In October, the Centers for Disease Control and Prevention (CDC), Atlanta, released new guidelines aimed at combating a deadly and growing problem within the nation’s hospitals—the spread of bacteria resistant to multiple types of antibiotics.
The “Management of Multidrug-Resistant Organisms in Healthcare Settings” guidelines call on health care facilities to establish comprehensive infection control programs and to take aggressive measures to reverse the steady rise in drug-resistant germs. For example, 30 years ago only 2 percent of Staphylococcus aureus infections were drug resistant, the CDC says. By 2004, that number climbed to 63 percent of reported cases.
In the following interview, John Jernigan, M.D., a medical epidemiologist with the CDC, discusses how the latest guidelines differ from the previous versions, what they mean for infection control managers, and why a new class of drug-resistant superbugs is on the rise.
Q: The CDC describes the “Management of Multidrug-Resistant Organisms in Healthcare Settings” as a new set of guidelines for health care facilities. How are these guidelines different than those developed several years ago by the Society for Healthcare Epidemiology of America (SHEA)?
A: The major differences between the SHEA guidance and the CDC guidelines center around a controversial issue—the role of active surveillance cultures.
Screening at-risk patients for multidrug-resistant organisms at the time of admission to either a unit or a hospital has been somewhat controversial.
Some scientists, including the authors of the SHEA guidelines, advocate the routine use of active screening to control certain pathogens. Other scientists argue that the precise role of active surveillance is, as yet, not clearly defined.
The CDC guidelines include a recommendation to use active surveillance cultures for certain multidrug-resistant organisms in patients and populations when other measures are failing to result in a reduction of resistance rates. But they allow each health care institution some flexibility in its approach, based upon the varying physical and functional characteristics of the facility, as well as the current rate of multidrug-resistant organisms. For example, ICU patients may have different needs than patients in long-term care facilities or cancer care patients.
The CDC document tries to focus on building a program that results in measurable effectiveness within an individual facility while allowing some flexibility in determining how to reach that goal.
Q: How do hospitals measure effectiveness?
A: The CDC document] emphasizes continuous and close monitoring of resistance rates as a measure of a program’s effectiveness. If, for example, one hospital chooses an approach that does not include active surveillance cultures, it is instructed to monitor the response to that approach by observing carefully what happens to its rates of infection and colonization with multidrug-resistant organisms. If the chosen approach isn’t successful at reducing these rates, then the guidelines recommend that a hospital take additional measures, including the use of active surveillance cultures. If a hospital isn’t successful using another approach, it will be led to a program that mirrors closely what is outlined in the SHEA guidelines.
If a hospital were to take an approach that didn’t use active surveillance and was showing levels of control equal to that achieved using active surveillance cultures, that’s a good outcome for patients, and it also sheds additional light on what other effective approaches might be. There may be more effective ways of controlling multidrug-resistant pathogens than what we currently know about, and so there may be opportunities to learn further.
Q: Do the new CDC guidelines offer any specific advice for OR nurses and infection control specialists? Is there anything that would change how either of these two groups do their work if their hospital adhered strictly to the new guidelines?
A: The guidelines place an emphasis on the level of institutional commitment necessary for success and on the resources that are needed to be available for detection, prevention and control.
This includes consultations both internally and externally, the necessary laboratory support, adherence monitoring and data analysis. Many of these activities are at the heart of what infection control practitioners do, and so increasing institutional resources and commitment to these activities should greatly assist their work.
If health care facilities follow these guidelines faithfully, I think infection control practitioners should find it easier to do what they are best trained to do—serve as a resource to help guide, advise and support an institutionwide program for preventing health care-associated infections, including those that are caused by multidrug-resistant organisms. Another difference is that these guidelines emphasize that effective control requires a multifaceted program representing a combination of interventions, including administrative support, judicious use of antimicrobials, surveillance to continuously monitor the impact of the [control measures], use of hand hygiene and barrier precautions. This means that many different groups of workers should be actively engaged as a team in addressing the problem. For example, materials management personnel should be actively engaged in making sure that all the appropriate supplies are available for barrier precautions in nursing, such as gowns and gloves, etc., and there will be direct implications for housekeeping departments who need to understand the important role of environmental cleaning as part of the solution. I don’t think it would have much direct impact on the operating room nurses.
