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Division of Infectious Diseases

M4 Students in our HIV Enhanced Education Track present Capstone Projects…and Today is MATCH DAY!

The UNMC College of Medicine offers a unique Enhanced Medical Education Track (EMET) program which provides an opportunity for medical students to delve into particular disciplines of interest in the field of medicine throughout their four year degree program. Track students attend seminars, preceptorships and complete a research project culminating in a poster or conference presentation.

Yesterday, on the eve of their Match Day, our two M4 Students, Rebecca Osborn and Daniel Cloonan (under the mentorship of Dr. Sara Bares) presented their Capstone Projects at UNMC College of Medicine.

Today, after years of hard work, months of interviews, weeks of decision and the most anxiety-filled week of their lives, they found out where they will be spending the next few years of their lives as newly minted doctors.

Rebecca’s project focused on a collaborative care program to help with medication adherence in patients living with HIV.  This collaborative worked with a local community pharmacy to create a program of direct engagement between pharmacists and patients in order to improve adherence. She will be submitting her work for presentation at a national conference and for publication. Rebecca will be continuing her medical training with Internal Medicine Residency at Yale. We wish her all the best and hope to see her again in the future for ID fellowship!

Daniel’s project looked at the gender affirming hormone therapy taken by transgender patients and possible interactions with Pre-exposure prophylaxis (PrEP), which is recommended to help prevent HIV infection in persons at high risk for acquiring the disease. Because of a fear of drug-drug interactions, many transgender individuals may avoid PrEP when they are at high risk, fearing an interruption in their hormone therapy. Daniel’s study is part of a larger study being led by Kim Scarsi, PharmD (HIV Clinical Pharmacist at the Specialty Care Center and Associate Professor in the College of Pharmacy) and Lauren Cirinccione, PharmD (Pharmacy Practice Fellow). The project, collaborating with the UNMC College of Pharmacy, hopes to answer this question and by doing so, remove some barriers to PrEP engagement when needed. Daniel will be continuing his medical training with a General Surgery Residency at Beth Israel Deaconess Medical Center. We wish him all the best in the future!

Each year, our UNMC HIV clinic takes two medical students into the EMET track, and we look forward to working with them over the course of their undergraduate medical training to immerse them in HIV care and Infectious Diseases. We will soon be announcing our new M1 EMET students, who will start working with us over the coming summer.

Congratulations again to Becky and Daniel, we are proud of you! And congratulations to all M4s out there who found out where they matched today!

More information about the EMET program can be found here.


 

What Patient Safety Means to Us – Part 2

In endeavoring to give you a real flavor of how important patient safety is to all of us, we have more comments today from our team. Patient safety is important to all of us and we wish we could highlight the all of important work everyone in our Division is doing to provide the best possible care while still preventing harm.

 

Adrienne Sy, RN, BSN; Quality Lead for CLABSI & CAUTI reduction starts us off today:

Patient safety means protecting someone’s loved one from harm.  My grandmother passed away after a fall two weeks before I took the NCLEX, and my mother-in-law passed away after a bloodstream infection three months after I got to marry her eldest son.

Two things that I am very excited to help run/coordinate are the CAUTI and CLABSI Roundups.  It gives me a chance to work with the nursing units, and I believe that these have been very helpful in identifying what is done well and what our areas of opportunity are.

 

Michelle Schwedhelm, RN adds a great global view of safety at Nebraska Medicine/UNMC:

Patient Safety is creating a safe zone and processes for patients seeking care at Nebraska Medicine. 

One project is doing Fire and Severe Weather Drills with our staff to assure they know how to evacuate and how to mitigate danger for our patients.  Another is our new Daily Shout Out meeting where we identify safety issues for patients and staff and encourage prompt resolution.  Visibility is at the highest levels of the organization.

