Inappropriate use or overuse of antibiotics can actually remove or “select” the sensitive microbes and promote overgrowth of resistant organisms when present. Each of these practices may serve as a focus for quality improvement interventions to reduce resistance.
Most healthcare-associated infections (more than 80%) originate from 4 specific patient sites: urinary tract, surgical-site (wound), bloodstream, and lung (pneumonia) (5). It is not coincidental that these infection sites are frequently associated with invasive procedures, and many times with indwelling invasive devices that may be used during the course of inpatient care. For example, urinary tract infections, the most common hospital-acquired infections, are usually associated with urinary catheter use. Similarly, bloodstream infections are usually associated with intravascular catheters, and hospital-acquired pneumonia is usually associated with ventilator use.
Because many of the invasive devices that are utilized during the course of inpatient care carry significant risk, including infection risk, it is incumbent upon hospitalists to be aware of these risks, to explain these risks to their patients, and to take all steps at their disposal to help reduce such risk in their patients. Dr. Julie Gerberding, Director of the CDC, has emphasized that the 2 greatest predictors of infection risk in the hospital are length of stay and use of invasive devices (6). While excellent evidence already demonstrates that hospitalists reduce length of stay (7), they should also spearhead the efforts to minimize the use of invasive devices whenever possible, and lead evidence-based efforts to minimize infection in hospitalized patients when invasive devices must be used.
Prevention of Resistance: Best Practices
CDC/SHM Collaboration
In September 2003, the Society of Hospital Medicine (SHM) and the CDC entered into a collaborative agreement to educate hospitalists about the reduction of hospital-acquired infections and the prevention of antimicrobial resistance. The long-term goals of this agreement include developing quality-improvement initiatives and research in the area of antimicrobial resistance reduction. The short-term goals include development of educational materials and resources for hospitalists aimed at reducing hospital-acquired infections and resistance. SHM has provided instruction in the reduction of hospital-acquired infections and antimicrobial resistance, in workshop format, to its membership at national, regional, and local chapter meetings. SHM has also developed an Internet-based educational tool for antimicrobial resistance on its Web site, which will soon be transformed into a new Web-based Resource Room to educate membership on antimicrobial resistance and reduction of hospital-acquired infections.
CDC Campaign
(www.cdc.gov/drugresistance/healthcare/)
The CDC, in collaboration with the National Institutes of Health (NIH) and the Food and Drug Administration (FDA), as well as professional societies, healthcare organizations, public health agencies, and corporate partners, has developed its Campaign to Prevent Antimicrobial Resistance to facilitate the implementation of educational and behavioral interventions that will assist clinicians in appropriate antimicrobial prescribing. The goals of these intervention programs are to improve clinician practices and prevent antimicrobial resistance. The campaign focuses on 4 main strategies: prevent infection, diagnose and treat infection, use antimicrobials wisely, and prevent transmission. Multiple 12-step programs have been developed (or are in the process of development), targeting specific patient populations, including hospitalized adults, dialysis patients, surgical patients, hospitalized children, and long-term-care patients. Each of these patient populations is relevant to the practicing hospitalist, who may access the educational materials and resources cost-free on the Internet. The CDC provides on-line resources (Web site listed above), including a downloadable slide-set, a 12-step fact sheet, and tips for patients. The program translates existing scientific evidence and national guidelines into action steps that can be taken now to prevent antimicrobial resistance.
The 12 Steps to Prevent Antimicrobial Resistance in Hospitalized Adults was the first intervention program to be initiated, because hospital patients are at especially high risk for serious antimicrobial-resistant infections. The rate of multiple drug-resistant organisms causing infection within our hospitals is increasing at a rapid rate. Currently, national data demonstrate that more than 50% of Staphylococcus aureus isolates causing infections in intensive care units (ICUs) are resistant to methicillin (MRSA), while more than 40% are resistant in other non-ICU hospital units (9). Similarly, gram-negative organisms have developed resistance, with more than 25% of Pseudomonas aeruginosa ICU isolates now resistant to fluoroquinolones (9), with a much higher percentage resistant at some institutions. This rapidly growing problem has led the CDC to develop the following 12 Steps to Prevent Antimicrobial Resistance in Hospitalized Adults: