Empiric Antibiotics and SSRRH Antibiogram (Patel, 9/25/24)

 Many thanks to Omi Patel, PharmD and head of our SSRRH pharmacy for an excellent and important talk on Empiric Antibiotics and the SSRRH Antibiogram. A recording of her presentation is available HERE. 

My notes:

Empiric antibiotics should be chosen based on many different factors:

• patient characteristics (age, comorbidities, recent hospitalization, etc)
• site of infection
• pharmacokinetics
• evidence-based guidelines (e.g. IDSA, John's Hopkins, Sanford guide)
• facility specific guidelines (CPMC, UCSF)
• clinical pathways (most recent possible)
• local antibiogram (which is what this talk focused on)

At SSRRH, there is a system-wide order set that offers empiric antibiotic options based on site of infection. It is available under order sets. Do NOTE these are not specific to SSRRH, and our local antibiogram should be consulted if using these order sets.

As noted above, the hospital specific antibiogram is essential to good antibiotic stewardship. Omi pointed out that for bacteria for which we have less than 30 isolates, the data is less reliable and trends over time (i.e. looking back at old antibiograms) may be helpful in choosing the empiric treatment. You can see on the antibiogram below, the numbers in red reflect the number of isolates from 2023 of that particular bacteria. Reach out to the pharmacist to help you with this. The "30 isolate rule" is a National standard so applies to any antibiogram

Gram Negative Organisms at SSRRH

trends over time for Morganella at SSRRH

Last year, at SSRRH 64% of Gram Negative Organisms were E Coli. Other more commonly isolated organisms include Klebsiella, Pseudomonas, Proteus and Enterobacter.

For general medical patients, >85% susceptibility is considered adequate for empiric antibiotics.

For ICU patients, the higher the better, >90% susceptibility is preferred.

Empiric UTI Treatment

In 2023, SSRRH changed to using Cefoxitin, a second generation cephalosporin, as our first line for empiric parenteral UTI treatment.

Of note, our current rates of susceptibility of E Coli to ciprofloxacin (80%), levofloxacin (77%) and Bactrim (79%) mean that we should NOT be using them for empiric treatment for UTI.

Omi reminded us of a few common clinical circumstances:

• Despite common practice, ceftriaxone does not concentrate well in the urine as cefoxitin. Ceftriaxone should not be first line for UTI treatment
• Once culture results return, use the specific data to drive antibiotic treatment moving forward
• If a patient has had a recent history-- meaning in the last 120 days) of infection at the same site, use that information (and NOT the antibiogram) to drive your empiric antibiotic choice
• ESBL is a form of resistance that presents in gram negative bacteria. 
• The CTX-M gene (aka Ceftriaxone resistance) is a surrogate marker for ESBL 
• Sutter labs will not specifically report out an ESBL organism, so LOOK for ceftriaxone resistance as a surrogate marker for ESBL organisms
• If you suspect an ESBL organism, do NOT use Zosyn, any cephalosporin for empiric treatment. Your best choice is a carbapenem

• For pseudomonas aeruginosa, the only oral abx for this organism locally is ciprofloxacin, and based on 2023 antibiogram, it is currently only 83% sensitive
• do NOT use levofloxacin (77% sensitive)

Empiric Staph Aureus 

• MRSA resistance to clindamycin has been consistently high since 2017 (around 59%)
• do NOT use clindamycin for MRSA coverage
• Resistance to TMP-SMX is increasing in Santa Rosa (>16% resistance rate)
• Doxycycline sensitivity (currently 95%) is significantly higher than tetracycline (68%).
• Tetracycline is NOT a good surrogate marker for doxy against MRSA. Therefore, susceptibilities should be reported separately.
• Doxycycline is a good local choice for empiric MRSA coverage

Empiric Group B Strep (GBS)

• Local GBS is resistant to clindamycin 50% of the time, GAS is resistant 25% of the time
• Clindamycin should never be used to empirically cover GBS in a pregnant woman without sensitivities 
• Unless sensitivity is known, linezolid is preferred over clindamycin to inhibit toxin production (usually just 3 days duration)

Restricted Antibiotics

At SSRRH, certain antibiotics are restricted to ID approval with the intention of preventing misuse/overuse and preserving susceptibility over time. This technique has proven successful in limiting our local resistance. The restricted antibiotics include:

Barriers to Fertility Care (Orozco-Llamas, 9/18/2024)

Many thanks to Dr. Orozco-Llamas for an excellent, thought-provoking presentation this week on Barriers to Fertility Care. A recording of her presentation is available HERE.

