Tori Whitacre Martonicz is the editor of 

.  She has been a writer and editor for over 30 years, and she has an MA and BA in English Composition/Literature from the University of Akron in Akron, OH. She lives in Ohio with her husband; son; 2 tiny dogs, Selena Brigid Sophia and Doctor Danger Dog; and a big black cat, Freya. She loves reading, writing, gardening, and spending time with her loved ones.

In this first installment of a 5-installment series,  

speaks with 2 managers at Sage Memorial Hospital, Navajo Health Foundation, Navajo Health Foundation, in Ganado, Arizona, about their infection prevention and control program, including their strengths, challenges, and what innovative ways they provide the very best care to their patients, staff, and community.

Christian Bigwater, BSBA, director of public relations and marketing, and Tiyarra Wauneka, environmental services supervisor, discuss the hospital's size and the issues that differ from larger hospitals in more urban areas.

The facility follows its Navajo Nation’s values: “The mission of Sage Memorial Hospital is to provide quality healthcare for the Dine people with respect, unity, beauty, and harmony in honor of K‘é an, the sacredness of life,” according to the 

: What is the hospital, how large is it, and whom do you serve?

: We're located in Granado, Arizona, and that's on the Navajo Nation. Primarily, we focus on our immediate community, which includes the chapters of Cornfields Ganado, Kinlichee, Klagetoh, [Lower] Greasewood [Springs], Steamboat, Wide Ruins, and Nazlini.

We do welcome patients and visitors [who] are beyond our service area. We do cater to both Navajo and non-Navajo [for] just little bit about the demographics of the people that we serve. And this is based off the Community Health Needs Assessment. Approximately 95% of patients [who] come in here are of American Indian or Alaskan descent. Although I did mention we do service other people and are welcome to come to the hospital, our primary visitors and patients are mainly Navajo.

 What unique challenges do you have in the infection prevention and control space that maybe a hospital in Boston or Houston may not have?

: Some of the challenges that we currently have with our infection control [within the hospital] is that because our hospital is a private hospital, we do have surrounding facilities, healthcare facilities that are funded by IHS [Indian Health Service]. And so being a private sector, we are faced with the challenge of ensuring that we get the proper training that we need to carry out the services that environmental services provide for our facility. Also, we are in a rural location. So often, we don't have access to those resources. If you were in a bigger city, where resources are nearby, so it takes time for us to receive supplies.

I will give the example of going into the pandemic. When we went into the pandemic, a lot of the health care facilities that were in a bigger city or town, I had access firsthand to all the PPE [personal protective equipment] supplies or any kind of disinfection solutions that they needed. But for our hospitals located on the reservation, it was hard to get those supplies for not only our hospital but for our community that we serve.

And here on the reservation, that community that we

 serve, we have a wide spread of community members. We don't have anything like street signs or streets with houses that are clustered together. We spread across a big section of land, where we're just scattered here and there. So that was our biggest challenge. And it's still our biggest challenge to ensure that we can get to all those communities [and] and team members that we serve and be able to find a reliable resource where we can get the things that we need for infection control, [like] our supplies, and sometimes it does take time for them to get it to us.

For example, if you were down in the Phoenix area, they could get supplies within a day, overnight. But for us, it could take anywhere from a week to 3 months to receive those supplies. So we have to plan ahead at least 3 months in advance to ensure that we constantly have the supplies that we need to take care of our community and our health care facility.

: You have everything all there in the hospital, [and] you have sterile processing environmental services. Do you have an IP [infection preventionist] on staff?

: Yes, we have 1 IP [who] is currently with us. And then myself included. So my team and I are the infection control and infection preventionist team that oversees our facility.

(This interview has been edited for clarity.)

Videos

What is infection control and prevention like on the Navajo Nation? Find out in this first of 5 installments in a conversation with managers at the Sage Memorial Hospital, Navajo Health Foundation. 

Providing Infection Prevention on the Navajo Nation

A version of this article first appeared in our sister publication, 

Yesterday, Pfizer Inc. declared that the US Food and Drug Administration (FDA) gave approval for their respiratory syncytial virus (RSV) vaccine, Abrysvo, to be used by older adults. This endorsement permits the use of Abrysvo in people aged 60 years and older to prevent lower respiratory tract disease caused by RSV.

Pfizer’s Abrysvo vaccine targets both RSV A and B strains with its 2 preF proteins. The FDA has approved Abrysvo based on comprehensive trial data that confirms its safety and efficacy.

“A vaccine to help prevent RSV had been an elusive public health goal for more than half a century," stated Annaliesa Anderson, PhD, senior vice president and chief scientific officer of vaccine research and development at Pfizer. “Abrysvo will address a need to help protect older adults against the potentially serious consequences of RSV disease. We are extremely grateful to the clinical trial participants, study investigator teams and our dedicated Pfizer colleagues for their roles in making this vaccine available.”