 

Dr. Kelly Cawcutt on preventing harm in the ICU:

Dr. Kelly Cawcutt, Associate Director of Infection Control and Epidemiology

Patient safety is about always providing the best patient-centered care while preventing harm, for all patients. I work in the ICU also, and there we are providing care to the sickest patients in the hospital and often have to use invasive procedures and devices for life support measures. Providing excellent clinical care is one component of patient safety, but through working in Infection Control, I can also focus on preventing harm are a larger scale from how we prevent the spread of infections in the hospital to which types of devices we use in the ICU. 

Some examples of projects I have worked on are developing a vascular access algorithm to ensure we use the right device at the right time for our patients – whether that is a peripheral IV, midline, central venous catheter or another type of device. I also am working on how to address and prevent ventilator-associated events, including pneumonia, for our patients who require mechanical ventilation in the ICU. These projects reduce harm, prevent adverse events and in the end, I believe this work helps save lives. 

 

To me, patient safety is about imagining yourself as each patient or family member being cared for in the hospital, and asking “is the care I’m delivering what I would want for myself or my family?”, and if the answer to that is “no”, personally seeking ways to improve that care for our patients. 

Dr. Jasmine Riviere Marcelin is the Associate Medical Director, Nebraska Medicine Antimicrobial Stewardship Program

Much of my work in Antimicrobial Stewardship is focused on reduction of antibiotic use, primarily with a patient safety mission. Antibiotics are the only drugs where an individual prescriber’s use can affect patients s/he never even cared for. For example, when patients are prescribed antibiotics for viral illnesses which do not require them, this may lead to development of bacteria resistant to antibiotics. When a patient in that community then develops a serious bacterial infection with this resistant organism, they may face grave complications from the actual bacteria or from use of alternative antibiotics with serious adverse effects or toxicities. Collaborating with the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) and Nebraska Health Network (NHN), I created several educational materials for outpatient prescribers on appropriate use of antibiotics in upper respiratory illnesses.

Additionally, skin/soft tissue infections are another area where antibiotics are overused, and I personally have seen patients develop kidney failure from combination treatment with vancomycin and piperacillin-tazobactam for cellulitis when only cefazolin was indicated. I am currently working on updating our institutional skin/soft tissue infection guidance document which will help antibiotic prescribers make the right treatment choices for specific skin/soft tissue infections. These are just two of the many projects our Antimicrobial Stewardship Team are working on to decrease antibiotic overuse and misuse, keeping patients safe by reducing adverse effects, drug toxicities and antibiotic resistance. 


 

Antimicrobial Stewardship Program Takes Patient Safety Personally

At Nebraska Medicine, our Antimicrobial Stewardship Program’s (ASP) clinical mission is to optimize the utilization of antimicrobial agents, thereby improving patient outcomes (by reducing the risk of adverse events and Clostridium difficile infection) and limiting the spread of antimicrobial resistance.   These Antimicrobial Stewardship activities have been mandated by the Joint Commission and our program has been expanding its reach to include our satellite hospitals and our outpatient clinics to achieve this mission. Since a large majority of inappropriate antibiotic use occurs outside of the hospital, our outpatient initiatives are currently focused on education of clinic providers and patients on not using antibiotics for conditions that do not require them.

On the inpatient side, our stewardship activities have many impacts on patient safety.  First, many studies have demonstrated the benefit of early Infectious Disease consultation for patients with Staphylococcus aureus bloodstream infection (SAB). When ID doctors are involved, patients are less likely to die or suffer complications, respond faster to therapy and will have fewer adverse effects.  At Nebraska Medicine, we review approximately 150 SAB cases per year to prompt ID consultation. In addition, the discussion between the ASP reviewer and the primary team ensures the appropriate antibiotic is started immediately, even in advance of the ID consultation.

Last year, our ASP program documented over 2500 reviews of patients for appropriate antibiotic use, with 381 interventions to reduce antibiotic use by either discontinuing or de-escalating therapy, with a 90% acceptance rate of interventions. Not only did we assist with narrowing antibiotic use, 97 patients with untreated or resistant infections were identified and subsequently initiated on therapy as a result of ASP review, and nearly 200 ID consult requests were implemented in highly complex cases.

