PACCARB 13th Public Mtg, Day 2 Pt 6: Welc, Opening Remarks & PANEL 4: Day-to-Day Provider Challenges

>>Martin Blaser: Good morning everyone. My name is Martin Blaser. I’m serving as the chair of PACCARB. It’s my pleasure to welcome everybody to the
second day of our public meeting, July 2019. Again, we have a very full agenda. We thank the many terrific presenters from
yesterday, and we have a great program for today. I’d like to turn over the microphone to my
co-chair, Dr. Lonnie King, who will make some further remarks.>>Lonnie King: Marty, thank you very much
and good morning everybody and welcome to day two of our public meeting. We’re very happy to have you here at a different
location in Tysons Corner. And we welcome everybody in the room and also,
especially those joining us virtually. So, we’re going to gain as much time as possible. As usual we have a jam-packed day, and today
we’re going to hear a lot of challenges about behavior change from those of that expertise
that are working in this area. And hopefully, we’ll discuss and come up with
some ways to address this — address this issue. So, again, welcome. And now, I’m going to turn it over to Dr.
Musmar for a roll call and for a special introduction.>>Jomana Musmar: Thank you, Dr. King. Welcome everyone. This is our second day as everybody mentioned,
so we’re just going to continue the same conflict — rules of engagement apply as yesterday. We ask that all of our presenters please turn
on your microphones when speaking and turn them off when others are speaking as well. This meeting is being recorded and transcribed. And so, we’ll go ahead and start off with
our voting members for roll call Marty Blazer.>>Martin Blaser: Here.>>Jomana Musmar: Mike Apley.>>Michael Apley: Here.>>Jomana Musmar: Helen Boucher.>>Helen Boucher: Here.>>Jomana Musmar: Angie Caliendo.>>Angela Caliendo: Here.>>Jomana Musmar: Alicia Cole.>>Alicia Cole: Here.>>Jomana Musmar: Sara Cosgrove.>>Sara Cosgrove: Here.>>Jomana Musmar: Paula Cray.>>Paula Fedorka-Cray: Here.>>Jomana Musmar: Christine Ginocchio. Locke Karriker. Lonnie King.>>Lonnie King: Here.>>Jomana Musmar: Kent Kester.>>Kent Kester: Here.>>Jomana Musmar: Ramanan Laxminarayan. Aileen Marty.>>Aileen Marty: Here.>>Jomana Musmar: Bob Weinstein.>>Robert Weinstein: Here.>>Jomana Musmar: David White.>>David White: Here.>>Jomana Musmar: On to our representatives,
Elaine Larson.>>Elaine Larson: Here.>>Jomana Musmar: Denise Toney.>>Denise Toney: Here.>>Jomana Musmar: Alice Johnson. Tiffany Lee. Kathy Talkington.>>Kathryn Talkington: Here.>>Jomana Musmar: Onto our regular government
employees. CDC, Rima Khabbaz.>>Rima Khabbaz: Here.>>Jomana Musmar: Dennis Dixon, NIH.>>Jane Knisely: Jane Knisely for Dennis Dixon.>>Jomana Musmar: Thank you, Jane. Christopher Houchen, SPRA.>>Christopher Houchen: Here.>>Jomana Musmar: Shari Ling. Dan Sigelman, FDA.>>Bill Flan: Bill Flan for Dan Sigelman.>>Jomana Musmar: Thank you, Bill. Larry Kerr.>>Lynn Philippe: Lynn Philippe for Larry
Kerr.>>Jomana Musmar: Thank you. Paige Waterman.>>Female Speaker: Twee Simm [phonetic sp]
for Paige Waterman.>>Jomana Musmar: Thank you, Twee. Sarah Tomlinson.>>Chelsea Shivley: Chelsea Shively for Sarah
Tomlinson.>>Jomana Musmar: Thank you, Chelsea. Jeff Silverstein.>>Jeff Silverstein: Here.>>Jomana Musmar: Thank you. Emilio Esteban. Okay, great. Thank you all so much. As you’ve seen yesterday, the Admiral had
introduced Dr. Tammy Beckham, and we have the honor of having her today. Dr. Tammy Beckham is the director of our Office
of Infectious Disease and HIV AIDS Policy, and we’re happy to have her this morning. Thanks for joining us.>>Tammy Beckham: Thanks, Jomana. And thank you all for taking time and allowing
me to insert myself today on your schedule. I really appreciate it. I know how busy you are. I’m really happy to be here with you today. And I look forward to the proceedings that
come from this meeting as well. So, as Jomana mentioned — well, first of
all, before I get out of the gate, let me say thank you to Jomana. Thank you to Sarah. Thank you to Aya [phonetic sp]. Thank you for the entire team that have put
these meetings together and the outstanding work that you guys do. We have a huge portfolio in the new office,
and I’m going to talk about that in a minute. But because of the exceptional leadership
of these individuals this is one thing that they always keep me informed and I stay on
top of. And I’m engaged with, but I know that things
are being taken care of very well in PACCARB. So, we have — you have, as you know already,
some of the finest leadership at HHS. And so, thanks Jomana and thanks to the team. We appreciate it. So, let me just start out — Adm. Giroir is
a hard act to follow, but I’m going to kind of talk a little bit about some of the things
he talked about yesterday. He mentioned yesterday that the Office of
Infectious Disease and HIV AIDS Policy has just been formed. And this is true. As of June 10th, the Office of HIV AIDS and
Infectious Disease Policy and the National Vaccine Program Office merged to form the
Office of Infectious Disease and HIV AIDS Policy. So, let me tell you a little bit about what’s
in that portfolio. It makes total sense to merge these two offices. There’s a lot of overlap with what was happening
in the Vaccines and Immunizations Office and what was happening with the Office of HIV
AIDS and Infectious Disease Policy. Well, that’s the new name — Okay. So, they just flip the terms on me. So, we have HIV, all things STIs, all things
viral hepatitis. We have tick borne diseases, and we also have
blood and tissue safety under the OHAIDP office. And that office, as you know, has merged with
MVPO, which was, again, everything, vaccines, immunizations. So, under the new office now we have five
Federal Advisory Committees in which PACCARB is one, and we have four others that meet
on a regular basis. Plus, we have that entire portfolio merged
into one. And so, as of June 10th, we’re working very
effectively across the new organization to look at synergies and to look at leveraging
opportunities. I mean, it’s only common when you talk about
HPV vaccinations that you also talk about STIs in the context of that as well. So, as we’re developing our new Federal Action
Plan for STIs and we look at HPV, there’s some clear commonalities there with vaccination,
et cetera. As is antimicrobial resistance and STIs as
well. So, there’s clear synergies between what was
happening in those two offices. And I’m thrilled to have the great team now
all under one roof and all working together under this new office. And I think we’re going to see some real opportunities
to cross communicate, to leverage, to synergize — some of those terms are Jomana’s favorite. So, I’ll throw those out there. And we’re just really excited to have everybody
together. And we think that with bringing the talent
and the expertise and the portfolios together, we’re going to just be able to strengthen
our mission, and we’re going to be able to really work across the broader spectrum of
infectious diseases and microbial resistance, vaccinations, et cetera. So, I think it’s also important for you to
know, and I think that Ash reiterated as well, that our commitment to antimicrobial resistance,
our commitment to this FACA, our commitment to vaccines and immunizations is as strong
if not stronger than before. We are fully committed to this mission space. And see this merger of these offices as a
way for us to strengthen ourselves and integrate more of what we do as we move forward. So, as a veterinarian too, this particular
federal advisory committee is very important to me. You guys are truly working from a One Health
perspective. I would say that within the context of all
things that are always discussed One Health, this is truly a venue where you’re actually
seeing one health in action. And so, it’s very near and dear and passionate
to me. And I’m thrilled to hear this morning that
there were things that committee members have learned so much about the veterinary side
and vice versa as well. And so, I think you guys really do put One
Health into action here. And I am thrilled for that and hope that we
can take this example and do that more across other topics as well. So, thank you guys very much for all your
work and everything that you’ve done. We really do appreciate it. I do think there’s some clear next steps for
you all with, you know, we talked about environment, we talked about fungi, all of those types
of initiatives. And so, I’m encouraged that you’re thinking
through those challenges that we have and look forward to your thoughts coming out of
this meeting and in the future of how we might continue to engage on some of those complex
challenges that we face. Some of the other things I want to talk just
this morning about a little bit is that, as the Admiral mentioned, now that you guys are
codified into legislation, this is a very good thing. We are excited about that. I want to reiterate what the Admiral said
about that as well as you are now in the proper legislation, this gives you more sustainability. And you continue to have our support within
the Office of the Assistant Secretary moving forward. We are committed to continuing to support
PACCARB and the committee as it moves forward in anything that the chairs need or the committee
needs, please reach out to me or through Jomana personally. We know that you guys are leading the effort
globally in providing priority recommendations as to what goes into the next national action
plan and we’re really thrilled about that as well. And just all the work that’s come out of here,
you guys are tackling some really tough problems and really helping guide the federal government’s
response and the national and global response to AMR. And it is truly a wicked challenge, another
term that Jomana likes to use. And we are thrilled that we have this level
of expertise across the committee, and we are thrilled that you guys are on board and
continuing to move forward. And so, I just want to say, again, thank you. I really do look forward to hearing about
the findings and the areas and the priorities that you are going to recommend for the 2020
to 2025 National Action Plan. There are some clear next logical steps for
this FACA, and I look forward to working with you as it moves forward. And just reiterating again what the Admiral
said yesterday, that you have our full support. And I also want to close by saying thank yous
to Dr. Blaser and Dr. King and the entire PACCARB team for hosting yet another great
meeting; and, again, approaching this from a One Health perspective, which is truly an
example we can take forward across a lot of different complex challenges we face in public
and animal health and environmental health. So, thank you guys very much. I’m happy to take any questions if you have
them.>>Martin Blaser: Yeah. Dr. Beckham, I wonder if I could ask a question? First, I just want to thank you and thank
you and Adm. Giroir. We feel your support, and it’s wonderful to
have it. You have gotten a very hardworking group of
people. People have worked nights and weekends in
addition to their day jobs because they’re really committed to that.>>Tammy Beckham: Right.>>Martin Blaser: So, we appreciate the support
from up high. As you and I discussed, we’re, we’re finding
that the field is expanding. That One Health, which was humans and animals,
now — yesterday we had a number of presentations about what’s happening in agriculture and
plants, and how agricultural practices are impacting on human health as well. It’s not just bacteria, but it’s fungi as
well, as we discussed. Maybe we should change the name of PACCARB
because now we’re worried about fungi, and we’re worried about other anti-microbials
other than antibiotics.>>Tammy Beckham: Right.>>Martin Blaser: Maybe it should be PACCARO,
Antimicrobial Resistant Organisms.>>Tammy Beckham: Right.>>Martin Blaser: I’m not sure, but I think
the people on the committee here are — we’re interested in serving where the problem will
take us.>>Tammy Beckham: Exactly. So, I would agree. I think there’s an opportunity for this committee
to do more and broaden the scope — and absolutely should. So, I think we are open to recommendations
as the committee sets forward what the next steps are for the committee. And so, we’d love to have that in some form
that we could take forward. So, I agree.>>Martin Blaser: Thank you very much.>>Angela Caliendo: Okay. Welcome back everybody. And Good Morning.>>Lonnie King: So, hang on just a sec.>>Angela Caliendo: Okay.>>Lonnie King: So, congratulations Dr. Beckham
on your new role. We really appreciate that and look forward
to continuing to work with you. I think it’s really interesting to have offices
infectious diseases and antimicrobial resistance. And I’m just reminded of a report that came
out a few years ago by Kate Jones, and she did a complete look at emerging infectious
diseases over six decades and how they were trending. And she categorized emerging — categorized
resistant bacteria as about 22 percent of all emerging infections and believes that
that is actually accelerating. So, it’s a nice — I think it’s a nice fit
and reminds us that this is an emerging infectious disease problem. Is that, that’s fine.>>Tammy Beckham: Exactly.>>Lonnie King: Again, thanks. And congratulations on your new role.>>Tammy Beckham: Thank you. I’m happy to be here. I’ve learned a lot, and I’ve got a great team. And I couldn’t think of a more challenging
yet thrilling role to be in. It’s incredible. So, I have to tell you all to be able to engage
with subject matter expertise that we have across the board here and work with levels
of experts that we have has just been absolutely thrilling. So, I want to thank you all again for all
your hard work here. There’s a lot more to be done. I will agree with you. And I look forward to what you guys might
propose moving forward on how this committee can continue to contribute in the ways that
