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Utah
Hospital Antibiotic Use Survey
Background
In the past ten
years, the incidence of infection and colonization with antimicrobial-resistant
organisms such as methicillin-resistant Staphylococcus aureus
(MRSA) and vancomycin-resistant enterococci (VRE) in patients in U.S.
hospitals has been rapidly increasing. In order to prevent the occurrence
of these infections and control their spread in hospitals, recommendations
for antimicrobial use in hospitals have been published,.
These recommendations emphasize that control of antimicrobial-resistant
bacteria in hospitals requires a collaborative, institution-wide approach.
Some studies have suggested that using specific guidelines to monitor
and limit the use of certain antimicrobials such as vancomycin in hospitals
can have a significant impact on the introduction and spread of these
organisms.
The
Hospital Infection Control Practices Advisory Committee (HICPAC) has
recommended that hospitals develop strategic plans to detect, prevent
and control antimicrobial infections. Part of these plans may include
developing antibiotic use policies (AUPs) to control and/or monitor
antimicrobial usage through hospital pharmacies by: inclusion/exclusion
of certain antibiotics from pharmacy stock, formulary modifications
based on microbial resistance patterns, stop-use policies, and independent
consultations with an infectious disease specialist for certain antibiotics.
In
1997 the Utah Department of Health, Bureau of Epidemiology was awarded
a grant from the Centers for Disease Control and Prevention to enhance
our epidemiology and laboratory capacity to investigate infectious
diseases. One of the objectives of this grant is to monitor trends
in antimicrobial resistance patterns associated with both hospital-
and community-acquired infections.
In
order to gain a better understanding of the role Utah hospital pharmacies
have in addressing the issue of antimicrobial resistance, a survey
was conducted to determine antibiotic use practices at hospital pharmacies.
In November of 1999, surveys were sent to all acute-care hospital
pharmacies in the state of Utah. Of 41 surveys mailed, 29 (71%) were
returned. The results of the survey are summarized below.
Results
Surveys
were returned from hospitals throughout the state. Of the 29 surveys
returned, 16 (55%) were from rural hospitals. However, urban hospitals
accounted for 83% of the available hospital beds and 75% of the patients
seen in participating hospitals in the previous 12 months. The size
of the participating hospitals ranged from 9 to 500 beds with a median
size of 45 beds, and the number of physicians with privileges at the
hospitals ranged from 3 to 944 with a median of 80. Not surprisingly,
urban hospitals tended to be much larger than rural hospitals. The
median number of beds at urban hospitals was 200 compared to a median
of 35 beds at rural hospitals, and urban hospitals treated a median
of 5,867 patients in the past year compared with a median of 672 patients
treated at rural hospitals.
Pharmacy
formularies of participating hospitals were organized in a variety
of ways with several hospitals using more than one method. The most
common method used was a simple listing of pharmaceuticals including
antibiotics available. Eighteen hospitals (62%) used this method (Table
1).
| Table
1: Organization of Hospital Formulary |
| Method
of Hospital Formulary |
Hospitals
Using Method* (n= 29) No. (%) |
A
listing of pharmaceuticals including antibiotics available
|
18
(62.1) |
A
formalized printed formulary document or notebook that
includes a listing and other policies
|
9
(31.0) |
A
file of documents (such as inserts) and policy memos
|
1
(3.4) |
A
computerized database
|
7
(24.1) |
Other
|
2
(6.8) |
| *percentages
do not add to 100 percent because hospitals could choose more
than one option |
Fifteen
(51.7%) of the hospitals surveyed stated that they had an AUP. Of
hospitals with AUPs, 7 (53.3%) have them as policies contained within
the formulary documentation. Only 7 hospitals (24%) have a separate
antibiotic use policy document. Urban and rural hospitals were similar
with respect to their antibiotic use policies (Table 2). Hospitals
with and without AUPs did not differ significantly in regard to average
number of beds or physicians with privileges at the hospital. However,
larger hospitals were more likely to have AUPs than smaller hospitals.
