SEP.EP.004.Video
Transcripts are auto-generated and may contain errors
Jennifer Ginestra: [00:00:00] Anywhere from 12 to 25% of all sepsis patients actually develop sepsis in the hospital. So that’s gonna be officially speaking. Patients whose sepsis develops after at least 48 hours of admission, and those patients tend to be sicker, even though they make up a minority of cases, they make up a greater proportion of deaths.
Nicole Kupchik: This is the sepsis spectrum, a podcast about antimicrobial resistance, sepsis, and how to expect the unexpected in your practice.
Meet Ra Resa, and for those listening air quotes around sista, not a person, but a problem I. A pathogen forged not in the wild, but within the hospital environment itself. Sista lives on hands on surfaces and the access ports of IV lines and the corners of catheter hubs. Severe. Resist. Resist doesn’t rush.
It adapts. It’s [00:01:00] homegrown coming in with a patient then given space to thrive. And once antibiotics are deployed, well, you know how that can go. Each course met with resistance, but not retreat. A fever is spike in vitals. By the time symptoms appear, the damage is well underway. Hospital onset sepsis emerges when systems falter, when documentation is delayed, when vital signs are missed, when teams are stretched thin, awareness, that’s the first step.
Understanding how resistant infections take hold inside hospitals. Is the next. With that knowledge, perhaps next time hospital ons, sepsis can be avoided.
Hi everyone, and welcome to the sepsis spectrum or as we like to call this season Microbial Mysteries. I’m Nicole kic, critical care nurse, clinical nurse specialist, and your guide through the [00:02:00] complicated and sometimes frustrating world of sepsis and antimicrobial resistance. On today’s episode, we’re going to get a handle on how healthcare associated infections ais are fueling both antimicrobial resistance a MR, and hospital onset sepsis, and why that’s such a big deal for patients and providers alike.
We’re gonna break down the major takeaways from the June, 2024 chest publication on hospital onset sepsis and why it should change how we approach infection control, antimicrobial stewardship, and treatment strategies. We’re gonna talk about the real world impact of delays, whether it’s slow, rapid response activation, or late antibiotics, and how those gaps can turn manageable infections into full-blown crises.
- We’re gonna walk through a tough clinical scenario involving ais, resistant bugs and hospital onset sepsis, using it to identify [00:03:00] key risks and craft evidence-based solutions, including antimicrobial stewardship amongst other things. And we’re hoping you’re gonna leave with best practices. You can apply right now, no matter your role to help prevent, recognize, and manage ais, MDRs, and hospital onset sepsis more effectively.
I’m honored to present two guests today who are helping shift how hospitals respond to one of the most serious threats in patient safety, hospital onset sepsis. Dr. Jennifer Ginestra is a physician and researcher at the University of Colorado whose work is redefining how we recognize and respond to deterioration in the hospital.
She focuses on the deadly consequences of delays, missed signs, and hospital acquired infections, and what must change to keep patients safe. She’s also co-author of Hospital Onset Sepsis, a National [00:04:00] Patient Safety Challenge, which was published in chest, the Journal of the American College of Chest Physicians in June, 2024, which we’ll be discussing momentarily.
- Dr. Emmy Minejima is an infectious diseases pharmacist and associate professor at the USC Mann School of Pharmacy. She leads antimicrobial stewardship at Los Angeles General Medical Center and focuses on improving antibiotic use and outcomes for some of our most vulnerable patients. Together they bring frontline insight into one of healthcare’s most preventable crises and what it takes to fix it.
Let’s get started, and I hope you enjoy this incredibly memorable conversation with Dr. Jennifer Ginestra and Dr. Emmy Meninga.
All right. I’d like to welcome both of you to the show. So, Dr. Ginestra, would [00:05:00] you mind telling us a little bit about what you do in the hospital?
Jennifer Ginestra: Sure. Um, first, thank you so much for having me. I’m excited to be here. Uh, I am a critical care physician, so I work, uh, on the medical intensive care unit. I also work on our critical care consult service, so I respond to rapid responses and critical care consults.
Um, and then outside the hospital, I’m also a researcher in health services and patient outcomes. Great. And then Dr. Men Jimma, would you
Nicole Kupchik: mind telling us what you do?
Emi Minejima: I am a faculty at the School of Pharmacy at University of Southern California. And, um, my practice is at the LA General Medical Center, uh, which is a safety net hospital, um, in Los Angeles.
Um, so I’m an ID pharmacist by training and I help run the antibiotic stewardship program, um, at the medical center.
Nicole Kupchik: Great. Okay. So I’m super excited about this episode we’re gonna talk about in-hospital sepsis. And I, I know all of us have done a lot of work in [00:06:00] identifying these patients and trying to kind of make sure they’re on the right antibiotics and the right pathway.
So Dr. Ginestra, your research is mostly focused on in-hospital sepsis. What exactly are you researching and can you give us some updates on what’s happening?
Jennifer Ginestra: Yeah, so hospital onset sepsis is a really interesting entity in that, um, it’s a group of patients that tend to be very sick and have pretty poor outcomes.
Um, and they’re a little bit challenging to study, but they’re very important to study. Um, so. I’ll distinguish. Hospital onset sepsis is different from what’s called community onset sepsis, which is I think what most people classically think of when they think of sepsis. It’s the patient that comes into the emergency room already with an infection already septic, and that makes up the majority of patients who have sepsis.
