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Meeting Recap: 2023 Nebraska Antimicrobial Stewardship Summit (Part 2)

This meeting recap was generously provided by: Jenna Preusker, PharmD, BCPS – Nebraska ASAP Pharmacy Coordinator

Part 2: Afternoon Sessions:

Starting off the afternoon, Dr. Krishna Rao, a Nebraska native, returned virtually to his home state from the University of Michigan to share updates related to the gut microbiome and non-traditional therapies for the treatment of Clostridioides difficile infections, reminding us that some recurrent and difficult-to-treat infections may require us to think outside of traditional antibiotic therapy. Some key take home points included: 

  • We are at an inflection point in the management of C. diff infections, from changing diagnostic methods to treatments that include monoclonal antibodies, live biotherapeutics, and fecal transplants. 
  • Treatment focus is now not just initial cure but preventing recurrence. Newer directions in research that are focused on mechanisms of action show promise.
  • FMT is one of several modalities used now in treating initial or recurrent CDI, but questions around efficacy and regulation remain.
  • So, what about probiotics? Dr. Rao shared that probiotics are generally safe and well-tolerated, but regulation as supplements and safety concerns impede deployment​. Probiotic clinical data has a lot of heterogeneity, low-quality of data, and safety concerns have precluded widespread deployment and recommendation by guidelines.

The final speakers in the general session joined us to share their practical experiences in diagnostic stewardship from right here in Nebraska. Dr. Renuga Vivekanandan and two of her infection preventionist colleagues, Becky Cook and Angel Pleuger shared their strategy at CHI for engaging frontline nursing and infection preventionist staff in diagnostic stewardship.

  • Diagnostic Stewardship ​can reduce unnecessary lab orders​, unnecessary antibiotic use​, create a collaborative culture​, and increase patient safety and outcomes.​
  • A multidisciplinary approach proved to be effective. Results were shared regionally to determine best practices and discuss lessons learned. 
  • Nursing driving initiatives for C. diff testing, CAUTI, and CLABSI prevention using standardized checklists resulted in improvement in CAUTI, CLABSI and C. diff rates at CHI.

During the afternoon, attendees had the option to attend sessions in breakout tracks, one with a focus on long-term care and one with an acute care and ambulatory focus.

In the long-term care track, Dr. Kara Jacobs-Slifka from the CDC led off the afternoon with a discussion of enhanced barrier precautions. Dr. Jacobs-Slifka provided a wealth of resources for facilities to refer to and recommended that when implementing enhanced barrier precautions, facilities should have a detailed implementation plan​ and expect surprises. She also noted that buy-in is critical​ and communication is key. 

Dr. Robin Jump followed with a presentation on recognizing and treating infections in LTC residents. She described non-localizing signs and symptoms that may indicate infection in long-term care residents​, ways to differentiate signs of acute cystitis from other reasons for those symptoms ​and the introduction of antibiotic use protocols for infections common to older adults.

To wrap up the day in the long-term care track, Nebraska Infection Control Assessment and Promotion Program’s (ICAP) own infection prevention supervisor, Kate Tyner, gave a practical presentation on the intersectionality of antibiotic stewardship and infection preventions, sharing several lessons learned through actual patient cases. Her take home message was to make it easy to do the right thing, through use of intake procedures, infection control and stewardship plans, IP notifications, and alerts to frontline staff. 

In the acute care track, we were joined by Dr. Christopher Evans, a pharmacist from the Tennessee Department of Health. He addressed the new CMS requirements for hospitals to begin participating in the Antibiotic Use and Resistance module within NHSN while sharing Tennessee’s progress and lessons learned over the last few years of their statewide initiative through use of a legislative mandate. His presentation recording will be a great resource to Nebraska hospitals beginning the AUR reporting process. 

The second session featured UNMC Instructor, Dr. Jonathan Ryder, with an update on antifungal therapies. He discussed current and future opportunities for antifungal stewardship as well as novel antifungal agents and their potential niches in clinical use. 

To wrap up the day in the acute care track, a pharmacist panel highlighted strategies for expanding the antimicrobial stewardship pharmacist workforce in the state of Nebraska. This dialogue featured Dr. Jenna Preusker from Nebraska ASAP, Dr. Scott Bergman from Nebraska Medicine, Dr. Danny Schroeder from Nebraska Medicine Bellevue, and Dr. Anthony Rodewald from Community Hospital in McCook. 