Furthermore, our ASP interventions have also resulted in reductions of vancomycin and piperacillin/tazobactam combination therapy when unnecessary. The combination of these two antibiotics has been shown to increase risk of kidney failure (which leads to worse clinical outcomes for patients), and the simple act of switching to alternative antibiotics to avoid this risk has tangible patient safety benefits.

In 2016, new initiatives were introduced to improve timing and redosing of antibiotic prophylaxis for surgery, in an effort to reduce the risk for surgical site infections (SSI). Coupled with the new SSI prophylaxis guidance, the program developed guidance on how to manage patients with beta-lactam allergies.  This is important for patient safety because many patients receive 2nd or 3rd line antibiotics inappropriately in the context of remote penicillin allergies. Sometimes, like in the case of surgical prophylaxis, the data is clear that use of antibiotics other than cefazolin can lead to increased SSI risk. Providing evidence-based guidance in collaboration with our allergists empowers physicians to provide best care for their patients without perceived harm of allergic reactions.

Antimicrobial stewardship is the balance between treating patients effectively and keeping them safe from harm.

Here at Nebraska Medicine, we take that balance personally; practicing Serious Medicine, delivering Extraordinary Care.


 

What Patient Safety Means To Us – Part 1

As mentioned on Monday, patient safety is a primary focus of our work, particularly in Infection Control and Epidemiology. To really highlight the commitment to this initiative, we wanted to share a series on what patient safety means to us and a few examples of how we have implemented that into our work.

 

Per Dr. Mark Rupp,  Division Chief and Medical Director of Infection Control & Epidemiology:

Patient safety, is the very reasonable expectation from our patients, that although in healthcare we do things that are inherently dangerous, we minimize the risk of harm as much as is possible.  Quite simply, we eliminate preventable harm.

In the Infection Control and Epidemiology Department our whole effort is dedicated toward minimizing the occurrence of healthcare associated infections (HAIs). 

In recent years at Nebraska Medicine we have taken aggressive measures to decrease central line associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI).  We emphasize horizontal interventions which are measures that impact all patients or broad groups of patients – examples of horizontal interventions are hand hygiene, chlorhexidine bathing, and environmental cleaning and disinfection.  At the present time we are in the middle of a campaign to decrease infection due to Clostridium difficile and launching programs to further limit infections following surgery (surgical site infections).  Much of the work we do is behind the scenes and includes making sure the air is safe, the water is free of pathogens, and systems to provide clean and sterilized instruments and devices are working properly.” 

 

Dr. Angela Hewlett, Medical Director of Clinical Operations for the Biocontainment Unit,  Associate Medical Director of Infection Control & Epidemiology and Director of Infectious Diseases Outpatient Clinic said:

To me, ‘patient safety’ is the practice of doing everything we can to prevent harm from coming to our patients.  Patient safety protocols should be based on the best available scientific evidence and always be accompanied by education (for healthcare workers as well as patients).

 Examples:

  1. After it was noted that patients with fractures were placed on a variety of antibiotic regimens in an effort to prevent infections, I worked on a collaborative project with the Department of Orthopaedic Surgery to standardize antibiotic recommendations for patients with fractures.  We created an Epic order set, and conducted educational sessions with multiple physician groups, including the Emergency Department, Trauma Surgery and Orthopedics.  This evidence-based protocol will help with patient safety by ensuring that patients are receiving appropriate antibiotics and dosing for an appropriate amount of time. 
  2.  Chlorhexidine (CHG) bathing is a modality that has been shown to decrease healthcare-associated infections, and is a standard practice for all inpatients at UNMC.  Dr. Andrea Green and I created a survey of nursing staff to determine what barriers exist in regards to CHG bathing of patients.   We used the information generated from the survey to create education on the benefits of CHG bathing in an effort to increase compliance with this practice. 

 

Kim Hayes, RN and Infection Preventionist added her perspective with:

What does patient safety mean to me?  First and foremost, we must not harm our patients during the course of their treatment, either in our cares or with our devices.  We must be mindful that our patients were not always as we see them and their families have the expectation that we will keep them safe and not let harm come to them while they stay with us.

