Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine (2022) / Chapter Skim
Currently Skimming:
5 Stewardship and Infection Prevention
5 Stewardship and Infection Prevention
Pages 165-222
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 165... ...
cites the optimal use of antimicrobial medicines in human and animal health as one of its main objectives (Mendelson and Matsoso, 2015)
|
From page 166... ...
This chapter presents the committee's analysis of key bottleneck problems related to stewardship and infection prevention, in both humans and animals. This is not an exhaustive analysis of every possible tool for stewardship or infection prevention.
|
From page 167... ...
Starting in 2017, the Joint Commission, the organization that accredits hospitals, has assessed hospital stewardship programs as part of their review (Joint Commission, 2016)
|
From page 168... ...
CDC surveys indicate that hospitals with 25 or fewer beds, many of them designated Critical Access Hospitals that support rural or remote areas, account for most of the remaining hospitals without complete stewardship programs (CDC, 2020g)
|
From page 169... ...
79% 96% 70% 93% 89% 76% 77% 85% 99% 84% 75% 92% 94% 73% 88% 100% 94% 86% 94% 92% 87% 96% 90% 98% 90% 93% 100% 93% 86% 88% 96% 74% 93% 97% 92% 100% 98% 94% 91% 83% 83% 84% 97% 86% 87% 88% 70–83% 81% 86% 84–89% 78% 96% 90–94% 75% 96–100% 88% FIGURE 5-1 Percentage of hospitals meeting all seven core elements of hospital antibiotic stewardship programs by state, 2019. NOTE: Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S.
|
From page 170... ...
Impact of a Telehealth Based Antimicrobial Stewardship Program in a Community Hospital Health System. Clinical Infectious Diseases, 71(3)
|
From page 171... ...
Nursing Homes, Long-Term Acute Care Hospitals, and Dialysis Centers There are several clinical practice settings similar to hospitals in their misuse of antimicrobials, vulnerable patient populations, and an administrative structure conducive to implementing change. Recent government response to the COVID-19 pandemic recognizes the unique importance of these practice settings, with the CDC creating special outbreak control teams to deploy to nursing homes, dialysis clinics, and other skilled nursing settings to prevent and control the spread of SARS-CoV-2 and other infectious diseases (CDC, 2021c)
|
From page 172... ...
. Yet a recent survey found that only a third of nursing homes had comprehensive antimicrobial stewardship programs (Fu et al., 2020)
|
From page 173... ...
National surveys of long-term acute care have found 84 percent of S aureus bloodstream infections acquired from central lines are resistant to methicillin; 44 percent of Enterococcus faecalis urinary tract infections acquired from catheters are resistant to vancomycin (Chitnis et al., 2012; Gould et al., 2006)
|
From page 174... ...
These practice settings also all have a financial relationship with CMS that could be used to encourage implementation of good stewardship practices. Recommendation 5-1: The Centers for Medicare & Medicaid Services should require nursing homes, long-term acute care hospitals, and dialysis centers to have antimicrobial steward ship programs and include that information on the Care Com pare website.
|
From page 175... ...
The Agency for Healthcare Research and Quality (AHRQ) provides simple toolkits to help nursing homes implement their stewardship programs.
|
From page 176... ...
. Record keeping in nursing homes can also be uneven; a recent national survey found only about half used electronic medical records (Bjarnadottir et al., 2017)
|
From page 177... ...
. Research in nursing homes has not found evidence that stewardship programs reduce infection, hospitalization, or mortality rates among residents, but do tend to reduce unnecessary antibiotic use and improve adherence to stewardship guidelines (Feldstein et al., 2018)
|
From page 178... ...
. CMS created the star rating system for nursing homes in 2008; it draws on inspection reports, staffing review, and quality measures such as vaccination coverage and percentage of residents with urinary tract infections, pressure sores, and in physical restraints (CMS, 2020; Horton et al., 2020)
|
From page 179... ...
The USDA's National Animal Health Monitoring System (NAHMS) conducts regular (every 5 to 10 years)
|
From page 180... ...
At the writing of this report, the FDA Center for Veterinary Medicine had pilot projects under way to get additional information on antimicrobial use in animals. In 2016, it funded two 5-year cooperative agreements, one characterizing antimicrobial use in U.S.
|
From page 181... ...