Sixty-nine percent of hospitals with 3000 or more patients a year
had AUPs while only 38% of hospitals with less than 3000 patients
a year had them. However, this difference was not statistically significant.
| Table
2: Antibiotic Use Policies at Utah hospitals, Rural vs. Urban |
| Antibiotic
Use Policy: |
Urban
(n=13)No. (%) |
Rural
(n=16)No. (%) |
State
(n=29)No. (%) |
Separate
Policy Document
|
4
(25.0) |
3
(23.1) |
7
(24.1) |
A
policy contained within formulary
|
4
(25.0) |
4
(30.8) |
8
(27.6) |
No
antibiotic use policy
|
8
(50.0) |
6
(46.2) |
14
(48.3) |
When developing an AUP, hospitals need to consider both the risk
of antimicrobial-resistant infections and their available resources
to combat them. Risk factors for the occurrence of antimicrobial
resistant infections include: urban location, number of occupied
beds, presence of a trauma center and/or burn unit, and affiliation
with a medical school. Therefore, large urban hospitals may have
a greater need for an aggressive AUP than smaller rural hospitals.
However, antimicrobial-resistant infections can occur at any hospital
so all hospitals should develop a plan appropriate to their needs.
Not
surprisingly, urban hospitals in Utah were more likely than rural
hospitals to employ aggressive strategies to control antibiotic usage
through hospital pharmacies (Table 3). The biggest difference between
urban and rural hospitals was a requirement for an independent consultation
with an infectious disease specialist for any antibiotics. Forty-six
percent of urban hospitals had such a policy compared to only 6 percent
of rural hospitals. This difference may represent a difference in
access to consultations with specialists. Urban hospitals were also
much more likely to take into consideration microbial resistance patterns
in their AUPs (62% versus 25%). This difference may reflect the greater
resources available at larger hospitals to track antimicrobial resistance
patterns.
| Table
3: Strategies to monitor/control antibiotic usage in Utah
hospital pharmacies. |
Strategy |
Urban(n=13)No.
(%) |
Rural(n=16)No.
(%) |
p-value |
A
policy for appropriate and contraindicated uses for vancomycin
|
6
(46.2) |
4
(25.0) |
0.23 |
Procedures
for inclusion or exclusion of antibiotics from the pharmacy
stock
|
11
(84.6) |
8
(50.0) |
0.05 |
A
stop-use policy for any antibiotics
|
8
(61.5) |
8
(50.0) |
0.53 |
An
independent consult required for any antibiotics
|
6
(46.2) |
1
(6.3) |
0.01 |
Procedures
for use of microbial resistance patterns or other laboratory
data pertinent to antibiotic use
|
8
(61.5) |
4
(25.0) |
0.04 |
Discussion
Overall,
the results of the survey illustrate that most Utah hospitals are
addressing the issue of antimicrobial resistance, some more aggressively
than others. However, more needs to be done. It was clear from the
survey that some large Utah hospitals need to develop comprehensive
antibiotic use policies. There are several Utah hospitals, including
a few large, urban hospitals, which do not appear to have addressed
the issue of antimicrobial-resistant infections at all. All Utah hospitals
should develop formal guidelines addressing the issue of antimicrobial
resistance in accordance with CDC and HICPAC recommendations.
References:
-
Centers
for Disease Control and Prevention. Recommendations for preventing
the spread of vancomycin resistance: recommendations of the Hospital
Infection Control Practices Advisory Committee (HICPAC). MMWR
1995;44(No. RR-12).
-
Centers
for Disease Control and Prevention. Interim guidelines for prevention
and control of staphylococcal infection associated with reduced
susceptibility to vancomycin. MMWR 1997;46:626-8,635.
-
Tenover
FC, McGowan JE. Reasons for the emergence of antibiotic resistance.
The American Journal of the Medical Sciences 1996:311(1):9-16.
-
Paul
SM, Finelli L, Crane GL, Spitalny KC. A statewide surveillance
system for Antimicrobial-resistant bacteria: New Jersey. Infection
Control and Hospital Epidemiology 1995:385-390.
-
Cohen
FL, Tartasky D. Microbial resistance to drug therapy: a review.
American Journal of Infection Control 1997;25:51-64.
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First
Utah Rabies of the Millennium
A
Pocketed Freetail bat (Tadarida femorosacca) ushered in the
first rabies season of the millennium on April 25, 2000, six weeks
earlier than the first reported case in 1999. A domestic dog, whose
vaccination expired seven weeks prior to the event, was exposed to
the rabid bat. The dog was revaccinated immediately and placed in
strict isolation for a minimum of 45 days.
