Ebola, Antibiotic Stewardship, Frozen Poop – PediaCast 301
Join Dr Mike in the PediaCast Studio for more news parents can use. This week’s topics include Ebola Virus Disease, pneumococcal vaccine, antibiotic stewardship, sore throats and bronchitis, college athletes and MRSA, and frozen poop capsules for C Diff.
- Ebola Virus Disease
- Pneumococcal Vaccine
- Antibiotic Stewardship
- Sore Throat & Bronchitis
- College Athletes & MRSA
- Frozen Poop Capsules & C Diff
- IDWeek 2014: Lessons Learned From Ebola
- CDC: Ebola Virus Disease
- CDC: Travel Health Notices
- WHO: Ebola News
- CONTACT DR MIKE – Ask Questions, Suggest Show Topics
- CONNECT NOW with a pediatric specialist from Nationwide Children’s – Referrals and Appointments
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It is Episode 301, for November 5th 2014. We’re calling this one “Ebola, Antibiotic Stewardship and Frozen Poop”.
I want to welcome everyone to the program. We have a News Parents Can Use edition of the program lined up for you this week. Right from the get-go, I want to give credit where credit is due for much of the content of today’s show. And a big hats-off to the organizers and presenters of IDWeek 2014. It’s an infectious disease conference held in Philadelphia. Quick disclaimer, I did not attend the actual conference. In fact, truth be told, I’ve never even heard of IDWeek before.
But there’s a little thing going around in the world called Ebola. You may have heard about it, and I came across a fantastic presentation by Dr. Bruce Ribner and his team at Emory regarding their experience treating Ebola patients in Atlanta, Georgia. We’ll get to more of that in a moment. But in finding this gem of a presentation, I was introduced to IDWeek 2014, of course, after the conference had ended. What I found was truly a treasure trove of information, most of which is pertinent for infectious disease physicians, primary care docs, and other health care providers. Some of it is pertinent for you, the parent, especially those of you interested in evidence-based medicine.
So today’s show is going to focus on infection. I’m really excited about it because we have some good stuff to talk about. In fact, we’ll get to the entire line up in a moment. But first, this is going to be a little bit longer of an introduction than your typical PediaCast, because right here from the get-go, I do want to say a few things about Ebola.
Now, keep in mind, it’s is early November 2014, and so this is going to be my thoughts and observations but you do have to put it into a context of the date, because if you listen to this episode and it’s a few months down the line or six months, or a year down the line, I don’t have a crystal ball and I don’t where this Ebola is really going to go. And so, these are just my thoughts and comments as of early November 2014.
I want to make clear too, that these are my observations and my thoughts. They don’t represent Nationwide Children’s Hospital or the Ohio State University or any other entity or organization. This is simply me, Dr. Mike, talking. Since most of you come here each week to hear what I have to say, and since the injection of informed opinion has always been part of the PediaCast formula, I do feel comfortable sharing my observations and my thoughts with you. I do it all the time. That’s what you expect.
Up until now, I have not mentioned Ebola, even though it’s by far the biggest medical story of the year. I’m not going to cover Ebola virus disease in our usual nuts-and-bolts fashion here. At least not here, not now. There are plenty of resources where you can get that information, and in due time, I’ll share some of those resources with you and provide some links in the Show Notes. What I really want to focus on here and now are just some general observations and thoughts that I truly hope will be helpful for you and your family.
So let’s start with some observations. First, there’s been a lot said in the media about Ebola, and at times, you really can’t get away from the story. And while Ebola is bad and deadly, there is a lens with which we must view the news, and that lens is this. The mainstream media, in my opinion, is not always looking out for your family’s best interest. And the end of the day, they’re corporations and they’re looking for ratings which translates into ad sales and that translates into money in their pocket.
The news organizations are competing with one another to get your attention. There is a tendency to sensationalize their presentations — you know what I’m talking about — in order to get you and me to pay attention, so their numbers go up, they can sell more ads, they can make more money, and that’s how the system works.
Now, this isn’t always a bad thing because we do need to pay attention to the story. We need to take Ebola seriously. We need to ramp up training and preparations. We need public awareness. We need to fight the infection at its source and we need to quickly contain and put out the fire whenever and wherever sparks and embers land. But we also need to keep the story in perspective, and sometimes, it’s hard to maintain this perspective when there’s all this sensationalism and to some degree fear-mongering in media.
Now, as of this recording, we have one case of Ebola that has slipped into the United States — just one case. Despite that person being infectious for several days and coming before he was admitted to the hospital, he came into contact with a good number of people which they have to be monitored, none of his casual contacts were infected. None of them. In fact, the only two people who caught the virus were healthcare workers who had significant contact with body fluids.
Now, that’s two too many, of course. But keep in mind, this is an unprecedented, one that forces us to make adjustments and learn as we go. We’ve done it before in this country with scourges like tuberculosis and small pox and measles and polio. In the past, like now, we don’t get it completely a 100% right out of the gate. There’s some learning that has to come along, but we do learn from our mistakes and we do move on to a successful day.
