There’s a war waging in
our nation’s hospitals and it appears that many healthcare workers and
patients on the frontlines are losing the fight.
The battle, an age-old
one that has undeniably gained momentum in recent years, revolves around
bacteria, and there’s a growing concern that today’s weapons aren’t
strong enough to tackle the more virulent and mutating strains.
Bacterial infections that could once be easily treated and cured by
penicillin are now becoming resistant to even the latest generation
antibiotics – an alarming trend that has been perpetuated by
inappropriate use of antibiotics by both caregivers and patients, and
perhaps even the general community’s reliance on antimicrobially-treated
products to kill microorganisms.
"The widespread use of
antimicrobials for therapy or prophylaxis, including topical, is the
major determinant of resistance. Through the selection and exchange of
genetic resistance elements, antibiotics promote the emergence of
multidrug-resistant strains of bacteria," the Centers for Disease
Control and Prevention noted. "Microorganisms in the normal human flora
sensitive to the given drug are suppressed, while resistant strains
persist and may become endemic in the hospital."
Two of the most important
antibiotic-resistant organisms that cause nosocomial infections,
Methicillin-resistant Staphylococcus aureus and vancomycin-resistant
Entercoccus, are now endemic in many healthcare institutions,
particularly in intensive care units. Nearly half of nosocomial S aureus
infections are methicillin-resistant, statistics from the National
Nosocomial Infections Surveillance System show. What’s more, VRE now
accounts for almost 25 percent of all nosocomial enterococcal infections
in hospitals included in the NNISS. The CDC reports that multi-resistant
Klebsiella and Pseudomonas aeruginosa are also becoming more prevalent
in many hospitals. Only a few antibiotics are effective against
Pseudomonas and even those aren’t effective against all strains.
If nosocomial infections
weren’t enough cause for concern, community-acquired drug-resistant
infections, such as MRSA, are also becoming more common and virulent,
and can be lethal in otherwise healthy individuals. These
community-acquired strains appear to be more readily spread that
hospital-acquired microbes and are understandably adding to healthcare
organizations’ concerns about managing drug-resistance organisms.
Limited next-generation drugs
Despite the pervasive
problem of antibiotic resistance, relatively few new drugs are in the
pipeline. Pharmaceutical experts contend that the high price of drug
development, coupled with drug companies’ reluctance to manufacture
antibiotics that will be used in the short-term, and therefore, will
slow profits and return on investment, has caused many pharmaceutical
giants to exit the antimicrobial market.
"We’re seeing half the
amount of money being spent on antibiotics today, as opposed to ten
years ago," said Dr. Frank Tally, chief scientific officer for Cubist
Pharamaceuticals, Lexington, MA, adding that the reasons behind the
decline are multifactorial.
Indeed. The Infectious
Diseases Society of American, Alexandria, VA, which has been
investigating the decline in new antibiotic research and development,
found that major drug companies are losing interest because these drugs
are not as profitable as those that treat chronic conditions and
lifestyle issues, and because R&D is expensive, risky and
time-consuming. An aggressive R&D program initiated today would likely
require ten or more years and an $800-million to $1.7-billion investment
to bring a new drug to market.
The end result of the
decline, the IDSA pointed out, is that the Food and Drug Administration
is approving few new antibiotics. Since 1998, only 10 new antibiotics
have been cleared for marketing, two of which are deemed truly novel
(that is, having a new target of action, with no cross-resistance with
other antibiotics). In 2002, none of the 89 new medicines making their
way onto the market was an antibiotic. Currently, only about five new
antibiotics are in the drug pipeline, out of more than 506 agents in
development.
One of the latest novel
antibiotics to hit the market is Cubicin by Cubist Pharmaceuticals. The
once-a-day injectable drug, which became available in 2003, is the first
antibiotic from a new class called cyclic lipopeptides and is a key
weapon against all gram-positive organisms, including MRSA. According to
Tally, Cubicin is unique because it has no high-level cross-resistance
with other antibiotics and is successful at rapidly killing the harmful
bacteria, as opposed to just inhibiting it.
Another new class of
antibiotics is showing promise against some drug-resistant bacteria. In
October, a team from the Denmark-based biotech company Novozymes and
researchers from Georgetown University and the David Geffen School of
Medicine at UCLA, reported that they have isolated a peptide from a
fungus that is as powerful as penicillin and even vancomycin. When the
so-called plectasin was tested in the laboratory and in animals, it
proved highly effective against Streptococcus pneumonia and
Streptococcus pyogenes, including strains that are now resistant to
conventional antibiotics.
