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Priya Nori, MD: “The immediate thing that the health care industry has to grapple with, even as COVID hopefully starts to settle down after the mass vaccination campaign … [will be] superbugs.”
There will be a lot of work to do in terms of infection prevention and control after the coronavirus disease 2019 (COVID-19) subsides, says Priya Nori, MD, the medical director of the antimicrobial stewardship program at Montefiore Health System. Nori tells Infection Control Today® that infection preventionists will be needed more than ever, if for no other reason than to assist other hospital departments. “If COVID-19 taught us anything, it’s that infection prevention, stewardship, infectious diseases—these are not meant to be parallel tracks. They’re meant to be all part of one integrated family where everybody is doing something toward the greater good, which is the goal of preventing and controlling these outbreaks.” Nori—who was recently featured in an ICT® article by Jan Dyer about the “next pandemic” and the superbugs that will cause it—believes that hospitals will begin building career paths for health care professionals and others who want to move into infection prevention. She points to the recently passed $1.9 trillion stimulus bill, which includes more funding for testing—and testing is an essential ingredient of infection prevention. Nori’s also an unabashed fan of Rochelle Walensky, MD, the director of the Centers for Disease Control and Prevention, pointing to Walensky’s extensive background in infection prevention. Walensky, says Nori, “really gets it, and she gets us. She gets what we do. I cannot imagine a better advocate and ally at a national level….”
Infection Control Today®: COVID-19 was the focus of our health care system over the last year, as well it should have been. These bacterial pathogens—some of them superbugs—are still with us a need to be dealt with. They’re still going to be there after the pandemic leaves. So how do you see this playing out?
Priya Nori, MD: That’s a fantastic question. You started the segment by saying the next pandemic. In lots of ways, this pandemic of superbugs was the original pandemic of our modern times. And it will also continue to haunt us after the existing pandemic of COVID-19. And also, it’s likely to be augmented by everything that’s going on with COVID. In that there’s lots of antibiotic use happening in patients admitted with COVID-19. They’re having very long hospital stays, and on account of that, they are susceptible to a host of other bacteria, fungi, etc. They’re very much synergistic, these two pandemics. COVID-19 is definitely fueling a rise in these superbugs, as
you said. So, I think that the immediate thing that the health care industry has to grapple with, even as COVID hopefully starts to settle down after the mass vaccination campaign, is that we’re going to have a lot of superbugs to deal with in hospitals, outside of hospitals. And we have to pivot our attention back to this in many ways. We have to think about control and prevention, and also new therapeutics that we need to make available to treat these very resistant and refractory types of infections.
ICT®: Do you think there’s going to be more money going toward infection prevention and control?
Nori: I do. I’m optimistic about that and for a couple of important reasons. One is that in the stimulus bill, there are funds earmarked for things like increasing testing. Testing is a fundamental leg of infection prevention of COVID-19. We need to identify those cases early, and then isolate those cases in order to prevent large outbreaks and clusters. I’m very excited about the testing piece. That’s number one. Number two is that this administration is very ... evidence scientifically minded. The team of experts they’ve assembled is just out of this world in terms of scientific discovery and policy. And we are very optimistic that they are on the right side of things. They understand very much the importance of building a prevention-based infrastructure, in bolstering our existing expertise and personnel who will lead this effort in terms of prevention. And then lastly, I had mentioned in that article that the infectious disease community in particular is incredibly thrilled about the new CDC director. She is a woman who spent her years researching HIV, who was seeing patients for many years. Who knows what it is like to be on the front lines. She is an incredible advocate for not only infectious diseases, faculty members and physicians, but also future workforce trainees, allied professionals and pharmacy and infection prevention and nursing. And she really gets it, and she gets us. She gets what we do. I cannot imagine a better advocate and ally at a national level, very close to the administration.
ICT®: You’re an infectious disease specialist. You’re a doctor. Many of my readers comprise infection preventionists with a nursing background. What’s your advice about integrating infection preventionists into antimicrobial stewardship programs?
Nori: Fantastic question. Thank you for raising that. I see that infection prevention, pharmacy, infectious diseases; these are all very closely related, and we are all extensions of each other. A really, truly high-functioning hospital-based program that takes care of patients in the inpatient setting and in ambulatory practices, emergency departments, dental practices, urgent cares, etc., really involves a very close relationship between all these parties. We shouldn’t really see it as silos. If COVID-19 taught us anything, it’s that infection prevention, stewardship, infectious diseases—these are not meant to be parallel tracks. They’re meant to be all part of one integrated family where everybody is doing something toward the greater good, which is the goal of preventing and controlling these outbreaks. Whether that be a viral respiratory pandemic, or superbugs, there’s plenty to go around. Everybody’s needed. We need to take more of an all-hands-on-deck approach. Rather than saying, “OK, well, that pertains to stewardship, so I’m not going to touch that” or “That pertains to the regulatory aspects of HAI reporting. So, me as a steward, I’m not going to go there.” That’s not really…. We all have to be fluid. We all have to develop skills in each area. And we have to be able to support each other, and even cover each other when there’s lots of important work to be done.
ICT®: Have antimicrobial stewardship programs improved in the last seven or eight years in your mind?
