Latest / The SHEA Podcast / COVID-19: Overuse and Misuse of Antibiotics During the Surge, 5/21

Transcript

COVID-19: Overuse and Misuse of Antibiotics During the Surge, 5/21 · The SHEA Podcast

• 0:08
  SPEAKER_00: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:25
  SPEAKER_00: I'm Dr.
• 0:26
  SPEAKER_00: Cindy Prince, Clinical Associate Professor of Epidemiology at the University of Florida, and I'll serve as your moderator.
• 0:33
  SPEAKER_00: Discussion on the podcast does not reflect Trey's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:51
  SPEAKER_00: Today's episode will focus on the overuse and misuse of antibiotics during the COVID-19 surge.
• 0:58
  SPEAKER_00: Our speaker is Dr.
• 0:59
  SPEAKER_00: Tamara Barlam.
• 1:00
  SPEAKER_00: Dr.
• 1:01
  SPEAKER_00: Barlam is the chief of the section of infectious diseases and director of the antimicrobial stewardship program at the Boston Medical Center.
• 1:09
  SPEAKER_00: She is an associate professor of medicine at Boston University School of Medicine.
• 1:14
  SPEAKER_00: Thank you for joining us today.
• 1:16
  SPEAKER_00: Before we start a discussion on the overuse and misuse of antibiotics, I'll get us started with a news and guidance update of the week.
• 1:24
  SPEAKER_00: This week the U.S.
• 1:25
  SPEAKER_00: surpassed 1.5 million confirmed cases of COVID-19 with almost 92,000 deaths.
• 1:32
  SPEAKER_00: The CDC updated their information for pediatric health care providers with current guidance on multisystem inflammatory syndrome or misc in children.
• 1:41
  SPEAKER_00: Given that children may develop the syndrome for up to about four weeks after infection, which can include asymptomatic infection, it's currently unknown how common this syndrome may be.
• 1:52
  SPEAKER_00: The guidance points out that children have presented with a fever and a variety of symptoms that include multi-organ involvement and elevated inflammatory markers.
• 2:02
  SPEAKER_00: Suspected cases of MISC should be reported to your local, state, or territorial health department.
• 2:08
  SPEAKER_00: The biotech company Moderna released interim results of their phase one trial of mRNA 1273, a COVID-19 vaccine candidate.
• 2:18
  SPEAKER_00: The trial includes three different dose levels of 25 micrograms, 100 micrograms and 250 micrograms with 15 participants per cohort ages 18 to 55.
• 2:30
  SPEAKER_00: Across the three groups, participants zero converted by day 15 after one dose.
• 2:36
  SPEAKER_00: For the 25 microgram dose arm, levels of binding antibodies measured on day 43 of the trial, or two weeks after a second dose were similar to those seen in convalescent SIRA.
• 2:47
  SPEAKER_00: For the 100 microgram dose ARM, levels of binding antibodies on day 43 after two doses were significantly higher than those measured in convalescent SIRA.
• 2:58
  SPEAKER_00: Data on neutralizing antibodies is incomplete, but at this point of eight participants for whom the data is available, all produce levels of neutralizing antibodies at or above that usually seen in convalescent SIRA.
• 3:10
  SPEAKER_00: The vaccine was generally well tolerated, and phase two will go forward with the 25 and 100 microgram doses.
• 3:18
  SPEAKER_00: Phase three is planned for July.
• 3:20
  SPEAKER_00: In the journal of the American Medical Association this week, two case series described the use of prone positioning in COVID-19 patients.
• 3:28
  SPEAKER_00: Al Hurar et al.
• 3:29
  SPEAKER_00: described the use of prone positioning in a week of non-intubated patients and a prospective single-center before or after study in France in late March to early April.
• 3:40
  SPEAKER_00: Among 24 patients in the study, 63% tolerated prone positioning for more than three hours.
• 3:47
  SPEAKER_00: Of those, six patients or 40% of that group responded, meaning that their partial pressure of arterial oxygen increased 20% or more during prone positioning compared to before.
• 3:58
  SPEAKER_00: After supination, the partial pressure of arterial oxygen was the same as prior to prone positioning.
• 4:05
  SPEAKER_00: Sartorini et al described the results of a cross-sectional study of 15 patients in Italy undergoing non-invasive ventilation or NIV with prone positioning.
• 4:15
  SPEAKER_00: The study group measured respiratory parameters before NIV, during NIV and pronation, and one hour after NIV.
• 4:22
  SPEAKER_00: They noted that the respiratory rate was lower and oxygenation was higher for all patients during and after pronation.
• 4:30
  SPEAKER_00: I now want to move into a discussion with Dr.
• 4:32
  SPEAKER_00: Barlam.
• 4:34
  SPEAKER_00: Dr.
• 4:34
  SPEAKER_00: Barlam, you're in Boston and all of the healthcare systems there just came out of a surge of COVID patients and it's leveling off to a more manageable number of patients for now.
• 4:44
  SPEAKER_00: But given that, what was the status of antibiotic stewardship during that surge and how were you managing antibiotic use for those patients?
• 4:53
  SPEAKER_01: Well, to say frankly, it was terrible.
• 4:56
  SPEAKER_01: At my institution, we actually had the highest proportion of cases in the state.
• 5:02
  SPEAKER_01: And at one point we were 70 to 80 percent patients with COVID.
• 5:06
  SPEAKER_01: I wouldn't say it was chaos.
• 5:07
  SPEAKER_01: I would say that overall we kept it together, but there was a lot of fear.
• 5:12
  SPEAKER_01: There was a lot of uncertainty because people really, this is a new disease, they didn't understand the disease, and they were very reluctant to listen to the advice of the stewardship team.
• 5:25
  SPEAKER_01: The other thing that was interesting is we were having rheumatology attending, serving as interns on medical services.
• 5:32
  SPEAKER_01: And, you know, so we were dealing with people who really were not used to this upfront care and really hadn't been in a position before to interact with the stewardship team.
• 5:43
  SPEAKER_01: So it was very interesting.
• 5:44
  SPEAKER_01: It did improve over time, I think, as people got more comfortable with the disease and understood that the fevers really were due to COVID and we really could use our clinical acumen the way we had, you know, three months earlier.
• 5:59
  SPEAKER_01: So it definitely improved, but there was a real spike of vancomycin and of anti-seudomonal antibiotics that we really had to get a handle on.
• 6:10
  SPEAKER_00: Wow.
• 6:10
  SPEAKER_00: So yeah, it sounds like a lot of challenges for you during that surge time.
• 6:15
  SPEAKER_00: We know some patients with clearly defined viral pneumonia related to COVID are being treated with antibiotics.
• 6:22
  SPEAKER_00: And obviously, considering it's well documented that antibiotics can't be used to treat viral infections.
• 6:27
  SPEAKER_00: Why do you think that continues?
• 6:28
  SPEAKER_00: What's the challenge?
• 6:29
  SPEAKER_01: Yeah, well, I mean, I would say that it continues even with people who are less sick, you know, that there is this strong belief that if somebody comes in with a viral pneumonia, there still is this tendency to, oh, I'll just cover them for secondary bacterial infection even before they get secondary bacterial infection.
• 6:46
  SPEAKER_01: But I go back again to the fact that these patients were so sick and they tended to, when they deteriorated, we saw them deteriorate sometimes over hours from being relatively stable.
• 6:57
  SPEAKER_01: I think there was, again, there was a lot of fear and a lot of uncertainty.
• 7:01
  SPEAKER_01: There also was less physical examination, to be honest, because people were trying to minimize the use of PPE and going into the room and that kind of exposure.
• 7:11
  SPEAKER_01: So I think that there's the general difficult message that patients with viral pneumonia shouldn't automatically be treated for secondary bacterial infection.
