The public is learning more about multi-drug resistant organisms (MDROs) due largely to recent buzz about methicillin-resistant Staphylococcus aureus (MRSA). Healthcare professionals, on the other hand, arent surprised at all by the consequences of MDROs and have known for decades that the only way to battle them is through investment, proper hygiene, teamwork, research and compliance to high standards.
Those basics dont change much. Bugs adapt, however, and that means knowledge must as well.
MRSA on the Radar Screen
National outbreaks of community-acquired MRSA (CA-MRSA) confirmed what clinicians long suspected: Strains that were typically associated with communities can spread through hospitals, and unlikely victims were falling prey in greater numbers, says Cassandra Salgado, MD, MS, assistant professor of medicine in the Division of Infectious Diseases, medical director of infection control and co-director of the epidemiology laboratory at the Medical University of South Carolina.
Hospital staffs have been aware of MDROs consequences for years, but recent media attention on MRSA may motivate hospital staffs to evaluate practices even more critically, Salgado says.
Perhaps institutions can describe successful and unsuccessful control measures, share experiences and collaborate on prevention and control efforts to help decrease the incidence of these worrisome organisms, Salgado says. This, she adds, requires teamwork among departments.
Overall, public attention hasnt made a big difference, says Michelle Farber, RN, CIC, infection control specialist at Mercy Hospital in Coon Rapids, Minn. Personally, I believe the motivation to reduce MRSA has been driven more by learning and applying the recent scientific evidence, than on public attention, Farber says.
Either way, increased public awareness is actually a great opportunity for certain healthcare professionals, says Stephen Weber, MD, MS. Weber is medical director of infection control and clinical quality at the University of Chicago Medical Center.
If were smart, well recognize this increased awareness and try to capitalize on it so we can better affect change, Weber says. I think that at any given time in an institution theres a lot of competing concerns. For awhile it may be influenza, external pay-for-performance measures; it may be about heart failure management or maybe its a new building going up or its faculty recruitment. Well, right now is a very unique opportunity because what people are thinking about is MRSA and MDROs. Weve already found it to be a great opportunity to get back in with senior managers and nursing leadership to really engage frontline staff because we have their attention right now, he adds.
Other Meddling Organisms
The public is focusing on MRSA, but healthcare professionals know that particular bug is just the tip of the iceberg. Epidemiologists across the country have different opinions on what organisms are most disconcerting. The answer to this question depends on the region, the facility and the population it serves. MRSA and Clostridium difficile (C. diff) are common concerns in most of the country, and in Chicago drug-resistant Acinetobacter is another big one, Weber says.
I am a big believer in doing very critical, and when possible, quantifiable institutional risk assessment, Weber adds. In other area places perhaps theyll have a greater concern for vancomycin-resistant enterococci (VRE). In another area it might be multi-drug-resistant tuberculosis or gonorrhea.
Farber agrees that some parts of the country are seeing Acinetobacter, as well as resistant pseudomonas. Her facility isolates patients who have MRSA, extended spectrum beta lactamase E coli (ESBLs), VRE and C. diff. VRE, C. diff and ESBL-producing gram negatives are on the rise across the country, according to Salgado.
A mistake that some hospital staffs make is to underestimate the consequences of MDROs on patients and the bottom line, a mistake that can lead to inadequate education and investment, Salgado says. Proper risk assessment is necessary in all healthcare facilities, but staff must have special training to evaluate that data.
Of course there are also common mistakes that individuals make when caring for patients with MDROs that help contribute to spread, Salgado says. These include overuse of broad-spectrum antibiotics and not being 100 percent compliant with hand hygiene, barrier precautions and disinfection of shared equipment.
Indeed, hand hygiene and other relatively simple measures are paramount, Farber says.
If we were able to reliably and consistently improve compliance with hand hygiene, cleaning the environment with adherence to standard precautions, the central line bundle, Surgical Care Improvement Project (SCIP) bundle and urinary tract bundles, we could control most of the MDRO and C. diff infections, Farber says.
Weber agrees that simple measures can have profound effects. You hear the statement made that clearly hand hygiene doesnt control MRSA, or that clearly isolation precautions as recommended by the Centers for Disease Control and Prevention (CDC) dont control MRSA, Weber says. I think a big mistake is to reach that conclusion. An analogy Im fond of using: If I prescribe a new medication to my patient on Monday and say, Take this and see if it makes you feel better, and they come back a week later and they say, Boy I dont feel any better, and I say to them, did you take the medicine, and they say, no, would I conclude that that medicine doesnt work? No. Id say, I need a better way to ensure that my patient takes this medicine. Yet we know that in a lot of healthcare facilities, people are only washing their hands 25 or at best 50 percent of the time. How you can look at that kind of application of that intervention and conclude that it doesnt work is beyond me, Weber says.
I think the challenge to us right now as a field as we develop and as we apply newer and more intensive strategies of things like active surveillance culturing, we also need to understand how in the world are we dropping the ball on things like hand hygiene and environmental control and appropriate implementation of isolation precautions, Weber adds.