It’s. Anywhere from 12 to 25% of all sepsis patients who actually develop sepsis in the hospital. So that’s gonna be officially speaking. Patients whose sepsis develops after at least 48 hours of [00:07:00] admission. Um, and those patients are tend to be sicker even though they make up a minority of cases, they make up a greater proportion of deaths.
Nicole Kupchik: So just in general, those patients don’t do as well and like why do you think that is? Is it just because they’re so sick or are there other reasons contributing to that?
Jennifer Ginestra: It’s a lot of different reasons. They are kind of different at baseline. So patients with hospital onset sepsis tend to have more comorbidities like heart failure and renal disease.
They’re more likely to have cancer. Um, they also tend to. Present differently with their sepsis in the hospital. So they are less likely to have typical signs and symptoms of infection like fever. Um, they’re more likely to have norm hermia or even hypothermia. Um, and they’re more likely to have hypotension and hypoxia.
Um. Their infections tend to also be in slightly different locations, so they’re more commonly gonna have an intraabdominal source in addition to the [00:08:00] other usual sources, but more likely than someone coming from the community and then the actual organisms that they’re infected with. It’s a slightly different group of organisms at different rates, so they’re more likely to have staph, enterococcus, even fungal infections, pseudomonas, and a little bit less likely to have infections caused by strep, for example.
Um, and overall they have, um, sort of a, potentially a different immune response, um, and other comorbidities that might come into play with their response to fluids, um, antimicrobials, things like that. I think the other big distinction is that there’s a little bit more diagnostic uncertainty when a patient decompensates in the hospital as to what’s going on than when they come in fresh to the ED with a clear story.
Um. What we end up seeing is that these patients are less likely to get timely care. So it’s probably a combination of the fact they’re a little bit different at baseline. They have different patterns of infection and [00:09:00] manifestations of infection and potentially a different immune response. And then lastly that we’re not quite as good as at caring for them as we are in the emergency room.
Nicole Kupchik: So what are you doing in your hospital to identify these patients?
Jennifer Ginestra: It’s a good question. So a lot of it is the usual bedside nurse and clinician sort of, um, recognition and awareness. We also do have, um, I think like many hospitals at this point, some degree of virtual monitoring, um, and alert systems for big changes in abnormal vitals, things like that.
But there’s not really one particular alert system or early warning system that has been shown to. The right balance of sensitive, picking up all the patients you wanna pick up so that they don’t fall through the cracks, but also specific so that you’re not alarming for every patient who’s a little bit tachycardic when they get up to go to the bathroom.
Um, so we do have a rapid response outreach team that’ll respond to the bedside when a patient’s decompensating, but I think in general, we don’t have very good predictive [00:10:00] systems in existence yet. Um, to identify the right patients at the right time.
Nicole Kupchik: And then of course, this gets much more complicated when we throw in antimicrobial resistance.
So can you tell us, are we seeing more antimicrobial resistance now than we had been in the past? And first I’ll, I’ll ask Dr. Escher that question and then I’m gonna ask Dr. Manju.
Jennifer Ginestra: Yeah, I, I think it’s a little bit of a mixed bag depending on which organism you look at. Um, pre pandemic, we were seeing some declines in things like MRSA and, um, in VRE Vancomycin, resistant enterococcus, I think there was a little bit of a surge.
There were some studies that suggested there were more than expected numbers of multi-drug resistant organism infections during the pandemic. Um. I think it still remains to be seen exactly where things land in the post pandemic era. Um. I think Dr. Mana may know a little bit more with her, uh, expertise about the latest trends, but that’s my [00:11:00] understanding.
Nicole Kupchik: Yeah. And then what are you seeing Dr. Minejima?
Emi Minejima: Yeah. Um, it’s definitely in line with Dr. Ginestra. Um, I think the CDC shows that compared to pre pandemic levels in, um, the most recent data we have is in 2022. We still do see an increase in some of the hospital onset multi-drug resistant organisms, or MDRs, most notably, like c.
VE, um, ESBL. Uh, definitely. Um, so we’re a safety and net hospital. Um, we’re a little bit unique probably then compared to some of our private institutions in that we actually don’t get a lot of sniff patients that get admitted into our hospitals. Um, and our, our skilled nursing facilities are the, you know, air places where you have those frequent flyer patients that come in and outta the hospital frequently are colonized with MDRs in their gut.
Um, and so since we don’t have those admissions. We don’t have really high rates of some of these really nasty gram-negative rods, like carbapenem resistant enterobacter. [00:12:00] But definitely we’re seeing a pretty steep rise in ESBL producing, um, gram-negative rods, which is problematic because typically what we reach for in terms of treatment of these ESBL organisms is a carbapenem, which we consider are.
Very safe beta lactam to use. Uh, the problem is that of course ovus of carbapenems, you’re just running out of other safe antibiotics to use. Um, if you develop resistance, um. Just as Dr. Ginestra said, rates of MRSA have been declining over the last decade. Our population is very similar in that we’ve seen a similar trend.