So, we have three cases of domestic Ebola in the United States, one of which was fatal, and there were likely be more. More cases, more people slipping through, there will probably be some more deaths. But did you know that 36,000 Americans died from the influenza virus during the most recent flu season. Thirty-six thousand deaths, did that get the same media treatment as Ebola? No. Why not? Well, it’s because you and me, the media-consuming public, we don’t care about that.
Most of you don’t really know anybody personally who died from the flu, and it just doesn’t really mean much to you because the flu’s been around and you’ve lived through the flu seasons. Even though 36 people died last flu season, you weren’t one of them. And so, it doesn’t really hit home for you, even though that’s a huge number. If the media could freak you out with that number, 36,000 deaths, they would do it. But the flu doesn’t grab headlines, Ebola does and that’s why you hear more about it.
Now, in all fairness, the flu doesn’t cause a 50% to 70% mortality rate like we’re seeing with Ebola in West Africa. I get that. But the reason that we’re seeing that kind of mortality in West Africa is because of the absence of a meaningful health care system. We don’t have that problem in America. Even at their worst, our private health and medical delivery systems are among the finest in the world. And we simply are not going to see a 50 to 70% mortality rate from Ebola, and we do have the infrastructure in place needed to identify Ebola when it happens and to track down those people who were exposed to it, to quarantine and contain it.
Now, who will do the job perfectly? No. There will be more learning to do as we proceed. Absolutely, that’s true. But will we see 36,000 Americans die from Ebola in the next 12 months? You and I both know that is extremely unlikely. So we need to keep perspective, and bringing this back to relevance for pediatric podcast, we need to share this perspective with our kids, because they’re getting the same gloom and doom at school, as you and I are seeing in the media, And actually, they’re getting it through the media as well. So as parents, we really do need to be the voice of reason with this holy bullet thing when we’re dealing with our kids.
OK, so as I see it, and again, this is my opinion, we as humans need to do several things, with this Ebola thing. As it turns out, these are things that are happening. First, West Africa needs the world to step up and help them in their time of crisis, and we’re seeing that.
Second, as I mentioned before, we need to learn as we go. It used to be in the medical world, when mistakes were made, there was a tendency to sweep them under the rug, with hope that nobody would notice. But this is the age of quality improvement and group cause analysis and instead of being embarrassed about mistakes, we want to bring them to the light and we want to learn from them. We want to know what we can do to avoid the same mistake in the future that truly has become a culture in healthcare today.
In that vein, I think part of what’s coming out with Dallas and with the CDC, is that transparency. And I think that America and the media in particular is being a bit too hard on Dallas and the CDC. The fact that we are discovering and sharing our failures and bringing them to the light in the emergency medical system and the delivery of hospital and nursing care in the acts of quarantine and containment, that transparency is how we learn. Sharing our failures allows us to improve.
Now, would this failures be as readily and as freely shared if it weren’t for media coverage. To a degree, I think they would. Because as I mentioned, that’s really become more of a culture in health care today. But the media certainly plays a role. And would the mistakes be as widely-known and as widely-criticized if it weren’t for the media? Probably not. So, I’m not throwing the media completely under the bus. They serve an important role, but there’s a fine balance, isn’t there? Between getting the truth out there and then using it to create fear and panic.
So we need to identify our mistakes. We need to own up to them. We need to learn from them. That’s what we call progress.
This brings me to the third thing we need to do. As we learn from our mistakes, we have to share what we’ve learned. So that future travelers tracking down a similar path can avoid the pitfalls that trip up those who went before them. That truly is the spirit behind the team at Emory, their presentation at IDWeek 2014. They wanted to share their experience in treating Ebola patients, to help those who would care for Ebola patients moving forward.
Now, I won’t replicate their presentation because they do a far better job than I would. But here are some of the things they shared: what does a hospital need to do in order to plan for the arrival of Ebola patients? What is clinical care — so the day-to-day job of doctors and nurses in the isolation ward — but what does that look like? What laboratory testing should be done? What experimental interventions are available? What did they learn in keeping staff and the hospital environment safe? What PPE or personal protective equipment did they use? What work? What didn’t work?
What pitfalls did they encounter and how did the team overcome them, including surprises in shipping? Shipping specimens — they had folks who wouldn’t ship them. What about unexpected adventures in waste management? How do they get rid of contaminated things? How do they deal with the media and communications? And what other lessons do they learn?
This is good stuff, and it’s a model for the open sharing of critical information during a crisis. So those of you who want the real skinny from the horse’s mouth, so to speak, without the sensational shock value reporting so common in the media, if you really want to take a look behind the scenes, I would encourage you to check out “Ebola: Lessons Learned from IDWeek 2014”. And I’ll put a link to it for you in the Show Notes, for this Episode Number 301 over at pediacast.org.