you’ve done over the last several years. So, thank you very much.>>Angela Caliendo: Okay, so now it’s me. Next time. Good morning everybody. And welcome back. As Lonnie mentioned earlier, we’ve heard in
the past from several associations and organizations discussing the strategies and guidelines in
place to promote antibiotic stewardship practices today. And so, now, we’re going to hear from a variety
of providers themselves, people that are in the trenches facing the challenges on a day
in and day out basis. And so, we will hear from a dentist, a pharmacist,
a pediatrician, and a veterinarian about their hurdles and professional perspectives. Again, we have a timer set up so please stick
to your time, so that we will have a chance to hear from everyone and have plenty of time
for discussion afterwards. So, our first presenter is Dr. Glenn Miller. He’s a dentist at Mount Vernon Dental Smiles
and founder of the Dental Whale Practice Group. So, Dr. Miller.>>Glen Miller: Good morning and thank you. I’m fortunate to have had a career as a dentist
and a dental entrepreneur. My current office, Mount Vernon Dental Smiles,
is located in Alexandria, Virginia, and I am affiliated with a dynamic dental management
service organization called Dental Whale, whose business foresight is improving the
landscape and future of dentistry. My career has been a mixture of clinical dentistry
and business ownership. The business bug took over about halfway through
my career. Since then, I have acquired over 15 dental
locations. During the due diligence phase of acquiring
a dental practice I might review 10, 20, or even 30 different locations before I zero
in on one. This has allowed me to look into hundreds
of dental practices and peel back the layers. It is with this background that I share my
experience with you today. Since I was looking for dental practices,
I could grow. I reviewed metrics and dental codes, specifically
periodontic and endodontic codes. Practices that were not providing these services
meant opportunity. They also meant something else I did not understand
at the time, and it had to do with unnecessary antibiotic prescriptions. Under-treatment of periodontal disease lends
to more infections with result and use of antibiotics in two ways. To combat existing infections and as a prophylaxis
taken before some dental procedures. If a patient has a painful abscess tooth,
and the dentist is not doing a root canal, then the protocol is to place a patient on
antibiotics and pain medications. It is fair to assume that these dentists wrote
more prescriptions than dentists who treat periodontal disease and endodontic emergencies. Now, I can add another metric to my due diligence
list, antibiotic use. Little background, antibiotics each year account
for the vast majority of medicines prescribed by dentists. Each year we write about 24.5 million prescriptions
for antibiotics. The estimated cost is over $500 million. General dentists and dental specialists are
the third highest prescribers of antibiotics in the nation. Prophylactic antibiotics taken before certain
dental procedures such as extractions, implant placement, and cleanings is common. Prophylaxis against infective endocarditis
is the main reason we pre-medicate patients with antibiotics. Indications for the use of systemic antibiotics
in dentistry are limited because most dental and periodontal diseases are best managed
by operative intervention and oral hygiene measures.>>Jomana Musmar: Dr. Miller, I’m sorry to
stop you. Should we advance the slides? Would you like us?>>Glen Miller: Oh, yes.>>Jomana Musmar: Please let us know when
to advance the slides for you so we can follow along.>>Glen Miller: Okay, we’ve got that one and
go to the next slide.>>Jomana Musmar: Okay. Thank you.>>Glen Miller: Thanks, Jomana. Indications for the use of systemic antibiotics
in dentistry are limited because most dental and periodontal diseases are best managed
by operative intervention and oral hygiene measures. A recent study found that 81 percent of prophylactic
antibiotics in dentistry were unnecessary. As I’ve shown you in the case of periodontal
or endodontic emergencies, antibiotic prescriptions are also often a symptom of the real problem. The real problem being systems or professional
choices that force us to write unnecessary prescriptions. So, how did we get here? What systems or choices forced the medical
dental profession to confront the question of prescribing when antibiotics are not called
for? Number one, failure to diagnose and treat
periodontal disease — I’ll spend a little bit more time on this — lack of communication
between professionals, specifically dentists and physicians; failure of professionals to
keep up with current literature and treatment options. If a dentist is not confident about his/her
sterilization and disinfection protocol, they may decide to cover the patient with antibiotics
just in case. Diagnostic uncertainty. Patients have been taught to demand antibiotics
and/or opioids by professional behaviors of community and paradigms. The insurance industry teaches patients not
to comply with our findings and recommendations. Lack of access to care, and this covers a
lot of different areas. And the threat of a lawsuit. I’m going to give you a little bit background
about the mouth/body connection since it’s very important. Next slide. It’s been reported that all known micro-organisms
associated with humans are at some time found in the oral cavity as either transient or
resident species. The mouth is a significant potential source
of both infection and inflammation. Poor oral hygiene or the presence of periodontitis
is associated with increasing concentrations of c-reactive protein, fibrinogen, and bacteria
entering the bloodstream directly. Periodontal disease can only be effectively
measured by the use of periodontal probe. Essentially, a small ruler that you see up
there and six-point measurements around each individual tooth, regardless of what the insurance
company tries to tell us or our patients. Periodontal infections are increasingly associated
with systemic diseases including cardiovascular disease, stroke, diabetes, preterm low birth
weight babies, respiratory infections, pancreatic cancer, and rheumatoid arthritis. Patients with chronic periodontal disease
will experience septicemia on a daily basis from brushing, chewing, and, if they ever
think about it, flossing. No one I know has ever covered this with prophylactic
antibiotics, nor should they. And yet we throw antibiotics at patients before
their dental procedures as if the bacterial load has never been systemically realized
before. Other oral factors to consider; broken teeth
and retained roots; abscessed teeth, which can be either symptomatic or non-symptomatic. The non-symptomatic ones we call sleeping
giants because when they awake, they can cause monstrous pain as the bacteria begin to replicate
and exert pressure on the surrounding tissue. Fungal infections; tonsillar or other lymph
node inflammation; the overall look of the oral soft tissues. For instance, gingival enlargement without
signs of periodontal disease can be indicative of blood dyscrasia such as leukemia. And even though some of these examples do
not lead to the overuse of antibiotics, the possible connection is always present. Without a dental clearance prior to invasive
surgery, the patient’s outcome may be compromised. So, which surgery should have a dental clearance
prior to? It should be mandatory for the following joint
replacements and implants, chemo cancer therapy treatments, transplants, cardiac surgery. Without a dental consultation the result is
often a lifetime of unnecessary prophylactic antibiotics. In the case of the prosthetic joint replacement,
dentists are asked frequently by physicians to provide our patients with prophylactic
antibiotics before cleanings and other treatments which many conditions that do not — excuse
me. Dentists are asked frequently by physicians
to provide our patients with prophylactic antibiotics before cleanings and other treatment
for many conditions that do not do not fall under the current American Heart Association
guidelines. Such is the case with the use of prophylactic
antibiotics in prosthetic joint replacements. Evidence fails to demonstrate an association
between dental procedures and prosthetic joint infections or any effectiveness for prophylactic
antibiotic coverage prior to dental procedures. Next slide. Oh, wait a minute. We have gone too far. We need to back up one to — there we go. Most postoperative prosthetic joint infections
come from skin bacteria, coagulates, negative staphylococcus. Staph aureus, a common oral bacterium, only
accounts for 13 percent of postoperative infections. This would suggest that a contamination from
skin rather than bloodborne spread is the most common mechanism of infection. The common cycle that dentist’s see. No dental parents by MDs prior to the medically
invasive procedures, which leads to a higher risk of postoperative infections. For those patients who get infections, there’s
a high likelihood they will be labeled as high risk. Therefore, the recommendation from MDs will
be a lifetime of prophylactic antibiotics prior to dental procedures. Medical legally we have no choice but to comply. The dentist generally ends up writing the
prescription even though current guidelines call for the physician to do that. Next slide. This is the last time I can remember being
asked by a physician — and by the way, the Cleveland Clinic was very easy to deal with. But this is the last time I can remember being
asked for a pre-surgical clearance. It was back in 2017. I show you this example for two reasons. How infrequently I get asked for pre-surgery
clearance, and how easy it is to miss an infection by visual oral exam. Next slide. If there’s — if a physician looked in this
patient’s mouth, they would see broken teeth and reasonably assume there’s an abscess. But what about the broken teeth that are sub-gingival
and not visible? Also, there may be visible teeth without any
apparent pathology that are abscessed. With a thorough dental exam these can be resolved
before surgery. The risk of adverse reactions to prophylactic
antibiotics in healthy patients is high. Dentists prescribe penicillin for many prophylactic
antibiotic prescriptions. Of all allergens, penicillin is the most frequent
medication related cause of anaphylaxis in humans, and its use is the cause of approximately
75 percent of fatal anaphylactic cases in the United States each year. Data has shown that there’s more risk to the
patient by providing prophylactic antibiotics than the risk of prosthetic joint infections. Clindamycin, a broad-spectrum antibiotic,
which is prescribed in the case of penicillin/amoxicillin analogy is strongly associated with clostridium
difficile infections that require hospitalization or already effect hospitalized patients, resulting
in 14,000 deaths per year. Dentists are the top prescribers of clindamycin. The lack of dental and patient perspective,
paradigms and when dentists don’t keep up. Postoperative procedures such as extractions,
placement, implants, and other oral surgery procedures have routinely been covered by
antibiotics after the procedure. Research shows that in the absence of any
systemic infections or medical compromising, the risk of infections is small. The risk of antibiotic usage is much higher. Diagnostic uncertainty, this can result from
the failure to keep up by the doctor or maybe just a tough case to diagnose. Patient paradigms, many patients have been
taught to demand antibiotics. When professionals use the empirical approach
to prescribe, patients who also use this rationale to make demands. Along with antibiotics. Patients demand opioids too. The demand for these classifications seem
to go hand in hand. The dentists who write the most antibiotic
prescriptions tend to write the most opioid scripts too. When dentists and physicians do not communicate
it leads to the overuse of antibiotics. Patients are advised accordingly, which puts
them squarely in the middle of what is truly needed versus the decision of the doctor in
a vacuum. Patients develop paradigms that lead them
to rely on or demand antibiotics. Now, the patient is part of the problem. When the insurance industry does not accept
our diagnosis, periodontal disease and patients believe the insurance company’s decision,
the patient ends up in a slippery slope towards more disease. Next slide. Access to care. This covers a lot of different areas. Emergency calls at night and on weekends. Dentists are apt to prescribe over the phone
instead of coming back to the office. The patients who want party drugs, and there
are plenty of them, they generally call Friday or Saturday at about five o’clock, and they
always have a good story. The rural community, lack of proximity, dentist
density, and definitive care all conspired to create more prescription writing. Lack of dental insurance and costs. When patients do not feel they can afford
proper dental care, more times than not the problem and costs are shifted in the medical
field where definitive care is lacking. In the case of emergency rooms, because emergency
rooms are not equipped to do dental procedures, most patients are given a regiment of antibiotics
and opioids. In my experience, when symptomatic patients
are placed on antibiotics, it takes anywhere from 48 to 72 hours for the antibiotics to
diminish the infection to the point of pain relief. Pain medication must get them to this lag
period. Then the need for pain med drops significantly
or completely. If the patient does not see a dentist after
the emergency room visit, he/she is ultimately going to return with the same problem. This leads to a vicious cycle of emergency
room visits and prescriptions. If they go to the dentist, the antibiotics
make the diagnosis much harder. Antibiotics cover up the symptoms to the point
