A primer on antibiotic-resistant superbugs and improving antibiotic stewardship

According to the Centers for Disease Control and Prevention (CDC), it is estimated that one out of every 25 hospitalized patients will contract a healthcare-associated infection (HAI). Each year HAI’s are a documented source of increased mortality and morbidity, significant costs for care delivery, and have a negative impact on the patient experience.

HAI’s are typically preventable through the implementation of recommended evidence-based practices. The CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) has authored numerous guidelines and guidance statements that directly reduce the risk for transmission of HAI’s such as multidrug-resistant organisms (MDROs) and other emergent pathogens.

Patients receiving medical care are now at potential risk for contracting MDROs because of exposure to the healthcare system, particularly when they receive antibiotic therapy. Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances like chemotherapy and organ transplants possible. Widespread use of antibiotics has increased the risk for antibiotic resistance exponentially across the globe. Therefore, antibiotic stewardship efforts should be a core element of an Infection Prevention and Control program across the healthcare continuum of care in both inpatient and outpatient settings.

Healthcare C-Suite executives, chief medical officers, infection preventionists, infectious disease specialists, and other healthcare facility leaders all play a critical role in building a sustainable antibiotic stewardship program and also reducing the overall risk for development of sepsis, both of which are a significant source for mortality and morbidity in healthcare.

Strategies for implementation across the continuum of care

The CDC has developed Core Elements of Hospital Antibiotic Stewardship Programs that include infection prevention intervention themes that encompass both a top-down and bottom-up approach. This approach improves collaboration between disciplines, and also requires executive leadership commitment to ensure sustainable success. The CDC’s core components include:

• Leadership commitment
• Accountability
• Drug expertise
• Action
• Tracking
• Reporting
• Education

The most significant intervention to success with a stewardship program is the presence of C-Suite leadership commitment. This leadership commitment sets the stage for accountability throughout the entire organization, and ensures that the stewardship program is properly resourced with people, time, and money to achieve the goals.

One of the critical elements of stewardship is ongoing training and education that will encourage dialog between the providers, patients, and healthcare team about improving stewardship efforts. Leaders in Medicine, Nursing, Pharmacy, and Healthcare Administration are equal stakeholders, and must be fully engaged in all stewardship efforts. It is also helpful to encourage a culture of transparency with results towards the program target by sharing both positive and negative outcomes with all associated stakeholders, including frontline staff and clinicians.

While leadership support is paramount for success, another component needed is expertise in the “Bugs and Drugs.” The drug expertise recommendation from CDC focuses on two vital components. First, facilities need a dedicated stewardship program leader with responsibility for managing the program and communicating with stakeholders, particularly prescribers, about the status towards goals of the stewardship program. Most programs have either a specially trained physician of pharmacist to serve in this capacity. The second recommendation for drug expertise is the pharmacy leader. This pharmacy leader collaborates with the stewardship program leader and ensures that clinical pharmacology considerations are accounted for throughout the program.

Some countries, such as the United Kingdom, have made substantial progress in improving stewardship efforts by deploying unit-based clinical pharmacists that actively engage with prescribers on therapeutic pharmacology discussions with the intent to reduce inappropriate use of antibiotics and antimicrobial agents when not clinically necessary. They can additionally work to ensure the proper “bug-to-drug” match using the facility’s antibiogram, thereby reducing the potential for resistance. Ideally, both the providers and pharmacy leaders would have specialty training in the principles of infectious disease, healthcare epidemiology, and antibiotic stewardship training. Training on these topics is readily available online and in person from respective clinical societies such as the Infectious Disease Society of America and the Society for Healthcare Epidemiology of America. For more information on available training, please refer to the additional resources at the end of this article.

While prescribers are proportionally the largest stakeholder by risk profile, it is important to engage other key groups within the antibiotic stewardship program including clinical nurses, infection preventionists and healthcare epidemiologists, public health personnel, quality improvement and patient safety professionals, information technology staff, and medical laboratory colleagues. Only with this collaborative team can stewardship efforts be positively impacted.

Many facilities that have demonstrated substantial improvements in inappropriate antibiotic prescribing have worked aggressively with colleagues in Information Technology as well as external electronic medical record (EMR) vendors to create custom modules in the patient’s chart that encourages better prescribing practices, monitors a patient’s total consumption of antibiotics and can provide intelligence to the provider about potential risks as well as the most appropriate “drug-to-bug” match for the suspected or confirmed microorganism. The specific dose, indication or use, and duration of the antibiotic treatment should be well documented in the medical record, and also in compliance with established prescribing and treatment guidelines both the institution and also relevant professional guidelines.

