EXECUTIVE SUMMARY

The antimicrobial drug-resistance problem is getting worse, increasing risk for healthcare patients and workers in all settings. Another disturbing trend affecting the healthcare environment is the continuation of outbreaks of preventable infections, such as measles and mumps.

  • A series of measles outbreaks in Germany was linked to unvaccinated healthcare workers. In the United States, measles cases climbed to more than 120 at the end of summer 2018.
  • One new study found that antimicrobial-resistant diseases were among the causes of periprosthetic joint infection in patients who had undergone total knee arthroplasty and total hip arthroplasty.
  • Patients need to be screened for antimicrobial resistance risk.

New research highlights the growing problem of antimicrobial drug-resistant organisms worldwide, leading to some predictions that up to 10 million people could die from these infections by 2050.1

As antimicrobial resistance (AMR) increases, another disturbing trend involves outbreaks of measles, mumps, chicken pox, and other preventable infections. These resurgent viral infections can affect healthcare settings, including ambulatory surgery centers (ASCs). The CDC recently revealed that as of Sept. 8, there were 137 reported cases of measles in 24 states and the District of Columbia. (Read much more about this deadly outbreak online at: http://bit.ly/2xqkRnz.)

In Germany in 2015, a series of measles outbreaks was linked to unvaccinated healthcare workers. Researchers identified eight measles outbreaks involving healthcare workers in Europe between 2010 and 2014. Of 719 cases of measles, 205 were linked to healthcare workers infecting patients and contracting infections from patients.

“I recently heard about a surgery center that had an exposure because of a healthcare worker not being vaccinated,” says Jeffrey Silvers, MD, medical director of quality, infection control, and pharmacy at Sutter Health in Sacramento, CA. “Measles is becoming much more common. There are a lot of people, unfortunately, who are not getting vaccinated. Our herd immunity of kids is lower than it used to be. It was 95%, and now it’s below 92%.”

Antimicrobial resistance can be found in all healthcare settings, including surgery centers. Studies highlight the problems of infections from methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and others. CRE has been on the rise for nearly two decades. It is associated with a higher mortality rate than carbapenem-susceptible infections.1-5 For example, Maryland health officials documented reports of a couple of residents with surgical sites infected with rapidly growing mycobacteria (RGM) after cosmetic procedures at a Dominican Republic clinic. In a study, investigators noted that RGMs are antimicrobial resistant and difficult to treat. Isolates from the RGM patients were resistant to multiple classes of antimicrobials.5

Emerging research suggests climate change has contributed to the rising rates of AMR. One new study says that both rising local temperatures and greater population density contributed to more antibiotic resistance. Investigators found that a temperature increase of 10° C was associated with a rise in antibiotic resistance of 2.2-4.2% for common pathogens, including antimicrobial-resistant Escherichia coli, Klebsiella pneumoniae, and MRSA.1

The CDC, World Health Organization (WHO), and the American College of Surgeons have published extensive guidelines for prevention of surgical site infections after operations. These include information about appropriate antibiotics and timing as well as proper skin preparation, says Robert G. Sawyer, MD, FACS, FIDSA, FCCM, chairman of the department of surgery at Western Michigan University Homer Stryker M.D. School of Medicine. Managing AMR is a huge concern for surgeons and other in healthcare, he notes.

“In this day and age, we’re most concerned about MRSA, and there are some screening programs to use before operations,” Sawyer says.

As surgery centers increasingly take on more complicated patients and procedures, the risk of AMR in patients rises, Silvers says.

“Make sure you have appropriate policies and procedures in place to ensure infections are not spread to patients,” Silvers adds. “Be aware that if there is even one case that develops in the center, they need to do a root cause analysis.”

The authors of a new study from Germany found that antimicrobial-resistant diseases were among the causes of periprosthetic joint infection among patients who had undergone total knee arthroplasty and total hip arthroplasty. Some of the AMR discovered included MRSA, methicillin-resistant Staphylococcus epidermidis, ampicillin-resistant Enterococcus, and VRE.6

As ASCs see more patients for additional orthopedic and other procedures, they are at greater risk of encountering a patient with MRSA. Sawyer offers several suggestions for how to prevent exposing a surgery center to antimicrobial-resistant infection outbreaks:

  • Evaluate patients for AMR risk.

