Infection Prevention

Antibiotic resistance: when miracle drugs turn deadly

by Susan Cantrell, ELS

Antibiotic-resistant infection. Those three little words can strike fear in any heart. One day, someone you love maybe just does not feel well or had a little boo-boo; the next thing you know, his or her life is hanging in the balance, in danger of being killed by deadly monsters so tiny you can’t even see them. How can you fight such a nebulous threat?

Unfortunately, the fight against antibiotic-resistant organisms needs to begin long before infection sets in. Antibiotics can be wonderful lifesavers–but–when misused, terrible, horrible, life-changing things can happen.

The how and why of antibiotic resistance

Kerri A. Thom, MD, MS, Society for Healthcare Epidemiology of America (SHEA), and assistant professor, Department of Epidemiology and Public Health, University of Maryland School of Medicine, explained how antibiotic resistance happens. "Antibiotic resistance develops when the bacterial genetic material is altered, rendering the antibiotics used to kill them ineffective. Resistance is a result of antibiotic exposure, or use, and in particular the overuse and misuse of antibiotics."

"Antibiotic-resistant bacteria can be spread from person-to-person, particularly among patients in the healthcare setting. These bacteria can also cause infections; in fact, a large portion of hospital-acquired infections (HAIs) is caused by antibiotic-resistant organisms. Infections due to antibiotic-resistant bacteria are often difficult to treat due to limited antibiotic options. In many cases, when first-line therapies are not available due to resistance, alternative agents that are more expensive, more toxic, or less effective are prescribed. In addition, infections caused by antibiotic-resistant bacteria may result in longer hospital stays and increased mortality."

Unfortunately, the cost of patient care is always a concern, and Thom noted that the cost of antibiotic-resistant infection is high. "Maragakis et al¹ estimate the cost of infection due to an antibiotic-resistant bacteria is approximately $6,000 to $30,000 greater than the cost of infection due to an antibiotic-susceptible bacteria. Factors that contribute to this increased cost likely include the use of more costly alternative antibiotic agents and prolonged hospital stays."

Sani-Cloth, Sani-Hands, and Chlorascrub from PDI

Contributing factors

Many are the reasons that antibioticresistant infections are on the rise. J. Hudson Garrett Jr., PhD, senior director, Clinical Affairs, PDI, Orangeburg, NY, offered explanation: "The prevalence of antibiotic resistance is rapidly increasing in both healthcare and community settings. According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance is a major patient and medication safety issue in modern healthcare. The Infectious Diseases Society of America (IDSA) and SHEA have published extensive guidelines for antimicrobial stewardship, which clearly outline that more than 50% of antimicrobial use is inappropriate."

Garrett outlined some of the ways that antibiotics are misused:

• Being given when they are not needed (eg, antibiotics administered for a viral infection such as influenza)

• Being continued when they are no longer necessary (eg, postoperatively following initial pre-surgical dose)

• Being administered at the wrong dose

• Using broad-spectrum agents to treat extremely susceptible bacteria

• Using the wrong antibiotic to treat an infection

"Improper administration of antibiotics leads to resistance and can result in increased patient mortality and morbidity, increased costs to care for the patient, and the creation of completely resistant super-microorganisms," stated Garrett.

Kathleen B. Stoessel, RN, BSN, MS, senior manager, Clinical Education, Kimberly-Clark Health Care, Roswell, GA, noted the far-reaching effects of antibiotic resistance. "The overuse and misuse of antimicrobials have resulted in the development of antimicrobial resistance in many parts of the world. As an example, epidemic strains of methicillin-resistant Staphylococcus aureus (MRSA) have tremendous potential for nosocomial transmission. In fact, one recent United States study found that the incidence of inpatients infected or colonized with MRSA was 8 to 11 times higher than previously estimated.² Additionally, the rise in drug-resistant tuberculosis (TB) and multidrug-resistant TB is a growing concern, as TB affects one third of the world’s population."^3,4

Stoessel cited a few more factors that contribute to the rise of antibiotic resistance. "Contributing factors for the widespread incidence of HAIs include an aging population, increasing numbers and crowding of people, more immunocompromised patients, increasingly aggressive medical interventions, failure of healthcare workers to follow basic infection control practices, and the misuse or overuse of antibiotics."^4,5

Kimberly-Clark Health Care, personal protective equipment

What can be done

How can staff and patients alike help to prevent the spread of antibiotic-resistant organisms? Thom, SHEA, briefly outlined two important measures: "Two primary methods of prevention include (1) the appropriate use of antibiotics, to prevent further development of resistance, also called antimicrobial stewardship, and (2) infection control, to prevent spread from person-to-person."

