Sandra Fyfe

Long COVID goes by several names: post-COVID conditions, postacute sequelae of SARS-COV-2 infection (PASC), long-haul COVID, post-acute COVID syndrome (PACS), and chronic COVID.

 But regardless of the term used, the exact definition and symptomology of the condition are still developing as the science unfolds.

Long COVID involves a constellation of mild to severe symptoms across body systems.

 According to the CDC, it consists of “new, recurring, or ongoing symptoms and clinical findings 4 or more weeks after infection, sometimes after initial symptom recovery.”

 Even those who have never tested positive—due to inadequate or inaccurate testing, false-negative antibody tests, or waning antibody levels—can develop long COVID, noted the agency. At present, no avail- able laboratory tests exist to confirm the condition.

Patients of any age can develop long COVID, but it is more common in adults.

 A recent meta-analysis of 41 studies published online in the 

 found the global prevalence of the condition to be 43%, which is higher than that of previously published findings.

 The authors estimated that approximately 200 million people have experienced or are experiencing long COVID worldwide.

Long COVID has documented, multiorgan system effects.

 According to Yale Medicine, the CDC, and Britain’s National Institute for Health and Care Excellence,

 these symptoms include, but are not limited to, the following:

 Rapid or irregular heartbeat (palpitations), autonomic dysfunction such as postural orthostatic tachycardia syndrome (POTS)

 Shortness of breath, chest pain or discomfort, cough

 Diarrhea, nausea and/ or abdominal pain, reduced appetite

Memory loss, brain fog, loss of smell and/or taste, headache, insomnia, numbness, delirium, visual impairment, and mobility problems

 Anxiety, depression, posttraumatic stress disorder

 Sore throat, earache, tinnitus, hearing loss

 Fatigue, dizziness, intermittent low-grade fever, postexertional malaise

Mary Ann Kliethermes, PharmD, director of medication safety and quality at the American Society of Health-System Pharmacists, shared some ways in which pharmacists can recognize long COVID in patients and assist them with managing their symptoms.

Although pharmacists do not diagnose long COVID in patients, they can help identify the condition, Kliethermes said. Pharmacists are increasingly likely to have contact with patients affected by long COVID and can use current data to identify those who may be at risk.

“Patients come to the pharmacy for help and may discuss their symptoms, seeking OTC relief for long COVID,” Kliethermes noted. She added that this is a good opportunity for pharmacists to provide counsel and recommend to patients that they visit a physician rather than attempt to treat themselves.

For long COVID management, currently, “there is no standard treatment protocol other than pulmonary and cardiac rehabilitation and the administration of supplemental oxygen,” Kliethermes told 

®. Patients may be treated for specific symptoms by a primary care physician or a specialist of the affected body system.

Pharmacists should help patients coordinate their prescriptions across specialties to prevent drug interactions, Kliethermes added. They can also coordinate with patients to evaluate what OTC drugs they are taking along with prescribed medicines, to prevent additional interactions and maximize effectiveness. Pharmacists can also advise patients which OTC products can help alleviate symptoms.

Kliethermes emphasized that there are no proven alternative medicine treatments for long COVID, so pharmacists should ensure these substances do not interact with medically approved treatments. Finally, she advised pharmacists to keep up with developments in the literature as the science evolves by monitoring clinical trials and using research databases such as PubMed.

Other medications are being examined for their potential global effectiveness, rather than just the ability to target individual symptoms. One theory is that long COVID symptoms are caused by microclotting. One study, whose findings were recently published in 

, explored the therapeutic implications of anticoagulant use: “Consistent with this [study’s data], in a preliminary report, it has been shown that suitable and closely monitored ‘triple’ anticoagulant therapy that leads to the removal of the micro clots also removes the other [long COVID] symptoms,” the study authors wrote.

Another possible avenue of treatment is antihistamines, with data from 2 case studies published in the 

 showing positive results for long COVID symptoms.

 The study authors noted that these data add to those of “previous studies, [whose authors] have reported that patients hospitalized with COVID-19 demonstrated symptom improvement after administration of a histamine antagonist.”

 Research in these areas is still nascent, and not yet clinically approved.

