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By Sue Barnes, RN, CIC, FAPIC
Since the 1940s antibiotics have been used to treat patients who have infections, greatly reducing the incidence of illness and death. However, misuse and overuse has contributed to development of bacterial resistance, making the antibiotics less effective and, in some cases, not effective at all. Each year in the United States, at least 2 million people become infected with multidrug resistant organisms (MDRO), while at least 23,000 people die each year as a direct result of these infections.1
To monitor, control and promote the appropriate use of antibiotics, antimicrobial stewardship programs (ASP) have been implemented in hospitals nationwide. These programs have proven effective in reducing the rate of resistance development, and consequently reducing the incidence of infections caused by MDROs. In addition, reducing the quantity and frequency of antibiotics administered has also been shown to reduce the incidence of Clostridium difficile infections, caused in part by the disruption of helpful intestinal bacteria by antibiotics.2
Various perspectives have been offered regarding the role of infection preventionists (IPs) in ASP including tracking multidrug-resistant organism (MDRO) rates to help assess the success of antimicrobial stewardship programs. Often not addressed, though perhaps the most significant role for IPs in antibiotic stewardship programs, is prevention and control of healthcare associated infections (HAI). For every infection prevented, fewer antibiotics are administered, there is less associated bacterial resistance pressure, less risk of Clostridium difficile infection, and fewer associated costs.
Overuse of Antibiotics and Proton Pump Inhibitors
The Centers for Disease Control and Prevention (CDC) estimates that at least 30 percent of all antibiotics prescribed in this country are unnecessary. The World Health Organization (WHO) considers misuse and overuse of antimicrobials one of the top three threats to human health. This is such a serious concern because with every dose of antibiotics prescribed and ingested, bacteria continue to develop mechanisms to resist those antibiotics. This leads to bacteria that are resistant to one or more antibiotics, or MDRO. Consequently, infections caused by these drug-resistant organisms such as MRSA, are more difficult and sometimes impossible to treat. So, new antibiotics are needed. However, pharmaceutical manufacturers are facing higher costs to develop new drugs that don’t always bring in adequate revenue to offset these costs when they enter the market. Therefore, these companies are instead investing in development of other types of medications that generate profits, for example, those used to treat chronic diseases.3 Currently, the rate at which at which antibiotics are losing their effectiveness due to bacterial resistance far exceeds the rate at which new antibiotics are being developed.
Antibiotic stewardship has been an organized effort since the late 1990s. To date it has been primarily implemented in hospitals and has largely been voluntary and self-regulated. In hospitals, oversight of antibiotic monitoring and control is typically provided by a formal antimicrobial stewardship program and/or committee. As of 2014, only the state of California has made this type of ASP mandatory by law.4
In addition to causing bacterial resistance, the inappropriate use of antibiotics increases the risk of Clostridium difficile (C. difficile) infections. This infection is caused in part by the antibiotic-induced reduction of helpful intestinal bacteria that normally retard outgrowth of inactive C. difficile spores. C. difficile infection can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from this pathogen most commonly affects older adults in hospitals or in long-term care facilities. However, studies show that there are increasing rates of C. difficile infection among individuals who have not been traditionally considered high risk, such as the young and healthy who have no history of antibiotic use. Each year in the United States, there are half a million cases of C. difficile infection resulting in more than 29,000 deaths. In recent years, C. difficile infections have become more frequent, severe and difficult to treat. Consequently, effective antimicrobial stewardship programs are becoming ever more critical.5
Proton pump inhibitor (PPI) use in the treatment of gastric acid-related conditions has also been reported to increase the risk of C. difficile infection (CDI). And as with antibiotics, PPI medications are often overprescribed. There are two mechanisms through which PPIs can cause an increased risk of CDI. First, by raising pH, PPIs may prevent gastric contents from killing C. difficile spores. Secondly, gastric contents of PPI-treated patients may promote germination and outgrowth of C. difficile spores. The Food and Drug Administration (FDA) reviewed 28 observational studies that investigated the relationship between PPI use and CDI. Twenty-three of the studies showed a higher risk of C. difficile infection or disease, associated with PPI exposure compared to no PPI exposure.14 So, in addition to antibiotics, this category of drugs is important to monitor and control. In some hospitals, PPI utilization is included in the Antibiotic Stewardship Program.6
Role of the IP in Antibiotic Stewardship Programs
Arguably, the most fundamental role for IPs in antibiotic stewardship programs is prevention and control of infections. If infections are prevented, then antibiotics to treat those infections will be avoided, the contribution of the additional antibiotic pressure to emerging bacterial resistance will be reduced, as will the risk of CDI. This role, however, is not always considered when ASP and the role of the IPs are discussed. Prevention and control of infections is accomplished in large part by ensuring compliance by healthcare workers and providers with the use of ever evolving evidence based products and practices to reduce all types of healthcare associated infections. Some of the most basic prevention measures include:
• Contact precautions: Full barrier precautions (gowns and gloves) are used for contact with patients who have MDRO and with their body substances and environment. Dedicated patient care items and equipment is used, or if items must be shared, they are cleaned and disinfected between patients. Use of electronic thermometers is avoided as the handles can easily become contaminated.