where it makes a diagnosis either impossible or difficult. My response I put the patient back in pain. I take that it’s not by choice or my preferred
method, but it’s necessary for me to secure a diagnosis. I take them off the antibiotics, and I place
them on more opioids. So, I’ve got to subject the patient to more
pain and more opioids in order to get my diagnosis. It’s kind of a catch 20 for the — catch 22
for the physicians. I understand that. It’s so much easier to give them pain meds
and opioids and hopefully that takes care of it but that’s a short-term solution. A better approach would be to implore the
patient to see a dentist ASAP, place them on pain meds only for two-to-four days with
no refills. Once definitive care is rendered, there’s
no need for additional antibiotics or pain med scripts. Cost of care, one of the reasons that patients
with dental emergencies show up in the emergency room. Conclusions and recommendations. Next slide. Prevent the infection in the first place. In my experience, traditional clinical dentistry
has always lagged behind the research of periodontal disease and its effects. Clinicians have been slow to embrace periodontal
treatment. It is standard for many dentists and hygienists
to just watch it. Even though I’ve seen an increase in periodontal
treatment or therapy over my career, I still see many patients that have never seen a periodontal
probe or have no clue to their overall oral health. In my mind, my profession is far from emphasizing
an acting on a disease process that affects much more than the mouth. Many still don’t identify the problem. Others identify it but fail to act on it. I’ve always asked myself what these questions
are waiting for, and the answer always comes back the same. When it gets worse. Honestly, I don’t even know what to make of
that answer cause my next question is when should you treat disease? My answer is when it’s first identified. You can’t diagnose if you don’t know, and
you won’t diagnose if you don’t care. My recommendation, first and foremost, as
dentists, we need to up our game in the identification, treatment, and appreciation of periodontal
disease. It is incumbent upon the individual dentists
who practice to aspire to this. Professional responsibility, in my mind, is
not being that a periodontal disease is not pushed to the front line of our consciousness
and treatment. I would encourage dental schools to spend
more time on the importance of periodontal disease, systemic medicine, and uses of antibiotics. And I also would ask public health service
agencies and organizations such as American Dental Association, the American Academy of
Periodontology to bring more public awareness to periodontal disease. My patients that understand periodontal disease
follow treatment recommendations and allow us to them maintain health. Our industry should also stop promoting PSR. PSR stands for Periodontal Screening and Recording. This technique relies on spot probing for
a diagnosis. True, thorough probing data is more tedious
to gather, but it’s thorough. I call the PSR the lazy dentist exam and diagnosis. Dentists should consider using oral microbial
rinses such as chlorhexidine instead of systemic antibiotics. And educating the public. I always asked my hygienist what the most
important job is. Cleaning teeth? No. Taking radiographs? No. Staying on time? We always pause on this one — [laughter] — it’s patient education. Period. A patient who is better educated on oral health
is more compliant and satisfied with our care. This is the ultimate proactive approach. Medical community. If dentists cannot get their heads wrapped
around periodontal disease, why should we expect the physicians to? Nonetheless, MDs have a professional responsibility
to do no harm. When a dentist is not consulted prior to invasive
surgery, the patient’s outcome is potentially compromised with the possibility of postop
infections or a lifetime of prophylactic antibiotics. Physicians should be writing the scripts,
not the dentist. Also, I think that the system should be developed
which requires dentists to notify the patient’s primary care physician whenever we write a
script. If the patient has a reaction to our antibiotics,
they may end up in the physician’s office, which we rarely find out about. Also, joint meetings between doctors and dentists
will help to bridge this divide. I feel that the only way to truly level the
playing field is to bring dentistry in the medical curriculum and make us part of the
medical industry. Separation of education and a lack of emphasis
on oral medicine will always lead us down different and separate paths. I’m sure many dentists would not like to hear
what I just said because right now dentistry enjoys professional freedom not found in many
professions. Responsibility preventing — insurance industry
is responsible for preventing early intervention of periodontal disease. Many insurance companies demand radiographic
evidence of periodontal disease before they will provide benefits for treatment. They will not accept our probing measurements
and diagnosis. Periodontal disease begins with attachment
loss long before radiographic evidence is realized. The only way to effectively diagnosis is with
a periodontal probe. This makes the patient question our diagnosis. If we do not have a strong relationship with
the patient, they will either seek no care or another dentist. Educating the patients and gaining their trust
is the only way that dentists can overcome this. Thank you.>>Angela Caliendo: Thank you, Dr. Miller. We’ll go through all the presentations and
then open it up for questions. Our next speaker is Dr. Nathan Wiehl. And he is the Director of Clinical Services
for Auburn Pharmacies and pharmacist in charge of Anderson County Hospital Pharmacy in Garnette,
Kansas. Welcome, Dr. Wiehl.>>Nathan Wiehl: Thank you very much. It’s a privilege to be here to give you my
insight on the challenges to implementing antimicrobial stewardship programs in a community
pharmacy setting. Next slide, please. As she said, I’m a director of Clinical Services
for Auburn Pharmacies. We’re an independently owned chain of 25 retail
pharmacies and three long-term care pharmacies in the eastern Kansas and western Missouri
market. I’m the pharmacist in charge of Anderson County
Hospital, which is a critical access regional facility for the Saint Luke’s health system
in Garnett, Kansas. And as part of that role, I sit on the Antimicrobial
Stewardship Committee for the Saint Luke’s health system. And it’s unrelated to this discussion, but
I’m board certified in advanced diabetes management. Next slide, please. During my short discussion today, I have a
few objectives I’d like to meet. First, explain the difference between antimicrobial
stewardship in the inpatient and outpatient settings, review pharmacy reimbursement for
antibiotics, and how the impact of DIR can fees can affect our decision making process
on services to provide, evaluate how pharmacy reimbursement for antibiotics compares to
the national average cost to dispense, and, lastly, explain how consumer education level
impacts the appropriate use of antibiotics. Next slide. So, diving into the differences between inpatient
and outpatient settings when it comes to antibiotic use and appropriateness. In an inpatient setting, the pertinent information
that’s available is readily available. It’s right at your fingertips. Information that allows us to evaluate renal
function, so we can appropriately dose antibiotics based on kidney function. We have a diagnosis readily available and
often required. So, we know, when that antibiotic is selected,
if we’re treating a UTI a pneumonia or Sepsis. We have cultures and susceptibilities on the
ready in case, you know, so we can evaluate what the microbes are susceptible to, what
isolates are susceptible to and make a decision based on that true evidence. We have access to dedicated infectious disease
experts, full teams of pharmacists and infectious disease experts to aid our decision-making
process if we need additional support. There’s monitoring of the patient that’s easily
available. Because they’re in house we can monitor symptoms,
vital signs like temperature, ins and out so we can see trends and actually evaluate
success of medication regiment. And we can monitor regular lab work. Trends in white blood cells, we can see a
procalcitonin level to evaluate the risk of infection or risk for sepsis. And then lastly, we’ve got a guaranteed medication
adherence where we can hang the bag or put the pill in the patient’s mouth. That you don’t get in an outpatient setting. Once you discharge a patient home or when
you see them in a clinic and refer them to the pharmacy to get their antibiotic, once
they’re gone, you have absolutely no way of monitoring their adherence. You have no way of monitoring their symptoms
without a lot of additional legwork. That gets really difficult once you see the
amount of reimbursement that pharmacies are given. So, next slide, please. This is a couple examples of the information
that we’re given in a community pharmacy setting. Couple — actually these are good prescriptions. Because they are electronic, we don’t have
to read any bad handwriting. But this first one here is Cephalexin 500
milligram, one capsule four times a day, and the provider. And that’s the extent of the information. We don’t know the kidney function. We don’t know what they’re treating. If it’s a skin and soft tissue infection or
a urinary tract infection. Hopefully, not an ammonia in this case. That would be an inappropriate selection. We’ve got no way of evaluating that. And the next example is a little bit more
concerning because it’s Levaquin 500 milligrams a day for two weeks in a 94-year-old female. We have no way of evaluating that renal function,
but my experience tells me that a 94-year-old female probably doesn’t have the kidney function
to support that dose. But, again, the information is not there for
us. But we could obtain some of this information
from the patient, but a significant number of times when somebody is ill, they’re not
coming into the pharmacy to pick up their own medication They’re sending family or friends
in to pick it up. So, the information that we could get from
that person isn’t reliable either. Next slide, please. Contrast that to the information that’s available
in a hospital management software. That top bar is a screenshot of patient information,
de-identified of course. It shows height, weight, and an estimated
creatinine clearance. They readily evaluate kidney function along
with patient allergies staring you in the face. The next bar is the order. You see cefpodoxime 200 milligram to be taken
twice a day for a urinary tract infection. So, we have the diagnosis there and know that
that is an appropriate selection for that diagnosis. The next pane down is an advanced monitoring
windows. It’s kind of a fine print there, but we can
track every dose that was given and the date and time it was administered to monitor for
compliance. We can see vital signs and track trends in
temperature and ins and outs to monitor for symptom improvement. We’ve got labs that are readily available. In this case, a procalcitonin level that’s
very high indicating sepsis and a urine culture that grew enterococcus physalis sensitive
to both ampicillin and Vancomycin. So, it’s a lot of information available within
a few clicks of a mouse for us to decide if that selection is appropriate or not. Next slide, please. This diagram is not my own. It came from a Dr. David Highnin from right
here in D.C. The senior officer at the Antibiotic Resistance
Project. But it’s a lot to digest, but once you do,
you kind of get an idea of the challenges presented to hospital providers in an inpatient
setting compared to an outpatient provider. In an inpatient setting, working from left
to right on that diagram, a hospital provider is supported by robust hospital policies that
are written to incentivize providers to use the tools at their discretion in the inpatient
setting. They have an electronic health record that
can be customized, and specific order sets custom tailored for aiding the provider when
ordering medications and labs for specific diagnosis. And then IT support that can, that can put
restrictions in place that guide providers to appropriate selections. For instance, when a Hurricane Maria devastated
Puerto Rico and the supply of IV mini bags was just decimated, we had to really ration
those bags. So, within our order set we could put restrictions
on certain antibiotics that had to be delivered IV push instead of IV piggyback. So, we could use those bags for more serious
patients in the ICU or surgery setting. But that was all possible because of the IT
support and that electronic health record. We’ve got teams of data analysts that measure
the success of the program that drive the hospital policy decision making process. And then teams of experts, including MDs and
pharmacists, that specialize in infectious disease and antimicrobial stewardship that
can provide technical expertise down to the hospital providers. And in an outpatient setting, I’m thinking
of a private practice that doesn’t have the support of a major health system. You really don’t get any of that. You’ve got no entity writing robust policies. You don’t have a team to measure, and you
don’t have the technical expertise. The best you could do is refer to an infectious
disease expert, which could delay treatment and worsen symptoms before — you know, before
the patient gets the antibiotics that they need. Next slide, please. So, those are some of the logistical challenges. I want to talk a little bit about the dollar
and cents challenges to community pharmacies when they need to make the decision about
trying to implement these programs. The Pharmacy Services Administrative Organization
for Auburn Pharmacies did a little data analysis for me. They looked at 435,000 prescription claims,
specifically for antibiotics across their network of independent pharmacies and discovered
