Published in the December 2006 issue of Today’s Hospitalist.
New recommendations from the CDC aim to help health care facilities around the country fight an increasingly critical threat: multidrug-resistant organisms.
The guidelines are part of a larger set of recommendations the agency is currently updating on isolation management. But with growing attention being paid to multidrug-resistant infections like methicillin-resistant Staphylococcus aureus (MRSA), the CDC decided to release this section of the guidelines early and published them online in October.
What makes this section of the guidelines unique is that they focus exclusively on infections caused by antimicrobial resistant organisms.
And while much of the infection-control literature concentrates on what can be done in the hospital setting, the new recommendations address infections from antimicrobial resistant organisms across the entire spectrum of health care facilities, including long-term care facilities, nursing homes, and home health and home infusion therapy agencies.
Like most guidelines, the new recommendations give a broad overview of strategies to combat multidrug-resistant infections. But they go one step further to make specific recommendations about the usefulness of emerging “and sometimes controversial “strategies like active surveillance cultures and culturing health care workers.
Here’s a look at what the guidelines have to say about several key strategies to prevent and treat infections caused by multidrug-resistant organisms, and where the guidelines weigh in on areas of debate.
The new CDC guidelines don’t focus exclusively on problems in the hospital setting, but target all health care settings.
That’s because hospitals need to look outside their own walls to combat resistant organisms, says Jane D. Siegel, MD, lead author of the guidelines. Patients now move continuously through all types of health care settings, from hospitals to ambulatory surgical settings and even home care.
“Many more patients are being managed in outpatient arenas,” Dr. Siegel explains. “Those settings are not used to tracking health care associated infections and antimicrobial resistance the same way that acute care hospitals have been doing.”
The CDC’s broad focus is a signal that “a real community process needs to occur” to achieve any meaningful infection control.
“Facilities can’t work in a vacuum,” Dr. Siegel adds. “We need to act on a community or regional basis.” The guidelines recommend, for example, that hospitals participate in regional or community coalitions formed to control antimicrobial resistance. They also urge facilities to share information about patients at the time of transfer.
Active surveillance cultures
One of the more contentious debates in combating multidrug-resistant infections is how and when to use active surveillance cultures.
According to Dr. Siegel, who is professor of pediatrics at the University of Texas Southwestern Medical Center in Dallas, some experts feel that because MRSA and vancomycin-resistant enterococcus (VRE) are becoming so widespread, hospitals should embrace much broader use of active surveillance cultures for those particular organisms.
Hospitals are trying to decide whether to require all patients admitted to a high-risk area like the ICU to have cultures done for MRSA or VRE. But Dr. Siegel points out one problem with a blanket approach: It can leave you vulnerable to blind spots.
“We don’t just have to worry about MRSA and VRE,” she explains. “We may have to worry about resistant gram negatives as well.”
Because of such concerns, as well as limited resources, the guidelines take a flexible approach based on assessing conditions within each facility. While active surveillance cultures are identified as an effective control tool, the guidelines say they should be used selectively only where needed.
Say, for instance, an ICU is seeing a large number of MRSA cases developing more than 48 or 72 hours after admission. The hospital may want to perform active surveillance cultures to identify patients who are entering the unit with asymptomatic MRSA colonization that would otherwise remain undetected.
But if there is little evidence for transmission of infection in a unit, it may be more appropriate to focus on other prevention strategies. Those include bundled practices to prevent central line associated bloodstream infections or ventilator associated pneumonia.
Culturing clinical staff
The guidelines also review areas that raise questions from physicians and other clinical staff. Take, again, the example of an ICU that is seeing a lot of MRSA cases. Should cultures be done on the staff working in the unit?
According to Dr. Siegel, the literature confirms that such culturing does take place. However, cultures of clinical staff are not what she calls a “first-state intervention.”
“In studies that have been done, it’s unusual for health care personnel to be the source of the organism,” she says. “We’ve seen it, particularly in cases of nurses who have artificial nails, chronic draining ear infections or weeping dermatitis. But that’s unusual, and we should focus on other interventions first.”
Surface cleaning is another common concern. Over the years, Dr. Siegel points out, infection-control experts have debated whether environmental surfaces play a role in transmission and how important it is to keep them clean.
The guidelines summarize data from newer studies, which show that when pathogens such as C. difficile or VRE are in the GI tract “especially when patients have diarrhea “contamination of the environment takes on a bigger role. In such cases, she says, the literature indicates that keeping surfaces clean and disinfected makes an impact.
The guidelines also stress the importance of administrative support in campaigns to reduce and eliminate multidrug-resistant organisms. While such support may not be the sexiest aspect of fighting infections, the literature does find evidence that getting the participation of senior administrators makes a big difference in whether or not infection-control programs succeed.
Getting physicians on board
But Dr. Siegel is quick to point out that updated evidence and new guidelines are all futile if physicians and other caregivers don’t get involved. That’s why the guidelines also focus on another key problem in infection control: the attitudes of physicians and other health care personnel.
“In surveys, physicians will say, ‘Yes, I think antimicrobial resistance is a big problem,’ but they’ll also say it’s not their personal problem,” says Dr. Siegel. That’s because physicians are convinced that they’re doing all the right things, like maintaining strict hand hygiene.
“But in fact, they may not be aware of resistance patterns in their facilities,” she adds. “The antimicrobials they’re prescribing may unknowingly encourage the emergence of resistance.”
Part of the problem is often a lack of hard data to support recommendations for preventing and treating multiple-resistant infections.
To address that problem, the new guidelines grade the quality of evidence behind each recommendation to help physicians decide which strategies may be the most promising.
The guidelines also review the literature on education for infection control. They include a review of studies examining educational initiatives that target staff who have contact with patients, as well as campaigns to educate patients and family members to remind health care workers about hand hygiene and other preventive measures.
All of the literature has reached the same conclusion, Dr. Siegel points out: Every member of the health care team must understand how each of them contributes to the problem of antimicrobial resistance and what each can do to prevent it.
For physicians, she says, that means understanding how organisms are spread from patient to patient in the hospital, and what they can do to prevent or interrupt that process. “Physicians also must understand how to make prudent choices when prescribing antibiotics.”
While the guidelines call on all clinicians to take more responsibility for preventing resistance, Dr. Siegel says that hospitalists have an especially vital role.
“Hospitalists can take the lead by modifying the antimicrobials they use based on the resistance they’re seeing in their facility,” she explains. They also have a major opportunity to reduce resistance through standardizing practices.
“Enough studies and strategies have been published to help health care personnel adhere to the recommendations,” she points out. “Now, it is now up to each provider to take an active role in prevention.”
Edward Doyle is Editor of Today’s Hospitalist.