With Abrysvo being granted approval, it becomes the second RSV vaccine to be approved after GSK's 

 after more than 50 years of working to develop an RSV vaccine. The approval was based on data obtained from a Phase 3 clinical trial (NCT05035212) called RENOIR (RSV vaccine Efficacy study iNOlder adults Immunized against RSV disease). This study is designed to evaluate the efficacy, safety, and immunogenicity of a single dose of the vaccine in adults aged 60 and above. The trial enrolled around 37,000 randomly assigned participants to receive either RSVpreF 120 μg or a placebo in a 1:1 ratio. The study is ongoing, and efficacy data is being collected during the second RSV season.

Edward E. Walsh, MD, Professor of Medicine at the University of Rochester Medical Center and principal investigator of the RENOIR trial, commented, "This 

 demonstrated the serious consequences and potential health risks this virus poses for older adults. Today’s FDA approval of Abrysvo recognizes significant scientific progress, and importantly helps provide older adults potential protection against RSV and an opportunity to improve community health by helping prevent the disease.”

RSV is a virus that spreads easily and causes respiratory illnesses worldwide. It mainly affects the lungs and airways, which can lead to serious health problems and even death. Older adults in the US are especially at risk from RSV, with the severity of the illness increasing with age and the presence of other health issues like asthma, congestive heart failure, or chronic obstructive pulmonary disease (COPD).

For most people who are generally healthy, RSV causes mild symptoms similar to a cold. They usually recover within 2 weeks without realizing they had the virus. Infants and young children, however, are more vulnerable to severe RSV infections. Pfizer is therefore seeking approval to give RSVpreF to pregnant people, to prevent medically attended lower respiratory tract disease (MA-LRTD) and serious MA-LRTD caused by RSV in babies from birth to 6 months old. The maternal vaccine was 

 by the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC), and a decision is expected by August 21, 2023.

The CDC Advisory Committee on Immunization Practices (ACIP) will have a meeting on June 21, 2023, to discuss the use of RSV vaccines in older adults. Pending the outcome of this meeting, Pfizer expects Abrysvo to be available in the third quarter of 2023, just in time for the anticipated RSV season this fall. Pfizer also reported positive top-line results earlier this month from a Phase 3 study on the safety and effectiveness of Abrysvo when coadministered with seasonal inactivated influenza vaccine (SIIV) in adults aged 65 and older. Additionally, Pfizer plans to conduct multiple clinical trials to evaluate RSVpreF in healthy children aged 2 to 5 years, children aged 5 to18 years with comorbidities, adults aged 18-60 years with comorbidities, and adults aged 18 years and older who are immunocompromised and at high risk for adverse RSV outcomes.

Articles

The FDA's decision to approve Abrysvo was based on data from a Phase 3 clinical trial, RENOIR, demonstrating the RSV vaccine's efficacy, immunogenicity, and safety in adults 60 and older.


FDA Approves Pfizer's Abrysvo Vaccine for Older Adults

Isis Lamphier, MPH, CIC, is an infection preventionist at Moffitt Cancer Center in Tampa, FL, and a member of the 

As a student in college, I was desperate to find a career that spoke to me that resonated with my aspirations and passion for aiding others. I was at a crossroads when asked to declare my major in the second year of my studies. I sampled various majors, but none captured my interest until infection prevention seemed to serendipitously come my way after countless late nights on my computer searching and seeking answers. The next day after the triumphant final night of my quest, I capered to my school’s college of public health and declared my major. At present, I proudly hold a master of public health (MPH) degree and have actively served as an infection preventionist (IP) for the past few years, including during the COVID-19 pandemic.

Traditionally, IPs have been recruited from nursing; in the last few years, a new pipeline has prepared students to enter careers in infection prevention and control, emphasizing public health or alternative degrees beyond nursing, such as microbiology. Colleges and universities have also designed certificate programs enabling students to obtain a certification in infection prevention.

In Association for Professionals in Infection Control and Epidemiology’s (APIC’s) MegaSurvey, there was a slight shift between 2015 to 2020 regarding the educational background of respondents

. In 2015, 82% of infection preventionists came from the nursing discipline; in 2020, 78% came from a nursing background.

 Among the respondents in 2020, a mere 8% originated from a public health background. The skillset of a public health graduate must continue to be considered when welcoming new infection preventionists to the table.

Lamphier in 2020 after completing her master of public health.

MPH graduates are trained in epidemiology, biostatistics, outbreak investigations, health care research

, and other invaluable disciplines. Within our studies, there is also an emphasis on critical thinking, leadership, and health communication. As an IP, delivering information is a regular function; therefore, understanding how to convey the information appropriately and to different audiences is key. This communication can include presenting infection rates to physicians, educating nurses about the different types of isolation, or being a stakeholder in a facility’s design and construction project.

Schools of public health also prepare future infection preventionists to learn the basics of epidemiological investigations, calculate and interpret critical data, and find and utilize relevant scientific literature. Through my experience as a student, I felt prepared to investigate my first outbreak when I started my first role as an IP and how to organize the data strategically. Cluster and outbreak investigations are unique features in public health programs. Public health programs also educate students on driving individual, interpersonal, and organizational change, essential for infection preventionists when introducing new products in a facility, drafting policies, and more.

