Fighting HAIs requires synergy of coordinated efforts
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It likely goes without saying that two of the most integral steps to fighting hospital-acquired infections are practicing antimicrobial stewardship and sound infection prevention strategies. We know that HAIs plague our health care systems and contribute to significantly increased morbidity, mortality and health care costs. The type of infections seen in health care are more commonly caused by multidrug-resistant bacteria and can easily spread from patient to patient, health care worker to patient, and environment to patient. A 2019 CDC report titled “Antibiotic Resistance Threats in the United States” sheds some light on the impact of MDR pathogens, which cause an estimated 2.8 million infections and at least 35,000 deaths each year. The report addresses core concepts such as antimicrobial stewardship, infection prevention and One Health approaches to combating antibiotic-resistant threats. Although these have been proven to be effective methods, we still have some barriers in everyday practice that make fighting HAIs challenging. Most clinicians would agree that when we collaborate in our efforts, we will be able to more effectively fight HAIs.
A good strategy for fighting HAIs consists of three parts:
- Nursing-based antimicrobial stewardship interventions
- Implementing rapid diagnostics
- Susceptibility testing for newer antimicrobial agents
These three types of interventions independently have demonstrated success at improving patient outcomes, but combined, they could be a triple threat to HAIs.
The CDC’s Core Elements of Hospital Antibiotic Stewardship Programs — leadership commitment, accountability, pharmacy expertise, action, tracking, reporting and education — address the first two strategies as top priorities for antimicrobial stewardship programs (ASPs). Susceptibility reporting is a key component of ASPs but having reliable susceptibility reports for some of the newer antibiotics continues to be a challenge.
Nursing-based interventions
Nursing-based interventions are a new addition in the 2019 report under the core elements of action. This emphasizes the important role nurses can play in ASPs, one centered on evaluating the most common indications for antibiotic use (eg, lower respiratory tract infections, UTIs and skin and soft tissue infections), optimizing microbiology cultures, IV-to-oral transitions and prompting timely antibiotic reviews.
Nurses are often the “first responders” when a patient is being evaluated for an infection. They are the first to evaluate the patient’s clinical status, collect cultures, receive orders for antibiotics and administer the drugs. In each of these steps, nurses can impact how we fight HAIs. In step 1, during the evaluation of a patient’s clinical status, a nurse can determine if the patient needs to be isolated to prevent the spread of infection. An example is a patient presenting with significant diarrhea who was prescribed outpatient antibiotics or came from a long-term care facility and may need enteric isolation and work-up for Clostridioides difficile-associated infection. In step 2, nurses are often obtaining cultures, and we have not used their expertise in obtaining timely and sterile specimens for culture. A key to optimizing treatment of HAI is identifying the causative pathogen, so if this step is missed, we are a significantly behind in our treatment approach. In step 3, administration of antibiotics is key to improved survival for many infections. Sepsis affects at least 1.7 million adults each year. Without prompt treatment with antibiotics, sepsis can rapidly lead to tissue damage, organ failure and death.
Rapid diagnostics
Rapid diagnostics are included in several of the core elements. The core element of leadership commitment suggests “hospital leadership can help ensure that other groups and departments in the hospital ... collaborate with stewardship programs.” Microbiology laboratory staff can “guide discussions on the potential implementation of rapid diagnostic tests” and work together with ASPs “to optimize the use of such tests and communicate the results.” The core element of action highlights that “facility-specific treatment guidelines ... should address diagnostic approaches ... including indications for rapid diagnostics.”
Rapid diagnostics have been proven beneficial in identifying a bug-drug mismatch, particularly for more highly resistant gram-positive and gram-negative pathogens, but they also can reduce the time to the discontinuation of antibiotic therapy. Invasive bloodstream infections, including bacterial and fungal infections, have been a focus for ASPs, and rapid diagnostic technologies play a crucial role. Microarray technology (eg, Verigene System or the BioFire FilmArray) and matrix-assisted laser desorption ionization time-of-flight mass spectrometry have improved pathogen identification and reduced the time it takes to identify resistance from days to hours. This information, coupled with pathogen-specific susceptibility or antibiogram data, is a powerful tool in getting patients on optimal treatment rapidly. Many organizations, including my ASP, have implemented blood culture review programs with treatment guidelines or algorithms as a strategy for fighting HAIs.
Susceptibility testing
Susceptibility reporting has always been a part of the core elements of tracking and reporting. The annual production and release of an antibiogram continues to be the pillar of this element. The CDC report proposes an evaluation of “new antibacterial susceptibility test interpretive criteria ...that might impact antibiotic use.” One intervention that is highlighted in the new report is a microbiology-based intervention that the lab, in coordination with the stewardship program, implement “selective reporting of antimicrobial susceptibility testing results” by “tailoring susceptibility reports to show antibiotics that are consistent with hospital treatment guidelines.”
A core principal of antimicrobial stewardship is using the most targeted antibiotic at the right dose and frequency for the most effective period of treatment. But what do you do when a pathogen’s sensitivities return as panresistant to all the antibiotics that your microbiology lab tests? You request added susceptibilities, of course. Unfortunately, it is not that simple. When treating HAIs, the rapid, targeted treatment can often save a patient’s life.
The CDC estimates that in 2017, carbapenem-resistant Enterobacteriaceae caused up to 13,100 infections and 1,100 deaths, and MDR Pseudomonas aeruginosa contributed to approximately 32,600 infections and 2,700 deaths. Treatment options for these serious infections are limited, and combination therapy is often required. Some agents (eg, polymyxins) cause significant toxicity. Many of the new agents have specific niches in the spectrum of coverage (see Table); therefore, susceptibility testing is important when making the decision to use these for treatment.
Ceftolozane-tazobactam (approved in 2014), ceftazidime-avibactam (approved in 2015), meropenem-vaborbactam (approved in 2017), and imipenem-cilastatin plus relebactam (approved in 2019) all have susceptibility testing available for Enterobacteriaceae and Pseudomonas. However, a barrier for microbiology labs is that the testing methods (disk diffusion and Etest) can be time and labor intensive. If labs are able to conduct susceptibility testing for the new agents, clear guidance for what pathogens should be tested and how those susceptibilities are reported is imperative to using those agents appropriately. By having timely sensitivity reporting of the new agents for the MDR gram-negative cases, we can treat our patients more quickly and effectively.
The CDC, along with other quality organizations like The Joint Commission and CMS, has emphasized the important role that antimicrobial stewardship can play in fighting HAIs. The 2019 core elements document gives stronger guidance for the involvement of multiple disciplines. The fight against HAIs must be an ongoing collaborative effort of physicians, pharmacists, microbiologists, nurses, infection preventionists and informatics specialists. It is the synergy of coordinated efforts such as nursing, rapid diagnostics and timely antibiotic susceptibility reporting that will give us the best chance of winning the fight against HAIs and saving our patients’ lives.
To quote John Ruskin: “Quality is never an accident. It is always the result of intelligent effort.”
Editor’s Note: For an opposing view on ASPs, click here.
- References:
- CDC. Antibiotic resistance threats in the United States, 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Accessed January 29, 2020.
- CDC. Core elements of hospital antibiotic stewardship programs. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html. Accessed January 15, 2020.
- For more information:
- Kimberly Boeser, PharmD, MPH, BCIDP, is an infectious diseases clinical pharmacist and antimicrobial stewardship coordinator at the University of Minnesota Medical Center-MHealth. She can be reached at kvarejc1@fairview.org.
Disclosure: Boeser reports no relevant financial disclosures.
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