that our average profit margin per prescription is $9.12. Compare that to the average cost to dispense
for an independent pharmacy of $10.79 per prescription. That came from the NCPA digest in 2018. You see that we’re already underwater in dispensing
antibiotics. And that’s before the DIR fees levied by pharmacy
benefit managers. DIR fees, direct and indirect remuneration
fees, is a retroactive recoupment of payment from a PBM based on non-transparent metrics
that were not — that they calculate and then recoup sometimes up to six months after the
point of sale. That in this case totaled almost 38 percent
of our profit margin. Adjusting our net profit margin down to $5.68,
about half of what it costs us to dispense. That cost to dispense includes salaries, utilities,
the cost of the vials and labels — all our overhead in dispensing a prescription. And pharmacists have the skillset to be able
to do this. When we get out of school, we have the tools
to help evaluate antibiotic appropriateness. But when it comes down to how much we’re reimbursed,
we can’t spend the time or invest the energy and effort into implementing those programs
when the dollars just aren’t there. Next slide, please. If you boil that information down a little
bit further, you can see by drug class across the board we’re underwater on all prescriptions. The blue bar represents the reimbursement. So, for your amino glycosides, antibiotics
that may be used to treat more serious infections, the reimbursement is higher, but the DIR fees
are also steeper, leading to a net loss in revenue. But across the board DIR fees are crippling
our profit margins, which, again, forces our decisions to be made not — the decisions
that are made are not the ones we want to make because we want to be able to provide
additional services. But you can’t when you can’t afford to. Next slide, please. So, in addition to a reimbursement barrier
to appropriate antibiotic selection, there’s also some insurance barriers just in access
to appropriate antibiotics. This is a case study. A patient was seen in a Saint Luke’s emergency
department for treatment of a urinary tract infection. Upon admission to the ED, the provider collected
a UA. They isolated enterococcus faecium, a pretty
sinister bacterium. A prescription for Cephalexin was written,
which on the face of it is a pretty poor choice. But even within the same four walls of a hospital
outpatient departments don’t have the tools at their discretion that inpatient departments
have to evaluate appropriate antibiotic use. So, three days go by, susceptibilities are
returned. And at that point when they realized it’s
a multi-drug resistant organism, the Antimicrobial Stewardship Director was consulted. His recommendation was a week of Linezolid
twice a day or a single dose of Fosfomycin, three grams. Because the provider anticipated some insurance
restrictions. Both meds were prescribed in the hopes that
one of the two would be covered, but neither was. And the patient again was unable to get the
medication they needed. The prior authorization — so the, the provider
was forced to contact the insurance company and provide them medical reasoning for the
antibiotic selection. ED providers are not well accustomed to doing
that, so they punted over to the primary care physician, who then wasn’t able to provide
the information either cause at that point they didn’t even know the patient had been
in the emergency room. So — and pharmacists have the information
available to provide that to do that prior authorization, but because we’re not deemed
medical providers, they won’t take — they won’t allow us to do those — to make those
phone calls. So, another day goes by, there’s no resolution. By the third of May, the patient worsened
and was admitted for aggressive IV antibiotic therapy, which ultimately costed it exponentially
more dollars than either one of those antibiotics would’ve cost from a pharmacy. Next slide, please. So, lastly, there is an education barrier
as well. A community pharmacy resident from Balls Foods
in the University of Kansas, Mary Beth-Seipel, did a study to assess the general knowledge
of appropriate antibiotic use in the public. What she found out that was over 30 percent
of non-college educated participants believed antibiotics worked on most cough and colds
compared to 16 percent of those with a college degree. And 43 percent of non-college educated participants
believed antibiotics killed viruses. Compare that to 20 percent of participants
with a college degree still thought antibiotics killed viruses. So, there is a — there is some education
improvement in the general public that needs to be made. Her conclusion was that that education level
influenced antibiotic appropriateness, but it still wasn’t great even in college educated
participants. And that community pharmacies were uniquely
positioned to be able to provide that education in a community setting if the conditions were
right to allow them to do that. Next slide, please. So, in conclusion, data available in an inpatient
setting to evaluate antibiotic appropriateness is currently not available in an outpatient
setting for outpatient providers and pharmacists to make those determinations. Inpatient antibiotic stewardship programs
are supported by robust hospital policies. They’ve got teams of IT professionals and
data analysts that are measuring and providing guidance to the policy decision making process. And there’s infectious disease experts on
the ready to assist them in the event that they need a little help. Next, reimbursement for antibiotics does not
allow for pharmacies to invest time, energy, and effort into evaluating antibiotic appropriateness
or implementing the programs to do so. And lastly, consumer education about appropriate
antibiotic use needs to be improved upon. And community pharmacists are in a unique
position to be able to do that. And again, if the situation and the environment
is right. So, next slide, please. That’s all I have for you today. Again, I appreciate the opportunity to come
present to you.>>Angela Caliendo: Thank you. That was very informative. Okay. So, our next speaker is Dr. John Santos. He’s the Director of Urgent Care for Children’s
Hospital Colorado and an Assistant Professor of Pediatrics.>>John Santos: Hello. Thanks for inviting me here today to speak
about antibiotic stewardship in pediatric urgent care. As all of you have already heard, the challenge
facing us now extends from the agricultural fields of America to hospital outbreaks in
England. And, based on the speaker following me, I’m
assuming even to our pets. Combating antibiotic resistance will take
the combined efforts of many areas. As chair of the American Academy of Pediatrics’
section on urgent care medicine and a pediatrician practicing in urgent care for nearly 10 years,
I’m here to talk about the role urgent care can play in combating antibiotic resistance
and specifically address some of the challenges and successes of pediatric focused urgent
care. Next slide. Recognizing the expanding role of urgent care
in the medical landscape, the AAP formed the subcommittee on Urgent Care in 2016 under
the section of emergency medicine. In only three years since the subcommittee
has grown to nearly 150 urgent care pediatricians encompassing all regions of the U.S. and working
in a variety of practice settings from hospital-based multi facility systems, like the one I am
part of at Children’s Hospital Colorado, to private standalone sites in Boise or Little
Rock. Given the explosive growth of our subcommittee
and urgent care in general, we petitioned the AAP to recognize urgent care medicine
as its own unique field with unique challenges and opportunities. And as of July 1st, we were granted status
as a provisional section on urgent care medicine. As a subcommittee, and now a provisional section,
our mission is to work with the AAP to advocate for pediatric urgent care and pediatric readiness
in general urgent care centers, to expand opportunities for pediatric urgent care education,
and to promote urgent care research and collaboration. Next slide. By working with AAP and it’s over 67,000 members
and the Urgent Care Association, who represent 3,500 providers, we can connect with a broad
group of pediatricians as well as the family, emergency, and internal medicine physicians
who make up the staff at most general urgent care locations. Additionally, the Society for Pediatric Urgent
Care, or SPUK, has about 350 members dedicated to pediatric specific urgent care. And the Pediatric Urgent Care Conference hosts
about 150 people each year, offering great opportunities for collaboration with a specialized
group of pediatric providers. Research from pediatric urgent care is also
advancing. With the PAS conference, sponsored by the
Academic Pediatric Association, boasting 10 abstracts in three platform presentations
this year that were focused on urgent care. By being able to leverage these groups in
the AAP together we are in a unique position to help define what pediatric urgent care
is and what it can be. Next slide. It comes as no surprise to people in this
room that antibiotic overuse is a serious concern in all areas of medicine, not just
urgent care. Well, one study noted that outpatient antibiotic
use had decreased by nearly a quarter in patients under 14-years-old, CDC data noted that there
was still over 266 million courses of antibiotics dispense from community pharmacies in 2014. This number is even ticked up against slightly
in 2015 and again in 2016 after four previous years of decline, with the 2016 data showing
about 270 million antibiotic prescriptions. Meanwhile, a recent study in JAMA found that
at least 30 percent of outpatient antibiotics are for inappropriate indications such as
viral Pharyngitis, asthma, bronchiolitis, influenza, nonsuppurative otitis media, and
of course viral URI also known as the common cold. If we extrapolate this rate and use the most
recent prescribing data from the CDC, we are looking at around 80 million courses of antibiotics
that could probably be avoided each year. Next slide. Now with the sense of the scope we are facing
in the outpatient world, I want to take a second to highlight the importance of urgent
care in this discussion. Urgent care is growing at nearly 5 percent
annually with 400 to 500 new sites opening every year. And in 2015, the most recent acts date — the
most recent year I had access to. There was between 8,000 and 10,000 locations
across the country. Urgent care sites are most prevalent in the
heavily populated states of New York, Texas, Florida, and California, but even a rural
state like Idaho has 64 urgent care locations. Combined, these sites had over $15 billion
in charges in 2015 and in 2017 there were 90 million visits to urgent care centers across
the country, representing nearly 10 percent of all outpatient visits in that year. While this still means that 90 percent of
outpatient visits are in an ED, office, or a specialty clinic, as a rapidly growing segment
of outpatient medicine, urgent care has an ability to significantly impact antibiotic
prescribing rates, both good and bad. Next slide. Unfortunately, I’m guessing the reason I’m
here today is to discuss — to address the bad. Last year, JAMA released a study that reported
antibiotic use was linked to nearly 40 percent of all urgent care visits. And of those, 45 percent were for antibiotic
inappropriate respiratory diagnoses. ED visits had the second highest rate of inappropriate
antibiotic use at 25 percent while office-based visits, which continue to make up most outpatient
visits, had an overall antibiotic prescription rate of 7 percent with about 14 percent inappropriate
antibiotic use. Interestingly, retail clinics which are also
listed up there and offer limited diagnosis capabilities and equipment, were associated
with antibiotic prescription rate almost as high as urgent care but have the lowest rate
of inappropriate antibiotic use. Next slide. However, as a pediatrician and a pediatric
urgent care practitioner, I want to highlight a specific challenge with caring for a pediatric
population in urgent care. While nearly a quarter of all urgent care
visits are for pediatric patients, less than 10 percent of urgent care locations have a
pediatrician on staff. Most of these are actually at dedicated pediatric
urgent care centers, which, while growing, continued to represent less than 5 percent
of all urgent care locations. Next slide. The reason I bring this up is that while the
healthcare world in general, and urgent care specifically, struggles with antibiotic stewardship,
if we look at how pediatricians approach antibiotic use, we begin to see a different picture. Most inappropriate antibiotic use is for the
common pediatric illnesses listed here. In this recent study from Pediatric Infectious
Disease Journal, we see that while family practice and NPs or PAs prescribed antibiotics
at nearly 30 percent of the time for URI in either the office or urgent care setting,
pediatricians only prescribed antibiotics 8 to 9 percent of the time in those areas. Research from children’s Colorado also backs
us up, where we have shown that our pediatricians have an antibiotic prescribing rate of 4 percent
in URI for both our urgent care and ED locations. So, there’s a good amount of evidence that
the pediatric community in both the outpatient, ED, and urgent care arenas have taken great
strides to be good stewards of antibiotics. Next slide. However, we recognize that pediatrics and
pediatric specific urgent care still has room for improvement. One current effort comes from a collaboration
between SPUK and the Antibiotic Resistance Action Center. This quality improvement project kicked off
earlier in 2019 and has three primary aims. It seeks to build capacity for quality improvement
projects and in pediatric urgent care, to understand the prescribing patterns for antibiotics
