The following review was originally posted by Dr. Marcelin to the September 2018 SHEA Journal Club and featured on Medscape’s SHEA Expert Commentary earlier this month.
Use of empiric antimicrobial treatment in acute care settings is often the result of the “diagnosis momentum” heuristic, wherein the antibiotics started in one location for “sepsis” are continued for several additional days after transfer to a second location. Vancomycin remains one of the most commonly prescribed inpatient antibiotics, despite a decline in prevalence of invasive MRSA infections. The authors of the first article “Rate of positive cultures necessitating definitive treatment in patients receiving empiric vancomycin therapy” compared the rate of actual positive culture requiring vancomycin to the rate of vancomycin use in a single-center retrospective observational study. The majority of these infections were SSTIs, bacteremia and pneumonia.
Concern for MRSA is likely the driver of overuse of vancomycin, yet this organism was confirmed in only 8.4% of the positive cultures. Over the three-month period studied, only 11% of 1662 patients on vancomycin had a positive culture necessitating vancomycin use as definitive therapy. This means that up to 90% of patients on empiric vancomycin can likely be safely de-escalated, especially after 48 hrs. of negative cultures. However, convincing prescribers to discontinue presents a separate challenge for Antimicrobial Stewardship Programs (ASP).
In the second article, “Microbiology Comment Nudge Improves Pneumonia Prescribing”, the authors capitalized on the fact that perhaps most decisions to start empiric vancomycin/piperacillin-tazobactam in setting of pneumonia occur in the context of concern for unidentified MRSA or Pseudomonas aeruginosa. Even with negative cultures, are prescribers continuing these antibiotics because of a fear that these bacteria are lurking in the cultures, but missed by the microbiology lab? In active stewardship education, we can tell people “the likelihood that MRSA or pseudomonas is going to be present in a person without specific risk factors is low”. In a complex patient care scenario however, prescribers can talk themselves into the possibility of these bacteria being present even when it highly unlikely. What if the micro lab could say unequivocally that these organisms were absent; would that change practice?
In this quasi-experimental study conducted within a 4-hospital system in Detroit, the microbiology lab cultured respiratory specimens of individuals being treated for pneumonia. The lab made a simple modification to their reporting system for normal “commensal respiratory flora” (which included growth of Neisseria, Corynebacterium and Streptococcus, with no dominant growth of any single organism). The lab added the statement: “No S. aureus/MRSA [methicillin-resistant Staphylococcus aureus] or P.[Pseudomonas] aeruginosa” to the report, and the ASP provided a brief education to prescribers.
After this behavioral nudge was implemented, prescribers were 34% (p<0.01) and 5.5-fold more likely to de-escalate antibiotics than when the report only stated “commensal respiratory flora”. Additionally, with fewer vancomycin/piperacillin-tazobactam combination days of therapy (DOT), they noted a 17% reduction in acute kidney injury (p<0.03) even after adjusting for severity of illness with APACHE II or Charlson comorbidity index scores. The DOT of MRSA and antipseudomonal therapy was reduced from 7 to 5 days (P<0.01). The authors do not state how long their lab took to finalize cultures, but assuming at least a preliminary result of the “commensal respiratory flora” comment nudge in 48 hrs. even the intervention arm had room for earlier de-escalation, with a median empiric DOT of 5 days. Multidrug-resistant organisms (MDROs) were not generally prevalent in either group, however there was a significant difference in development of subsequent MDROs after the culture result nudge (8% vs 1%, p=0.035). Despite these significant stewardship outcomes, however, no effect on mortality, development of Clostridium difficile infection, or change in length of ICU/hospital stay was observed.
Behavioral nudges use positive reinforcement and indirect messaging to influence decision-making, and exist in many areas of our clinical environment already. Many microbiology labs already include resistance markers in the rapid diagnostic test results, which serve to passively guide prescribers to appropriate antibiotic choices. As ASPs aim to collaborate with prescribers to change behaviors, these behavioral nudges can be a useful low-effort/high-yield tool to further assist with antibiotic de-escalation, even in critically ill patients.
References:
Dustin Waters and Joshua Caraccio Rate of positive cultures necessitating definitive treatment in patients receiving empiric vancomycin therapy. Infection Control & Hospital Epidemiology, Volume 39, Issue 8 August 2018 https://doi.org/10.1017/ice.2018.123
Mary Musgrove et al. Microbiology Comment Nudge Improves Pneumonia Prescribing. Open Forum Infectious Diseases, Volume 5, Issue 7, 1 July 2018, https://doi.org/10.1093/ofid/ofy162
Under the coaching of Vintage Ballroom instructor, Rebekah Pasqualetto, three pediatric patients are teaming up with the doctors’ who saved them to put on the biggest performance of their young lives. The dancing isn’t easy. Between school, doctor appointments, and daily lives the girls dedicated two months to learning three styles of dance: Rumba, Merengue, and Country Swing. Each song matches the personality of each child. 11-year old Daisy likes to dance with her friends to the latest pop hits. 12-year old Maura has dance training from previous years of ballet. Even with surgery restrictions, Maura is adamant about performing a trick on the dance floor. 12-year old Raeleigh loves fashion, she is very considerate of others. Raeleigh will be joined on the dance floor by her younger sister Addisyn who suffers from watching Raeleigh undergo treatment.