Overall, the 2023 Nebraska Antimicrobial Stewardship Summit was a great success. We thank all of the attendees, the planning committee, and hosting organizations for a great day of furthering Nebraska’s antibiotic stewardship education to save antibiotics so antibiotics can save lives. For those not able to attend, recordings of the presentations are being made available by Nebraska ASAP/ICAP for anyone to listen and learn. 

 We look forward to seeing everyone again next year at the 2024 Nebraska Antimicrobial Stewardship Summit to be held on Friday, May 31, 2024. Mark your calendars now!!

Check out our first post if you missed it to learn more about the morning Summit sessions!

2023 session recordings are now available on the Nebraska ASAP YouTube channel: Nebraska ASAP – YouTube

Meeting Recap: 2023 Nebraska Antimicrobial Stewardship Summit (Part 1)

This meeting recap was generously provided by: Jenna Preusker, PharmD, BCPS – Nebraska ASAP Pharmacy Coordinator

The 2023 Nebraska Antimicrobial Stewardship Summit was held on Friday, June 2, 2023 at the Embassy Suites Conference Center in La Vista, NE. The event was hosted by the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) in conjunction with the Nebraska Department of Health and Human Services and UNMC. Over 200 participants were in attendance and included physicians, advanced practice practitioners, pharmacists, infection preventionists, nurses, and others.

The day opened with a warm welcome from our Nebraska state epidemiologist, Dr. Matt Donahue. 

Following Dr. Donahue, our keynote presentation on communication strategies for antibiotic stewards was delivered by Dr. Julia Szymczak, a sociologist from the University of Utah who has dedicated her career to studying the topic. Key points included:  

  • Stewards need more than proficiency in ID, microbiology, data analytics, and informatics​; they also need social and communicative skills to implement change in complex organizations.
  • In her studies interviewing hundreds of clinicians that interact with antibiotic stewards, Dr. Szymczak learned that positive interactions included:
    • Communicating information of value in a thoughtful manner
    • Attempting to understand where the provider is coming from
    • Created a shared sense of mission between the steward and provider

Applying the 3 Cs of Stewardship (Context, Communication, and Collaboration) to encounters in the unique facility in which you work can improve interactions.

Following Dr. Szymczak’s engaging presentation, we welcomed Dr. Salman Ashraf to give an update from the Nebraska Healthcare Associated Infections and Antimicrobial Resistance Program at Nebraska DHHS. Dr. Ashraf’s discussion included:

  • Trends in healthcare-associated infections
    • Nebraska has the highest SIR for surgical site infections (SSIs) following colon surgeries in the nation and the fourth highest following abdominal hysterectomies. Collaborative efforts are ongoing to decrease SSIs. 
    • Nebraska critical access hospitals have the highest SIR for C. difficile Infections among all 50 states in the US in 2021 (with 36 facilities contributing to this report). 
  • Nebraska DHHS has funding assistance available to assist facilities in the implementation of NHSN AUR reporting. 
  • Trends in multidrug resistant organisms (CRE/CP-CRE, CRPA, C. auris) ​
    • CRE/CP-CRE and CRPA isolates are increasing in Nebraska
    • No isolates of C. auris have been identified in Nebraska recently, but all yeast isolates from normal sterile site need to be identified to the species level. C. auris is commonly misidentified in labs. 
  • CDC’s updated guidance to prevention and response to MDROs ​
  • Nebraska DHHS protocol for tracking targeted MDROs and keeping facilities informed​
  • LTCF support with infection prevention and control and antimicrobial stewardship efforts​
  • Healthcare-associated legionnaires’ disease

Through the rest of the morning general session agenda, we heard expert updates from: 

Dr. Bradley Langford, a pharmacist with Ontario Public Health who shared data showing COVID-19’s impact on antibiotic use and resistance. Did you know…

  • Unnecessary antibiotic use is estimated to be high in COVID-19 patients. Only 8.6% of hospitalized COVID-19 patients had a bacterial co-infection, but during the pandemic 74.6% of COVID-19 patients received antibiotics. 
  • There was a high prevalence of antibiotic resistance in COVID-19 patients. Predictors for resistance include low and middle-income countries, ICU setting of care, comorbid diabetes, and receipt of IL-6 inhibitor therapy (i.e. tocilizumab). 
  • Moving forward, efforts must be made to increase focus on health equity, global trust and collaboration, and private-public partnerships. Stewards can bring attention to the importance of antibiotic stewardship, avoid antibiotic use in viral pneumonia, and leverage technology to extend reach. 

