Antibiotic Stewardship ECHO: How Does Your Facility Manage? – 2/15/18

Antibiotic Stewardship ECHO: How Does Your Facility Manage? – 2/15/18


Hi, good afternoon, it’s Charlie Krasner. I’m here with my sidekicks. (laughs) We’re gonna talk today about (inaudible) We’re gonna talk today about infection control issue which is sort of when you work in the hospital takes everything involved. We wanna reconsider MRSA isolation precautions. Do we really need what we’re killing
or is it overkill? Does everybody have the slides up? We want to hear from people about what they are doing in their facilities and their thoughts on it. Since this is the Stewardship program, I always talk about C. diff. Before I get going I came
across this abstract that’s gonna be published very shortly and then click on
next to disease and you know we’ve talked about PPI -do they increase the odds of infection? Does acid suppression increase the risk that c-diff develops and there’s been some questions back and forth, some people say yes and some no. This was sort of a definitive retrospective study; it was from the health hospital Corporation of America and they looked at all their hospitals and they looked at more than a million patient records and they did a cohort study, retrospectively to see what factors seem to increase the risk of getting C. diff. over somebody who didn’t have infection. So when you’re doing it for more than a million patients you can get a very good result and there was an increase of PPI risk of 44 percent. So that means if you had 100 patients on Rocephin and let’s say 20 got C. diff., you had 100 patients on Rocephin and they were on protonix about 28 of them would get C. diff. The odds were very, strongly positive that the use of PPI increase the risk of C. diff. H2 antagonist (inaudible) was not as significant, probably because not as potent but did increse risk by 13 percent. A lot of patients are put on PPI’s in the ICU
and get transferred before can continue on it or they come in
that they don’t know why they’re on it, they had gastritis 5 years ago and they’re still on it. If you work with your infection control and stewardship their comment was that
reducing acid suppression and combining metabolic stewardship may
greatly reduce the possible onset of CDI. Again, it’s an easy thing to do. Why is this patient on a PPI? The other risk factors, just starting on
antibiotics. The antibiotics they felt the worst were the carbapenem things like meropenem -zosyn. (inaudible) and increased the risk about a 100 percent so these are significant risk factors What’s interesting is tetracycline is known to reduce C. diff. but the clindamycin actually, they weren’t sure why- maybe because it wasn’t used very much, they thought it decreased risk with clindamycin which sort of goes against our second nature to think it does, but the big take home is that (inaudible) zosyn, carbapenems, double your risk compared to some other
some other antibiotics and the PPI’s. So if you’re into antibiotic
stewardship, you may also want to look at PPI’s. Maybe tell your hospitals, does this is patient really need to be on it – and maybe get them off. Particularly if they’re gonna be on antibiotics. Okay, that seems like a million charts, it seems like it answers their question. Alright, so I’m gonna give you the next few slides and talk about infectious disease precautions and hospitals. A little issue of it, how we ended up on contact precautions 12 years ago. So 1910, barrier nursing where nurses would use gowns was introduced and not much changed until about the early 1970’s when they came up with specific precaution categories you know, like respiratory precaution wound precaution, drainage precaution. So you’d have specific approaches to each
one. But then the HIV came along by the 1980’s and instead of trying to guess who’s at high risk, who’s that low risk, who has infection -we came up with universal precaution. Assume that every blood and body fluid is infected. So we don’t treat patients differently. You got blood, you got pus. You know that you’re at risk for
infection. And so every patient is thought to possibly have an infection. And this was combined with standard precaution. Standard precautions, yes you do universal precautions, but yes if somebody has an infection, they have diarrhea, you want to confine them with gloves, gowns and masks to protect your exposure from the body fluid. So we had standard precautions and
universal precautions put together. But then, in 2007 for the first time the CDC recommended what they called contact precautions. They were recommending gloves and gowns for all patients who are infected with multi drug-resistant bacteria and so that makes sense you know you have somebody who has an infection he’s got pneumonia (inaudible) he’s got whatever you definitely want to use precautions. But for the first time now it was extended to patients who are asymptomatic, patients who had no obvious infection but I’ve been identified as being colonized. So not only just affected, but those colonized, that we should do contact precautions. And the usual target
