University of Wisconsin
School of Medicine and Public Health

Crnich Research

Christopher Crnich, MD, PhD | Healthcare-Associated Infections

Welcome to the Crnich Research Group! Led by Christopher Crnich, MD, PhD, our work emphasizes reduction of healthcare associated infections within long-term care facilities and the Veterans Health Administration (VHA) through antibiotic stewardship program implementation and the optimization of antibiotics to treat and prevent complex infections. 

Mission

Our objective is to develop novel solutions to reduce healthcare-associated infections and antibiotic resistance within the VHA and long-term care facilities.

Overview

Dr. Crnich's research program is currently engaged in a number of qualitative and quantitative projects focused on:

  1. Testing therapies to treat and prevent complex infections;
  2. Understanding how antibiotic-resistant bacteria are spread and the role antibiotics play in this process; and
  3. Implementing and evaluating strategies to prevent the spread of antibiotic-resistant bacteria and improve the use of antibiotics in long-term care facilities and the VHA.

Dr. Crnich collaborates with experts throughout Wisconsin and across the United States to develop these innovative programs.

Currently Funded Research Studies

Training the Next Generation of Wisconsin Nursing Home Infection Preventionists Program

Funder: Civil Money Penalty Fund (CMP)

Dates: 10/01/2018-09/30/2020

This project responds to a recent federal regulation that requires nursing homes have a qualified infection preventionist on staff. To develop this capacity in Wisconsin nursing homes, we have assembled a steering committee of experienced infection prevention and control and nursing home professionals and have identified additional subject matter experts to create training resource content. We are utilizing the UW Division of Continuing Studies and the Interprofessional Continuing Education Partnership to build and accredit our online curriculum modules. We will also be offering in-person training workshops to deliver scenario-based learning activities to those who complete the 14 modules of our online training.

A Cluster Randomized Trial to Assess the Impact of Facilitated Implementation on Antibiotic Stewardship in Wisconsin Nursing Homes (IMUNIFI)

Funder: Wisconsin Partnership Program, UW School of Medicine and Public Health 

Dates: 04/01/18–03/31/21

IMUNIFI is a hybrid Type 2 effectiveness-implementation study in which we will introduce the Wisconsin UTI Improvement Toolkit, developed by the Wisconsin Healthcare-Associated Infections in Long-Term Care Coalition, in 25-50 nursing homes. NHs will be randomized to internally-driven implementation with the others randomized to externally-facilitated implementation based on coaching and peer-to-peer learning. The effects of the two implementation approaches will be assessed using a mixed methods approach.

Optimizing Antibiotic Prescribing on Discharge to Long-Term Care Facilities

Funder: Agency for Healthcare Research and Quality (AHRQ)

Dates: 04/01/2019-01/31/2022

A major challenge to improving antibiotic utilization in LTCFs is that 40-50% of LTCF antibiotic use is initiated in acute care hospitals prior to LTCF admission. Furthermore, an estimated 70% of antibiotic prescribing on hospital discharge is inappropriate and patients prescribed antibiotics on discharge to a LTCF often lack information regarding the antibiotic indication, duration, and culture results in patients’ discharge summaries. In this trial, investigators will conduct a retrospective cohort study to identify high-value targets of interventions to optimize antibiotic prescribing on transition from hospitals to LTCFs. Investigators will conduct in-depth interviews with hospital and LTCF providers, nurses, and administrators to identify and describe barriers and facilitators of interventions to optimize antibiotic prescribing on transition from hospitals to LTCFs. Additionally, they will collaborate with key hospital and LTCF stakeholders to develop and refine candidate interventions to address high-value targets and gaps that are identified by the cohort studies and interviews.

