Multidrug-resistant organisms (MDROs) have become the bane of the US healthcare system, increasing healthcare costs and utilization while worsening outcomes for patients. In some places, the problem is so bad that we already have speculation about a “post-antibiotic era” – a time when essentially all antibiotics are no longer effective in treating common infections due to increases in bacterial resistance. The good news is that we already have evidence-based approaches to reduce the prevalence of highly-resistant organisms in healthcare facilities. (Hint: they do not involve blasting the bacteria with increasingly powerful antibiotics.)
We tend to take this one for granted. All healthcare workers wash their hands…right? Unfortunately, when studies have measured this objectively, they found that, on average, healthcare workers in US hospitals miss more than half of all hand hygiene opportunities. A big part of the problem is that most people are pretty good about washing hands on the way into a patient care room and on the way out, but they tend to miss opportunities in between.
The World Health Organization (WHO) has published “Five Moments for Hand Hygiene,” including
- Before touching a patient
- Before clean or aseptic procedures
- After exposure to body fluids
- After touching a patient
- After touching a patient’s surroundings
You can imagine how several of these would be missed. Maybe a nurse goes to hang an IV bag after performing hand hygiene on the way into the room, but then does not wash again between hanging the bag and giving oral medications. That IV medication may have been prepared in the clean environment of a pharmacy, but the bag then gets passed across multiple unclean surfaces before arriving at a patient’s bedside. Even with hand hygiene on the way into the room, the nurse’s hands could be contaminated by handling the IV bag and pass resistant bacteria on to the patient by way of the subsequent oral medications.
So, how do you get people to wash their hands? I imagine the first answer that comes to mind for most of us is “education.” In a sense, I agree, but it needs to be the right kind of education. We all know that training modules, posters and newsletters accomplish little, if anything, when it comes to changing behaviors. The most successful hand hygiene campaigns involve continuous monitoring with immediate feedback, meaning someone gets the unenviable task of playing hall monitor – calling out other staff members when they see a missed opportunity for hand hygiene. When presented in a constructive manner (and, perhaps, accompanied by some sort of incentive for staff members to improve their compliance), this type of intervention can start to effect cultural shifts with a sense of shared purpose.
Antibiotic overuse is perhaps the greatest factor driving the rise of MDROs, so it stands to reason that curbing unnecessary antibiotic use would decrease rates of MDROs in a given population. One large literature review concluded that implementing an antimicrobial stewardship program (ASP) resulted in a 17% decrease in rates of antibiotic resistance. When ASPs were coupled with interventions to improve hand hygiene rates, the drop in MDROs increased to 66%.
In addition to reducing rates of drug resistance, ASPs demonstrate “ripple effects” that consistently save individual healthcare facilities hundreds of thousands of dollars per year. Just in case cutting MDROs by two-thirds doesn’t seem like a compelling enough reason to have a well-developed ASP…
Let me be clear here – I’m not a fan of the MRSA nasal swab. Or the VRE rectal swab, for that matter. When I talk about surveillance, I’m thinking mostly of a robust Infection Prevention program to keep tabs on patterns of antibiotic resistance at a given facility. In my mind, if we’re doing the other things on this list well, it won’t matter whether the screening swab is positive because we won’t be giving resistant organisms a chance to be transmitted anyway.
A good Infection Prevention (IP) team tracks all resistant organisms diagnosed in its facility to ensure that special precautions are implemented when required (although they often are not necessary…see my post on contact precautions). Infection preventionists can also be good resources on hand hygiene initiatives, as well as regulatory requirements for MDRO reporting. With consistent, up-to-date data on MDROs, the IP team can often spot outbreaks early and take steps to arrest them.
You can’t change what you can’t measure. A gut feeling that your facility has a lot of MDROs is a lot less helpful than a line list of organisms, dates and locations. These data points, typically maintained by the IP team, can be invaluable for pattern recognition and assessment of progress when it comes to MDRO transmission.
Historically, the idea of “decolonization” applied mostly to eliminating asymptomatic patient carriage of Staph aureus. However, we have a growing body of evidence to show that universal decolonization with the same measures previously used to manage Staph aureus can also significantly impact other MDROs. Daily chlorhexidine baths for all patients, for example, cut rates of MRSA and VRE (both colonization and infection) by more than half in one large meta-analysis. Decolonization plus aggressive environmental cleaning, as implemented by one VA Community Living Center in North Carolina, decreased MRSA infections by almost 90% and MRSA colonization by over 70%. Even though the intervention was focused on MRSA, the CLC also observed a marked decreased in ESBL E coli (62%) with no new cases of ESBL Klebsiella, VRE, CRE or C difficile recorded during a four-year follow up period.