The biological mechanism of long COVID remains unclear. Recent studies findings published in 

 examined the potential causes, including injury to 1 or more organs due to acute SARS-CoV-2 infection, the virus persistently infecting specific tissues, or the reactivation of neurotrophic pathogens (such as herpesviruses), as COVID-19 dysregulates the immune system. Those investigators also noted that long COVID may be caused by SARS-CoV-2 interacting with the patient’s virome or microbiome communities or by coagulation or clotting issues, or result from dysfunctional vagus nerve or brainstem signals. Other possibilities include primed immune cell ongoing activity, and autoimmunity caused by “molecular mimicry between pathogen and host proteins.”

 Because of the wide range of potential causes, the authors emphasized that the individualized array of symptoms in each patient will require different approaches to offer the best care.

While the science develops, pharmacists can help patients manage this mysterious and often debilitating condition. Pharmacists and providers can follow the CDC’s interim guidance

 on evaluating and caring for patients with long COVID.

“Understanding of post-COVID conditions remains incomplete and guidance for healthcare professionals will likely change over time as the evidence evolves,” the CDC wrote.

It is essential to afford practicing pharmacists the time and access to resources and professional development to keep up with emerging research, so they are prepared to identify patients with long COVID and assist them with symptom management and recovery.

1. Post-Covid Conditions: Information for Healthcare Providers. Centers for Disease Control and Prevention. Updated July 9, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fclinical-care%2Flate-sequelae.html

2. Chen C, Haupert SR, Zimmermann L, Shi X, Fritsche LG, Mukherjee B. Global Prevalence of Post COVID-19 Condition or Long COVID: A Meta-Analysis and Systematic Review [published online ahead of print, 2022 Apr 16]. 

. 2022;jiac136. doi:10.1093/infdis/jiac136

3. Long COVID (Post-Acute Sequelae of SARS CoV-2 infection, PASC). Yale Medicine. 2022. Accessed April 20, 2022. 

https://www.yalemedicine.org/conditions/long-covid-post-acute-sequelae-of-sars-cov-2-infection-pasc#:~:text=Lon20COVID%2C%20or%20what,)%20COVID%2D19

4. COVID-19 rapid guideline: managing the long-term effects of COVID-19. National Institute for Health and Care Excellence. Published December 18, 2020. Updated November 21, 2021. Accessed April 20, 2022. 

https://www.nice.org.uk/guidance/ng188/chapter/Recommendations

5. Kell DB, Laubscher GJ, Pretorius E. A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications. 

. 2022;479(4):537-559. doi:10.1042/BCJ20220016

6. Pinto MD, Lambert N, Downs CA, Abrahim H, Hughes TD, Rahmani AM, Burton CW, Chakraborty R. Antihistamines for Postacute Sequelae of SARS-CoV-2 Infection. 

. 2022 Mar;18(3):335-338. doi: 10.1016/j.nurpra.2021.12.016. Epub 2022 Feb 7. PMID: 35153633; PMCID: PMC8820139.

7. Malone RW, Tisdall P, Fremont-Smith P, et al. COVID-19: Famotidine, Histamine, Mast Cells, and Mechanisms. 

. 2021;12:633680. Published 2021 Mar 23. doi:10.3389/fphar.2021.633680

8. Hogan Ii RB, Hogan Iii RB, Cannon T, et al. Dual-histamine receptor blockade with cetirizine - famotidine reduces pulmonary symptoms in COVID-19 patients. 

. 2020;63:101942. doi:10.1016/j.pupt.2020.101942

9. Ennis M, Tiligada K. Histamine receptors and COVID-19. 

. 2021;70(1):67-75. doi:10.1007/s00011-020-01422-1

10. Proal AD, VanElzakker MB. Long COVID or Post-acute Sequelae of COVID-19 (PASC): An Overview of Biological Factors That May Contribute to Persistent Symptoms. 

. 2021;12:698169. Published 2021 Jun 23. doi:10.3389/fmicb.2021.698169

11. Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance. Centers for Disease Control and Prevention. Updated June 14, 2021. Accessed April 20, 2002. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-index.html

Articles

Staying abreast of current data on the condition is vital. 

How Pharmacists Can Help with Long COVID Symptom Management

Iwona Szydłowska, MD, of the department of gynecology, endocrinology and gynecological oncology at Pomeranian Medical University in Szczecin, Poland, and colleagues used PubMed and Medline to conduct the literature review. Researchers examined 272 English language, full-text articles from 120 publications and assessed the correlation between diet and uterine fibroid (UF) risk and treatment.