This information would support the design and implementation of stewardship programs. Prescription data would help make more sense of raw antimicrobial use information as it would clarify what species is being treated; it would also allow insight into where stewardship programs are working and what practices help promote them (Pinto Ferreira, 2017)
|
From page 182... ...
. Therefore, mandatory electronic prescriptions are a valuable long-term goal in veterinary medicine.
|
From page 183... ...
There are other ways to monitor antimicrobial use to inform stewardship programs in each state. In any case, the monitoring system used is less important than the measures of use derived.
|
From page 184... ...
. For these reasons, agricultural extension is already highlighted in USDA and CDC's antimicrobial resistance programming (NIMSS, 2017)
|
From page 185... ...
in veterinary medicine is held back by challenges in availability and use of veterinary diagnostic tests. Some of the factors that encourage reliance on empiric treatment in human medicine apply to veterinary medicine as well (e.g., slow turnaround time for diagnostic test results)
|
From page 186... ...
Since the late 1980s, CLSI has convened the Sub-Committee on Veterinary Antimicrobial Susceptibility Testing to develop interpretive breakpoints for bacterial pathogens in animals (Lubbers, 2021)
|
From page 187... ...
This committee would work with the CLSI Veterinary Antimicrobial Susceptibility Testing subcommittee and with clinical stakeholders to assess the various microbe–drug–species combinations and identify the most urgent needs for animal health and public health. The committee need not start from scratch.
|
From page 188... ...
Both epidemiological and clinical studies are needed to assess the effectiveness of national and regional stewardship programs. Better education and member outreach, something the associations have experience with, could help strengthen efforts to increase diagnostic testing.
|
From page 189... ...
By making test results available to clinicians before they start empiric treatment, diagnostic testing can avoid much unnecessary empiric treatment. In a 2018 commentary, Jim O'Neill, the lead commissioner of the O'Neill report, described rapid diagnostics as "the single biggest potential game changer in the fight against antimicrobial resistance" (Collier and O'Neill, 2018)
|
From page 190... ...
Despite wide agreement that rapid diagnostic tests could reduce unnecessary reliance on antimicrobials, their uptake has been slow and uneven (PCAST, 2020; Review on Antimicrobial Resistance, 2015)
|
From page 191... ...
One rapid diagnostic test that would optimize patient care is a pointof-care test to distinguish viral from bacterial infection. A blood test that can make this distinction in 12 hours, rapid only in comparison to traditional culture and disk susceptibility testing methods, is projected to hasten de-escalation in hospitals, with the potential to reduce antimicrobial use by 14 percent (Yui et al., 2020)
|
From page 192... ...
. The limited use of rapid diagnostics has downstream negative consequences for antimicrobial resistance (Roope et al., 2019)
|
From page 193... ...
could help remove that barrier by supporting the outcomes research on diagnostic testing that the CDC, the Infectious Diseases Society of America (IDSA) , and other societies use to inform their practice guidelines.
|
From page 194... ...
° Reduction in morbidity and mortality (note: ideal outcome measure, but difficult to demonstrate) ° Faster time to isolation for infection control when indicated; reduction of isolation time when not indicated ° Identification of patient populations or subsets who would receive maximum benefit Direct Economic Value ° Overall cost savings in patient management ° Reduced costs associated with antimicrobial treatments ° Reduced hospitalization costs (e.g., length of stay, days in intensive care unit, days of ventilator use)
|
From page 195... ...
Even with sufficient evidence to inform treatment guidelines, rapid diagnostic tests still face an uphill battle, with many clinicians choosing to wait for traditional culture and susceptibility testing before de-escalating or changing treatment. For example, genotypic assays that screen for the mecA gene can accurately determine resistance or susceptibility to methicillin in staphylococci, including Staphylococcus aureus (Bakthavatchalam et al., 2017)
|
From page 196... ...
. Though aware of these barriers, the committee encourages more attention to the evidence linking diagnostic testing with patient outcomes.
|
From page 197... ...