Lamphier in 2023 at Moffitt Cancer Center

I express immense gratitude to the nurses and other professionals who have provided invaluable clinical assistance and understanding in my journey in infection prevention. I also appreciate those who listened attentively to my voice and professional opinion and embraced my diverse background without hesitation. I acknowledge the potential challenges associated with witnessing someone from a different background entering a field that has been traditionally nurse-driven. I plan to continue to be an advocate for the inclusion of public health graduates in the field of infection prevention and control.

The future infection prevention and control pathway is inclusive and invites master of public health graduates and other degrees besides nursing to enter this evolving field.


Embarking on the Infection Preventionist Role: The Path of an MPH Graduate

SHARON WARD-FORE, MS, MT(ASCP), CIC, FAPIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

According to the Surgical Site Infection Guidelines published in 2017 by the American College of Surgeons and Surgical Infection Society, the most common and costly type of health care–associated infections (HAIs) are surgical site infections (SSIs), accounting for 20% of all HAIs. SSIs occur in an estimated 2% to 5% of patients undergoing inpatient surgery and up to 25% of major surgical procedures.

 Annual incidence of SSIs in the United States is between 160,000 and 300,000, costing from $3.5 billion to $10 billion annually. On average, an SSI increases a patient’s length of stay by 9.7 days, yet approximately half of all SSIs are preventable when evidence-based prevention strategies are implemented.

Infection preventionists (IPs) are vital in supporting the perioperative team by sharing the most current, evidence-based surgical infection prevention strategies to help improve SSI prevention. The operating room (OR) is a challenging environment, with various surgical personnel and medical devices coming together to help improve patients’ lives. Covering surgical services as a novice or even a seasoned IP can be intimidating. In addition to the basic environment of care items, the OR has unique infection prevention challenges. Surgical attire, or OR scrubs (the special surgical clothing required for personnel within the OR suite), is intended to promote cleanliness and reduce microbial contamination in the surgical suite to prevent SSIs.

The human body is a significant source of bacterial contamination in the surgical environment. SSIs have been traced to bacteria from surgical personnel’s hair, scalp, and skin.

 However, maintaining a clean surgical space and reducing microbial contamination wasn’t always a consideration. Through the timeline of surgical attire (

), one can begin to see the development of a better understanding of infection and organism transmission through the changes in clothing.

Surgical attire was initially known as surgical greens because of their color, then were later referred to as scrubs because they’re worn in a scrubbed environment. In 1894, Dr Hunter Robber said, “It is safer and better that all should put on a complete change of costume rather than simply don a sterilized coat and pair of trousers over ordinary clothing.”

 He also suggested that the clothing be made white so they could easily be washed.

When electricity was discovered and electric lights were used in the OR instead of windows and skylights, the combination of bright lights and white attire led to significant glare. “There was a green ghosting effect when shifting gaze from bloody red innards to white backgrounds,” Hunter said.

In 1914, Harry Sherman, MD, FACS, believed that a color scheme might evolve from the red of blood and tissues. He recommended green, a color “less wearisome to the eyes, and [one that] minimized reflection.” He also said green “keeps the surgeon’s eye acute to red and pink.”

 Sky blue became popular for surgical apparel in the 1950s when color television began to be used for videotaping and closed-circuit teaching.

 Today, our surgical scrubs are primarily jade green or misty blue, depending on the vendor’s name given to the color.

Surgical attire has come a long way, but it is—and will probably always be—a hot-button issue due to the variety of organizations and agencies providing input as well as the difficulty of creating and enforcing policies designed for patient and staff safety. The guidance and recommendations are plentiful, which is why it’s vital for IPs covering the OR and the perioperative team to know what the surgical attire policies are as well as the sources used to develop them. Some of the regulatory agencies and professional organizations that have provided recommendations, guidelines, or position statements include the following:

Association of periOperative Registered Nurses (AORN)

Centers for Medicare & Medicaid Services (CMS)

Occupational Health and Safety Administration

Association for Professionals in Infection Control and Epidemiology



To further complicate the surgical attire issue, some states have established their own surgical attire dress code requirements or have adopted a version of AORN or other guidelines. Your local health department may also have further information about state-specific surgical attire requirements, so be sure to contact them as you develop your surgical attire policy.

If your health care facility participates in the CMS programs, you’ll need to follow their surgical attire requirements to be in compliance. They have their own Hospital Infection Control Survey Worksheet that includes a section on surgical procedures with specific surgical attire elements to be assessed by surveyors.6 You’ll need to follow these or risk getting cited. In some instances, they do differ from AORN. Some medical devices and equipment also include manufacturer instructions for use (MIFU) that require wearing specific surgical attire. Check those devices and equipment MIFUs carefully.