Thom also mentioned some points brought out by Garrett that bear reiterating: "Healthcare providers as well as patients can curb the development of antibiotic resistance by the judicious use of antibiotics: using antibiotics in appropriate settings, for example, to treat bacterial infections but not viral infections; prescribing the correct antibiotic dosages; and only taking medication that is prescribed for you. In addition, infection control efforts, such as practicing proper hand hygiene before and after caring for patients or interacting with their environment, performing surveillance for antibiotic-resistant pathogens, and using barrier precautions when indicated, are essential in limiting the spread of bacteria from patient-to-patient."

Products that can help

Naturally, the healthcare-product industry is hard at work in developing products, technologies, and services to help prevent the development and spread of antibiotic-resistant organisms. Thom, SHEA, commented on some types of products that she believes are useful tools in the battle. "Novel products that improve compliance with essential measures such as hand washing are needed. Some recent advances in this area include the use of video surveillance, radiofrequency identification, and electronic sensors to remind providers to wash their hands when appropriate, to provide individual and immediate feedback, and, ultimately, to improve compliance.^6,7 Further, our understanding of the role of the environment in bacterial spread is evolving. Newer and more novel technologies aimed at reducing environmental contamination, and thus limiting spread of bacteria from this route, are becoming available. These technologies include the use of antimicrobial coatings to prevent adherence of bacteria on surfaces, the use of ultraviolet light^8,9 and hydrogen peroxide vapors^10,11 for decontamination of patient rooms and environmental surfaces, and, finally, the use of products like invisible florescent markers to provide direct and visual feedback to environmental services personnel regarding the cleanliness of the environment."¹²

PDI is one company that is zeroing in on the environment as a means of transmission. Garrett explained: "The use of germicides and disinfectants, such as Sani-Cloth and Chlorascrub, do not demonstrate the potential to cause antimicrobial resistance due to the mechanism of action. Because these products are used on the environmental surfaces and the skin respectively, they are designed to disable the microorganism completely but do not alter the organism’s genetic code like an antibiotic does. With disinfectants, reduced susceptibility does not correlate with the failure of the disinfectant because the concentrations used still greatly exceed the cidal level. According to the CDC’s ‘Guideline for Disinfection and Sterilization in Healthcare Facilities,¹³ in this circumstance, the use of the word ‘resistance’ is not correct; the preferred term is ‘reduced susceptibility.’ To date, there is no clinical data that exists to show that antibiotic-resistant bacteria are less sensitive to chemical germicides than antibiotic-sensitive bacteria at currently used germicide contact conditions and concentration."

Garrett recounted a clinical study that used PDI products with excellent results. "In 2009, in a 100+-bed, high-acuity, long-term–care facility in Pennsylvania, a clinical study evaluated the effectiveness of an environmental-surface–disinfection and hand-hygiene intervention. In this landmark study, the facility implemented a multidisciplinary infection prevention program that targeted a thorough environmental disinfection program focusing on high-touch, shared surfaces using Sani-Cloth Plus and Super Sani-Cloth, and a healthcare provider- and resident-centered hand-hygiene program using Sani-Hands alcohol-based–gel hand wipes. The study resulted in HAI rates decreasing from 2.42% to 0.55%, a decrease in acute-care transfers due to infection by 22, and, most significantly, a $33,000 decrease in the costs of antibiotics for treatment of resident infections as compared to the previous year. Due to the high incidence of antimicrobial resistance in the long-term-care–facility setting, and the presence of Clostridium difficile infections, this decrease in antibiotic use is extremely significant not only in cost but also in improving resident quality of life and patient outcomes."

BD GeneOhm MRSA ACP Assay

BD has an interesting product that targets MRSA. Jason Hwang, market segment director, core microbiology, Point of Care Diagnostics, Lab Automation, BD Diagnostics-Diagnostic Systems, Sparks, MD, talked about why MRSA is the focus. "The cost of MRSA infections in the U.S. alone is astronomical; thus, infection preventionists, infectious disease specialists, and clinical microbiologists are pursuing a wide variety of strategies aimed at reducing MRSA and MSSA (methicillin-susceptible S aureus) infections.¹⁴

One strategy that is being implemented is active surveillance of patients admitted to hospitals or other healthcare facilities for MRSA colonization, in an effort to identify patients who may serve as a reservoir of infection for other patients.¹⁴ Implementation of a MRSA active surveillance program as part of a comprehensive infection control strategy, which includes hand hygiene, patient isolation, and barrier precautions, has effectively been shown to reduce MRSA infections and hospital costs."

