By Cereste Duprat-Fabre, MSN, RN, NP, CBIS and Marianne Knox, RN, BSN, CCM, CBIS
Rainbow Rehabilitation Centers

Superbugs (germs with Antibiotic Resistance/ Antimicrobial Resistance) continue to be a challenge to physicians and health care workers worldwide. According to the CDC, “antibiotic resistance is one of the biggest public health challenges of our time.” The list of offending bacteria, viruses and fungi resistant to antibiotics/antimicrobials continues to grow within health care facilities and has spread into the community. Due to rising numbers of deaths, illnesses and associated costs for treatment, consumer groups, insurance companies and governmental agencies are demanding health care settings be accountable when an infection is acquired during a patient’s stay in a health care facility. Resistant bacteria are found in veterinary and agriculture industries (when food animals are fed antibiotics or animal feces are in water or used as fertilizers in crops). Resistant infections are also spreading in the community (antibiotic resistant TB, food born illness and sexually transmitted diseases). Because of increasing illnesses and deaths, the US government and agencies such as the CDC have taken ambitious steps to fight this growing threat. The US has developed a national action plan and is collaborating with multiple agencies worldwide to study and develop strategies to treat and prevent the spread of these infections.

What is Antibiotic Resistance

Antibiotic resistance happens when germs like bacteria, viruses and fungi develop the ability to defeat the drugs designed to kill them. The germs are not killed and continue to grow and cause infection and illness. Antibiotic resistance does not mean the body is becoming resistant to antibiotics; it is that bacteria have become resistant to the antibiotics designed to kill them.

Bacteria, viruses and fungi are ingenious small life forms that look for ways to survive and have always mutated, under pressure from antibiotics, into new strains. Studies have shown germs are sharing resistance with one another, even if they have never been exposed to antibiotics. These new strains are more toxic, difficult or impossible to treat due to antibiotics that have been used in the past or are no longer effective. In many cases, antibiotic resistant infections require extended hospital stays, additional follow-up doctor visits, and costly toxic treatment alternatives. The combination of antibiotic overuse and fewer new antibiotics being developed has fueled this mutation and spread of antibiotic resistant organisms (AROs).

AROs can be easily spread from person to person in health care facilities and in the community. Even when AROs are treated, they can remain colonized as germs living in or on the body, not causing illness to the host. AROs can be transmitted from environmental surfaces, foods or from person to person if prevention measures are not used effectively. In most instances, ARO infections target patients who have a reduced ability to fight infection due to pre-existing medical conditions, recent surgeries and/or indwelling medical devices, and especially those who are hospitalized, particularly in intensive care units (ICUs). Long-term care facilities have seen an increase in AROs from patients either coming from the hospital or from the spread amongst their physically compromised patients.

Generally, a healthy person is far less likely to become infected but can be colonized with no symptoms, potentially posing a risk to others in health care facilities or in the community. Click here for a list of ARO threats in the US.

ARO Prevention & Control

Successful prevention and control of AROs has been documented by using a variety of combined interventions. For patients these include:

  • Antimicrobial resistance awareness
  • Prudent use of antimicrobials
  • Maintenance of general health and managing chronic conditions
  • Preventative vaccinations
  • Handwashing
  • Cleaning scrapes/wounds and obtaining early intervention when ill
  • Always insisting your health care providers wash their hands and use gloves

For health care organizations:

  • Active surveillance of infections and awareness of antibiotic resistance patterns in the facility and community
  • Appropriate antibiotic prescription
  • AR education
  • Improvements in standard precautions
  • Diligent hand hygiene
  • Use of personal protective equipment (gloves, gowns, face masks, respirators, goggles and face shields)
  • Barrier precautions until patients are culture-negative for a target ARO

Know when to report infections and antibiotic treatment failures to the public health department. Enhanced cleaning of environmental surfaces and equipment is also a very important part of infection prevention. Private rooms are also suggested for infected patients. If a private room is not available, cohorting patients with similar infections and cohorting their caregivers is suggested.