being (inaudible) This was the biggest extension from actually infected people to those who are only colonized. And they felt we should do this contact
precautions. So, this is not a new concept – contact precautions. This was Doctor Schwiner in 1656 – he introduced the first contact precaution outfit, and this was in Rome, 1656. and they had about half a million people die of plague. He felt that the plague was transmitted by bad air. (inaudible) So its bad air. So he developed this beak and he put like flowers and spices inside the beak so that it would neutralize the bad air and then he had this wax gown. So it’s very similar to what we see nowadays with people walking around with personal protective things. But that has been around for about hundred years and you can actually buy this from Halloween stores, they can sell you that. It’s called the black death mask. Alright. (laughs) Anyway, so, contact precaution – This is an opportunity cost, okay. (inaudible) Wearing gowns, gloves and masks… There are a lot of drawbacks and anybody that works in a hospital can point them out. It comes at a cost to other things that we could be doing. So first of all, it is extremely burdensome. You walk down a hospital and
everybody has to be in gowns and gloves. It gets gets very difficult and if you’re busy it really gets frustrating. So, they found that the more patients who are in contact precautions adherence by health care workers fall off the greater use of isolation. You only have a few patients
people adhere to or when you get to 60 or 70 percent people in isolation, people get tired. In the emergency room, the patient often times can’t get moved out of the ER until they get a special room so there’s definitely delays in the emergency room. And then as you know when you try to get somebody to a skills facility, they throw up barriers so takes an average of almost two days to get somebody who’s in contact precautions discharged to the skilled facility, and I know the hospitals here are wall to wall people particularly the flu going on, so there is costs to this. As a health care work, as a physician nurse you get tired of putting this on so all the times you do like a drive-by, you just waive at the patients instead of going into examine them and not putting on – (inaudible) And so obviously the patient feels he doesn’t know what’s going on, he’s unhappy. He says why am I in this, Satisfaction goes way down. And so finally, I can just let the cost.. and then environmental burden; we are throwing away so many hundreds of
thousands of gowns into the into the waste. I just can’t imagine, it must be millions and billions of pounds of this junk. So, content precautions are not “oh let’s just do it” -there are costs to it. And so, when you look at states, when the outbreak of MRSA committee party came around the 2000s a lot of legislators and hospital systems said oh we’ve got a
we have to start screening through contact precautions and screening so it changes for a lot of things but presently, California, Illinois, New
Jersey and Pennsylvania as well as – I work in the VA – the entire Department of Veterans Affairs require active hospital surveillance everybody in those states, the VA, has to be screened for it (inaudible) the hospital messages to ICU and then put in contact precautions (inaudible) in California, they go overboard and everything, if you fail to follow mandatory culturing and reporting, this could result in sanctions, fines and even jail time for members of the hospital. Nevada is not like that; I found out since 2011, you have to submit data to the national healthcare safety Network related to health care (inaudible) rates of patients by the patient care location within the hospital as well as bloodstream infections so there they are just (inaudible) it’s just reporting of cases Alright so, what what is some of – before we talk about the cost of doing the MRSA screening, what are some of the facilities that you guys do, can you tell us? What your policy is in terms of screening for MRSA and reporting it. Hi, this is Karen, Carson Valley Medical Center and we only screen ventilated patients, but not any other type of patient unless there’s a direct reason, like we’re checking a culture or whatnot. Checking culture, that’s looking for an infection not looking for screening (inaudible) So that makes sense. Are there any other places? (inaudible) At the VA. We screen admissions, transfers, discharges and deaths in the