My notes:

2020 American Society for Reproductive Medicine definition for infertility:

• Inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing or any combination of those factors.

• Need for medical intervention to achieve a successful pregnancy either as an individual or with a partner

In patients having regular, unprotected vaginal-penile intercourse, evaluation should be initiated at 

• 12 months when the female is under 35 years of age
• 6 months when female is 35 - 40 years
• Immediate evaluation may be warranted in female >40 years

Infertility affects 15% of heterosexual couples in the US

Male factor accounts for 40-50%

Female factor accounts for 35-50%

Unexplained fertility accounts for ~30%

This talk did not cover the usual fertility evaluation, but a typical plan for infertility includes diagnostic services (serum lab tests, semen analysis, imaging and diagnostic procedures, e.g. laparoscopy or hysteroscopy) and treatment services, including medications (clomiphene/letrozole), surgery (laparoscopy or hysteroscopy), intrauterine inseminations (IUI) and in vitro fertilization (IVF)

Each of these components has an associated cost:

For patients who need fertility specialty care, costs are generally self pay. At our local fertility clinic-- Advanced Fertility Associates, Inc, here are some current out of pocket costs:

• Consult $280 

• US done in-house $275  (even if done already at outside facility)

• Blood work $350 (often needs repeating)

• IUI $400 per cycle

• IVF $10,000-$15,000 per cycle

It is important to note that fertility treatments do not every guarantee a successful pregnancy and many of these costs need to be multiplied to achieve success. If you look at the graph below from KFF, you can see that whereas a single cycle of IUI may cost about $3500 dollars, the average cost per successful pregnancy is over $10,000 dollars. 

Ovulation stimulating medication is relatively low-cost for our Medi-Cal and uninsured patients (~$18 for a course of clomiphene and/or letrozole), but there is currently no in clinic IUI offered at our community health centers. Patients can be counseled on doing home insemination, which has a lower success rate.

We know that IVF has been in the national political conversations lately. It is important to note that there is wide variability in states regarding private insurance mandates around fertility care. 

As of June 2024, 23 states have mandates requiring insurance companies to include some coverage for infertility diagnosis and treatment. Of these, 15 states specifically require coverage for IVF. Most require a clinical diagnosis of infertility, often requiring all people seeking coverage, including single people and people in same sex partnerships, to demonstrate clinical infertility (sometimes requiring a rounds of IUI before covering IVF).

Where policies cover IVF, coverage is limited by either a dollar limit or a maximum number of IVF cycles.  Several of the states that mandate insurance coverage of infertility treatment do not require religious organizations, small businesses, or employers who self-insure to offer coverage. Several states require that the patient be married. Many states place an age limit on infertility treatment.

No state Medicaid (in California, MediCal) currently covers IUI or IVF.

***

All this being said, patients of color and patients with low SES have higher rates of infertility! In fact

• All non-white racial and ethnic groups (black, other race, and Hispanic) are significantly more likely to experience infertility than whites.

• Both high school dropouts and high school graduates are significantly more likely to experience infertility than four-year college graduates. 

• Women who are not white and women who are of lower SES are significantly less likely to report ever having received infertility treatment.

This is an equity issue. It shouldn't be surprising that women seeking fertility treatments tend to be older, white, of higher income and privately insured. 

Also of note, there is evidence that women who work with pesticides have higher rates of infertility. See image below for details on two studies that are highlighted. This is particularly relevant to many of our local SoCo patients who work in vineyards and local farming industry. 

What can primary care docs working in the safety net do with patients who need fertility services?

• Talk to your  patients about fertility!

