New PCR-based GI panel for stool diagnostics and C. difficile testing update

The GLA microbiology lab is now performing a new PCR-based method for testing for gastrointestinal pathogenic microorganisms. This replaces routine stool bacterial cultures and also detects C. difficile, norovirus, and common parasites, including Entamoeba histolytica, Giardia lamblia, and Cryptosporidium.

A full list of the pathogens targeted with this test is available at:

https://www.biofiredx.com/products/the-filmarray-panels/filmarraygi/

This test is orderable as “GI Panel” in CPRS and is available from the Microbiology Test Order Screen that can be reached from many inpatient and outpatient order sets. Stool O&Ps and specific testing for Microsporidia now require ID approval.

Please note that for patients with new-onset diarrhea who are on or have recently received antibiotics, C. difficile PCR testing should be ordered, not the full GI Panel. C. difficile testing has also recently been updated, as all positive PCR tests (either from the GI Panel or the specific C. difficile PCR) will be reflexed for toxin immunoassay testing. Samples that are PCR positive and toxin negative are likely to represent colonization with C. difficile and not active infection.

Also remember that stool microbiology testing should be done on frankly liquid bowel movements (Bristol stool chart 7). Also do not test in the setting of recent laxatives, stool softener, or tube feed initiation.

Please contact the Infectious Diseases service (fellow pager UCLA 89321; antibiotic approval pager VA 73022) with any questions.

New GLA antibiogram from 2018

Our 2018 antibiogram, which compiles antimicrobial resistance data from GLA isolates from the calendar year 2018 is now available here.  Overall resistance patterns are largely stable compared to 2017 with a few caveats (see below). 

For Gram-negative rods in the hospital setting:

• Amikacin resistance remains very low and so is still the most active agent vs. multi-drug resistant Gram-negative rod infections at GLA.

• Carbapenem-resistant Enterobacteriaceae remain somewhat uncommon at GLA.

• There is not much overall difference between piperacillin-tazobactam, cefepime, and meropenem for most Enterobacteriaceae and Pseudomonas (all are better than fluoroquinolones), though there has been a slight decrease in susceptibility to cefepime among all nosocomial non-urine isolates.  Please note that >30% nosocomial Pseudomonas isolates are resistant to meropenem.

• Ceftriaxone resistance is increasing among all nosocomial E. coli isolates (non-urine: 47% vs. 19% from 2017; urine: 36% vs. 26% from 2017)

• Pseudomonas is less frequently encountered in the urine as compared to other sites.

For Gram-negative rods in the outpatient setting:

• While cephalexin and cefadroxil remain first-line options for outpatient UTI treatment at GLA, our outpatient E. coli urinary isolate cefazolin susceptibility has decreased to 77% according to breakpoints established for serum (was 92% in 2017).  We are in the process of determining susceptibility according to breakpoints established for urine (which are much higher).

• Fluoroquinolones and TMP-SMX susceptibilities remain similar (~75-80%).

Key trends among Gram-positive isolates:

• MRSA remains quite common (~60% of nosocomial non-blood isolates, ~30% of nosocomial blood isolates, and ~40% of outpatient isolates).

• Doxycycline resistance decreased among non-blood nosocomial S. aureus isolates (19% vs. 30%) from 2017.

Antibiotic Awareness Week: VHA Leading the Way

The week of November 12-16 is Antibiotic Awareness Week. This year’s theme is “VHA Leading the Way: Smart Use of Antibiotics Leads to Best Care for Patients.” For each day of the week, the below documents highlight the efforts that have made the VHA a leader in antimicrobial stewardship in several different arenas:

Monday, November 12: Overview of antimicrobial stewardship within the VA Healthcare System

Tuesday, November 13: VHA leading the way in inpatient stewardship

Wednesday, November 14: VHA leading the way in outpatient stewardship

Thursday, November 15: VHA leading the way in stewardship in long-term care

Friday, November 16: How we all can do our part to be antibiotic aware

Antimicrobial approval pager and new ID pharmacist

GLA now (again) has a dedicated antibiotic approval pager:

VA pager 73022

Two ways to access:

1.       From VA phone: *11, then 73022, enter in callback number

2.       Via internet text message: https://secure.usamobility.net/ (TEXT MESSAGE MUST INCLUDE CALLBACK NUMBER)

All requests for restricted antimicrobial use will be reviewed/approved Monday through Friday 8AM-4:30PM, either by our new ID pharmacist Phuong Nguyen or an ID fellow on an antimicrobial stewardship rotation.  In addition to having Phuong as an ID pharmacotherapy resource, please also consult the VA-GLA Infectious Diseases website (www.vaglaid.org) for clinical guidance on the use of antimicrobials and other valuable ID-related resources.

Other notes:

§  Antimicrobials at GLA are classified as unrestricted, restricted by guideline or always require approval. As such, many restricted antimicrobials are available without prior approval for use in accordance with GLA ID guidelines to treat specified infections.

§  During nights and weekends, pharmacy can release restricted antimicrobials pending ID approval (obtain via consult pager UCLA 89321). For continued therapy, such approval must be received by 11 AM on the next day.

§  Can still send e-consults for less urgent approvals, particularly after-hours and on weekends.

Link to VA-GLA Infectious Diseases Site: http://www.vaglaid.org/

ID Pharmacy Contact:

Phuong Nguyen, PharmD

Ext. 47057

Pager Number: 73022

New C. difficile guidelines and order sets!

The Infectious Diseases Society of America guidelines on the management of Clostridium difficile-associated disease have been recently updated.  The most notable change in recommendations from prior guidelines is that oral metronidazole is no longer a first-line option in the management of mild-to-moderate disease. 

Our local guidelines (available under the Guidelines/GLA Guidelines link above) have been updated accordingly.  Both the standard 10-14d course of oral vancomycin for initial disease and oral vancomycin tapers for recurrent disease no longer require approval from the Infectious Diseases service.  We have also created order sets for management of C. difficile in the "Outpatient Antibiotic Protocols" and "Inpatient Antibiotic Protocols" order sets that are available within most CPRS order sets.  The ID service highly encourages use of the antibiotic protocol order sets, as they are routinely updated to be consistent with local and national guidelines for management of common infectious conditions.

GLA will also be soon be participating in a VA Cooperative Studies Program study in which patients with first recurrence of C. difficile disease will be randomized to receive a standard vs. tapering vancomycin course vs. fidaxomicin.  More details to follow.