Drugs vs. “Bugs”: Antimicrobial Resistance and the Power of Stewardship

Antimicrobial-resistance

Image credit: EPMM

When you’re sick you take drugs… right? And by taking those drugs, like say antibiotics when you have the flu, you get better… right? Wrong, very very wrong! The flu is actually a viral infection, meaning that along with getting plenty of rest the flu can only be treated with an antiviral! I sat down with Dr. Andrew Morris, an infectious disease specialist and Director of the Sinai Health System-University Health Network Antimicrobial Stewardship Program (ASP) to get to the bottom of the do’s and don’ts when it comes to taking antibiotics and to learn a bit more about the emerging global health threat of antimicrobial resistance (AMR).

Infectious disease specialists, you guessed it, identify and treat infections. Specialists use a wide range of antimicrobial agents (e.g. antibiotics, antivirals, etc.) to treat symptoms– but, as Dr. Morris describes, overuse and improper use of antimicrobials (ahem taking antibiotics when you have the flu) coupled with few antimicrobials on the market has contributed to the emerging global health crisis known as antimicrobial resistance.

Dr. Morris defines antimicrobial resistance as “when antibiotics don’t work because the germs have outsmarted the antibiotics”. Smart germs? Well, not so much brain capacity, more of a real-world example of survival of the fittest courtesy of our friend Charles Darwin. When bacteria (for example) are exposed to an antibiotic, only the resistant survive and spread. This problem intensifies when people are unnecessarily prescribed antibiotics. These redundant, repeat exposures are like bacteria boot camp, training whole populations of bacteria to resist antibiotics, so these treatments become ineffective in the future. Imagine dying from an ear infection?!

ar-happens

Image credit: CDC

Thankfully, we here at Mount Sinai and University Health Network have Dr. Andrew Morris and his SHS-UHN Antimicrobial Stewardship Program (ASP) team. Composed of physicians, pharmacists, nurses, and data analysts, the interprofessional team directly interfaces with prescribers, coaches others in the healthcare team, analyzes data, and conducts research to identify best practices when it comes to treating patients like you and me! Exposed to the tragic consequences of antimicrobial resistance early in his medical career, when a young patient under his care died from an otherwise treatable pseudomonas infection, Dr. Morris yearned to improve how antibiotics were used, effectively launching his career in antimicrobial stewardship.

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The SHS-UHN ASP Team: Standing (left to right): Sophia Virani, Sarwat Abbasi, Margot Renshaw, Dr. Linda Dresser, Dr. Chaim Bell, Linda Jorgoni, Dr. Shahid Husain, Dr. Lianne Jeffs, Dr. Warren McIsaac, Janice Takata-Shewchuk Seated (left to right): Dr. Sandra Nelson, Dr. Andrew Morris, Yoshiko Nakamachi, Dr. Miranda So, Dr. Mark McIntyre, Lopa Naik.

The ASP team takes a research-based approach to arrive at their recommendations, using both their successes and failures to inform decision-making on how to proceed further. And they have been pretty successful at doing just that. For example, after noticing gaps in practice for treating patients with Staphylococcus aureus bacteremia were related to high mortality, they decided the way to fill this gap was for patients to be seen by an infectious disease specialist – an easy fix which lead to a 30% drop in mortality!

According to Dr. Morris, the hardest task is to understand the cause of the problem, he explains that there are many drivers of behavior, like cultural factors, a lack of knowledge, or emotional factors so the first step is to figure out problems and then identify ways to tackle them. I stopped him there – medicine and emotions? How could they possibly be related? Dr. Morris then asked what happened when I got sick when I was little, I responded that my parents would give me medication. He then asked why… why? To make me feel better of course, which is exactly where the problem lies!

Sometimes you need medications to get better, but many times you would have healed on your own, but since you had medication, you think that’s why you got better.

This is like a placebo effect but with real medicine. Dr. Morris explains that the link between receiving antibiotics, feeling better, and associating antibiotics with making you feel better creates an attachment to antibiotics for the rest of your life. The same goes for doctors who also receive a natural feedback when they see their patients get better after they’ve administered medication. This dynamic is hard to overcome, which is why audits and coaching by the ASP team are essential for success.