Two projects that I have been involved with were the CAUTI reduction team during which every nurse/tech in the facility was instructed in catheter insertion and appropriate catheter cares, supply lines were standardized and we updated our devices(sterile piston irrigation set).  The second was moving from the outdated split septum IV infusion sets and connectors to meet the industry standard with the needleless sets and connectors.  This was an enterprise wide change that touched every department and made IV treatment safer.  Alligator clips no longer popped off and infused medications into the bed linens, needles were no longer used in the system, so nurses are safer today as a result.  

Learn more about ID and Infection Control at UNMC.

 

 


 

Patient Safety Awareness Week

“4 in 10 Americans say they have experienced a medical error in their own care or in the care of a loved one.”

Preventable Harm is critical to reduce in healthcare. It is a major cause of death, disability and costs, therefore the Institute for Healthcare Improvement created an initiative of Patient Safety Awareness Week from March 11 to the 17th. The mission is to raise awareness among providers and patients alike, to recognize the paramount importance of patient safety and that no matter what, WE ARE ALL PATIENTS. We all want medical care that is both excellent and safe.

How can you get involved with the events this week?

Take the pledge to help reduce harm.

Join the webinar at 12pm Central time for Engaging Patients and Providers: Speaking Up for a Culture of Safety

Join the Twitter chat. #PSAW18 Friday March 18th from 11AM -12PM Central Time on  Building a Culture of safety.

Check out resources for your institution and other events here: http://www.unitedforpatientsafety.org/

Here in the realm of Infectious Diseases, much of our work surrounds efforts that directly impact, and improve, patient safety. From antibiotic stewardship aid in improving our drug choices while minimizing adverse events to choosing the right types of IV catheters to even what may seem mundane, like making sure hand washing is easy-to-do and DONE! Throughout this week, we will be posting thoughts on what patient safety means to us and projects we have worked on that focus on patient safety.  This will included a broader array of the invaluable team members helping us all work toward safer healthcare everyday.


 

Match Day – Congratulations and Best Wishes!

Today is the day in which “the MATCH” happens for our 2018 students. This morning, at 11 AM they will find out if they matched into a residency program and this Friday, March 16, they will find out where they matched. Match Day is a day full of anxiety, excitement and some trepidation as you find out if you need to move, what city and state you may be relocating to before entering years of medical training as a resident.

The Match is meant to remove pressure and bias from both students and institutions during the process of choosing a residency program, but it is laced with the unknown and lack of control of where you go, and what you do next. It is a unique right of passage for physicians as they launch into the years of training after earning their MD.

Congratulations to medical students at UNMC and across the country as you celebrate and take the next steps toward becoming the future of medicine. No matter the result, you have come this far and you will continue to step forward as a physician into a realm of extraordinary opportunity to witness, and care for humanity, with all of it’s vulnerability and complexity.

From the UNMC ID Division, we wish you all the best and of course, we hope to see you join us again as fellows!


 

Happy International Women’s Day! Meet the Women Faculty of UNMC ID

March 8, International Women’s Day, was created as a day to recognize the women’s rights movements around the world. This year’s theme is #PressforProgress, fueled by ongoing global activism and advocacy for women’s rights in all facets of life.

In an age where more women than men are enrolled in US medical schools, and 52% of adult Infectious Disease Fellows are women,  young aspiring female doctors may look to the composition of faculty in their desired specialty as an indication of their likelihood to “fit in” with that specialty.  UNMC ID is a division that embodies #PressforProgress. Of 21 Faculty members within our division, 12 are women, and we are proud of every one of them.

Meet the Women Faculty of UNMC ID:

Dr. Sara Hurtado Bares, MD is an Assistant Professor of Medicine and Associate Director of the Specialty Care Clinic which serves our patients living with HIV. Her primary research and clinical interests lie with HIV prevention, and she is currently principal investigator of several studies looking at delivery of HIV pre-exposure prophylaxis to high-risk patients. Dr. Bares is also passionate about medical education; she is the director of the HIV track of the UNMC College of Medicine Enhanced Medical Education Tracks Course and co-directs the medical student microbiology/infectious disease courses called Defenses & Invaders with Dr. Andrea Zimmer.