OK, I’m winding down here. Important thing number four, as I mentioned we need to fight Ebola at the source and stomp out fires where the sparks and ember land. In other words, we need to contain it when it slips through. We need to learn from our mistakes. We need to share our lessons, and all of these things are happening. So that’s great. And then, finally, number four, we need to take these lessons to heart and we need to prepare.
In this regard, I’m really proud to be part of an organization like Nationwide Children’s Hospital. We aren’t standing by and watching. We have action committees and town hall meetings with providers and staff. We have training with donning and doffing. We’re considering the lessons that have been learned. And we’re preparing.
Are we doing a perfect job? Probably not, I don’t think anyone is going to do a perfect job because there’s still things to learn as we’re traveling down this unprecedented road. But our preparation is flexible. As new data and recommendations emerge, things change and we’re going to have to keep on top of that, and continue to stay prepared.
We’re doing that here in Nationwide Children’s just as hospitals all across the country are doing. So my fellow Americans, parents and providers alike, let’s give Ebola the respect it deserves, but let’s also maintain the right perspective. Let’s allow for some shaky steps as we travel down an unprecedented path, but let’s learn from those shaky steps and let’s put what we learn into practice and let us emerge victorious as we have with many deadly infectious diseases of our past.
This is where I insert a plug to get your children vaccinated, because while immunizations do not cause autism, they will protect your kids from the things that once upon a time were as feared as Ebola is in our day, and things that can wreck havoc again without the protection of lessons learned in the past. That’s my two cents on Ebola and getting your kids vaccinated against the diseases that we can protect them against.
By the way the best collection of evidence-based information on Ebola virus disease is located at the CDC website — cdc.gov/ebola. Look for the link in the Show Notes for Episode 301. It covers signs and symptoms, transmission, risk of exposure, outbreaks, prevention, diagnosis, treatment, and the latest most up-to-date guidance and recommendation for health care workers.
Other links, I’ll put a link to IDWeek 2014, Lessons Learned from Ebola, that’s really a great resource.
Also, the CDC, they have travel health notices so it’s up-to-date listing of where Ebola is, what countries are safe, which countries aren’t safe. The World Health Organization has a great resource on Ebola news as well. I’ll put a link to that in the Show Notes, too.
All right, I waited this long to spout off on Ebola. If more needs to be said, I’ll say it. And again, just remember, it is early November 2014, as I’m making these comments, things might change. We’ll see and I’ll make more comments if I need to as time goes on. But, for now, let’s move on.
So what we’re going to talk about during the remainder of this program after our break. First off, pneumococcal vaccine. I put a plugin for immunizations a few moments ago. This one has been around relatively short time when you compare it to other vaccines that are out there, but it’s making a big difference in the lives of our children. I’ll share exactly how so coming up.
Also, antibiotic stewardship — inappropriate use of antibiotics leads to the development of resistant organisms, antibiotic-resistant organisms, and you know this. How are doctors training doctors to use antibiotics appropriately because not all doctors do? It’s something we call antibiotic stewardship and we’ll take a look at that in both the inpatient and the outpatient settings.
Then, sore throats and bronchitis — two important and key examples of antibiotics being used inappropriately especially in the world of adult medicine. And while this is a pediatric podcast, let’s face it, most of you listening are adults and you’ve probably been prescribed an antibiotics for a sore throat and or bronchitis in the past, but is this appropriate? Or are you contributing, too, to the problem? We’ll take a look.
And then, college athletes and MRSA — MRSA is Methicillin-resistant Staphylococcus aureus. If you have a college athlete in the family, you’ll certainly want to know what MRSA is and what you should do about it.
Finally, at the end of the program, for my final word, frozen poop capsules and C.diff. That’s all I’m going to say. If you want to know more, you just have to hang around till the end.
Don’t forget, PediaCast is your show. If there’s a topic you’d like me to talk about or if you have a question for me to put on the program, it’s easy to get in touch. Just head to pediacast.org and click on the Contact link.
Also, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals, so if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let’s take a quick break, so I can grab a sip of water, and we’ll move on with News Parents Can Use right after this.
Dr. Mike Patrick: All right, we are back. The pneumococcal vaccine recommended for young children, not only prevents illness and death but has also dramatically reduced the incidence of severe antibiotic-resistant infections. This, according to research presented at IDWeek 2014 in Philadelphia.
Pneumococcal infection, which can cause everything from ear infections to pneumonia and meningitis, is the most common vaccine-preventable bacterial cause of death. It also causes blood infections. The 13-valent pneumococcal conjugate vaccine or PCV13 was first available in 2010, replacing the older 7-valent pneumococcal conjugate vaccine, also known as PCV7.
What’s the difference there? Well, the 13-valent one protects against 13 different strains of the pneumococcal bacteria, and the older 7-valent one protect it against 7 strains of pneumococcal bacteria. The new 13-valent vaccine reduce the incidence of antibiotic-resistant invasive pneumococcal disease by 62% from 2009 to 2013 among children under five years old. That’s impressive.
The study is the first report of the effectiveness of PCV13 to combat antibiotic-resistant infections, a vaccination recommended for children under five years old. Three-quarters of states require it for entry into daycare, and 85% of US children have received the recommended four doses.
Dr. Sara Tomczyk, lead researcher and epidemic intelligence officer for the Respiratory Diseases Branch at the Centers for Disease Control and Prevention in Atlanta, Georgia says, “We’re at risk of living in a post-antibiotic world, where these miracle medications no longer work, but this vaccine is part of the solution to protecting ourselves from the growing threat of antibiotic resistance. Not only does this vaccine prevent pneumococcal infection, which means fewer antibiotics are prescribed, but it also prevents antibiotic-resistant infections.”
US government’s Healthy People 2020 initiative set a goal of reducing antibiotic-resistant invasive pneumococcal disease from 9.3 to 6 cases per 100,000 children. In the course of analyzing the data for this study, the team realized that the goal had actually been met nine years early due to the effectiveness of the pneumococcal vaccine. Currently, the rate is 3.5 cases per 100,000 children.
PCV13 is given to children in four doses — at two, four, six and 12 through 15 months of age. The study collected data representing approximately 10% of the United States population, which is considered illustrative of the country as a whole. Dr. Tomczyk says, “PCV13 is effective against 13 strains of pneumococcal bacteria, while PCV7 was effective against 7 strains. One dose of PCV13 is also recommended for all adults 65 and older, followed by a dose of the pneumococcal polysaccharide vaccine or PPSV23, six to 12 months later. Additionally, one dose of PCV13 is recommended for adults 19 and older with certain cancers, HIV and kidney failure, followed by doses of PPSV23.
The researchers sum up by saying, “The pneumococcal conjugate vaccine (PCV13) significantly reduces serious infections, including those caused by antibiotic-resistant superbugs. Since the vaccine was introduced in 2010, the incidence of antibiotic-resistant invasive pneumococcal disease decreased by 62% among children under five years old. The vaccine is so effective the Healthy People 2020 goal of reducing antibiotic-resistant invasive pneumococcal disease from 9.3 to 6 cases per 100,000 children was met nine years early and has since dropped to 3.5 cases.
Also, PCV13 prevents serious illness, such as pneumonia, meningitis and blood stream infections. The vaccine is recommended for all children five years of age and younger.
So the take-home, make sure that your young children have had their pneumococcal vaccines. If you aren’t sure or they haven’t, be sure to talk to your child’s doctor and do it sooner rather than later.
Hospitalized children go home sooner and are less likely to be readmitted when the hospital has an antibiotic stewardship program that’s dedicated to controlling antibiotic prescriptions and treatment. This is according to another study presented at IDWeek 2014 in Philadelphia. This one being the first to show the benefits of a stewardship program on children’s health.
Antibiotic stewardship programs are increasingly being used to manage how and when antibiotics are prescribed in hospitals and other health care facilities across the country. Often led by epidemiologists or infectious diseases physicians, stewardship programs are designed to promote the appropriate use of antibiotics. Research shows up to half of antibiotics prescribed at hospitals are unnecessary or inappropriate, helping to foster the rise of antibiotic-resistant infections, which are difficult or impossible to treat.
Dr. Jason Newland, lead author of the study and medical director of patient safety and systems reliability at Children’s Mercy Hospital in Kansas City, Missouri says, “Studies have shown stewardship programs reduce antibiotic use and decrease the risk of antibiotic resistance, but this is the first to demonstrate that these programs actually reduce length of stay and readmission in children. These findings reinforce the health benefits of antibiotic stewardship programs for some of our most vulnerable patients.” He adds, “It’s clear that more hospitals should invest their resources in implementing such programs.”
Over the course of the five-year study, the antibiotic stewardship program at Children’s Mercy Hospital-Kansas City recommended that the prescribed antibiotic be discontinued or the dose or type of antibiotic changed in 1,191 of 7,051 hospitalized children reviewed by the program. It works out to about 17% of the kids. So at about 17% of the kids, the antibiotic stewardship program recommended stopping the antibiotic or changing the type of the antibiotic or the dose.
Now, don’t confuse this program with antibiotic police because each child’s attending physician still have the ultimate authority in accepting or rejecting the stewardship program’s recommendation. So the attending physician have the final say.
When the recommendations were followed, the length of stay was shorter, and 30-day readmissions were reduced among children who did not have complex chronic care issues, such as cerebral palsy or congenital heart disease. The length of stay averaged 68 hours and there were no 30-day readmissions among children whose doctor followed the recommendation, while the length of stay averaged 82 hours and 3.5% were readmitted within 30 days among those whose doctor did not follow the recommendation.
Now, I’m going to pause here. To be fair and this is my own side comment, I’d like to know a little bit more about the kids whose doctors decided not to go with the recommendation. Maybe the attending doctors who rejected the recommendation, maybe they did know something about the kid’s history or about the kid’s illness and they really did know what they were doing, and it was something that the infectious disease doctor or the epidemiologist wasn’t aware of.
