How can healthcare providers help prevent the spread of antimicrobial resistance?
The Centers for Disease Control and Prevention (CDC) estimates more than 2 million illnesses and 23,000 deaths are attributable to antimicrobial-resistant infections in the United States each year. Resistant infections are more difficult to treat, and are associated with prolonged hospital stays and greater disability and death compared with infections caused by susceptible organisms. There are currently few antibiotics left in the treatment arsenal against resistant infections, and even fewer new drugs in the development pipeline.
In CDC's Antibiotic Resistance Threats in the United States, 2013 report, two important healthcare-associated pathogens, Clostridium difficile (C. diff) and carbapenem-resistant Enterobacteriaceae (CRE), are classified as organisms with a threat level of Urgent.
Clostridium difficile (CDI, C. difficile, C. diff)
Although resistance to antibiotics used to treat C. diff infections is not yet a problem, C. diff is able to cause disease and spread rapidly because it is naturally resistant to many of the antibiotics used to treat other infections. In most cases of CDI, the use of antibiotics was a major contributing factor.
CDC reports that C. diff results in more than 250,000 infections and 14,000 deaths per year. A recent point-prevalence survey conducted in 10 states (Magill et al) found that CDI accounted for 12.1% of all healthcare-associated infections (HAIs) in the United States, making it the most prevalent HAI. Of the >18,700 HAIs reported by California hospitals in 2012, more than half (10,667 [57%]) were hospital-onset CDI.
Strategies to prevent CDI include:
· Preventing patient exposure to C. diff via the hands of healthcare personnel and the environment, e.g. disinfection and barrier methods
· Reducing the risk of CDI if the organism is encountered by the patient, e.g. antimicrobial usage restriction and stewardship
Transfer of patients among healthcare facilities has been associated with the spread of antimicrobial-resistant organisms, including C. diff. Communication between facilities when patients with CDI are transferred is another important tool for preventing interfacility spread of C. diff.
For detailed prevention strategies, see:
2014 Compendium Update: Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals - Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update a collaboration between SHEA, IDSA, AHA, APIC and the Joint Commission.
APIC's Preventing Transmission of Clostridium difficile in Healthcare Settings 2013 Fishbone 11 x 17 diagram is a detailed description of prevention methods for CDI.
Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by SHEA and IDSA published by SHEA/IDSA.
Carbapenem-resistant Enterobacteriacear (CRE)
CRE are bacteria of the Enterobacteriaceae family, including Klebsiella pneumoniae and Escherichia coli (E. coli) that are nonsusceptible to the carbapenem class of antimicrobials. There are few antibiotic options for treating CRE infections, and Invasive CRE infections have been associated with >40% mortality. CRE are highly transmissible in healthcare settings and have been identified throughout the United States, including California. The HAI Program's California CRE Prevalence Survey found overall low prevalence of CRE compared with regions of the United States where CRE are now common, but higher prevalence in long term acute care (LTAC) facilities and in the southern region compared with other regions of California.
Patients infected or colonized with CRE can serve as reservoirs that facilitate the spread of CRE from one facility to another. Carbapenem resistance also has the potential to spread to bacteria that commonly cause community-acquired infections, e.g. E. coli.. To prevent CRE from becoming widespread in California, collaboration is needed among healthcare providers, facilities, and public health. The CDC 2012 CRE Toolkit - Guidance for Control of CRE outlines measures clinicians and healthcare facilities should take to prevent CRE transmission within and among facilities. The Healthcare-Associated Infections (HAI) Program created a CDPH Interfacility Infection Control Transfer Form to assist communication between facilities when patients are transferred.
To prevent spread of CRE, healthcare providers should:
1. Understand CRE prevalence in their facility and region
2. Ensure their laboratory can identify CRE and has protocols in place to immediately alert clinical and infection prevention staff when CRE are identified
3. Implement contact precautions for patients colonized or infected with CRE; wherever possible, dedicate rooms, equipment and staff for patients with CRE
4. Perform CRE screening to identify unrecognized CRE colonization among epidemiologically linked contacts of known CRE colonized or infected patients
5. Communicate with other healthcare facilities when transferring or receiving patients with CRE
6. Prescribe antibiotics appropriately, and promote antimicrobial stewardship (link)
7. Discontinue devices (e.g. central venous catheters, urinary catheters) as soon as no longer necessary
8. Participate in facility-based and regional efforts to prevent transmission of CRE
9. Notify health departments of CRE clusters or outbreaks
Antimicrobial Stewardship Programs
The use of antibiotics is the most important factor in the development of antimicrobial resistance. Antimicrobial stewardship programs aim to measure and promote use of the appropriate agent, dose, duration, and route of administration of antimicrobial agents, in order to improve patient outcomes while minimizing toxicity and the emergence of antimicrobial resistance. Antimicrobial stewardship is essential in the control of Clostridium difficile infections and the emergence of infections due to multidrug resistant organisms, and can also reduce excessive costs attributable to inappropriate antimicrobial use.
