Stemming the threat of MDROs

The dire statistics from the Centers for Disease Control and Prevention (CDC) on the soaring rates of antibiotic-resistant infection and resulting mortality haunt the long-term care (LTC) industry. Data show that antibiotic-resistant organisms account for roughly 2 million illnesses per year and 23,000 deaths; Clostridium difficile infections result in roughly 250,000 illnesses per year with 14,000 deaths. Although the total yearly cost to the U.S. economy of antibiotic-resistant organisms associated with urinary tract infections (UTIs), pneumonia, skin and soft tissue infections and C. diff have been difficult to calculate, estimates have ranged as high as $20 billion (for direct healthcare costs) and an additional $35 billion in lost productivity (2008 dollars).

And even though the simple act of hand-washing is the first line of defense against these insidious bugs, it’s going to take more than a burst of soap to mop up this mess.

WHAT’S POSING THE THREAT?

“The ‘garden variety’ multidrug-resistant organisms (MDROs) such as Methicillin-resistant Staphylococcus aureus  (MRSA), Vancomycin-resistant enterococcus (VRE) and extended-spectrum beta-lactamases (ESBLs) continue to be identified in the LTC population and cause a variety of infections,” says Phenelle Segal, RN, CIC, president of Infection Control Consulting Services in Delray Beach, Fla. “Unfortunately however, we are seeing the ‘newest kid on the block’ that was originally identified in the hospital setting but has become more common in LTC facilities. The highly-resistant carbapenem-resistant enterobacteriaceae (CRE) group of organisms that was limited to Klebsiella pneumoniae but is now represented by many gram-negative organisms, has a high mortality rate, and there are no traditional antibiotics to combat illness from this group.”

David Condoluci, DO, chief patient safety and quality officer for Kennedy University Hospital in Stratford, NJ, adds: “In skilled nursing facilities, the antibiotic-resistant infections become a major problem because many residents are in closed quarters, plus they’re very debilitated. So if strict infection control procedures are not in place, these organisms can be transferred from one patient to another and can spread throughout the facility. And an infection such as C. diff can cause complications like sepsis.”

And if all that weren’t enough, “Hospitals are discharging patients at such an early stage of their illness that residents are being admitted to nursing homes with similar issues to the acute care facilities,” Segal says.

WHAT CREATED THIS SITUATION?

Beyond diligent hand-washing, Condoluci says, there is one blatant culprit: “Over the years, the use and abuse of antibiotics have caused these organisms to become resistant. In particular, the multiresistant gram-negative rods are sometimes immune to—not just some—but all of the traditional antibiotics we have available.”

The situation is critical, Segal explains, because “resistant organisms continue to outsmart the development of antibiotics to combat the infections resulting from them. Morbidity and mortality statistics tell the story of how dire a situation it is.”

But with stringent infection control, as outlined below, Condoluci says, “We will be able to control the emergence of these organisms. But in the end, organisms are very adaptable to their environment. So while we need to be diligent about how infections spread, we’re always going to see resistant organisms because the use of antibiotics is very pervasive in our society.”

And that pervasiveness is not limited to physicians prescribing antibiotics. Antibiotics are put in the feed of animals to help fatten them up and avoid some of the infections they might be predisposed to. “That, too, creates resistant bacteria. So I think MDROs are going to be around for the foreseeable future for sure, but that doesn’t mean we can’t be judicious and control how we use antibiotics and how we can prevent the emergence of these resistant organisms with good infection prevention practices and the use of antimicrobial agents,” Condoluci advises.

BEST PRACTICES

Condoluci outlines specific standards to be adhered to by not just LTC facilities, but by physicians, sub-acute facilities and hospitals:

1. Restrict antibiotic usage to only those with absolute infections. Limit usage to short periods of time, and do not extend usage any longer than necessary. Prescribe the least broad and most effective antibiotic so you’re not putting pressure on the facility’s environment. This approach will preserve the opportunity to use other antibiotics in the future.
2. Remove any devices as quickly as possible once they’re no longer needed for the resident’s care. Any device that’s put into the body that breaks the skin is an opportunity for infection. This includes Foley catheters, tubes that deliver nutrition or antibiotics, PICC lines and long-term vent units. All of these can be colonized with MDROs, leaving residents vulnerable to pneumonia or sepsis.
3. Reposition immobile residents to avoid decubiti, another potential source of infection.
4. Schedule adequate staff for each shift to ensure that your volume of residents is being cared for, and that complexities are being addressed.
5. Instruct staff to adhere to good infection control practices, and require everyone to use these practices in their daily routines. Proper and continual staff training is important.
6. Encourage family members to be advocates for their friends and loved ones. Just the fact that someone is watching over the care of a resident heightens everyone’s awareness. Administrators and directors of nursing need to have an open door policy and encourage family and friends to ask questions and state their concerns.

NATIONAL EFFORTS

Sept. 18, the White House released a 33-page report entitled “National Strategy for Combating Antibiotic-Resistant Bacteria,” in which a series of goals and benchmarks have been targeted to be met by 2020. Among these anticipated outcomes:

• eliminate the use of medically important antibiotics for growth promotion in animals;
• develop and disseminate licensed point-of-need diagnostic tests to distinguish between bacterial and viral infections in 20 minutes or less; and
• accelerate the development of new antibiotics, other therapeutics and vaccines. The government’s Biomedical Advanced Research and Development Authority has been challenged to file FDA new drug applications for a new antibiotic by the end of 2018.

“Honestly,” Condoluci says, “People want to do the right thing. They don’t go into this field to hurt people. But that said, there’s a lot of pressure and a lot of demands today, and we need to make sure that everybody is adhering to the best standards and practices.”

Tobi Schwartz-Cassell is a freelance writer based in Cherry Hill, NJ.

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