Ensure your health care facility’s surgical attire policy complies with the state and local agencies, MIFU, and CMS (if applicable). If none of these are relevant, then the health care facility’s chosen surgical attire, evidence-based guidelines, and consensus statements can be used to develop policies. If your health care facility does not have specific state or local surgical attire requirements, does not have MIFUs that mandate specific surgical attire, is not a CMS participant, and a Joint Commission standard does not explicitly require your facility, then you can choose which evidence-based guidelines or consensus statements to develop your surgical attire policies.

 Surveyors, like The Joint Commission, will survey your specific surgical attire policy. As you know, they don’t make the policy; they confirm that you are following your surgical attire policy.

Most facilities follow AORN’s surgical attire guidelines or incorporate parts of them into their facility-specific surgical attire policies. AORN recently updated the 2015 guidelines on surgical attire in 2019, published in 2020. IPs, including me, have struggled with issues that are addressed in these updated guidelines, including head coverings, arm coverings, beards, shoes, and scrubs outside the surgical suite. What’s not discussed in AORN’s 2020 surgical attire guidelines are patient clothing or linens used in the OR, masks as personal protective equipment, and the use of masks at the sterile field. If you want this information, refer to the AORN Guideline for Sterile Technique

 and the AORN Guideline for Transmission-Based Precautions.

addresses wearing rings, bracelets, watches, nail polish, artificial nails, and other nail treatments.

The rationale for AORN’s 2020 Guideline for Surgical Attire

 includes recommendations for selecting, wearing, and cleaning surgical attire. They are based on the highest-quality evidence available. Recommendations are rated as regulatory requirement, recommendation, conditional recommendation, or no recommendation. These categories are based on the level of evidence, an assessment of the benefits vs harms of implementing specific interventions, and consideration of resources required to implement the interventions

Regulatory requirement: Perioperative team members must implement the recommendation.

Recommendation: Perioperative team members should implement the recommendation unless there is a clear and compelling rationale for an alternative approach.

Conditional recommendation: Perioperative team members may implement the intervention, although the degree of implementation may vary depending on the benefit-harm assessment for the specific setting.

No recommendation: Perioperative team members will need to evaluate whether to implement the practice issue.

AORN states that the guidelines’ recommendations are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the “many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.”

 AORN recognizes that one size does not fit all, and not every organization or professional specialty will use or agree with these guidelines. However, the document does provide evidence-based guidance on surgical attire that can serve as a credible resource to help health care facilities develop perioperative policies and procedures while also considering guidance from professional organizations, state and local agencies, MIFU, and CMS (if applicable).

Development of policies and procedures for surgical attire should be a team sport, ensuring input from all the disciplines (eg surgeons, anesthesia, nursing, infection prevention, environmental services, sterile processing, nurse educator) that contribute to providing quality patient care based on the most up-to-date, evidence-based best practices, with SSI prevention at top of mind.

Human bodies, especially surgical personnel's hair, scalp, and skin, are a major source of bacterial contamination in the surgical environment and a major cause of SSIs. Yet, not it hasn't always been a consideration.

Surgical Attire: Policy Development Resources

 which features infection prevention and control professionals at all levels speaking with each other, giving best practices, and telling stories of what has worked—and not worked—for them in their facilities. 

Do you have a best practice to share? A question you need answering? Or have an answer to the weekly question?  If so, please send them to tmartonicz@mjhlifesciences.com and help out those in the IPC community. 

Next week: Do you have an answer to "How do you help others in your facility to remember infection prevention and control requirements that they consistently seem to forget?"

“We are never getting rid of these masks, are we?” a nurse on the rehab wing asked me as I passed through the nurse’s station. I had heard the question numerous times and still did not know the answer. The staff—and patients—wanted our facility to go back to normal.

A few weeks later, the conversation on unmasking finally happened. Our Director of Nursing broached the subject of unmasking. She discussed that all counties in the state had been in moderate community transmission for a few weeks, and the numbers in the state had been good. She questioned if this was the time to do it. As the infection preventionist, my initial gut response was ‘NO! We need our masks.' The reality of the situation said if we are ever going to try it, now is the time to do it.

Once the decision was made to unmask, the question became, how do we do it? I knew that doing it wrong could lead to chaos! What I learned is that the key to successfully unmasking is staff education.

The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

 in the Sept. 27, 2022, update lays out the guidelines for when masks can be removed in health care settings. That is the easy part. Once the masks are off, the risk increases for COVID-19 outbreaks, so we must ensure we are taking all possible precautions. This is where staff education comes into play.

The staff needs to understand that not wearing masks is a privilege. As with all privileges, this one comes with great responsibility. The responsibilities that come along with no masks in a long-term care facility are self-reporting exposures to COVID-19, self-reporting illness, and masking during periods of illness and exposure.

Education should include what situations would require the facility to return to mandatory masking and how that will be communicated to staff and visitors. Ensure the team understands that you, as the IP, will expect 100% compliance when such situations occur. A reminder that in the future, when they are asked to mask it, it will be for a reason (ie outbreak, high COVID-19 levels, etc.) can be helpful.