community living center, and we used to do it in acute care and ICU. But now in acute care we just do admissions and ICU we do admissions and transfers in. So the CLC is like a nursing facility, what do you do when the patients are positive? Do you keep them in isolation or what do you do? They go into enhanced barrier precautions, CLC we concentrate more on education because you can’t keep them in their room so it’s more of a “keep your hands clean” visiting in the areas the common areas and housekeeping concentrates more on a all the high touch areas, disinfecting and cleaning that because they get problems with outbreaks and since they’re moving around and many have dementia it’s a constant battle. CLC’s are the hardest place. We have Amy McHolmes from Renown, tell us what you do there. So about 3 years ago, we stopped doing any screening for VRE and MRSA and we have not seen any increase, so we only isolate using contact precautions on any active infections. So we isolate through out their stay (inaudible) rehab facility then it’s a little different. So do you know what percent of people are in isolation now versus when you were doing the contact? Oh gosh, a lot less. Probably, 40-50 less patients a day. (inaudible) That’s wonderful. So let’s go over some of the data, why we may want to think if consider giving contact isolating. So, the question is, does detective in isolating MRSA, so looking for a systematic colonization doesn’t lead to improve infection rates. Are we nipping infections in the bud by isolating (inaudible) even though they’ll have no signs or symptoms of infection. So, one of the studies was in the New England Journal, and this was a multi Hospital investigation, and they had a very active surveillance of everybody to look for MRCA and VRE. It basically led to a doubling of the
amount of patients in isolation, but, when they look at transmission rate there was no change in transmission rate. So oftentimes you say, “oh, this patient’s got MRSA” but when they can do is they can do a genetic analysis of that MRSA and see what’s related to people in the hospital or was it not was it just a community (inaudible) So often times even though it’s MRSA, when you look at these infections, it’s very rare that the person who developed MRI has actually had it transmitted from another patient it’s almost always that the patients are
coming in with it. So they got the doubles contact isolation but no effect on transmission rate. What they found is that most infections of MRCA are from the patient’s themselves and rarely from patient to patient. And they looked at ICU’s another study where people acquire MRCA infections in the ICU where they actually from other patients and there’s less than 2 percent of ICU patients who’ve got worse infections. -Actually were from transmitted from somebody else. So you have maybe 5 percent of your ICU patients getting MRSA infections and only 150 of those 5 percent got it from the other patients. So it’s very rare, maybe 1 in 500 to 1 in a 1000 patients consistently move (inaudible) to get infections are transmitted. So you have to basically isolate about a 1000 patients to reduce maybe one one case of person-to-person transmission. The CDC did a study the
public publishing England Journal and they found that 4 percent of hospitalized patients got health care-associated infections – so all types of infections. Approximately only 1 in 20 of these healthcare infections were MRSA, so less than one out of every 500 patients actually got MRSA
infections in the hospital and most of these were from the patient’s own (inaudible) So not patient-to-patient. And so they felt there was no evidence that contact precautions added anything over approved used of
standard precautions so there’s really no evidence that it helps. So, there is a nice editorial gamma a few months by doctor (inaudible) expert in isolation he calls this “MRCA exceptionalism”. MRSA is obviously a threat to patients but so are a lot of other infections. Should we specifically be focusing our energy on MRCA at the risk of coming back in other areas. MRCA counted only 11 percent of
hospital for acquired bacterial infections (inaudible) Which, 89 percent of other health care so
health care hospital-associated infections for other bacteria. And he says universal MRSA screening may detect more MRSA colonization but will miss other serious infections. So we may be putting people in contact isolation, but we’re missing you know the fact that they have (inaudible) We’re pouring all this effort and money into MRCA isolation as a cost of all those things we talked about probably no benefit at
all in terms of reducing MRSA and that really addressing the fact that
there are a lot of healthcare associated infections and MRSA is only one small
(inaudible). So, whether contact precautions and anything to optimal use
the modern standard cautions not no. Earlier studies suggested some benefit
to contact precaution but all were done before the widespread use of things like chlorhexidine, bathing, efforts to improve hand hygiene, and environmental cleaning – which incidentally work not to just prevent MRSA, but all infections. Universal precautions plus standard precautions plus these other interventions don’t just deal with MRSA but they probably reduce the risk of all infections that are important. And so, when he talked about was that there
presently 40 hospitals including Dartmouth Medical Center, have totally dropped strict universal immersive VRE contact isolation procedures fell to the
last ten years, and what they think is a much more instead of you know Grill approach, they’re very much more nuanced and selective approach. So obviously they
will put somebody who’s gotten active infection.