Improving and Evaluating Virtual Health to Enhance Physical Distancing Measures in Wisconsin Nursing Homes

Funder: Wisconsin Partnership Program, ICTR COVID-19 Response Grant Award

Dates: 06/01/2020- 05/31/2021

Nursing homes (NHs) are ground zero for the coronavirus disease 2019 (COVID-19) pandemic in the United States. In response, NHs across the country have begun to introduce aggressive physical distancing measure to reduce the likelihood of COVID-19 introductions. Telemedicine, which allows care in NHs to continue to be delivered without the need for an in-person visit, is one physical distancing tool the Centers for Medicare and Medicaid Services (CMS) has promoted as a means of reducing COVID-19 introductions into NHs. Nevertheless, adoption of telemedicine in Wisconsin NHs prior to COVID-19 was limited. As a result, Wisconsin NHs have begun to implement telemedicine on the fly with little guidance on what technology to employ and how to structure workflows that maximize the quality of care and resident outcomes. The objective of this project is to perform a formal work system analysis of the existing telemedicine model (telemedicine 1.0) in a sample of Wisconsin NHs covered by the UW Long Term Care APP group.

Developing a Novel Antibiogram Tool to Improve Empiric Antibiotic Prescribing in Nursing Homes

Funder: Agency for Healthcare Research and Quality (AHRQ)

Dates: 09/01/2020-08/31/2023

Empiric antibiotic selection decisions in nursing homes (NHs) are frequently suboptimal, threatening resident safety by increasing risks of adverse drug events and antibiotic resistance. Cumulative susceptibility reports based on patient cultures, known as antibiograms, are increasingly used in NHs to help guide empiric antibiotic decisions. Most NHs collect an insufficient number of cultures to permit development of a facility-specific antibiogram. In this multi-site study, we propose to develop and evaluate an alternative approach to characterizing local susceptibility patterns in NHs, called a weighted incidence syndromic combined antibiogram (WISCA). This work will also lead to the development of a toolkit to support the implementation and evaluation of WISCAs in NHs. Outcomes from this work will help support future studies examining the effects of WISCAs on antibiotic decisions in NHs. We are optimistic that this and subsequent research in this area will lead to tangible improvements in the quality and safety of antibiotic use in NHs.

Cooperative Studies Program #2001: Investigation of Rifampin to Reduce Pedal Amputations for Osteomyelitis in Diabetics - VA Intrepid

Funder: VA Office of Research and Development

Dates: 11/27/2017-07/30/2022

Despite use of powerful antibiotics prescribed over a long period of time, many diabetic patients remain at a high risk for needing an amputation of part of the foot or lower leg because the osteomyelitis is not cured. Some small research studies have shown that addition of rifampin to other antibiotics is effective in treating osteomyelitis in both diabetics and non-diabetics. However, because few diabetics with osteomyelitis have been studied, there is no definite proof that it is better than the usual treatments for diabetic patients.

VA Intrepid is a randomized, double-blind, placebo-controlled, investigation of a six-week course of rifampin vs. placebo added to backbone antibacterial therapy for the treatment of diabetic foot osteomyelitis (infection of the bone). Dr. Crnich is a part of a national team conducting this trial.

VA CoronavirUs Research and Efficacy Studies-1 (VA CURES-1)

Funder: VA Office of Research and Development

Dates: 8/01/2020-06/30/2022

SARS-Coronavirus 2 (SARS-CoV-2; COVID-19) infections and deaths continue to climb across the United States and around the world. Nearly 20% of infected patients are admitted to the hospital, and up to half of those hospitalized progress to ICU admission, respiratory failure or death. Older men with comorbidities (e.g. hypertension, diabetes, heart, disease, obesity and immunocompromised) experience these advanced stages of COVID-19. These clinical features are commonly shared with the veteran population.

Currently, there are no drugs or other therapeutics approved by the FDA to prevent or treat COVID-19 infection. Convalescent plasma therapy is being used empirically, although only five of six small uncontrolled case series and a recent study with non-randomized controls suggest improvement in selected outcomes; outcomes in another small randomized trial were equivocal. VA CURES-1 is a double-blinded, placebo-controlled RCT designed to compare the effect of convalescent plasma vs. saline placebo and determine definitively whether this intervention is effective in a population at high risk of complications and death from SARS-CoV-2 infection. Dr. Crnich is a part of a national team conducting this trial.

