Reducing Antimicrobial Resistance and Hospital-Associated Infections: The Role of the Hospitalist

Prevent Infection

1. Vaccinate
2. Get the catheters out

Diagnose and Treat Infection Effectively

3. Target the pathogen
4. Access the experts

Use Antimicrobials Wisely

5. Practice antimicrobial control
6. Use local data
7. Treat infection, not contamination
8. Treat infection, not colonization
9. Know when to say “no” to vanco
10. Stop treatment when infection is cured or unlikely

Prevent Transmission

11. Isolate the pathogen
12. Break the chain of contagion

These steps are designed to optimize patient safety and the outcome of infectious disease management, and hospitalists have the ability to utilize these recommendations to improve the care of their patients.

Hospitalists must employ efforts to prevent infections that may occur during hospitalization as well as those that may bring patients back to the hospital. Such efforts include predischarge influenza and pneumococcal vaccination when indicated, to reduce the more than 100,000 hospitalizations and 20,000 deaths due to influenza and the more than 12,000 deaths due to Streptococcus pneumoniae (10). Clinicians should get annual influenza vaccines as well, to reduce transmission to patients and to other healthcare workers.

Because catheters and other invasive devices are the No. 1 cause of hospital-acquired infections, evidence-based efforts must be utilized to reduce the likelihood of such infections. An estimated 250,000 catheter-related bloodstream infections (CR-BSI) occur each year, with an attributable cost of at least $25,000 per infection and an attributable mortality of 12–25% (11). Because of this, the CDC has recommended adherence to performance indicators for reducing bloodstream infections (8,12). Such performance indicators are based on strong evidence (13-15) and include the following:

1. Appropriate site selection for catheter placement (i.e., subclavian over femoral or internal jugular) (14)
2. Appropriate hand hygiene and aseptic technique (including use of maximal sterile barriers) during catheter placement
3. Adequate skin asepsis (using chlorhexidine preferentially over iodine or alcohol based solutions) (15)
4. Catheter discontinuation when no longer essential
5. Antibiotic-impregnated catheters in high-risk patients

Recent studies have demonstrated that CR-BSI can be significantly reduced or even virtually eliminated with educational efforts combined with strict adherence to evidence based guidelines for prevention, as well as efforts to remove catheters early (16).

To diagnose and treat infections effectively, hospitalists must obtain appropriate cultures, target empiric therapy to the likely pathogens and local antibiogram data, and target final therapy to the known pathogens and antimicrobial susceptibility test results. The correct regimen, timing, dosage, route, and duration of antibiotic can impact morbidity and mortality in patients presenting with infectious diseases. Therefore, careful selection becomes crucial, and accessing infectious disease expertise in complex or critically ill patients with infectious diseases can be lifesaving.

Wise or appropriate use of antimicrobials can be facilitated by multiple efforts within hospitals. First, practicing antimicrobial control at the institutional level may involve use of standardized antimicrobial order forms, formulary restrictions, prior approval to start or continue specific antimicrobials, pharmacy substitution or switch, multidisciplinary drug utilization evaluation, provider performance feedback, or computerized decision support ordering systems. Many of these efforts can reduce costs while improving outcomes. Second, because the prevalence of resistance can vary by location, patient population, hospital unit, and length of stay, knowledge of the inpatient population that one treats (e.g., community vs. tertiary care, immunocompetent vs. immunosuppressed, or ICU vs. non-ICU) as well as the local antibiogram can help clinicians make decisions regarding initial antimicrobial selections.