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Peers and Perspectives

1rem

Skin and soft tissue infections (SSTIs) are an ongoing challenge that, like many 

 efforts, were exacerbated by the COVID-19 pandemic.

Bruce M. Jones, PharmD, FIDSA, BCPS, is an infectious diseases clinical pharmacy specialist at St. Joseph's/Candler Health System in Savannah, GA, and a self-proclaimed antimicrobial steward.

“When we talk about some of these newer novel agents, it’s how do we use them but use them for appropriateness, use them for the right patients, so that we maintain that stewardship type of mindset.”

Jones works primarily in the inpatient setting, and spoke frankly about the common problem of patients initially receiving unnecessary antibiotics. “A lot of what we see from a challenge standpoint is these patients come in, they’re on IV 

, it’s usually the main reason why they’re there,” he explained. “How do we transition them to the outpatient side?”

In this mini podcast, Jones breaks down the “very straightforward criteria” he uses to decide whether an SSTI patient should be inpatient or outpatient.

However, there is some nuance. “I always say, sometimes it’s things beyond the infection that will buy that ticket to admission,” Jones noted. “What we’ve found from our research is the number 1 reason why patients get admitted for these infections is failure of outpatient oral therapy.”

Jones emphasized the importance of including patients in the decision of whether they should be inpatient or outpatient. He strives to work with a patient, including them in their own treatment. Jones said, “We find that about 23-26% of the time, just by speaking to them, we can remove that allergy.”

Overall, Jones spoke positively about recent developments in antibiotics and efforts to use them vigilantly. “I feel optimistic about the agents that are out there and where we are with the science. The biggest barrier, I would say, is how do we get that information to the general clinician?”

Tune in to learn more about Jones’s methods and successes with antimicrobial stewardship, as well as a thorough explanation of the daily and overarching challenges he faces as a clinical pharmacist treating SSTI patients.

In this mini-podcast, infectious diseases clinical pharmacy specialist Bruce M. Jones, PharmD, FIDSA, BCPS, breaks down the “very straightforward criteria” he uses to decide whether a skin and soft tissue infection (SSTI) patient should be inpatient or outpatient.

How Do We Transition Patients on Heavy Antibiotics to Outpatient?

The effects of the COVID-19 pandemic continue to reverberate across other areas of health and medicine.

Notably, the US Centers for Disease Control and Prevention (CDC), reported 

 worsened by at least 15% during the pandemic.

“The biggest one that is concerning us is carbapenem-resistance among the gram-negatives, and that has increased,” said Christian Sandrock, MD, MPH, FCCP, vice chair for Quality and Safety, division vice chief of Internal Medicine, director of Critical Care, and professor of medicine at UC Davis Medical Center.

Assistant Managing Editor John Parkinson interviews Sandrock about how his institution is battling these bugs, the need for new therapies, and what we can all do to boost 

From the vantage point of his teaching hospital in Sacramento, Sandrock said, “We’ve actually seen things get a little bit worse, unfortunately.” Now is the time to renew the fight against the global threat of AMR.

Specifically, Sandrock discusses significant strides need takes to combat the rise in hospital-acquired bacterial pneumonia (HABP) and ventilator-acquired bacterial pneumonia (VABP).

In this podcast episode, Christian Sandrock, MD, MPH, FCCP, describes the need to make significant progress in antimicrobial stewardship.

COVID-19 Pandemic Drove Carbapenem Resistance in Gram-Negative Infections

“Usually for antibiotic awareness you have a week,” said Dr. Teena Chopra, “But for 

a whole month has been dedicated, for a reason.”

Awareness Month and Antimicrobial Awareness Week. As Chopra explains, too often the people most affected by a lack of vigilance in these areas already experience marginalization and discrimination.

“We are all global citizens, and having that uniform, consistent health care for all is where we need to move toward,” said Chopra.

Teena Chopra, MD, MPH is the Corporate Medical Director of Hospital Epidemiology at Detroit Medical Center, as well as a professor at the Wayne State University School of Medicine.

Chopra credits several mentors as inspiring her to specialize in infectious disease. Living and working in Detroit, MI, she has seen firsthand how infectious diseases can ravage underserved populations, moving her to practice where she’s most needed.

causes an estimated half a million infections a year and over a billion dollars in expenses in the US alone.

The Centers for Disease Control and Prevention (CDC) classifies 

However, until the disease touches their lives, the general public is largely unaware of its prevalence or even what 

 is. “We, as the health care community, need to raise more awareness for 

Listen in as Chopra discusses treatment regimens for 

 infection (CDI), as well as the populations disproportionately affected by this debilitating disease.

