Keeping Our Eyes on the Antimicrobial Stewardship Ball: Dr. Tom Price as the next secretary of HHS

This is a guest post from Judy Guzman-Cottrill. Dr. Guzman-Cottrill is a Professor of Pediatrics at Oregon Health & Science University and also an infection prevention and healthcare epidemiology consultant for the Oregon Health Authority’s HAI Program, where she serves as the Medical Director for Ebola and Emerging Pathogen Preparedness. 


Many healthcare providers ponder what the incoming 2017 administration will mean for their work, including myself. Dan and Eli have already written several blog posts about public health funding threats. As my description above says, I'm a hybrid of sorts: a part-time pediatric infectious disease clinical faculty member at Oregon Health and Science University, and a part-time consultant to the Oregon State Health Department’s HAI program.

First, we’ve all been thinking about our patients and their families. The next administration’s plan for the Affordable Care Act seems to change constantly. During President-Elect Trump’s campaign, he promised to completely repeal the ACA within his first hundred days in office. Post-election, he has suggested that the ACA will be repealed or amended. After meeting with President Obama, Mr. Trump has stated that he will maintain the continued coverage for preexisting conditions and young adult coverage on parents’ plans until 26 years of age. Most recently, however, Mr. Trump selected Dr. Tom Price to serve as secretary of Health and Human Services. What will his leadership mean for our patients, including those who rely on Medicaid and Medicare? Dr. Price has also supported changes which would not require insurers to cover pre-existing conditions. Almost more concerning to me is that Dr. Price is a member of the Association of American Physicians and Surgeons (AAPS), an organization that vehemently opposes antibiotic stewardship legislation, has publicly opposed the IDSA Lyme Disease guidelines on several occasions, and whose executive director has publicly supported a potential link between MMR vaccine and autism as recently as 2015. Important note: It is unclear to me which of these specific stances are also personally supported by Dr. Price. It would be good to know.

What about public health, MDRO prevention, and infection prevention? I already mentioned the AAPS opposition to antibiotic stewardship legislation. Will all of our hard work be left to the wayside? Over the past decade, I've been amazed by the accomplishments our field has made in improving judicious antibiotic use. Our surgical and critical care colleagues are finally starting to feel comfortable with shorter days of antibiotic therapy, and narrower spectrum. Hospitals are starting to fund physicians and pharmacists along with the informatics experts necessary to develop and maintain effective stewardship programs. During clinical rounds, even ID consultants are asking themselves, “Does this patient really need more antibiotics? Or am I prescribing them a personal anxiolytic?!” Stewardship progress is everywhere, including NICUs across the country, partnering with the CDC, to decrease antibiotic exposure in neonates. I worry that Dr. Price, an orthopedic surgeon, will tout stewardship as needless control over physicians who should prescribe antibiotics to whomever, whenever they please.

ID clinicians and public health colleagues, let’s all keep an eye on Dr. Price. We should be strong, vocal advocates for our at-risk patients and our public health programs, to ensure that our infection prevention and healthcare epidemiology work continues into the next decade.

Proton Pump Inhibitors and ESBL

We have written frequently about the many HAI and MDRO that have been linked to PPI use including VAP, CAP, HAP in non-ICU settings, SBP in patients with cirrhosis, and, of course, C. difficile. In the US, PPIs are the third most prescribed medication, they are addictive since withdrawal symptoms can develop and are now available over-the-counter.

Researchers at Amphia Hospital, an 850-bed teaching facility in the Netherlands, completed two prevalence studies (November 2014 and 2015) on all adult patients who had stayed for no more than 2 days. The cross-section study just published in CID (free full text) linked rectal carriage of ESBL-producing Enterobacteriaceae to pre-admission use of PPI and H2-antagonists among other factors.

Rectal cultures were available from 570 patients and 259 (45%) had a history of PPI use, while very few used H2-blockers or antacids. I have included the univariable and multivariable analyses below. More than concurrent antibiotic use or prior hospital admission, PPIs were associated with four times the risk of ESBL rectal carriage. (OR 3.89, 95% CI 1.65-9.19).  This is a very nicely completed study and provides more evidence supporting the inclusion of PPIs targets in our "antimicrobial" stewardship programs.

21st Century Cures (But Doesn't Prevent) Act

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Soy un perdedor
I'm a loser baby, so why don't you kill me?

-Beck (Loser)
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There was a lot of excitement yesterday when the US Senate approved the 21st Century Cures Act, which would increase NIH funding, address issues with the mental health delivery and alter the approval process for pharmaceuticals and devices. Unfortunately, along with the winners there are several losers in this legislation.

And the big loser is?  - The Prevention and Public Health Fund. Dan has written often (here, here, and here) about how this fund is a frequent target for cuts. And this time, it seems even worse. Per reports, "[the bill] also cuts $3.5 billion, or about 30%, from Obamacare’s Prevention and Public Health Fund, which fosters work to prevent Alzheimer’s disease, hospital-acquired infections and other conditions."

So apart from the Cubs win, we can all agree that 2016 was a real loser for the HAI and public health communities.

ID Match 2017: Turning point or artifact of "all in" approach?