“The aim of the review was to evaluate data on natural, non-hormonal, effective, and safe therapeutic options for treatment of this disease,” the authors said. They used a collection of keywords in combination: leiomyoma, uterine fibroids, uterine myoma, curcumin, dairy products, diet, fruits, plants, vegetables, turmeric, green tea, selenium, carotenoids, Vitamin A, Vitamin C, Vitamin D, Vitamin E, dysbiosis, and gut microbiota. The results of the literature analysis revealed found statistically relevant effects from some vitamins, plant compounds, and 1 trace element.

After study analysis, they reported a strong link between Vitamin D deficiency and UF. They recommended analogs of 25-hydroxyvitamin D3 as therapy because tissue 24-hydroxylase is unable to degrade it. “Vitamin D3 may be a promising option in prevention and treatment of UFs. The majority of presented studies consider treatment with Vitamin D3 as safe and effective,” the authors said.

 Concentrations of physiological vitamin D prevent fibroid cells from growing, especially in women with vitamin D deficiency, researchers said.

While past Vitamin A research contradicts itself, synthetic retinoid analogs in addition to a Vitamin A-rich diet may prevent tumors from growing, Szydłowska and colleagues explained. Vitamin A “reduces cell proliferation and extracellular matrix formation and increases apoptosis in fibroids,” they noted.

Szydłowska and colleagues reported little data on Vitamin E, and the existing study results they did find were contradictory. In fact, high concentrations may contribute to fibroid growth, especially in Caucasian women.

 “Vitamin E, despite its antioxidant properties, appears not to demonstrate proven beneficial effects in terms of leiomyoma prevention and management,” the authors reported.

Vitamin C also did not have much data for its role in UF, with researchers reporting a non-statistically significant association with increased risk of UF.

“A diet enriched in fruits and vegetables, as sources of carotenoids, polyphenols, quercetin, and indole-3-carbinol, constitutes an easily modifiable lifestyle element with beneficial results in patients with UFs,” researchers said. However, researchers added that there were caveats. For example, high consumption of β-carotene combined with smoking cigarettes actually increased the risk of uterine fibroids.

 The role of polyphenols in UF prevention was dependent on the type selected by the patient, the dose, and the duration of use. Curcumin/turmeric possesses anti-inflammatory properties and researchers said it appeared to be a good choice for women at risk of developing UF in addition to women who had already been diagnosed.

Szydłowska and colleagues reported that the analysis showed selenium may have a role in prevention and treatment in UF, but did not affect the number of tumors. No other trace elements were found to be beneficial. The role of probiotics has not been fully investigated, but dairy products such as yogurt may also play a protective role, the authors said.

In addition to genetic predisposition, substances associated with UF formation included heavy metals, endocrine-disrupting chemicals (EDC), and cigarettes. A diet low in antioxidants and fiber is also correlated with UF growth. Researchers said EDCs can bind to hormone receptors and stimulate them to change the production and/or function of the hormones. “Induction of both genomic and non-genomic signaling and pro-inflammatory effects of EDCs increase the risk of UFs,” they said.

Szydłowska and colleagues concluded that vitamins, plant compounds, and selenium are useful in treating and preventing UF. “Natural compounds present as an alternative route in UF treatment, especially in patients with contraindications for hormonal therapy,” they said. They emphasized the usefulness of this therapy and said that even for conventional treatment of UFs therapeutic effects can be strengthened by these compounds.

This article was originally published on Contemporary OB/GYN.

Szydłowska I, Nawrocka-Rutkowska J, Brodowska A, Marciniak A, Starczewski A, Szczuko M. Dietary Natural Compounds and Vitamins as Potential Cofactors in Uterine Fibroids Growth and Development. 

. 2022;14(4):734. Published 2022 Feb 9. doi:10.3390/nu14040734

Ciebiera M, Szymańska-Majchrzak J, Sentkowska A, et al. Alpha-Tocopherol Serum Levels Are Increased in Caucasian Women with Uterine Fibroids: A Pilot Study. 

. 2018;2018:6793726. Published 2018 Jul 24. doi:10.1155/2018/6793726

Terry KL, Missmer SA, Hankinson SE, Willett WC, De Vivo I. Lycopene and other carotenoid intake in relation to risk of uterine leiomyomata. 