• Refer to WHPC or GYN clinic at Vista SRCH

• Education on infertility and ovulation cycle

• Mental health resources

• Diet and lifestyle modifications

• Guidance on when to refer and providing financial information

References:

• Bill Status - SB-729 Health Care Coverage: Treatment for Infertility and Fertility Services. leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202320240SB729.
• Figà-Talamanca, Irene. “Occupational risk factors and reproductive health of women.” Occupational medicine (Oxford, England) vol. 56,8 (2006): 521-31. doi:10.1093/occmed/kql114
• Fuortes, L et al. “Association between female infertility and agricultural work history.” American journal of industrial medicine vol. 31,4 (1997): 445-51.
• Gaskins, Audrey J, and Jorge E Chavarro. “Diet and fertility: a review.” American journal of obstetrics and gynecology vol. 218,4 (2018): 379-389. doi:10.1016/j.ajog.2017.08.010
• “Infertility: An Overview Patient Education Booklet.” Infertility: An Overview Patient Education Booklet | ReproductiveFacts.Org, American Society for Reproductive Medicine, www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/infertility-an-overview-booklet/.
• Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstetrics & Gynecology 133(6):p e377-e384, June 2019. | DOI: 10.1097/AOG.0000000000003271
• Katz, Patricia et al. “Costs of infertility treatment: results from an 18-month prospective cohort study.” Fertility and sterility vol. 95,3 (2011): 915-21.
• Mays, Mackenzie. “A Bay Area Cancer Patient Froze Her Eggs in Hopes of Having Children. She Can’t Afford to Finish IVF - Los Angeles Times.” Los Angeles Times, 9 Apr. 2024, www.latimes.com/california/story/2024-03-31/ivf-isnt-covered-by-insurance-in-california-hopeful-parents-are-struggling-to-afford-fertility-care.
• Phillips, Kiwita, et al. “Infertility: Evaluation and Management.” AAFP, 15 June 2023, www.aafp.org/pubs/afp/issues/2023/0600/infertility.html.
• Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. “Definitions of infertility and recurrent pregnancy loss: a committee opinion.” Fertility and sterility vol. 113,3 (2020): 533-535. doi:10.1016/j.fertnstert.2019.11.025
• Weigel, Gabriela, et al. “Coverage and Use of Fertility Services in the U.S. | KFF.” KFF, 15 Sept. 2020, www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s.

CKD transition to Hemodialysis (Cheung, 9/11/2024)

 Many thanks to Dr. Eric Cheung, nephrologist, for a great talk on transitioning patients with CKD to Hemodialysis. 

A recording of his presentation is available HERE. 

My notes:

Dr. Cheung began with the global trends of dialysis. While center-based hemodialysis (HD) is much more common in the US (~90% of US pts), home peritoneal dialysis (PD) is much more common in developing countries (it’s cheaper and requires less infrastructure). Interestingly PD rates are also quite high in Hong Kong (80%) where ALL patients are mandated to start dialysis on PD. 

In general the highest rates of dialysis are in the wealthiest countries. 

 

In the US, there are 468,000 patients on dialysis, and 193,000 with a functional transplant.

One area we need to improve in is telling our patients they have CKD.  

• Of patients who have CKD 1-3 (who are thus asymptomatic), less than 10% know they have CKD
• For patients who are CKD stage 4, only 45% know they have CKD. Yikes!

 

There are several types of transition from advanced CKD:

• Advanced CKD -> dialysis
• Advanced CKD -> pre-emptive transplantation
• Changing dialysis modalities (HD>> PD, PD>> HD)
• Failed transplant -> dialysis
• Dialysis -> transplant

And don’t forget that no initiation of dialysis is an option- just conservative management

 

Categorizing patient risk for progression from CKD to HD:

• High Risk Patients: any patient with diabetes (especially those with proteinuria), uncontrolled HTN, CHF, cirrhosis, >60 years old, and Polycystic kidney disease.
• Lower Risk Patients: AKI with recovery (i.e. Sepsis, cardiac arrest, dehydration, obstructive uropathy), ironically Polycystic kidney disease (really based on family history—if hx of PKD on HD high risk for HD, if PKD but no progression, unlikely to progress)

There is an online calculator to help! https://kidneyfailurerisk.com

 

Does it help to start dialysis early (GFR 10-14) vs late (GFR 5-7)?