When educating staff, I recommend taking the time to speak to staff one on one or in small groups. This allows you to make sure they understand what you expect from them.

My facility was unmasked on March 16, 2023. It has been several weeks, and things have been going great. The staff is happy, and the residents are pleased to see their caregivers' faces. When we had an exposure that required one floor to be put back in masks during exposure testing. The staff was adherent with no pushback. The reality of no masks is that, eventually, there will be an outbreak. But we had outbreaks with our masks on too. So, in the end, it was worth taking the chance to get back to this little bit of normal.

In the first of this new series, IPC Pros Helping Each Other: When is the right time to unmask in long-term care? One IP explains how she and her facility unmasked and what led to their decision.

 IPC PROs Helping Each Other: When to Unmask a Long-term Care Facility 

is the physician executive who leads the Medical Information Team at epocrates. After training in internal medicine, pulmonary, and critical care specialties, she worked in health care policy before joining the epocrates team in 2006. Her team creates and curates clinical decision support tools for the moments of care.

“Take these pills for 10 days, even if you feel better sooner.” I vividly recall how, in years past, I would impress upon patients the importance of completing an entirely long antibiotic course. My mind’s eye beheld the specter of a half-treated infection raging back in fuller force and powered by newly resistant organisms. Now we know better: The shortest effective course is the way to reduce the risk of patient adverse drug events, antimicrobial resistance, and unnecessary health care costs.

According to the CDC, clinicians prescribed 211 million outpatient antibiotic prescriptions in 2021, which is equivalent to 636 prescriptions for every 1000 individuals, though prescribing rates varied widely by state.

 Once an antibiotic prescription is started, every additional day of use holds the potential for the added risk of adverse events (AEs) for the patient. A study of inpatients with pneumonia

 revealed that antibiotics prescribed at discharge were often excessive in duration, and that each day of excess treatment was linked to a 5% increase in antibiotic-related AEs. Although some AEs, such as anaphylaxis, occur early in a treatment course regardless of intended duration, the risk for AEs, such as hepatotoxicity, nephrotoxicity, and some gastrointestinal effects, changes to the microbiome, and specific drug interactions, can compound over time.

Each additional day of antibiotic exposure also holds the potential to contribute to the emergence of antimicrobial resistance in the patient’s community. More prolonged exposure affords more opportunities for resistance to develop and for natural selection to favor resistant organisms that can then spread to new hosts. Drug-specific pharmacokinetics are also a factor in considering course duration. For example, the elimination half-life for a drug like azithromycin is significantly longer than some other antibiotics so that appropriate courses may be shorter.

New data on the noninferiority of shorter courses emerge yearly for common infections like pneumonia, sinusitis, urinary tract infection, and cellulitis. In 2021, the American College of Physicians

recommended limiting antibiotic durations to 5 days for chronic obstructive pulmonary disease exacerbations and acute uncomplicated bronchitis. They also recommended 5 days for community-acquired pneumonia, considering an extension based on clinical signs.

It takes time for new evidence to translate into practice changes; the lag time between the “lab bench and the bedside” might average 17 years for health care interventions, per one estimate

 or a median duration of 10 days for most conditions studied. Investigators noted that typical durations exceeded those recommended in clinical practice guidelines available at that time, including excessively long courses for sinusitis, community-acquired pneumonia, cellulitis, and cystitis.

Duration of therapy isn’t the only vital component of antibiotic prescribing. The CDC estimates

 that up to half of outpatient antibiotic use is inappropriate in 1 or more ways, including inappropriate duration, dosing, antibiotic choice, as well as unnecessary use of an antibiotic in the first place. In choosing an antibiotic, prescribers are often encouraged to incorporate local antimicrobial resistance and susceptibility patterns into their decision-making. Historically, these data have been hard to find outside the hospital setting. The new Bugs + Drugs feature in the epocrates mobile app offers free geolocalized ambulatory setting antimicrobial susceptibility data on urinary and skin/soft-tissue organisms centered on any zip code in the US.

Indeed, some patients with underlying conditions or other clinical factors may warrant a longer duration of antibiotics. However, long durations—regardless of patient characteristics, infection type, specific antibiotic, and local resistance patterns—are no longer supported by recent evidence. The CDC and major specialty societies concur that the shortest effective antibiotic duration is the one that provides the best outcome for patients and their communities. Reduced AEs translate into reduced unnecessary health care costs. It’s not always the case that a single change in how we practice can benefit individuals and society; this is one of those changes where incentives are well aligned. It’s no wonder that the refrain of “shorter is better” is increasingly inspiring changes to antibiotic prescribing in both inpatient and outpatient settings.

This article is intended for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

Outpatient antibiotic prescriptions — United States, 2020 | antibiotic use | CDC. Published October 24, 2022. Accessed April 14, 2023. https://www.cdc.gov/antibiotic-use/data/report-2021.html

Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. 

. 2019;171(3):153-163. doi:10.7326/M18-3640

Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. 

. 2021;174(6):822-827. doi:10.7326/M20-7355

Rice LB. The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and clostridium difficile. 