. 2008;198(1):37.e1-37.e378. doi:10.1016/j.ajog.2007.05.033

Vitamins and diet can play a role in the prevention and treatment of uterine fibroids, according to a literature review spanning 20 years published in the journal Nutrients. 

The Role Supplements Can Play in Uterine Fibroids

Spironolactone and oral contraceptives work well for acne treatment, but providers should be familiar with their adverse effects (AEs) and risks, said Julie Harper, MD, in a presentation at Maui Derm for Dermatologists 2022 held January 24 to 28 in Maui, Hawaii.

Julie Harper, who is a board-certified dermatologist in private practice at the Dermatology and Skin Care Center of Birmingham in Alabama provided a road map detailing recommendations on how to use these medications to achieve optimal outcomes and how to evaluate their AEs and risks. Spironolactone is an anti-androgen shown to be effective in treating acne, although it is not approved by the FDA for this purpose.

Harper recommended a maximum dose of 100 mg once a day and suggested that it be used in conjunction with topical treatments such as retinoids, benzoyl peroxide, topical dapsone, and topical antibiotics. It also can be used with oral medications such doxycycline, minocycline, sarecycline (Seysara; Almirall), oral contraceptives, and isotretinoin.

“Spironolactone’s use in combination with oral contraceptives reduces irregular menstrual periods and prevents pregnancy, which is important because its anti-androgen properties can increase the risk of feminization in male fetuses late in the first trimester,” Harper said.

Spironolactone’s possible AEs increase in higher doses, and include menstrual irregularities, breast tenderness and/or swelling, fatigue, headaches, diuresis, and orthostatic hypotension, she noted.

 It can be used long term, except when patients experience severe AEs, are pregnant, or acne subsides, Harper said.

As for risks, she highlighted a study by Plovanich et al that showed spironolactone carries a small risk of hyperkalemia, so healthy patients’ potassium may be monitored while taking the drug.

 Older patients, those with a history of cardiac or renal disease, or impaired liver function, and those on high doses should have potassium monitored, Harper said. Additionally, patients taking ACE inhibitors, angiotensin II antagonists, aldosterone blockers, non-steroidal anti-inflammatory drugs (NSAIDS) such as indomethacin, salt substitutes, potassium supplements, and rimethoprim/sulfamethoxazole require potassium monitoring.

Harper noted that spironolactone has a black box warning and is tumorigenic in chronic toxicity studies in rats, so it should be used only in specific conditions under the Use and Indications information. She said there is no evidence of an increased risk of breast, uterine, or ovarian cancer with its use. It should not be used during pregnancy, but only appears in low levels in breast milk and is considered compatible for lactation, she added.

Oral contraceptives can also be used to treat acne, including ethinyl estradiol 10 mg to 50 mg and 1st through 4th generation progestin.

 When using oral contraceptives to treat acne, providers should take a complete patient history to prevent serious AEs, Harper said. The FDA has approved Ortho-Tri-Cyclen (Janssen Pharmaceuticals), Estrostep FE, (Warner Chilcottt Inc), and Yaz (Bayer) for treatment, she reported.

Risks of taking oral contraceptives include venous thromboembolism, stroke, myocardial infarction, and breast cancer.

 Taking a thorough patient history is essential before prescribing oral contraceptives to treat acne, Harper said. She cautioned that patients who are pregnant, breastfeeding less than 6 weeks postpartum, are older than 35 and heavy smokers (more than 15 cigarettes/day), have hypertension, have diabetes mellitus with nephropathy, retinopathy, neuropathy, or vascular disease, have a history of deep vein thrombosis, heart disease, or stroke should not receive this treatment.

In addition, patients with migraine headaches (with focal neurological symptoms at any age or without focal neurological symptoms but more than 35 years of age), and/or who have cirrhosis or liver tumor (benign or malignant) also should not be prescribed oral contraceptives for acne.

Providers should note that some antibiotics interfere with contraceptive effectiveness and advise their patients of this.

 Patients should see improvement in acne after 3 cycles of pills, Harper said.

This article was originally published on Dermatology Times.

Harper JC. Oral contraceptives and spironolactone for acne. Presented at: Maui Derm 2022; January 24 to 28, 2022; Wailea, Hawaii.

Plovanich M, Weng QY, Mostaghimi A. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. 

. 2015;151(9):941-944. doi:10.1001/jamadermatol.2015.34.

