Antibiotic Presentation

Campaign to Prevent
AntimicrobiaI
Resistance
Centers for Disease Control and Prevention
National Center for nfectious Diseases
Division of Healthcare Quality Promotion
Link to: Campaign to Prevent Antimicrobial Resistance Online
Link to: Federal Action Plan to Combat Antimicrobial Resistance
Clinicians hold the solution!
New Resistant Bacteria
Emergence of AntimicrobiaI Resistance
Susceptible Bacteria
Campaign to Prevent AntimicrobiaI Resistance in HeaIthcare Settings
Resistant Bacteria
Resistance Gene Transfer
Resistant Strains
Rare
Resistant Strains
Dominant
AntimicrobiaI
Exposure
SeIection for AntimicrobiaI-Resistant Strains
Antimicrobial Resistance:
Key Prevention Strategies
Optimize
Use
Prevent
Transmission
Prevent
nfection
Effective
Diagnosis
and Treatment
Pathogen
Ant|m|crob|a|-Res|stant Pathogen
AntimicrobiaI
Resistance
AntimicrobiaI Use
Infection
8uscept|b|e Pathogen
Key Prevention Strategies
Prevent infection
Diagnose and treat
infection effectiveIy
Use antimicrobiaIs wiseIy
Prevent transmission
Campaign to Prevent AntimicrobiaI
Resistance in HeaIthcare Settings
General health communication strategy
Goals:
inform clinicians, patients, and other stakeholders
raise awareness about the escalating problem of
antimicrobial resistance in healthcare settings
motivate interest and acceptance of
interventional programs to prevent resistance
12 Steps to Prevent AntimicrobiaI
Resistance
Targeted intervention programs for clinicians caring for high-
risk patients
- hospitalized adults - emergency patients - dialysis patients
- hospitalized children - obstetrical patients - surgical patients
- geriatric patients - critical care patients
Goal: mprove clinician practices and prevent antimicrobial
resistance
Partnership with professional societies; evidence base
published in peer-reviewed specialty journals
Educational tools Web-based/didactic learning modules,
pocket cards, slide presentations, etc
Resistance: HospitaIized AduIts
12 Contain your contagion
11 solate the pathogen
10 Stop treatment when cured
9 Know when to say "no to vanco
8 Treat infection, not colonization
7 Treat infection, not contamination
6 Use local data
5 Practice antimicrobial control
4 Access the experts
3 Target the pathogen
2 Get the catheters out
1 Vaccinate
Prevent Transmission
Use Antimicrobials Wisely
Diagnose and Treat Effectively
Prevent nfection
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$taphylococcus aureus
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Vancomycin-resistant
enterococci
Non-Intensive Care Unit Patients
Intensive Care Unit Patients
AntimicrobiaI Resistance Among Pathogens
Causing HospitaI-Acquired Infections
Source: National Nosocomial nfections Surveillance (NNS) System
Link to: NNIS Online at CDC
12 Steps to Prevent AntimicrobiaI Resistance: HospitaIized AduIts
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rdgeneration cephaIosporin-
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FIuoroquinoIone-resistant
Pseudomonas aeruginosa
Non-Intensive Care Unit Patients
Intensive Care Unit Patients
AntimicrobiaI Resistance Among Pathogens
Causing HospitaI-Acquired Infections
PrevaIence of AntimicrobiaI-Resistant (R)
Pathogens Causing HospitaI-Acquired Intensive
Care Unit Infections: 1999 versus 199-1998
Organism # IsoIates % Increase*
FIuoroquinoIone-R Pseudomonas spp. 2,7 9%
rd generation cephaIosporin-R E. coli 1,1 8%
MethiciIIin-R $taphylococcus aureus 2, %
Vancomycin-R enterococci ,7 %
Imipenem-R Pseudomonas spp. 1,89 2%
Percent increase in proportion of pathogens resistant to indicated antimicrobial
12 Steps to Prevent AntimicrobiaI Resistance:
HospitaIized AduIts
1. Vaccinate
2. Get the catheters out
3. Target the pathogen
4. Access the experts
5. Practice antimicrobial control
6. Use local data
7. Treat infection, not contamination
8. Treat infection, not colonization
9. Know when to say "no to vanco
10. Stop treatment when infection is
cured or unlikely
11. solate the pathogen
12. Contain the contagion
Diagnose and Treat
Infection EffectiveIy
Prevent Infection
Use AntimicrobiaIs WiseIy
Fact:
Predischarge influenza and pneumococcal
vaccination of at-risk hospital patients AND
influenza vaccination of healthcare personnel
will prevent infections.
