CHOC Encourages Appropriate Use of Antimicrobial Agents

By: M. Tuan Tran, infectious disease pharmacist at CHOC, and Dr. Negar Ashouri, infectious disease specialist at CHOC

With the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission set to require the adoption of core elements of antimicrobial stewardship in 2017, CHOC Children’s will continue to uphold the appropriate use of antimicrobial agents through its existing antimicrobial stewardship program.

CHOC’s multidisciplinary collaborative’s goals include:

    • Optimizing selection, dosing and duration of therapy
    • Reducing adverse events including secondary infection (e.g. clostridium difficile infection)
    • Improving patient outcomes
    • Slowing the emergence of antimicrobial resistance
    • Preserving supply especially during critical shortages and reduce health care expenditures

The collaborative’s strategies include:

    • Pre-authorization of broad spectrum agents such as meropenem, cefepime, vancomycin, daptomycin and linezolid
    • Daily review (prospective audit with feedback) of antimicrobial orders
    • Development of care guidelines, dosing protocols and order sentences in the electronic health record
    • Dose optimization based on PK/PD principles (e.g. prolonged infusion of beta-lactams)
    • Document indication and duration for all antimicrobial orders
    • Antibiotic time-out at 48-72 hours to: reevaluate need to continue treatment; streamline, de-escalate based upon culture result; convert intravenous to oral route when appropriate; reassess optimal treatment duration
    • Track trends and share antibiotic utilization data as well as resistance trends
    • Provide education for staff, patients and family of optimal antimicrobial therapy use

Changes to clinical practice patterns to promote the appropriate use of antibiotics is a patient safety issue and public health imperative:  Antibiotics are the second most commonly used class of drugs in the United States, and studies indicate that 30 to 50 percent of antibiotics prescribed in hospitals are unnecessary or inappropriate. Further, antibiotic exposure is the single most important risk factor for the development of clostridium difficile infection.


“Through education and teamwork we can reduce the unnecessary use of antibiotics, therefore minimizing the risk of potential side effects to ensure we have effective antibiotics available for the generations to come.”

– Dr. Negar Ashouri, infectious disease specialist at CHOC


The Centers for Disease Control and Prevention (CDC) estimates that 2 million illnesses and 23,000 deaths are caused annually by drug-resistant bacteria in the U.S. alone. Avoidable costs from antibiotic misuse range from $27 billion to $42 billion per year in the U.S. At the same time, the discovery and development of new antibiotics have dropped precipitously from the 1980s onward. All antibiotics approved for use in patients today are derived from a limited number of classes of agents that were discovered by the mid-1980s (see figure 1).

Figure 1.

figure1

Source: A Scientific Roadmap for Antibiotic Discovery. The Pew Charitable Trusts, May 2016.

Here are some common reasons for misuse of antibiotics in health care settings:

  • Use of antibiotics when not needed
  • Continued treatment when no longer necessary
  • Use of broad-spectrum agents when more targeted/narrower options are available
  • Wrong antibiotic given to treat an organism/infection
  • Incorrect dosing and frequency

Antibiotics can also affect beneficial bacteria that are part of our normal flora:

  • An average child receives 10 to 20 courses of antibiotics before age 18
  • Antibiotics affect microbiota flora which may not fully recover after a course of antibiotics
  • Overuse of antibiotics may be contributing to obesity, diabetes, inflammatory bowel disease and asthma

For information about the appropriate use of antibiotics for your patients and families, please visit our CHOC Blog.

CHOC Neonatology by the Numbers

In honor of Prematurity Awareness Month, we share an inside look at our neonatologists and services they provide to care for babies daily in Orange County. CHOC Children’s is proud to have a Neonatal Intensive Care Unit (NICU) rated by the American Academy of Pediatrics as a Level 4 – the highest rating available. Our NICU is also rated among the top 35 NICUs in the nation by U.S. News & World Report. CHOC is proud to be entrusted with giving babies a healthy start.

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What CHOC Physicians are Grateful for this Thanksgiving

As Thanksgiving approaches, CHOC Children’s physicians explain what they’ll consider when giving thanks this holiday.

 

“CHOC has provided me with lifelDr. Neda Zadehong blessings. I am grateful to have grown up at and with this hospital, from the initial CHOC Tower to the current Bill Holmes Tower, through pediatric residency training and beyond.  To now be a member of such a remarkable team of providers — including our nurses and support staff — is both humbling and inspiring. Every day, I am especially thankful for the families who cross our threshold, and entrust the care of their most precious children to us. With continued commitment and dedication toward the health and well-being of our children, the future will be brighter than any of us can imagine.”
– Dr. Neda Zadeh, genetics

 

Dr. Kenneth Grant

 

 

“I am thankful to be working for an organization that creates an environment where our patients become our family. I am also grateful that CHOC Children’s has the foresight to invest in the innovative ideas we have to improve the health care we provide.”
 – Dr. Kenneth Grant, gastroenterology

 

 

 

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“I am thankful for the opportunity with be partnered with an excellent children’s hospital. I am also thankful for the pleasure of working with other positive people who provide outstanding care to the children of Orange County. Together, we work to improve the care and services we deliver to our most important resource — our children.”
– Dr. Daniel Mackey, pediatrics

 

 

 

 

Dr. Lilbeth Torno

“I am grateful for the incredible team we have in oncology, inlcuding   doctors, nurse practitioners, physician assistants, nurses, the research team, members of ancillary services, our inpatient, clinic and OPI staff, administrative support, and other subspecialists, who all have great minds and compassionate hearts, and walk the difficult cancer journey with our patients and their families. I am humbled to be with such great company here at CHOC, who care deeply for children.”
– Dr. Lilibeth Torno, oncology

 

 