Q: Has the CDC put any kind of dollar amount on what it would cost to adhere to these new guidelines?
A: It’s difficult to put a precise dollar amount on what the cost would be, as it’s likely to vary greatly from institution to institution depending on their individual circumstances. One might also ask the question, “How much would it cost (a hospital) to fail to adhere to the guidelines?” There are a number of cost effectiveness analyses in the literature suggesting that implementing successful control measures saves money. Health care-associated infections are extremely costly, and it appears that multidrug-resistant infections are more costly than those caused by drug-sensitive infections. Infections with drug-resistant organisms lead to increased lengths of stay, more complicated hospitalizations and an increased risk of death. These infections can cost tens of thousands of dollars each. Preventing even a few of them can save a lot of money for an institution.
Q: You talked about the importance of monitoring incidence rates. Will the CDC be involved in monitoring compliance with the measures or with tracking incidence rates at hospitals?
A: We are not a regulatory agency, and so we will not be monitoring rates unless hospitals want to work voluntarily with us to do so. We do have a surveillance tool that is available, voluntary and confidential. It’s called the National Health care Safety Network (NHSN). It’s an online, Web-based tool that allows hospitals to use standardized surveillance methodologies and definitions to measure infection rates and processes of care (www.cdc.gov/ncidod/hip/NNIS/members/nhsn.htm).
This includes infections caused by multidrug-resistant organisms. Hospitals can submit data to a centralized database over a secure data network through the Internet and get confidential feedback and reports that compare their local experience with that of the aggregate experience of all hospitals in the nation that are submitting the same data to the CDC.
This provides an excellent way for a hospital to monitor its progress and compare it with other facilities in a confidential manner.
Q: Taking a step back from the specific guidelines for a moment, what’s behind the surge in drug-resistant infections? Is it related to the quality of care at hospitals or is it some other factor, such as the overuse of antibiotics?
A: I think there is a confluence of multiple, complicated factors. Certainly, the overuse of antibiotics is an important component, depending on which drug-resistant organism you are talking about.
Antibiotics may play a more prominent role with some resistant organisms than with others, although there is little doubt that increased antibiotic use creates a selective advantage for resistant organisms and contributes to their spread.
Having said that, it’s not clear how much of the large volume of antibiotic use we see in hospitals today is inappropriate. We have patient populations in hospitals that are more ill, in general, than they used to be.
Not because patients are getting sicker, but because more and more medical care is being provided outside the hospital.
Those who are sick enough to require hospitalization now tend to be the sickest patients; and these patients often require more complicated and invasive treatments and more antibiotic use—all of which can add up to higher risk of resistant infections.
Much of the emergence of drug resistance can be attributed to transmission of resistant organisms from patient to patient in the hospital. This is especially true for MRSA (methicillin-resistant Staphylococcus aureus).
Most of the MRSA infections out there are a result of transmission that occurred during an encounter with the health care system. We know that, for example, hand hygiene—probably the single most important measure for preventing transmission of organisms from one patient to another—is woefully inadequate in hospitals across the country. People are actively working on that problem to find out how best to change the behavior of health care workers.
I don’t think poor adherence is the result of health care workers who are bad or neglectful people. I think certain barriers exist within the complex processes characteristic of today’s hospitals that work against adherence.
We need to learn a lot more about making changes in the systems of delivery that help overcome these barriers. We think that there is a lot of room for improvement in terms of basic infection control measures to prevent transmission of these organisms from one patient to another.
Q: We read a lot about MRSA being one of the more deadly and difficult pathogens to cope with. Are there other drug-resistant pathogens that hospitals need to be concerned about? And are there different ways of approaching how to deal with each of these different superbugs?
A: There are many emerging drug-resistant organisms in the United States and around the world that we should be aware of and make efforts to control.
These include strains of S. aureus that have intermediate susceptibility or are resistant to vancomycin (i.e., vancomycin-intermediate S. aureus, vancomycin-resistant S. aureus), and gram negative organisms that are resistant to multiple classes of antimicrobial agents such as certain types of Escherichia coli, Klebsiella pneumoniae and Acinetobacter baumannii.
There are many commonalities between the epidemiology of these organisms, and therefore many of the same prevention and control strategies can be used to address a variety of these resistant pathogens. Many of the interventions that one might put into place to control multidrug-resistant S. aureus, for example, would also work against other pathogens.
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