Maybe these children stayed in the hospital longer and were more likely to be readmitted because they really were sicker. And that’s why the attending physician did not go with the committee’s recommendation. Just saying, just putting that out there.
The most common recommendation was to discontinue the antibiotic, because the antimicrobial stewardship program deemed it wasn’t necessary. Those who continued the antibiotic remained in the hospital, of course, so they could be monitored.
Dr. Newland says, “Skeptics say stopping the antibiotics and sending the kids home sooner will lead to more children being readmitted, but we didn’t find that. What we found was that kids were being taken off unnecessary antibiotics sooner, and in a safe manner.”
Researchers point out that more than 2 million people are infected with antibiotic-resistant infections every year and 23,000 of these patients die, according to latest figures from the Centers for Disease Control and Prevention.
The investigators claim antibiotic stewardship programs improve the care of hospitalized children. When antibiotic stewardship recommendations were followed, children had shorter hospital stays and were less likely to be readmitted 30 days after leaving the hospital. Antibiotic stewardship programs are designed to reduce inappropriately prescribed antibiotics. As many as 50% of antibiotics prescribed at hospitals are inappropriate, leading to antibiotic resistance, and antibiotic-resistant infections kill more than 20,000 people every year.
OK, so antibiotic stewardship programs certainly sound like a great idea and can help with the inappropriate use of antibiotics for inpatients or folks in the hospital, but what about the outpatient setting? What about patients being seen in doctor’s offices, urgent cares or emergency rooms?
Well, program that provide antibiotic prescribing guidance to primary care physicians caring for children is also effective, but its improvements were off after regular auditing and feedback are discontinued. This is from researchers at the Children’s Hospital of Philadelphia — also known as CHOP to those of us at the industry — and this was published in the Journal of the American Medical Association. While this research wasn’t presented at IDWeek 2014, it did, strangely enough, come out of the same time, where hundreds of infectious disease experts were meeting in the city of brotherly love.
Study leader, Dr. Jeffrey Gerber says, “Our findings suggest that interventions with outpatient healthcare providers should include continued feedback to clinicians in order to remain effective. Because disease-causing microorganisms have been developing resistance to commonly used antibiotics, public health experts advocate more selective use of those medications. The antimicrobial stewardship program in the current study included prospective audits of prescription patterns, evaluating prescriptions based on current prescribing guidelines for specific conditions issued by professional organizations. The program staff then provided personalized, private feedback reports to the practitioners, advising them whether their prescriptions followed current recommendations.”
The study team analyzed electronic health records of 1.2 million office visits at 18 community-based primary care offices within the CHOP pediatric network, focusing on prescriptions for common bacterial respiratory infections in children. The researchers randomized the 18 practices into two groups — one receiving the intervention, which was an hour-long session of clinician education, followed by audit and feedback — and the other group received no intervention at all.
The researchers previously reported in June 2013 that inappropriate prescribing decreased significantly in the intervention group, from 26.8% to 14.3%, compared to a decrease from 28.4% to 22.6% in the control group.
Because the previous study covered a 12-month intervention period, the current study evaluated the durability of the effects. The team followed antibiotic prescription patterns for 18 months after the auditing and feedback ended. Prescribing of broad-spectrum antibiotics, which according to guidelines are typically reserved as second-line treatments, increased over the extended time period, reverting to above-baseline levels. After adjusting the data set for the additional 18 months after intervention had ended, the study team found inappropriate prescribing rose from 16.7% to 27.9% in the intervention group, and from 25.4% to 30.2% in controls.
Dr. Gerber says, “Our results suggest that audit and feedback were crucial parts of this intervention, but for the initial benefits of this program to persist, there needs to be continued, active feedback to the clinicians in primary care offices.”
All right, let me pause. So a couple of observations here. First, I just want to say that the inappropriate use of antibiotics is a real problem, and it’s one we have to get a handle on in order to reduce the incidence of antibiotic-resistant infections. And to make a difference, we doctors have to change our practice, which can be a hard thing to do.
On the other hand, I think the researchers really need to zero in on why prescribing behaviors reverted back over the 18-month period following the intervention. Why did doctors go back to doing things the way they had done them before? And I think you really need to understand the reason that is, in order to figure out what you need to do next.
Were the recommended interventions not working? Maybe doctors did do the first-line antibiotic and they were seeing a lot of these kids coming back and needing the second-line antibiotic and so that’s why they just started doing the second line one right out of the gate, and then those kids got better and didn’t come back. I mean, is that the case? We don’t know. That wasn’t included in the study to try and figure out why.
Was there a fear that it wouldn’t work or is it simply a matter of trying to train an old dog a new trick, and the old dog goes back to doing things the old way after awhile? If you know more about why behaviors reverted , then you might be able to design a more effective intervention when it will have lasting effects rather than one that needs to keep blasting on its own.
