By Gary Evans, Senior Staff Writer
Once largely consigned to separate silos, infection prevention and antibiotic stewardship are starting to show signs of a powerful partnership. The CDC’s most recent update1 on the threat of antibiotic-resistant bacteria emphasizes that drug stewardship and infection control must essentially be inseparable if they are going to be successful.
“We recommend three critical strategies doctors, nurses, and other healthcare providers need to take with every patient, every interaction, to prevent infections and stop the spread of antibiotic resistance,” CDC Director Tom Frieden, MD, MPH, says at a recent press conference. “First is preventing the spread of bacteria between patients. Second is preventing infections related to catheters and surgeries. And third is improving antibiotic use through antibiotic stewardship.”
It is a message welcomed by clinicians who are trying to bring multiple strategies to bear on one of the great challenges in modern healthcare: preserving the efficacy of life-saving antibiotics.
“What I like about this report is that this is the first time the CDC has connected all the dots together,” says Mohamad Fakih, MD, MPH, senior medical director for antimicrobial stewardship and infection prevention at Ascension Health in St. Louis. “There is a connection — if a patient does not develop a central line infection, then antibiotics will not be needed or used. Also, appropriate surgical antimicrobial prophylaxis — which is part of antibiotic stewardship — reduces your surgical site infection rate.”
Fakih and colleagues are implementing strategies that include determining the best, narrow-spectrum drugs for infections, with respect to both treating the patient and limiting the selection of resistant bacteria.
“For example, we are looking at the best antibiotics to treat pneumonia in the hospital setting that will help the patient while also making sure that the duration of use is appropriate — not giving more [antibiotics] than needed,” he says. “We advocate the most narrow-spectrum antibiotic for treating an infection if possible.”
The Ascension system includes some 130 hospitals and Fakih and colleagues monitor antibiotic utilization trends to pick up outliers and intervene as necessary.
“We discuss this with the hospital pharmacy, infectious disease physicians and administrative leadership,” he says. “If we find any opportunities for improvement we counsel them and give them feedback.”
The Ascension hospitals are joining the CDC’s National Healthcare Safety Network module for monitoring antibiotic use and resistance in order to get a better picture of local variations in pathogens and susceptibility patterns. The critical accompaniment to these stewardship efforts will be an ongoing emphasis on infection prevention, he says.
“There is a connection and I think the CDC is making sure that people see it,” Fakih says. “I truly believe that infection prevention and antimicrobial stewardship efforts should be a partnership.”
Though healthcare-associated infections are being reduced nationally — most notably a 50% decrease in central line-associated bloodstream infections (CLABSIs) between 2008 and 2014 — one in seven catheter- and procedure-related infections are still caused by antibiotic-resistant pathogens, the CDC reported. In addition, there was a 17% decrease in surgical site infections (SSIs) between 2008 and 2014 for 10 key procedures. However, one in seven remaining SSIs are caused by antibiotic-resistant bacteria. Catheter-associated urinary tract infections (CAUTIs) are still proving difficult to reduce, with 10% caused by resistant bacteria, the CDC notes.
The CDC report specifically cites seven problem pathogens that are proving persistently dangerous to patients. This vanguard is led by Clostridium difficile, which kills some 15,000 patients a year and was reduced by only an incremental 8% between 2011 and 2014. As infection preventionists are well aware, C. diff is not an antibiotic-resistant pathogen in the classic sense, but a byproduct of overusing and misusing broad spectrum antibiotics that kill off commensal bacteria and leave the patient’s gut vulnerable to what the CDC terms “deadly diarrhea.” Thus, antibiotic stewardship and rigorous infection control must be combined to prevent C. diff, a spore former that is notoriously difficult to remove from healthcare worker hands and contaminated objects and surfaces. In addition to C. diff, the following six antibiotic-resistant bacteria are on the CDC’s enemies list:
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CRE (carbapenem-resistant Enterobacteriaceae);
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MRSA (methicillin-resistant Staphylococcus aureus);
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ESBL-producing Enterobacteriaceae (extended-spectrum ß-lactamases);
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VRE (vancomycin-resistant enterococci);
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multidrug-resistant Pseudomonas aeruginosa;
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multidrug-resistant Acinetobacter.
PROGRESS, PERIL
Though certainly progress has been made, on any given day about 1 in 25 hospitalized patients has at least one HAI.
“These infections are bad enough, but even more serious when caused by resistant bacteria,” Frieden says. “It’s deeply concerning. We’re seeing a lot of drug-resistant bacteria. That means that infections will be harder to treat, they’ll be more expensive to treat, and patients will be less likely to survive.”
