The prevalence of antibiotic resistant pathological bacteria highlights the need for antibiotic stewardship.
In June of 2017 the Society for Healthcare Epidemiology of America reported that an alarming 5.2% of inpatients across healthcare facilities in the Washington D.C. area tested positive for Carbapenem-resistant Enterobacteriaceae or CRE. CRE are “a family of germs that are difficult to treat because they have high levels of resistance to antibiotics.” For example, E. coli is a member of this family of bacteria. According to the press release, one facility reported a prevalence of 29.4%, “indicating the potential for hyperendemicity.”
This report highlights the increasing need for antibiotic stewardship. Misuse and overuse of antimicrobials is one of the world’s most pressing public health problems.
Nowhere is this more urgent right now than in nursing homes, according to the Association of Practitioners in Infection Control and Epidemiology (APIC), where patients are especially vulnerable to infections due to multiple comorbidities, advanced age, and immune dysfunction. In May the American Journal of Infection Control reported MDR-GNB colonization prevalence ranged from 11.2%-59.1%, with a pooled average of 27 percent. The prevalence is such that living in a nursing home is itself considered a risk factor, and frequent transfers aid the spread of infection and introduction of pathogens into acute care settings. Bacterial strains are becoming resistant to nearly all drugs that would be considered for treatment while few new antibacterial treatments are being developed.
So what can be done? Thankfully, there are examples where antimicrobial stewardship has led to a reduction in the prevalence of drug resistant bacteria.
From 2008 - 2012 Wilhelminenspital – a hospital in Vienna Austria – recorded a steady increase of mortality rates due to Clostridium difficile infections. They knew something had to be done. In 2013 they conducted a study that demonstrated significant and measurable decrease in Clostridium difficile infections (CDI) by reducing their use of Moxifloxacin in treatment for community acquired pneumonia (CAP).
Their success in reducing the infections came from a combination of reduced Moxifloxacin, distribution of information on CDI, and continuation of concrete hygiene behaviors which had been implemented years earlier. According to the study, routine hygiene measures included a visit from an infection control specialist in every case of CDI to augment hand hygiene, i.e., hand-washing and disinfection in the appropriate indications, protective clothing, change to a sporicidal surface disinfectant, and strict isolation of the patient whenever possible.
The biggest difficulty posed in the study was finding alternatives to the highly promoted Moxifloxacin, which proved effective for multiple respiratory infections, patients with insufficient kidney function, and patients allergic to penicillin.
The challenge of finding alternative antibiotic treatments when implementing antimicrobial stewardship programs will likely only become more difficult as more bacteria becomes resistant. This fact only serves to highlight the urgent need for such programs while a range of optimal clinical responses exist.
A key goal of improving antibiotic prescription behavior is to only prescribe antibiotics when they are needed according to current guidelines. As we at Infection Prevention Services seek to help healthcare facilities decrease the transmission of disease, it is our view that evidence-based antimicrobial stewardship should be a key priority.