Barrier Precautions

Infection prevention barrier precautions provide a foundation for infection prevention practices that span the spectrum of healthcare settings that include hospitals, home care, ambulatory care, freestanding specialty care sites, and long-term care. Having a standardized approach to barrier precautions, also referred to as isolation precautions, both simplifies and unifies the actions that healthcare personnel take, regardless of the setting.

Infection control precautions fall into different categories depending on the identified infection. However, protecting the patient by preventing the spread of any potential microorganism, known or unknown, is the goal. Infection prevention specialists can assign a particular precaution when warranted as a notice to health care workers, family and visitors. Personal protective equipment should be provided as needed.

Standard precautions are used for all patient care contact and include thorough hand hygiene (washing your hands with soap and water or using alcohol hand rubs) and the use of gloves to control infection. Gowns, masks and eye protection are also recommended when a splash of body secretions is possible. Hand hygiene and personal protective equipment changes are recommended for caregivers whenever they move between patients and even when they perform procedures to different areas of the body on the same patient.

Contact precautions are intended to prevent transmission of infectious agents including AROs that are transmitted by direct or indirect contact with the patient or the patient’s environment. In addition to standard precautions, wearing a gown and gloves (personal protective equipment) upon entering the room and removal of these items before leaving the room is recommended. Using private rooms, avoiding sharing of equipment, limiting transportation, and having the patient stay in the room are all strategies used with contact precautions. Masks and eye protection may also be required for splash potential.

Droplet and respiratory precautions are also implemented for airborne infections when warranted. Patients should wear masks when caregivers enter the room. Additionally, caregivers should also utilize masks. When possible, transportation of the patient should be limited. When possible, patients should be placed in a private room. There are highly specialized airborne precautions for certain illnesses such as TB that require negative pressure rooms and respirators.

What is Being Done to Combat the Problem

Antibiotic resistance has become a national priority, and the U.S. government has taken ambitious steps to fight this threat. A U.S. National Strategy for Combating Antibiotic Resistant Bacteria and an accompanying U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria (National Action Plan) was put in place and provided the following action plan:

  • Respond to new and ongoing public health threats
  • Strengthen detection of resistance
  • Enhance efforts to slow the emergence and spread of resistance
  • Improve antibiotics use and reporting
  • Advance development of rapid diagnostics
  • Enhance infection control measures
  • Accelerate research on new antibiotics and antibiotic alternatives

The U.S. government has also participated in the UN General Assembly High-Level Meeting which covered topics related to antibiotic resistance. The U.S. government launched the Antimicrobial Resistance Challenge, a yearlong campaign spearheaded by the CDC to encourage global organizations to make formal commitments that further the progress against resistance. The main goal is to prevent the spread of the AROs in this country and worldwide.

The bottom line is, antibiotic resistant microorganisms are a serious public health threat in health care facilities and in the community worldwide due to lack of available antibiotics. Healthcare facilities must not accept ongoing ARO outbreaks or high infection rates as the status quo. With appropriate infection prevention measures and combined interventions, facilities can significantly reduce and prevent AROs.


Resources

  • Combating antibiotic resistance, a global threat – Antibiotic / Antimicrobial Resistance (AM/AMR) https://www.cdc.gov/drugresistance/ index.html
  • Association for Professionals in Infection Control and Epidemiology – APIC.org
  • Centers for Medicare and Medicaid Services PreventInfection.org
  • Centers for Disease Control and Prevention cdc.gov https://www.cdc.gov/ infectioncontrol/guidelines/mdro/
  • http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html. Community-Associated Methicillin-Resistant Staphylococcus Aureus: An Enemy amidst Us Eric F. Kong, Jennifer K. Johnson, Mary Ann Jabra-Rizk, October 2016
  • Community-associated MRSA: Superbug at our doorstep Michael Hawkes, Michelle Baron, John Conly, Lindsay Nicolle, Clare Barry and Elizabeth L. Ford-Jones January 2007
  • Clostridium difficile A multifaceted approach to prevention. David J. Witt and Sue Barnes. Spring 2013. APIC.org