The literature is replete with white papers, research studies, guidance documents and strategic plans addressing the escalating problem of antibiotic-resistant bacteria. The continued emergence of multi-drug resistant organisms (MDROs) combined with a decreasing antimicrobial pipeline for new drugs has long been recognized as a serious threat to patient safety by infection control professionals.
In 2006, the Centers for Disease Control noted in the guideline “Management of Multi-Drug Resistant Organisms in the Healthcare Setting” that MDRO control must include attention to judicious antibiotic use. Most recently, an executive order issued by President Obama to combat antibiotic-resistant bacteria calls for antimicrobial stewardship programs throughout the patient care delivery system.
Stewardship programs can help optimize the therapeutic use of antibiotics - appropriate selection, dosage, route of administration and duration of therapy - and decrease the incidence of MDRO infections that are associated with poor patient outcomes. Antimicrobial stewardship (AMS) is an interprofessional effort, to which the infection preventionist (IP) is a major contributor.
In 2012, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiologists of America (SHEA) published a position paper, “Antimicrobial Stewardship – A Collaborative Partnership Between Infection Preventionists and Healthcare Epidemiologists.”1 The authors provided broad examples of strategies used by IPs and healthcare epidemiologists to improve stewardship. Using a few of these examples, let’s consider some implications for an IP’s practice and the IP’s contribution as a collaborative partner in AMS:
1) Identification of MDROs detected among the population served
- Maintains line listings of patients with sentinel pathogens
- Establishes a system for flagging MDRO patients in the EMR
- Monitors compliance with isolation practices to reduce the risk of cross-transmission of the MDROs
- Establishes an alert system for identification of new MDROs
2) Monitoring and trending MDROs
- Quantifying healthcare acquisition of MDROs to assess the effectiveness of prevention measures
- Monitoring susceptibility profiles for resistance patterns
- Performing cluster/outbreak investigations associated with MDROs
- Preparing unit-based and facility-wide MDRO for comparative analysis and reporting
- Presenting data to Pharmacy and Therapeutics and Infection Control Committee
- Facilitating the implementation of MDRO control measures
- Reporting CMS mandated surveillance for MDROs
- Participating in research to identify risk factors of patients with MDROs
3) Education of clinicians on prudent and appropriate use of antibiotics
- Promotes antibiotic best practices, e.g. get cultures before starting antibiotics; appropriate choice and administration of surgical antimicrobial prophylaxis with prompt discontinuation.
- Translates antibiogram data and evolving resistance patterns
- Presents MDRO and antibiotic utilization data at unit-level performance improvement committees
- Discusses inappropriate antibiotic use with clinicians as detected through routine surveillance activities, e.g. patient with surgical site infection did not get prophylactic antibiotic in appropriate time frame
Although IPs are not prescribers of antibiotics, their scope of practice includes collection, analysis and reporting of MDRO data, which provides essential trending metrics for the antimicrobial stewardship team. Additionally, IPs assist with facilitation of antibiotic best practices and educate clinicians on resistance patterns and MDRO prevention measures.