The materials used in decolonization (usually topical chlorhexidine, mupirocin and/or iodine) are generally inexpensive and well-tolerated by patients with remarkably few serious adverse reactions. Thus, decolonization, whether universal or targeted to specific organisms, can be a safe, cost-effective option for controlling MDROs at the facility level.
Decreasing unnecessary device use
Bacteria love medical devices. Those metal and plastic surfaces against human tissue offer a safe haven from the immune system. Immune cells have to be delivered via the bloodstream, and medical devices get no direct blood flow. With no immune cells to chase them away, bacteria attach to inorganic surfaces with impunity, slime-coating them with a layer of tenacious biofilm that offers even more protection from host immunity. Central lines, bladder catheters and endotracheal tubes may be necessary to patient care, but the longer and more frequently we use them, the more opportunities they provide for device-associated infections.
Central venous lines are probably the lowest-hanging fruit in the group. We tend to place these and then forget about them as long as the patient still has working IV access. IV access is not always critical, however – particularly once patients have been stabilized from the worst of their illness. Medications (especially antibiotics) can often be safely converted to enteral forms (oral or through a feeding tube), rendering the central line unnecessary. Even when IV medications are required, we often have room for improvement with regard to access. Non-tunneled lines could be converted to tunneled lines when patients need them for an extended period. Many patients do just fine with peripheral access and do not necessarily need a central line despite treatment over weeks. Even when venous access is difficult, the midline provides a nice compromise between the peripheral IV and the PICC – offering more reliable access than the peripheral with a lower risk of DVT and line-associated infection than the PICC.
Bladder catheters and endotracheal tubes may not be so easily substituted, so the key with these items is to be aggressive about attempts to remove them. Make sure that Foley is in place because the patient can’t void without it and not just because it’s more convenient for staff to track urine output. See if patients can be pushed to extubation sooner or converted to tracheostomy when they will likely require prolonged ventilatory support. When these devices can’t be removed, maintenance is another important element, including regular oral care for intubated patients and regular cleaning of the tubing and skin around the insertion site of a urinary catheter.
Decreasing medical device use will not only reduce opportunities for resistant organisms to set up shop, it will also improve a number of other quality metrics, since device-related infections have been a particular concern among regulatory bodies in recent years.
We’ve all heard reports of how filthy surfaces can get in the healthcare environment. From the doctor’s tie to the countertops to the phones in patient rooms, there are a lot of places to deposit resistant bacteria, and many can be easily overlooked. MDROs will seize this opportunity, and, without intervention, they may persist on surfaces for weeks or more. (C difficile might be the most extreme example of this, with viable organisms recovered from a hospital floor five months after exposure.) I have seen outbreaks traced to water coolers, hospital plumbing, reusable basins…if it’s a surface in a hospital, it could potentially become a source of transmission for MDROs.
Environmental cleaning in a healthcare facility should be consistent and thorough – preferably with regular audits of quality and quantity. Special attention should be paid to high-touch surfaces like doorknobs and countertops, and some high-touch surfaces like privacy curtains may require either a separate cleaning process or replacement, if no reliable cleaning process is in place. In some cases, the cleaning agents may need to be tailored to the job. For example, C difficile and norovirus are not reliably killed by the alcohol or quaternary ammonium products most often used to clean hospitals – bleach-based products are a better bet.
Some newer technologies show promise to help improve environmental cleaning in the healthcare setting. UV-C lamps and hydrogen peroxide vapor units are probably the most visible at present. While we know these interventions are effective at killing microbes, they have yet to prove themselves superior to manual cleaning on a broader scale. If your facility already owns one of these technologies, it may be a useful supplement to existing cleaning practices. If not, an investment in traditional cleaning resources and auditing will likely yield better results than an investment in relatively unproven new cleaning devices.
MDROs threaten the quality of healthcare in the US, and our previous approach of expanding the antibiotic arsenal to compensate has only made the problem worse. Fortunately, years of experience and a sizable body of medical literature have shown us that our best defense is a combination of tracking these organisms, eliminating places for them to hide and avoiding unnecessary antibiotic exposures. Antimicrobial stewardship, infection prevention programs and input from experts in infection and hospital epidemiology are all critical to reducing healthcare costs, improving outcomes and ensuring that we have effective antimicrobial options for years to come.