Missed Episode 6 of Contagion Community? 

Listen in on the conversation and feel free to offer your feedback on this episode, interest in participating in the podcast, or suggest ideas for future episodes. Please email your correspondence to Nina Cosdon: 

Dr. Teena Chopra discusses the global need to do more to prevent healthcare-associated infections like C difficile in vulnerable patient populations.

C difficile, Antimicrobials, and the Patients Most Affected

, where we delve into factors that create and widen health care disparities.

Although the development of antibiotics remains a challenge, there are some legislative strategies that could make it more attractive and get more players involved. 

On the fourth episode of the Contagion Community podcast, Evan Loh, MD, the CEO of Paratek Pharmaceuticals, discusses passing federal legislation to improve antibiotic development and reduce antimicrobial resistance.

Antimicrobial resistance (AMR) has been an ongoing public health problem for many years. A global analysis published in 

back in January estimated that antimicrobial resistance was the leading cause of death worldwide in 2019. Investigators estimated that resistance itself caused 1.27 million deaths that same year, and that antimicrobial-resistant infections played a role in 4.95 million deaths.

It has been something the medical community is quite aware of and has tried to do its part by developing antimicrobial stewardship programs at hospitals and medical centers to reduce the burden of AMR. Another issue within this public health concern has been antibiotic development. With it taking so many years to create new therapies, and reimbursement less attractive, larger pharmaceutical companies have left antibiotic development altogether. These life-saving medicines have become the domain of small, independent biopharmaceutical companies.

Combine those issues with 2 years of the COVID-19 pandemic, and this significant health topic has been shelved for some time.

Paratek Pharmaceuticals is a good example of a company in the antibiotic space. This smaller company has developed an FDA-approved tetracycline-class antibiotic for adult patients with community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections. This antibiotic is also being studied for a variety of other potential indications.

, which has a mission to “improve the regulatory, investment, and commercial environment for antimicrobial drug and diagnostic device development to provide doctors and patients with innovative infectious disease treatment options.”

Paratek’s CEO Evan Loh, MD, is passionate about these life-saving medicines and has been active in his support of the Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms Act of 2021 (DISARM) Act, which is a bill in Congress. “This bill requires additional payment under Medicare's inpatient prospective payment system for services that involve certain antimicrobial drugs, in accordance with specified limitations. Additionally, the Government Accountability Office must report on the barriers to developing such antimicrobial drugs and must recommend ways to address such barriers,” 

Along with governmental advocacy, Loh also sees the value in public and private partnerships to enable greater involvement in the antimicrobial space.

 about the challenges of developing antibiotics and providing incentives such as the DISARM act to attract more pharmaceutical companies to get involved in developing these vital medicines.

Forging an Evolutionary Regulatory Path for Antibiotic Development

This cephalosporin antibiotic was examined against colistin-susceptible gram-negative infections. 

Cefiderocol Demonstrates Efficacy Against Pseudomonas in Immunocompromised

A novel approach using this emerging technology looks to interfere with antibiotic resistance expression and reduce this global health issue.

Harnessing CRISPR to Battle Antimicrobial Resistance

A study finds that despite the development of some new agents for highly-resistant pathogens, prescribers are reluctant to utilize these therapies.

Clinicians are Choosing Older, Generic Antibiotics Over Newer Ones for Gram-Negative Infections 

PEN-FAST is a validated risk stratification tool that promotes efficient, safe, and effective de-labeling of penicillin allergies.

PEN-FAST Forward: Accelerating Penicillin Allergy De-Labeling 

Pivmecillinam (Pivya) was given the nod from the federal agency, and is indicated for female adults with uncomplicated urinary tract infections (UTIs) caused by susceptible isolates of Escherichia coli, Proteus mirabilis and Staphylococcus saprophyticus. 

FDA Approves Antibiotic for Uncomplicated UTIs

In today’s world of sophisticated, complex tests, an evolving relationship between laboratory professionals and clinicians can aid 

How Aligning Laboratory Professionals and Infectious Disease Clinicians Can Deliver the Optimal Diagnostics, Treatments

In a traditional medical setting, when we think about the laboratory and diagnostic tests being conducted and we think about the clinic or hospital areas where patients are being cared for, they appear as 2 separate silos with laboratorians and clinicians possibly having very little to no interaction.

However, the development of more sophisticated assays such as rapid diagnostics and PCR testing, combined with concepts like time-to-treat and antimicrobial stewardship have led to the prospective need for the convergence of these 2 groups working together. 