Measuring outpatient antibiotic prescribing. CDC. Reviewed October 5, 2022. Accessed April 5, 2023. 

https://www.cdc.gov/antibiotic-use/data/outpatient-prescribing/index.html

Is it truly beneficial to prescribe longer courses of antibiotics?

The Duration of Antibiotics:  Why Short Is Good in the Long Run 

REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

(Adobe Stock 93777242 by Bits and Splits)

Antimicrobial resistance (AMR) is a global public health concern impacting personal and population health levels. Increases in AMR have led to the emergence of multidrug-resistant organisms (MDROs), where once an antibiotic could kill or render the pathogen ineffective, now the antibiotic has little to no impact on the infection’s clinical course. This leads to increased morbidity and mortality in humans, but the full impact is still unknown for the global public health environment.

In 2019, an estimated 2.8 million MDRO-related infections occurred in the United States, resulting in 38,000 deaths.

 Additionally, the annual costs of treating MDRO infections exceed $4.6 billion.

 At the local level, infection preventionists see the impacts of AMR daily. Patients with MDRO infections often have higher acuity with more severe illness, requiring extensive treatment methods and additional resources dedicated by the health care treatment team (eg, personal protective equipment usage, dedicated equipment, and enhanced precautions). They also often result in poorer outcomes. Isolation precautions are one infection control tool to decrease the risk of cross-transmission of MDROs in health care facilities. However, the prevention of the development of additional MDROs in health care facilities frequently falls under the work of the antimicrobial stewardship program (ASP).

Policy development is needed to address increasing AMR at regional and national levels. This can be accomplished with local-level policy changes to enhance and support ASP initiatives and to work with regional policy makers to push policy at a more significant community level.

The inappropriate use of antibiotics has long been a public health concern, from the emergence of methicillin-resistant Staphylococcus aureus as a significant health care–associated infection in the 1990s to the current concerns with MDR gram-negative organisms and fungal pathogens (eg, 

). Antimicrobial stewardship efforts are a driving force in preventing the continued practices resulting in the evolution of resistance in these organisms.

Although AMR in microorganisms has developed due to inappropriate clinical use, extensive agricultural use and wastewater runoff have also contributed to the more significant environmental burden.

 One Health is a scientific concept where the interconnections between humans, animals, and the environment all impact community health and well-being.

 From a One Health perspective, the key factors influencing AMR globally are inappropriate antibiotic use in humans and animals, environmental contamination, and poor infection prevention practices.

 One Health focuses on understanding AMR through several methods: surveillance and reporting of AMR, following the epidemiology of MDR pathogens, understanding the impacts on human and animal health, and developing policy and process changes to decrease the risks of AMR.

Animal and agricultural use of antibiotics tends to have a broader use for prophylactic purposes and usage without clinical or therapeutic relevance. Broad-based usage as a preventive for livestock and animal populations has led to misuse and overuse related to increased resistance. In humans, prophylactic use of antibiotics is more limited, which is often due to exposure to communicable diseases or high-risk patients undergoing procedures. However, even with these stricter guidelines, inappropriate use of antibiotics is common in humans.

Other practices that impact the global incidence of MDR pathogens include food production and distribution, international travel (including medical tourism), climate change, and lack of sanitation and environmental hygiene. A more holistic approach can be appreciated as we apply these One Health concepts to local infection prevention and ASP initiatives.

The Joint Commission and other regulatory bodies have developed guidance for various aspects of antimicrobial stewardship activities in health care facilities. In January 2023, The Joint Commission updated the standards to include 12 elements of performance. These elements include ensuring the dedication of resources to ASP efforts, having multidisciplinary involvement in the program, data collection on specified metrics and reporting to the facility leadership, addressing prescribing practices for common clinical indications, and demonstrating implementation of action plans to improve performance.

Similarly, the Centers for Medicare & Medicaid Services (CMS) has included ASP activities in the health care facility Conditions of Participation.

 Additionally, starting in January 2024, reporting of antibiotic use and antibiotic-resistance data will be included in the CMS Promoting Interoperability (formerly titled Meaningful Use) Program for health care facilities.

 A key component of all these requirements is that infection prevention collaborate with ASPs and actively work with stakeholders to perform surveillance reporting, analyze and interpret data, and implement evidence-based practices.

Infection preventionists should be tightly aligned with their facility’s ASP. Inappropriate antibiotic use can take the form of a mismatch of antibiotic to the pathogen, incomplete courses of antibiotics, overuse of antibiotics for colonization or nonbacterial infections, and prolonged courses of antibiotics. ASPs are accountable for addressing these issues and others. Infection prevention and ASP are 2 arms of the same preventive body, impacting patient safety and outcomes. As ASPs evolved in health care, the role of the infection preventionist has not always been well understood, as it often varies based on local levels of support and resources. Some programs have infection preventionists reporting data or statistics on pathogens of interest and MDROs, whereas others may be more intimately involved in developing policy, interventions, education, and strategic plans to advance the ASP agenda.