The problem is compounded in certain patient populations and settings like long-term acute care hospitals (LTACs). One in four catheter-related infections in LTACs are caused by a drug-resistant bacteria, afflicting patients that may stay a month before they move somewhere else on the healthcare continuum. Indeed, with a combination of severely ill patients, high antibiotic use and lengths of stay measured in weeks, LTACs have been described as a perfect storm for emergence of multidrug-resistant organisms.
“Part of this is the intensity of the patient population,” says Sue Dolan, RN, MS, CIC, hospital epidemiologist at Children’s Hospital (Aurora) Colorado and 2016 president of the Association for Professionals in Infection Control and Epidemiology (APIC). “They have multiple active diagnoses in addition to the acute episode [causing current hospitalization]. They have a number of comorbidities. All of the patients in that setting are higher risk patients.”
In giving CRE its highest public health threat rating of “urgent,” the CDC previously reported that while some 4% of U.S. short-stay hospitals had at least one patient with a serious CRE infection during the first half of 2012, about 18% of LTACs had one.2
“The other thing is that these patients are traveling between healthcare facilities as well,” Dolan notes. “Because of their multiple underlying diagnoses, they are in and out of a variety of facilities with a higher risk of exposure to drug-resistant organisms. Lastly, they have more exposure to medications and will have devices in for longer periods of time.”
Many of the some 500 LTACs nationally may have someone doing infection prevention among a number of other duties, but Dolan was surprised that infection control was not listed as a department in some of the facilities she looked at on the Web.
“They list a wide variety of [clinical] expertise but they do not list an infection preventionist, so that was striking to me,” she says. “Even if they have one, what is their value and how does leadership view that program?”
CMS REG COMING
They may begin to view it with greater urgency. CMS is targeting an antibiotic stewardship regulation by 2017 and recently announced a pilot project to assess the infection risks during transitions of care between hospitals and nursing homes. In addition, APIC continues to lobby for infection prevention resources and personnel across the healthcare continuum, including LTACs, ambulatory care, cancer centers and other settings where patients are at risk, Dolan says.
For the CDC’s part, Frieden says, “We need to do much more, we’re working with other federal partners, especially the CMS, to prevent infections in healthcare and use the data that’s reported to target prevention at every level.”
Overall, both the measured success thus far and the continued challenges ahead validate and underscore the importance of infection control programs in the nation’s healthcare settings.
“That came through very loud and clear to me,” Dolan says. “The spotlight is currently on antimicrobial resistance, but when you look at the structure — the mechanisms that are being put together to address these issues — those are things that infection preventionists are experts on. Especially the prevention side, and we work very closely in collaborative relations with pharmacists, frontline staff, and the laboratory. So the IP is pretty key to this effort. The [CDC report] shows that the work that has been done and the efforts focused on the hospital setting have been making a difference. But this needs to go beyond hospitals so that the strategies can be used in other healthcare settings and tailored to things that might be different in those settings. That’s the big picture, and IPs are key in this work both in hospitals and outside the hospital settings like LTACs.”
Indeed, clinicians need to form regional and network information systems so they know what antibiotic resistance patterns are in their community hospitals and long-term care facilities, says Peter Pronovost, MD, PhD, FCCM, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine in Baltimore. Such knowledge across the continuum would enable clinicians to make the link to other facilities when patients are hospitalized in acute care settings. Preventing infections and preserving antibiotics requires attention to detail in every task, thus the highly publicized success of Pronovost’s point-by-point checklist for insertion of central venous catheters.
“It requires constant vigilance,” he says. “We [recently] saw a bump in our C. diff infections and we noticed part of that was due to some of our practices regarding cleaning rooms and practices of some of our antibiotic prescribing.”
Again infection control and drug usage go hand in hand, particularly for a pathogen that can persist in the environment like C. diff. As far as catheter-related infections, remember that a CLABSI has a staggering 25% mortality rate.
“Prevent infections before they start,” Pronovost says. “Check catheters frequently, and remove them when you no longer need them. Ask if you actually need them before you even place them. And finally, use the right antibiotics for the right duration.”
Antibiotics may need to be adjusted based on lab results and new information about organisms causing the infections, he says. A “time-out” 48 hours after drugs are initiated is recommended to determine if antibiotic therapy is still needed or if it should be refined, Pronovost says.
“A common mistake we make is to continue vancomycin when there is no presence of MRSA, the prime infection that the antibiotic treats,” he says. “We often tell our staff at Johns Hopkins, ‘If it doesn’t grow, let it go.’
REFERENCES
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CDC. Making Health Care Safer: Protect patients from antibiotic resistance. March 3, 2016
Available at: : 1.usa.gov/1TT1N7B
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Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: 1.usa.gov/1FYcc8e