Nori: They absolutely have. And this is because of lots of external support and internal support. There have been very forward-thinking policies and regulations at the federal level that not only emphasize the need for stewardship programs, but also mandate it in terms of condition of participation for CMS funding for Joint Commission accreditation. That goes on and on. So, any well-versed, very well-educated hospital executive knows that they need to show that they have a well-functioning accountable stewardship program that’s led by the right people, that’s looking at the right outcomes, and that is truly well-integrated to the overall scheme of patient safety and quality in the hospital. There are things that have been kind of handed to us at a national and federal level that make us really increase our game to be accountable to these different metrics that the federal government is looking at. And so yes, I would say that lots of hospitals throughout the country now have stewardship programs. They have programs that are run by infectious diseases, trained pharmacists, and physicians like myself. This is all moving in the right direction.
ICT®: We’ve had some articles here at Infection Control Today® that say that there might not be enough infection preventionists to go around. Especially if outside of the health care system they start hiring infection preventionists and that’s possible with school districts needing that expertise and public health departments needing that expertise and private industry needing that expertise. What do you see as possible solution to that problem?
Nori: Yes, this is a big problem. Absolutely. There’s lots of work to be done and not enough people currently to do it. And I believe the answer lies in the incentive structure that’s built around entering this field and this career path from either nursing, pharmacy or a medical standpoint. I think the mindset has to shift away from rewarding or incentivizing things that bring in money to hospitals, and instead shifting that to things that prevent loss of money for hospitals. These are stewardship programs, HAI prevention programs. And then even public facing things, as you said, prevention of infections in the community, working with the health department. We need to make it attractive for individuals to enter this extremely rewarding line of work. And I don’t know if this will happen in the next two to five or even 10 years. But I am optimistic about having the right people at the helm, in Washington and at the CDC, who really understand that this is badly needed after what we all just went through. I think that’s grossly apparent.
ICT®: What’s your main concern as an infection prevention physician?
Nori: Superbugs is the major one. And this is because these are the pathogens, in hospitals, outside of hospitals, in skilled nursing facilities—these are everywhere. These are in wastewater. These are everywhere you look all over the world, really. And the thing that makes them so challenging is that they’re hard to get rid of. They’re hard to treat. And once they’re treated, they’re hard to eradicate from the environment. These things are really with us. They’re part of our ecology. The best way to really shift the public’s focus and attention on this challenge is to not overblow how scary these things are, but to be very transparent and upfront about the fact that these infections [will] kill millions of people over the course of the next decade or so. And they kill tens of thousands of persons per year. And that this is going to be the issue of our generation if we don’t do something about it.
ICT®: I’ve used the word pandemic. And I think in Jan Dyer’s article, one of the experts—it might have been you—said you’re more concerned about epidemics than pandemics. Is there a possibility that one of these bacteriological pathogens could start a pandemic, a worldwide pandemic?
Nori: So yes and no. Yes, in the sense that essentially a pandemic is something that crosses borders. And it’s something that starts in one place locally and then, due to a number of human or environmental factors, can very quickly pass across borders to some very distant location, and then start a cluster there and really take off. And so, in that sense, yes, they could, in some ways fit into the definition of pandemics. However, in general, bacteria and fungi are not quite as transmissible as respiratory viruses. SARS-CoV-2 is a perfect example. It’s actually rather infectious. It’s not the most infectious thing we’ve ever dealt with in our lifetimes. But it is very infectious. And this is why it is still very much with us. This is still why it’s always two or three steps ahead of all of our control measures. Bacteria don’t really function like that. You might find that one person infected may infect a couple of other people, but certainly won’t tip off as sort of a huge hospital cluster or an entire school building or something like that. The numbers are not quite the same as what it would be for a viral pandemic.
ICT®: Where do you see the day-to-day work of infection preventionists going after the pandemic subsides? How will it change? How will their routine change? How will their roundings change?
Nori: Well, as I said before, there is still lots and lots of work to be done. In fact, lots of hospitals are in the process of looking back to do some accounting to see exactly what happened during COVID to other hospital associated infections. I had mentioned earlier that COVID fuels a lot of these. And so now is the time to take stock to see exactly what happened. Conduct somewhat of a root cause analysis and say, “OK, the next time around, how can we prevent these things?” or “How can we keep a very close eye to make sure that COVID patients are not getting these other harmful outcomes along the way?” It’s not as if they will suddenly have all this free time and their work will go away. I think they still have to account for the past year or so of all the things that we couldn’t do because our attention was entirely shifted toward the pandemic. I think the first thing will be to understand, “OK. What just happened? How can we learn from that?” And then, the second thing would be to put into place really well-structured programs to bolster our surveillance and prevention efforts.
ICT®: Doctor Nori, is something I neglected to ask you that you think is pertinent and that you would want infection preventionists and other health care professionals to know about dealing with bacterial problems?
Nori: I would say that let’s not forget about these. These superbugs, as we call them, they were always in the background. They were something that was on the forefront of our minds in terms of the infection prevention community. This was the most recent thing that we were grappling with up until the pandemic. And the pandemic definitely did not make that go away. If anything, it amplified it. And we’re going to be dealing with this for many years to come until in a very concerted, multidisciplinary and organized way we address it, we tackle these issues. We really emphasize judicious antimicrobial-antibiotic prescribing, both in the hospital, in the clinics, in the urgent care centers, dental clinics. We have to intensify our efforts to kind of get things back in order and back under control. That’s a big one. And then if I could just sort of make a plug for advocacy. I think that we need champions out there while we’re doing this important, very patient-centered work. We need advocates on a policy level. We need people in Washington who are fighting for us. Who are raising flags about the important work that we do and the desperate need to build up our workforce and to make sure that the incentive structures are in place so that we can continue to train and educate and grow future generations of infection preventionists and physicians and stewards such as myself.
This interview has been edited for clarity and length.