Diagnostic Stewardship as a ‘Nudge’ to Reduce Inappropriate Antibiotic Use for Urinary Tract Infections

Funder: VA Office of Research and Development

Dates: 10/01/2020–09/30/2024

Antibiotic-resistant bacteria are estimated by the Centers for Disease Control and Prevention (CDC) to kill over 23,000 Americans yearly. Overuse of antibiotics is a leading cause, and reducing unnecessary antibiotic use is a national priority. A major factor in antibiotic overuse is inappropriate or unnecessary culturing, particularly unnecessary urine culturing that identifies colonization and leads to overdiagnosis of urinary tract infections (UTI).

Diagnostic stewardship is a novel approach to limiting antibiotic use by modifying the ordering, processing, or reporting of a “positive” culture that generally should not be treated. Modifying how tests are ordered, processed, and reported can help improve patient care by using existing technology more effectively. This is a ‘nudge’ approach, developed from psychology and behavioral economics. This work uses the electronic medical record (EMR) in an innovative, mostly behind the scenes fashion to improve appropriateness of ordering and reporting of tests.

The aims of this study are as follows:

  • Aim 1: Define best UTI diagnostic stewardship criteria, based on literature and Delphi method expert panel.
  • Aim 2: Use iterative user-centered design process to develop EMR interface and lab protocols, with clinicians and other stakeholders (nurses, doctors, technicians, and IT representatives).
  • Aim 3: Conduct a pragmatic proof-of-concept hybrid effectiveness implementation study of the UTI diagnostic stewardship interventions in 3 CDC-CREATE Network Healthcare Systems evaluating benefits and any adverse events.

Dr. Crnich is a part of a national team conducting this trial.

Targeted Contact Precautions Use to Prevent MRSA Transmission

Funder: VA Office of Research and Development

Dates: 10/01/2020-09/30/2024

Methicillin-resistant Staphylococcus aureus (MRSA) infections are responsible for over 100,000 U.S. hospitalizations each year and have caused more deaths than HIV infection. The major mechanism believed to lead to patient-to-patient transmission in the healthcare setting is contamination of healthcare personnel hands and clothing with MRSA. Healthcare personnel acquire/become contaminated with MRSA from one patient on their hands and clothing and can then transmit the bacteria to other patients. CDC, the VA and other international organizations recommend the use of contact precautions (gloves and gowns) to decrease the transmission of antibiotic-resistant bacteria in acute care settings. Contact precautions decrease the transmission of antibiotic-resistant bacteria because healthcare personnel using gloves and gowns when caring for patients with MRSA discard the contaminated gloves and gowns on room exit, prior to seeing the next patient.

However, contact precautions remain controversial. Some observational studies have shown that there can also be negative aspects of contact precautions, including decreased visits by healthcare personnel, potential psychological side effects such as anxiety and depression, decreased patient satisfaction, and decreased healthcare personnel satisfaction due to the inconvenience of donning and doffing gloves and gowns. Additionally, there are the costs of the gloves and gown.

The aims of this study are to:

  1. Perform a multi-site, geographically diverse cohort study at VA facilities and enroll patients with MRSA colonization or infection to determine the rate of MRSA transmission to healthcare personnel gloves and gowns in ICU and non-ICU settings;
  2. Determine which patient risk factors, including comorbid conditions and severity of illness markers, which patient care interactions and which healthcare personnel types are associated with greater transmission of MRSA; and
  3. Develop a dynamic transmission model to compare the cost-effectiveness of different contact precaution strategies.

Prospective Students

I am always looking for talented and motivated students and post-docs who are interested in projects focused on healthcare-associated infections, particularly those that involve infections caused by antibiotic-resistant microorganisms and/or those that occur in the long-term care setting. I encourage prospective students and post-docs to contact me even without a specific project in mind.

  • Prospective undergraduate students should contact me by e-mail. Please include a resume, a list of coursework and grades, and a brief statement of your interests.
  • Prospective graduate students should contact me by email. Please include a CV‚ a list of coursework and grades‚ your GRE scores, and a brief statement of your research interests.
  • Prospective residents or fellows should contact me by email. Please include a CV‚ a list of prior research experience, and a brief statement of your research interests.
  • Prospective post-docs should contact me by email. Please include a CV and a brief statement of your research interests.