Office of Epidemiology
Office of Epidemiology April 2000 Utah Department of Health
inside... Utah Hospital Antibiotic Use Survey
It’s Time Again for Summer Food Safety!
First Utah Rabies of the Millennium
Notice to Healthcare Providers and Local Health Departments
Monthly Morbidity Summary

 

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

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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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