OR WAIT null SECS
By Luci Perri, RN, MSN, MPH, CIC, FAPIC
During his Nobel Prize acceptance speech, Alexander Fleming spoke of the potential organisms to develop resistance to penicillin due to overuse and under dosing. Almost like an eerie prediction since Fleming’s Nobel Prize lecture in 1945, we have seen antimicrobial resistance evolve slowly to what now seems like lightning-speed. By the 1990’s, methicillin resistant Staph aureus (MRSA) became commonplace in hospitals and the community. Vancomycin resistant enterococcus (VRE) emerged around the same time as MRSA. Extended-spectrum beta-lactamases (ESBLs) appeared on the scene in the late 1980s, although third-generation cephalosporins (e.g. ceftazidime, ceftriaxone) had only been introduced about nine years earlier. The increased reliance on carbapenems (e.g. doripenem, imipenem) from 2002-2006 resulted in the development of carbapenem resistant Enterobacteriaceae (CRE). According to the 2010 National Healthcare Safety Network report, 12 percent of the Klebsiella pneumoniae isolates were resistant to carbapenems. Most recently, cases of resistant Candida auris have been reported in the U.S. and some strains are resistant to the three major classes of antifungals.
Resistant organisms contribute to over 2 million healthcare associated infections and 23,000 deaths per year in the U. S. Another 250,000 people develop Clostridium difficile infections and 14,000 die every year. These numbers most likely underestimate the occurrence and effects of resistant organisms due to the reporting mechanisms. Multidrug-resistant organisms increase length of stay, add approximately $20 billion per year to healthcare expenditures, and at substantial human costs (e.g. time lost from work and family roles, long lasting debility). Increasing antimicrobial resistance is so concerning that the Centers for Disease Control and Prevention (CDC) prioritized resistant organisms in 2013. Clostridium difficile and CREs are among the urgent threat organisms while MRSA, VRE, and ESBLs are some of the organisms considered a high threat. Antimicrobial resistance has been a mounting public health concern and in 2015, the National Action Plan for Combating Antibiotic-Resistant Bacteria was published. The first goal of this plan is “Slow the Emergence of Resistant Bacteria and Prevent the Spread of Resistant Infections.” This goal encompasses antimicrobial stewardship and the directive for the Centers for Medicare and Medicaid Services (CMS) to develop an antimicrobial stewardship standard that reflects the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs. Potentially, the shape of the future may be seen in the current CMS Infection Control Worksheet, which contains language related to AMSPs (1C: Systems to Prevent Transmission of MDROs and Promote Antimicrobial Stewardship) since the indicators in these standards are evidence based and recommended by an expert panel, including the CDC.
Nationally, about 48.1 percent of hospitals have an active antimicrobial stewardship program, despite the call to action from several sources over the years (primarily IDSA, SHEA, and PIDS). The first recommendation in the Society for Healthcare Epidemiology of America (SHEA), Infectious Disease Society of America (IDSA) and Pediatric Infectious Disease Society (PIDS) Antimicrobial Stewardship policy is for mandatory antimicrobial stewardship programs (ASP) through CMS for all participating healthcare facilities. In June 2016, CMS published a proposed change to the Infection Control Conditions of Participation for hospitals and critical access hospitals. Briefly, this proposed change rolled antimicrobial stewardship requirements into the Infection Control standard (482.82), although the proposed regulation clearly states that the antimicrobial stewardship leader should be a pharmacist or physician since infection preventionists typically don’t prescribe medications. This change to the Conditions of Participation (CoP) is expected to take effect in late 2017 or early 2018. The Joint Commission’s antimicrobial stewardship standard, MM.09.01.01, became effective in January 2017. It appears the age of mandated antimicrobial stewardship is upon us. Since TJC, CMS, and CDC all indicate participation of the infection preventionists is extremely important to the success of the AMSP, how can this be accomplished without becoming overwhelmed?
The role of the IP
Obtaining facility leadership support is a key element in the success of the ASP. Infection preventionists can assist to develop the proposal by furnishing facility specific healthcare associated infection data for the proposal. From the infection prevention perspective, a desired outcome of the ASP is to reduce C difficile and multi-drug resistant organism (MDRO) infections. A key element of C-suite interest in the ASP is improving throughput: freeing beds for admissions by decreasing length of stay related to MDRO infections. Be sure to include infection preventionist time in the proposal since participation in the program is included in the CDC Core Elements document, mandated by TJC, and in the CMS proposed regulation.