California law requires that general acute care hospitals implement programs for monitoring the judicious use of antibiotics and requires a quality improvement committee with responsibility for oversight. California is the only state with this type of mandate. CDPH performed a statewide assessment of antimicrobial stewardship programs and published the findings in 2013 at The State of Antimicrobial Stewardship in California. In 2014 CDPH launched the Spotlight on Antimicrobial Stewardship Programs project, which allows hospitals to share their antimicrobial stewardship program strategies and progress, and identifies California physician, pharmacists, and infection prevention leaders willing to serve as mentors to other hospitals in various stages of antimicrobial stewardship program implementation. The Spotlight on Antimicrobial Stewardship Program Project Invitation 2014 remains open to allow additional hospitals to participate - join the project today!
Antimicrobial stewardship resources:
CDC's Core Elements for Hospital Antibiotic Stweardship Programs and Checklist for Hospital Antibiotic Stewardship Programs.
Infectious Diseases Society of America (IDSA): http://www.idsociety.org/Antimicrobial_Agents/#Antimicrobial Stewardship
Society of Healthcare Epidemiology of America (SHEA): http://www.shea-online.org/PriorityTopics/AntimicrobialStewardship.aspx
Stanford School of Medicine: http://bugsanddrugs.stanford.edu/
Greater New York Hospital Association http://www.gnyha.org/whatwedo/quality-patient-safety/infection-control-prevention/
California Antibiogram Project
The CDPH HAI Program California Antibiogram Project collects information on specific antimicrobial-organism combinations across California general acute care hospitals. Participation is optional and hospital identifiers are voluntary. California Annual Antibiograms 2008-2010 reviewed demographic and susceptibility data from 59 laboratories representing 85 hospitals; 75% self-identified as laboratories serving community hospitals.
Patient Education Resources:
The HAI Program's "Me and My Family" webpage for the general public contains information on proper hand hygiene, HAIs, antimicrobial resistance awareness, infection prevention, influenza and communicating with healthcare providers.
CDC provides consumer educational information at: http://www.cdc.gov/getsmart/specific-groups/hcp/index.html
WHO provides additional consumer educational information at: http://www.who.int/mediacentre/factsheets/fs194/en/
National and International Campaigns and Resources Against Antimicrobial Resistance
CDC’s Detect and Protect Against Antimicrobial Resistance Initiative (known as AR Initiative) identifies four core actions to be addressed by all partners in antimicrobial resistance:
1. Detect and track patterns of antibiotic resistance.
2. Respond to outbreaks involving antibiotic-resistant bacteria.
3. Prevent infections from occurring and resistant bacteria from spreading.
4. Discover new antibiotics and new diagnostic tests for resistant bacteria.
The 2015 President's Budget requests $30 million annual funding for 5 years for the AR Initiative to achieve measurable results in the first three core actions (Detect, Respond and Prevent) and provide financial support for the National Institutes of Health (NIH) and private industry to address these issues. CDC's AR initiative lays out a roadmap for fighting resistance on two fronts:
1. Improve detection through regional labs - A new regional lab network and resistance-bacteria bank will speed up outbreak detection and provide a tool to aid development of new antibiotics and diagnostics.
2. Prevent infections and improve antibiotic prescribing practices in healthcare facilities and in the community - Closer collaboration with healthcare facilities and large health systems will strengthen stewardship programs and reduce antibiotic resistance.
Go to http://www.cdc.gov/drugresistance/resources.html for additional CDC resources on antimicrobial resistance.
The Infectious Diseases Society of America (IDSA) 10 x '20 Initiative seeks a global commitment to create an antibiotic Research and Development enterprise powerful enough to produce 10 new systemic antibiotics by the year 2020.
Food and Drug Administration (FDA) provides additional campaign and resources on antimicrobial resistance at: http://www.fda.gov/AnimalVeterinary/SafetyHealth/AntimicrobialResistance/default.htm
The Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was created in 2009 with the goal of improving cooperation between the US and the EU in three key areas: (1) appropriate therapeutic use of antimicrobial drugs in medical and veterinary communities, (2) prevention of healthcare and community-associated drug-resistant infections, and (3) strategies for improving the pipeline of new antimicrobial drugs. See the 2014 TATFAR Progress Report.
ISGlobal Barcelona Institute for Global Health contribute to the understanding of the causes and risk factors for antibiotic resistance, and to the development of new drugs and vaccines. There is multiple antimicrobial resistance leading projects being worked on within ISGlobal.