"BBL CHROMagar MRSA II and the BD GeneOhm MRSA ACP assay are two laboratory methods available from BD for MRSA active surveillance. BBL CHROMagar MRSA II is a selective and differential medium, which incorporates cefoxitin for the detection of MRSA from anterior nares specimens. The medium suppresses the growth of non-MRSA, allowing for growth of MRSA, which appears as strong, mauve-colored colonies on the plate. Results are available within 20 to 26 hours. The test is easy to perform, does not require any instrumentation, and is easily integrated in to a routine laboratory workflow."

"The BD GeneOhm MRSA ACP assay is a rapid molecular method that detects MRSA DNA from nares specimens within 2 hours. Rapid identification of patients colonized with MRSA enables infection control measures to be implemented earlier, reducing transmission and infection. The assay is performed on a real-time PCR [polymerase chain reaction] instrument."

Hwang cited a study performed at a 3-hospital, 850-bed organization with approximately 40,000 annual admissions that used BD GeneOhm MRSA assay during one shift per day. The results were that it "captured 95% of the possible isolation-days and reduced MRSA infection rates by 70% in less than 2 years."¹⁵

The role of soft surfaces in the potential for transmission of infection is gaining recognition. Kimberly-Clark has a product designed to reduce the risk for transmission of pathogens via soft surfaces. Stoessel talked about it to Healthcare Purchasing News: "Quality surgical fabrics, ie, surgical gowns, drapes, and sterilization wraps, are key components in the strategy to reduce the risk for pathogen transmission. An effective barrier fabric should provide a means of protecting patients and healthcare workers during use and thus promote a safe environment of care. As an example, gowns, drapes, and sterilization wraps should be resistant to penetration by blood and other body fluids. Microorganisms can be transferred through barrier materials by wicking of fluids or pressure or leaning on a flooded area of the product. Mechanical action, such as pressure, can result in both liquid and dry penetration of microbes if the pressure exceeds the maximum level of resistance provided by the material."

"Purchasing agents and end-users should request and obtain the manufacturers’ data verifying that materials used in surgical fabrics are protective barriers against the transfer of microorganisms, particulates, and fluids to minimize strike-through and the potential for personnel contamination.¹⁶ One of the test results to ask for is the fabric’s bacterial filtration efficiency (BFE), ie, the ability of a material to prevent the passage of aerosolized bacteria. The ASTM F2101 is the standard test method used to measure the BFE of surgical fabrics, although it is not required.¹⁷ It is important to note that this test method does not define acceptable levels of BFE but establishes a basis for comparison of different surgical fabrics. Therefore, when looking at the results for this test method, it is necessary to understand the specific condition under which testing is conducted. The maximum BFE that can be determined by this method is 99.9%. A higher BFE percentage indicates a better protection level."

Resources

There is a great deal of information and education available on the topic of antimicrobial resistance and healthcare facilities’ roles in preventing transmission. Start with organizations such as SHEA, IDSA, APIC, and CDC. Vendors have a great deal of useful information to offer as well.

Thom encouraged interested ones to attend SHEA’s upcoming annual meeting. "SHEA will hold a hybrid meeting offering a basic and an advanced epidemiology course, alongside a leadership forum devoted to antimicrobial stewardship, at its spring 2012 conference, April 13 to April 16. For more information and to register for the meeting, go to www.shea2012.org."

"SHEA also offers online antimicrobial stewardship training focused on strategies and interventions for real world practice at https://www.extendmed.com/antimicrobial/home.html. Finally, SHEA hosts an online resource page with additional educational materials and resources at http://www.shea-online.org/GuidelinesResources/
FeaturedTopicsinHAIPrevention/AntimicrobialStewardship.aspx."

PDI is collaborating with CDC on the "Get Smart: Know When Antibiotics Work" campaign, said Garrett. "For more information on preventing antimicrobial resistance, please visit the program’s website at http://www.cdc.gov/getsmart."

Kimberly-Clark is one vendor well-known for its wealth of educational offerings. Stoessel described a couple of their resources. "Kimberly-Clark Health Care’s Knowledge Network has provided continuing education (CE) courses to more than 100,000 clinicians since 2003 on HAI management and prevention topics. These courses are delivered in a variety of formats that include faculty presentations, Kimberly-Clark–representative–facilitated DVDs, the education bus, and online. Information on Knowledge Network programs for clinicians can be found at http://www.kchealthcare.com/us/healthcare/home/continuing-education.aspx."