Back to basics
While the development of
new classes of antibiotics is critically important, sources agreed that
it isn’t healthcare’s greatest weapon against bacterial infection.
Instead, facilities should be focusing on preventing infections, as
opposed to trying to tackle them from the back end.
"Obviously, infection
control is key to reducing the number of healthcare-associated
infections," said Nicole Coffin, a CDC spokesperson. "Antibiotics are
important, but it’s far better if you can prevent infections from
occurring in the first place."
Some predict that the
emphasis on infection prevention will become magnified in light of
initiatives that will mandate the reporting of infection rates. Such
initiatives will likely draw attention to areas where facilities have
become lax, according to consultant Charles Hancock, president of
Hancock & Associates, Fairport, NY.
"People will become much
more aware, and as a result, I believe we’ll start seeing a reaction
where healthcare organizations will be scrambling to close the gaps," he
said.
Data show some of the
biggest gaps revolve around the most basic infection control practices.
Appropriate handwashing, for example, remains one of the most elusive
practices in healthcare, despite ongoing educational efforts and
healthcare workers’ understanding of its importance in reducing the
spread of infection. The CDC reports that about half of all
hospital-acquired infections are caused by improper handwashing by staff
and/or patients at the hospital – findings that helped promulgate the
development of the agency’s new hand hygiene guidelines for healthcare
workers, which includes the use of alcohol-based handrubs.
"It’s something that is
so simple, yet so difficult for healthcare facilities to get their
employees to do properly," said Libby Chinnes, infection control
consultant and president of Mt. Laurel, SC-based IC Solutions. She said
staffing turnovers and poorly designed facilities that don’t make sinks
readily accessible are just two of the factors contributing to the
handwashing conundrum.
Of course, other factors
also play a key role in the spread – and prevention – of infection.
Contaminated surfaces are a common mode of transmission, yet despite the
abundance of data highlighting the risks and the guidelines available to
improve the cleanliness of environmental surfaces, many healthcare
organizations are falling short. One University of Arizona study
revealed that the television remote control is the leading carrier of
bacteria in patients’ hospital rooms – surpassing even the toilet bowl
flusher. The study also showed that newly opened disposable remotes,
such as those manufactured by Nosocontrol, harbor virtually no bacteria
and can serve as a quick and relatively inexpensive fix.
Not surprisingly,
doorknobs, telephones and handrails, which are some of the most
frequently touched surfaces, can also serve as excellent hosts for cross
contamination, added Tony Fitzgerald, president of the American Society
for Healthcare Environmental Services, Chicago. And that’s just the tip
of the iceberg. Carts, countertops, floors and virtually any other
surface can prove problematic if they aren’t adequately cleaned and
maintained. Hancock said he’s also concerned about some facilities’ lax
dress codes, including the decision by some workers to wash their scrubs
at home. "It’s a practice that’s discouraged, but you’d be surprised how
much that still goes on," he said.
Of course, central
service also plays a vital role in the process. After all, if
instruments and medical devices aren’t properly cleaned and sterilized,
even the best efforts by frontline caregivers to halt spread of
bacterial infection (or any type of infection) won’t be sufficient,
stressed CS consultant Natalie Lind, who also serves as educational
director for the International Association of Healthcare Central Service
Materiel Management.
"Although drug resistance
organisms are indeed a problem, we can’t lose sight of the fact that if
we leave any matter on an instrument, that can kill a patient," she
said.
‘Bundled up’ care
Aside from handwashing,
standard precautions, environmental surface disinfection and instrument
processing, there are a number of other factors that can make or break a
healthcare facility’s efforts to reduce the rate of bacterial
infections.
Through its 100,000 Lives
Campaign, the Institute for Healthcare Improvement has identified a
"bundle" of practices that can dramatically cut incidence rates of
several types of bacterial infections, including surgical site
infections, central line bloodstream infections and
ventilator-associated pneumonia. So far, nearly 2,900 hospitals have
joined the campaign since it was announced in December 2004, and the
results have been dramatic for those that have committed to the
specified clinically supported components for care, according to IHI
director Frances Griffin.
By incorporating a bundle
of five care steps, facilities participating in the IHI campaign have
been able to significantly reduce the rate of central line infections.