One more comment, teaching old dogs new tricks. It takes a dog that wants to be trained, and since those doing the training tend to be younger dogs, an interesting dynamics is established. It takes overcoming some difficult obstacles to figure out how best to encourage young dogs and old dogs to work and learn from each other. Hopefully, the point of my analogy is coming through.
Stay tuned, because in the near future, here on PediaCast, I’ll have much more to say about keeping old dogs on their toes and facilitating a means by which young dogs and old dogs can learn from each other. And when the time comes to say more about that, I will; but for now, it must remain a bit of a mystery.
All right, so we’ve introduced this concept of antibiotic stewardship, which is a fancy way of saying, “Come on, guys. Let’s use antibiotics the right way. Let’s only use them when they’re needed, and when they are needed, let’s use the right ones.” That’s what the doctors are saying amongst themselves. But what about patients? How can they be on their toes with regard to antibiotic stewardship? And since my adult listeners are sometimes patients themselves, let me ask you this, how can you be on your toes?
Well, consider this, a vast majority of people who see their doctors for sore throats or acute bronchitis receive antibiotics, yet only a small percentage should. This is according to analysis of two major national surveys presented last year at IDWeek 2013, and published in JAMA Internal Medicine.
Sore throats and acute bronchitis are usually caused by viruses — let me say that again, sore throats and acute bronchitis are usually caused by viruses — and antibiotics, which only treat bacterial infections, do not help. You’ve heard this before, you’ll hear it again. It’s a really important concept.
Harvard University researchers analyzed the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey and determined that doctors prescribed antibiotics in 60% of visits for sore throats and 73% of visits for acute bronchitis. The antibiotic prescribing rate should be about 10% for sore throats and nearly 0% for acute bronchitis.
While antibiotic stewardship programs have helped reduce the misuse of the medications in hospitals, the analyses suggest the message isn’t reaching the community, with patients continuing to request antibiotics for conditions they don’t cure, and doctors prescribing them. The inappropriate use of antibiotics adds to the creation of drug-resistant bacteria, or superbugs, which are very difficult to treat and are a public health threat.
Dr. Jeffrey Linder, associate professor of medicine at Harvard Medical School and senior author of the study says, “People need to understand that by taking antibiotics for viral infections, they’re putting something in their bodies they don’t need. Taking antibiotics unnecessarily exposes people to adverse drug reactions, allergies, yeast infections and nausea, with no benefit.”
Now to be clear in adults and children, sore throats caused sore throats caused by Group A streptococcus bacteria, also known as strep throat, these infections should be treated with antibiotics. But while people often think they have strep throat, streptococcus is the cause only about 10% of the time. In most cases, 90% of the time, a virus causes the sore throat.
Now, here’s a side comment. You can’t reliably tell the difference between strep throat and a viral sore throat by obtaining a history and performing a physical examination. You need to do a strep test before deciding to use an antibiotic — period. So if you or your kids see a doctor and hear she tells you it’s strep throat, and wants to prescribe an antibiotic without doing a strep test, that’s a red flag with regarding antibiotic stewardship. Say something, you can blame me. Now, I know every time you get an antibiotic, you get better.
Guess what, viral infections get better on their own. And by the time you see a doctor, and you get an inappropriate prescription for an antibiotic and you get it filled at the pharmacy, and you take it a couple, guess what? By that time, your immune system starts winning the battle. You start feeling better but it wasn’t the antibiotic doing the work. It was your immune system. Or you really needed was a bit more patience.
Dr. Linder goes on to say, “Acute bronchitis is almost always viral, and even when bacteria are involved, there is no need for antibiotics unless the patient develops pneumonia.”
To assess the antibiotic prescribing rate for sore throat, researchers determined there were 94 million visits to primary care physicians and emergency rooms for sore throats between 1997 and 2010, based on an extrapolation of 8,191 visits in the study. Physicians prescribed antibiotics 60% of the time, a decrease from 73% from numbers reported by the same authors in 2001.
So it made some improvement but we have a long way to go.
Regarding acute bronchitis, researchers calculated there were 39 million visits to primary care physicians and emergency rooms between 1996 and 2010, based on an extrapolation of 3,667 actual visits. Researchers determined there was a significant increase in the number of visits for acute bronchitis to primary care doctors, from 1.1 million in 1996 to 3.4 million in 2010. They also noted an increase in the antibiotic prescribing rate in emergency rooms for acute bronchitis from 69% to 73%, during the same 14-year period.
Dr. Linder says most sore throats and cases of acute bronchitis should be treated with rest, fluids and using a humidifier. They don’t require a visit to the doctor. A cough, runny nose and hoarseness are usually signs that a sore throat is viral and not caused by strep. Pain relievers can also help. Acute bronchitis, also known as a chest cold involves swelling and inflammation of the bronchial tubes in the lungs and typically follows a head cold or flu, which are viral infections. While this illness typically lasts a week or two, the cough may linger for a few weeks.