You got draining wounds, you got diarrhea, you’re gonna want put that person in isolation, okay. So those are people obviously you want to continue contact precautions and those are those are not really those are not people picked up on screen but those are people with active infection. They say bathing patients – when you’re bathing patients nurses, there’s a lot of
exposure to the patients so they probably should be wearing gowns and
gloves when they’re cleaning patients and focusing on evidence base to register IDs decreased risk from all pathogens such as sterile central line placement and nurses tell you about you know, sometimes doctors will put (inaudible) without even gowns or gloves, using chlorhexidine body wash. A big focus on hand hygiene – (inaudible) healthcare associated infections and active infection, they feel that you can eliminate contact precaution to patients to be colonized with MRSA in theory. This is some of the things that we’re trying, or other places are trying. Nozin – I know the VA is using Nozin. What are you guys doing with Nozin at the VA? Hi, this is Beth. We did the Nozin trial in our CLC, but we’re not using it at this point on surgical or anything else. So we’re not really using it. What would be the indication for – The indication like for surgical patients, short-term patients – you provide, you use the Nozin, the CHD bathing, you wouldn’t have to do any isolation, you don’t screen MRSA or anything like that, you’re just more proactive versus reacting to a screening culture. Like you said, it takes care of more than just MRSA. And the other thing is, I know at Northern Nevada Medical Center we’re using the UV lights, and that has shown to be very effective. Are you guys using it anywhere else? (inaudible) We only use it in the ICU on all discharges -all isolation discharges and in all of our procedural areas every night. (inaudible) And it seems like it’s effective – all infections. (inaudible) Some people are recommending Mupirocin ointment, they had some studies where they were trying to decolonize all these patients who had MRSA. (inaudible) It’s probably not something you’d wanna use (inaudible) And then, I know the VA is trying to get some electronic monitors, for hand-washing. Is that right? That is right, we can’t wait. Unfortunately, we can’t take it to a
patient – to a specific employee, but we can take it to the unit, and hopefully, maybe, to their service position -versus nurse, versus something else. We’re working on that. We also use UV lights on all the units. CLC in the OR and in the bathrooms on the two bed wards, ’cause if you only discharge one patient and there’s another one in there they can- they can UV light the bathroom. How long do you use the UV light for? 5 minutes, 10 minutes? It runs for 4 minutes.. so you have to do one side of the bed, the other side of the bed and then the bathroom, so that would be about 12 to 15 minutes. That’s pretty quick. I think contact precautions seemed like
it was a reaction -an overreaction to an epidemic that was developing, and I think with more modern things that we’re doing these days with a focus on hand-washing,
Chlorhexidine body wash, a much more focused approach to isolating only patients who have active infection use the universal and standard precautions. I think it would be reasonable to stop putting people in isolation just because their carrier. Your guys’ thoughts on that? It’s working for us, right. (inaudible) Do you remember when Sweden was the goal standard years and years ago? Where they actually tested the nurses and employees, and if they were positive they were sent home. And they had negative come back in, and if their rates were really low. But that was a long time ago. I know solme doctors are Renown were disagreeing with it, what was your argument against – (inaudible) Wow, that was over 3 year ago, so just that the CDC guidelines still supported putting up – with the active surveillance and then isolating everyone even if they were just colonized. So CDC still supported it, and then there were several other older articles that were cited. Yeah, the person – the physican wrote when doctor recommended not doing it, a physician wrote 12 page article with about 20 references, but all the references were of course older references that