However, it has started to actually creep back up a little bit slowly over the last couple of years. I would say probably post COVID. Um, so that’s something that we’re just monitoring. Um. So MDROs definitely are a big issue. Um, our rate of new antibiotics in the pipeline that have activity against these multi-drug resistant [00:13:00] organisms is, um, not robust.
Um, so it’s really up to a lot of the clinicians and antibiotic steward programs to. Think of interventions, um, and unique methods in order to preserve a lot of the things that we are already using. Um, so we have, uh, very strong infection control at our, um, um, health system. And to make sure that we can identify, uh, patients that have colonization with MDs, uh, making sure that that’s alerted to both the clinician, the nurse and antibiotic stewardship so we can, uh, monitor these patients closely.
But also if something happens where they do have signs of sepsis, um, during the admission that we use our knowledge about specific resistance mechanism, known resistance mechanisms, or known colonization from these patients in order to come up with the best empiric therapy for these patients.
Nicole Kupchik: Finding [00:14:00] now, are a lot of clinicians using antibiotics, do you think pretty routinely across the country, or are we still seeing a lot of variability in practice?
If you had to guess.
Emi Minejima: Um, definitely variability still, I would say. Um, so I think definitely your resource rich settings with, um, a very strong antibiotic stewardship program that’s longstanding. They typically have the FTEs or full-time employees that can staff, um, antibiotic stewardship to help guide, uh, clinicians on the front line with appropriate and, um, empiric choices.
Um, they also have the, um. Staff to develop, you know, a care pathway or empiric guidance that is tailored to a specific ICU or tailored to the specific institution, which is really important because every hospital is different. They carry different formularies, they carry different, you know, patient populations which result in different types of, um, MDRs, uh, [00:15:00] different, uh, antibiograms.
Um, so. Taking the national guidelines and tailoring it to your specific site is really important. But sometimes, you know, if, if you have a very, um, uh, you know, a stewardship team that’s in its infancy, they might not have had the time or the expertise to develop something that is, uh, very. Fine tuned to their specific, um, patient population.
Um, in addition, typically the large academic medical centers are the places where you might see a longstanding antibiotic stewardship program that’s well staffed and a very multidisciplinary antibiotic stewardship team. But perhaps when you get to those smaller community hospitals or rural hospitals where they don’t have the, um, FTEs.
They may not be able to hire a, you know, an ID pharmacist or an ID physician, or a critical care physician, critical care pharmacist with expertise on, okay, what, what [00:16:00] are the types of infections that you see in your specific population? What are the types of resistance, um, you know, patterns that you see?
And developing a empiric path, you know, guideline pathway specific to that institution. Um, because you. Um, Dr. RA’s paper, you’re looking at hospital onset sepsis really highlighted. These patients are different and it is sometimes very difficult to pick up. Okay. When, when is that time? Zero. When do those patients start exhibiting those symptoms and then you have an hour and to get the right antibiotic into them.
Um, and that’s not a lot of time because you know, you have to think of the physician at the bedside making the assessment. They have to put in the antibiotic order, and then the pharmacist has to verify that order. Then there’s many other steps that probably most don’t know about in that, you know, the order gets, um.
Put into the pharmacy, a [00:17:00] technician has to notice that the order is there. They have to, you know, depending on the availability of a ready-made antibiotic versus something that they have to compound. Um, then, you know, the technician has to get the pharmacist to check off to make sure that it was compounded correctly.
Somebody has to run up that medication to the nursing station, and then the nurse has to know that medication is ready to hang at the patient’s bedside. So there’s actually a lot of steps that go on from when the physician at the bedside notices sepsis puts in the antibiotic order to the time the nurse actually can.
Doing all of those steps within one hour is really challenging. And, you know, that’s something that our institution has really struggled with. Um, so, uh, you know, it it, it takes a village and with, you know, a big multidisciplinary disciplinary group [00:18:00] to make sure that each patient from sepsis recognition to, you know, getting the antibiotic into them.
Work together, work to come up with interventions or a pathway, um, that is gonna be the most conducive to the existing workflow. Um, and making sure that there’s appropriate follow up after, um, and that, you know, deescalation happens, appropriate durations, um, follow up on cultures, um, things like that happen.
Um, so it’s. It can be challenging just based on whatever setting you’re at. And so, yes. Um, long story. Um, but there’s a lot of variability in terms of what an antibiotic stewardship program and a sepsis team, uh, might do in order to, um, improve how we deliver antibiotics to a patient.
Nicole Kupchik: Yeah. And Dr. Sra, do you see in the FU a future that includes [00:19:00] ai?
To help us identify these patients that are already hospitalized and getting sick in front of us, or do what? What do you, what does the future look like, do you think?
Jennifer Ginestra: I think it definitely is gonna play a role. I think that it’s, we’ve already been, I don’t know, maybe five, 10 years into a number of groups trying to develop.
You know, AI is, is sort of a, a big umbrella term, but I’ll say in the, you know, more specific, um, statistical term of machine learning algorithms. So you’re really using advanced methods, um, to identify patients and patterns of patients that maybe. Harder for us to identify based on a few criteria, uncover patterns that maybe aren’t as obvious on the surface so that we could try to figure out which patients truly need our help.
