Global consensus taking shape on drug resistance

International recommendations expected this year

With antibiotic resistance increasingly a global problem, infection control professionals from around the world recently convened in Toronto to try to hammer out consensus stra te gies to prevent nosocomial infections with drug-impervious pathogens. As a result, the first international infection control recommendations on the issue are expected to be issued in the coming months, participants advise Hospital Infection Control.

Comparing infection control approaches at the Global Consensus Conference on March 19-21, 1999, were clinicians and other invited "delegates" from such nations as Canada, the United Kingdom, Australia, Hong Kong, Chile, and Denmark. Plans call for the recommendations to be published later this year in the American Journal of Infection Control, the Canadian Journal of Infection Control, and the United Kingdom’s Journal of Hospital Infection.

"Antimicrobial resistance is a global problem, and there is often inconsistency in how we approach it in different areas," says Karen Green, RN, CIC, conference delegate and infection control nurse at Mount Sinai Hospital in Toronto. "The goal was to try and look at a reasonable set of recommendations that could be agreed upon by people providing care in different areas of the world and in many different settings."

The consensus document based on the conference proceedings is intended to guide health care policy, research, and practice in both public and private sectors. Participants declined to comment on the specific nature of the impending recommendations, but topics in workshop sessions included barrier precautions, patient isolation, screening, skin cleansing antisepsis, and decontamination and disinfection of environment and equipment.

Discussions reveal differences

"For the first time, a group of [ICPs] from different countries sat down together," says Carla Alvarado, MS, CIC, conference delegate and director of the occupational health and safety department at the University of Wisconsin Hospital and Clinics. "It was a wonderful learning experience, because even though you read the publications from the other countries, [when] you are sitting down and discussing the issues together, you see the differences in how you do things."

For example, different global practices were discussed in the workshop on decontamination and environmental disinfection, an important issue because pathogens like vancomycin-resistant enterococci have been shown to contaminate hospital environments even after infected or colonized patients have been discharged.

"One of the subtleties that I found most interesting was that the United Kingdom does not use a combined disinfectant/detergent, which is a very standard item in U.S. health care," Alvarado tells HIC. "They use detergent in the general cleaning and they add a disinfectant when required, whereas we use a broad-based combination disinfectant/detergent product for most cleaning in health care facilities. It’s important to know what the other countries’ practices are, because you are here today; you are in England tomorrow."

Indeed, resistant pathogens like Staphylococcus aureus with intermediate resistant to vancomycin — which was first documented in Japan — are mentioned prominently in the CDC’s recently updated emerging infections plan.1 In the plan, the CDC warns that "because of the ease and frequency of modern travel, it is no longer possible to protect the health of U.S. citizens without addressing infectious disease problems that are occurring elsewhere in the world."

MRSA declines in Denmark’s ICUs

By the same token, taking a global view may provide needed insights for clinicians in the United States, where the CDC recently reported a continuing increase in drug-resistant pathogens in sentinel intensive care units. (See related story, at right.) For example, Dominique Monnet, DPharm, PhD, a conference delegate from Denmark, said adoption of strict antibiotic controls there has resulted in an overall decrease in the prevalence of methicillin-resistant S. aureus. Cultural differences may account for some of the success, he adds.

"It seems that the changes that we implement can be thoughtfully carried out because our health care staff is not overtaxed when it comes to workload," he told conference attendees. "They have time to pay close attention to details that contribute to prevention when caring for patients. . . . Reinforced infection control efforts and more judicious use of antibiotics has led to a marked decrease in and maintained control of resistance."

In addition, Jose Cruz, DSc, a regional advisor for the Pan American Health Organization, highlighted the global nature of resistance in the consensus conference keynote.

According to Cruz, major factors contributing to the problem of antibiotic resistance include the high prevalence of infectious disease; inadequate pharmaceutical storage conditions and lack of regimen compliance; the failure to implement basic hygienic practices, such as hand washing; and the overuse of antibiotics.

"In Latin America, antibiotics are freely available and are commonly administered to treat viral infections," he told attendees. "This is a prime example of antibiotic misuse, since we know that antibiotics are only effective in treating bacterial infections, not those caused by viruses."

More emphasis also needs to be given to decreasing the use of invasive medical devices, added Julie Gerberding, MD, MPH, director of the CDC hospital infections program.

"The utilization of catheters, for example, is something we need to be thinking about," she told conference delegates. "Minimizing to the extent possible the number of lines going into our patients will reduce the likelihood of their developing an infection."

Reference

1. Centers for Disease Control and Prevention. Preventing emerging infectious diseases: A strategy for the 21st century. Overview of the updated CDC plan. MMWR 1998; 47(No. RR-15):1-14.