Dr. Kelly Cawcutt, MD is an Assistant Professor of Medicine and Associate Medical Director of Infection Control and Epidemiology.  She is also a board-certified Critical Care Physician, and regularly attends on the ICU services at UNMC. Dr. Cawcutt is also creator and co-administrator of the UNMC ID Social Media platforms with Dr. Jasmine Marcelin, and recently published a commentary on the value of Social Media in academic medicine.

Dr. Razan El-Ramahi, MBBS is an Assistant Professor of Medicine.  Her clinical and research interests include infections in Oncology/Immunocompromised patients. She also attends on the inpatient Oncology Infectious Disease service and sees patients in the General Infectious Diseases clinic.

Dr. Diana Florescu, MD is an Associate Professor of Medicine. Dr. Florescu’s clinical and research interests include infections in solid organ transplant recipients. She attends on the inpatient Transplant Infectious Diseases service and is regularly involved in teaching residents and fellows.

Dr. Alison Freifeld, MD is a Professor of Medicine. Her clinical and research expertise lies in the Oncology/Immunocompromised patients, and she is the founder and Director of the Oncology Infectious Disease Service at UNMC. Dr. Freifeld is internationally known in her field and has published/edited several books, countless peer-reviewed publications, including authoring the Clinical Practice Guidelines for Management of Febrile Neutropenia. Dr. Freifeld sees immunocompromised patients with infections in the outpatient clinic, and works closely with oncologists at UNMC.

Dr. Andrea Green Hines, MD is an Assistant Professor in the departments of Internal Medicine and Pediatrics, and Medical Director of the Antimicrobial Stewardship Program at Children’s Hospital & Medical Center. Dr. Green Hines is also the Program Director of the Pediatric Infectious Diseases Fellowship Program at UNMC. Her clinical practice comprises both adult and pediatric medicine. She attends on the Oncology Infectious Diseases and Pediatric Infectious Diseases services at UNMC and the Pediatric Infectious Disease Service at Children’s Hospital & Medical Center. Her research interests include antimicrobial stewardship in pediatric populations.

Dr. Angela Hewlett, MD is an Associate Professor of Medicine and Associate director of Infection Control and Epidemiology. Dr. Hewlett is also the Medical Director of the Nebraska Biocontainment Unit which was selected to care for Americans affected by the recent Ebola epidemic in West Africa. Her work with the BCU allows her to collaborate with the Department of Justice and Department of Health and Human Services to ensure that personnel are always trained to be ready for any possible global health threat. Dr. Hewlett also has an interest in Orthopedic Infectious Diseases, which comprises much of her outpatient clinical practice. She attends on the inpatient General Infectious Disease service, and is an adviser for the medical student ID interest group on campus.

Dr. Jasmine Riviere Marcelin, MD is an Assistant Professor of Medicine and Associate Medical Director of the Nebraska Medicine Antimicrobial Stewardship Program. Her clinical and research interests include HIV treatment and prevention and Antimicrobial Stewardship.  She is passionate about medical education and co-directs the HIV track of the UNMC College of Medicine Enhanced Medical Education Tracks Course with Dr. Sara Bares.  She is also co-adminstrator of the UNMC ID Social Media platforms with Dr. Kelly Cawcutt and is passionate about improving diversity in medicine.

Dr. Kari Neemann, MD is an Assistant Professor in the departments of Medicine and Pediatrics. Like Dr. Green Hines, Dr. Neemann’s clinical practice comprises both adult and pediatric medicine. She attends on the Oncology Infectious Diseases and Pediatric Infectious Diseases services at UNMC and the Pediatric Infectious Disease Service at Children’s Hospital & Medical Center. Her research interests include infections in children and in adults with cancer.

