Bacteria battling back against antimicrobials
Bacteria battling back against antimicrobials
Resistance to drugs is slowly getting stronger
Vancomycin-resistant bacteria aren’t likely to suddenly sneak up on home infusion providers, but that doesn’t diminish the threat this problem presents to you and your patients. As the world watches, the health care industry could be on the verge of an epidemic for which there currently is no treatment.
"The majority of infectious disease physicians feel that we are in a crisis," says Brooks Gainer, MD, a member of the Morgantown (WV) Internal Medicine Group, a clinical associate professor of infectious disease at West Virginia University School of Medicine, and with a practice primarily in infection control at Monongalia General Hospital in Morgantown. "It’s a major problem. Resistant strep pneumonia wasn’t a problem, but from 1990 until now it has gone from 1% to as high as 35% to 40% of strep pneumonia being resistant to penicillin. And now you’ve also got flesh-eating strep coming back."
The Sentry Antimicrobial Surveillance, a project sponsored by Bristol-Myers Squibb Company in 1997 as the first worldwide longitudinal microbial surveillance program on infectious diseases, highlights the problem. First-year data from the program show an infection rate of up to 18% in vancomycin-resistant enterococci (VRE) from bloodstream infections in the Americas and Europe.
Infection suspected in a recent death
The most recent warning flag regarding the growing crisis popped up in New York early this year. A patient was admitted to a hospital with a high fever and died 12 hours later. This patient had been hospitalized with a severe methicillin-resistant Staphylococcus aureus infection, for which vancomycin was used for six weeks.
According to a spokeswoman for the State of New York Department of Health, officials there believe the infection was responsible for the patient’s death. This could not be confirmed because no autopsy was conducted at the request of the family.
A total of 38 individuals who came in contact with the patient were tested; none tested positive. The New York patient is the fourth such patient known to be infected with vancomycin-resistant S. aureus, following two prior cases in 1997 in Michigan and New Jersey and a case in Japan in 1996.
Gainer cautions against comforting yourself with the supposition that such resistance appears only in patients who have recently been released from the hospital.
"Two years ago, I had a young man with a ruptured appendix who had never been in the hospital, had not been on antibiotics in years, nobody in his family had been sick, and was a healthy college student. He had a vancomycin-resistant infection."
What are the contributing factors?
"If you look at older literature in the late 1970s, antibiotics were used incorrectly up to 50% of the time," says Gainer. "Patients were receiving antibiotics for too long, too short, not the right dose, not the right drug for the bug, etc."
However, there are other factors contributing to the spread of antibiotic resistance.
• "In the home care market, the only real area in which there has been abuse was when Medicare provided coverage of vancomycin, but that was being abused by doctors who went with vancomycin because it was covered even if a patient could have been treated with something else," says Gainer.
• "Another theory is that when hospitals started restricting formularies, this led to using the same drugs over and over on these bugs, which allows bacteria to become resistant," he says.
• "A third issue developed in 1988," says Gainer. "When we went to universal [infection control] precautions for everything, the basic principles of infection control such as hand washing were forgotten." The result has been disastrous, he maintains. "Now, people think they have gloves on so they are protected, but you see people coming out of a room with gloves on and in a hospital they pick up charts or files and then take the gloves off," says Gainer. "They may be protected, but they are contaminating the environment. That’s why some people propose that if we got rid of the gloves we would be in better shape."
Gainer says it all comes down to three basic facts: the misuse and overuse of antibiotics; not following good infection control practices; and the prevalence of sicker patients.
He sees a newer factor contributing to the problem, as well. "One of the biggest concerns is that because of all the changes in the health care system, physician control is becoming a problem," says Gainer. He uses the following example:
"A physician wants me to see one of his managed care patients, and the MCO is hesitant to let me see the patient, even though this physician is uncomfortable treating a patient for six months to a year with antibiotics," he says. What’s a provi der to do?
Gainer recommends home infusion providers take the following steps to slow the spread of antibiotic-resistant infections:
• Question how you’re treating patients.
"Use as narrow a spectrum drug as you can," he says. "Is there really a need for four to six weeks of IV antibiotic therapy? The bugs are smarter than we are, so we have to get back to a more selective use."
Gainer also advocates careful patient follow-up. "I had three patients who I thought had the flu, but following up, it turned out to be bacteremic and we don’t have a source," he says.
• Be sure your staff and your patients’ caregivers practice safe infection control practices.
"Caregivers must practice the same infection control practices to avoid contamination in the home," he says.
Infection control is even being re-evaluated in hospitals, where, according to Gainer, they are going back to strict isolation for patients and the use of gowns, masks, and gloves.
"They’re also trying to keep the patients out of the hospital and in the home, which until recently has been an ignored area of infection control," says Gainer.
Once patients are in the home, however, it’s up to you to educate them about infection control practices, which entail much more than simply clean hands and sterile dressings.
"You don’t want an oncology patient receiving visitors in the home who may have VRE," says Gainer. "Keep the patient at the home and discourage letting everyone come and visit because they’re home. You could cause some of your visitors problems if the wrong kind of person comes to visit, and that’s not stressed enough. If Aunt Sue on chemotherapy with breast cancer comes to visit and I’m being treated with a staph infection and she picks it up from me, it could be the end of her because of her compromised state."
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