Surveillance, data collection, analysis and presentation to various audiences are the strong suit in the infection preventionist’s toolbox. Other team members such as physicians and pharmacists are not as experienced in this skillset. Therefore, infection preventionists can assist the ASP leader and other team members with data analysis and presentation designed for the intended audience.
Surveillance undeniably involves reviewing clinical culture results. Notify the pharmacist or other appropriate team member of any antibiotic susceptibilities/prescribed antibiotic mismatches. Since infection preventionists spend a fair amount of time reviewing microbiology results, notify the ASP Team Leader or other appropriate team member (e.g. Pharmacist) of any unusual resistance patterns or organisms that are noted during surveillance. MDRO surveillance data can be provided to the ASP team as an outcome measure of success.
Work in partnership with the department that is assigned the responsibility of producing the antibiogram to ensure it is developed and published in a timely manner so it is meaningful to clinicians. If the antibiogram is developed six months before it is published, it may not be viewed as a credible resource by Providers. The antibiogram should be easily accessible to clinicians or it won’t be used. After developing a game plan to ensure accessibility, help to ‘spread the word’ to providers when the antibiogram is available to help guide clinical decisions.
While rounding, speak with nursing services personnel to get them on board since the traditional focus of an ASP is usually providers and pharmacists. However, since nurses recommend and collect cultures based on the patient’s signs and symptoms, front-line staff can be a great asset to the goal of the ASP. Assist nurses to identify when a culture may not be needed (e.g. does the patient have an infection?) and how to approach the ordering provider to discuss their concerns. Listen to the concerns of bedside nurses as well and take the opportunity to educate when needed. For example, some nurses may not be comfortable reviewing organism susceptibilities.
Additionally, many infection preventionists round with a clinical team regularly, such as in the ICU. From the ASP perspective, one advantage to this type of rounds is being able to hear the plan of care first-hand, which lends itself to prompting questions about lines, catheters, and antibiotic use. If at first, this seems uncomfortable, practice a conversation with an ally, to allay any concerns or fears. Perhaps a good way to start the conversation is to ask for clarification of a concerning proposed plan.
Some experts recommend starting an ASP with something small but important, particularly if an ASP is viewed as something that is ‘done to’ clinical staff rather than as a collaborative endeavor. A quick review of the infection prevention risk assessment and annual plan will provide some direction for a targeted approach. For example, if C. difficile is a concern, work with the ASP team to create a plan that includes the best evidence based practice to support the goal. Include actions for nursing services personnel such as prompt isolation of patients with diarrhea not attributed to medications or chronic conditions. Since treatment of asymptomatic bacteriuria is a major contributor to antibiotic misuse and can increase asymptomatic urinary tract infection surveillance findings, the infection preventionist can collaborate with Nursing staff to decrease urine culture collection. This change would be beneficial to all involved. The infection preventionist can also develop education related to these initiatives that is appropriate to both Providers and staff that can be included in training upon hire or credentialing and on-going instruction.
Don’t forget about the other strategies contained in the annual plan that contribute to safe patient care such as hand hygiene, timely initiation of appropriate transmission based precautions, personal protective equipment (PPE) worn in the isolation room, environmental cleaning and disinfection, and disinfection of patient care equipment. These actions also contribute to controlling the spread of MDROs and are an important aspect of the ASP.
Equally as important are what may be considered the gamut of ‘normal’ infection prevention activities such as HAI surveillance and observing practice to ensure it corresponds to policy and guidelines. While it may be more glamorous to be able to report decreased HAIs (outcome measure) due to the ASP, realistically, outcomes may take a while to respond to changes in antibiotic prescribing, particularly if the facility has relatively low rates. However, changes in practice (process measures) may provide a more realistic reporting statistic, since changes in practice may occur more rapidly than actual numbers of infections. Practice modifications contribute to the overall success of the ASP, which is to prevent the increase of resistant organisms.
At some point, the ASP will most likely develop clinical algorithms, craft order sets, or design order entry to limit antibiotic use. These opportunities permit the infection preventionist to contribute to the team’s efforts and that these endeavors are consistent with infection prevention principles and practice.