• 7:20
  SPEAKER_01: And I think the second thing was that COVID was really difficult to interpret.
• 7:25
  SPEAKER_01: I think, again, over time there was an increasing acceptance that if they had X-rays consistent with COVID, ground glass opacities, no focal pneumonias, if they had a normal Y count, no left shift, if they had a normal ProCal, you know, that all these factors started to reassure the clinicians that they didn't have to automatically put them on antibiotics.
• 7:51
  SPEAKER_01: So it was partly practices that weren't ideal before COVID, and then it was in the face of COVID, there were just so many challenges to break through that.
• 8:02
  SPEAKER_00: Yeah, that makes sense.
• 8:03
  SPEAKER_00: So, how about the converse of that?
• 8:05
  SPEAKER_00: Are there circumstances where you would consider treating COVID patients with antibiotics, either to help prevent or to help mitigate other conditions that may present along with or because of COVID?
• 8:16
  SPEAKER_01: Yeah, so we definitely did see secondary bacterial infections.
• 8:20
  SPEAKER_01: We also were a site that used a fair amount of IL-6 inhibitors, which can potentially increase the risk of infection.
• 8:28
  SPEAKER_01: So we did okay with that.
• 8:29
  SPEAKER_01: We actually, our rate of infection was lower than other sites, but there were occasional infections.
• 8:35
  SPEAKER_01: We also had people who got through the acute phase but then had been in the hospital for three, four, or five weeks.
• 8:43
  SPEAKER_01: And as you can imagine, being in the hospital with intubated or with IDs or lines, et cetera, there are going to be instances where they get nosocomial infections or secondary infections for the COVID.
• 8:57
  SPEAKER_01: So there definitely was a subset that appropriately needed to be treated with antibiotics.
• 9:03
  SPEAKER_01: And we certainly didn't want to discourage that, especially empirically when people were critically ill.
• 9:09
  SPEAKER_01: But I think you have to balance that with what stewardship is, which is don't forget that if they're coming from their home and they were healthy, there's absolutely no reason if you're going to treat them for secondary pneumonia, that you give them pseudomonas coverage.
• 9:23
  SPEAKER_01: They're not going to have pseudomonas, you know.
• 9:25
  SPEAKER_01: So it's those type of lessons, you know, that they knew, but it was almost like you had to relearn them in the face of the pandemic.
• 9:34
  SPEAKER_00: So given both the fact that you saw that there was sometimes a need for use of antimicrobials, but then also use of antimicrobials that was not always necessarily correct.
• 9:45
  SPEAKER_00: How do you think COVID is contributing potentially to the rise of multidrug-resistant organisms?
• 9:52
  SPEAKER_00: Maybe are not going to be able to be treated by many antibiotics across the globe given that we're in a pandemic and you know your experience is probably applicable in in many places around the world?
• 10:02
  SPEAKER_01: I think that's such a good question.
• 10:04
  SPEAKER_01: I think it is going to contribute for a number of reasons.
• 10:08
  SPEAKER_01: Although I think that my institution has a pretty similar distribution of cases to other hospitals throughout the country, and a significant proportion of people are on some antibiotic at some point during the hospital stay.
• 10:21
  SPEAKER_01: But all of a sudden, you have, you know, 80% of your hospital lies population who have an infectious disease.
• 10:29
  SPEAKER_01: So that's unusual.
• 10:31
  SPEAKER_01: So just the volume of cases being shifted away from normal medical illnesses of, you know, angina and diabetes management and things of that sort, and really all being put into the compartment of some infectious disease is going to drive more antibiotic use.
• 10:48
  SPEAKER_01: And we saw just a really marked spike, as I mentioned, in the use of antibiotics when COVID surged.
• 10:56
  SPEAKER_01: So I think it's just the volume of antibiotics and knowing that antibiotics select for resistance and the fact that when you have an infectious disease that has such high rates and that there even appropriately there's going to be more antibiotic use because they are at risk for long hospital stays.