• Hand Hygiene: Meticulous hand hygiene is performed according to the CDC or World Health Organization guidelines before and after entering the patient room, with soap and water or an alcoholbased handhygiene product. For CDI patients, hand hygiene with soap and water is recommended instead of alcohol based sanitizer.
• Environmental cleaning: Daily and as-needed manual environmental cleaning with friction and disinfection of all surfaces in the patient zone is performed to prevent the transmission of healthcare associated infections. Sporicidal products are used in the presence of spore forming organisms such as C. difficile and norovirus.
• Education: Patient, family, visitor, healthcare personnel and hospital administration are provided with regular training regarding transmission, epidemiology and prevention of healthcare associated infection.
Given the continuing occurrence of preventable infections despite the application of these standard measures, many IPs are expanding their infection prevention bundles and programs to include one or more “plus measures” to further reduce infection risk. Often a plus measure(s) is implemented in advance of randomized controlled trials, if the existing evidence of efficacy, and safety profile is considered sufficient by IPs and other experts.7-9
This early adoption of new products and practices is another critical IP role, not only for optimizing infection prevention, but also for efforts in support of ASP, such as use of antiseptics instead of antibiotics when efficacy is equivalent.10 Examples of when the efficacy of antiseptics are equivalent to antibiotics include surgical irrigation solutions, and nasal decolonization for prevention of surgical site infection (SSI) and intensive care unit (ICU) device associated infections such as catheter-associated bloodstream infections. Currently, use of antibiotic based surgical wound irrigation solution is common in orthopedic procedures such as joint replacements. However, antibiotic irrigation has been shown to be ineffective in reducing SSI, as well as contributing to the continuing emergence of antibiotic resistance.10 There are antiseptic-based surgical irrigation solutions now available. The one that is FDA approved contains 0.05 percent chlorhexidine, which is a very effective antiseptic, with sustained efficacy for at least 48 hours after application.13 As for nasal decolonization performed to suppress bacteria in the patient’s nasal vestibule in advance of high risk surgical procedures, the most commonly used agent is mupirocin which is an antibiotic ointment. While it is generally effective, there are increasing cases of mupirocin resistant-bacteria, and it requires five days of application to reach its full effect. This antibiotic ointment is typically self-administered by patients at home prior to surgery, and patients are not always compliant.10 There are nasal antiseptic products available now which offer a non-antibiotic option for pre-surgical nasal decolonization. There are two types of nasal antiseptics. One is alcohol-based, the other iodine-based. These are easy to use and require a single application during the pre-operative preparation period. These products are generally not more expensive than mupirocin, are equally or more effective and have no associated risk of inducing antibiotic resistance.11 Recent guideline updates from the Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) recommend these antiseptics as alternatives to antibiotic ointment for nasal decolonization and reflect the recognition of the utility of these new tools in infection prevention and control.15
Examples of infection prevention plus measures include:
• Hand Hygiene: Automated hand hygiene compliance monitoring and hand sanitizer with added essential oils.
• Environmental cleaning solid surfaces: Ultraviolet (UV) light and hydrogen peroxide (HP) vapor disinfection systems, and solid surfaces impregnated with antimicrobials such as copper, silver or organosilane.
• Environmental cleaning soft surfaces: Hydrogen peroxide based disinfection spray for privacy curtains, silver ion laundry treatment for patient gowns, curtains and bed linen, and textiles impregnated with antimicrobials such as triclosan, silane quaternary ammonium, zinc pyrithione or silver.
• Device associated infections: Chlorhexidine for bathing patients with indwelling devices such as vascular catheters and bladder catheters.