Emily McCutchen, the manager of the Nebraska Public Health Laboratory gave an engaging presentation about the services NPHL provides to both healthcare facilities and citizens of the state of Nebraska. Highlights include:

  • NPHL can aid labs with the impending danger of Candida auris. It was noted that healthcare and clinical labs must make sure their instruments are up to date to avoid misidentification of C. auris.
  • NPHL educational efforts include lab alerts, newsletters, laboratory surveys, statewide laboratory calls, individual communications and trainings. 
  • Future directions and opportunities for NPHL include sequencing for clinical care, same-day sequencing, direct from specimen sequencing, and wastewater surveillance for resistant organisms.

During the lunch break and throughout the day, attendees had the chance to give their live impressions from the conference to Dr. Rick Starlin and Dan German with Nebraska ICAP. Attendee and presenter interviews are being compiled into a podcast that will be shared on an upcoming Nebraska ICAP Dirty Drinks podcast episode scheduled for June 29. Check them out on Twitter, @dirty_drinks! 

Patient-care organizations in Nebraska also provided antibiotic stewardship information at several booths throughout the day. It was a great networking opportunity and a chance to learn about the various antibiotic stewardship services available for no cost to all facilities in Nebraska.

Check out our second post to learn more about the afternoon Summit sessions!

2023 session recordings are now available on the Nebraska ASAP YouTube channel: Nebraska ASAP – YouTube

In Case You Missed It: UNMC ID Launches Program to Improve Health Equity

The UNMC ID Division is launching Achieving Equitable Health Outcomes in Nebraska, a program to support Nebraska-based organizations in improving health equity in alignment with the Joint Commission’s new priority. See the flyer below and check out this linked website for more information.

Interested in learning more? The next meeting is next Wednesday, July 19th, at 12pm.

Last Words – by Graduating Fellow Dr. Bryan Walker

The following reflection was provided by graduating UNMC ID fellow, Dr. Bryan Walker.

Dr. Walker will be transferring to the University of Tennessee Medical Center where he will be practicing in general infectious diseases! Congrats Bryan!

Reflecting upon my time at UNMC as an infectious diseases fellow, I am struck by the amount of change experienced over the past two years.  I entered fellowship in the summer of 2021, amid the Covid-19 pandemic, and, like so many others, feeling a degree of fatigue. In addition, my wife and I moved from Tennessee expecting our first child. Although we knew we were going somewhere special for my training, uncertainty still loomed.

Thankfully, the life that my family and I were able to make in Omaha and the training I received at UNMC during these changes was remarkable. Upon our daughter’s birth on July 8th, we almost immediately felt the support and goodwill, not only of the fellowship, but of the entire division.  Faculty, staff, and co-fellows reached out to offer congratulations and support. Many of them I had not even met yet! My transition into my clinical rotations the following month was met similarly.  

Early on in my training I learned that the system of support I found at UNMC was not only integral to my thriving in fellowship but was also invaluable in my becoming a competent infectious diseases attending physician.  From the microbiology lab to the bedside, to working with some of the most amazing attendings, pharmacists, nurses, care technicians, medical students, and residents, I am leaving fellowship with a breadth of knowledge and experience, confident and comfortable practicing and teaching in most clinical settings across varying patient populations. I have additionally gained colleagues and collaborators that I know will be with me throughout my career. Further, my time working across disciplines with our pharmacy colleagues on anti-microbial stewardship has left me comfortable in taking on the responsibility of being an anti-microbial steward. Finally, my time spent conducting clinical research while at UNMC has been transformative, informing not only my future research interests but how I utilize the literature to better inform my clinical practice. I know all of this will pay dividends as I head off toward the start of my career.

So much of medical training comes down to putting some part of life on hold in hopes of obtaining the preparation needed to effectively care for those in need and, like good campers, leaving the profession better off than when we found it. I think a concern we all face in training is wondering, at times, if it will all be worth it. In other words, we occasionally question if gambling on our future selves, teachers, and colleagues will pay off. Reflecting on the uncertainty present prior to the start of my fellowship and threading that through my time as an ID fellow at UNMC, I am so grateful that the answer to my question is a resounding yes. 

– Dr. Bryan Walker, ID physician and graduating UNMC ID fellow, 2023

Today is National HIV Testing Day!

Each year, June 27th is observed as National HIV Testing Day (NHTD).  This year’s NHTD theme is “Take the Test & Take the Next Step.”  The act of getting tested is the first step in either treatment or prevention that leads to individuals being empowered to live long and healthy lives.  

 HIV testing is the pathway to engaging in care to keep yourself healthy, regardless of the test result. People who receive a negative test result can take advantage of HIV prevention tools such as pre-exposure prophylaxis (PrEP), condoms, and other sexual health services such as vaccines and testing for sexually transmitted infections. People who receive a positive test result can rapidly start HIV treatment (antiretroviral therapy, or ART) to stay healthy.