“It's such a different world now compared to even 10 years ago,” said Rodney E. Rohde, PhD, SV/SM/MB(ASCP)CM, FACSc, University Distinguished and Regents’ professor and chair for the Medical Laboratory Science Program in the College of Health Professions, Texas State University. “When you look at outcomes on data, you may need to know specific genotypes; you may need to have a full background on oncogenes; you might even have to have a pretty strong background in how to interpret statistical data—and I'm not talking about typical statistical data—I'm talking about the kind of high-level understanding of certain microarray gene expression analysis.”



, which means getting patients optimal therapy in an efficient, timely manner remains critical, especially when seeing patients who are experiencing difficult-to-treat, gram-negative bacterial infections. Medical complications for these patients can include multidrug resistance combined with a treatment paradigm in which less effective testing is being conducted followed by prescribing practices that include broad-spectrum antibiotics, which do not always align with positive outcomes.

This is where laboratorians can play a key role. And some are advocating for laboratory professionals to be added to 

, especially as they can, “execute systemic interventions, facilitating appropriate identification of infections (and noninfections) through diagnostic stewardship.”

Rohde talks about “being careful with how you work through testing.” He says there are situations where patients come into the emergency room and get a battery of tests that might not be warranted.

“Due to some confusion, or due to maybe not being certain, a dozen tests are ordered that are unnecessary…not only does that waste quality of health care, but it also wastes money. So, it gets to the bottom line of finance around the laboratory and the hospital overall.”

He says one strategy that can help alleviate this waste is the use of the diagnostic management team (DMT). These teams are designed to offer health care professionals assistance in selecting the appropriate diagnostic tests and interpreting results for individual patients. Rohde also says there are education programs that offer doctoral level medical lab scientist degrees, and should go a long way in bridging the knowledge gap.

“If you think about the laboratory and their role in providing that data that informs physicians and pharmacists, it just makes sense that we're on the same team. [This way, we] can discuss whether it's something as simple as what's the best test or assay to utilize to deal with a particular condition or disease,” Rohde said. 

“We need to be certain, or as close to certain as we can get, that we're getting an accurate diagnosis, followed by an accurate susceptibility test, so that patients gets the right drug.”



Contagion will be introducing a podcast titled, From Pathogen to Diagnosis: Unraveling the Infectious Disease Mystery, and Rohde will be the host. Look for the podcast's launch in June.


1. Van Helden S, Ha D. Expanding the Antibiotic Stewardship Team Can Lead to Greater Adoption of Practices. 

. February-March 2024, Vol. 09, No. 1. https://www.contagionlive.com/view/expanding-the-antibiotic-stewardship-team-can-lead-to-greater-adoption-of-practices




In today’s world of sophisticated, complex tests, an evolving relationship between laboratory professionals and clinicians can aid in providing a quicker diagnosis and help to achieve better patient outcomes.   

Why Aligning Laboratory Professionals and Infectious Disease Clinicians Can Deliver Favorable Diagnostics, Treatments

A new paper discusses how these variables can be connected to create situations where patients get less-than-optimal outcomes.

How Disparities and Social Determinants of Health Can Affect Antimicrobial Stewardship

One of the emerging, important themes in public health and medicine is the discussion around social determinants of health and disparities as it relates to clinical care.

Jacinda Abdul-Mutakabbir, PharmD, MPH, AAHIVP, assistant professor of Clinical Pharmacy, University of California San Diego, has been studying disparities and social determinants and explains her approach in tackling such large topics.

“When I think about the social determinants of health, I think about what the CDC [Centers for Disease Control and Prevention] has defined as important to accommodate health-related needs. So, I think about environment, health care, access to health care, resources, education, socioeconomic status.”

She takes those individual points and thinks about the deficiencies in those areas and how they might be interconnected, which can create a cascading effect that can lead to serious health consequences. Abdul-Mutakabbir uses the example of how someone who may have limited education, who then may only be qualified to do certain jobs. This can lead people to live and work in places where there might be environmental issues such as pollution or mold that can lead to health problems. People in these situations may also be underinsured, which limits their assess to care. And completing the loop in this cycle, people in these situations may have limited health literacy so are uncertain of how to  navigate the system to get the medical care they need.

Frequently, these disparities can be witnessed more so in racially and ethnically minoritized backgrounds.

Abdul-Mutakabbir was the senior author in a paper published earlier this month in the journal 

Infection Control & Hospital Epidemiology

 on this topic—as it relates to infectious disease and antimicrobial stewardship.

