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Be Antibiotics Aware…in Long-Term Care Facilities

Nebraska ASAP efforts promote antimicrobial stewardship activities in long-term care facilities across the state

Up to 70% of residents in long-term care facilities receive at least one course of systemic antibiotic annually, with 40-75% of prescribed antibiotics being considered unnecessary or inappropriate.  As part of the condition for participation, the Centers for Medicare and Medicaid Services (CMS) will require all long-term care facilities to have an antibiotic stewardship program (ASP) by November 28, 2017.  However, most nursing home lack both the experience and the expertise required to develop a comprehensive ASP.

The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), which represents a partnership between University of Nebraska Medical Center/ Nebraska Medicine and Nebraska Department of Health and Human Services, is focused on helping LTCF across Nebraska in development of their own ASP. The Nebraska ASAP has already partnered with 5 LTCFs to provide assessments, implementation strategies and shared resources to start and sustain their own ASP. Learn more about these efforts here.

The Nebraska ASAP team
Front row L-R: Trevor Van Schooneveld MD (co-medical director), Regina Nailon (Clinical Nurse Research Coordinator), Sue Beach (administrative senior assistant), Kate Tyner (Nurse Coordinator), Scott Bergman PharmD (co-Pharmacy coordinator)
Back row L-R: Terri Micheels (Infection Control manager), Mark Rupp MD (Associate medical director), Jonathan Nguyen (Administrator), Shelly Schwedhelm (Executive Director of Emergency Preparedness), Salman Ashraf MBBS (ASAP medical director), Philip Chung PharmD (Pharmacy Coordinator)

Content provided by Dr. Salman Ashraf, Medical Director, Nebraska ASAP

Be Antibiotics Aware… in Hospitals

Since 2004, (Antimicrobial Stewardship Program (ASP) at Nebraska Medicine) has been helping patients to receive the best antimicrobials for their infection, and assisting with decisions by prescribers on when to avoid giving antibiotics. The philosophy of the program is not to restrict access to life saving medications, but to focus on patient safety by guiding clinicians in the optimal use of these potentially dangerous drugs. Antibiotics are associated with more adverse events than any pharmaceutical class besides cancer chemotherapy and account for 19% of all emergency department visits for adverse drug reactions.  As they became safer and more convenient to use over the last several decades, prescriptions for antibiotics went up. The spectrum also improved against Gram-negative organisms that live in our gastrointestinal tract which led to a rise in epidemic Clostridium difficile infection. Resistance to these miracle drugs also increased over the same time. Therefore, the situation we find ourselves in with antibiotics today is a product of their own success. In a recent study, it was found that 20% of patients receiving antibiotics during hospitalization developed an adverse event related to their therapy.1 Furthermore, it was discovered that 20% of these patients were receiving antibiotics that weren’t clinically necessary for their condition.

The ASP at Nebraska Medicine has become well-known for developing guidance documents that help clinicians choose antibiotics and diagnostic testing according to evidence and local epidemiology. This year we have developed guidance for treating diabetic foot infections and acute exacerbations of chronic bronchitis while revising our standards for managing bloodstream infections and Clostridium difficile. Although patients with diabetes do have frequent exposure to the healthcare system that could put them at risk for multi-drug resistant infections, the reality is soft tissue infections in this population are only rarely caused by pathogens such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa at our institution. We are taught in medical and pharmacy school that diabetes causes immunosuppression and these resistant organisms are more prevalent in infections of the foot than other skin sites. While this is true, the incidence is under 10% overall. It is important to put this in perspective since the fear of resistant infection has led to virtually all patients with diabetes receiving vancomycin and piperacillin-tazobactam upon admission to the hospital. This is despite the cause of resistance being overuse of antibiotics. Couple this with the discovery of synergistic toxicity between these agents that damages kidneys at an alarming rate, and you have a significant patient safety concern.2 Bringing these facts to the attention of clinicians is why having an antimicrobial stewardship program is so important.  That is one of the reasons the state of Nebraska has followed the lead of the Centers for Disease Control and Prevention and named this Antibiotic Awareness week.

References

  1. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of Adverse Events with Antibiotics in Hospitalized Patients. JAMA Internal Med. 2017; 177(9):1308-1315 https://www.ncbi.nlm.nih.gov/pubmed/28604925
  2. Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin plus piperacillin-tazobactam and acute kidney injury in adults: A systematic review and meta-analysis. Crit Care Med. 2017 (Oct 28): Ahead of Print https://www.ncbi.nlm.nih.gov/pubmed/29088001.

