Optimize Infection Prevention Using Antimicrobial Stewardship
Philip C. Carling, M.D.
Division of Infectious Disease
Ron E. Polk, Pharm.D.
School of Pharmacy
Virginia Commonwealth University
Over the past several years it has become increasingly evident that current infection prevention (IP) initiatives are generally not realizing their hoped-for potential . Although there have been improvements in central line associated bacteremias and class I surgical site infection rates through focused process enhancements, many hospitals continue to experience high rates of Clostridium difficile associated infection (CDI), MRSA, and VRE acquisition as well as worsening problems with transmission of resistant Gram-negative pathogens such as Acinetobacter baumannii. It is now becoming increasingly evident that broader perspectives and initiatives similar to those which represent the core concepts of antimicrobial stewardship (AS) are urgently needed in the realm of IP [2,3].
While substantially sequential studies of CDI (1980’s), VRE (1990’s), MRSA (2000’s) and most recently Acinetobacter epidemiology were undertaken, there was a failure to optimize broadly effective transmission prevention solutions. Narrowly focused interventions such as using chlorine-based surface disinfectant in C. difficile infected patient rooms or the extensive use of isolation for patients colonized but not infected with MRSA and VRE in relatively endemic settings have provided disappointingly little overall impact on HAI rates [4,5]. As the importance of each new “pathogen of the decade” became recognized, such narrowly focused interventions were embraced only to be subsequently found to have less impact than had been hoped.
This problem was vividly illustrated in countries that focused on search and destroy interventions to limit the spread of MRSA. While these efforts were successful in containing MRSA transmission in a pre-endemic environment, overall HAI rates in these countries failed to improve during the same time period . Now, a decade later, enteric Gram-negative infections in Great Britain are increasing in the face of focused efforts to control MRSA infections . The belated recognition that we are paying a rapidly escalating price for lost global and local AS opportunities has placed a new emphasis on the need to optimize traditional IP practices. Although the basic IP paradigm is intrinsically simple (Figure 1), effective application of interventions to broadly prevent pathogen transmission have proven to be quite challenging.
Below is an evaluation of individual infection control measures which need to be better integrated to tackle today’s challenges.
Isolation: The intrinsic value of isolation practice has been recognized since ancient times (Figure 1). While screening and single room contact isolation for MRSA colonized patients has increased greatly in recent years, the value of such programs has not been clearly substantiated . In addition, there are substantial challenges related to appropriately determining when to implement and discontinue these logistically complex practices. Furthermore, recent studies have clearly demonstrated their adverse impact on optimal direct patient care, and the increasingly adverse impact on the patient’s emotional well being as well as on hand hygiene [8,9].
Hand Hygiene: As the development of alcohol based hand rub (ABHR) products greatly facilitated hand hygiene, there was widespread belief that our collective failure to cleanse our hands before as well as after patient contact was the major factor responsible for ongoing pathogen transmission in healthcare as well as community settings. As a result, there have been extensive, resource intensive efforts to improve hand hygiene compliance. Now, after the publication of more than 2,000 peer-reviewed English language articles over the past 10 years, the great enthusiasm for quickly reaping substantial benefits from optimizing hand hygiene practice has been tempered by the realization that acceptance inertia, psychological barriers, suboptimal application technique and particularly the pressures of providing direct patient care can limit the impact of this intervention . As pointed out by Pittet, the latter problem has been shown to be particularly relevant in intensive care unit settings where patient care providers frequently encounter at least 30-40 “hand hygiene moments” an hour, each requiring at least twenty seconds or more to carry out effectively using ABHRs .
Environmental Hygiene: The recently evolving appreciation of the role of surfaces in the transmission of many HAPs (MRSA, VRE, C. difficile, Acinetobacter, Pseudomonas, and others) and many viral pathogens (norovirus, rotavirus, adenovirus, influenza virus) raises the possibility that improving the safety of near-patient surfaces can favorably impact HAP transmission. Although it had been assumed that the cleaning of near-patient surfaces (Figure 1) was being optimized in healthcare settings by the use of broadly effective surface disinfectants, recent studies have confirmed non-policy compliant substandard thoroughness of cleaning in essentially all healthcare settings so far studied in the U.S. and abroad . Despite the demonstration that improving the thoroughness of traditional cleaning practices through objective monitoring and feedback can significantly decrease acquisition of HAPs such as MRSA and VRE, the impact of sustained improvement in bioburden diminution of near-patient surfaces remains to be quantified . Although optimizing surface microbial cleanliness is likely to have value, there has been a recent explosion of incompletely studied interventions (such as antimicrobial surfaces and semi-automated technologies) that kill/sterilize environmental microbes which are being commercially promoted as “the solution” to the infection transmission problem in healthcare settings.
Antimicrobial Stewardship: While the impact of antimicrobial therapy in facilitating antibiotic-specific resistance became vividly evident within a few years of the widespread use of these agents in hospitalized patients, it was not until two decades later that Drs. John McGowen and Maxwell Finland developed a model hospital-based antimicrobial stewardship program at Boston City Hospital in the early 1970’s . Unfortunately, such programs failed to gain widespread acceptance over the next thirty years due to the simplistic hope that the rapid evolution of new therapeutic options would solve “the problem.” Although it appears that the specter of much more widespread and more readily transferable resistance is stimulating greater adoption of hospital-based AS programs, focusing on antimicrobial resistance issues exclusively in hospitals represents only the tip of the iceberg . Since its inception 30 years ago, APUA and its leadership have embraced wide perspectives well beyond hospital walls to broadly address AS from the manufacturing process through non-healthcare use issues to optimizing outpatient as well as in hospital prescribing practices. The proponents of APUA’s stewardship perspectives have long advocated a multi-faceted simultaneously implemented range of interventions to address resistance issues in which no single component has been considered to be “the answer” or more critical to progress than another. In 1998, John Burke warned of the futility of focusing on a single component of antimicrobial stewardship, which he said was like squeezing a balloon; as you squeeze one area, another pops out . In the same editorial Burke also pointed to the “perverse and unintended consequences of component management” with respect to AS.
Conclusions: It is now becoming increasingly evident that there needs to be a movement away from such “component management” interventions that continue to be serially and independently championed if we are to realize broad-based gains in IP. All the basic components of transmission interventions (Figure 1) need to be seen as mutually critical to broadly optimizing outcomes. As with AS, interventions that advocate any single one of the three basic components of IP practice is really like squeezing a balloon.
As stewardship initiatives have been widely implemented in non-acute care hospital settings, IP interventions similarly and urgently need to move more proactively into these settings. As recent reports have shown, IP initiatives have had significant shortcomings in healthcare settings such as long-term facilities, ambulatory surgical centers, ambulatory dialysis centers, long-term acute care facilities, and even the community [12,17]. Given the interconnectedness of the microbial world, the likelihood is that a broader, more stewardship-like health systems approach to IP to include these settings will also benefit our most vulnerable hospitalized patients as well as the health of society at large. Unfortunately, the recent explosive dissemination of commensal enteric bacteria with broadly transmissible resistance to all currently available antibiotics clearly places a new sense of urgency on optimizing IP practices as a defense of last resort against such organisms .
In the context of these perspectives and the escalating problem of antimicrobial resistance to essentially all human pathogens, it is becoming increasingly evident that IP initiatives need to be viewed in a much more global, “stewardship-like” manner. AS and IP need to be seen as inseparable sides of the same coin since both short- and long-term antimicrobial effectiveness depend on optimization of both of these modalities equally.
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