Julie Harper, MD, of the Dermatology and Skin Care Center of Birmingham, Alabama explained the use, side effects, and risks of spironolactone and oral contraceptives.

Risks, Rewards of Hormonal Acne Treatment: A Delicate Balance

Implementing rapid diagnostic technologies (RDTs) into a health system can improve outcomes for patients and may be helpful in reducing unnecessary antibiotic use, according to data presented at the 2019 Annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition.

Katie Lusardi, PharmD and Clinical Pharmacist of Infectious Disease and Antimicrobial Stewardship at the University of Arkansas for Medical Sciences and Brandon Hill, PharmD and Clinical Pharmacist of Infectious Diseases at University of Virginia Health reviewed the multitude of RDT platforms available to practitioners and noted the role these technologies can play in collaborating with antimicrobial stewardship programs (ASPs). 

Dr Lusardi noted that all platforms for RDT offer organism identification, while some also give markers for antibiotic resistance and susceptibility results. There are a wide variety of blood and respiratory RDT platforms available, she said, but RDT are only impactful when the data are available quickly, in conjunction with active interventions to help guide antibiotic decisions. 

There are a number of benefits to RDTs, according to Dr Hill. He noted that high rates of hospital-acquired infections can lead to a lack of reimbursement from the Centers for Medicare and Medicaid Services (CMS), but showing how RDTs can impact patient care and the use of antimicrobials may convince the hospital “C suite” staff to invest in more of these technologies. 

publicly reported data available to patients on Medicare.gov

 to demonstrate to hospital administrators that RDTs can improve facility standings. Effective and timely care can improve sepsis recognition and management, he said. 

As of March, hospitals are being asked by CMS to establish ASPs, and RDTs can help facilities gain traction in reducing unnecessary antibiotic use. 

Dr Hill connected how using RDT can play a role in helping to fulfil the some of the CDC’s Core Elements of an ASP:

RDT helps clinical pharmacists streamline the process for identifying appropriate treatment options and ensuring those medications are administered in a timely manner.

RDT helps with prospective audit and feedback and offers measurable outcomes.

RDT results can be used to monitor compliance with ASP recommendations and can provide a tangible outcome to be tracked following implementation.

ASPs can use RDT to facilitate communication with key stakeholders on outcomes, and results can show pharmacy activities and their impact.

Educating administrators and clinicians on RDT can improve acceptance when beginning a new initiative; providing RDT data to raise confidence in ASP and new technology.

Dr Hill noted that the Society of Infectious Disease Pharmacists (SIDP) have stated that “RDTs are 1 strategy for ASPs to achieve goals set forth by Joint Commission’s antimicrobial stewardship requirement in the acute care setting,” and the Infectious Disease Society of America (IDSA) has backed using RDTs as part of an ASP.

The most important outcomes of RDT are reducing inappropriate antimicrobial use and patient-specific outcomes such as mortality. Although the initial cost of setting up an RDT can be high, the cost pays off in effective implementation, Dr Hill added.

To persuade hospital leadership to embrace purchasing more RDT technologies, Dr Hill suggested enlisting an interdisciplinary group, incorporating goals and a vision for the health system, and highlighting previously published studies that show patient and institution specific benefits of RDT.

Although the literature are limited in showing that respiratory-focused RDTs decrease unnecessary antibiotic prescriptions for respiratory diseases, in some studies, RDT usage has been connected with a shortened time for patients to receive antivirals. More promising results are seen with RDTs for positive blood cultures. Several studies have shown reduced antimicrobial consumption, and time to effective therapy with RDT results are combined with active ASP interventions, when compared to RDTs alone or traditional laboratory methods.

Dr Hill urged attendees to prepare a detailed RDT proposal that predicts changes in outcomes of interest such as potential clinical and financial benefits. Implementation also should have regular updates on the impact of RDT in collaboration with an ASP based on pre-determined tracking and reporting methods. Finally, Dr Hill said that development of a structured algorithm for implementing RDT and ASP interventions are key in successfully implementing these strategies.

Lusardi K, Hill B. Rapid diagnostic technologies and antibiotic stewardship: better together [210-L01]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

RDTs can improve outcomes and reduce unnecessary antibiotic use. 