Content provided by Scott Bergman, PharmD, Pharmacy Coordinator, Nebraska Medicine Antimicrobial Stewardship Program

Be Antibiotics Aware…to Preserve our Future

Antimicrobial Stewardship: Preserving the Future

Antimicrobials were an amazing discovery and have been appropriately credited, along with vaccination and sanitation, with the significant improvements in human life expectancy over the last century.  With their amazing impact has come the opportunity for new therapies including organ transplant, complex surgery, and care for extremely preterm infants.  The success of these medical interventions is founded upon the ability to treat the inevitable infections which develop with highly effective and safe antimicrobials.  Unfortunately, we now live in an era where the utility of these amazing agents is threatened by the emergence and spread of antimicrobial resistance.

Antimicrobial resistance is a growing worldwide problem.  The CDC highlighted this in their Antibiotic Resistance Threat Report, which estimated at least 2 million people become ill and 23,000 die from antibiotic-resistant infections each year.  The key driver of antimicrobial resistance is antimicrobial use which eliminates susceptible pathogens leaving only those which are resistant to grow and expand.  Antimicrobial use in both humans and animals can promote resistance and resistant pathogen infections are associated with worsened clinical and economic outcomes.  One group estimated that if antimicrobial resistance is left unchecked, by the 2050 it would kill more persons yearly than cancer.

Compounding the issue of resistance is the fact that the antimicrobials used in hospitals, ambulatory clinics, and long-term care facilities (LTCF) are often inappropriate or unnecessary.   Inappropriate antimicrobial use results in worsened patient outcomes, toxicity including C. difficile infection, and increased cost.  To mitigate these issues the CDC has recommend facilities of all types institute antimicrobial stewardship programs.  Antimicrobial stewardship programs employ strategies or processes designed to help clinicians decide if an antimicrobial is necessary and if so what agent, dose, and duration is optimal.  The CDC states, “Antimicrobial stewardship interventions have been proven to improve individual patient outcomes, reduce the overall burden of antibiotic resistance, and save healthcare dollars.”  Implementation of antimicrobial stewardship programs offer the advantages of making patient care safer, more effective, more efficient, and often less expensive.

The CDC and the State of Nebraska have appointed this week as 2017 US Antibiotic Awareness Week, and so over the next five days, we will be highlighting the ongoing antimicrobial stewardship activities at the University of Nebraska Medical Center (UNMC) and Nebraska Medicine (NM).  We will describe the successes of the NM Program, which has been promoting improvements in antimicrobial use for over a decade.  We will also explain the role the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP), a partnership between NM, UNMC and the State of Nebraska, has had in promoting stewardship in smaller hospitals, LTCF, and ambulatory settings.  Finally, we will be highlighting some of the strategies and activities that are effective in improving antimicrobial use and with each post, introducing you to some key members of our stewardship teams.

Content Provided by Dr. Trevor Van Schooneveld, Medical Director, Nebraska Medicine Antimicrobial Stewardship Program

In Nebraska, US Antibiotic Awareness Week Kicks off with Proclamation from Governor Pete Ricketts

Antibiotic resistance is a growing national and global concern. Many factors contribute to increasing antibiotic resistance, including inappropriate or unnecessary antibiotic use in both humans and animals. Antimicrobial Stewardship is the commitment to appropriate use of antimicrobials, and both clinicians and patients can be antimicrobial stewards.  The Centers for Disease Control and Prevention (CDC) has declared November 13-19 US Antibiotic Awareness Week, with several web-based and national events to raise awareness. To commemorate this important week, on Wednesday November 8, 2017, Nebraska Governor Pete Ricketts signed an official proclamation at the Nebraska State Capitol declaring this week Antibiotic Awareness Week in Nebraska.

The proclamation signing was largely due to the efforts of Dr. Maureen Tierney, leader of Nebraska’s Healthcare Associated Infections Program, who prepared and submitted the initial draft of the Proclamation to the Governor’s office.  In attendance were Dr. Tom Williams (Director of Public Health and Chief Medical Officer), Jennifer Roberts-Johnson (Deputy Director of Public Health), Dr. Safranek (State Epidemiologist), and representatives from ASAP (Dr. Ashraf, Phil Chung, Kate Tyner, Teri Fitzgerald, and Sue Beach), MDstewardship, the Nebraska Hospital Association, the Nebraska Healthcare Association, and the Great Plains QIN/QIO.  During her speech at the Proclamation Signing Ceremony, Dr. Tierney spoke about the consequences of inappropriate antibiotic use and the need for antibiotic stewardship.