This evaluation should occur at the initial physician-patient meeting. The literature supports preoperative screening for MRSA, as it is one of the leading causes of surgical site infection.7

Surgeons and staff can ask patients these questions:

- Have you been hospitalized recently?

- Have you received antibiotics recently?

- Has anyone ever told you that you have contracted MRSA or drug-resistant bacteria?

“If patients fall into one of those categories, or if they’re just medically unwell ... then someone should check to see what’s going on,” Sawyer offers. “What resistant bacteria have they been diagnosed with in the past?”

If patients have been diagnosed with AMR, then the surgery center can make certain antibiotics used after surgery will work for that patient. Or, the ASC could decide to refer the patient to a hospital surgery setting that is better able to ensure the patient’s safety.

“Some centers would not operate on those patients,” Sawyer notes. “Or, if they do, they might want to isolate those patients from other patients so they don’t spread the bacteria.”

  • Change antibiotic prophylaxis and improve infection control.

Adjust antimicrobial prophylaxis according to a patient’s resistance pattern. Also, strictly enforce staff wearing gloves, masks, and avoiding contact with AMR patients.

A negative air flow room is not necessary for these cases, partly because transmission occurs most commonly because of patient-to-healthcare worker-to-patient transfer. “A negative air flow room wouldn’t change that,” Sawyer notes.

  • Know the area’s antibiotic-resistant bacteria.

“There are regional differences about which resistant bacteria happens to be out there,” Sawyer says. “Some places know they have a lot of MRSA and others have resistant Klebsiella.”

State and city health departments should offer some information about which AMR strains are common in an organization’s area. Some states, like South Carolina, collect and analyze antibiogram data from all acute care institutions to create statewide antibiograms and to provide comparative looks at institution-specific susceptibility rates. (Learn more about the South Carolina antibiogram program online at: http://bit.ly/2pryMpd.)

  • Follow up with patients after surgery for surgical site infections.

Some institutions provide post-surgery emails notifying surgery centers of patients who contracted infections. This reporting varies according to the organization, Sawyer notes. The goal is to know the types of organisms causing infection in the institution. If there are cases of AMR, the surgery center will learn of this quickly and respond appropriately.

“Somebody has to look at the data and say, ‘We’ve had three MRSA infections last month, and three this month, so we need to look at whether there’s something going on in our surgery center,’” Sawyer explains.

“ASCs have to do a good job of following up and documenting infections that occurred and gain an understanding of whether there is a common pathogen causing those infections.”

REFERENCES

  1. MacFadden DR, McGough SF, Fisman D, et al. Antibiotic resistance increases with local temperature. Nat Clim Change 2018;8:510-514.
  2. Rump B, Timen A, Hulscher M, Verweij M. Ethics of infection control measures for carriers of antimicrobial drug-resistant organisms. Emerg Infect Dis 2018;24:1609-1616.
  3. Pelrano G, Matsumura Y, Adams MD, et al. Genomic epidemiology of global carbapenemase-producing Enterobacter spp., 2008-2014. Emerg Infect Dis 2018;24:1010-1019.
  4. Lutgring JD, Zhu W, de Man TJB, et al. Phenotypic and genotypic characterization of Enterobacteriaceae producing oxacillinase-48-like carbapenemases, United States. Emerg Infect Dis 2018;24:700-705.
  5. Schnabel D, Esposito DH, Gaines J, et al. Multistate US outbreak of rapidly growing mycobacterial infections associated with medical tourism to the Dominican Republic, 2013-2014. Emerg Infect Dis 2016;22:1340-1347.
  6. Rosteius T, Jansen O, Fehmer T, et al. Evaluating the microbial pattern of periprosthetic joint infections of the hip and knee. J Med Microbiol 2018; Sep 12. doi: 10.1099/jmm.0.000835. [Epub ahead of print].
  7. Goyal N, Miller A, Tripathi M, Parvizi J. Methicillin-resistant Staphylococcus aureus (MRSA): Colonisation and pre-operative screening. Bone Joint J 2013;95-B:4-9.