Seasoned PediaCast listeners know this is right. I had one of those coughs last winter. Remember, we talked about this in detail. The virus destroys cells that line the airway. These cells make up the mucociliary elevator. So these are cells with hair-like projections that move things up and out of the lungs, and up the trachea and in to the mouth. When that’s not working, because the cells have been destroyed by a virus, the body resorts to coughing to get stuff up and to keep stuff out.
So you need to cough. It’s a protective cough. And how long do you cough? Well, until your body makes new cells of that mucociliary elevator, which usually takes three to four weeks. Now, you shouldn’t have a fever that entire time, just the cough. And of course, there are other things that can cause a chronic cough. Things like foreign bodies in the airways, especially in kids — proptosis, tuberculosis, some cancers — so by all means, see a doctor if you have a chronic cough, but don’t demand an antibiotic. And fellow doctors, if an antibiotic isn’t needed, don’t prescribe one.
All this stuff really goes for adult patients and adult doctors, too. Let’s all jump onboard the antibiotic stewardship wagon. I know it’s a pediatric podcast, but this topic pertains to moms and dads, too.
Maybe I’m generalizing a bit here, and you can write in and scold me, if you think that’s true. I’m fine with that. But I really feel pediatricians have been preaching these news for a couple of decades. In my experience as the adult patients and the adult doctors who are still playing the bronchitis card, and it’s really time to put that deck away.
The researchers sum up by saying sore throats and acute bronchitis usually are caused by viruses, and antibiotics won’t help and yet they are prescribed most of the time, according to two national surveys. The surveys found patients receive antibiotics in 60% of doctor visits for sore throat and 73% of doctor visits for acute bronchitis — again, in adults — but the prescribing rate should be about 10% for sore throats and near 0% for bronchitis.
The results suggest significant misuse of antibiotics continues which fuels the creation of antibiotic-resistant superbugs.
Can you tell I’m passionate about this topic?
All right, let’s move on. One of those superbugs is MRSA, which stands for methicillin-resistant Staphylocuccus aureus. You’ve probably heard of it. Even if they don’t show signs of infections, college athletes who play football, soccer, and other contact sports are more likely to carry this bacteria. So says more research recently published and presented at IDWeek 2014 in Philadelphia.
This puts these college athletes at a higher risk for infection and increases the likelihood of spreading the superbug, which can cause serious and even fatal infections.
The study is the first to observe college athletes who are not part of a large MRSA outbreak. Investigators say contact sport athlete are more than twice as likely as non-contact athletes to be colonized with MRSA, meaning they carry the bug on their bodies, usually in their noses and throats.
Throughout the two-year study, colonization with MRSA ranged from 8 to 31% in contact sports athletes compared to 0 to 23% of non-contact athletes. About 5 to 10% of the general population is colonized with MRSA, just to compare.
Dr. Natalia Jimenez-Truque, research instructor of Vanderbilt University Medical Center in Nashville says, “This study shows that even outside of a full-scale outbreak, when athletes are healthy and that there are no infections, there are still a substantial number of them who are colonized with these potentially harmful bacteria. Sports teams can decrease the spread of MRSA by encouraging good hygiene in their athletes, including frequent hand washing and avoiding sharing towels and personal items such as soap and razors.”
Researchers analyzed the time it took for college athletes to be colonized with Staphylococcus aureus (staph), including MRSA, the antibiotic-resistant variety, and how long they carried it. The study followed 377 male and female Vanderbilt University varsity athletes playing 14 different sports, including 224 who played contact sports such as football, soccer, basketball and lacrosse, comparing rates of MRSA colonization to 153 students who played non-contact sports, including baseball, cross country and golf. Each athlete had monthly nasal and throat swabs over the course of two academic years. The study also found contact athletes acquired MRSA more quickly and were colonized longer than non-contact athletes.
MRSA is a leading cause of skin and soft tissue infections, which often heal on their own or easily treated. But the invasive form of MRSA can cause pneumonia and infections of the blood, heart, bone, joints and central nervous system, and kills about 18,000 people every year. Invasive MRSA is difficult to treat because standard antibiotic therapy may be ineffective, and physicians often must turn to powerful antibiotics delivered through an IV.
Athletes in contact sports are at higher risk of getting colonized or infected by MRSA because they have skin-to-skin contact and often have cuts and scrapes that allow the bug to enter the body.
Researchers say athletes can reduce the risk of spreading the bacteria by covering any open wounds, regularly washing their hands, showering after practice and games, and not sharing razors, towels, and other personal equipment. Athletes with scratches and cuts should cover them or not practice or play in games; towels and clothes should be washed daily; shared equipment and facilities should be cleaned routinely. While keeping equipment clean is important, researchers found little staph in the athletic environment itself, such as the locker room and weight room, suggesting that MRSA is most often spread person to person.
Researchers conclude by saying, “Staph is a problematic germ for us — always has been, always will be — and we need to do all we can to reduce the risk of infection in those at highest risk, such as college athletes.”