A standard methodology for ASP and infection prevention programs to work together is diagnostic stewardship initiatives. Diagnostic stewardship includes using microbial diagnostic tests to direct the most appropriate therapeutic interventions. These initiatives ensure patients are diagnosed accurately and are treated with the most appropriate antibiotic for the infection. Examples of diagnostic stewardship initiatives include developing criteria for proper testing of patients for urinary tract infections, bloodstream infections, and 

 infections. Laboratory tests can be optimized to help identify colonization vs active disease, as has been developed for 

 with a 2-step process where an initial highly sensitive test is used first to cast a broad net, followed by a more specific toxin-based test to narrow the diagnostics.

Policy development is needed to address increasing AMR at regional and national levels. This can be accomplished with local-level policy changes to enhance and support ASP initiatives and to work with regional policy makers to push policy at a more significant community level. Continued attention by regulatory bodies will help drive the adoption of best practices for ASPs. Similarly, tying reimbursement and financial penalties to reporting efforts highlights health care leaders’ importance in increasing resource allocation and support for ASP activities.

To effectively treat patients who have infections caused by MDROs, the development of new classes and types of antibiotics must be prioritized. Antibiotic development is traditionally not a moneymaker for pharmaceutical companies; therefore, developing new ones is a low priority for drug development. Recently, 230 organizations, health care leaders, public health agencies, and industry representatives have petitioned US Congress to support the Pioneering Antimicrobial Subscriptions To End Up surging Resistance (PASTEUR) Act.

 The PASTEUR Act will incentivize the production of novel antimicrobial agents to offer treatment options for patients and ensure appropriate use requirements, thereby decreasing the risk of escalating AMR.

As the relationship between infection prevention and ASP grows, infection preventionists are key stakeholders in the battle against the rise of MDROs and AMR. The collaboration between the programs is a natural fit, with many parallel goals. The infection preventionist can bring preventive and MDRO mitigation strategies, public health guidance, and biopreparedness formats to the ASP initiatives. Additionally, both programs can look to the One Health concept as an example of how to have a more holistic view of AMR prevention. The environmental impacts of AMR are connected to the community and individual health of patients. The link between facility-level ASP efforts and the more significant global health outcomes can be seen in tactics such as effective surveillance, understanding the epidemiology and emerging MDROs, and diagnostic stewardship. Through these collaborative efforts, the rate of development of AMR and MDROs will decline, and overall patient outcomes and community health will improve.

Antibiotics no longer work against many infections due to MDROs, causing more illness and death. What is antimicrobial resistance (AMR) doing to the environment? 

Exploring the Environmental Impact of Antibiotic Overuse

has 20 years of experience in infection prevention and health care quality. She is the director of infection prevention for Mercy, a multistate health care system, including more than 40 acute care, managed, and specialty hospitals.


 is the manager for infection prevention for Mercy Hospital St Louis, an 859-bed comprehensive health care facility in Missouri.

Proper hand hygiene significantly impacts health care–acquired infections (HAIs), and monitoring completion is essential to improving performance.

Some hospitals invest in electronic monitoring systems (EMSs) to alleviate concerns about traditional in-person observation methods.

 Recognizing the importance of hand hygiene and accurate data to demonstrate actual performance with efforts around quality improvement, Mercy health care system leadership implemented Clean Hands Safe Hands LLC (an EMS headquartered in Atlanta, Georgia) in 2019. The EMS was implemented house-wide in 12 acute care hospitals (> 4000 licensed beds in 26 units), including Missouri, Oklahoma, and Arkansas facilities between 2020 and 2021.

Sensor on the Side of Alcohol Foam Dispenser Communicates With Magnet Inside the Dispenser

The EMS uses a personalized badging system to identify hand hygiene adherence down to the individual health care provider (HCP) level.

 Each HCP is issued a badge holder/reel with Bluetooth technology to communicate with sensors placed in the alcohol foam and soap dispensers (

). Additional sensors (motion sensors) are placed at the door of all patient care rooms. The EMS correlates a room entry/exit with an HCP badge and interaction with a hand hygiene dispenser (sanitizer or soap) immediately before or after the entry/exit. An audible alert sounds as a reminder if a hand hygiene event is not detected within a defined time. Cloud-based technology gathers all data points, with almost real-time results available through the EMS computer program platform.

There are 2 critical areas where the EMS offered benefits to Mercy: data availability and process improvement. There was a dramatic increase in the overall number of hand hygiene observations completed, allowing observation at all times of the day or night and removing the biases of the in-person observation process. The computer system associated with the EMS was crucial in transitioning those data into useful information. Real-time feedback and adherence trending was available to unit leaders and coworkers by logging into the system. Still, there were also automated emails of results sent to many HCPs, and the data helped fuel healthy competition between individual HCPs or patient care units/departments. Information was available in general adherence reports, as well as advanced graphics that could identify HCPs or certain rooms with higher and lower performance (

Examples of Advanced Reporting Functionality by the EMS* 

(Bubble Plots that Signal HCP* by Number of Observations and Performance; Blueprints Signal Rooms by Number of Opportunities and Performance)

*EMS is emergency medical services, and HCP is health care personnel.