The full Proclamation states:

“WHEREAS, the CDC has declared the week of Nov 13th through the 19th U.S. Antibiotic Awareness Week as a way to improve antibiotic stewardship in communities, in healthcare facilities, and on the farm in collaboration with state-based programs; and

WHEREAS, the Nebraska Department of Public Health’s Healthcare Associated Infections program is dedicated to the reduction of antibiotic resistance, a major threat to the public health; and

WHEREAS, the inappropriate use of antibiotics may lead to further antibiotic resistance and an increase in untoward complications such as C. difficile; and

WHEREAS, the observance of Antibiotic Awareness Week will help patients be antibiotics aware and support smart use of antibiotics by prescribers.

NOW, THEREFORE, I, Pete Ricketts, Governor of the State of Nebraska, DO HEREBY PROCLAIM the week of November 13, 2017 as ANTIBIOTIC AWARENESS WEEK in Nebraska, and I do hereby urge all citizens to take due note of the observance.”

Formerly known as Get Smart About Antibiotic Week, US Antibiotic Awareness Week is an annual observance designated by the CDC to promote appropriate antibiotic use in the United States.

Dr. Maureen Tierney MD, Nebraska DHHS HAI Medical Director reading the proclamation with Gov. Pete Ricketts. Dr. Ashraf and Phil Chung are in the background

Pictured in the Warner Room at the State Capitol before the ceremony: Phil Chung, ASAP Pharmacy Coordinator, Dr. Salman Ashraf MBBS, ASAP Medical Director, Kate Tyner, ASAP nurse coordinator, Peg Gilbert of Grand Island and Dr. Anna Fisher PhD, of Bellevue

Content courtesy Phil Chung, PharmD

Photos courtesy Sue Beach

Nebraska ICAP Launches a New Website Making Access to Infection Prevention and Control Resources Much Easier

Nebraska ICAP (Infection Control Assessment and Promotion Program) is supported by the Nebraska DHHS HAI (Healthcare Associated Infections) Program via a CDC grant. The project is a result of a partnership between University of Nebraska Medical Center/ Nebraska Medicine and Nebraska Department of Health and Human Services HAI Program. It serves as a statewide infection prevention and control resource for all healthcare facilities in Nebraska. ICAP offers no cost, peer-to-peer infection control assessments and recommendations. ICAP team includes experienced infection preventionists, infectious disease trained medical directors, and professional educators.

ICAP team has already visited over 100 facilities in the state of Nebraska. They visit only those healthcare facilities who invite them. Nebraska ICAP assessments are friendly and educational. The visits have no negative regulatory consequence, but should help facilities feel more prepared for a regulatory visit. The goal is to help all the healthcare facilities improve their infection prevention and control infrastructure by providing easy access to subject matter experts and other resources.

During the last couple of years Nebraska ICAP team has made numerous recommendations and developed several tools to help healthcare facilities strengthen their infection prevention and control program. Recently, ICAP has launched a new website that compiles some of the more commonly used tools and recommendations from their visits. These resources are now available to all healthcare facilities without any charge.

According to Dr. Muhammad Salman Ashraf, an Associate Professor in the division of Infectious Diseases at UNMC, who is also the medical director for Nebraska ICAP, healthcare facilities and healthcare workers including infection preventionists can now visit ICAP website (https://icap.nebraskamed.com) and find answers to many of their day-to-day questions. They are also encouraged to contact ICAP team if they are unable to find what they are looking for and the ICAP team will make every possible effort to help them.

Infection preventionists from all healthcare facilities are welcomed to join Nebraska ICAP email distribution list, free of charge, by sending a request via email to Nebraska ICAP Administrative Sr. Assistant, Sue Beach at subeach@nebraskamed.com . Nebraska ICAP will use the email distribution list to keep everyone informed of important ICAP related events and will alert everyone when new tools and resources are posted online.


 

Infectious Diseases Journal Club – Should Patients with CAUTI Receive Early Empiric Antibiotics?

On 10/17/2017, Dr. Ashraf discussed an interesting study during UNMC Infectious Diseases Division Journal Club. The study entitled, “Empirical Antibiotic Treatment Does Not Improve Outcomes in Catheter-Associated Urinary Tract Infection: Prospective Cohort Study” was conducted in Israel and published in the Journal Clinical Infectious Diseases in August 2017.
In this prospective observational cohort study, the authors studied the outcome of adult patients with indwelling urinary catheters who were diagnosed with catheter associated urinary tract infections (CAUTI). This cohort consisted of 315 elderly patients with mean age of 79.2 + 11.5 years. Close to a third (30.8%) of patients in this cohort died within 30 days (all-cause mortality) and median survival time of the cohort was only 82 days.