And if we continue to travel down this path, of treating anything (and everything) with pills, we are going to be in big trouble. Already we are seeing the consequences of antibiotic resistance from overuse in our agricultural system, where antibiotics that are used to boost animal growth end up in our food systems or groundwater networks from manure fertilizer run off. These instances create additional opportunities for bacteria to develop resistance and for humans to be exposed. Additionally, the lack of regulation and shortage of antibiotics in low income countries, coupled with drug resistance contributes to the crisis observed. Soon enough, easily treatable infections will become life threatening, hence my ear infection example, because we no longer have medication that can effectively clear these simple infections!

spreads

Image credit: CDC

So what can YOU do? Always talk to your doctor before taking antibiotics and take them as prescribed, try to look for antibiotic free meat products, and keep up proper hygiene and sanitation practices to avoid getting sick! While there is no easy solution or silver AMR bullet, it starts with better coordination … infection prevention and control, research and development, innovation, epidemiology and surveillance of antibiotics and antibiotic resistance. In Ontario, and especially here on University Avenue, we see the positive effects of stewardship on patient experiences and population health, so at least you can find comfort in knowing Dr. Morris and the ASP team at SHS-UHN have your back!

For more, check out the Sinai Health System-University Health Network Antimicrobial Stewardship Program website!

 

TTC VIP CHANGES – and the big picture

TTC-BlogTO

image credit: BlogTO

Originally, this was just going to be a quick piece about the changes to the TTC VIP program, but then something bigger happened. So that we’re covered, the TTC VIP program, the crowning jewel in our sustainable transportation crown, with over 2.6 thousand UHN participants, is coming to a close. The TTC has chosen to end this particular bulk purchasing plan in December 2018 (or, um, now).

Before I shake my fist in the air, it turns out the TTC hasn’t so much ended this as switched it to PRESTO. If you are on UHN’s or another workplace VIP program, you may even get a complimentary PRESTO card. This make the whole program a lot easier, and with some sweet savings. This version also requires a 12-month commitment, costs $134 per month and provides the same unlimited travel. More here.

Or skip the commitment, load your PRESTO card with cash and pay individual fares. The upside here is you can use the 2-hour transfer … hop on and off the system within a 2-hour period without being charged another fare.

OK, you talked transit, what’s the bigger picture? 

COP24

COP24 is the nickname for the 24th Conference of the Parties to the United Nations Framework Convention on Climate Change (UNFCCC). Image Credit: COP24

COP24 is happening this very minute in Katowice, Poland! Reps from around the world are meeting to talk (and act) on climate change on a global scale (gotta be global since climate change doesn’t really get the whole national or provincial borders thing). You probably remember COP21 in Paris, and the landmark Paris Agreement? All the more relevant now.

Why are you talking about COP24 on a TTC post?

Because the biggest cause of climate change is us humans burning fossil fuels. And the biggest burn source in Ontario comes from transportation. And when people switch from driving gas-burning SOVs (Single Occupancy Vehicles) to cleaner substitutes like public transportation, that’s a major win for our climate, health and future. It’s also a win for Toronto’s soul-crushing congestion problem. 

 

Is this climate change thing that big a deal?

In 1 word: YES. In a few words, Sir David Attenborough (of “Blue Planet” fame) said it best at COP24: “The collapse of civilisation and the natural world is on the horizon”. In many more words, see below. Grab a coffee (fairtrade, organic, natch) and get comfy…

There’s the Climate Transparency Report which works for “Ambitious climate action through country comparisons”. This really appeals to the competitive side of human nature. I hope it works as (spoiler alert) Canadians generate the most pollution-per-person in the G20 … triple the average GHG emissions for G20 countries. Not a proud moment.

There’s the 2018 Greenhouse Gas Progress Report “Climate Action in Ontario: What’s Next?” by the Environmental Commissioner of Ontario (ECO).

There’s the The Lancet Countdown: Tracking Progress on Health and Climate Change.

Canada’s Greenhouse Gas Indicators and more on the MOECC site.

And if you look Stateside, they’ve released the National Climate Assessment (even if their leader doesn’t buy it).

Is there a nutshell version?

Livin’ the COG-life (Coal, Oil & Gas, my fancy new acronym) creates the emissions that cause and worsen climate change. When Ontario closed coal plants 5 years ago, that took a big juicy chunk out of our emissions (and out of our smog days, which haven’t happened since). Yay! But we will stall on climate progress unless we look beyond electricity. Transportation is the next big hurdle.

Climate change - 1 page - eco

Image Source: my mashup of graphs from the ECO 2018 Greenhouse Gas Progress Report

After canceling Cap & Trade, Ontario has a new proposed Environment Plan. It looks strangely similar to what they did in Australia (which unfortunately saw more pollution, not less). The comment period is open until January 28, 2019.

OK, this is too big for me to deal!