And a lot of the reasons that some of our alert systems in that have been implemented in the past have failed are because A, the sensitivity specificity question that I brought up earlier were either alarming on [00:20:00] far too many patients, um, without a lot of specificity. So you’re showing up to the bedside for a lot of patients who aren’t septic.
Or we’re not specific enough to. The patients who truly need our help. And so the question is, which patient is going to get sick and not be noticed? Which patient is gonna get sick and actually have delays in care? And then which patient is actually gonna be harmed by those delays and which patients need X approach to treatment?
And which ones need y? Which ones would benefit from aggressive fluid resuscitation strategy? And which ones would benefit from a more conservative, vasopressor forward strategy? And that’s, I think, where things are. Hopefully headed is using AI and machine learning to try to understand the heterogeneity of these patients because we call sepsis a syndrome.
We kind of call everything sepsis as if all the patients are nails and we just have the one hammer. But it’s actually a. Big variety, I think, of underlying immune systems, [00:21:00] patients, comorbidities and bugs that we’re dealing with. Um, and potentially different phenotypes of how that manifests in patients.
And so I think that’s where hopefully AI will be very helpful is to uncover those patterns, help us identify high risk subgroups, and then help deploy teams to the right place without interfering in workflow or adding alert fatigue and things like that.
Nicole Kupchik: Yeah, I’m excited to see where it does go and how long it’s gonna take us to get there.
But I, I just, I really do feel AI is gonna play a role. All right, so we’re going to go to a quick break and when we come back, we’re gonna get, dig a little deeper into hospital acquired infections, antibiotic drug resistance, and just what do we do differently in hospital acquired infections.
Are you a nurse infection, preventionist, or healthcare professional who wants to stay ahead of the curve? Visit sepsis podcast.org to learn how you can receive free nursing CE credits by listening to or watching [00:22:00] the sepsis spectrum. It’s our way of supporting you and together better understanding the ever evolving world of sepsis care and a MR.
And now back to the show.
Welcome back. So, Dr. Ginestra, I wanna talk about the, uh, paper that you were an author on. It was, uh, published in June of 2024 in Chest, and it specifically addressed hospital onset sepsis. What takeaways from that paper do you think would be helpful to anyone working in a hospital that’s listening in?
Jennifer Ginestra: Yeah, so the paper that we wrote, our, our goal was really to highlight this entity as kind of distinct entity.
Um. That at least warrants more research, if not potentially different management than what we’re doing for sepsis historically for community [00:23:00] onset sepsis. And we, what we wanted to highlight was that it has not been studied very extensively. The vast majority of research in sepsis is in that community onset group.
Um, that’s where all the sepsis trials have been and a lot of the observational research as well. And there’s certainly a growing interest in body of literature in hospital onset sepsis. But there are a ton of knowledge gaps, a ton of things that we just. Don’t know how to deal with. So even how we identify cases in retrospective research, um, the clinical heterogeneity that we spoke about, how we understand different subgroups and is this something that’s truly distinct from community onset?
Is it just a different phenotype? Um. Also management decisions. Should we be doing the same things for these patients? Because a lot of those trials, like I said, weren’t studied in hospital onset sepsis, and we know those patients are a little different. Um, there’s also prevention issues that I think are very relevant to what we’re talking about today that have to do with all of the hospital acquired infections that lead to sepsis, don’t have [00:24:00] necessarily robust prevention efforts around them equally.
Um, and we can get back to. The other sort of big questions are how do we ensure that the care that we deliver for these patients is equitable? Um, and, and patient centered so that at the end of the day, for these patients who have a pretty high risk of mortality, a good proportion of them have potentially a terminal illness like cancer.
How do we make sure that we are. Doing the, the best that we can to prolong their survival, but also to ensure their quality of life in that. Um, and to make sure that that escalation of care to the ICU invasive procedures, all of that is still in line with their ultimate goals. Um, so there are a lot of different areas of, of sort of growth that we still need clinically and in research in this space.
And that was the, the point of that paper was really to highlight that need for awareness and, and work in this space.
Nicole Kupchik: I mean it because it’s complicated. It’s extremely complicated because you’ve got somebody who’s already sick.
[music]: Mm-hmm. And then
Nicole Kupchik: develop [00:25:00] another issue while they’re hospitalized. So let me ask, at what point do you get Dr.
Mana involved? So Dr. Mana is a pharm d who’s got a specialty in infectious disease. When do you get someone with her specialty involved?
Jennifer Ginestra: That’s a great question. Um, and so like we talked about, patients with hospital onset sepsis are more likely to have drug resistant organisms. So if you look at patients with community onset sepsis, about a quarter of them might have a drug resistant organism, but in hospital onset sepsis, it could be up to half of patients with a bloodstream infection developed in the hospital, have a resistant organism.
And so. You’re talking about using broader antimicrobials to cover these and potentially more challenging situations where that diagnostic uncertainty comes into play. You’re trying to figure out is this a hospital acquired pneumonia and sepsis, or is this. Heart failure [00:26:00] exacerbation or iatrogenic volume overload.
So there may be questions diagnostically about whether this is the right diagnosis and then there are often questions about coverage that come up. Um, so I would say that when to get them involved, well upfront, your empiric coverage should ideally cover the main risk factors. So. Most, any patient who develops sepsis in the hospital is gonna need pseudomonal coverage, so that’s gonna be your fourth generation cephalosporin cefapime, or piperacillin tazobactam, which may be different in your health system.