• The IDEAL study for ASYMPTOMATIC patients with CKD shows us that there is NO difference in mortality. So…
• if the eGFR is >15 or is 5-15 without symptoms -> monitor (of course with the help of your friendly neighborhood nephrologist
• if the eGFR is 5-15 with symptoms or <5 -> start dialysis
• 
  

Initiation of dialysis is risky!  Especially the first several months— there is a 7-10x increase in death (even over all dialysis patients who already have a high mortality)! Cardiovascular and infectious causes are major causes of increased mortality. Indications to initiate dialysis include:

·         Absolute indications: uremic encephalopathy, uremic pericarditis/pleuritis

·         Common indications: declining  nutrition/appetite, fatigue/malaise, mild cognitive impairment

Ideally, initiation starts gradually with advanced planning including setting expectations and getting long-term access coordinated (see below).

However, some patients need to start HD in the hospital – if no other option, poorly controlled HTN or hypotension, active angina, hx of seizures, or lack of social support.

 

Hemodialysis Access:

·         AV fistula is preferred and often lasts the longest and is basically a direct connection of the artery and vein in the forearm. Greatest risk of clot in the first month but thereafter clots are uncommon. Can last decades.

·         AV graft needed sometimes in vasculopaths and connect the artery and vein, but tends to clot when no longer in use.

·         Central venous catheter/tunneled cath: definitely least preferred but often used in transition. It is inserted into the internal jugular (NEVER the subclavian due to risk of stenosis), double lumen 14-16 french.

Tips from your friendly nephrologist for primary care providers:

 Medications to avoid/adjust:

o   DM: ask CKD progresses, pts generally need less insulin needed because it hangs around longer; ALWAYS stop metformin when GFR <30 to avoid lactic acidosis; and d/c thiazolidinediones

o   HTN: as CKD progresses, stop ACE/ARBs (but after they start on HD they are great HTN meds)

o   Seizure/Pain meds: avoid gabapentin and baclofen which have toxic metabolites in CKD/ESRD

o   Antibiotics: Bactrim/Septra – don’t use in CKD patients since the SMX component can cause hyperkalemia; Cefepime can accumulate (care with this!)

 Preserve the Veins in your CKD patients long BEFORE they may need dialysis!

• Avoid subclavian lines
• Avoid PICC lines and midlines as much as possible
• For phlebotomy, use dorsal veins of the dominant hand instead of AC fossa

And last but not least. . .Dr. Cheung’s personally preferred form of dialysis? (and hopefully he never needs it!)….HD at HOME!  (yes, this is actually an option). Rare but has lower mortality and complications than HD at centers

Neurodiversity in Medical Education (Biradar, 9/4/2024)

Deep gratitude this week to Dr. Sony Biradar for a thought-provoking Grand Rounds presentation on Neurodiversity in Medical Education. It was one of those presentations that sticks with you all day, makes you wonder if maybe you've been thinking about things incorrectly for a long time. I recommend watching the recording if you or someone you love identifies as neurodivergent OR if you work with or supervise someone who does.

A link to the recording will be available HERE.

Here are some key take homes:

• Neurotypical describes someone whose cognition is aligned with societal norms, i.e. whose brain functions are considered usual or expected by society.
• Neurodivergence describes someone whose cognition and processing are different than "the societal norm".
• Some neurodivergent people have an associated diagnosis (e.g. ADHD, autism), but not all.
• 15-20% of the population is neurodivergent 
• Neurodivergent people suffer high rates of unemployment, have disproportionate rates of anxiety, depression and risk of suicide

Dr. Biradar spent a fair amount of time talking about the idea of disability as a social construct -- first, that neurodivergence has long existed in society and may even have some developmental benefits that has ensured its persistence. In the medical model of disability (one which we are all a part of), impairments that affect one's quality of life need to be "fixed". In contrast, in the social model of disability, conditions are themselves not a disability, it is societal structures that make them disabling. 