Again, to sum up and be sure to pass this information along to your student athletes, whether they’re in college or high school or middle school, it’s still great advice. Cover open wounds, wash hands regularly, shower after games and practice, and don’t share razors, towels and other personal equipment.
All right, that almost concludes this week’s edition of PediaCast. Don’t touch that knob quite yet, because coming up after the break, I have a story you’ve all been waiting for, I’m sure. Frozen poop capsules.
Don’t go away.
Dr. Mike Patrick: A preliminary study has shown the potential of treating recurrent clostridium difficile infection with oral administration of frozen encapsulated fecal material from unrelated donors.
That’s right, folks, frozen capsules of someone else’s poop. You heard it here first.
What’s more, this intervention resolved the stubborn and sometimes bloody diarrhea in 90% of patients with an infection of the large bowel caused by the bacteria known more simply as C.diff.
So, we can look at this and say, “Ooh, are they serious?” But keep in mind, we’re talking about a pretty serious infection here. This is stubborn diarrhea, bloody at times, and these are folks who really just want this diarrhea to go away and nothing else is working. And so, yeah, they do resort to this.
The study from researchers at Massachusetts General Hospital in Boston was recently published in the Journal of the American Medical Association and presented at IDWeek 2014 in Philadelphia. Recurrent C.diff infection is a major cause of illness and death with a recent increase in the number of adult and pediatric patients affected worldwide. Standard treatment with oral administration of the antibiotics metronidazole or vancomycin is increasingly associated with treatment failures, meaning antibiotic resistance is becoming a real problem.
Fecal microbiota transplantation — just a fancy way of saying reconstitution of normal flora or gut bacteria by a stool transplant from a healthy individual — has been shown to be effective in treating relapsing, recurrent C.diff infections. The majority of reported Fecal microbiota transplantation procedures have been performed with fresh stool suspensions from related donors; however practical barriers and safety concerns have prevented its widespread use, according to background information from the article.
To address these barriers, the use of frozen fecal matter from carefully screened healthy donors has been used for fecal microbiota transplantation. The frozen product was first given through a colonoscope, so up the rectum, but more recent trials delivered it through a nasal gastric tube, pass through the nasal passages and into the stomach.
Building on this work, researchers generated a capsulized version of the frozen stool that can be administered orally and obviates the need for any gastrointestinal procedures. Dr. Ilan Youngster and colleagues conducted a study to evaluate the safety and rate of diarrhea resolution associated with oral administration of frozen poop capsules for patients with recurrent C.diff infection. The study included 20 patients with at least three episodes of mild to moderate C.diff infections and failure of a six-to-eight-week taper with oral vancomycin or at least two episodes of severe C.diff infections requiring hospitalization. Healthy volunteers were screened as potential donors and the poop capsules were generated and frozen. Patients received 15 capsules on two consecutive days and were followed up for symptom resolution and adverse events for up to six months.
Among the 20 patients, 14 of them — so 70% — had clinical resolution of their diarrhea after the first administration of capsules and remained symptom free at eight weeks. All six nonresponders were retreated seven days after the first procedure, and four of these patients obtained resolution of their diarrhea, resulting in an overall 90% rate of clinical resolution of diarrhea.
Daily number of bowel movements decreased from a median of 5 the day prior to administration to 2 at Day Three and only one per day at eight weeks post-treatment. Self-reported health rating using a standardized questionnaire scale of one to ten improved significantly over the study period, from a median of 5 for overall health and 4.5 for gastrointestinal health the day prior to treatment, to an average of 8 for both ratings at eight weeks post-treatment.
No adverse events attributed to the poop capsules were observed.
The author say, “If reproduced in future larger studies with active controls, these results may help make fecal microbiota transplantation accessible to a wider population of patients, in addition to potentially making the procedure safer. The use of frozen poop allows for screening of donors in advance. Furthermore, storage of frozen material allows for retesting of donors for possible incubating viral infections prior to administration. The use of capsules obviates the need for invasive procedures for administration, further increasing the safety of fecal microbiota transplantation by avoiding procedure-associated complications and significantly reducing the cost.”
So there you have it, if the results hold up in future studies, the day may come when stubborn C.diff infections are treated with frozen poop capsules. It’s true, and that’s my final word.
I want to thank all of you for taking a part of PediaCast and making it a part of your day. Maybe you took the whole thing. I don’t know, that didn’t sound right. I have show fatigue here, folks.
Dr. Mike Patrick: I want to thank all of you for making PediaCast a part of your day. There, that’s what I was trying to say.
Also thanks to the folks who put on IDWeek 2013 and 2014. Lots of good information there and things that I think are relevant for moms and dads everywhere.
That does wrap our time together. PediaCast is a production of Nationwide Children’s Hospital. Don’t forget, PediaCast and our single-topic, short format program, PediaBytes, are both available on iHeartRadio Talk, which you’ll find on the Web at iHeart.com and the iHeart Radio app for mobile devices.
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Until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next time on PediaCast.