Dr. Kimberly Scarsi, PharmD is an Associate Professor of Pharmacy. Her clinical practice is as an HIV pharmacist at the Specialty Care center. She also facilitates the Infectious Disease sections of the School of Pharmacy, and precepts the ambulatory clinic rotation for pharmacy students. Dr. Scarsi’s  primary research focus is on pharmacologic studies of treatments for HIV, focusing on women living with HIV and treating co-infections with HIV/TB, and she collaborates with Dr. Swindells and Dr. Bares on many local, multi-center and multinational research projects.

Dr. Susan Swindells, MBBS is a Professor of Medicine and Director of the Specialty Care Clinic which serves our patients living with HIV. She was honored as a Distinguished Scientist at UNMC in 2011, and in 2013 received the UNMC Innovation, Development and Engagement Award (IDEA) award. Her clinical and research interests include treatment of persons living with HIV and persons co-infected with HIV and Tuberculosis.  Dr. Swindells is on the writing group for the Department of Health & Human Services HIV guidelines as an HIV/TB co-infection content expert, and the Principal Investigator on a multinational study recently presented at the Conference on Retroviruses and Opportunistic Infections (CROI) that showed 1 month of treatment for latent TB infection is as effective as 9 months of treatment in persons living with HIV.

Dr. Andrea Zimmer, MD is an Assistant Professor of Medicine. Her clinical and research interests include infections in Oncology/Immunocompromised patients. She attends on the inpatient Oncology Infectious Disease service and sees immunocompromised patients with infections in the outpatient clinic also. Dr. Zimmer is also involved with medical education and co-directs the medical student microbiology/infectious disease courses called Defenses and Invaders with Dr. Sara Bares.

Join us today on #InternationalWomensDay and everyday as we #PressforProgress and celebrate these women who are invaluable assets to our Faculty and Division. Learn more about the UNMC Division of Infectious Diseases here.


 

New Staff Spotlight – Danny Schroeder, PharmD

Tell us about the position you are starting:  I have recently started my role at Nebraska Medicine Bellevue as an Antimicrobial Stewardship pharmacist. I reach out to physicians at Nebraska Medicine Bellevue to discuss antibiotic therapy and try to obtain the best and safest therapy for our patients here. In addition, I work with Dr. Jasmine Marcelin in this role, she helps guide me with her expertise on some of Bellevue’s more complicated patients.

Tell us about your background:  I was born and raised in Omaha, Nebraska. I completed my pre-pharmacy studies at the University of Nebraska at Lincoln and came back to Omaha and obtained my PharmD in 2012 at the University of Nebraska Medical Center College of Pharmacy. I started at Nebraska Medicine Bellevue right after I graduated in 2012 as a casual pharmacist and started my full time position at Bellevue in early 2013.

Why UNMC? I obtained my PharmD at UNMC so I already knew how great of an organization UNMC is. I knew once I graduated that if I had a chance to get a position at UNMC I would take it. Everyone I know that works for the organization is happy working here and I enjoy working with all of the staff from UNMC as well. I also have an interest in teaching so working at an academic institution can help me pursue that interest.

What about ID makes you excited?  As I have been working at Nebraska Medicine Bellevue I found that the patients that have interested me most have been patients with infections. Progress notes from ID attending physicians have always been my favorite notes to read because it is fascinating to me how they go about figuring out what is wrong with their patients. I am excited to join the detective crew and do my part to help tackle these cases. In addition, I feel like I learn something new in the ID realm every day, there are advancements and new therapies introduced often and I am always eager to learn new treatment mechanisms.

Tell us something interesting about yourself UNRELATED to medicine: I really enjoy having a good beer. My wife and I traveled to Germany in 2016 and we attended an Oktoberfest celebration in Stuttgart. I also enjoy outdoor activities like hiking and disc golf. Lastly, I am a dog person, my wife and I have two Shih Tzus and they take up a lot of our time!

 

Danny Schroeder is joining the Nebraska Medicine Antimicrobial Stewardship Program (ASP) Team as an ASP Pharmacist primarily located at our Bellevue campus. We are pleased to have the opportunity to add this ASP complement to our Bellevue campus – Danny has been a great asset to the team.

CROI 2018 – The Official UNMC ID Guide of Where We Will Be!