Prevent Infection
Step 1: Vaccinate
Need for HospitaI-Based Vaccination:
US Persons Aged or OIder Who Report
Vaccination
(BehavioraI Risk Factor SurveiIIance System, United States 1991999)
1
2
7
8
9
1
199 199 1997 1999
InfIuenza Vaccine
PneumococcaI
Vaccine
ink to:
Healthy People 2010 Goal
Link to: US Vaccination Rates...MMWR 2001;50:532-7
$tep 1: Vaccinate
Need for HospitaI-Based Vaccination:
Postdischarge Vaccination Status of
HospitaIized AduIts
nfluenza Pneumococcal
Population Vaccine Vaccine
Age 18-64 years 17% vaccinated 31% vaccinated
with medical risk
Age > 65 years 45% vaccinated 68% vaccinated
Hospitalized for
pneumonia 35% vaccinated 20% vaccinated
during influenza
season
Link to: CDC, National Health Interview Survey, 1997
Link to: Medicare beneficiaries in 12 western states, 1994
$tep 1: Vaccinate
$tep 1: Vaccinate
Need for HeaIthcare PersonneI Immunization
Programs: InfIuenza Vaccination Rates (199-1997)
34% All healthcare personnel
38% Healthcare personnel at high risk
63% All adults > 65 yrs of age
% Vaccinated
Source: 1997 National Health Interview Survey
Walker FJ, et al: Infect Control Hosp Epidemiol 2000;21:113
Link to: ACIP Influenza Immunization Recommendations
One or more high-risk medical conditions including diabetes, current cancer treatment, or chronic heart,
lung, or kidney disease.
Healthcare workers included persons currently employed in healthcare occupations, regardless of
setting, and persons currently employed in healthcare settings without a healthcare occupation.
Actions:
give influenza/S. pneumonia vaccine to
at-risk patients before discharge
get influenza vaccine annually
Link to: CDC facts about influenza and pneumococcal vaccine
Link to: ACIP: Vaccine standing orders
Prevent Infection
Step 1: Vaccinate
Fact: Predischarge influenza and pneumococcal vaccination
of at-risk hospital patients and influenza vaccination of
healthcare personnel will prevent infections.
Link to: ACIP Influenza immunization recommendations
Fact:
Catheters and other invasive devices are the #1
exogenous cause of hospital-acquired infections.
Prevent Infection
Step 2:
Get the catheters out
BiofiIm on Intravenous Catheter Connecter
2 Hours After Insertion
Scanning Electron Micrograph
Link to: Biofilms and device-associated infections
$tep 2: Get the catheters out
Fact: Catheters and other invasive devices are the #1
exogenous cause of hospital-acquired infections.
Actions:
use catheters only when essential
use the correct catheter
use proper insertion and catheter-care
protocols
remove catheters when not essential
Coming soon.guidelines for preventing catheter-associated bloodstream infections
ink to: Urinary catheter infection prevention
Prevent Infection
Step 2: Get the catheters out
Fact:
Appropriate antimicrobial therapy (correct
regimen, timing, dosage, route, and duration)
saves lives.
iagnose and Treat
Infection Effectively
Step :
Target the pathogen
Inappropriate AntimicrobiaI Therapy:
PrevaIence Among Intensive Care Patients
Source: Kollef M, et al: Chest 1999;115:462-74
%
1%
2%
%
%
%
Community-acquired infection
Hospital-acquired infection
Hospital-acquired infection after
initial community-acquired infection
nappropriate
Antimicrobial Therapy
(n = 655 CU patients with infection)
Patient Group
17.1%
.%
.2%
$tep 3: Target the pathogen
Inappropriate AntimicrobiaI Therapy:
Impact on MortaIity
Source: Kollef M, et al: Chest 1999;115:462-74
1
2
42.0% mortality
17.7% mortality
ReIative Risk = 2.7
(95% C.. 1.83-3.08; P .001)
# Deaths
# Survivors
nappropriate
Therapy
Appropriate
Therapy
SusceptibiIity Testing Proficiency:
8 CIinicaI MicrobioIogy Laboratories
Test Organism Accuracy
Methicillin-resistant Staphylococcus aureus 100%
Vancomycin-resistant Enterococcus faecium 100%
Fluoroquinolone-resistant Pseudomonas aeruginosa 100%
Erythromycin-resistant Streptococcus pneumoniae 97%
Carbapenem-resistant Serratia marcescens 75%
Extended-spectrum beta-lactamase Klebsiella pneumoniae 42%
Source: Steward CD, et al: Diagn Microbiol Infect Dis 2000;38:59-67
Link to: MASTER Online at CDC
CDC's MASTER: Improving AntimicrobiaI
SusceptibiIity Testing Proficiency
Fact: Appropriate antimicrobial therapy saves lives.