Nearly half of this cohort (49.2%) received appropriate empiric antibiotic coverage within 48 hours of either admission to hospital (if infection was acquired outside of the hospital) or collection of urine culture (if infection occurred during the hospital stay). Interestingly, appropriate early empiric antibiotic treatment (within 48 hours) had no statistically significant association with 30 day mortality {propensity score-matched odds ratio 1.39 (0.76-2.55)}. Similarly, appropriate empiric antibiotic treatment had no statistically significant association with long-term survival in the propensity-matched cohort (hazard ratio, 0.99, 95% confidence interval 0.75-1.3)

The authors of this study acknowledged that the findings of the study are at odds with several published studies that shows mortality benefit when appropriate antibiotic is used early in severe bacterial infections. Whether the difference is related to the fact that it is difficult to distinguish between symptomatic urinary tract infection and febrile illness from another etiology is unclear. Another possible explanation is that this cohort consisted of very old patients with high prevalence of multi-drug resistant organism that was at high risk of mortality even at the baseline. The authors suggested that the use of antibiotic in patients suspected of CAUTI can be deferred until better understanding of the fever cause and sepsis trend and culture results should be used for directed antibiotic treatment.

This study sparked a lot of spirited discussion at Journal Club. Even though this study opens up a new way to approach older patients presenting with CAUTI, we may need further studies that can validate these findings. We may also need to identify sub-group of patients within this patient population, if any, who may benefit from early appropriate antibiotic treatment. Another important question that we should ask is what should be considered early appropriate antibiotic treatment. Whether 48 hour is a good cut off to define early appropriate antibiotic coverage or should it be much less than that. We will be looking forward to finding these answers in future studies. Read more about the study discussed here.

Content courtesy Dr. Salman Ashraf

Photos courtesy Jonathan Nguyen

Dr. Salman Ashraf discussing his article

Dr. Kelly Cawcutt engaging the group discussing the article from an Infectious Disease/Critical Care Medicine perspective

Student Interest Group Update: Dr. Ali Khan Inspires Interest in Infectious Diseases, Epidemiology and Public Health

Two student interest groups, the Infectious Diseases Interest Group and and the Student Alliance for Global Health, collaborated to host a presentation by Dr. Ali Khan, Dean of the College of Public Health and former director for the Office of Public Health Preparedness and Response at the CDC. His professional endeavors have focused on emerging infectious diseases, bioterrorism, and global health security.

The meeting was held in October and had an excellent turnout with close to 60 attendees including students from the College of Medicine, College of Public Health, Pharmacy, and Physicians Assistants.

Dr. Khan spent the first bit of the meeting sharing about how he became interested and involved with infectious diseases and epidemiology, starting with his schooling in Brooklyn for both undergraduate studies and medical school. He told us about his early exposures to epidemiology with the National Center for Infectious Disease and his eventual involvement with the CDC. Throughout his presentation, Dr. Khan emphasized how influential mentors were for advice and motivation in his career. He encouraged all of the students to both ensure they find great mentors to learn from as well as engage in mentoring relationships with younger students.

Next Dr. Khan shared several interesting details about some of the more recent epidemics, including the 2014 Ebola outbreak and the 2001 anthrax attacks. Of particular interest,  during the Ebola outbreak, was the unique need to carefully understand cultural practices and learn how to educate communities about how to prevent disease spread. He explained how many cases of Ebola were contracted through contact with diseased persons and how funeral practices in the area were contributing to the spread.

A curious detail about the anthrax outbreak came down to the design of envelopes and how mail sorting facilities work! Dr. Khan explained that because letters are sorted with a machine that essentially clamps down on letters to read barcodes, the envelopes have gaps incorporated into how they seal so that air can escape during the sorting process. However, this design caused anthrax spores to be flung all around mail sorting facilities during the outbreak and he explained how this created a unique challenge for public health agencies.

The time was then opened up for questions from the students which Dr. Khan gladly answered with enthusiasm! Overall, the students were inspired by his talk and found his stories fascinating.

Content courtesy of Jonathan Seaman and the IDIG at UNMC. 


 

UNMC ID Fellowship Coordinator Sandy Nelson TAGME-certified!

It is with great pleasure that we announce that our UNMC Infectious Diseases Fellowship Coordinator, Sandy Nelson has passed her examination administered by the National Board for Certification: Training Administrators of Graduate Medical Education (TAGME) and has earned the designation C-TAGME.

C-TAGME is available to individuals who have served as a program coordinator for two years and successfully completed 15 hours of education credits. C-TAGME is earned by individuals after successful completion of a rigorous examination that covers multiple content areas such as recruitment, ACGME/AOA policies and procedures, and overall Fellowship Program Management. Sandy’s successful completion of the certification demonstrates her ability to find the correct answer for these and many other areas, rather than a focus on instant recall, a philosophy of TAGME.