The Nebraska Medicine/UNMC Specialty Care Clinic specializes in the prevention and treatment of HIV.  Our clinic is staffed with doctors, nurse practitioners, pharmacists, nurses, social workers, and more!  We are all here to provide the highest level of care in a judgement-free atmosphere.  There is a wide range of prevention and treatment options available and we would be happy to review your best options with you.  If you or someone you know could potentially benefit from HIV testing, we invite you to our clinic, located at 804 South 52nd Street Omaha, NE 68106.  We can also be reached at 402-559-2666.  We look forward to serving you!

Content adapted from HIV.gov, visit the link for more information about National HIV Testing Day.

Last Words – by Graduating Fellow Dr. Mackenzie Keintz

The following reflection was provided by graduating UNMC ID fellow, Dr. Mackenzie Keintz.

Dr. Keintz will be transitioning to an infectious diseases faculty position here at UNMC ID! Congrats Mackenzie!

“My mentor, Dr. Jasmine Marcelin, likes to joke that I decided to go into infectious disease in-utero. While this is somewhat of an exaggeration, I did start this journey to become an infectious disease physician before I ever stepped foot into medical education. The journey was long, over a decade since I made the decision but now as I stand on the precipice of being an independent ID doctor, I feel significant gratitude for the road that has led me here. 

I started at UNMC in 2018 as an internal medicine resident. I quickly found a home in the division of infectious disease. The mentorship that followed affirmed my decision to pursue ID and eventually persuaded me to stay here at UNMC for my fellowship training. 

Although I could spend hours telling you about the wonderful training I received during fellowship about all manners of infectious disease, the thing that has meant the most to me has been the relationships I have built with both faculty and my co-fellows. It has been a wonderful experience learning from some of the best clinical and research clinicians and pharmacists in the field. My practice style has been influenced by each one of you throughout the years, and the combination has made me a better physician. The mentorship I have received has prepared me to excel in the field and I cannot thank you all enough. 

As I transition to the faculty, I aspire to embody the compassion of Dr. Marcelin, the stewardship of Dr. Van Schooneveld, the leadership skills of Dr. Rupp, the thoroughness of Dr. Schnaubelt, the educational aptitude of Dr. Cortes, the kindness of Dr. Walker and many other skills imparted by the faculty I have had the privilege to work alongside. The lessons I have learned from each of you are endless, and I am immensely grateful for the profound influence you’ve had on me. I am so excited to join this exceptional division for another year and I hope I can make even a fraction of the impact you have all given me to the next class of fellows, residents, and students. Thank you all!”

– Dr. Mackenzie Keintz, ID physician and graduating UNMC ID fellow, 2023

UNMC ID Launches Program to Improve Health Equity

The UNMC ID Division is launching Achieving Equitable Health Outcomes in Nebraska, a program to support Nebraska-based organizations in improving health equity in alignment with the Joint Commission’s new priority. See the flyer below and check out this linked website for more information.

Interested in learning more? The first meeting is TODAY, June 21st, at 12pm.

For more information, see https://www.unmc.edu/intmed/divisions/id/echo/health-equity/phase2.html.

Research Digest: Ventilator-Associated Events

Research Digest is a periodic installment that recognizes the world-class clinical research performed right here at UNMC ID. This week, we feature three articles exploring infectious complications associated with ventilator use. As always, be sure to check out the linked full articles for more details.

The first article, co-authored by Dr. Kelly Cawcutt and Dr. Trevor Van Schooneveld (pictured right), provides commentary on the usefulness of risk factors and outcome research on ventilator-associated events (VAE), which include pneumonia as well as a diverse set of additional disorders such as pulmonary edema and mucus plugging among many others. They review multiple previous studies which have attempted to characterize the impact of adverse ventilator-associated events and further distinguish them from specifically ventilatory-associated pneumonia (VAP). The authors conclude that risk factors and outcome research which identify ways to prevent VAE may not be applicable to improvement in the smaller subcategory of VAP. Read the full details here.

In the second article, also co-authored by Dr. Cawcutt (pictured left), ID experts offer guidance on strategies to prevent VAP and VAE as well as non-ventilator hospital-acquired pneumonia. These recommendations are stratified by patient population, offering specific guidance for neonates, pediatric patients, and adults. Cumulating in an extensive update guided by expert testimony and reviewed and approved by a panel of ID specialists, this article provides the medical community with essential tips to avoid common yet life-threatening adverse events. Read the full recommendations at this link.

