Antibiotic Stewardship at SSRRH (Nadeau, 1/26/2022)

The Adult Medicine Service of the Santa Rosa Family Medicine Residency have had the honor and privilege of rounding daily with the SSRRH Pharmacists for the last 4+ years, and we are better physicians for it! This week, Sue Nadeau, one of our wonderful pharmacists, gave us an important Grand Rounds on Antibiotic Stewardship at SSRRH.

To watch the presentation, please click HERE.

The presentation covered 4 important topics in antibiotic stewardship, and 1 on anticoagulation (because you cannot NOT talk about warfarin, even in 2022)

• QT prolongation
• Warfarin
•  Extended-spectrum beta lactam (ESBL) E Coli
• Extended infusions of beta lactam antibiotics
• IV to oral antibiotics

QT Prolongation  or long QT syndrome (LQTS) is a disorder of myocardial repolarization characterized by a prolonged QT interval on EKG. 

• LQTS is associated with an increased risk of polymorphic ventricular tachycardia, a  life-threatening cardiac arrhythmia aka torsade de pointes 
• Primary symptoms include palpitations, syncope, seizures, and sudden cardiac death.
• For men, normal QTc is ~350-450
• For women, normal QTc is ~360-460

Some of the long list of drugs that affect QT

There are LOTS of meds that lengthen the QTc, and the most commonly rx'd antibiotics are azithromycin, ciprofloxacin, and fluconazole (see chart for additional culprits)

Tips to avoid QT prolongation: 

1) Check EKG on admission (QTc>500 should definitely get your attention)

2) Review chronic medications that prolong QT (e.g. cardiac, antipsychotics, SSRI, TCA, oral cancer meds, HIV meds). Hold if needed

3) Check electrolytes: potassium and magnesium (normal levels decrease risk of Torsade)

4) Check renal function (and dose adjust if indicated)

5) Call the pharmacist for any questions

And. . .whenever possible do NOT use azithromycin or ciprofloxacin, particularly in high risk 

Warfarin is metabolized in the liver via cytochrome P450 

• Drug interactions occur when meds compete for the same enzyme system
• We all know that drugs interactions are a BIG deal with warfarin
• Drugs well known for warfarin interactions: amiodarone, metronidazole, Bactrim (aka TMP/SMX), fluconazole, voriconazole, macrolides (including azithromycin, though in the literature less often)

ESBL E Coli

• In the Sutter system, ceftriaxone (Rocephin) resistance seen on the sensitivities report in any E Coli is a proxy marker for ESBL
• Our E Coli has gone from 95% to 93% sensitive to Rocephin, new antibiogram will be out in the spring (April)
• Meropenem (with ID approval) is the medication of choice, EVEN if the E Coli appears to be sensitive to fluoroquinolones

Extended infusion of beta lactam antibiotics-- for pip/taz, cefepime, and meropenem

• Beta lactam antibiotics are bactericidal just during the administration, but stopping a 30 minute admin can allow an organism to quickly begin to replicate
• Extended duration infusions (usually 4 hours) have been shown to decrease bacterial load and improve outcomes
• Currently these happen for ICU patients with the above abx, but can be ordered for non-ICU patients if deemed clinically indicated (e.g. quite sick, still spiking fevers, etc)
• need to discuss with bedside RN because infusion will use the line for long periods of time, sometimes patients need an additional line
• These are 4 hour infusions q8 hours

IV to Oral antibiotics

Oral is better! Decreased risk of line infections, decreased risk of thrombophlebitis, decreased cost (of actual medication as well as nursing and admin costs), earlier discharge

We should really be thinking about transitioning to PO abx as soon as we can. Here are guidelines:

• Afebrile x24 hours
• Blood cultures no growth x48 hours
• Tolerating PO diet
• Improved clinical status
• Normal or decreasing WBC count
• Hemodynamically stable (e.g. normal vital signs x 24 hours)

We are SO blessed at SSRRH to have the benefit of a number of pharmacy-driven protocols, including:

• Dose adjustments (primarily renal, but occasional hepatic)
• Dose optimization (e.g. gentamicin, vancomycin by protocol)
• Automatic alerts
• Automatic stop orders (e.g. azithromycin x 5 days, oseltamivir x 5 days)
• Drug drug interaction checks
• Shortest effective duration

Thanks to Sue, Carolyn Dam, and the whole pharmacy team for their amazing collaboration in caring for our patients!

Race-Based Affinity Caucusing as a Tool for Promoting Equity and Inclusion (Washington, 1/19/2022)

Many thanks to Dr. Sharon Washington for an important presentation on Race-Based Affinity Caucusing as a Tool for Promoting Equity and Inclusion. 

It is always worth your time to listen to Dr. Washington. She has been a tremendous resource and teacher for our anti-racism work at Santa Rosa Family Medicine Residency. A recording of her presentation is available HERE. 