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Notice
to Healthcare Providers and Local Health Departments– Revised
Hepatitis Serology Panel
Effective
April 1, 2000 the Current Procedural Terminology (CPT) Board of
the American Medical Association revised the hepatitis serology
panel (CPT #80059) to include the tests for IgM antibody to hepatitis
A virus (IgM anti-HAV) and IgM antibody to hepatitis B core antigen
(IgM anti-HBc). This panel should be ordered to accurately determine
the cause of illness in patients with signs and/or symptoms of acute
viral hepatitis and for timely prophylaxis of contacts. Positive
tests for hepatitis A virus total antibody (anti-HAV) in asymptomatic
patients are only useful to identify immunity to the virus due to
a previous infection at an undetermined time. At the state level,
one of the goals of viral hepatitis surveillance is monitoring disease
incidence by identifying acute infections. Beginning July 1, 2000,
the Bureau of Epidemiology will no longer follow up on reports of
hepatitis A tests that are only positive for total antibodies. For
questions please contact the Communicable Disease Control Program,
Bureau of Epidemiology at (801) 538-6191.
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It’s
Time Again For Summer Food Safety!
Every
summer, people take advantage of the nice, warm weather by filling
the season with numerous outdoor activities and being satiated with
barbequed hamburgers, potato salads, chips, and dips. A native Utahn
would also add jello salad to the list. Unfortunately, an increase
in some enteric diseases may accompany the summer months due to
improper food handling. By implementing some simple precautions,
however, summer cooks can avoid inflicting others, and themselves,
with foodborne illnesses.
Choose
foods carefully
Select
foods based on available resources and facilities. If one is planning
on a day hike and taking sandwiches for lunch, he or she would be
better off taking a peanut butter and jelly sandwich rather than
one needing refrigeration. The availability of hand washing facilities
should also play a role in deciding which foods to prepare for summer’s
activities. If no such facilities are available, one should avoid
handling raw chicken or beef.
Prepare
food carefully
One
of the most effective ways to prevent summer food hazards includes
washing hands thoroughly before any food handling. It is also wise
to prepare as much food as possible at home. Many summer excursions
include spots where food preparation facilities are less than adequate.
To
avoid cross-contamination, clean cutting boards and utensils used
for raw meats with hot, soapy water prior to their use with ready-to-eat
foods. Contamination may also be avoided if one washes his or her
hands frequently during food preparation. In addition, always use
clean, treated water for washing hands, utensils, or dishes since
lake, river, or stream water may contain harmful pathogens.
Food
handlers need to cook meats thoroughly as well. Cook raw hamburger
and chicken until the meat is no longer pink in the middle and the
juices run clear.
Store
food appropriately
Remember
one simple rule: keep hot foods hot and cold foods cold.
Keep hot foods on the grill, fire, coals, or warming pan and keep
cold foods in the shade, in a cooler, or sitting on ice until serving
time.
Protect
food from insects such as flies, which can spread bacteria, and
store food so that it is inaccessible to animals like rodents. It
is not only important to keep food away from animals, but to keep
some items away from each other too. Store uncooked meats and ready-to-eat
foods in separate containers to avoid cross-contamination.
Eat
food promptly
Eat
food as soon as it is served and put it away as soon as possible
following the meal. Do not allow it to sit for prolonged periods
of time. Avoid eating food that should be refrigerated if it has
been sitting at room temperature for more than two hours. Less time
is needed if it is warmer than room temperature (such as sitting
out on a picnic table).
Improper
food-handling can ruin the most carefully planned summer activity.
Fortunately, by implementing these simple precautions, summer food
hazards can easily be prevented.
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Utah
Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary - April 2000 - Provisional Data
The Epidemiology Newsletter is published monthly by the Utah Department
of Health, Division of Epidemiology and Laboratory Services, Bureau
of Epidemiology, to disseminate epidemiologic information to the health
care professional and the general public.
Send comments to:
The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104,
or call (801) 538-6191
Approval
8000008: Appropriation 3705
Rod Betit, Executive
Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory
Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau
of Epidemiology
Gerrie Dowdle, MSPH, Managing Editor
Connie Dean, Production Assistant
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