Actions:
culture the patient
target empiric therapy to likely pathogens and
local antibiogram
target definitive therapy to known pathogens
and antimicrobial susceptibility test results
Link to: IDSA guidelines for evaluating fever in critically ill adults
iagnose and Treat Infection Effectively
Step : Target the pathogen
Fact:
nfectious diseases expert input improves
the outcome of serious infections.
iagnose and Treat
Infection Effectively
Step :
Access the experts
Infectious Diseases Expert Resources
Infectious Diseases
SpeciaIists
OptimaI
Patient Care
OptimaI
Patient Care
nfection Control
Professionals
Healthcare
Epidemiologists
Clinical
Pharmacists
Clinical
Pharmacologists
Surgical nfection
Experts
Clinical
Microbiologists
$tep 4: Access the experts
Fact: nfectious diseases expert input improves the
outcome of serious infections.
Action:
consult infectious diseases experts
about patients with serious infections
Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals
iagnose and Treat Infection Effectively
Step : Access the experts
Fact:
Programs to improve antimicrobial use
are effective.
&se Antimicrobials Wisely
Step : Practice
antimicrobiaI controI
Methods to Improve AntimicrobiaI Use
Passive prescriber education
Standardized antimicrobial order forms
Formulary restrictions
Prior approval to start/continue
Pharmacy substitution or switch
Multidisciplinary drug utilization evaluation (DUE)
nteractive prescriber education
Provider/unit performance feedback
Computerized decision support/online ordering
$tep 5: Practice antimicrobial control
Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals
Computerized AntimicrobiaI Decision Support
ocal clinician-derived consensus guidelines embedded in
computer-assisted decision support programs
62,759 patients receiving antimicrobials over 7 years
1988 1994
Medicare case-mix index 1.7481 2.0520
Hospital mortality 3.65% 2.65%
Antimicrobial cost per treated patient $122.66 $51.90
Properly timed preoperative antimicrobial 40% 99.1%
Stable antimicrobial resistance
Adverse drug events decreased by 30%
Source: Pestotnik SL, et al: Ann Intern Med 1996;124:884-90
$tep 5: Practice antimicrobial control
Step : Practice antimicrobiaI controI
Fact: Programs to improve antimicrobial use are effective.
Action:
engage in local antimicrobial use quality
improvement efforts
Link to: Methods to improve antimicrobial use and prevent resistance
Source: Schiff GD, et al: Jt Comm J Qual Improv 2001;27:387-402
Fact:
The prevalence of resistance can vary
by time, locale, patient population,
hospital unit, and length of stay.
Step : Use IocaI data
Trimethoprim/SuIfamethoxazoIe (TMP/SMX)
Resistance Among BacteriaI Patient IsoIates*
San Francisco GeneraI HospitaI
Martin JN, et al: J Infect Dis 1999;180:1809-18
* 30,886 patient isolates
Staphylococcus aureus
Escherichia coli
Enterobacter spp.
Klebsiella pneumoniae
Morganella spp.
Proteus spp.
Serratia spp.
Citrobacter spp.
0
10
20
30
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50
60
1988 1989 1990 1991 1992 1993 1994 1995 P
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Non-HV units (n = 28,966 patient isolates)
HV units (n = 1,920 patient isolates)
Prevalence of TMP/SMX use
among ADS patients
$tep 6: &se local data
PrevaIence of FIuoroquinoIone-Resistant
Escherichia coli: VariabiIity Among Patient
PopuIations
0
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Patient Characteristics
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San Francisco GeneraI HospitaI 199-1997
$tep 6: &se local data
Step : Use IocaI data
Fact: The prevalence of resistance can vary by locale, patient
population, hospital unit, and length of stay.
Actions:
know your local antibiogram
know your patient population
Link to: NCCLS Proposed Guidance for Antibiogram Development
Fact:
A major cause of antimicrobial overuse
is "treatment of contaminated cultures.