In the paper, Abdul-Mutakabbir and her coauthors provide the well-recognized example of disparities during the acute phase of the COVID-19 pandemic. “People from racially and ethnically minoritized backgrounds were disproportionately represented in rates of disease, hospitalization, and death from SARS-CoV-2, yet, once vaccines were available, these groups were the least represented among persons who received the COVID-19 vaccine,” the authors wrote.



In terms of identifying and mitigating health inequities in infection prevention and antimicrobial stewardship the authors explain it can be broken down into 2 main areas. “These can be broadly grouped into themes including (1) diversity of the healthcare workforce and patient access to clinicians, where many minoritized communities are underrepresented, and (2) challenges with availability and quality of data, affecting patient care and community health outcomes.”

In trying to alleviate these issues with stewardship, Abdul-Mutakabbir stresses the importance of data collection first and foremost. “My first strategy is evaluate the disparities in your institution, because you can't just blindly address things…you have to definitively know. And then after we do that evaluation, we have to educate because it's not enough for us to know that folks are collecting the data. Everybody has to speak the same language, but then talk about how social drivers contribute to what it is that we saw.”

“We have to figure out what changes do we want to see?" explains Abdul-Mutakabbir. “It's not enough for us to stay in our ivory towers. We have to go out and we have to talk to our governmental agencies; we have to talk to our friends that are involved in policy work—that's how we create sustainable change…the data is important for that, because we have to have something to point to when we want to advocate.”

 spoke with Abdul-Mutakabbir at last year’s IDWeek as she was presenting on these important topics, and she offers some insights on these emerging subjects and strategies to reduce and eliminate disparities and health inequities. 



Marcelin JR, Hicks LA, Evans CD, Wiley Z, Kalu IC, Abdul-Mutakabbir JC. Advancing health equity through action in antimicrobial stewardship and healthcare epidemiology. Infection Control & Hospital Epidemiology. Published online 2024:1-8. doi:10.1017/ice.2024.7

A new paper outlines how these variables can be connected to create situations where patients get less-than-optimal outcomes.

How the development of antimicrobial stewardship programs can be an effective strategy for beginning to reduce this critical timing for patients in ICUs. 

From Written Prescription to Treatment

Logistics and employee silos in medical settings can sometimes unintentionally delay the time from when a prescription for an antimicrobial is ordered to the time the treatment is given to the patient. This can be especially challenging and concerning in cases for patients in the intensive care unit (ICU) who may be dealing with difficult-to-treat infections or may be at-risk for sepsis, which can lead to a greater mortality rate, so time-to-treat is critical.

In fact, studies around the development of septic shock of severely critical patients have shown the time-to-treatment as being a strong predicator of survival.

“Every hour of delayed effective antibiotic increases mortality by 8%,” said Debra A. Goff, PharmD, FIDSA, FCCP, professor of Pharmacy, The Ohio State University.

Goff helped lead a team of investigators who examined the period of time between when the prescription was written to the administration of the antimicrobials were infused. They looked at the infusion of antibiotics across 7 Latin American countries’ ICUs that were implementing antimicrobial stewardship programs (ASP). The countries included in the study were Argentina, Brazil, Chile, Costa Rica, Peru, Mexico, and Colombia. The findings were presented as a poster, Antibiotic Stewardship Initiative to identify and optimize antibiotic administration hang-time in 7 intensive care units (ICU) hospitals in Latin America, at IDWeek.

The investigators defined hang-time compliant as antibiotic administration within an elapsed time of 1 hour from the time of the written antibiotic order was given. Any patient with a suspected infection in the ICU (sepsis and/or septic shock secondary to urinary, intra-abdominal, soft tissue infections and pneumonia), who had a first dose of the antibiotic was included.

The investigators evaluated 1207 prescriptions and the most common diagnosis was sepsis and septic shock from urinary and pulmonary sources. Hang time adherence was 38.5% (22.5%-74.0%). The time range was 2 minutes to 1080 minutes the investigators wrote.

“We were very surprised because the results [showed] that the hang-time adherence was less than 50%. In the worst-case scenario, the hand time adherence was just 22%,” stated the study’s presenting author, Christian J. Pallares, MD, MSc, Clínica Imbanaco grupo quirónsalud, Universidad El Bosque, Colombia.

“I think the results were shocking to some of the physicians, and they just couldn't comprehend—why did it take 18 hours to get the antibiotic? And having the pharmacist there to explain, here's what happened. And then the nurse, not being aware that the drug actually was delivered, you started to realize there's multiple steps in this process. And together, they developed strategies [around making this process better],” Goff said.