I worked in a health system before where cefapime was the drug of choice based on our pseudomonal sensitivities, and I currently work in a health system where PTAs are drug of choice. So whatever is in your system is the best choice for antimon, then you’re probably gonna want anti coverage as well.
Then beyond. You need to think about risk factors for other drug resistant organisms. V-R-E-E-S-B-L-C-R-E. Um, you need to think about risk factors for [00:27:00] c diff. Um, and those are individual to the patient, and those risk factors are listed in society guidelines, but hopefully are also part of your antibiotic guidelines in your health system.
Those would include things like longing lines, prior colonization, um. Prior IV antibiotic exposure in the last 90 days. Um, for some things like ESBLs, even travel to or hospitalization in an endemic region. Um, and there are pools online to help you find that. Um, so some of those empiric choices upfront can be guided by those, um, risk factors when I start to get people involved is.
If a patient has a complicated prior micro history, so if they’ve grown multiple bugs in the past that have different resistance patterns or um, they are now growing a bug that has a challenging resistance pattern. Or they’re getting worse and I don’t know why. So basically, if you need help, have a low threshold and you’re not wrong to ask upfront with your [00:28:00] empiric coverage as well, to just check in with your ID pharmacist, your antimicrobial stewardship team to make sure that what you’re choosing is appropriately brought to cover their risk, but not inappropriately broad.
’cause both ways have risk.
Nicole Kupchik: Yeah. And Dr. Men, now let me ask you that question because I’m sure there are very limited. People with your specialty. So how would you answer that question? When should infectious disease get involved?
Emi Minejima: Yeah. Um, so at our institution we actually have two different services. We do have the traditional ID consult.
So that is when, you know, if Dr. Janero wanted a formal consult from an ID specialist about a very complex patient, uh, they would go see the patient at bedside, make recommendations, um. Follow the patient. We have a separate service, antibiotic stewardship service, and so we actually are monitoring all patients on antibiotics, especially in the ICU, usually more in the background.
Um, so usually we’re monitoring, you know, [00:29:00] a list of priority antibiotics. So for our institution, we choose things that are. Broad spectrum beta-lactams. Uh, we also have a restriction policy on certain antibiotics as well. So we prioritize what our, I see, um, for any patients in the ICU on a daily basis. So, um, you know, the ICU team may not necessarily know that we’re following their patients along with them, but we’re usually in the background.
Um, if we do notice that there might be room for maybe optimization of. Anything related to their antibiotic therapy, we’ll typically call the ICU provider, try to have a discussion as to, you know, what they see. ’cause obviously we’re only doing chart review and so what they see at the bedside may not necessarily translate into what we’re seeing just from chart review.
So we wanna have that discussion with them, um, and then come up with a, you know, plan. Um, that is, you know, of course, something that the ICU provider is comfortable with. We’re [00:30:00] never trying to shove down anything, you know, tell him how to prescribe. Um, but, uh, we’re just there as a resource. Um, and so for our institution, we’ve had this longstanding, you know, daily stewardship rounds for several years.
So a lot of our teams, both Medicine, surgical, ICU, they kind of expect our phone call on a daily basis. Um, and so it is more of a collaborative, um. Discussion. However, when we were ramping up to this point, um, they did not like us or, you know, it, it, it wasn’t as received ’cause they thought that we were trying to, you know, take away their prescribing autonomy, which it was not.
Um, that was not the purpose. We’re all there for the same purpose, just to optimize how the patient is, you know, their potential outcome when they’re, um, in our hospital with infection. Um. It, it was a gradual process that we worked up to, and now you know, we’re at a. Um, uh, a great place [00:31:00] with a lot of our providers.
Um, and we’re actually now having the reverse effect where, um, sometimes a lot of our trainees, um, aren’t thinking about, you know, okay, what is the best empiric regimen for this? You know, their patient in front of them, the, they just gone in the habit of calling us and asking, okay, what do I do for this patient, um, for every single one of their patients?
So, you know, um. There’s some pros and cons to being a very available service for any type of um, uh, I guess more of a curbside that typically are full ID consult team, um, uh, may not be available.
Nicole Kupchik: Well, I wanted to just chat just for a couple minutes about extended administration of a lot of the antibiotics we’re giving.
Pip pip-tazo has been one of those drugs we’ve been giving ex, you know, on an extended administration. Do you see other drugs getting added to that type of an approach? Of using extended administration?
Emi Minejima: Yeah, I mean, theoretically when you’re trying to optimize pharmacokinetics and [00:32:00] pharmacodynamics of a drug, atezo, carbapenem, their class of beta-lactam, um, they’re within a class called a beta-lactam class.
So theoretically you could do that to any beta-lactam to optimize our pharmacokinetics and pharmacodynamics challenge with that. There’s many. Um, and uh, the main thing though is that it doesn’t necessarily improve mortality outcomes or survival benefit in all of your patients. And so the approach that we’ve taken is that we actually do not do an institution-wide, um, extended infusion policy for pip atezo or am Meropenem, but we.
Do it on a case by case basis.
