By Karin Lillis
The Centers for Disease Control and Prevention (CDC) reports “historically high” levels of Clostridium difficile infections in healthcare settings, attributing around 14,000 patient deaths each year to the hospital-acquired infection. Those at the most risk are elderly people who are in the hospital and on antibiotics. Antimicrobial stewardship programs – multidisciplinary efforts to measure and regulate the use of antimicrobials – are key to helping healthcare organizations reduce the risk of encountering multidrug-resistant organisms (MDROs) like C. diff.
“There is a huge amount of data regarding the use and misuse of antimicrobials. We used to think if one is good, two are better and three even better. We're realizing that antibiotics do have ill effects. We're experiencing more resistant pathogens and there are not enough new medications coming on the market to combat that,” says Trevor Van Schooneveld, MD, medical director of the antimicrobial stewardship program at the University of Nebraska Medical Center in Omaha. “Even if we could, it doesn't change the ill effects of antibiotics. Even if we had six new antibiotics a year, we don't need to overuse them.”
Hospital infection preventionists play a key role in antimicrobial stewardship programs, say Edward J. Septimus, MD, FIDSA, FACP, FSHEA, and Linda R. Greene, RN, MPS, CIC, manager of infection prevention at Highland Hospital, Rochester, N.Y. Septimus, clinical professor of internal medicine at Texas A&M Health Science Center, offers an example:
Mrs. Jones in bed 3 is in respiratory distress and on a ventilator. The lab culture came back with a positive result for pseudomonas, and the rounding team reviews the appropriate antibiotic to combat the infection. “The infection preventionist standing next to me had an 'a-ha' moment. She asked if the patient met the right definition of infection,” Septimus says. The team reviewed the CDC protocol and the records, and found the problem actually was a questionable IV infiltrate. The patient didn't receive unnecessary antibiotics. “The infection preventionist knew what to ask,” he says. “The patient was OK the next day.”
“The infection preventionist is generally the first one who is going to identify the drug-resistant organisms and help disseminate the information,” says Greene, who also serves as a board member of the Association for Professionals in Infection Control and Epidemiology (APIC). “He or she is really a connector – often talking to pharmacists and infection diseases specialists and reviewing patient charts. The Infection preventionist is the person with the information who can help solidify an antimicrobial stewardship program.”
Julia Moody, MS SM(ASCP), clinical director of infection prevention for HCA Clinical Services Group, agrees. Because infection preventionists track infection and transmission numbers over time, they provide information that will help hospitals analyze the success of antimicrobial stewardship programs, Moody says. “We can tell team members if our (infection and transmission rates) are trending upward or downward. Are we really tight on our evidence-based care practices, and what are our rates (of cases of MDROs)?”
As educators who teach at the unit level, infection preventionists also can help bring front-line workers on board.
“Who better to help coordinate with the stakeholders?” notes Septimus. The infection preventionist is especially helpful in bringing nurses and lab staff on board. “You might have a policy on paper, but if you don't have ownership at the unit level, it leads to poor practice,” Septimus says. “(Front-line workers) need to know why they're doing certain things before they can take ownership” in antimicrobial protection efforts.
Moody notes, however, that antimicrobial stewardship is often a new skill that infection preventionists are learning. “It's easier for those folks who come from the microbiology or public health realm because they already have a strong knowledge base,” she says. “But most come from nursing backgrounds and … might need to ask themselves, 'Is this something I need to learn more about?' That's where mentoring comes in handy – teaming up with a strong member of the community or facility, like the lead microbiologist for the lab.”
“Antimicrobial stewardship can be implemented in (all kinds) of facilities, even on a small scale,” says Van Schooneveld. Most of the robust antimicrobial stewardship programs – led by hospital infectious disease physicians and clinical pharmacists – are at larger healthcare systems and teaching facilities. Many smaller community hospitals don't have the same infectious disease resources available as large healthcare systems and academic facilities, says Moody. Often, she notes, there may not be an infectious disease expert on staff, so the infection preventionist “plays more of a lead role because of his or her knowledge of MDROs and C. diff cases driven by antibiotics.” Van Schooneveld said recently spoke to a clinical microtechnologist in a small, rural Nebraska hospital, who reviews all culture results and what drugs a patient is on. If it looks like the infection isn't responding to the drug, she contacts the patient's doctor.
“Before we used to just observe compliance, but we have to ask why when something happens,” Septimus says. “If we see someone is not washing (his or her) hands, ask, 'Why?' Are all the hand sanitizer dispensers empty, for example, on a Sunday and there were not enough environmental services people to refill them?” Make sure healthcare workers have the tools they need right at the point of care, Septimus says, to ensure compliance.
Teamwork is key to any antimicrobial stewardship program's success, and the infection preventionist needs to feel confident enough to speak up if he or she sees a problem.
“It could be something as simple as a resident saying a patient has a new MRSA infection, but you look at the (lab results) and it's gram-negative, not Staphylococcus aureus. You can have a quick dialog, 'Is there something I missed here?' That usually gets the conversation started,” Greene says.
Septimus agrees. “Get rid of the hierarchy. There is a mindset never to challenge the attending physician, but they have the same … accountability as everyone else,” he says. “Just because the doctor is a specialist in infectious diseases doesn't mean he or she knows everything.”
Greene says she has first-hand experience when she had to ask a physician for clarification. “The doctor said, 'Thanks for pointing that out. I didn't see those reports come out.'' she says “You never want to assume the role of the provider, but some things are quite obvious – and the infection preventionist is the one reviewing the chart (and data).”
Karin Lillis is a freelance writer.
- Infectious Diseases Society of America's stewardship guidelines: http://www.idsociety.org/Stewardship_Policy/
- Society for Healthcare Epidemiology of America stewardship guidelines: http://www.shea-online.org/HAITopics/AntimicrobialStewardship.aspx