Dr. Washington opened with two recent articles from the medical literature exploring racial harms in the healthcare setting and recommended that leadership teams could explore caucusing as a tool to support community, connection, and racial healing and equity in the health care setting

Paper #1: Racism as Experienced by Physicians of Color in the Health Care Setting, Serafina et al, Family Medicine 2020, exploring racism as experienced by physicians of color

• 71 physician participants, 88% family medicine physicians
• 72% female, 1.4% gender non-binary
• 34% black, 34% Asian, 24.7% Hispanic/Latinx, 1.4% Native American/Alaskan Native
• 33% English as a second language (ESL)
• Dr. Washington notes two caveats
• we know that physicians are higher in medical hierarchy, and this study doesn't take into account experiences of nurses, support staff, that are also BIPOC
• the study also doesn't include color/lightness of skin (which we know plays a role in the experience of racism), and which we know from previous studies is likely to be lighter than those of staff lower in medical hierarchy

Findings from this study

Experiences offered by Physicians of color (POC):

• more likely to experience racism from colleagues than from patients
• 23% POC reported a patient refused their care because of their race/ethnicity
• ESL POC report more incidents of racism than those with English as first language
• Experiences of micro-aggressions are associated with secondary trauma/stress with ongoing implications in the mental and physical health of these POC
• surprisingly, not statistically significantly associated with compassion fatigue or burnout

Qualitative themes from this same study:

How has institutional racism affected you?

• exclusion from leadership advancement (treated differently than non-black counterparts)
• assumptions discounting abilities or expressing stereotypes
• being held to higher standards than white counterpart
• numerous microaggressions in the workplace without response from the institution

Incidences of racism from a colleague. . .

• many did not have an example of experience of racism from colleague 
• microaggressions from colleagues: assumption they are not a doctor because of race, general lack of respect, homogeneity bias
• assumptions: e.g.  about medical knowledge in context of accented English
• invalidation: lack of trust

Instances of racism from a patient. . .

• microaggressions
• assumptions
• patient refusal of care
• adaptation: comments on "where were you born and how how well I speak English"
• psychological burden of patient questions "where are you from", "Are you Korean"
• patients reacting differently to the same advice when offered by a colleague
• differential treatment: non-verbal, body language

Dr. Washington remarks: above are the experiences that POC revisit (and hyper-revisit), struggle to let go of, not for lack of conscious effort, experiences that can cause physical and chemical reactions when these types of instances happen with patients, colleagues, staff, etc. have weathering/long term effects on physical and mental well-being, ability to stay in the work place

Recommendation for promoting inclusion includes listening to POC, offer diverse representation in leadership, staff and recruitment, empowering BIPOC leadership

Paper #2 When Racial Trauma is the Chief Complaint among Healthcare Staff, Mollica et al., Lancet 2020

• learners (students, residents) and lower level health care staff are more vulnerable to racial trauma, particularly during pandemic
• seeing selves in the disparities, seeing structural and interpersonal practices
• creating a safe and trusting environment where staff can share their racial trauma
• training managers and supervisors (skills, time)
• engage in deep listening to the trauma stories
• provide concrete support, if needed (e.g. escort at night to the car, restorative time off)

Note from Dr. Washington: while the title includes "health care staff" this is actually another paper about physicians. Researchers need to be reflecting on the power hierarchy and be sure to extend beyond physician experience when reporting on this topic

Racial Affinity Group Caucusing is approach to bring people together, based on shared mindset, identities, orientation (e.g. physicians come together, nurses have meetings)

• allow group to focus on manifestations of how we internalize racial oppression in a system that is hierarchical, promotes dominance, and is inherently racism
• identify where behaviors originate
• collectively find new behaviors that stop self-perpetuation of cycles of these concepts
• allows groups that identify as white to come together, people who identify as black (or African descent), groups who identify as Latinx (or Hispanic)
• the bigger the group, the more specific these groups can be
• allows people to be in "safer space", grounded in "shared experiences" to explore structural racism, how we contribute to perpetuation
• seek to explore ways in which we contribute in unintentional ways
• build communication skills to stay present and effectively navigate cross-racial dynamics
• our bodily reactions can make it hard to stay present if we don't have the racial literacy to stay present in our bodies
• allow for creation of community of dialogue, accountability, support institutional growth of equity and racial inclusion
• challenges white folks to do their own work (and not rely on BIPOC to do the work)
• allow white people to develop a racial identity, own one's racial identity (just like BIPOC do every day)
• leverage the sense of self to be committed to growing together in anti-racism
• within BIPOC spaces caucusing allows be understood, collaborate, not have to explain or be believed
• have more nuanced, deeper more complex conversations about intersection and deeper identities, how BIPOC perpetuate other forms of bias and dominance in other identities

What does caucusing look like?

Priming content: e.g. podcast, readings, video content

Groups (as defined by the institution) but self-selected by the participant

Planned curriculum discussion, agenda with a trained facilitator/moderator

Engage in dialogue and discussion during the session

Have some sort of report out: sharing, transparency, accountability to the other caucus groups

What is caucusing is NOT?

not place to whine/complain, not hate fest, hot pot for racism

people are not assigned for multi-racial or mixed race person (they can be fluid), people self-identify and choose the group 

A final note: Caucusing is NOT "the only answer" to solving racism in the health care setting.