CROI 2018 is here and we want to be sure YOU know where to find us in Boston. Below is the list of faculty presentations and posters from our Division. Come visit us at CROI – We would LOVE to meet you! Find us on Twitter @UNMC_ID ; #UNMCID

Content courtesy of Kim Scarsi, Sue Swindells and the entire HIV group at UNMC ID

Oral presentations:

Monday March 5 2018, 11:15am (in Oral Abstract O-02 ART: New Data and new insights, Auditorium) 

Abstract 27: COMPARATIVE LYMPHOID TISSUE PHARMACOKINETICS (PK) OF INTEGRASE INHIBITORS (INSTI) 

Courtney V. Fletcher, Ann Thorkelson, Lee Winchester, Timothy Mykris, Jon Weinhold, Kayla Campbell, Jodi Anderson, Jacob Zulk, Puleng Moshele, Timothy Schacker

*****

Monday March 5 2018, 11:40 AM to 11:50 AM (in Oral Abstract O-03: ADVANCES IN TB AND CRYPTOCOCCAL MENINGITIS TREATMENT AND PREVENTION, Ballroom C)

Late-Breaker Abstract 37LB: ONE MONTH OF RIFAPENTINE/ISONIAZID TO PREVENT TB IN PEOPLE WITH HIV: BRIEF-TB/A5279 

Susan Swindells, Ritesh Ramchandani, Amita Gupta, Constance A. Benson, Jorge T. Leon-Cruz, Ayotunde Omoz-Oarhe, Marc Antoine Jean Juste, Javier R. Lama, Javier A. Valencia, Sharlaa Badal-Faesen, Laura E. Moran, Courtney V. Fletcher, Eric Nuermberger, Richard E. Chaisson (presenter)

*****

Monday March 5 2018, 1:30pm (in Themed Discussion TD-02, Room 304-306, “Clinical Pharmacology of HIV-TB coinfection”)

Abstract 455: EFAVIRENZ PHARMACOKINETICS IN HIV/TB COINFECTED PERSONS RECEIVING RIFAPENTINE

Anthony Podany, Erin Sizemore, Michael Chen, Neil A. Martinson, Rodney Dawson, Sharlaa Badal-Faesen, Sachiko Miyahara, Ekaterina Kurbatova, William C. Whitworth, Richard E. Chaisson, Susan E. Dorman, Payam Nahid, Kelly Dooley, Susan Swindells, for the AIDS Clinical Trials Group & Tuberculosis Trials Consortium A5349 / Study 31 Team

*****

Wednesday March 7 2018, 11:30am (in the Oral Abstract session O-12, Ballroom C “Critical Issues in women’s health and early treatment of pediatric HIV infection”)

Abstract 141: VAGINAL CONTRACEPTIVE HORMONE EXPOSURE PROFOUNDLY ALTERED BY EFV- AND ATV/R-BASED ART

Kimberly K. Scarsi, Yoninah S. Cramer, David Gingrich, Susan L. Rosenkranz, Francesca Aweeka, Robert Coombs, Carmen D. Zorrilla, Kristine Coughlin, Laura E. Moran, Baiba Berzins, Catherine Godfrey, Susan E. Cohn, for the AIDS Clinical Trials Group A5316 Study Team

*****

Poster Presentations:

Monday March 5 2018, 2:30-4pm (Poster P-F1 ANTIRETROVIRAL, ANTITUBERCULAR, AND ANTIMALARIAL PHARMACOKINETICS Poster Hall D)

Abstract 455: EFAVIRENZ PHARMACOKINETICS IN HIV/TB COINFECTED PERSONS RECEIVING RIFAPENTINE

Anthony Podany, Erin Sizemore, Michael Chen, Neil A. Martinson, Rodney Dawson, Sharlaa Badal-Faesen, Sachiko Miyahara, Ekaterina Kurbatova, William C. Whitworth, Richard E. Chaisson, Susan E. Dorman, Payam Nahid, Kelly Dooley, Susan Swindells, for the AIDS Clinical Trials Group & Tuberculosis Trials Consortium A5349 / Study 31 Team