Rapid Diagnostic Technologies Can Play a Role in Antimicrobial Stewardship Programs

A pharmacist-led, hospital-based infusion center based in Teaneck, NJ has been successful in both controlling costs and implementing a comprehensive, integrated care team, according to a presentation at the annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition being held in Las Vegas this week.  

To begin her presentation, Nancy Palamara, PharmD, the Director of Pharmacy Services at the Infusion Therapy and MS Center at Holy Name Medical Center in Teaneck, NJ opened her presentation with what she dubbed “mysterious case of the ‘high cost pharmacy.’” She noted that the hospital where she worked had the lowest cost in every area except drug spending when compared to all hospitals in the state. In fact, she explained, their hospital had the highest drug spending.  

Palamara attributed this to the hospital “doing such a good job of controlling inpatient costs” that it skewed the results. She attributed the highest spend to having a lack of control in outpatient spending, where there was “far less control and no contract negotiating.” As a solution, a team was created to help manage costs that could be controlled outside, such as maximizing reimbursement. The team also reached out to hospital management and implemented a program where the infusion team reported into a few pharmacy managers, rather than falling into the model that had been in place, which was the oncology department. 

Palamara explained that pharmacy managers can play a strategic role in hospital settings because they can provide two essential skill sets in their role. The first skill set centers on clinical training, where pharmacists offer skills such as direct patient care and help with continuity of care and medication assistance. Secondly, pharmacists have operations skills such as an understanding of supply chain, improving processes, and streamlining workflow. This knowledge ensures the best patient care and best practices for cost saving and smooth operation.  

Despite these skills sets, Palamara noted that those involved in the infusion department were initially skeptical. She acknowledged that some of the nurses in the center were resistant to be managed by non-nurse staff, which she attributed to a misconception that pharmacists are largely science and operations oriented rather than staying centered on compassionate patient care. In addition, pharmacy managers do not have the same level of support staff as nurses. This means they need to be sure they spend enough time with pharmacy staff and finding time to make the rounds, Palamara noted in her presentation. 

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After two years of implementing the pharmacy manager model in the infusion unit, however, Palamara said the outcomes have been a patter on better communication with fully engaged nurses who now embrace the model and are now working as a “truly interdisciplinary care team.” The culture of the clinical setting had also greatly improved, she said.

She attributed the success to the open-mindedness of her C-suite staff, who embraced the concept the pharmacy staff support, the work of the director/manager, the clinical pharmacy specialists, the nurses. and the administrative assistants working as a collaborative care team. 

Palamara N, Schiller D, Tichy EM. Advancing pharmacy practice with strategic clinical leadership [208-L04]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

Pharmacists provide clinical training and operational skillsets.

Pharmacy Managers as Strategic Leaders: What Is the Effect?

Despite some reductions in the overall antibiotic resistance problem, much more work needs to be done, according to a presenter at the 2019 Annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition.

Captain Arjun Srinivasan, MD, who is associate director for Healthcare-Associated Infection Prevention Programs with the Centers for Disease Control (CDC) began his talk by explaining that every year in the United States, 2.8 million people have an infection that resists first-line antibiotic treatment. 

Dr. Srinivasan noted that although there has been progress in health care settings, over the past 5 years there have been important reductions in some areas, other organisms, like drug-resistant gonorrhea, present ongoing challenges.

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He noted that the Centers for Medicare and Medicaid Services (CMS) has urged health systems, by March of 2020, to implement Infection Control and 

programs for all acute care and critical access hospitals in the United States. 

He noted that the CMS recommendations align with the 7 Core Elements of Antibiotic Stewardship outlined in 2014 by the CDC. Srinivasan said that the number of hospitals that self-report they have implemented all 7 elements of these stewardship recommendations has increased from 41% to 85%, and, he noted, every type of hospital from larger to smaller health systems have reported progress.

Dr. Srinivasan detailed a number of important enhancements under each Core Element heading, specifically:

 – Hospital leaders must ensure their facilities invest enough time, money, lab equipment and IT technology. Top executives are urged to meet with the stewardship team to understand what resources are necessary to meet antibiotic stewardship goals. Top leaders should be kept informed of progress.

 – There is a need for program management and outcomes that should be co-led by a physician and a pharmacist. Leadership requires collaboration and good communication skills. Dr. Srinivasan reported that 59% of current programs are currently co-led by a physician and a pharmacist, and he said, these programs are the model to follow.