in specialized pediatric urgent care centers, and finally, to implement a trial of interventions
to reduce inappropriate antibiotics prescribing. Overall, this project seeks to reduce inappropriate
antibiotic use in participating pediatric urgent cares by 20 percent. Although, this study is still in progress,
I do have some preliminary data I can share. Next slide. I apologize, this is going to be look a little
bit small here, but the study group is comprised of 153 providers at 20 different institutions
across the country. As you can see in the pie chart, most antibiotic
use was for appropriate indications such as ear infection, strep throat, and skin infection. However, there are still a few prescriptions
for non-suppurative otitis and pharyngitis is not broken down into strep versus viral. However, we assume based on some of our data
that the vast majority of this was for strep. If we drill down into ear infections specifically,
or acute otitis media, now we can see that amoxicillin was by far the most common antibiotic
used, followed by amox clav, reflecting that when antibiotics were prescribed, there is
good use of narrow spectrum antibiotics. Next slide. If we look at the interventions, there are
several ways we can try to help promote antibiotic stewardship in our locations. One that we’ve decided to use at Children’s
Colorado is posting a signed commitment letter from our providers in patient care rooms. In other settings this intervention has been
shown to decrease inappropriate antibiotic use by nearly 20 percent. We are also going to be rolling out a DART
module, or Dialogue Around Respiratory Illness Treatment, that was developed by Seattle Children’s
hospital to help educate providers about ways to discuss respiratory illnesses with patient
families. At Children’s Colorado, we’ve also begun to
provide patient education handouts for strep throat and strep throat testing. That includes information such as most sore
throats are caused by viruses and do not need antibiotics and talks about how the presence
of cough or runny nose makes it even more likely their sore throat is caused by a virus
and does not need antibiotics. We are also using language similar to the
CDC regarding delayed antibiotic use, especially for ear infections. This includes many options for supportive
care during an illness and waiting to see how the patient does before prescribing antibiotics
if that is the necessary approach. Truthfully, discussing supportive care is
one of the main things I talk about with patients. When a concerned mother tells me her child
just wants to sleep all day, I talk about how important rest is for fighting off an
illness. And point out that if you or I had the option
of sleeping all day when we were sick, we would. Kids actually have that luxury, so they do. It really is good to be a kid. Since the majority of illnesses we see in
pediatrics are respiratory, I also bring up things like a cool mist humidifier or a nasal
saline spray to help relieve congestion or giving honey to help relieve cough. While many providers may think a parent wants
an antibiotic, I argue that they mostly just want to be able to do something to help their
child. Empowering them with these simple tools for
supportive care is usually all a parent really wants. Next slide. When I was preparing for this talk, I surveyed
my colleagues about some of what they see as challenges with antibiotic stewardship
in pediatric urgent care. These are a few of the common quotes that
came up and I think reflect some of the challenges very well. “Every time she gets a cold she ends up with
strep throat.” Here, I usually take a second to educate about
sore throat along with cough and congestion, and how that’s very unlikely to be strep,
as I already mentioned. Having a handout at our disposal that specifically
says this helps this conversation go a lot smoother and tends to add some weight to sort
of the discussion that we have. “Well my doctor gave me antibiotics, and my
kid has the same symptoms.” This one’s tough because we often go out of
our way to avoid disparaging someone’s PCP. But also recognize that about 30 percent of
antibiotics are prescribed inappropriately. So, there’s a good chance that the parent
might not have actually needed antibiotics anyway. There’s also some differences in prescribing
guidelines between pediatrics and adult medicine. So, oftentimes, I’ll try to highlight some
of these differences to describe and explain sort of why I would not do antibiotics for
a child. The next one is, “We are going out of town
tomorrow and want to get her started on something before we leave.” This is a super common refrain. And it’s actually sort of the danger of the
easy and convenient care that urgent care offers. Many of these patients in this scenario would
not have been able to get in with their PCP, and in the past, would have either just gone
on their trip and given a time or gone to an ED. However, urgent care tends to be open at more
convenient times than a PCPs office, and for those who are cost-conscious, is much less
expensive than an ED visit. In these situations, I try to focus on supportive
measures like I mentioned earlier, as well as the notion of giving things time. If a family is flying, I talk about giving
Ibuprofen before getting on a plane since a child with congestion, even without an ear
infection, can have ear pain with pressure changes. If any of you have flown with a congestion
as well it’s the same thing with adults. And I’ll often admit my bias, but I’ll suggest
that the family find a pediatric specific urgent care if they think they still need
to be seen again while traveling. “She’s allergic to penicillin.” I included this because it’s so overused and
paints us into corner with antibiotic use. Getting a rash while taking Amoxicillin is
common and frequently misidentified as an allergy. The incidents of true allergy to penicillin
is quite low. One recent study in Academic Peds found that
37 or — excuse me, found that at least 67 percent of patients with reported allergy
to penicillin were unlikely to have a true allergy. While another article from our ENT colleagues
found that nearly 90 percent of patients with a listed penicillin allergy in their chart
didn’t really have a penicillin allergy on further review. On a purely non-scientific note, one of our
pediatric allergy specialists at Children’s Hospital recently told me his allergy tested
96 kids with reported penicillin allergy and has not had a single one with true anaphylaxis. This is important because not being able to
use penicillin, primarily Amoxicillin, can force us to prescribe broad spectrum antibiotics
that are often more expensive and contribute to antibiotic resistance. “We knew something was wrong because she wanted
to come.” So, this is often my favorite ones. I rarely disagree with a parent that their
child is sick. But just like the whiny husband with man-flu,
everyone handles illnesses differently. You know, cough and congestions are terrible. They keep kids up at night and they keep parents
up too. So, everyone at the house is miserable and
tired, which was — which — in any way — also when a patient’s throat hurts, they don’t
want to eat or drink. We all know how stubborn kids can be with
eating and drinking to begin with. However, none of these things necessarily
mean antibiotic is going to help. Most viral illnesses get better in three to
four days and kids are a lot tougher than we sometimes give them credit for. Often supporting them through an illness with
antipyretics, nasal, saline, rest, and bribing them with a popsicle or two to keep them hydrated
is generally a pretty good approach. Next slide. So, that’s all I have for you initially. Except as a pediatrician, I’m pretty sure
I’m required to have at least a few pics of Moana, Frozen, Minions, that sort of stuff. So, there you go. You got that. And thanks for your time, and I look forward
to any questions you have in the Q&A session.>>Angela Caliendo: Thank you very much. Okay, our final speaker in this group is Dr.
Mark Hitt. He practices internal medicine in the Atlanta
— at the Atlanta [sic] Veterinary — I’m sorry, Atlantic Veterinary Internal Medicine
and Oncology Clinic.>>Mark Hitt: Good morning. Thank you very much to the council for having
me. I appreciate all the sense of organization
that’s gone into this, Dr. Musamar in particular. I have a background that goes back over 40
years in veterinary medicine. I’ve been a veterinary technician, a kennel
boy, a veterinary student, general practitioner, academic associate professor, and then in
the last 25 years specialty in veterinary internal medicine and oncology. Next slide. So, a lot of people don’t know what veterinary
new medicine actually is. And — alright, breath. So, I just thought I’d put a quick slide up
here just to illustrate that it goes well beyond your small animal practice that you’re
most familiar with. Most small animal practices are not encumbered
by the metric data analysis and accumulation that goes with corporate and government regulation. That may be changing as we get more into a
stewardship issues for antibiotics, for controlled substances. We’re beginning to see more and more need
to provide data. But right now, there are very few metrics
available to give you on antibiotic use that is not out of date or minimized. The general practices can be anything from
small animal and equine. Then there’s food animal, poultry, and aquaculture. The last three engage field services, diagnostic
labs, various sizes of corporate advice in everything from the epidemiologic groups to
fire engine practices. I am in the second tier of veterinary medicine
with specialty private practice. We function in a referral center that incorporates
individual practices of surgery, neurology, imaging, radiology, cardiology, ophthalmology,
all of the specialties. And as such, we — they act independently
very often and there is no infectious control program basically that has sway or power over
their individual actions. And this is pretty common except for when
you get to the university level, where you start seeing stewardship issues and efforts
underway. It is a good day when people come to the internist
and ask them to act as an infectious disease officer. That is several times a week but compared
to the number of times that antibiotics prescribed it’s relatively minimal. Tertiary level of veterinary practice would
be the university hospitals largely. Next slide. So, what species do we work with? Just to give you a broad spectrum here, it’s
— I do canines and felines 99 percent, pet pockets, avians, amphibians, reptiles, fishes
are all seen by our emergency practice and general practices that are out there. Next slide. So, the question was today to provide some
information on what the barriers are to proper antibiotic use in private special — or, excuse
me, private veterinary practices. And it comes down to focusing on what are
the appropriate and then the inappropriate uses of antibiotics. And I think the goal today is certainly focused
on the inappropriate. We’re looking at the need for continuing education. We need to have veterinarians go back and
review pharmacokinetic issues, pharmacodynamics. We need to use more culture and sensitivities. We need to work on client compliance. This has been an issue for the pediatricians
I’m sure. It’s an issue across the board. We’ll talk more about these points in a few
minutes. We’re looking at rising costs to consumers
for appropriate antibiotic use. And then nosocomial risks that are rising
in veterinary medicine as well and as part of the resistance package that we have to
deal with. There is the question of how do we identify
alternatives to antibiotics. We’re looking currently at UV light for sanitation. We’ve just installed a hyperbaric oxygen therapy
unit to be an adjunct for certain types of infections. We’re looking for — I don’t think phage therapy
is going to hit our world very quickly, but it’s an issue. And we know the world is coming to our doorstep
soon. I think that one of the better resources I
found online was provided by WHO, which looks at the antibiotic stewardship through access,
watch or monitoring, and then reservation of antibiotics. And that’s something that we see coming our
way. Next slide. So, antibiotic choices in that veterinary
medicine, there again this is a little bit of informative for you all as well because
many are not aware of what we have available in veterinary medicine. And it’s pretty much everything that you would
use in human medicine. So, the standard classes of antibiotics are
there. And I would say that — I’m going to highlight
the fluoroquinolones because they’ve been the workhorse for the last 10 years. Starting with the inappropriate use of ciprofloxacin. Enrofloxacin is hitting our veterinary market,
marbofloxacin, pradofloxacin. Sulfonamides not used very often anymore because
of the side effect risks. There are way too many lawyers in the world,
so we do tend to avoid issues where we can, but we still use them. And then the rising tide of chloramphenicol. It’s something that has never gone out of
our sites but is an antibiotic that was used much more in the 80s and 90s and then kind
of faded with the rise with fluoroquinolones. But it is now back on our radar as we hit
more resistance in our culture and sensitivity patterns and clinical cases. Glycopeptide type antibiotics such as Vancomycin,
clindamycin. We don’t use much Vancomycin. We also don’t have much of a clustered in
difficile issue. I’ve had one clinical case in a cat in 20
years. That was — I actually have evidence-based
data for. Clindamycin is used all the time in veterinary
medicine for predominantly dental infections. Then there are certain antibiotics that we
even look at as sort of on the reserve list that most veterinarians are not educated about. And they’ll see it on a culture and sensitivity