• 11:15
  SPEAKER_01: They are at risk for potentially secondary pneumonias.
• 11:18
  SPEAKER_01: It's just going to increase the volume of antibiotic use.
• 11:21
  SPEAKER_01: And once you increase the volume of antibiotic use, you are going to contribute to the emergence of antibiotic resistance and that subset of patients who really have prolonged hospital courses are going to potentially be exposed to a number of different antibiotics that can contribute to the so-called superbugs.
• 11:39
  SPEAKER_00: Yeah, thank you.
• 11:40
  SPEAKER_00: It's interesting because we are so focused right now on COVID-19 and thinking about what can happen down the line.
• 11:47
  SPEAKER_00: It's just, you know, maybe not at the forefront of all of our thinking at the moment.
• 11:52
  SPEAKER_00: I appreciate your perspective on that.
• 11:54
  SPEAKER_00: So for your antibiotic stewardship program, what have you learned so far in dealing with the pandemic?
• 12:00
  SPEAKER_00: What are your lessons learned, if you will?
• 12:02
  SPEAKER_01: Well, I think that it really shines a light on how difficult sometimes it is to treat pneumonia appropriately because it's always been, even in research studies, we know that it's really hard to get a definitive diagnosis in a significant proportion of the patients who have pneumonia.
• 12:19
  SPEAKER_01: And so there's always that doubt.
• 12:21
  SPEAKER_01: And so when you add to it the fact that these patients can be quite sick, when you add to it that it's a new illness, when you add to it kind of chaos within the hospital, just in terms of the amount of work and the fatigue of the healthcare providers, it's going to make a disease that was always a little bit difficult to treat because unlike a bloodstream infection, unlike a urinary tract infection, where you just send the sample and you get the organism, pneumonia has always been more complicated than that.
• 12:49
  SPEAKER_01: So it's really learning how to balance people's fears.
• 12:54
  SPEAKER_01: They're not wanting to miss something in patients who are quite sick and do have a risk of severe morbidity and even of mortality.
• 13:03
  SPEAKER_01: I think it really is something that shone the light on some of the practices that are not as easy with an infectious disease.
• 13:11
  SPEAKER_01: So it created opportunities as well for us and the opportunity to really speak about these things and talk about using clinical judgment even in these settings and really using evidence-based medicine and not just react to panic and over-treatment.
• 13:30
  SPEAKER_00: I and I know you've been very busy, and so you know, maybe implementing changes at this very moment may not be possible.
• 13:37
  SPEAKER_00: But are you thinking about or are you making any changes to your stewardship program in light of COVID-19 other to prepare for what might be another surge, which a lot of people are worrying about, or even just for the regular volume of cases until a vaccine's developed?
• 13:51
  SPEAKER_01: Yeah, so actually one interesting thing that we saw was we had a marked increase in positive blood cultures with what were clearly contaminants, you know, coag negative staph, gram-positive bacilli, these type of things in a single culture.
• 14:08
  SPEAKER_01: And so we investigated that, and it turned out that most of those were samples that were being drawn on the units as opposed to biphlebotomy, because of where the patients were all over the hospital.
• 14:19
  SPEAKER_01: So I think some of those processes broke down a little bit.
• 14:22
  SPEAKER_01: But we used it as an opportunity actually to put in place a more sensible algorithm for getting blood cultures, which we had had trouble doing before.
• 14:33
  SPEAKER_01: But because our microlab actually ran out of space to store and incubate blood cultures because of the volume, it really was an impetus to make a change that I would have liked to have made a long time ago.
• 14:47
  SPEAKER_01: So really getting away from checking, you know, every 24 hours when really the recommendations might be every 48 hours, really not just without thinking, just doing blood cultures in someone who's been in the hospital, you know, for a week and had maybe a spike and then do daily blood cultures for three or four days, which we were seeing.
• 15:08
  SPEAKER_01: So so we were able to really say, you know, look, this is how you should be doing blood cultures.