 

goodman_tg“I am most grateful to the people behind the scenes at the hospital who do all the invisible jobs that are so important to keep CHOC Children’s running: the housekeepers, lab and x-ray technologists, bio-medical engineers, pharmacy technicians, scrub technicians, security guards and maintenance staff that work tirelessly, 24-hours a day.”
– Dr. Gary Goodman, critical care

 

 

 

 

 

Dr. William Loudon

“I am most thankful for the ability to practice alongside of the caring and professional staff and physicians at CHOC, who all share the common goal of caring for children. Working together, we are able to tackle incredibly complex and varied problems that present in the amazingly diverse population of children that we serve.”
Dr. William Loudon, neurosurgery

 

 

 

 

 

 

“I am thankDr. Amy Harrisonful for so many things here at CHOC. I feel truly blessed every day to have found a professional community of like-minded caregivers who share a passion and dedication for continued improvement in the care we provide. I am also so grateful for the opportunity to meet and care for such incredibly courageous patients and to become a part of their families. Finally, I am thankful to my teams within the pulmonary division, the Cystic Fibrosis Center and the muscular dystrophy clinics for their selfless care of our patients. I wish our entire community a healthy and happy holiday season.”
Dr. Amy Harrison, pulmonology

 

choc_zupanc

“I’m thankful for the opportunity to serve my patients and families, and to help them secure bright futures through CHOC’s world-class care. I am also so grateful to work among a team that is steadfastly committed to the health and well-being of children in our community and beyond. “
Dr. Mary Zupanc, neurology

 

 

 

 

 

 

 

aminian

“I am thankful for the platform CHOC has given us to provide service to a community that inspires me daily. I am humbled to just be part of it all.”
Dr. Afshin Aminian, orthopaedics

New Coordinated-Care Tools for High-Risk Asthma Patients Improving Health, Costs

Asthma is among the illnesses CHOC is focusing on as a component of its population health initiative. (Other acute care conditions of focus include: bronchiolitis, community acquired pneumonia, acute gastroenteritis, headache and acne.) As a prevalent health care problem in Southern California, asthma results in emergency (ED) visits, hospital admissions, school days missed and administration of complex medications to manage the condition.

In an effort to better coordinate care for these patients, CHOC recently reviewed the data on how frequently children with asthma go to the ED and what their physicians are doing to care for them.  After identifying the care gaps, CHOC provided physicians with clinical care guidelines and tools to help them implement the guidelines. CHOC has also created a patient registry, which helped identify patients who required an asthma action plan. CHOC demonstrated an 18% reduction in ED visits, year-over-year, for patients in their largest primary care practice, CHOC Clinics, which coordinates care for 27,000 of Orange County’s highest risk children.

CHOC Children's

CHOC also identified a subset of its highest-risk Medi-Cal patients with asthma (cohort of 178 children with frequent ED visits, hospitalizations, and/or use of oral steroids) and enrolled them in the CHOC Breathmobile program, a mobile asthma clinic. Over a 15-month period CHOC saw a reduction of:

  • ED visits from 104 to 12
  • Hospital admissions from 13 to 0

As part of CHOC’s comprehensive pediatric system of care, the organization has shifted its approach to become a “promoter of population health,” rather than focusing only on hospital care. To that end, CHOC is outreaching to practicing pediatricians to help them better coordinate care for their patients. The new guidelines and tools to coordinate care for high-risk asthma patients is just one example of how this shift is truly improving children’s health and lowering health care costs.

For more information, please contact Dr. Mike Weiss or Shahab Dadjou, CHOC’s division of population health, at 714-509-9229.

Nasal Flu Vaccine Not Recommended This Season – What Patients and Families Should Know

An advisory committee of the Centers for Disease Control and Prevention (CDC) recently recommended that the nasal spray influenza vaccine not be used this upcoming flu season. In this Q&A, Dr. Jasjit Singh, medical director of infection prevention and control at CHOC Children’s, offers an explanation for your patients and their families.

Q: What does this mean for influenza vaccine recommendations for the upcoming flu season?

A: All individuals over the age of 6 months are recommended to get the influenza vaccine, and that will continue to be the case.  However, for this season at least, the nasal flu vaccine is not an option. Therefore, parents will need to plan for their children to get the flu shot this upcoming season.

Jasjit Singh, M.D.
Jasjit Singh, M.D.

Q: How does the standard flu shot differ from the nasal spray version in terms of composition and effectiveness?

A: Both the flu shot and the nasal spray contain the anticipated predominant circulating strains of influenza every year, but the nasal spray strains are made of weakened live virus while the flu shot is made of inactivated viral components. The CDC reviewed data from this past season that suggested that the nasal spray did not perform as well as it had in the past.

Q: Besides ensuring their children get a flu shot, what else can parents do to help prevent the flu?

A: In addition to ensuring their child is vaccinated against the flu every year, there are many things parents and other caregivers can do to help prevent the flu. Use proper hand-washing techniques, use respiratory etiquette, and stay home from work or school if you are sick with the flu, to prevent spreading it to others.

Q: What do you anticipate will be parents’ reactions to this recommendation? Is there anything else you’d like them to know? Is there anything else you’d like to share with parents about the importance of vaccinations?

A:  Vaccinations are one of the most effective public health measures that have been developed and they save thousands of lives each year. Influenza vaccinations are important because young children can get quite sick from the flu, and some even require hospitalization. Every year there are pediatric deaths in the U.S. due to influenza, about half of which occur in normal healthy children. Children can pass influenza on to the elderly or other fragile members of our community. It’s important for adults to get the flu shot too, particularly those who are caring for young children. Even though the nasal spray is not an option for vaccinating this particular season, it is still important to have your child vaccinated for this year.