occasionally and they’ll say, “Oh, I wonder if I should use that.” And the answer is no. Fosfomycin I’ve used once, I think in 30 years. Colistin I’ve never used. Linezolid I’ve used twice in 30 years with
appropriate guidance, I felt. And tigecycline for staph aureus infections. I can’t recall a veterinarian that’s used
that. And we’re trying to stay away from those. But veterinarians and antibiotics is a lot
like gun control. Don’t try and take away our antibiotics. You will get a broad spectrum of controversy
coming back at you. And I say that somewhat facetiously because
we know that we have to be cognizant and judicious in our use. Next slide. So, veterinarians need to be cognizant in
their selection. We look to certainly that organisms are gram-negative
or gram-positive. We look to whether organisms are anaerobic
or aerobic. But I think we have to go back to the pharmacodynamics
of our antibiotics. And the two biggest things that are novel
thoughts to a lot of veterinarians who graduated before the last 10 years is going to be whether
antibiotics are concentration dependent or time dependent and the appropriate doses. I think that there needs to be a return in
veterinary education to basics of infectious disease, including host status, organism that
we’re dealing with and it’s attributes, and then what are the effective doses that are
likely to be playing a role. Appropriate treatment selection with antibiotics
goes to correct dosing. It goes to compliance. It goes to those barriers we talked about
a minute ago. Appropriate drug selection is also influenced
then by the patient, the host. What organ system are we dealing with? What data do we have about the health of the
organ systems overall? Can we use amino glycoside? Do we have to adjust its dosing, would be
a good example. Has the animal had adverse drug reactions
previously? We see few adverse drug reactions that are
life-threatening in veterinary medicine to antibiotics, but we do see them. We also see many less prominent side effects
that are interpreted as adverse drug reactions. And there, again, it’s a matter of proper
education. So, we also look then for guidelines to how
to use antibiotics. And this could be as simple as a manual of
antibiotic use for infectious disease, looking at the organ system, looking at the species,
looking at the comorbidity thoughts or adding those in, and picking an antibiotic as best
use for the situation without a culture and sensitivity. But if you give us the opportunity, we’re
going to ask for that culture and sensitivity given that it’s going to take two to three
days to get a result. So, antibiotic use in small animal veterinary
medicine is an everyday event whether it’s general practice or specialty care. I think that the specialists are more judicious,
but overall, it’s still a minuscule amount of antibiotics I think compared to, say, aquaculture. Next slide. So, we’re concerned about the pathogens. You know, we’re treating bacterial infections. We’re concerned about resistance. That’s what’s influencing our inappropriate
use sometimes. We’ve all heard that resistance is coming
with our pathogens. That’s been the story since I graduated in
1979. I also remember my mentor in 1980 telling
me it’s not something to worry about until the next millennia, which has been here now
close to 20 years. And it is on our doorstep. We face it daily. So, we see every situation you would see in
human medicine. I’ll show a couple of examples in a minute. Treatment — I come back to review by the
veterinarians. We need to be concerned that we’re using the
antibiotics correctly. And that goes back again to education. We are dealing with zoonosis and reverse zoonosis. Helicobacter, for example, wants to be vastly
over-treated in veterinary medicine. Helicobacter pylori is a gastritis producing
organism. Dogs most commonly probably have it, say 70
percent of canines carry it. It’s a superficial gastric mucosal infection
of no real significance. The vast majority of the time. However, it gets treated all the time because
people have it. Well, the dogs usually get it from people. Just as an evidence of reverse zoonosis. Nosocomial infections are a rising threat,
especially referral hospitals, academic university hospitals, those facilities that are obtaining
or are getting cases that are much more difficult in scope — that have had many more antibiotics
before arrival. So, the resistance issues are on the rise. Next slide, please. So, here, are the organisms we deal with are
the same ones that you look at every day in human medicine. The E. coli’s all the standards, the klebsiellas
are facing as the extended spectrum beta lactamase resistant organisms. Mycobacterium are showing up occasionally,
actinomycetes more often. And then the saprophytes, the Acinetobacter,
pulvini [phonetic sp], enterococcus, all of these organisms we see. So, next slide. So, what are the barriers when we see these
organisms to using the appropriate antibiotics? Approved products in veterinary medicine are
few. We’re supposed to use approved products for
veterinary medicine when we can. Cost implications to the clients are heavy. People want to use less expensive options. New antibiotics or routes or administration
are not coming down the pipeline as we had thought or hoped 20 years ago. Compounding pharmacies do provide some options,
but they have their own difficulties to deal with in quality assessment. Reduced fluoroquinolones sensitivity is really
one of the biggest issues that we face because it’s been our work horse, and now it’s just
declining in its efficacy. Where people reach for the next level. That’s where I fear for people reaching for
those reserve drugs on occasion. We’re going back to more use of chloramphenicol,
trimethoprim sulfa — short term anyway. And then we’re trying to avoid those reserve
drugs, as I said. Next slide. So, we’re facing there again, kind of back
hitting the same points over and over. But inappropriate use of the antibiotics,
you know, is there any evidence that gives us metrics on this? I guess would be my point. And there — I don’t think there really is
any real evidence of the metrics of it. You can take individual practices, but you’re
still left with uncertainty. The appropriate use of antibiotics, there’s
still selection pressure with resistance even when you use the proper choice of an antibiotic. Bacteria resistance can be multiple forms,
and there again we’re faced with these same organisms. Next slide. So, just a very brief, a waste of 10 seconds
here. But in 1984, I went to a resident seminar
at the University of Missouri on client compliance, and somebody had done the phone backs to the
patients, the human facility. And they found that at one-week compliance
for once-a-day treatment was 87 percent. If you did TID treatment for two weeks, it
was 27 percent. Now, you take that and put it in a 17-year-old
hissing mad cat, and I think that it’s compliance is going to be less. So, next slide. So, what is true in human veterinary medicine
is true for veterinary medicine. We run all the same risks of increased mortality,
morbidity, grieving, loss, increased hospital costs, and then also legal litigation if we
make the inappropriate choices. Next slide. So, principle of control, surveillance, culture
monitoring. We do this in our facility, but it is a rare
event that many facilities would do this. Next slide. And so, we do go for the standards of care
in preventing nosocomial infections and treating them. This’ll be in the slides available for review. Next slide. And I’m running out of time here. So, next slide. And active regulatory role that’s coming down
the pipe, I’ve been told be ready to be warned about it. It is a concern. We do look for more information that helps
us make wise decisions. Next slide. So, in summary, continued education for veterinarians
and hospital teams. We want to prevent infections where we can. We’re looking for appropriate cultures and
sensitivities. And then interpreting those sensitivities
correctly — it was hammered home to me last night at dinner. Proper use of antibiotics by clients. Concurrent therapies, what else can we use? And then nosocomial awareness. And then if we can get the labs to share data,
that would be a big help. And then there’s a lack of micro-clinical
microbiologists. Thank you. Next slide. Thank you.>>Angela Caliendo: Thank you, gentlemen. I appreciate the — these are excellent presentations
and actually somewhat sobering for us of what life is like in the trenches. So, we’re going to open it up for questions. Wow. Okay. Marty, I’ll give you the first shot.>>Martin Blaser: Thank you very much. And I’d like to thank everyone for coming
to speak to us today. These were quite enlightening. And I have many questions, but — [coughs]
excuse me. I just want to start with Dr. Miller. So, the CDC — as was mentioned, the CDC estimates
that about a third of all the antibiotics used in medical practice are unnecessary,
but recent estimates that for dentists it’s about 80 percent. So, can you give us some insight about what’s
the reason for this big difference between dentists and other doctors?>>Glen Miller: The 80 percent number, as
I know it, has to do with prophylactic antibiotics. The report that I read said that 81 percent
were unnecessary. One of the main reasons, in my mind, is we
don’t prevent periodontal disease. We let periodontal disease get out of control,
which allows more infections to happen, which means more antibiotic usage. And then the patients that have periodontal
disease are also more likely to get prophylactic antibiotics. And so, it’s a double-edged sword with periodontal
disease. That’s why I spend a fair amount of time on
it. So, a lot of it’s coming from the fact that
we don’t control it in the first place, and the second place, when the infections come,
we’ve got to throw antibiotics at it instead of doing definitive care.>>Martin Blaser: So, let me just push back
a little, and that is that these guidelines come from recognized authorities — experts
in the field who take into account these kinds of issues. So, I just — I wonder if that may be self-serving.>>Glen Miller: I’m not sure I understand
the question.>>Martin Blaser: Well, you know, people — doctors
who prescribe a lot often say, “We — oh, well my patients are sicker than everybody
else’s patients.” But on average that can’t be the case. It should average out. So, the societies that make guidelines about
use of prophylactic antibiotics are taking into account issues like periodontal disease. It’s mostly about endocarditis risk and about
risk in prosthetic infections, in which the true indications for prophylaxis that are
evidence-based are actually quite minimal. So — but dentists are prescribing a lot more
than that. That that’s my question.>>Glen Miller: When I first started my career,
we use prophylactic antibiotics for everything. I mean, we never even consulted with an MD. We just wrote prescriptions. And also, we wrote multiple prescriptions
refills because we didn’t want to be bothered by it. So, we handed out a lot of antibiotics in
the beginning. That paradigm seems to be still manifest in
my profession. I still see a lot of dentists writing prescriptions
for antibiotics that are totally unnecessary. And I think the main reason for that is, once
again, I’ll go back to periodontal disease, but the other thing is that they don’t keep
up the literature. I mean, even when I was reviewing the literature,
and I keep — I believe that I tend to keep up on things. There are some things that I was prescribing
antibiotics for — it was like, “Oh, my gosh. I’ve been doing this a long time.” So, I think we get into paradigms and habits. But the push of the industry when I got into
dentistry was antibiotics for just about everything. And I see that wave still continuing. It’s starting to abate a little bit, but that
whole tidal wave is just such a mass that it’s been hard for dentistry to diminish it.>>Martin Blaser: Yeah. And that sounds closer to the case. Thank you.>>Glen Miller: I think it’s habit, habits
and paradigms.>>Martin Blaser: Yeah.>>Angela Caliendo: Okay. Kathy.>>Kathryn Talkington: Thanks, a couple of
questions. First for Nathan. Yeah, you talked a little bit about the sort
of ins — the problems for having pharmacists get involved in what in stewardship and the
incentives. And you talked a little bit about payment
reimbursement. In lieu of the fact that that’s probably going
to be hard to get changed in the near future, is there anything else? Are there other incentives that you think
would be helpful on the outpatient side? You talked a little bit about information. It’d be helpful to have more data and knowledge
about what the conditions are. Are there other things that could happen while
reimbursement issues are addressed?>>Nathan Wiehl: Sure. Information, if it were to flow from the provider
to the pharmacist, then patients, you know, might have a better chance at a more favorable
outcome. In the case that I presented you, if the pharmacist
dispensing the prescription, had the islet, saw that they were treating an enterococcus
bacterium that probably wouldn’t have responded to Cephalexin. That would have given them a fighting chance. Now, I’m not going to say that every pharmacist
would have caught that. But if that were the usual case, if we were
to get that information as standard of practice, then we would adjust our behavior and adjust
our practice to accommodate that. So, we would — because when more pressure
is put on pharmacies to perform, we typically do because we want to be able to be viewed
as medical providers eventually. But yeah, the flow of information — or if
we had access to the health exchanges with information between hospitals, if we could
log into a platform and see renal function or see lab work without having the provider
to send it over — if we had access to that, then I think we’ve got a better opportunity
to have favorable outcomes for sure.>>Kathryn Talkington: Thanks. And I just have one quick question for Dr.