"In addition to CE for clinicians, Kimberly-Clark has established a new program to educate patients about HAIs and steps they can take to aid in their prevention. Information provided through this initiative includes prevention strategies for surgical-site infection, MRSA infections, and healthcare-associated pneumonia. The goal of the Kimberly-Clark HAI Patient Education Program is to empower patients, families, and visitors through awareness and education to join the fight against the transmission of pathogens and infections in the healthcare environment. Information on Kimberly-Clark’s HAI Patient Education Program can be found at http://www.haiwatch.com/patients/HaiwatchPatientPage.htm."

"BD provides educational materials, tools, and resources to clinicians, infection control practitioners, and laboratorians on the detection and prevention of MRSA and C difficile in healthcare settings," said Hwang. "BD also provides webinars and workshops for different infectious diseases, and available laboratory methods and technology used to identify and diagnose these organisms, targeted at healthcare personnel. For more information, please visit us on our website at www.bd.com/geneohm."

References

1. Maragakis LL, Perencevich EN, Cosgrove SE. Expert Rev Anti Infect Ther 2008 Oct;6(5):751-763. Review.

2. Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) National Prevalence Study of Methicillin-Resistant Staphylococcus aureus (MRSA) in U.S. Healthcare Facilities, Executive Summary, June 25, 2007. http://www.apic.org/Content/NavigationMenu/
ResearchFoundation/PreviousStudies/NationalMRSAPrevalenceStudy/MRSA_Study_Results.htm

3. Learning from SARS. Renewal of Public Health in Canada. A report of the National Advisory Committee on SARS and Public Health; October 2003. http://www.phac-aspc.gc.ca/publicat/sars-sras/pdf/sars-e.pdf

4. Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Health Care Infection Control Practices Advisory Committee, 2007. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, June 2007. Am J Infect Control 2007;35(10 Suppl 2):S65-S164. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

5. World Health Organization. Prevention of Hospital-Acquired Infections: A Practical Guide. 2nd edition. 2002.

6. Armellino D, Hussain E, Schilling ME, Senicola W, Eichorn A, Dlugacz Y, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis 2012 Jan;54(1):1-7. Epub 2011 Nov 21.

7. Ellingson K, Polgreen PM, Schneider A, Shinkunas L, Kaldjian LC, Wright D, et al. Healthcare personnel perceptions of hand hygiene monitoring technology. Infect Control Hosp Epidemiol 2011 Nov;32(11):1091-1096.

8. Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol 2010 Oct;31(10):1025-1029.

9. Stibich M, Stachowiak J, Tanner B, Berkheiser M, Moore L, Raad I, et al. Evaluation of a pulsed-xenon ultraviolet room disinfection device for impact on hospital operations and microbial reduction. Infect Control Hosp Epidemiol 2011 Mar;32(3):286-288.

10. Otter JA, Yezli S, Schouten MA, van Zanten AR, Houmes-Zielman G, Nohlmans-Paulssen MK. Hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram-negative rods during an outbreak. Am J Infect Control 2010 Nov;38(9):754-756.11. Otter JA, French GL. Survival of nosocomial bacteria and spores on surfaces and inactivation by hydrogen peroxide vapor. J Clin Microbiol 2009 Jan;47(1):205-207. Epub 2008 Oct 29.

12. Carling PC, Briggs JL Perkins J, Highlander D. Improved cleaning of patient rooms using a new targeting method. Clin Infect Dis 2006 Feb 1;42(3):385-388. Epub 205 Dec 29.

13. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Centers for Disease Control and Prevention. Guideline for disinfection and sterilization in healthcare facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

14. CLSI. Surveillance for MRSA: Principles, Practices, and Challenges; A Report. CLSI document X07-R. Wayne, PA: Clinical and Laboratory Standards Institute, 2010.

15. Robicsek A, Beaumont JL, Paule SM, Hacek DM, Thomson RB Jr, Kaul, KL, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med 2008;148:409-418.

16. Association of periOperative Registered Nurses. Recommended practices for selection and use of surgical gowns and drapes. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2011:119-123.

17. ASTM. ASTM F2101 – 07. Standard Test Method for Evaluating the Bacterial Filtration Efficiency (BFE) of Medical Face Mask Materials, Using a Biological Aerosol of Staphylococcus aureus. West Conshohocken, PA; ASTM International; 2007.