We appreciate Sandy’s commitment to the Infectious Diseases Fellowship with her achievement of this distinguished certification, and her tireless contributions to the success of the Fellows and the program over the last 3 years.  Please join us in congratulating Sandy on this substantial accomplishment!

For more information about the UNMC Infectious Diseases Fellowship click here

Practice Makes Perfect – Drills with the Nebraska Biocontainment Unit

The Nebraska Biocontainment Unit (NBU) is one of ten Regional Ebola and other Special Pathogen Treatment Centers (RESPTC) in the United States that has the capacity to care for patients with a highly hazardous communicable disease. As part of ongoing preparedness efforts the NBU coordinated a 2 day exercise on October 12 & 13, 2017 that included county and state public health officials, the Nebraska Public Health Lab, Midwest Medical Transport, Omaha Fire Department, CHI Health Creighton University Medical Center Bergan Mercy and Children’s Hospital and Medical Center, the UNMC rapid response institutional review board and multiple supporting ancillary departments within Nebraska Medicine.

In this recent exercise, the NBU tested multiple processes including the transfer of patients from local assessment hospitals, admitting both an adult and a pediatric patient into the NBU and activating the rapid response IRB for protocol review as well as the administration of a recognized experimental medication for Ebola virus disease. Once both of the simulated patients’ had been admitted, the NBU team comprised of physicians, nurses, respiratory therapists, and patient care technicians completed 6 hours of care interventions using established NBU protocols. The emphasis during this full scale exercise was on optimizing care coordination for two patients who required multiple interventions. These interventions included obtaining labs, containing body fluid spills, and the administration of an experimental drug therapy which required obtaining informed consent by the appropriate physicians.

The focus of the exercises conducted in the NBU is to enhance practices that will provide safe and effective patient care while providing optimal protection for the providers. The staff members that comprise the NBU team are dedicated professionals who seek to advance preparedness for highly hazardous communicable diseases. The NBU continually strives to advance these efforts by routinely holding structured trainings and coordinating exercises to test protocols and incorporating best practices.

 

Dr. Angela Hewlett and Dr. Ted Cieslak obtain informed consent for an experimental medication.

Dr. Angela Hewlett communicates with Kate Boulter, Nurse Manager, NBU.

Dr. Angela Hewlett observes Dr. Jim Sullivan preparing to place a central line in the NBU simulator.

Photo Credit: Taylor Wilson, Nebraska Medicine and Jeff Peters, RN, Nebraska Medicine Bellevue

Written content courtesy of Angela Vasa and Dr. Angela Hewlett.

ID Journal Club – Highlights C. difficile Infections

Content and review by Dr. Trevor Van Schooneveld

C. difficile infection (CDI) is a difficult to control pathogen and the contribution of aggressive infection control practices and antibiotic stewardship have generally been assessed in single hospitals over short periods of time. This study evaluated the impact of advanced infection control practices and an aggressive national antimicrobial stewardship program on the incidence of CDI in the Grampian region of Scotland, which represents 11% of that regions population. The authors found that infection control measures had little impact on CDI rates.  Interestingly, the implementation of an antibiotic stewardship program that decreased the use of macrolides, clindamycin, broad-spectrum cephalosporins, fluoroquinolones, and amoxicillin-clavulanate 50% was associated with major changes in both CDI epidemiology and prevalence.  Declining use of the targeted antibiotics predicted near elimination of the R001 and R027 multidrug resistant CDI phenotypes.  CDI rates declined 68% in hospitals and 45% in the community during the stewardship intervention.

This study had a number of interesting findings.  First, the infection control measures did not improve CDI rates.  Whole genome sequencing data from the UK suggest that the majority of CDI is not acquired from other CDI cases in the hospital and thus the advanced measures implemented there would not be effective.  Second, there may be a threshold effect for antibiotic use that when use of the high risk agents drops below a certain level epidemic multidrug resistant strains lose their advantage and disappear.  Third, while use of the targeted agents declined, use of alternative agents including carbapenems increased and increasing carbapenem use was associated with increased CDI risk.  These findings strongly suggest antimicrobial stewardship strategies are essential to controlling CDI.  Additionally, the targeting of high-risk agents may be beneficial beyond their general influence of decreasing antibiotic exposure and may have profound effects on CDI epidemiology.  An unanswered question if the exclusion of the targeted agents altered the clinical outcome of various infectious syndromes such as pneumonia, UTI, and skin/soft tissue infection.

Read the full article here.


 

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