• 15:13
  SPEAKER_01: The other interesting thing is for people who are listening who have Epic at their hospitals, it usually took us, I don't know, sometimes months to get a request put through Epic, and then it had to be approved, and then it had to be programmed.
• 15:28
  SPEAKER_01: We were literally getting Epic changes within an hour.
• 15:31
  SPEAKER_01: Wow.
• 15:32
  SPEAKER_01: So it was really kind of cool in that way.
• 15:35
  SPEAKER_01: And we put in reminders about you have just checked blood cultures within 24 hours, you know, you need to wait another 24.
• 15:44
  SPEAKER_01: We, those kind of things we were able to immediately put into place.
• 15:48
  SPEAKER_01: The next day, practically, we saw that our volume of blood cultures decreased, and we went from reviewing in my stewardship rounds 20 positive blood cultures, a lot of which were coag negative staffs, to five or six or three or four.
• 16:03
  SPEAKER_01: So that was a good change.
• 16:05
  SPEAKER_01: The other thing that we did is now that we have come down in numbers and we are anticipating another surge.
• 16:12
  SPEAKER_01: It may not be a huge surge, it may be a huge surge, but as Massachusetts starts to open again and when the flu season starts, et cetera, we really are expecting that this might happen again.
• 16:25
  SPEAKER_01: So we started multidisciplinary meetings with the hospital medicine physicians, with the intensivists, and we really came up with some common sense agreements, if you will, about how we should approach the coverage.
• 16:40
  SPEAKER_01: So if someone comes in and clearly has COVID pneumonia and no evidence of a bacterial pneumonia, agreement that they don't empirically start them on antibiotics.
• 16:50
  SPEAKER_01: If they're coming from the community and for whatever reason there is a concern about CAF, they don't have to use an antiseudomonal agent and vancomycin.
• 16:59
  SPEAKER_01: You know, so we were able to work on an algorithm now that the surge is subsiding with buy-in from the different services that we hope we can then have ready for the next surge.
• 17:11
  SPEAKER_01: That in the middle of the surge, it was just impossible to do because people were just too busy and too anxious.
• 17:17
  SPEAKER_01: And as I said, many of them were unfamiliar with the services that they were leading because they were basically being recruited to cover other services than they were used to covering.
• 17:27
  SPEAKER_01: So I would say that those are probably the major things that we have done.
• 17:31
  SPEAKER_01: And I'm hoping that it'll be helpful when we start to see either blips or actually recurrent surges in the future.
• 17:39
  SPEAKER_00: I think that's great that you were able to make those quality improvements and you're able to do some planning ahead for the third when and if comes.
• 17:47
  SPEAKER_00: So Dr.
• 17:48
  SPEAKER_00: Barlum, thank you so much.
• 17:49
  SPEAKER_00: This has been extremely helpful and informative, just kind of keeping the idea of antimicrobial stewardship in the forefront, even as we're dealing with the pandemic, just emphasizing how important this program is.
• 18:01
  SPEAKER_01: Well, thank you.
• 18:01
  SPEAKER_01: It was my pleasure.
• 18:07
  SPEAKER_00: Thank you very much to our speaker for sharing your perspectives and experiences, and a sincere thank you from Shay to all healthcare personnel for all that you're doing to respond to COVID-19.
• 18:17
  SPEAKER_00: This podcast can be accessed on Shay's online education center learning CE under the Rapid Response Program.
• 18:25
  SPEAKER_00: You'll also find additional resources such as the recorded webinars for healthcare facility outbreak preparedness and the SHAY COVID-19 town halls.
• 18:34
  SPEAKER_00: Additional resources available on Learning CE pertinent to this pandemic include SHAY CDC Outbreak Response Training Program, ORTP, and the Prevention Course in HAI Knowledge and Control Prevention Check.
• 18:48
  SPEAKER_00: That concludes this episode of the Rapid Response Podcast.
• 18:52
  SPEAKER_00: Thank you for tuning in.