The prevalence of neurodiversity in medical training has not been well-studied, nor has the experience of students and trainees. Dr. Biradar posits that certain adaptive behaviors/challenges may be heightened in neurodivergent trainees:

• masking: trying to hide one's neurodivergence may lead to increased exhaustion, higher rates of burnout, and even increased suicidality
• hidden curriculum (socialization that happens for trainees when what they see differs from what is said/what they are taught)
• imposter syndrome: may be increased for neurodivergent trainees
• double empathy: a type of stereotype threat. . .
• otherness: when trainees feel different from the norm, this may impact their ability to learn and perform

Dr. Biradar talked about how the process of moving through residency training-- acquiring knowledge and skills from attendings -- may simply be more challenging for neurodivergent trainees simply because the way they work/think is, by definition, different from the "medical norm". 

Residency training is known to be intense, overwhelming, and stressful. The inputs are numerous.

Experiencing this level of stress as a neurodivergent learner may be particularly overwhelming. Don't forget intersectionality,  Dr. Biradar cautions, for we know that other identities (namely BIPOC learners already experience these 

What can we do? How do we support neurodivergent learners? 

Start with being strength-based, says Dr. Biradar. Look for ways to help learners demonstrate their strengths, do not just focus on their deficits. Also, consider the theory of multiple intelligences-- different ways that learners learn and acquire new information (oral, visual, audio, reading, etc). Offer multiple options.  Promote psychological safety in your learning environment, as well as mentorship. Also encourage and promote increased neurodiversity in leadership and encourage community. 

Finally, consider the concept of compassionate pedagogy, asks us to be critical of institutional and cultural practices in medical training.  Compassionate pedagogy is a collection of teaching practices designed to foster human connection, communication, and wellbeing. The approach revolves around listening to students’ lived experiences and offering flexibility to accommodate their struggles. If we want our students to learn well, we need to honor the often imperfect way they show up. 

Dr. Biradar closed her presentation with the comic below, which captures some of the challenges of neurodivergent learners -- and the potential benefit of medication treatment for some conditions (in this case ADHD). 

References:

AoME Insights Embracing Neurodiversity in our Healthcare Educators 29 March 2023. (2023). Academy of Medical Educators.

https://www.youtube.com/watch?v=Ugx2WjkKvSI

Duong D, Vogel L. Untapped potential: embracing neurodiversity in medicine. CMAJ. 2022 Jul 18;194(27):E951-E952. doi:

10.1503/cmaj.1096006. PMID: 35851534; PMCID: PMC9299741.

Fung, L.K. & Doyle, N. (2021). Neurodiversity. The new diversity. In: Neurodiversity. From Phenomenology to Neurobiology and

Enhancing Technologies.

Goldberg H. Unraveling Neurodiversity: Insights from Neuroscientific Perspectives. Encyclopedia. 2023; 3(3):972-980.

https://doi.org/10.3390/encyclopedia3030070

Hamilton LG, Petty S. Compassionate pedagogy for neurodiversity in higher education: A conceptual analysis. Front Psychol. 2023 Feb

16;14:1093290. doi: 10.3389/fpsyg.2023.1093290. Erratum in: Front Psychol. 2024 Feb 20;14:1345256. doi:

10.3389/fpsyg.2023.1345256. PMID: 36874864; PMCID: PMC9978378.

Robinson D. Neurodiversity in medical education: How can we improve postgraduate learning for neurodiverse doctors? Med Teach.

2022 May;44(5):564-566. doi: 10.1080/0142159X.2022.2039383. Epub 2022 Mar 2. PMID: 35236237.

Shaw SCK, Fossi A, Carravallah LA, Rabenstein K, Ross W, Doherty M. The experiences of autistic doctors: a cross-sectional study.

Front Psychiatry. 2023 Jul 18;14:1160994. doi: 10.3389/fpsyt.2023.1160994. PMID: 37533891; PMCID: PMC10393275.

Syharat CM, Hain A, Zaghi AE, Gabriel R, Berdanier CGP. Experiences of neurodivergent students in graduate STEM programs. Front

Psychol. 2023 Jun 15;14:1149068. doi: 10.3389/fpsyg.2023.1149068. PMID: 37397290; PMCID: PMC10311419.

Taylor G. Editorial: Embracing neurodiversity in medicine. Aust J Gen Pract. 2021 Mar;50(3):101. doi: 10.31128/AJGP-03-21-1234e.

PMID: 33634273.