Caucusing must be combined with a comprehensive PROGRAM of equity and inclusion, including DEI leadership, committees, curriculum and trainings, policy, metrics of accountability, dashboards, and a concrete commitment of the organization to anti-racism work. 

Neonatal Indirect Hyperbilirubinemia (>35 weeks) (Kutilda, 1/5/2022)

Many thanks to Dr. Pumi Kutilda who is such a dedicated teacher for our residents and gave an excellent detail-packed, graphic-filled presentation on Neonatal Indirect Hyperbilirubinemia this week. 

A recording of her presentation is available HERE.

Abbreviations used below: Total serum bilirubin (TsB), Transcutaneous bilirubin (TcB), gestational age (GA), Red blood cells (RBC), Risk factors (RF)

• Severe hyperbilirubinemia TsB >20 mg/dl (during first 28 days)
• Critical hyperbilirubinemia TsB>25 mg/dl  (during first 28 days)
• Cholestasis is defined as Direct bilirubin >1 mg/dl (need be checked only ONCE)
• RBC lifespan in newborns is 70-80 days (compared to 120 for adults)
• the lower the GA, the lower the RBC lifespan-- which puts preemies at higher risk
• High levels of free unconjugated bilirubin (not bound to albumin) crosses the blood brain barrier (specifically the globus pallidus) and causes neurological effects (i.e. kernicterus)
• this is why babies w/low albumin (<3) are at higher risk for hyperbilirubinemia 
  

History and Physical Exam are essential in diagnosis and management

• Prematurity 
•  <35 weeks GA, be sure to use the Preemie Bili Tool
•  >35 weeks GA use the regular Bili Tool 
• Polycythemia
• Known Hemolysis
• History of dehydration, suboptimal breastfeeding, poor latch, etc
• Constipation

Work up for Neonatal Hyperbilirubinemia

CBC + Diff, reticulocyte count + blood smear (retic count is critical because determines whether or not there is hemolysis, may need to be done serially), albumin, BMP/CMP, Direct bilirubin (just once to rule out conjugated hyperbilirubinemia), CBG/ABG + lactate (if hypoxic), G6PD (if hemolysis identified), Urine Culture (silent infection), thyroid function tests (if persistent jaundice >2 weeks)

See Pumi's excellent graphic for representation of how the peripheral blood smear can determine diagnosis

Where do we go wrong with diagnosing hyperbilirubinemia?

• missed hemolytic disease (e.g. G6PD deficiency)
• not repeating reticulocyte count

Physical Exam

lethargy, s/sx dehydration, hypertonia, "scared" upward gaze, high pitched cry

Screening and Management

1) Promote breastfeeding 

            Should be based on feeding cues

            No forced or supplemental feeding <24 hours (very minimal intake first 24 hours)

            Amount to feed is based on time after birth (H)

                    12-24 hours: 5-10ml q2-3 hour

                    24-48 hours: 10-30ml q2-3 hours

                    48-72 hours: 15-30ml q2-3 hour

                    72-96 hours: >30ml >8 times/day

2) Risk factor assessment 

    MOST important RF: gestation age <38 weeks, sibling who required phototherapy, visible jaundice first 24 hours, maternal coomb's positive

    LESS important RF: male, non-white (esp SE Asian), exclusive breastfeeding, cephalohematoma or significant bruising

Absence of these risk factors means extremely low risk for severe hyperbilirubinemia

    

3) Hour specific TcB screening: @12 hours, 24 hours (plotted on hour specific nomogram)

4) Assess adequate intake via both weight measurements AND stool patterns

                                #stools + # urine             weight loss %

                                    <24 hours 1+1                     <3%

                                    48 hours 2+2                        <7%

                                    72 hours 3+3                        7%

5) Risk factors for phototherapy: GA + hemolytic disease, suspected sepsis, asphyxia, acidosis, serum albumin <3

Added Pearls

• Both ibuprofen and naproxen increase bilirubin so are not used in newborns (indomethacin is used instead, eg PFO closure)
• To avoid degradation and ensure accurate measurements, blood should be carefully handled,  drawn into clouded red tube, and sent to lab to evaluated right away (<2 hours)
• Of note, TcB using one of two specific machines (JM103, JM105-- one of which we have at SSRRH) correlates VERY well with TsB except when TsB gets very high (>17). 
• We should be considering the TcB results as quite accurate as long as TcB is <13. 
• IF TcB>13, TsB indicated right away
• Home phototherapy (via bili blanket) is an option for medically stable patients (no neurotoxicity risk factors, no hemolysis, feeding well and well appearing). Costs about $200 delivery and $85/day. Patients have to pay up front but are generally reimbursed by their insurance
• There are new guidelines from UCSF (Northern California Neonatal Consortium), not active at SSRRH yet but soon will be. Keep your eye out

Words Matter: Bias and Stigma in Medical Documentation (Walsh-Felz, 12/15/2021)

 Many thanks to senior resident Dr. Devin Walsh-Felz for a pratice-changing Grand Rounds this week about how we transmit bias and stigma in our chart notes. Her presentation was titled Words Matter: Bias and Stigma in Medical Documentation.

It is definitely worth watching!  A link is available HERE. 

A summary of her presentation is currently in progress.