There’s help out there, especially if you join a Green Team. Or go even further with Carbon Conversations, starting up again in February, with a January taster session! Put the cherry on the sundae and get there with your PRESTO card. 🙂

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Huge Savings from Ongoing LED Retrofits

As I mentioned in my Terminator themed T8 blog, I’ll be back. And now I’m back to let you know how the roll out of our T8 retrofit program is going. Since that original blog *checks watch* three years ago (!) we have replaced huge numbers of lamps throughout UHN, so this is a story that all sites can celebrate! Here are some quick numbers for lamps retrofitted at each site:

  • TGH – 5,500
  • TWH – 6,000
  • PMH – 6,500
  • TRI – 2,000

Total UHN: 20,000 lamps!

For those that are wondering what I’m talking about when I say “LED T8 tube” check the image below. The 8 refers to the diameter of the lamp in eighths of an inch (eight eighths is one inch).

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This is an LED T8 tube

Energy Savings

So far, we have primarily installed new LED tubes in 24 hour applications, such as lobbies, hallways, stairwells, mechanical spaces, etc. The long run hours of these lamps mean that we are savings lots of energy and getting a faster payback.

UHN-wide savings total almost 1,500,000 kWh based on the 20,000 T8 lamps replaced. This is equivalent to the electricity consumption of 155 houses in Ontario!

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Other Benefits of LED

Light Levels: In certain hallways at TGH, people were asking if the walls had been painted. This is because the LED lamps produce slightly more light than the old fluorescent lamps, enhancing hallway appearance and safety in previously under lit areas. We recognize that higher light output is not always desired and are also purchasing lower wattage T8s for sensitive areas.

Shatterproof: The LED lamps are made of a shatterproof plastic material, meaning they are safer to install and service than glass fluorescent tubes.

No Mercury: Old fluorescent lamps use mercury, a highly toxic substance, as a key component to make the lamp function. If a fluorescent lamp were to break, the mercury would escape and risk exposure to building occupants. LEDs have no mercury or any materials that can be released into the air. They are considered to be electronic waste, however, and must still be disposed of appropriately.

Longer service life: Fluorescent lamps have a typical service life of 20,000 hours and tend to degrade in performance and colour throughout their life. The LEDs installed have 50,000 hour life and new ones we are now purchasing have 70,000 hour lifespans. This extended life will free up some of our maintenance staff time that is spent changing light bulbs so that they can work on important tasks, such as preventive maintenance.

Ongoing Project

Since our original T8 supply contract, costs of LEDs have dropped almost in half and we have a new contract in place. Additionally, the LED lamps are now only 15W instead of the original 18W, while maintaining the exact same light output. With the lower cost of purchase and increased energy savings, it is now very cost effective to replace lamps not only in 24 hour areas, but in all areas. We are aggressively pursuing more replacements across UHN, including the following projects that are underway:

  • TRI: 2,100 lamps (including relamping all T8s in Lyndurst and Rumsey Centre)
  • TGH: 5,000 lamps
  • KDT: 9,000 lamps (relamping the entire building)

I would like to thank the facilities teams who have worked hard to make these projects a success, especially at TRI and TGH, where facilities staff have done all the relamping work in house. Bravo!

Water tastes better without the plastic

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CCSO Green Team admire their new plastic-free water cooler. Nice!

Normally, the CCSO Green team wouldn’t be able to stand in this spot as the space was Continue reading

#1 in MUSH!

We’ve often joked about acronym bingo, what with all the BRBs, IMOs and OMGs, but have you heard of MUSH? Not the bowl full in Goodnight Moon, but Municipalities, Universities, Schools and Hospitals … that MUSH.

Turns out this is a pretty important category when it comes to energy, since we are Continue reading

Better than Candy, Operation Green’s Supplies Haul

On the day after Halloween, most of us have had plenty of “fun-size” treats. What’s better than going door-to-door for candy? How about going unit-to-unit, collecting medical supplies to donate to communities in need? That’s what our fantastic team from Operation Green does every month.

Nicole and Meghan, the new Operation Green Leads, are both medical students who Continue reading

Putting The Habit In Habitat Protection since 1999 – Talkin’ Trash, October 2018

In the ever-changing mental list of “things good and bad” that most us keep, “tension” usually ends up on the not-so-good column…which is unfair because, in reality, there are many good things about tension.  Tension keeps bridges bridging,  and raindrops dropping…not to mention it’s what had you on the edge of your seat when Obi Wan Kenobi dueled Darth Vader as Luke and Co. tri to escape (yah, dating myself here), it kept you from going to the bathroom for all seven-minutes and forty-seconds of the 2010 Winter Olympics men’s hockey gold medal game overtime period, and it makes resolution of the slightly out-of-sync background rhythm and wandering time signatures in Coffee (of the Sylvan Esso, not the free-range organic soypuccino, kind) oh so satisfying.

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