Step 7: Treat infection,
not contamination
BIood CuIture Contamination Benchmarks
(9 institutions; 7,18 bIood cuItures)
Contamination Rate
(percentile)
10th 50th 90th
Hospitalized adults 5.4 2.5 0.9
Hospitalized children 7.3 2.3 0.7
Neonates 6.5 2.1 0.0
percent of cultures contaminated
Link to: College of American Pathologist contaminated blood culture survey
Source: Schifman RB, et al: Q-Probes Study 93-08. College Am Path 1993.
$tep 7: Treat infection, not contamination
Positive BIood CuItures Obtained Through CentraI
Venous Catheters Do Not ReIiabIy Predict True
Bacteremia*
Catheter Peripheral Vein
Sample Sample
Predictive Value
Positive 63% 73%
Predictive Value
Negative 99% 98%
Source: DesJardin JA, et al: Ann Intern Med 1999;131:641-7
55 paired cultures from hospitalized
hematology/oncology patients
Interpreting a "Positive" BIood CuIture
True Bacteremia:
Unlikely Uncertain ikely
S. aureus
S. pneumoniae
Enterobacteriaceae
P. aeruginosa
Candida albicans
Corynebacterium spp.
Non-anthracis Bacillus spp.
Propionibacterium acnes
Coagulase-negative
staphylococci
Source: Kim SD, et al: Infect Control Hosp Epidemiol 2000;21:213-7
Pre-test probability
patient risk factors
prosthetic devices
clinical evidence
Post-test probability
# positive/# cultures
compare antibiograms
compare genotypes
Step 7: Treat infection, not contamination
Fact: A major cause of antimicrobial overuse is "treatment of
contaminated cultures.
Actions:
use proper antisepsis for blood and other cultures
culture the blood, not the skin or catheter hub
use proper methods to obtain and process
all cultures
Link to: CAP standards for specimen collection and management
Fact:
A major cause of antimicrobial overuse
is "treatment of colonization.
Step 8: Treat infection,
not coIonization
Invasive Bronchoscopic Diagnostic Tests Reduce
AntimicrobiaI Use in Suspected
VentiIator-Associated Pneumonia*
nvasive Noninvasive
Diagnosis Diagnosis
Antimicrobial-free 11.0 7.5 P < .001
days (at day 28)
Mortality 16.2% 25.8% P = .022
Source: Fagon JY, et al: Ann Intern Med 2000;132:621-30
413 patients; 31 intensive care units
$tep 8: Treat infection, not colonization
Step 8: Treat infection, not coIonization
Fact: A major cause of antimicrobial overuse is treatment of
colonization.
Actions:
treat pneumonia, not the tracheal aspirate
treat bacteremia, not the catheter tip or hub
treat urinary tract infection, not the indwelling
catheter
Link to: IDSA guideline for evaluating fever in critically ill adults
Fact:
Vancomycin overuse promotes
emergence, selection, and spread
of resistant pathogens.
Step 9: Know when to
say "no" to vanco
Vancomycin UtiIization in HospitaIs
(defined daily doses per 1,000 patient days)
on-|6U heme-0nc Hed |6U Hed-8urg

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Source: National Nosocomial Infections Surveillance (NNIS) System
$tep 9: now when to say 'no" to vanco
$. aureus
PeniciIIin
[19s]
PeniciIIin-resistant
$. aureus
EvoIution of Drug Resistance in $. aureus
Link to: CDC Facts about VISA Link to: CDC Facts about VRE
MethiciIIin
[197s]
MethiciIIin-resistant
$. aureus (MRSA)
Vancomycin-resistant
enterococci (VRE)
Vancomycin
[199s]
[1997]
Vancomycin
intermediate-
resistant
$. aureus
(VISA)
Vancomycin-
resistant
$. aureus
$tep 9: now when to say 'no" to vanco
Step 9: Know when to say "no" to vanco
Fact: Vancomycin overuse promotes emergence, selection, and
spread of resistant pathogens.
Actions:
treat infection, not contaminants or colonization
fever in a patient with an intravenous catheter
is not a routine indication for vancomycin
Link to: CDC guidelines to prevent vancomycin resistance
Fact:
Failure to stop unnecessary
antimicrobial treatment contributes
to overuse and resistance.