Dr. Jonathan Ryder, 2nd year UNMC ID fellow

The last article, authored by Dr. Jonathan Ryer (pictured left) and Dr. Andre Kalil (pictured right), explores the association between COVID-19 and VAP. This patient population has been noted to experience VAP at a much higher rate than patients infected with other viruses. Adding to this, there is also an increased risk of shock and bloodstream infections in COVID-19 patients. This article comments on the questions that still exist surrounding this trend and what may be behind it. While a clear cause remains elusive, as the authors note, “[there is]…one thing we can say with certainty: patients hospitalized with COVID-19 are undoubtedly requiring longer hospital/ICU stay and prolonged mechanical ventilation duration, are more frequently proned, and are receiving more immunosuppressive drugs than any other respiratory viral infection ever before.” These factors provide clues to the potential cause of the increased risk of VAP. Read the whole commentary here.

Meeting Recap: Nebraska HIV Prevention & Care Update

The 2023 Nebraska HIV Prevention & Care Update was a great success on 5/18/23 at UNO Barbara Weitz Center for Community Engagement. Hosted by the Nebraska Dept of Health and Human Services and KS/NE AIDS Education and Training Center, the program featured presenters and panelists representing the health department, Nebraska Medicine/UNMC Specialty Care Center, community-based organizations, and consumers of HIV care. Over 100 participants joined in person and virtually from across the region.

Here is a quick summary of what was discussed:

  • New developments in HIV care in 2023
  • Patient perspectives on aging with HIV
  • Barriers to HIV prevention and PrEP for cisgender Black women
  • HIV prevention and care needs for incarcerated and system-impacted people
  • Updates in oral health access and correlations of health for people with HIV
  • Best practices regarding PrEP uptake in disproportionally impacted communities of color in Nebraska
  • HIV prevention and PrEP disparities for people who are Transgender
  • Socioeconomic barriers to engaging patients in HIV care
  • Lessons learned with long-acting antiretroviral therapy

For more information about this year’s conference, or if you are interested in getting involved in future Nebraska HIV Update conferences, please contact Nichole Regan at nregan@nebraskamed.com.

Improving HIV Care: UNMC ID’s Telehealth Intervention Receives National Recognition

Earlier this month, the Specialty Care Clinic’s telehealth intervention plan was recognized and published as a ‘Best Practice’ on TargetHIV.org. This achievement follows from extensive research into existing patients utilizing the telehealth platform and confirmed that HIV care delivered via phone or video chat can be just as effective as care provided in a clinic for patients who prefer it. Read on for the details about Target HIV, best practices, and how the COVID-19 pandemic changed how effective HIV care could be offered at Nebraska Medicine.

What is TargetHIV?

From their webpage, “The TargetHIV website is the one-stop shop for technical assistance and training resources for HRSA’s Ryan White HIV/AIDS Program (RWHAP), the federal program that funds local and state agencies to deliver HIV care for people with HIV who are uninsured or underinsured.“

Essentially, TargetHIV is a nationally recognized resource for clinics looking to improve care of patients living with HIV.

What are Best Practices?

In short, ‘Best Practices’ are exactly that: documented successes in HIV care which are published on the TargetHIV webpage so others can learn from and implement similar interventions. This section gathers and shares what works in RWHAP-funded settings to improve outcomes for people with HIV and to support replication by others.

Why did the Specialty Care Clinic start to trial telehealth care?

During the COVID-19 pandemic, HIV clinics had to transform care delivery for people with HIV, with many clinics transitioning rapidly to alternative methods such as telehealth. In March 2020, SCC recognized the need to adjust its clinic operations to promote patient and staff safety during the pandemic. This adjustment, limiting in-person interactions, conflicted with the clinic’s usual approach to promoting retention in care and viral suppression, which relied on patients making frequent visits to the clinic not only for clinical care but also for ongoing medication adherence and case management support. Prior to March 2020, SCC did not offer telehealth services.

How did it go?

Great! Analysis of the first six months of telehealth offerings (around the beginning of the COVID-19 pandemic) revealed that 35% of visits utilized telehealth technology. In all patients, viral suppression rates were high, but telehealth patients actually maintained a higher rate of viral suppression than patients who visited the clinic in-person during the same time period. This indicates that telehealth HIV care can be highly effective for those patients who choose it.

What else can I find on the Specialty Care Clinic Telehealth Best Practices webpage?

The SCC published all the information that another clinic might find useful when implementing telehealth for their patients, including planning and implementation tips for setting up telehealth, lessons learned during this trial phase, and additional resources for those looking to get started. Check it out here for more information

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