[music]: Oh, okay. Um,
Emi Minejima: based on the patient, the severity of illness, the type of infection they have, and the organism that they have, um, which is different than many other institutions, they take an approach to just make it a system, um, wide policy that any pep or carbapenem order is always going to be extended infusion.
[00:33:00] Um, so it, it is up to the institution on how they want to administer it. Um. The main thing with us is that we had a policy that was approved, but we had so much pushback after implementation that we decided to, um, kind of roll back the requirement to make it an extended infusion for all.
Nicole Kupchik: Got it. So can you just give us a quick example of like patient A and patient B, like which one you would do an extended infusion approach?
Emi Minejima: Sure. Um, yeah, so patient a is a community onset urinary tract infection here for likely an e coli urinary tract infection. Um, this patient is going to be fine with just giving, you know, axone or another beta-lactam intermittent infusion. They have a low risk for mortality. They’re likely going to respond very quickly to a couple doses of antibiotic, and then they’re gonna be able to be discharged from the facility with continuation with oral antibiotics, [00:34:00] likely to finish out at home separately.
You have patient B. Patient has been hospitalized for over 48 hours initially for an mi. Subsequently develops, uh, pneumonia symptoms and we’re worried about ventilator associated pneumonia 48 hours later, vent setting. They’re not improving isolation of pseudomonas orgen in the, um, you know, bay AAL culture.
And we noticed that the MIC two cefepime or uh, carbapenem was on the higher range. And so because of the severity of illness of the patient, the high MIC and the knowledge that Pseudomonas Subinoy VAP is already difficult to treat, we decide to give them high dose carbapenem at an extended infusion as well in order to maximize the pharmacokinetics and pharmacodynamics of the organism of the bug drug combination, and then, um, improve their chance for survival.
Nicole Kupchik: So can you, um, just for those of [00:35:00] us who aren’t aware, can you just explain, um, is the MIC reported when cultures are done or how, what does that look like?
Emi Minejima: Yeah, so usually, and of course this practice also does vary based on institution, but at ours, when you do a standard culture and susceptibility test and the report becomes available in the electronic medical record, you’ll see the source.
So whether it was, uh, blood versus urine versus. This respiratory culture, it has your list of antibiotics that that organism was tested against. It usually has the actual MIC minimum inhibitory concentration for that bug drug pair. And then it has the MIC interpretation. So if a pseudomonas ceap pair has an MIC of two.
Do we consider that susceptible, intermediate, or resistant? Um, and that report is usually available, um, per patient, um, in the chart. Um, there are some institutions that decide [00:36:00] not to report the MIC ’cause unfortunately, it is interpreted incorrectly, um, a lot of the times. Um, and so all they give is the MIC interpretation.
So if it’s a susceptible, intermediate, or resistant pathogen.
Nicole Kupchik: Are you seeing a similar approach in your facility with extended infusion of antibiotics and MIC reporting or, uh, like what are you seeing clinically where you work?
Jennifer Ginestra: Yeah, I would say it’s similar. We do have the MIC and interpretation reported.
Um, in terms of extended infusions, I don’t think that that’s really taken on fully. It’s the sort of thing that, yeah, on a case by case basis might be recommended by the pharmacist and particularly challenging to treat cases, but I think for similar reasons of administration complex of having a longer continuous infusion, it.
Some of the data being a little bit mixed as to the survival benefit that hasn’t [00:37:00] taken on a, a universal, uh, approach to our care in our facility.
Nicole Kupchik: Yeah, I think a lot of nurses will be happy to hear that. There are some facilities that are approaching this on a case by case because it, it. Ties up an IV line for a lot of hours out of the day and it can, it can be very challenging.
Yeah. So, Dr. Ster, I wanted to ask, which hospital acquired infection does CMS not require reporting for and why not? And like why does any of this matter? Great question.
Jennifer Ginestra: So hospital acquired infections, um, are infections that you develop in the hospital and there are. Two main bodies that track these in the us.
The first is the National Healthcare, uh, safety Network that tracks these mostly for surveillance and it tracks a lot of hospital acquired infections. The second is CMS, the Center for Medicaid and Medicare Services, which will require all hospitals to report a certain subset of hospital acquired infections quarterly, what their rates are.
And that’s not every [00:38:00] hospital acquired infection, but it’s a certain key few. So the most common, the, uh, CLABSI central line associated bloodstream infections, co catheter associated UTIs, also MR ssa, bacteremia, c diff infection, and certain surgical sites. In and they track those not only to be able to report public quality metrics to be able to compare hospitals, but also they tie those rates and, and quality metrics to reimbursement through.
Um. Medicare reimbursement rates. So they’ll penalize hospitals. If they don’t report, they’ll penalize hospitals that fall into the lowest 25% of very high rates of hospital acquired infections by reducing their reimbursement rates across the board, not just for sepsis. And then in 2008. Medicare actually also introduced a non-payment type rule where if a patient develops a hospital acquired infection, they won’t pay for that [00:39:00] higher complexity DRG that they might have ended up with.
They’ll just pay for what they initially came into the hospital with, and they won’t reimburse for anything that has to do with that hospital acquired infection. So all of that is to incentivize hospitals and healthcare systems to implement surveillance and prevention strategies to really get those rates down, which has.
