testing.  A larger C. difficile reduction project is ongoing hospital-wide, and antimicrobial stewardship plays a significant role in this.  Additionally, we have updated several clinical guidance documents including alternatives to vancomycin + pipercillin/tazobactam combination therapy to avoid renal injury, skin & soft issue infections, and published an approach to inpatient allergy management.

We are also focusing efforts on Outpatient Antimicrobial Stewardship. While this program is still in its nascent stages, in collaboration with Nebraska ASAP we have developed a series of resources for antimicrobial stewardship in the outpatient setting including educational modules. The program goals are to reduce unnecessary antibiotic prescribing in the ambulatory setting throughout the Nebraska Medicine network.

Finally, the stewardship team has been working the Nebraska Medicine Sepsis Committee to assist in developing a management strategy for this common and highly lethal condition.  Initial work focused on sepsis recognition and implementation of screening to identify patients for early intervention.  This was highly successful with a 47% decrease in sepsis mortality at Nebraska Medicine between 2014 and 2016.  With the recent introduction of new sepsis definitions the Sepsis Committee elected to implement these new definitions to better focus aggressive care on those patients most likely to benefit from it. In addition, the current nurse screening protocol is being replaced this month with an advanced sepsis early warning model which mines large amounts of data available in our electronic record to more accurately identify patients at risk of developing sepsis.

Over the years the mission of the ASP at Nebraska Medicine has not changed, but our methods and activities have expanded to meet the challenges of our ever changing healthcare landscape.

Keep looking for updates to clinical guidance on our website!

Content courtesy Dr. Trevor Van Schooneveld and Dr. Jasmine Marcelin

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