Dr. Diana Florescu is coordinating the fundraiser with Child Life, Vintage Ballroom, and Nebraska Dance Festival. The organizers of Nebraska Dance Festival – Amanda & Ilya Reyzin and Igor Litvinov – are supporting Child Life Services from University of Nebraska Medical Center! Through their donation, they will share the gift of reading and spread some fun to pediatric patients at Nebraska Medicine. Hospitalization can be a scary and isolating experience for children and teens. Many of the kids are hospitalized for long periods of time – months or even years – due to the severity of their illnesses. Books and games will allow kids to experience normalcy, socialization, and continued growth and development while hospitalized.
During the month rotation a small special project is also conducted and a specialized curriculum/lecture series is conducted. ID fellows are exposed to the infection control literature during a monthly infection control journal club in which they take turns critiquing recent publications along with IPs and faculty. The infection control experience is capped off by attendance of the SHEA/CDC basic course in Hospital Epidemiology. For the ID fellow interested in infection control as a career, opportunity for a third year of Fellowship directed toward specialized training in infection control and hospital epidemiology is encouraged.
Penicillin allergies are 
Once a penicillin allergy is listed in a patient’s record, they are more likely to receive inappropriate broad-spectrum antibiotics – a 
There’s an age-old joke that if a team wants a detailed history on a patient, just consult ID. If our attention to detail is already expected, shouldn’t we feel empowered to take that allergy history and de-label the penicillin allergy? Inpatient allergy consultations are difficult to coordinate when those divisions may be understaffed and allergists are busy with outpatient practices. So how can we capitalize on their expertise when they can’t see the patient in the hospital? Simple: partner with them to create 
In honor of Sir Alexander Fleming and 
Dr. Angela Hewlett has been elected to the Executive Board of the 
Dr. Jasmine Marcelin was awarded the SHEA Race Against Resistance Scholarship, funding provided for a new Antimicrobial Stewardship clincian to learn more about the field. Dr. Marcelin partnered with Physicians Weekly to co-moderate two twitter chats on 
Dr. Susan Swindells was awarded the Department of Medicine Faculty Clinical and Educational Mentoring Award.
Dr. Trevor Van Schooneveld was recently named UNMC College of Medicine Resident Program Director of the Month in September (ID Fellowship Program Director)
Dr. Sara Bares was recently inducted into the UNMC Interprofessional Academy of Educators. She also recently was awarded the ACTG Network Minority HIV Investigator Mentoring Award.
What a terrific group of talented and accomplished individuals. Kudos to our faculty and staff for their continued hard work and dedication to advancing academic Infectious Diseases!
The Rapid Prediction of Carbapenem Resistance in Patients With Klebsiella pneumoniae Bacteremia Using Electronic Medical Record Data.
Using Patient Risk Factors to Identify Whether Carbapenem-Resistant Enterobacteriaceae Infections Are Caused by Carbapenemase-Producing Organisms
The following snippets are Notes from the Field published in MMWR with new information about CRE organisms: 
Is there more neuroinvasive disease than in the past? Neuroinvasive disease (e.g., meningitis, encephalitis, or acute flaccid paralysis) occurred in about 46% of West Nile Virus infections 
How do I test for it? Should I re-test? In general, diagnosis of West Nile Virus requires testing blood for antibodies to the virus. IgM antibodies present indicate a current or recent infection. If a person has neurologic symptoms (concerning for neuroinvasive disease), lumbar puncture is recommended with testing of the cerebrospinal fluid for West Nile IgM. If the initial IgM test is negative but suspicion for West Nile Virus is high, the antibody test should be repeated in 10 days (Convalescent testing), particularly if symptoms persist.
Can it be prevented? There is no vaccine for West Nile Virus. You can prevent West Nile infection by preventing mosquito bites. Use long sleeves, pants and insect repellents such as DEET or Picardin. Check out the EPA repellent information to help choose the best option here: 
The 
These outbreaks are only a small sample of the infectious diseases that are occurring in the world today. The 
Content courtesy Dr. Angela Hewlett, Director of the Nebraska Biocontainment Unit
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