In the sense that a number of those acquired infections have improved and gone down. I think the piece that’s challenging here is that there are other infections that you can get in the hospital that are not one of those. So that would be things like, uh, ventilator associated pneumonia is tracked, but it’s not tied to reimbursement, non ventilator associated pneumonia.
Um, anything that isn’t tied to a device basically. So. UTIs that aren’t from a catheter bloodstream, infections that aren’t from a central line, things like that. Um, other skin and soft tissue infections are not tied to reimbursement, not tied to these quality metrics and therefore not tied to these incentivized prevention programs.
The other pieces that we then can’t compare which programs [00:40:00] worked because we don’t have mandatory reporting across hospitals to say, oh, you implemented a, hospital B, implemented B, and these work better than another. So. It’s, um, it’s an interesting policy space that starts to influence what healthcare systems are doing to prevent these infections.
And where it really matters for hospital onset sepsis is that the reportable, sort of classic hospital acquired infections of CLABSIs, SC Diff, et cetera, only account for 14% of hospital onset sepsis cases. So that leads, I didn’t realize that. 86% of these hospital onset sepsis cases are from an infection that’s not tracked by CMS, um, which means that there’s a lot of room for improvement in these other things that get, get less attention, and there’s a reason that they get less attention.
Part of it is CMS is trying to track things that are theoretically potentially preventable because they’re device related and it’s much easier to just remove a device or have [00:41:00] sterile technique to insert it, that sort of thing. It’s much harder to present, prevent non ventilator associated pneumonia ’cause that’s then you’re talking about working on delirium, dysphagia.
Those things are much more challenging. They’re also much harder to identify in a standardized way. ’cause we just don’t have as standardized of criteria for identifying those cases. It would require a much higher burden of data collection going through charts and that sort of thing. So there’s reasons why they’re not necessarily tracked the same way and not tied to reimbursement the same way.
But I think a side effect to be aware of one for clinicians when we’re talking about hospital onset sepsis, it’s not just CLABSIs and cos it’s a lot of other stuff. And then two, from like a healthcare leadership perspective, there may not be the same motivation or funding for these prevention efforts for those other groups of infections, but it doesn’t mean that they’re less important or that they won’t have as big, if not bigger of an impact on the case fatality rates.
Nicole Kupchik: Wow. I, and I honestly did not know that statistic about. CMS [00:42:00] and yeah, 14%. I’m just a little mind blown right now. Wow. Yeah.
Jennifer Ginestra: And if you include ventilator associated pneumonias, which is another sort of classically tracked, and a lot of hospitals do track that, it’s just not tied to reimbursement. If you include that, we’re still only at like 28% of cases, you’re still, you still have three quarters of hospital onset sepsis cases that have nothing to do with what we classically think of as hospital acquired infections.
Nicole Kupchik: Can you talk a little bit about the role of the rapid response team and I, you know, just assisting with identification treatment strategies for patients who do have hospital acquired infections who are deteriorating?
Jennifer Ginestra: Yeah. It’s, it’s, um. It’s a challenging space because there’s definitely some data that suggests that rapid response teams improve care in the sense that they help, um, patients get blood cultures collected more quickly, get antibiotics more quickly, potentially a higher level of care ICU transfer more quickly.
Um, and in some cases it’s been shown to improve outcomes as well. Although the [00:43:00] data, I would say in rapid response team activation is very mixed. Part of that is because. There’s about a billion ways you can design a rapid response team. There’s all of the, um, efferent arms. So basically all the information that feeds into triggering a rapid response.
Um, there’s a lot of variation on what might trigger it, what your threshold is, um, how you’re monitoring those things, who can activate it. Then there’s a lot of variation in the afferent arm. So what actually gets deployed? Um, who goes to the bedside? What are they doing? Um. There’s actually an interesting study out of Cleveland Clinic a few years ago that, um, showed that they, they had really no change or even kind of a, a worsening in their outcomes after deploying a rapid response team.
Then they made some changes to it and it improved outcomes. It really was a, a helpful demonstration that it’s not just having one, but it’s how you do it and what it does that matters. Um, and so there’s probably not a one size fits all of what is the best fit for response team to [00:44:00] onset ep. Place where that can be really helpful is, again, the, you know, a lot of times rapid response teams will have, uh, a nurse, often a critical care certified nurse who is deployed and can get an IV help start fluids, start antibiotics, obtain cultures, obtain labs, um.
Sometimes you’ll also have a nurse coordinator or a critical care physician or other physician who can help kind of get the big picture of, does this patient want a higher level of care? Does this, you know, what is on the differential for this patient? Kind of take a step back and think things through.
Um, so I think particularly when we’re talking about these cases where there’s diagnostic uncertainty, it can be helpful to not only get things moving, but to get some new eyes on the situation. Um. And potentially some experts as well to help think through what’s most likely and and get things moving.
Nicole Kupchik: Dr. Schneer, I just wanna wrap up the episode by asking what three [00:45:00] points or takeaways would you give to other clinicians who are working in a similar space as you and treating patients who have hospital acquired infections?
Jennifer Ginestra: Yeah. I first is that hospital in. Can lead to hospital onset sepsis, about a quarter of those infections will lead to sepsis.