• Surgical infection prevention: Nasal decolonization with antiseptics, surgical wound irrigation before closure with antiseptic irrigation, UV light disinfection for the environment, and UV/HEPA air filtration and disinfection systems.
Best Practices for the ASP Committee
Within the ASP oversight group whether it is part of another committee or free standing, representatives should be included from the IP department. The ASP committee or group will typically look to the IP representative to report on trends in CDI and MDRO and for reports regarding any use of antiseptics instead of antibiotics where efficacy is equivalent. In addition, nurse leaders, such as Dr. Mary Lou Manning, have recommended that support is needed from nursing as well. This might include adding an assessment of antibiotic necessity to daily nursing huddles and rounds, much as nurses currently perform daily assessment of urinary catheter necessity.12 The ASP committee or oversight group will also typically review reports of trends in antibiotic prescribing and utilization provided by pharmacy, as well as antimicrobial resistance patterns and trends typically provided by the laboratory.
In conclusion, when considering the IP role in ASP, it is important to remember that the core work of IP departments, the prevention of infections, is a critical contribution to ASP. In preventing infections, antibiotics required to treat those infections are avoided, as is the contribution of those antibiotics to bacterial resistance. And perhaps most importantly, the CDI risk associated with those avoided antibiotics is eliminated. In addition, the role IP departments play as early adopters of new products and practices, can further support ASP not only by optimizing infection prevention, but also by supporting the replacement of antibiotics with antiseptics where efficacy is equivalent. And, of course, tracking and reporting trends in CDI and MDRO by IPs is another important function supporting ASP.
Sue Barnes, RN, CIC, FAPIC, is a national infection prevention thought leader and policy specialist.
1. Centers for Disease Control and Prevention (CDC) website at: https://www.cdc.gov/drugresistance/
2. Lillis K. IPs Play Key Role in ASP Efforts. Infection Control Today. Aug. 3, 2013. Accessed at: http://www.infectioncontroltoday.com/articles/2013/08/infection-preventionists-play-key-role-in-antimicrobial-stewardship-efforts.aspx
3. News brief. Is antibiotic development declining? Pharmacy Times. Jan. 1, 2008. Accessed at: http://www.pharmacytimes.com/publications/issue/2008/2008-01/2008-01-8349
4. California Legislative Information. SB-1311 Hospitals: antimicrobial stewardship. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1311.
5. Bernatz JT, Safdar N, Hetzel S, Anderson PA. Antibiotic Overuse is a Major Risk Factor for Clostridium difficile Infection in Surgical Patients. Infect Control Hosp Epidemiol. 2017 Jul 31:1-4.
6. Lewis PO, Lundberg TS, Tharp JL, Runnels CW. Implementation of Global Strategies to Prevent Hospital-Onset Clostridium difficile Infection: Targeting Proton Pump Inhibitors and Probiotics. Ann Pharmacother. 2017 Aug 1.
7. Septimus E, et al. Closing the Translation Gap: Toolkit-based Implementation of Universal Decolonization in Adult Intensive Care Units Reduces Central Line-associated Bloodstream Infections in 95 Community Hospitals. Clin Infect Dis 2016 Jul 15;63(2):172-7.
8. Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation 2015 JAMA Surgery. 150 (5), pp 390-395.
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10. Roberts CD, Leaper DJ, Assadian O. The Role of Topical Antiseptic Agents Within Antimicrobial Stewardship Strategies for Prevention and Treatment of Surgical Site and Chronic Open Wound Infection. Adv Wound Care (New Rochelle). 2017 Feb 1;6(2):63-71.
11. Rezapoor M, Nicholson T, Tabatabaee RM, Chen AF, Maltenfort MG, Parvizi J. Povidone-Iodine-Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study. J Arthroplasty. 2017 May 3.
12. Manning ML, Pfeiffer J, Larson EL. Combating antibiotic resistance: The role of nursing in antibiotic stewardship. Am J Infect Control. 2016 Dec 1;44(12):1454-1457.
13. Edmiston CE Jr, Bruden B, Rucinski MC, Henen C, Graham MB, Lewis BL. Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. 2013 May;41(5 Suppl):S49-55.
14. FDA Drug Safety Communication: Clostridium difficile associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs). https://www.fda.gov/Drugs/DrugSafety/ucm290510.htm
15. Health Research & Educational Trust (February 2017). Surgical Site Infections Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org.