This wording has been updated from the earlier recommended “Drug Expertise” to better reflect the role of pharmacists and showcase their vital importance this area, he said. Dr. Srinivasan added that most US hospitals don’t have access to infectious disease-trained pharmacists, so general clinical pharmacists need to be supported with education and resources.

This involves implementing the antibiotic interventions. The top two priorities Dr. Srinivasan noted were prospective audit and feedback, and reviewing therapy, where an expert gives providers feedback on antibiotic interventions. Providers are encouraged to seek preauthorization–currently only 41% do. They should also seek permission for certain restricted antibiotics. The third priority is to have facility-specific treatment guidelines. Srinivasan said focus was needed on 3 conditions that are most often prescribed antibiotics: lower respiratory infections, urinary tract infections, and skin and soft tissue infections. Providers are urged to follow treatment guidelines, optimize therapy length, have better urine culture practices, and narrow spectrum therapy for skin and soft tissue infections for antibiotic stewardship.

Facilities should report on use and resistance to prescribers, pharmacists, nurses, and hospital leadership regularly, and share information among different types of hospitals. Providers should compare reports with peers, and summaries should be regularly shared with leadership and hospital board, Dr. Srinivasan explained.

Teaching adverse reactions, resistance and optimal prescribing to prescribers, pharmacists, and nurses is a necessary aspect of stewardship. Srinivasan said case-based teaching is especially effective. Information should also be tailored to a specific provider group. In addition, providers need to better educate patients about judicious antibiotic use. 

Prescription monitoring, intervention impact, and disease resistance patterns need to be tracked, Dr. Srinivasan said. Outcome measures, process measures of adherence to treatment guidelines and recommendations should be tracked and reported; hospitals report data to CDC’s National Healthcare Safety Network Antibiotic Use option to benchmark use.

Multiple measures are needed to ensure implementation, Dr. Srinivasan said. The use of the Standardized Antimicrobial Administration Ratio (SAAR), a ratio of actual use to predicted antibiotic use can facilitate tracking of antibiotic use.

“Predicted use is modeled based on all data submitted and is risk adjusted based on a variety of hospital characteristics, but not on any patient level factors,” Dr. Srinivasan said. SAARS was endorsed by the Quality Forum 2016 and can be used for different groups of antibiotics, adult and pediatric locations, ICU and non-ICU locations, and calculated at individual unit level or hospital wide.

Many facilities have rates of use greater than 1 (

using more antibiotics than other hospitals

). Dr. Srinivasan stressed that SAARS just records rates of use and not appropriateness. He pointed out that higher rates of use are a reason to investigate that particular location, and added that 25% of locations are using 20% more antibiotics worldwide. “This is a new metric and we are still trying to understand what the values mean,” he said.

Changing prescriber behavior and “helping find the bright spots,” meaning, following behaviors that are effectively reducing unnecessary use of antibiotics are both key in reducing antibiotic resistance. 

In outpatient settings, Dr. Srinivasan emphasized that providers can tell patients that avoiding unnecessary antibiotics can protect them. Educating patients can also help them avoid adverse drug reactions and avoid disruption of the microbiome, which can increase the risk of sepsis.

Dr. Srinivasan urged a collaborative process in creating stewardship programs because it provides partnership and solidarity between different providers. While the CMS is now urging antibiotic stewardship in all hospitals, it needs to be enforced to work, he said. 

Dr. Srinivasan noted how bedside nurses play a critical role–because they administer antibiotics. They can prompt the provider and care team, and educate the patient and family, he said. He also emphasized the pharmacist’s role in helping with antibiotic stewardship: pharmacists can verify penicillin allergy, avoid duplicate anaerobic coverage, deescalate anti-MRSA coverage by confirming infection, avoid treatment of ASB, and limit antibiotic duration when symptoms improve. 

According to Dr. Srinivasan, the CDC is urging judicious antibiotic use accreditation for urgent care centers. They are also working with the Health Services Resource Administration to reach out to federally qualified rural health care programs to improve antibiotic stewardship. CDC officials are also working with National Center for Quality Assurance to expand health Effectiveness Data information Set measures for outpatient prescribing.

Srinivasan A. CDC update 2019: Antibiotic stewardship in America’s hospitals [337-L04]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

Health systems urged to adopt antibiotic stewardship programs by March 2020. 