Hospital Infection Prevention-The day-care connection to drug resistance: Parental pressure leads to antibiotic pressure

Encourage written policies, waterless hand washing

Pressure from parents to avoid lost work and get their sick children back in day-care centers is contributing to the kind of misuse and overuse of antibiotics that fuels the rise of resistant organisms, reports Michael Brady, MD, professor of pediatrics and preventive medicine in the College of Medicine at The Ohio State University in Columbus.

With the increase in double-income families and single-parent homes, parents who stay home with a sick child may lose critical work time. "If they have a situation where a child has an illness that prevents the child from attending day care, there is a tremendous amount of pressure on the part of the family to try to do something in order to try to make the child better sooner so that they can get back to work," Brady told attendees recently in Minneapolis at the 27th annual conference of the Association for Professionals in Infection Control and Epidemiology.

Antibiotics often used for viral illnesses

Under such conditions, physicians may be pressured to prescribe antibiotics when antibiotics are not appropriate, such as when the illness is viral. This prescribing pattern results in the kind of antimicrobial pressure in the community that favors the rise of resistant pathogens. "There is a tremendous amount of pressure for overuse of antibiotics," Brady said. "This has resulted in probably very little benefit to the families, but it has resulted in marked increases in resistance."

Currently, some 60% of all women with young children work at least some portion of the time outside their home, Brady told APIC attendees. In addition, 23% of children have only one parent in their households. "What this means is that greater than 11 million children in the United States who are less than school age are cared for at an out-of-home setting at least for some portion of the day," he says.

Brady supported his argument with the example of the continuing increase of penicillin resistance in pneumococcus. "There is a direct correlation with day-care center attendance, and I think it is very clear that this pressure to use antibiotics is part of that problem." he says. "Obviously, there is a risk for secondary transmission [to] family members."

Unlucky 13 days of illness a year

Infections result in about 13 days per year when the average child needs to be removed from the day-care center and at least one of the parents loses a day of work, he said. "Diarrhea, which is one of the more common ones, results in about 4.7 [sick] days per year," he said. "There is a significant amount of work lost. Thirteen days a year might start rubbing the employers the wrong way and might give parents a tremendous problem with the ability to take care of their child correctly and also to try to avoid problems at work."

Urging ICPs attending the session to consult with day-care centers to help them reduce infections, Brady said infection control in some centers is akin to a "third world" setting. Day-care centers face an abundance of predisposing problems, including that they generally have preschool children with high infection susceptibility due to little previous exposure to infectious diseases. The younger ones have understandably poor hygiene, so staff who are typically poorly compensated must make the effort to institute some element of infection control.

Staff IC efforts depend on administrators

"Very infrequently will you have in child care centers people who have professional training that will give them insights into infection control," he said. "There are usually a few administrative staff, maybe a few professional staff, but a large number of people who are just essentially baby sitters. So their ability to understand infection control is going to be dependent upon the effort put out by the administrators."

In that regard, one of the most important factors — and the first thing to ask about — is written infection control policies, he said. "When they've looked at rates of infections and done some nice statistical analysis, one of the most important issues is if a program has written policies related to infection control," he said. "[If so,] they were much less likely — even if the policies weren't necessarily perfect — to have high rates of infections compared to those places that didn't have written policies."

With workers going rapidly from child to child, the cardinal principle of hand washing is difficult to enforce. However, Brady recommended that ICPs encourage the use of waterless soaps in such settings, which are not likely to have an abundance of well-placed sinks. "This might be an area where some of the waterless soaps would probably be very valuable," he said.