This bundle of care steps includes using proper hand hygiene; wearing
maximal barrier precautions; cleaning the patient’s skin with
chlorhexidine when the line is put in; finding the best vein to insert
the line; and checking the line for infection each day. The bundle for
the prevention of ventilator-associated pneumonia consists of elevating
the head of the bed to between 30 and 45 degrees; daily "sedation
vacation" and daily assessment of readiness to extubate; peptic ulcer
disease prophylaxis; and deep venous thrombosis prophylaxis (unless
contraindicated).
Numerous facilities have
found success in reducing both central line infections and VAP by
establishing a "Vents and CL Collaborative Team" and implementing the
care bundles. Seattle’s Swedish Medical Center, for example, achieved
168 days without a VAP in 6 ICUs across three campuses, and the
University of Rochester/Strong in New York went without a VAP for 231
days in its MICU, 492 days in its CVICU and 135 days in the SICU. Our
Lady of Lourdes in Birmingham, NY, went 290 days without a VAP and 166
days without a central line BSI in its ICU.
For preventing SSIs,
which are the second most common type of adverse event occurring in
hospitalized patients, IHI’s bundle includes appropriate use of
antibiotics, appropriate hair removal (clipping, not shaving),
maintenance of postoperative glucose control for major cardiac patients;
and establishment of postoperative normothermia for colorectal surgery
patients. Oklahoma City-based Mercy Health Center managed to slash SSIs
by 78 percent in one year using evidence-based strategies, including the
IHI’s SSI bundle.
Proper preoperative skin
prep that limits the amount of bacteria on the patient’s skin is also
essential, added Cynthia Crosby, vice president of clinical affairs at
Medi-Flex, Leawood, KS. Medi-Flex’s ChloraPrep product is the first
FDA-approved preoperative skin prep that contains the CDC-preferred
amount of chlorhexidine gluconate.
"The combination of 2
percent chlorhexidine and 70 percent alcohol is superior to other
preoperative skin preps because it kills the bacteria on the skin
quickly and continues to kill it for a minimum of 48 hours," noted
Crosby. The University of Pittsburgh Medical Center began using
ChloraPrep as part of a multi-faceted initiative to drive down
catheter-related bloodstream infections and was able to cut the rate by
71.4 percent after only one year.
Although applying the
bundles may appear simple, Griffin stressed that isn’t the case. "Most
healthcare [professionals] are aware of these components already, but
many [fall short] when it comes to implementing them all together. If
just one component is missing, you won’t see major improvements. It
isn’t easy, but it’s the ongoing commitment to each component that
drives success."
Rallying the troops
Perhaps the biggest part
of a healthcare organization’s infection control program revolves around
ongoing education and teamwork – not just at the individual department
level, but across the entire care system.
Because virtually every
department plays a role in infection prevention, from nursing, surgical
services and purchasing to food services, environmental services and
sterile processing, to name a few, Chinnes stressed that ICPs must
develop solid working relationships with each discipline and work to
have each department represented in multidisciplinary infection control
committees.
"Nurses and physicians
aren’t the only ones on the frontlines. I consider other healthcare
professionals, such as housekeeping and sterile processing staff,
frontline caregivers as well," Chinnes explained, adding that some
facilities still mistakenly view CS and environment services as menial
jobs. "Each department is critical to the process. If one isn’t doing
its job, that’s going to be a problem for everyone."
From the environmental
services standpoint, ASHES’ Fitzgerald said it is "mission critical"
that the ES department has a voting representative on the infection
control committee. "The environmental services department plays a big
part in supporting the policies and procedures developed by the
infection control committee, so it would be better to have a voice from
the start."
Fitzgerald stressed that
cleaning is everyone’s responsibility and is non-negotiable in any
healthcare setting. "Remember, a surgeon cannot cut if his surgical
suite is not cleaned by an ES professional."
The same can be said for
CS, Lind pointed out. "If we send a dirty instrument into the O.R., for
example, it won’t matter how good that surgeon is. That patient’s going
to be in real trouble."
Sources agreed that
involvement and buy-in from purchasing is equally important. After all,
if healthcare workers are being told to no longer use a certain product
– such as the need to replace razors with clippers in the O.R. – that
will only work if purchasing is aware of the change.
"You can round up all
these products in the department, but if you aren’t pulling the
purchasing department into the loop and letting them know that they
should no longer be processing orders and purchasing these products,
you’ll just end up right back where you started," Griffin explained.
"This has to be an organizational approach where everyone is recognized
as being vital to the process." HPN
Respiratory hygiene station
Battling
bacteria: System-wide attacks are best weapon