*****

Tuesday March 6 2019, 2:30-4pm: (Poster P-F3 ANTIRETROVIRAL PHARMACOKINETICS, PHARMACOGENETICS, AND DRUG INTERACTIONS, Poster Hall D)

Abstract 466:  CYP2B6 VARIANTS ALTER ETONOGESTREL PHARMACOKINETICS WHEN COMBINED WITH EFAVIRENZ

Megan Neary, Catherine Chappell, Kimberly K. Scarsi, Shadia Nakalema, Joshua Matovu, Sharon L. Achilles, Beatrice A. Chen, Marco Siccardi, Andrew Owen, Mohammed Lamorde

See you there!


 

Stewardship-driven Ertapenem Restriction: Can Reduced Utilization Affect the Antibiogram?

In this article review we learn about the impact of a large-scale, multi-institutional Antimicrobial Stewardship Intervention on significantly reducing the overall use of ertapenem without subsequent downstream effect on carbapenem-resistant Enterobacteriaceae (CRE) non-susceptibility patterns.

Delgado A, Gawrys GW, Duhon BM, Lee GC (2017). Impact of an Antimicrobial Stewardship Initiative on Ertapenem Use and Carbapenem Susceptibilities at Four Community Hospitals. J Infect Dis Ther 5: 341. doi:10.4172/2332-0877.1000341

Ertapenem has no activity against Pseudomonas spp. isolates, and although there is a theoretical risk of increasing carbapenem resistant Pseudomonas spp. isolates with ertapenem use, clinical studies have demonstrated that this is not the case.  Nevertheless, ertapenem use can potentially select for CRE, and there remains clinical value in minimizing its use.

The authors conducted a retrospective pre-post quality improvement study designed to reduce ertapenem usage, hoping to also demonstrate an effect in the prevalence of resistant Pseudomonas spp. and Enterobacteriaceae as a result of this intervention.  The multifaceted stewardship intervention was largely educational, but was supported by modification of electronic orders and providing audit-feedback opportunities to high frequency prescribers. They also included as a counter measure, evaluation of use of other alternative antimicrobials.

Copyright: © 2017 Delgado A, et al. Click to enlarge

They were successful in significantly reducing ertapenem utilization by 60% with mean days of therapy (DOT) per 1000 adjusted patient days declining from 17.6 to 7.0, p<0.001. There was a decrease in overall antibiotic use but as expected, ceftriaxone and fluoroquinolones were highly utilized and increased around October 2014 (3 months after electronic alert restricting ertapenem).  They reported stability of carbapenem use as a class.  They only reviewed Pseudomonas aeruginosa, Escherichia coli and Klebsiella pneumoniae isolates; so potential effect on other Enterobacteriaceae could not be assessed. There was no change in % of P. aeruginosa non-susceptibility to carbapenems, however the average incidence of carbapenem non-susceptible P. aeruginosa isolates per 10,000 adjusted patient days decreased from 4.9 to 3.7 (p=0.03). There were no changes in % or average incidence of carbapenem non-susceptible E. coli or K. pneumoniae.

Copyright: © 2017 Delgado A, et al. Click to enlarge.

The authors achieved the goal of reduced ertapenem usage from 18.3 to 5.1 DOT, but did not show an associated change in carbapenem non-susceptible organisms. Furthermore, their overall carbapenem use was stable (though appears to have slightly trended upwards on the graph) despite significant ertapenem utilization reductions; without a breakdown of individual carbapenem use, it is impossible to know if there was a concordant increase in imipinem/meropenem use to account for this.  Antibiotic shortages occurred during the study period, which unfortunately adds a confounder to the overall reduction of antibiotic utilization, as well as overall carbapenem utilization. – could these shortages have caused an increase in meropenem use? Additionally, limited (though number not specified)  carbapenem non-susceptible isolates at baseline makes it difficult to draw conclusions about effect of the intervention on the antibiogram. However, it demonstrates well that a multifaceted intervention can have significant impact on antibiotic utilization.


 

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