Stewardship’s Role in Hang-Time Compliance

One strategy to overcome this treatment challenge is through the utilization of ASPs, which can play a vital role in reducing the gap to IV administration.

In the study, a stewardship improvement protocol was developed creating a collaborative effort between physicians, pharmacists, and nurses. One of the interesting facets of the study was the development of ASPs in Latin America. Goff explained many pharmacists continue to work in a traditional way in these countries, so the adoption of the ASPs was a novel way to bring them into the fold as well as other support staff such as nurses. 

“In many of these Latin American countries, pharmacists are still in primary dispensing roles, so they really don't work on a multidisciplinary team,” Goff said. “And I knew, as I've done in other countries, this is a really great way to start a stewardship initiative. And with their leadership, it succeeded in such a great way.”

Goff and Perez says they are planning another phase of the study where they really want to incorporate ways for the ASPs to decrease the hang-time and work towards a better adherence.

“We need to improve that, and we need to work as a team,” Perez said.



From Prescription to Treatment: Decreasing the “Hang-Time” of IV Administration of Antimicrobials

A recent novel study found reduced mortality rates in combining therapies in patients being treated for these specific bacteremia.

Examining Beta-Lactams With Vancomycin for Bloodstream Infections for MRSA

When treating bloodstream infections (BSIs) due to methicillin-resistant 

(MRSA), the first-line of care is to prescribe monotherapy vancomycin (VAN). In the literature, however, there has been in vitro and clinical evidence to suggest a combination of certain beta-lactam antibiotics and vancomycin is efficacious against MRSA.

At the Detroit Medical Center, a MRSA BSI treatment pathway was implemented, which incorporates early use of combination therapy with VAN and cefazolin (CFZ). Subsequently, a group of investigators at the medical center wanted to study patients receiving vancomycin monotherapy vs combination therapy with VAN + CFZ for treatment of MRSA BSIs.

“There have been no studies that have exclusively looked at vancomycin and cefazolin together," said study investigator Kaylee Caniff, PharmD, BCIDP, postdoctoral research fellow, Infectious Diseases Outcomes, Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University. "[We] found that there was a reduced mortality rate when combining cefazolin within the first five days of bacteremia compared to vancomycin monotherapy.” 

“VAN + CFZ was associated a lower 30-day mortality rate (3.4% vs. 9.8%, p = 0.022) and shorter duration of bacteremia (49.0 [35.0-74.0] hours vs. 62.0 [42.0-95.8] hours, p = 0.005),” the investigators reported. “After adjusting for confounders, VAN + CFZ receipt was independently associated with reduced 30-day mortality (aOR 0.31, 95% CI 0.11-0.93).”

This was a retrospective, observational study of patients hospitalized with MRSA BSI at the Detroit Medical Center from 2006-2021. Patients included in the study were initiated on vancomycin within 72 hours of the index culture. Multivariable logistic regression was performed to identify independent predictors of 30-day mortality.

Exclusion criteria included those patients that received < 5 days of vancomycin, transferred to an outside hospital, received an alternative anti-MRSA antibiotic, received > 5 days of non-CFZ beta-lactam, or initiated on CFZ > 120 hours after index culture.

The investigators noted that except for the combination therapy group more likely to receive an infectious diseases clinician consult, there were no significant differences between the 2 cohorts for infectious source, demographics, comorbidities, MRSA risk factors, and illness severity.

“Mortality is where we found the benefit. We did not find a difference in persistent bacteremia,” said Caniff. “It trended towards that direction, but it was not significant. I think this is likely because my study had less complicated cases due to the exclusionary criteria."

A total of 359 patients were included with 145 patients receiving VAN + CFZ in the one cohort, and and 214 receiving monotherapy VAN in the other.

“In patients with MRSA BSI, the addition of CFZ to VAN within 120 hours of index culture was associated with improved outcomes. To our knowledge, this is the first study specifically examining VAN + CFZ in this population,” the investigators reported.



 spoke to Caniff recently at IDWeek who provided more insights on the study and the takeaways from it.

Caniff K, Coyne A, Rybak M. Unexpected Allies: Vancomycin and Cefazolin Combination Therapy in Methicillin-Resistant Staphylococcus aureus Bacteremia. Presented at: IDWeek 2023. October 11-14, 2023; Boston, MA. Abstract 1033.

A recent novel study found reduced mortality rates in combining these therapies in patients being treated for this specific bacteremia.

A study showed utilizing a PCR-based test can narrow therapy quicker and help in resolving these infections sooner. 

Antibiotics

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