Hitt as well. You had talked a little bit about metrics
and the lack of metrics in terms of antibiotic use in the veterinary field, in your field. What — if there were metrics do you think
that would be something that could be easily developed, and are there systems in place
to measure use that could be helpful?>>Mark Hitt: I think that it comes back to
the basics of veterinary practices and how it’s structured in the U.S., or if not, the
world. That only now is there sort of a consolidation
of veterinary practices by industry that are providing uniform computer systems, uniform
reporting back, bean counters that are looking at, you know, where money is being spent,
or which distributors and how much antibiotics are purchased. The software systems are disparate. They’re not linked or unified in any way. There are probably 25 different software electronic
patient systems. We have also no pressure from insurance plans
or insurance providers. I’m both blessed with that, that I don’t have
to deal with it. But on the other hand, there’s a lot of data
that comes from that information. So, that — right now, only 2 percent of small
animal clients have pet — health insurance policies for their animals. Some parts of Europe, in the United Kingdom,
it may be 70 percent, 60 percent — Germany, Denmark, 70, 80 percent. Whereas in the States, people don’t think
about that. So, pet insurance has not raised its head
very strongly, but I think that’s where a lot of your data comes from in the human world. It’s the requirements for reporting. I think that there’s a lot of independence
by history, just as with dentistry, in veterinary practices. Independence of action and getting us to report
just controlled substances is a whole new world for us. We’ve had a lot of independence there. And that may be a model for the future. Hopefully, not quite as strict. But in recent couple of years, veterinarians
are now required to have three hours a year for Maryland, for use of controlled substances
— three hours of continuing education. And it almost all involves human abuse. So, it’s — okay, we’re learning. Our recording systems — you know, we now
have at least 20 hours a month of employee time. Just going back to recording how controlled
substances are used, filling all the paperwork out, dotting all the t’s and i’s, and making
sure the logs all match. It’s just reached a new intensity, and I think
that getting that layered down on top of veterinary medicine will be its own struggle in the future. And it’s not that some level shouldn’t happen,
it’s just that it will be a bit of a struggle to reign in veterinary medicine, so.>>Angela Caliendo: Okay. So, we have a lot of people with questions
and not a lot of time so please limit to one question. So, Mike, you’re next. Choose wisely.>>Michael Apley: Dr. Wiehl, I just wanted
to follow up. So, you talked about the cost challenges to
having a stewardship role in advising. How much would that need to be increased,
and then when that’s increased, what is — what other barriers are there for the interaction
of the pharmacist with the physician in actually having input received and having the authority
or the status, if you will, to have that type of input? And does there need to be some change regulatory
wise?>>Nathan Wiehl: Well, I think there’s already
legislation written to recognize pharmacists as providers, but right now it’s deemed by
the CBO as being too costly. But I think in reality, it’s the other way. I believe in situations like this, it could
be it could be cost savings when we can intervene and get a more favorable outcome from a patient
that may otherwise take three or four days to jump through insurance hoops. But I think that initially it starts with
the information. If we have the information at our fingertips. A colleague of mine — Antimicrobial Stewardship
Director for St Luke’s, Nick Bennett — has told me that even when you have all the information
an evaluation could take anywhere between five and 15 minutes. And in a retail pharmacy setting time is money. It’s a volume game anymore with the reimbursement
that we get. So, being able to tell you, you know, an exact
dollar figure I don’t know. Because chain pharmacies are paid better by
PBMs that they’re affiliated with or paid better or get a better net profit because
they’re buying so much better. And that’s one of the reasons why my company
has bolstered up to 228 locations, simply so we can buy medications better to lower
our cost and therefore be able to provide additional services that independent single
store or two or three store groups can’t do. So, I can’t really give you a dollar figure. But elimination of those retroactive DIR fees,
where we can appropriately budget for services down the road rather than three to six months
after point of sale. Getting a recoupment back to the point where
we can’t evaluate our books to decide if those are services that we can provide.>>Angela Caliendo: Okay. Aileen.>>Aileen Marty: Okay. Thank you very much. Thank all of you for wonderful presentations. And Dr. Santos in particular, congratulations
on the inroads that pediatricians are making in curbing inappropriate use of antibiotics. But my question is for Dr. Miller. And I’m, I’m wondering how familiar you are
with the experimental porphyromonas gingivalis vaccine. It’s a chimeric KS2A1 vaccine that targets
the major virulence factor of the bacterium. And if so, can you recommend on its potential
value as it may relate to human periodontal disease and then thereby decreasing, you know,
the need for antibiotics for dental procedures? And moreover, what are your thoughts on our
government promoting and incentivizing the development of vaccines for oral pathogens
such as this key pathogen as a mechanism for combating antibiotic resistance?>>Glen Miller: Well, that’s a big question. I’m not sure I have an answer for that. I’m not sure about the — I have not heard
about the vaccines, so I’m not sure how to answer your question there.>>Aileen Marty: Well, how about the general
part of the question, which is our promoting and incentivizing the development of vaccines
against oral pathogens.>>Glen Miller: Anything that’s going to decrease
our use of antibiotics I think is something that’s going to be beneficial, so.>>Aileen Marty: Thank you.>>Angela Caliendo: Okay, Paula?>>Paula Fedorka-Cray: Yes. This question is for Dr. Hitt. You know, you made the comment that use in
small animals may be minuscule. But have you considered the interaction with
the human factor in all of this? I mean, there is much more intimate contact
between dogs and cats than there than there is between a fish. And you specifically use the aquaculture example.>>Mark Hitt: I use the agriculture analogy
simply because it’s a matter of tons compared to milligrams. But — I’m sorry, I lost track of your question.>>Paula Fedorka-Cray: So, are you — what
effect — have you looked at what effect that there might be between this more intimate
contact between dogs and cats and humans than other food animals or –>>Mark Hitt: There’s limited information
that about the transmission of infection pathogens between the two species. Certainly for, you know, more common issues
such as toxocara or round worm infections and larval brand problems or rabies virus
and those kinds of zoonotic issues. I think the one that’s been studied the most
in veterinary medicine would be staph infections. And is there a role for methicillin resistant
staph aureus to be harbored in pets and then transmitted back and forth with humans? And it’s been that it can happen, but it’s
not a common event. It’s more of a concern when we have a dog
with methicillin resistant staph aureus that’s been pursued it’s usually from the human. And yet there’s very little data that shows
it going the other direction. Occasionally, a human will come up with methicillin
resistant staph pseudo intermediates, which is a veterinary pathogen, through probably
close contact and open wounds. But there’s, to my knowledge, not much data
published. I have to say it’s a little outside of my
expertise.>>Paula Fedorka-Cray: Right. And I think that that’s a major point.>>Mark Hitt: Yeah.>>Paula Fedorka-Cray: I think that there
is very little information available. And so, we really don’t know but, we have
— we use more human related pharmaceuticals in small animal medicine than we do in food
animal medicine.>>Mark Hitt: Yes ma’am.>>Paula Fedorka-Cray: And I think that that’s
an issue that deserves study.>>Mark Hitt: Agreed.>>Paula Fedorka-Cray: Thank you.>>Angela Caliendo: Elaine.>>Elaine Larson: This is for Dr. Santos. A terrific panel, thank you so much. We just finished a study that’s not published
yet, we’re writing up the manuscript, looking at the risk of infection and with multi-drug
resistant organisms in children who are residents at pediatric long-term care facilities versus
children who are admitted to acute care, who are not coming from Peds long-term care. And as you — it’s about — we had about 1200
from Peds long-term care and 260,000 from not long-term care. Much to our surprise, the children who are
at very high risk they’re vulnerable in Peds long term care — it’s like a nursing home
for kids — had much higher rates, about two and a half times the risk of any kind of an
HAI, but they had a significantly lower risk of MDROs. And it’s the opposite of what one would think
because they’re sick. They’re — they have all the risk factors
of adults in long-term care. And we can’t –we can’t figure out any reason. Is there any thought that you might have about
why this disparate finding would be there?>>John Santos: No. It’s a really interesting finding, and it
would be — I don’t know what the next step would be to try to look into that a little
bit further. Certainly, I would have thought the opposite
as you say.>>Elaine Larson: Right. And ironically, the Peds long term care kids
also had a significantly higher risk of c difficile, hospital acquired c difficile,
which you would think would be consistent with, you know, more antibiotics, and they
also had more antibiotics in long-term care. It’s very strange. So, something else is going on that is, you
know, with MDROs. Anyway, it’s something to think about.>>John Santos: Yeah, it definitely would
be interesting to look at further certainly. Thank you.>>Angela Caliendo: Sara.>>Sara Cosgrove: Well, thanks to all the
speakers. My question is for Dr Wiehl. I’ve been informed by several colleagues that
many of the big pharmacy chains are sending automatic refill requests for antibiotics. And whereas this may be appropriate for cholesterol
medications and so forth, not for antibiotics. And I just wondered if that’s something that
your pharmacy does, or if, you know, what strategy would we even begin to take to make
that stop? Because it’s just an open invitation for prolonged
unnecessary courses and/or prolonged residence of pills in someone’s medicine cabinet to,
you know, take at will.>>Nathan Wiehl: Yeah, that’s a very good
question. I don’t know of any — and I have a lot of
colleagues that work for major pharmacy chains. I don’t think that it’s anything that is a
conscious decision being made on the pharmacy staff. It’s probably that a patient is phoning in
a refill using an automated system that then the computer system finds doesn’t have any
refills and automatically sends that. So, I don’t think that there’s — I think
if that same patient were to actually talk to a pharmacist, and they said, “I would like
for you to request a refill.” They’d probably say, “I don’t think you were
intended to have one. You should probably contact your doctor.” So, it’s probably a setting in their pharmacy
management software. We have disabled that feature in our system,
simply because of that reason. We want to be able to discuss with patients
whether they need a refill or not. And it frustrates providers like crazy when
they get unnecessary refill requests. And we’re cognizant of that. My organization is largely in rural areas,
where we’re the only pharmacy in the county in a lot of cases. And we have very good working relationships
with our providers. So, we take steps not to infuriate them if
we possibly can. But I also think that there is a difference
in community pharmacies, independent pharmacies, and chain pharmacies. Nothing against my colleagues that work for
major chains, but they don’t have the support of their owners or their companies to get
more involved in-patient care. They staff the least to make the most profit,
they’re slashing hours, and under the guise of health initiatives. You see Walgreens and CVS out there promoting
these health initiatives, but at the same time they’re cutting their support staff,
putting more and more burden on the pharmacists for the regular filling process. And it’s forcing everybody in the industry
to try to remain competitive with them. But if they had staffing standards that were
equivalent to a community pharmacy, they probably wouldn’t have the reputation of making bad
decisions like that and sending requests off like that.>>Angela Caliendo: Kent.>>Kent Kester: So, again, great talks by
all the presenters, and I was struck by a number of recurrent themes across a number
of the presentations. So, you know, Dr. Hitt, I just — you know,