Another way to contribute to the ASP team is to register with the health department to receive outbreak alerts for the local area and geographic region. This will benefit the entire team to know in advance what pathogenic organisms patients may bring into the facility so a feasible plan of action, including appropriate antibiotics, can be developed before patients (and pathogens) arrive.
In summary, increasing antimicrobial resistance is a national public health concern that has sparked a national initiative. ASPs will most likely be federally mandated in late 2017 or possibly early 2018. TJC included ASPs in their standards which became effective in January 2017. No doubt other accrediting agencies will soon follow their lead, particularly those with (CMS) deeming authority.
The infection preventionist is an integral part of the ASP although how to operationalize the role may seem overwhelming. The following briefly summarizes how infection preventionists can contribute to the ASP:
1. Provide healthcare associated infection data for the ASP proposal to garner C-Suite support.
2. Assist ASP team members with data analysis and (data) presentation
3. Partnering with the responsible department, work to ensure the antibiogram is published timely and accessible to providers
4. Get frontline staff on board, listen to their concerns, and help to address the issues
5. Educate nursing services personnel
6. Assist with and develop educational material for providers and staff
7. Observe practice while rounding
8. Round with the ICU teams to prevent inappropriate antibiotic use
9. Report HAI surveillance data (e.g. MDRO trends over time) and practice measures to the ASP team
10. Share health department outbreak alerts with the ASP team
11. Assist with the development of algorithms, order sets, or order entry criteria to decrease antibiotic use,
The infection preventionist possesses a unique skillset and can be a major contributor to the Antimicrobial Stewardship Program, without sacrificing basic infection prevention responsibilities. Lastly, there are some helpful implementation tools on the Agency for Healthcare Research and Quality website such as the “Toolkit to Reduce C. difficile Through Antimicrobial Stewardship” (https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/cdifftoolkit/cdiffover.html). Another good resource is the CMS Interpretive Guidelines, which will be published after the antimicrobial stewardship standard is finalized.
1. "Sir Alexander Fleming - Nobel Lecture: Penicillin". Nobelprize.org. Nobel Media AB 2014. http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.html. Accessed July 23, 2017.
2. Raygada, J. L., & Levine, D. P. (2009). Methicillin-Resistant Staphylococcus aureus: A Growing Risk in the Hospital and in the Community. American Health & Drug Benefits, 2(2), 86–95.
3. Cetinkaya, Y., Falk, P., & Mayhall, C. G. (2000). Vancomycin-Resistant Enterococci. Clinical Microbiology Reviews, 13(4), 686–707.
4. Paterson, D. L., & Bonomo, R. A. (2005). Extended-Spectrum ß-Lactamases: A Clinical Update. Clinical Microbiology Reviews, 18(4), 657–686. http://doi.org/10.1128/CMR.18.4.657-686.2005
5. Hidron, A., Edwards, J., Patel, J., Horan, T., Sievert, D., Pollock, D., & Fridkin, S. (2008). Antimicrobial-Resistant Pathogens Associated with Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infection Control & Hospital Epidemiology, 29(11), 996-1011. doi:10.1086/591861
6. Perez, F., & Van Duin, D. (2013). Carbapenem-resistant Enterobacteriaceae: A menace to our most vulnerable patients. Cleveland Clinic Journal of Medicine, 80(4), 225–233. http://doi.org/10.3949/ccjm.80a.12182
7. Chowdhary A, Sharma C, Meis JF (2017) Candida auris: A rapidly emerging cause of hospital-acquired multidrug-resistant fungal infections globally. PLoS Pathog 13(5): e1006290. https://doi.org/10.1371/journal.ppat.1006290. Published May 18, 2017. Accessed July 23, 2017
8. Centers for Disease Control and Prevention (CDC). Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed July 24, 2017.
9. Fishman, N. (2012). Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infection Control & Hospital Epidemiology, 33(4), 322-327. doi:10.1086/665010
10. The White House. National Strategy for Combating Antibiotic-Resistant Bacteria. Washington, D.C.: September 2014. Accessed July 23, 2017.
11. Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 482 and 485 [CMS–3295–P] RIN 0938–AS21 Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care. Federal Register. Proposed Rules. Thursday, June 16, 2016; 81(116).