The dust is still settling from this year’s ID Match, but at first glance it looks like a much-needed step in the right direction. Compared with last year, the number of unfilled positions (on match day, that is, which doesn’t count positions that will be filled after the match) is down to 80 from 117, and the number of unfilled programs is down to 54 from 82. This is not to minimize the pain for programs that didn’t match—>50 is still way too many, and comparable to the number of unfilled programs in 2014.

This dramatic shift from the trend of the last three years must be due in part to the “all-in” strategy that IDSA is pursuing (requiring that all ACGME positions be offered in the match, trying to minimize those positions offered before or after). The question is how much of this shift reflects an absolute increase in the number of trainees after the post-match numbers are included. For example, there is still the chance that interested individuals opt out of the match, hoping to snag a good position afterwards (obviating the expense, time and anxiety the interview circuit). 

The challenges to attracting the next generation of ID physicians remain daunting, and this one-year change in match results (temporally associated with a new “all in” policy) shouldn’t detract from the urgency of these efforts. We’ll have a much better sense of how we are doing (at least from the training program side) after another 1-2 years of the “all in” match. If programs and applicants continue to adhere to the "all in" approach (i.e. how will it be enforced?), at least it should give us a more accurate assessment of the supply-demand situation.

I’d welcome input from other program directors, IDSA leadership, and anyone else with thoughts on this year’s match results!

Mycobacterium chimaera outbreak: A practical review

Mike recently posted a “how to guide” for centers struggling with the response to this global outbreak. Now there’s also a review available online from ICHE—Mike and I each contributed, but the heavy lifting was done by our colleagues in Switzerland (Sommerstein, Schreiber, Hasse, Marschall and Sax). Table 1 in this paper (see below) provides practical interim suggestions. Check it out—and thanks to Cambridge for making this an open access article.

On a personal note: it’s been over a month since I posted on this blog—since the Cubs won the World Series, in fact. That event, and the US presidential election shortly thereafter, has me wondering if the world has somehow shifted on its axis. This is not a political blog, but it’s disingenuous not to recognize the anxiety we feel about an incoming U.S. administration that has had such a creative relationship with facts, with science, and with the idea of the common good. I’ll admit it has been hard for me to sleep some nights, amidst justifiable concerns about what may happen to our healthcare system, and to AHRQ, CDC, NIH, VHA, etc.

At some point, though, we just need to redouble our own efforts, wherever we are, to do the work we do best, and to speak up when things happen that threaten progress toward safe, effective and accessible health care. One of my favorite songs by Paul Simon has it right: “still, tomorrow is gonna be another working day (and I'm trying to get some rest).”

The almighty influenza vaccine

A recent study in Clinical Infectious Disease that analyzed the effectiveness of the influenza vaccine for the 2014-15 season was sent to me by a colleague. Wow. Overall effectiveness (for influenza A and B combined) was a whopping 19%, but for influenza A was 6%. Honestly, placebo is more effective than that. For the 2015-16 season, overall effectiveness was 47%, and 55% for influenza A.

CDC used to cite that the flu vaccine was 70-90% effective, but more recently they have revised that significantly. I was quite surprised when I looked at the CDC website today and I made the graph below from their data.

In 12 consecutive flu seasons, effectiveness hit 60% just once. If you average those 12 seasons, the effectiveness was 41%. We are sorely in need of a better vaccine. The CDC analysis begs many questions: Should hospitals make this weakly effective vaccine a condition of employment? Should SHEA take another look at its guideline? Does anyone still believe that we should fire healthcare workers that are not vaccinated with a vaccine that provides such poor protection? How many hospitals fire employees who come to work sick with influenza? Would you rather be hospitalized at a hospital with a mandatory flu vaccine policy or a hospital that makes a serious attempt to minimize presenteeism?

CAUTI SCHMAUTI ! (part 4)

A new paper in Infection Control and Hospital Epidemiology takes us another step closer to reclassifying CAUTI from a healthcare associated infection to a healthcare associated myth. Tom Fraser and colleagues at the Cleveland Clinic worked with their ICUs to reach consensus to limit urine cultures in patients with fever to kidney transplant recipients, neutropenic patients, patients with recent GU surgery, and patients with evidence of urinary tract obstruction. One year later, here’s what they found:

• There was no significant change in urinary catheter utilization (approximately 70% of patient days were associated with catheter use 1 year before and after implementation of changes in ordering urine cultures).
• The number of urine cultures ordered fell by ~50%.
• The CAUTI rate fell from 3.0 to 1.9/1,000 catheter days, a significant reduction of 33%.
• There was no change in the rate of healthcare associated bloodstream infections, and no change in the subset due to Enterobacteriacae, which implies that there was no increase in bacteremic urinary tract infections. The potential for bacteremia is a major reason for treating CAUTI.

A similar study from Mayo Clinic showed similar findings (50% reduction in urine cultures ordered and a 30% reduction in CAUTI).

It would be interesting to know how many cases of C. difficile have been caused by treating this noninfection, or as the Cleveland authors call it, “an artificial construct designed to reflect clinical events for surveillance purposes.” And as we become more serious about antibiotic stewardship, “CAUTI” should be viewed as low hanging fruit.

In previous posts on this blog (here and here) there have been discussions questioning the existence of CAUTI. We now seem to be reaching a tipping point where it’s becoming increasingly clear that the opportunity cost of this medicalized artificial construct outweighs the benefit of continued focus.