Um, but that’s not the whole picture. Those traditionally reported infections account for only a small amount of those hospital onset sepsis cases. And so for clinicians to be aware of that. Patients can develop sepsis in the hospital, not just from the Coty, the clabsi, the classic things, but also aspiration, pneumonia, other skin and soft tissue infections, even a bloodstream infection without a catheter.
So I think that awareness of those risks, and then also awareness from a systems level that these are. Additional sources of infection and risk that need to be addressed with prevention strategies that don’t necessarily have, uh, prevention strategies as [00:46:00] robust yet in as we do for things like cardio and clabsi.
Um, the second would be just knowing that patients with hospital onset sepsis are different than the patient coming through the ed. They tend to be higher risk. They might manifest sepsis in a more subtle way. The diagnosis may be less certain upfront, but they do have a high risk of needing ICU, needing mechanical ventilation, needing pressors, and a high risk of death, and they also have a high risk of drug resistant infections.
So. Starting their empiric therapy, you wanna be thoughtful about their severity of illness as well as their risk factors. So usually you’re gonna be covering pseudomonas and MRSA. You also need to think about risk factors for other drug resistant organisms, and also think about things like fungal infections and c diff, which patients in the hospital are gonna be more at risk of.
And then in choosing that empiric therapy and continued therapy, engaging with your antibiotic stewardship teams and your pharmacist and using your local antibiogram, [00:47:00] really pull in those experts because these cases aren’t as straightforward as the patient coming from the community. Um, and then the last piece is gonna be that deescalation is key.
So there are. Risks to not covering the patients broadly enough. But there are also risks to covering too broadly and leaving patients on big gun antibiotics that they don’t need. So really make sure that you get blood cultures drawn. Check things like a MRSA air screen check a procalcitonin, if your suspicion for infection is low and you think it’s gonna have a good negative predictive value, and use those tools to help you deescalate as soon as you can.
Nicole Kupchik: Amazing. That’s a lot of, that’s some great advice. Now, Dr. Men Jimma, I’m gonna pose this question to you. So if you could offer a few points of advice to clinicians, especially in these complicated patients, what would, what would be some parting thoughts from you?
Emi Minejima: Yeah, um, so, um, I’ll take a approach from like a ID pharmacist or maybe a, um.
Staff approach. [00:48:00] Um.
These patients obviously are unique. So what can you do to aid the clinician to make that diagnosis sooner? And then what can you do to help to help them get the right antibiotic sooner? Um, so obviously trying. To have a robust infection control to prevent any of these hospital acquired infections is gonna be really important.
Um, so collaboration with infection control, um, department is going to be important between infection control ICU and also antibiotic stewardship. And then from an antibiotic stewardship perspective, can we come up with other unique strategies in order to make getting that first antibiotic dose to them sooner?
So, um, there’s, you know, interesting work and using ai, you know, machine learning models, um, like the Inspire trial. Of course, this was done in the non critically ill, [00:49:00] but, um, using, uh, machine learning to figure out. In your patient population who is at risk for MDRs so that you can try to tailor who gets the carbapenem versus maybe who gets the ceftriaxone, um, when they had that onset of sepsis.
Um, second is okay, can you create certain things in the EHR to make it easier for the clinician to order the right antibiotic for the patient? So there’s a lot of investigation into order sets.
Making sure that you provide education, I think is a big part of antibiotic stewardship. Um, especially at larger academic centers. Um, every July we have to have that same, um, education piece to our new, um, interns that are coming in about the importance of stewardship and, um, how it really is everybody’s responsibility to utilize the antibiotics in the, uh, an effective and safe way for our patients.
Nicole Kupchik: It is definitely complicated and [00:50:00] I just wanna thank both of you for coming today. You both are experts in your field and just sharing your, your knowledge and I think a lot of helpful tips that other clinicians will be able to use at the bedside.
Jennifer Ginestra: Thank you for having me. Thanks.
Nicole Kupchik: Boy, those were some complicated topics we just chatted about and we all know recognition of hospital onset sepsis is very, very difficult. It is so hard to identify when you’ve got a patient who’s already sick and gets sicker and, and then that often ties into antimicrobial resistance. So I just wanna thank Dr.
Ginestra and Dr. Meninga for just talking about these complex issues. Thank you for joining me on today’s episode of the Sepsis Spectrum. If you like the show, we wanna hear about it. Please leave a review wherever you’re enjoying the podcast. It helps a ton. You [00:51:00] can also reach me in our awesome team at info at sepsis.
Dot org or visit sepsis podcast.org to share any stories of your own questions, concerns, or episode ideas. To learn more about Sepsis Alliance, visit sepsis.org. The sepsis spectrum is brought to you by Sepsis Alliance. I’m your host, Nicole kic. Our executive producers are Alison Strickland, Hannah Sass, Claudia Orth and Alex Colvin. Our producers are Aaron Corny, Rob Goldman s Shahnti Brooke, and me Nicole Kubic. Our post-production producer is Tim Scott. Our editor and engineer is Jason Portizo, and our music is by Omer Ben-Zvi. To learn more about Sepsis Alliances podcast, legal disclaimer and compliance policies, you can visit sepsis podcast.org/disclaimers.
The sepsis spectrum is a human content and sepsis alliance production.[00:52:00]
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