supported it, (inaudible) -those rates anyway. It’s something that we’ve watched very closely over the years, and our rates have actually declined. (inaudible) (inaudible) ..is only specific to strep (inaudible) What Nozin does – I don’t know anything about that. What does that hit? It hits some bacteria like staff and I believe VRE. It also covers viral pathogen. (inaudible) It’s alcohol. It probably burns you. It doesn’t- it’s got a citrus-y flavor -smell (inaudible) So I think the bottom line is that, you know If contact precautions have come and gone, that it’s really – we’ve superseded with good infection control measures, hand-washing particularly, gowns and gloves for drainage, that we can go away with it and have a lot of benefits. Save money, save the environment, make patients happier. Put your patients in and out of hospitals. Do any of you else have any experiences
stopping or what are you doing with MRSA isolation patients? Well at the VA we’re still required to isolate everyone, but the MDRO program office center offices is looking at the recent studies about taking patients
out of contact isolation. we’ve also had conference calls about it
and Dr. Evans -the infectious disease the head of the MDRO program said there wasn’t quite enough evidence yet, but that was some months ago, and they also published a study in 2011 that showed a reduction in (inaudible). But we use a bundle approach so it’s surveillance, isolation, hand hygiene, changing the culture, but that was 2011, so they are looking at what you’re talking about, Dr. Krasner, of maybe looking to see if we can stop
some of the isolation. But as of 6 months ago, I think that was about when it was, he said there’s still not enough evidence for them to decide to change the whole bundle approach. What are you guys doing with C. diff. carriers? (inaudible) You’re not putting them in isolation? No, no isolation. That’s another thing, we’ve always assumed they’re really contagious. (inaudible) There’s very little evidence that good hand washing that you transmit it. So patients that are no longer having diarrhea can be taken out of isolation. That’s what we do too. Hopefully it’ll be a more pleasant place to work in the hospital. And by focusing on what’s important – the hand washing, and the sterile techniques, (inaudible) body wash, wearing gowns when you bathe patients. I think the patients benefit, it’s a better place. So, Dr. Krasner, this is Karen, Carson Valley Medical Center. So we have a unique challenge though, Our critical access hospital conditions of
participation came out a new version October 2016, and they specifically state that – as far as isolation and MPRA’s go that we have to follow nationally-recognized guidelines such as (inaudible) and CDC and
OSHA and those kind of things, so when I did the research back then, all of those guidelines were still saying and I reached out to our state, they were still saying to isolate for history of MDRO so, I think it’s as far as work and their conditions of participation we have abide by that. It was a big debate at (inaudible) two or three years ago, there were several sessions about contact precautions versus not contact precautions, and there’s definitely two groups -two sides. The right and the wrong (laughs). That’s like saying there’s two sides to global warming. (laughs) You don’t know yet. Yeah, we don’t know yet. Does anyone else have any comments or questions? Please feel free to un-mute yourself with the icon below, left corner of the student window. Or with *6 if you are joined by phone. Karen, does it actually list MRSA as an MBRO? Because it’s not a multiple drug-resistant. Yeah, I haven’t read it lately but from what I recall yeah I think it’s specifically says like VRE, MRSA, and it says
other multi-drug resistent -something like that I haven’t read it in the while but (inaudible) So you guys may wanna have a chance to review what your hospital policy is, and talk to your physicians, you may want to consider changing it but it doesn’t mean go crazy it means that you do the quick standard precautions, and watch all the stuff you’re doing, as a substitute for putting people in isolation. Alright, thank you all very much. Thanks. Thank you.

Add a Comment

Your email address will not be published. Required fields are marked *