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Division of Infectious Diseases

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.


 

Global Efforts in Education in Lagos

Education is critical in prevent of infection and UNMC and Nebraska Medicine continue their global efforts.

A team recently traveled to Lagos, Nigeria – a city of 20 million people for such a purpose. They visited the 68 Nigerian Army Reference Hospital, Yaba in Lagos with two days of workshops/education with various leaders and clinical staff from the Army hospital.  Education efforts touched on various topics such as infection prevention and control; PPE; waste management; our Nebraska Biocontainment Unit among other topics.  Attending were Shelly Schwedhelm, MSN, RN, NEA-BC; Dr. Dele Davies, MD, MHCM; and Dr. John Lowe, PhD from UNMC.  Others attending included USAMRIID infectious disease physicians, an infectious disease MD from Singapore who shared their SARS experience and one from South Korea who shared details of their MERS experience.

Learn more about education efforts here.


 

Fantastic Presentation by Guest Speaker Dr. Bearman on “Hospital Infection Prevention: Processes, Pragmatisim, and Controversies”.

The UNMC ID Division was pleased to host Dr Gonzalo Bearman, MD, MPH as a visiting professor 10/19/17-10/20/17.  Dr Bearman, who is a Professor of Medicine, ID Division Chief  and Medical Director of Hospital Epidemiology at Virginia Commonwealth University, gave an insightful and thought provoking grand rounds presentation on 10/20/17 entitled: “Hospital Infection Prevention: Processes, Pragmatisim, and Controversies”.

Dr. Bearman’s research focus is on the epidemiology of hospital-acquired infections with multiple articles in peer-reviewed publications. He is also passionate about education and dissemination of medical information and in addition to lectures in the College of Medicine and School of Public Health, launched an online magazine called the Medical Literacy Messenger and a blog discussing issues in Infection Prevention and Control and Hospital Epidemiology.

In his presentation, Dr Bearman expanded the concept of “Satisfice” a combination of satisfy and suffice, initially coined by Nobel prize winner Herbert Simon, to the field of Infection Prevention.  To satisfice we need to find satisfactory solutions in a pragmatic manner for complex problems  – not perfect solutions that are not practical.  Dr Bearman is a proponent for Horizontal Infection Prevention solutions – interventions that cut across the board and impact all of our patients – examples include hand hygiene, standard infection control measures, antiseptic bathing, standardized methods to insert and care for indwelling lines and catheters.

During the session he described various approaches that his institution has implemented to decrease the rates of hospital-acquired infections.  The most intriguing was the concept of healthcare provider attire and their bare below the elbows (BBE) approach. This non-mandated approach suggests that healthcare providers put away the white coat, wear short sleeved clothing such as team scrubs, team vests, and avoid wearing watches, bracelets or rings.  In a survey to assess healthcare worker perception of this practice, Dr. Bearman’s team found that many providers laundered their white coats infrequently and most viewed the white coat as a potential source of bacterial transmission.  Despite the BBE approach being non-mandatory, 2/3 of healthcare workers were compliant to this attire suggestion, and as part of a multi-faceted approach that included the BBE attire recommendations, Dr. Bearman’s team noted a significant decrease in hospital-acquired infections. This approach is very promising (and cheap), but requires a substantial paradigm shift and culture change as of course, the white coat has been a long-standing symbol of tradition in medical education.

After Grand Rounds, Dr. Bearman had some time to sit with members of our Infection Prevention and Control and Antimicrobial Stewardship teams for some small group discussion.  He gave some advice to one of our PhD students working in Infection Prevention and Control, and discussed strategies for reducing hospital-acquired infections with our Infection Prevention nurses.

Dr. Bearman’s top 3 infection prevention pearls from our small group discussion:

  • The science is better: while we cannot prevent ALL infections, we know more now what to do to prevent infections in the hospital
  • Look for practical solutions to real life implementations
  • Learn to be nimble –if it doesn’t work, be open to making a change! Human beings don’t always function in linear function in systems that are chaotic.

To learn more about Dr. Bearman’s research click here. Thank you Dr. Bearman for visiting us, we enjoyed your talks and hope you can visit again!

 

At Nebraska Medicine, we strongly adhere to the concept of Horizontal Infection Prevention interventions.  Click here to learn more about Nebraska Medicine horizontal infection prevention efforts.

Content courtesy of Drs. Rupp and Marcelin.

BBE photo courtesy Dr. Bearman 


 

Happy Respiratory Care Week!

It is our great pleasure to celebrate Respiratory Care Practitioners this week! They are critical to the excellent care of our patients and in the prevention of ventilator associated events such as ventilator associated pneumonia – so say congratulations and thank them for their efforts this week!

To help kick off the week, Dr. Cawcutt and Joleen Strohsahl spoke to our respiratory care practitioners on the algorithms of ventilator associated events, bundled care, workflows and how infection control defines and reports these rates. There was an excellent conversation on ways we can continue to improve the care of our patients every day.

Prevention of all Healthcare Associated Infections is truly a team effort and we are grateful to have such fantastic colleagues as part of our multidisciplinary teams.


 

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