when we heard from Dr. Miller how it seems like some practices are ingrained in dentistry. And, you know, maybe it just takes a long
time to sort of get that out of the system as more people get trained. And as Dr. Santos described, you know, oftentimes
in urgent care, as well as in private practice, there’s a push by the parents. You know, the kid’s sick, need some antibiotics. So, in veterinary practice, you know, there’s
sort of the dichotomy of, you know, sort of the routine — you know, the owner brings
the dog in with diarrhea and the dog gets metronidazole and out the door — you know,
but, maybe the sample’s not evaluated or, you know, routine cultures aren’t necessarily
sent. And the owner wants an antibiotic and so it’s
provided. And sometimes, you know, then there’s the
cost issue of cultures. Because, you know, let’s face it, people don’t
necessarily want to pay big money routinely for what they view as routine sort of veterinary
care. How does that get addressed? Because on the one hand metrics are important,
but on the other hand these are like really practiced technical operational aspects that
sort of undergird a lot of this sort of stuff.>>Mark Hitt: I think we come back to the
same efforts that are being made at the pharmacy and the pediatric level, which is to get the
information to the client in some way that antibiotics aren’t always the answer. Whether it’s information brochures at the
front or a poster or just — I’m not sure how you get it out to the mass media kind
of scenario. But it really comes back to the basics that,
you know, maybe you could use the analogy of what your pediatrician’s office has told
you applies to your dog. That, you know, the client comes in with hemorrhagic
gastroenteritis for a dog, and they can’t hospitalize. And they — you don’t know as the veterinarian
is it a clostridium perfringens issue or not, or is it just garbage gut, you know, eating
out of the trashcan? So, the pressure is there to not wait. And the client’s thinking it’s going to be
4:00 a.m. when they need that antibiotic and they didn’t get it. And then they’re going to blame you the next
morning. We have the phone messages waiting for us
in the morning for the antibiotics we didn’t dispense. And I think the progress that’s been made
is also maybe lost in this discussion for all of us. That it is better than what it was. But in essence, I think it goes back to the
education of the client to try and reduce the pressure on us to make those prescriptions. And then that we are able and willing to stand
up. And that’s what it comes down to. Can you take that extra five minutes of discussion
with the client and make the person reassured that you or the system will be there if they
do need the antibiotic? There’ve been times I’ve written the antibiotics
and said, “Do not fill this unless you end up needing it, but let’s give it till tomorrow
morning and see what happens.” And a fair number of those don’t get filled. So, it is a matter of education in my mind.>>Angela Caliendo: So, Dr. Hitt, I’m curious
how much of the problem do you think is that the distribution of antibiotics from the veterinary
practice itself is a source of their revenue? Do you think that drives any of this?>>Mark Hitt: I think your question is on
revenue and how it drives the use of antibiotics. I think that 15 to 20 years ago, 10 years
ago even, that was a much — it would have been a much more relevant question, not that
it loses relevance now. But in the intervening decade we are competing
with the grocery store pharmacies and Walmarts for veterinary products. They will sell veterinary products now. So, if I write a prescription for Clavamox
as a veterinary form of augmentin, they can fill it at their — even pharmacy. I can’t compete. We don’t stock anything beyond occasional
use for either in hospital or patients that definitely have to go home with it right at
that moment. We are no longer competitive price wise, so
it’s less of an issue. It’s not a profit center for most people any
longer. If your veterinary practice is depending on
prescription antibiotics for a profit center, then you are probably — you might want to
reconsider that function of that.>>Angela Caliendo: So, you’d like me to find
a new vet? [laughs]>>Mark Hitt: It shouldn’t be a profit center
any long term really.>>Angela Caliendo: All right, thanks. Ramanan.>>Ramanan Laxminarayan: Thanks. So, question for Dr. Santos. So, there’s some research showing that that
poorer families are more likely to get antibiotics, or you, know, it’s correlated inversely with
income. And one thing which didn’t come up with, you
know, many of the reasons that you provided why someone is asking for an antibiotic is
— you know, are there people who really can’t take time off because they have no leave? I mean, this is really — people working in
Walmart, for instance, they can’t afford to take the day off or even a few hours off. So, that’s actually a much — I mean, is it
possible that that’s a much bigger driver rather than people saying, “Well, I have to
go away for the weekend. I’d prefer to get them on antibiotics before
I leave.” There’s a lot of people who are just — who
are working two, three jobs and then getting that antibiotic for the kid is because without
the antibiotic the kid can’t go to school. They can’t afford to keep them at home. And that probably represents a large proportion
of people, perhaps not in your practices per say, but have you heard of that?>>John Santos: Yeah, I think it’s a great
— it’s a great observation. Certainly, you know, there’s many pressures
on families and parents certainly. And people working multiple jobs, non-traditional
hours, all sorts of things, trying to find daycare available. Especially, if a child’s sick a lot of daycares
won’t take a kid if they have a fever or anything along those lines. I think my challenge and my push-back on that
though, is that is an antibiotic going to help? That’s always what it comes down to. You know, if a kid has a viral illness — a
cough, congestion, cold type thing — that antibiotic isn’t going to help that kid get
back to daycare any faster at all. So, I think, again, there’s — it’s relatively
rare where, you know, doing something early, especially in the urgent care setting when
kids come in, pretty early that getting that antibiotics started is going to make that
much of a difference.>>Ramanan Laxminarayan: I don’t — I’m not
disagreeing with it. I’m just saying how do we disabled that particular
reason?>>John Santos: Yeah. And, again, I think that comes back to what
Mark has talked about as well as some of the others on the panel. A lot of it is education. You know, there was talk about education level
and how that impacts patient’s perception of the use of antibiotics and whether it will
help or not. And so, I see my role, just like Mark had
mentioned, as being an educator and talking to families about what things that they can
do to try to help their child feel better as opposed to throwing antibiotics at a viral
infection or it’s not going to make as much of a difference.>>Angela Caliendo: Jane.>>Female Speaker: Thank you. And thanks for the great talks. My question is for Dr. Santos, and it regards
the role of diagnostics in the urgent care setting. So, what rapid diagnostic tests do you use,
and which do you find to be most valuable in helping to make that decision of whether
or not to prescribe an antibiotic? And I guess the second part to the question
is what’s your wish list for what the ideal diagnostic would be to enable you to make
the best decision?>>John Santos: Thanks for the question. So, in our current institution at Children’s
Colorado the primary rapid test that we have is rapid strep. That being one of the more common sort of
complaints for sore throat. It’s well validated, has pretty good specificity
and sensitivity overall. So, anytime we are concerned about strep throat
we will go ahead and do a rapid strep. I think our group is very good about if the
rapid strep is negative to not treat. We see plenty of families that come in where
they’re at their PCPs office, and, you know, the strep was negative but threw them on amox
anyway because they figured that’s what it was. And they come back a couple of days later
with rash, which is a common issue with Amoxicillon if it’s not strep. So, that’s one of our approaches. If our strep is negative, we will send it
through a culture, which takes longer to come back. But that helps give us confirmatory testing
about whether that truly was negative or not. And if it is n-positive on our follow up culture
we have a system where we can call families back and go ahead and get antibiotics started
at that point in time. As far as other testing, we do not have an
— I know commonly a lot of places will have a rapid flu test. We don’t use the rapid flu at children’s Colorado
right now. From talking with their discussions with our
lab, we just didn’t think it was quite as accurate as we’d like it to be. So, if we have concerns, true high concern
for flu, we will send a PCR from our system. Flu is one of those ones where, you know,
I think we were focusing on bacteria, but, as someone mentioned, potentially we should
look at other things too. Flu is one of those ones I think where we’re
always challenged with, you know, “Hey, he’s got flu. Flu is all over the place. Let’s get him on Tamiflu or an antiviral.” And we, again, I take that opportunity to
educate that the recommendation is that for otherwise healthy pediatric patients with
no other sort of comorbidities, that really Tamiflu is not indicated generally. And so, I actually don’t mind not having rapid
flu truthfully, because that would put me in that more difficult position sometimes
of getting asked to do a test, doing a test, and saying, “Yes, it is flu, but I’m still
not going to treat you.” I’d rather be able to say truthfully that,
“Yeah, it probably is flu, but it’s not necessarily going to make much of a difference in the
child’s outcome.”>>Angela Caliendo: Okay. And our last question goes to Lonnie.>>Lonnie King: Thanks to all of you for a
really nice presentation. So, Dr. Hitt, just a — and Angie kind of
brought this up, but probably the trend for companion animals the fastest growth in practices
are by corporations. And certainly, looking at Banfield now in
a position where they’re talking about a thousand different — or not Banfield, but Walmart
is thinking about, you know, opening a thousand practices over a period of time and dropping
the cost of the visit in care by 30 to 40 percent. So, probably what’s made up on that is right
next door to them are food, toys, and a pharmacy. And whether that’s, you know, heartworm and
flea and tick prevention and also antibiotics. So, I just wondered in your mind, how difficult
would that be to start a really effective stewardship program when you have maybe a
corporate profit or mission or business model that’s like that, and is that going to be
a further barrier for us to move in to be more effective?>>Mark Hitt: I think the question is the
veterinary equivalent of the, the minute outpatient facility. They’re already in test marketing in Targets
in Walmarts in the south for veterinary medicine. And you get what you pay for largely. They can take your temperature and they can
do a quick check over and physical, but –>>Lonnie King: — antibiotics. And are they really going to do stewardship
programs, or are they going to incorporate antibiotics as part of the algorithm for treatment
because it’s part of the profit motive?>>Mark Hitt: They’re going to face the same
pressures that the human minute clinics do, outpatient clinics. That the client wants an answer. They want an answer quickly, and they have
— they’re — the clinic’s profit is in the volume. They can’t do that more effectively than your
general practitioner can, unless they cut the time and make things less available. So, the pressure to dispense that antibiotic
is going to be higher just as you see in human medicine. So, consolidation and, you know, downplaying
the value. Essentially, the general practices no longer
have routine small incidences of normal veterinary care to deflate the cost of the overall system,
so that when you would go in with a patient who is really sick, your costs may not be
as high because they could buffer those costs out over the entire population of their clientele
or their patients. Now, if you take the high profit margin quick
visits and set them aside and take them away from general practices, they’re going to have
to up their game on quality and time spent with the client and take the opposite track. Whereas the minute clinics, if it’s in the
volume, they have to turn things over and that’s going to take — they’re not going
to have the communications time. And the pressure is going to be to dispense
that antibiotic.>>Angela Caliendo: Okay. Thank you. This session is over.>>Martin Blaser: Thank you very much panelists,
Dr. Caliando, PACCARB members, and we’ll take a five-minute biological break. And come back by 11:05 a.m. Thank you, very much.>>Female Speaker: Produced by the U.S. Department
of Health and Human Services at taxpayer expense.

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