Especially in developing countries, antimicrobial stewardship plans need to take a broad view, with an eye on reducing the need for antimi crobials. The WHO has put considerable emphasis on infection preven tion in its toolkits for antimicrobial stewardship programs in low- and middle-income countries, though these toolkits are intended for use in clinical medicine, where concepts like infection prevention are necessar ily somewhat narrow in scope (Pierce et al., 2020; WHO, 2019a)
|
From page 198... ...
Although many studies have assessed the efficacy of vaccines in reducing infections, few high-quality studies evaluate their effect on antibiotic use and antimicrobial resistance. Figure 5-4 shows several possible pathways through which use of vaccines could reduce antimicrobial resistance.
|
From page 199... ...
gonorrhoeae, and group B strep vaccines in development Preferentially targeting PCV Some, PCV antimicrobial-resistant lineages of infectious bacteria Preventing hospital- MRSA, CRE, and Acinetobacter No population study acquired infections vaccines data yet, vaccines still in development in pipeline Protecting against diseases Influenza, measles, COVID-19 Little, and mostly that make patients prone to concerning secondary bacterial infection antimicrobial use Preventing nonbacterial Influenza, rotavirus, COVID-19, infections that produce malaria, and dengue, as well as syndromes that prompt RSV vaccine in development antimicrobial use or misuse NOTE: CRE = carbapenem-resistant Enterobacteriaceae; Hib = Haemophilus influenzae type b; MRSA = Methicillin-resistant Staphylococcus aureus; PCV = pneumococcal conjugate vaccine; RSV = respiratory syncytial virus; TCV = typhoid conjugate vaccine. It follows that by reducing use of antibiotics, immunization would in turn slow the emergence of resistance.
|
From page 200... ...
Since their introduction, multiple studies, mostly in high-income countries, have shown an association between pneumococcal conjugate vaccines and reduced antibiotic use, reduced use of second-line antibiotics, and reduced incidence of resistant infections (Klugman and Black, 2018)
|
From page 201... ...
. A similar pattern holds with typhoid conjugate vaccines, which are underused in endemic areas, but preventing multidrug-resistant infections is an important reason for adoption (Khan et al., 2017)
|
From page 202... ...
. Adding measures of resistance to immunization trials would be a relatively minor additional effort that could yield a disproportionate payoff in terms of understanding this tool for infection prevention.
|
From page 203... ...
. Increasing azithromycin-resistant Salmonella Typhi in South Asia has prompted calls for wider use of a new typhoid conjugate vaccine (Bhutta, 2020; Carter et al., 2020)
|
From page 204... ...
. The Wellcome Trust has recently supported research investigating the effect of vaccines on measures of antimicrobial resistance and use (Wellcome, 2021)
|
From page 205... ...
Clinical Infectious Diseases 61(7)
|
From page 206... ...
2015b. The core elements of antibiotic stewardship for nursing homes.
|
From page 207... ...
2019c. Core elements of hospital antibiotic stewardship programs.
|
From page 208... ...
2012. Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010.
|
From page 209... ...
2015. Infection prevention and control in nursing homes: A qualitative study of decision-making regarding isolation-based practices.
|
From page 210... ...
Clinical Infectious Diseases 70(7)
|
From page 211... ...
2020. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey.
|
From page 212... ...
Clinical Infectious Diseases 68(8)
|
From page 213... ...
Clinical Infectious Diseases 68(Suppl 2)
|
From page 214... ...
Clinical Infectious Diseases 65(11)
|
From page 215... ...
Clinical Infectious Diseases 57(9)
|
From page 216... ...
2017. Implementing an antibiotic stewardship program at a long-term acute care hospital in Detroit, Michigan.
|
From page 217... ...
Acute care hospitals: Findings from the 2014 National Healthcare Safety Network annual hospital survey. Clinical Infectious Diseases 63(4)
|
From page 218... ...
2016. Optimizing antibiotic use in nursing homes through antibiotic stewardship.
|
From page 219... ...
Clinical Infectious Diseases 62(9)
|
From page 220... ...
Clinical Infectious Diseases 73(4)
|
From page 221... ...
: Collaboration across Washington State to improve antimicrobial use. Open Forum Infectious Diseases 4(Suppl 1)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.