The rise of Clostridium difficile infection from antibiotic exposure

Clostridium difficile is the most common cause of healthcare-associated diarrhea disease, and the major risk factor for development of this disease is exposure to antibiotics. The CDC has recently estimated that roughly 500,000 Clostridium difficile infections occurred in the U.S. in 2011, of which 29,000 of those hospitalized patients died from complications of the infectious disease within thirty days of the initial diagnosis. Some 83,000 of the patients with infection experienced at least one recurrence within 30 days of the initial diagnosis.

Overuse or inappropriate use of antibiotics is the biggest risk factor in developing the disease. Antibiotics kill the natural, protective flora found in the patient’s gut, which can then allow the Clostridium difficile flora to overtake the bowel and result in infection. CDC studies have demonstrated that 30 to 50 percent of antibiotics prescribed in U.S. hospitals are unnecessary or clinically incorrect. Clostridium difficile is a tremendous source of mortality and morbidity to the healthcare delivery system, and directly impacts both acute care and post-acute care healthcare settings.

An antibiotic stewardship program leader must work with prescribers and the clinical pharmacist to ensure that antibiotics are indicated for the patient’s condition, and carefully taken by the patient according to the prescribed directions. It is important to discontinue antibiotics as soon as they are not medically necessary. The use of advanced laboratory methods to rapidly detect the presence of superbugs in the patients can improve mortality and morbidity. These results must be integrated directly into the patient’s medical record with the ability to instantly alert the provider and healthcare team about critical results. For antibiotic resistant pathogens, basic infection prevention and control measures must be strictly adhered to in order to prevent transmission in the healthcare environment.

Disinfection equally important

Clinicians should follow isolation precaution guidelines when caring for patients with suspected or confirmed Clostridium difficile (i.e., wearing gloves and a gown) even during short visits. Given the role of the clinical environment of care, it is helpful to collaborate with the facility’s Environmental Services professionals to ensure they are cleaning room surfaces thoroughly on a daily basis and upon discharge. It is important to use an EPA-approved, spore-killing disinfectant for units where there is potential transmission. Clostridium difficile and many other antibiotic-resistant microorganisms are readily transmitted in the environment via the contaminated hands of healthcare providers and patients, as well as contaminated environmental surfaces. Reducing the presence of multidrug-resistant microorganisms present in the clinical environment of care will help to mitigate transmission, but also directly supplement the antibiotic stewardship program. Educational programs geared to reducing the risk of transmission from the clinical environment of care are available for Environmental Services professionals and technicians from the Association for the Healthcare Environment.

Summary

Emergent pathogens and antimicrobial resistance continue to plague the global healthcare system, however basic infection prevention and control practices will greatly assist providers and the entire healthcare delivery team in reducing the risk for transmission of these pathogens. Maintaining a clean and sanitary environment, reducing the overuse of antibiotics, sanitizing hands often, and keeping the patient’s own skin intact will reduce the potential risk for transmission of many emergent pathogens such as Clostridium difficile.

In addition, healthcare professionals should carefully follow the evidence-based recommendations from the CDC for isolation precautions, use of personal protective equipment, disinfection and sterilization, and hand hygiene. These core recommendations will guide the clinician and other healthcare personnel in the adherence to interventions that will significantly reduce the overall incidence of HAI’s and also occupational exposure to the clinical personnel.

Antibiotic Stewardship is possible, but only with the ongoing collaboration of the entire stakeholder team, as well as the engagement of external partners, such as public health and the patients themselves. Reducing antibiotic stewardship improves patient outcomes, improves the quality of care provided for the population, and reduces unnecessary healthcare costs. These tenants are directly aligned with the healthcare industry’s focus on improving patient safety but also with the Institute for Healthcare Improvement Triple Aim theory. Antimicrobial Stewardship is an initiative that will not only be important in protecting patients today, but even more important in protecting the use of these vital drugs for the patients that desperately need them in the future.

Additional resources:

• Primer on Healthcare Epidemiology, Infection Control, and Antimicrobial Stewardship, Society for Healthcare Epidemiology of America; http://www.fellowscourse.shea-online.org/Default.aspx.
• Antimicrobial Resistance Resources for Professionals, Infectious Disease Society of America; http://www.idsociety.org/View_All_Antimicrobial_Resistance__for_Professionals/.
• AHE Environmental Services Designation Programs, Association for the Healthcare Environment; http://www.ahe.org/ahe/lead/certifications.shtml.
• Centers for Disease Control and Prevention Core Elements of Hospital Antibiotic Stewardship Program, US Centers for Disease Control and Prevention; http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html