Announcements

Wellbeing Committee News

Posted on Dec 2, 2019 in Announcements | 0 comments

The Summit campus Peer Support Program is turning one year old this month. We reached out to about 25 people – that’s 2 a month. We don’t keep data other than the date of contact, but we were able to, by memory, reach out to most of those we contacted and 80% said they felt at least a little better after talking to us.  90% thought the program added to the sense of community of the med center. 

The program works best when we can pair people with those is similar specialties.  Emily Abe learned how to do lead a support conversation earlier this month so now we have a surgeon on our team! Thanks, Emily!

We will help Eden, Alta Bates and SEBMG start programs in the coming year. Which will potentially help those of us who work in those setting. 

Thanks to all involved – especially JillKC for her leadership.   Please contact me with questions or comments!

Leif Hass

Potential benefits of probiotics and proton pump inhibitor (PPI) minimization on hospital-acquired Clostridium Difficile infection

Posted on Dec 2, 2019 in Announcements | 0 comments

Normal gut flora is thought to prevent Clostridium Difficile (C.diff) colonization and disease. Antibiotics causes a disruption in this gut flora, making patients more vulnerable to C.diff disease and recurrences. The 2018 Infectious Disease Society of America (IDSA)/Society for Healthcare Epidemiology of America (SHEA) guidelines recommends oral vancomycin or fidaxomicin for first-line therapy of initial Cdiff disease. Oral metronidazole is no longer recommended as first-line therapy for initial episodes given its lower clinical response rate. 

The use of probiotics may decrease the risk of developing C.diff infections in those patients taking antibiotics by replenishing some of the natural gut microflora that may have been lost. Current guidelines do not make a recommendation either for or against probiotics use, although some evidence exists that supports its use.

A 2017 Cochrane review article based on 31 randomized trials (8672 patients) with moderate evidence suggested that the risk of C.Diff-associated diarrhea (CDAD) is reduced by 60% when probiotics are used. A post-hoc analysis, however, demonstrated that probiotics were effective among trials with a high baseline CDAD risk (>5%) but not in trials with a baseline risk ≤ 5%.

Short-term use of probiotics appeared to be safe and effective in patients who were not immunocompromised or severely debilitated. Although further research is needed, the benefits and harms of probiotics can be evaluated on a case-by-case basis.

Proton Pump Inhibitors (PPI) such as pantoprazole have been associated with increased occurrence of CDAD by decreasing gastric acid production and allowing C.diff to proliferate in the host. In a 2017 systematic review article by Trifan A. et al, a significant association between C.diff infections and PPI use was found. The IDSA guidelines currently has no recommendations on the use of PPIs, although they recommend discontinuing unnecessary PPI usage. If the following indications are not present, discontinuation of PPIs should be considered: coagulopathy, >48 hours of mechanical ventilation, GI ulcer/bleeding, PUD, GERD, or chronic NSAID use.

References:

  • Johnston, Brad C, and Kristian Thorlund. “Probiotics for the Prevention of Clostridium Difficile Associated Diarrhea in Adults and Children.” Cochrane Database of Systematic Reviews, 2009, doi:10.1002/14651858.cd006095.pub2.
  • Mcdonald, L Clifford, et al. “Clinical Practice Guidelines for Clostridium Difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).” Clinical Infectious Diseases, vol. 66, no. 7, 2018, pp. 987–994., doi:10.1093/cid/ciy149.
  • Trifan, Anca, et al. “Proton Pump Inhibitors Therapy and Risk of Clostridium Difficile Infection: Systematic Review and Meta-Analysis.” World Journal of Gastroenterology, vol. 23, no. 35, 2017, pp. 6500–6515., doi:10.3748/wjg.v23.i35.6500.

Why Sutter Community Connect (SCC)

Posted on Dec 2, 2019 in Announcements | 0 comments

2019 ABSMC Town Hall with David Clark, Interim CEO

Posted on Nov 1, 2019 in Announcements | 0 comments

ePOLST Form Location Update

Posted on Nov 1, 2019 in Announcements | 0 comments

Reducing Vancomycin Prescribing in Non-Purulent Cellulitis

Posted on Nov 1, 2019 in Announcements | 0 comments

Reducing Vancomycin Prescribing in Non-Purulent Cellulitis

The Infectious Diseases Society of America (IDSA) guidelines recommend that MRSA coverage is not routinely needed in non-purulent cellulitis because Streptococcus species constitute the most common causative organisms.  The distinction between purulent and non-purulent skin and soft tissue (SSTIs) is based on the presence of drainage, abscess, and systemic signs of infection.   A prospective study from 2010 of hospitalized adults with non-purulent cellulitis found that 73% had serologic evidence for streptococcal infection, and overall 95.8% responded to cefazolin monotherapy. A separate study of emergency room patients with non-purulent cellulitis randomized to cephalexin alone or cephalexin plus Bactrim found no difference in response rates and concluded that the addition of anti‐MRSA therapy for uncomplicated cellulitis was unnecessary.

IDSA recommends cefazolin for mild to moderate non-purulent cellulitis in the absence of penetrating trauma, history of MRSA cellulitis, failed oral antibiotics, failed incision & drainage (I&D), immunosuppression, hypotension, or end-organ dysfunction. IDSA currently does not recommend routine treatment for MRSA in the absence of these patient characteristics and risk factors.  Avoiding MRSA-active antibiotics (i.e. vancomycin) offers an opportunity to improve antimicrobial stewardship efforts and reduce unwanted complications such as acute kidney injury and infusion reactions.

For hemodynamically-stable patients without altered mental status, oral options are as follows:

  • For MSSA and streptococcus coverage: cephalexin, clindamycin, amoxicillin-clavulanate.
  • For MRSA coverage: doxycycline, trimethoprim-sulfamethoxazole, clindamycin.

References:

  • Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 59, Issue 2, 15 July 2014, Pages e10–e52, https://doi.org/10.1093/cid/ciu296
  • Jeng A, Beheshti M, Li J, Nathan R. The role of beta‐hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore).2010;89(4):217–226.
  • Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim‐sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis.2013;56(12):1754–1762.
  • Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325–337. doi:10.1001/jama.2016.8825

 

Justin J. Roth, Pharm.D., BCPS
Clinical Pharmacy Manager
Alta Bates Summit Medical Center (Summit Campus)