One key to improving hand hygiene was the audible alert when a hand hygiene event was not captured, which served as a reminder to the HCP and offered the unexpected benefit of improving the impression of patients about commitment to safety. Upon hearing the reminder, if staff cleaned their hands, they were given credit for proper hand hygiene by the EMS. Based on the results, the increased conversations around hand hygiene from bedside staff to senior leadership further drove process improvement. Workflow optimization and reduction of unnecessary steps necessitating additional hand hygiene were realized. Overall, continual process improvement activities resulted in a 26% increase in hand hygiene performance, from 50% at baseline to 76%, in 1.5 years. Current hand hygiene performance is averaging 84% across the health system.

There were some limitations to using an EMS, and some of them were unexpected. The primary drawback was a higher-than-expected amount of daily work for infection preventionists and other staff charged with maintenance, which is well described elsewhere.

 Continued education was needed to explain how the system worked, which the EMS personnel assisted with via training and resources. HCPs were required to wear a badge to be monitored, and some individuals avoided the system by not wearing their assigned badge. Breakage of the badges, sensors, or sanitizer dispensers was common.

The design of this EMS resulted in inherent “noise” in the system or some incorrect estimation of adherence, which led to initial mistrust of the system. The motion sensors were better at detecting entry/exit of 1 HCP but not as good at detecting groups and busy units, areas with sliding doors and curtains, and small patient rooms. Because of this, workarounds were created to appease the system, including hand hygiene dispenses where the product was not used on the hands. HCPs who strive for perfection are not able to attain that. Overall, there were challenges to belief in results and the ability of the EMS to impact hand hygiene performance, some of which were rectified over time.

Despite some disadvantages, Mercy found value in the EMS, most prominently the organizational efforts to implement and improve performance. Implementing a system was key to understanding that the results from the manual observation process were flawed. The large quantity of data allowed attention to be brought to procedures followed by entire departments that required consultation from infection preventionists to ensure patient safety was maintained.

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articles

Hand hygiene requirements for inpatient health care are numerous and varied. An electronic system to help monitor adherence with some indications benefits the hospital, although it may also introduce some drawbacks.

The Advantages and Disadvantages  of Using a Hand Hygiene Monitoring System

This article first appeared on our sister publication, 

The FDA has approved Innoviva’s antibiotic, sulbactam-durlobactam (Xacduro), for the treatment of hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) caused by 

The antibiotic is an intravenous drug that combines sulbactam, a beta-lactam antibacterial, and durlobactam, a beta-lactamase inhibitor.

“The FDA is dedicated to supporting the development of safe and effective treatment options for infections caused by difficult-to-treat bacteria like 

 complex,” said Peter Kim, MD, MS, director of the Division of Anti-Infectives in the FDA’s Center for Drug Evaluation and Research. “Today’s approval helps address a high unmet medical need by providing an additional treatment option for some of the sickest patients in our nation’s hospitals.”

In April, the FDA’s Antimicrobial Drugs Advisory Committee (AMDAC) 


Data from the pivotal phase 3 ATTACK trial were recently published in 

. Sulbactam-durlobactam demonstrated statistical non-inferiority versus colistin for the primary endpoint of 28-day all-cause mortality in patients with carbapenem-resistant 

and demonstrated a significant difference in clinical cure rates.

For the study, 181 patients were randomly assigned to sulbactam–durlobactam or colistin. There were 176 hospital-acquired bacterial pneumonia, ventilator-associated bacterial pneumonia, or ventilated pneumonia cases, and 5 bloodstream infections.

Of these, 125 participants were confirmed with laboratory-confirmed carbapenem-resistant ABC isolates included in the primary efficacy analysis. 28-day all-cause mortality was 12 (19%) of 63 in the sulbactam–durlobactam group and 20 (32%) of 62 in the colistin group, a difference of –13·2% (95% CI –30·0 to 3·5), which met criteria for non-inferiority.

“The safety and efficacy demonstrated during the phase 3 ATTACK trial by sulbactam-durlobactam, which was designed specifically for treating serious infections caused by 

, are very promising and provide hope that we’ll have a novel, desperately needed, effective treatment option against this lethal pathogen,” said Keith Kaye, MD, MPH, chief, Division of Allergy, Immunology and Infectious Diseases at Rutgers Robert Wood Johnson Medical School.

Sulbactam-durlobactam also exhibited a favorable safety profile with a statistically significant lower incidence of nephrotoxicity as measured by modified Risk–Injury–Failure–Loss and End-stage kidney disease (RIFLE) criteria. "Incidence of nephrotoxicity was significantly (

 <.001) lower with sulbactam–durlobactam than colistin (12 [13%] of 91 

 32 [38%] of 85),” the investigators wrote.



Trade name Xacduro is an antibiotic meant to treat hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) caused by Acinetobacter baumannii.