Another mistake is to have poor communication with administrators about the importance of MDROs.
I dont think anyone in our field is walking around saying, Were at zero right now, but I think that some of the administrators to whom we report might think that, Weber says. Its a mistake to allow the ones to hold the purse strings to believe that theres no problem.
The Role Drugs Play
Drugs can be a panacea, but the process is often slow. That may be necessary, says John A. Bosso, PharmD, FCCP, BCPS, professor and chair of the Department of Clinical Pharmacy and Outcome Sciences at the Medical University of South Carolina.
It takes many years to get a new drug to market, because of necessary requirements to document efficacy and safety, Bosso says. Everyone debates whether the process takes too long but in the U.S. Food and Drug Administrations (FDAs) defense, they do fast-track important new drugs.
To Bosso, the more important issue is the lack of new antibiotics. Many in the pharmaceutical industry have backed away from new antibiotic development, probably because of poor return on investment, Bosso says. They would rather come out with a new statin-or-like drug that patients take chronically. The Infectious Diseases Society of America (IDSA) has been pushing the FDA to incentivize the industry to develop more antibiotics. In terms of the timing issue (new strains, etc.), it is worth developing new antibiotics, especially if they represent new classes and/or mechanisms of action.
Ironically, while antibiotics play a role in the evolution and emergence of MDROs, they are also essential in the treatment of these same infections, Bosso says.
Prevention is vital but additional resources are definitely necessary, Weber adds.
If anyone says the way to fight multi-drug resistance is to stay one step ahead of the bugs, thats just not a winning strategy, Weber says. We need to slow the bugs down, not just speed ourselves up.
Moving Toward Zero Tolerance
It is absolutely possible to move toward zero tolerance when it comes to MDROs, Farber says. Her staff has made great strides in this arena and won the Minnesota Hospital Associations 2004 Patient Safety Award and the 2004 Patient Care Innovation Award for reducing ventilator associated pneumonia (VAP).
Some of the steps the staff members took include:
- Implementing the Institute for Healthcare Improvement (IHI) ventilator and central line bundle concept
- Developing fact sheets and in-services to remind and motivate ICU staff members
- Visibly tracking compliance, partly through a goal sheet for daily multidisciplinary rounds Posting outcome measures and real-time feedback on bundle compliance. This was the duty of the clinical nurse specialist and two nurse champions on the unit.
- Building strong collaborative interdepartmental relationships
- Reporting ICU infections to staff, physicians, hospital leadership and various hospital committees
- Completing a critical event analysis that includes risk factors and compliance with infection prevention measures every time an infection is suspected. The analysis is posted.
- Reporting and posting each ventilator associated infection or central line associated infection with initials of the patient near the staff break rooms, to maintain motivation and show that each complication happens to a real patient.
The staff celebrated these successes and shared its good news with hospitals statewide and with the community.
As infection control community members move into a new year, they should look at their electronic methods of tracking patients who require isolation, even if they are convinced that the system is adequate, Weber says.
A lot of hospitals have electronic flags to identify patients who are known as MRSA or VRE or other dug-resistant carriers, and when we tested our system we found that even with this electronic system, people were not getting isolated, Weber says.
Its been very hard for folks at other institutions to feel like thats whats going on at their place, he adds. We were stunned to see how poorly it was performing. Weve actually adopted a much more aggressive system. Over the last two years our proportion of MRSA is stable in the institution and VRE has gone slightly down and some of the gram negatives have also stabilized. I dont know if its cause and effect per say, but I would really say that were looking critically at all the basics that we do and not accepting fair-to-midland results. Were saying, If we want to have zero tolerance lets have zero tolerance at accepting bad hand hygiene, bad isolation, bad practices. Thats the way that zero tolerance can lead to great success.
Members of central sterile, environmental services and infection control know that it takes hospital-wide cooperation to beat infections. It must be realized, however, that members of other specialties have limitations, Weber contends.
We have to be fair in seeing that our colleagues in other branches of clinical care have their own sets of priorities too and we just need to integrate ours with theirs to ensure that the overall safety for patients is improved and not just one dimension of it, he says.
Looking into the future, Farber is hopeful that a staph vaccine will be created and that hospitals can reduce staph infections. Her hope only stretches so far, however. Unfortunately, microorganisms are very hardy and develop resistance to new antibiotics, so this phenomenon will not get any better, she says.
If members of the American healthcare system prioritize the control of MDROs, success will occur, Salgado believes.
This problem did not escalate to this serious level overnight, and it will take much cooperation and patience to succeed in control, Salgado says. Perhaps by increasing research efforts and support of hospital and public health infection control programs.
People are better understanding that MDROs are preventable. That attitude has Weber excited.
I think theres some cause for optimism that maybe we will see a turnaround, he says. At the end of the day, its got to help, because to continue on this pathway people are going to increasingly start to view and rightly so that hospitals are far too dangerous a place to go to get better.