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Strategies hospitalists can take to prevent antibiotic resistance
ORLANDO, Fla. — As antibiotic resistance continues to plague hospitals, a presenter at Hospital Medicine 2018 discussed approaches that hospitalists should implement to control the spread of multidrug-resistant organisms.
A growing issue
“Antimicrobial resistance is a threat to all of our patients across the health care system and even in the community,” Lisa L. Maragakis, MD, MPH, associate professor of medicine in the division of infectious diseases at Johns Hopkins University, said during her presentation.
She noted that estimates from the CDC indicate that there are more than 2 million antibiotic resistant infections and 23,000 related deaths in the United States annually.
“These are staggering numbers that we need to keep in mind when we are prescribing antibiotics and when we are thinking about the types of pathogens that may be causing infections in our patients,” she said.
Antibiotics themselves drive antibiotic resistance and are among the most commonly prescribed drugs in both the inpatient and outpatient setting, according to Maragakis. It is estimated that more than half of the time, antibiotics are prescribed when they are not indicated, for the wrong agent, at the incorrect dose and for the wrong duration, she said.
In addition to antibiotics as a risk factor, antibiotic resistance can occur through the transfer of multidrug-resistant organisms from patient to patient and from the environment to patients, she said.
Maragakis noted that the National Action Plan for Combating Antibiotic Resistant Bacteria to prevent, detect and control infection-related illness and death was published in 2015. In the national action plan is a list of pathogens that are urgent and serious antibiotic resistance threats including Clostridium difficile, carbapenem-resistant Enterobacteriaceae and Neisseria gonorrhoeae, among several others.
“Simultaneous action is needed to ensure that these threats don’t become something that gets out of hand and we won’t have therapeutic options to treat our patients,” Maragakis said.
Containing antibiotic resistance
“Antibiotic resistance is akin to a wildfire that is at risk of getting out of control and we all have a role and responsibility to respond, take action and control and hopefully extinguish this fire,” Maragakis said.
The CDC released a containment strategy to control antibiotic resistance, according to Maragakis. The components of the strategy include rapid identification of organisms, infection control assessments of the facilities when these organisms occur, colonization screenings, a coordinated response between facilities and continued assessment and screening, she said.
“Early aggressive response to emerging pathogens can slow emergence and decrease infections,” she stressed.
Maragakis also emphasized the importance of responding to even a single isolate of an emerging antibiotic resistant pathogen.
Hospitalists can take several steps to help prevent antibiotic resistance, including identifying patients who are at-risk, using isolation precautions when indicated, taking infection prevention measures, collaborating with infection control staff and public health authorities and communicating with other facilities about the patient’s status when they are being transferred, she said.
Risk factors for multidrug-resistant organisms may include but are not limited to undergoing dialysis, staying in the hospital for more than 7 days, receiving active chemotherapy and travelling recently, according to Maragakis.
Hospitalists should utilize their hospital’s antibiogram to track rates of resistance in the hospital and inform patient care decisions, but only when also considering patient risk factors, medical and antimicrobial history, she said. Hospitalists should also partner with their microbiology lab, antimicrobial stewardship program and colleagues and narrow antibiotic therapy to match their hospital’s microbiology results, she said.
According to Maragakis, there are four things that hospitalists should consider when approaching antibiotic decisions:
ensure that the patient has an infection that requires antibiotics;
order appropriate cultures before starting antibiotics and target empiric therapy based on disease progress;
implement “daily time out” to assess whether antibiotics can be stopped, narrowed or switched to oral therapy; and
use the minimum appropriate duration of antibiotic therapy for patient’s diagnosis.
Infection prevention
“Infection prevention matters because there are a wide range of things beyond antibiotics that drive transmission of these multidrug-resistant organisms,” Maragakis said.
“We have a variety of tools at our disposal to prevent infections,” she said.
Hospitalists should continually practice hand hygiene, isolation precautions, cleaning and disinfecting environment and equipment and antimicrobial stewardship, she said.
“Beyond evidence-based best practices, we must address implementation science and what is actually happening at the bedside not what we know needs to happen as this continues to be a challenge,” Maragakis said. “We need more research to improve the evidence, but we also need to figure out ways to standardize and optimize work flows to reduce ambiguity and make sure that we can protect our patients every time. There is also a need for better products, technologies, and environmental design to facilitate infection prevention.” – by Alaina Tedesco
Reference:
Maragakis LL. Finding Nemo: How to choose antibiotics for multidrug-resistant bugs. Presented at: Hospital Medicine 2018; April 9-11; Orlando, Fla.
Disclosure: Maragakis reports receiving research funding from Clorox, Inc.