&se Antimicrobials
Wisely
Step 1: Stop treatment
when infection is cured
or unIikeIy
Short-Course AntimicrobiaI Treatment of
New PuImonary InfiItrates in an ICU
Standard Experimental
Variable Therapy (n = 42) Therapy (n = 39)
Regimen clinician discretion ciprofloxacin 400 mg
(all treated; 18 drugs) (V bid x 3 days)
Treatment > 3 days 97% 28%
Antimicrobial resistance 35% 15%
ength of stay
mean/median 14.7/9 days 9.4/4 days
Mortality (30 day) 31% 13%
Antimicrobial cost
mean/total $640/$16,004 $259/$6,484
Link to: Singh N, et al. Am J Respir Crit Care Med 2000;162:505-11
$tep 10: $top treatment when infection is cured or unlikely
Fact: Failure to stop unnecessary antimicrobial treatment
contributes to overuse and resistance.
Actions:
when infection is cured
when cultures are negative and infection
is unlikely
when infection is not diagnosed
Step 1: Stop antimicrobiaI treatment
Fact:
Patient-to-patient spread of
pathogens can be prevented.
Step 11:
IsoIate the pathogen
A Decade of Progress (1990-1999):
Hospital-Acquired nfection Rates in NNS
ntensive Care Units
Coronary 43% 42% 40%
Medical 44% 56% 46%
Surgical 31% 38% 30%
Pediatric 32% 26% 59%
Type of CU BS VAP UT
BS = central line-associated bloodstream infection rate
VAP = ventilator-associated pneumonia rate
UT = catheter-associated urinary tract infection rate
Link to: MMWR: Successful Healthcare Infection Prevention: Case History
Source: National Nosocomial Infections Surveillance (NNIS) System
$tep 11: Isolate the pathogen
Step 11: IsoIate the pathogen
Fact: Patient-to-patient spread of pathogens can be
prevented.
Actions:
use standard infection control precautions
contain infectious body fluids (use approved
airborne/droplet/contact isolation precautions)
when in doubt, consult infection control
experts
Link to: A VRE prevention success story
Link to: CDC isolation guidelines and recommendations
Fact:
Healthcare personnel can spread
antimicrobial-resistant pathogens from
patient to patient.
Step 12:
Contain your contagion
Airborne Transmission of Pathogens From
HeaIthcare PersonneI to Patients
Pathogen Circumstance
nfluenza virus ack of vaccination
Varicella-Zoster virus Disseminated infection
Mycobacterium tuberculosis Cavitary disease
Bordetella pertussis Undiagnosed prolonged cough
Streptococcus pyogenes Asymptomatic carriage;
perioperative transmission
Staphylococcus aureus Viral UR
("cloud healthcare provider)
Link to: "Cloud" healthcare personnel
Source: Sherertz RJ, et al: Emerg Infect Dis 2001;7:241-244
$tep 12: Contain your contagion
Improved Patient Outcomes Associated
With Proper Hand Hygiene
gnaz Philipp Semmelweis
(1818-1865)
Chlorinated lime hand antisepsis
Link to: Ignaz Semmelweis
Impact of Hand Hygiene on HospitaI
Infections
ear Author Setting mpact on nfection Rates
1977 Casewell adult CU Klebsiella decreased
1982 Maki adult CU decreased
1984 Massanari adult CU decreased
1990 Simmons adult CU no effect
1992 Doebbeling adult CU decreased with one versus
another hand hygiene product
1994 Webster NCU MRSA eliminated
1995 Zafar nursery MRSA eliminated
1999 Pittet hospital MRSA decreased
CU = intensive care unit; NCU = neonatal CU
MRSA = methicillin-resistant Staphylococcus aureus .
Link to: Improving hand hygiene
Source: Pittet D: Emerg Infect Dis 2001;7:234-240
Step 12: Break the chain of contagion
Fact: Healthcare personnel can spread antimicrobial-
resistant pathogens from patient to patient.
Actions:
stay home when you are sick
contain your contagion
keep your hands clean
set an example!
Link to: Health guidelines for healthcare personnel
Coming soon.new guidelines for hand hygiene
Resistance: HospitaIized AduIts
12 Contain your contagion
11 solate the pathogen
10 Stop treatment when cured
9 Know when to say "no to vanco
8 Treat infection, not colonization
7 Treat infection, not contamination
6 Use local data
5 Practice antimicrobial control
4 Access the experts
3 Target the pathogen
2 Get the catheters out
1 Vaccinate
Use Antimicrobials Wisely
Diagnose and Treat Effectively
Prevent nfection
Clinicians hold the solution.
Take steps NOW to prevent antimicrobial resistance!
Campaign to Prevent
AntimicrobiaI
Resistance
Funded by the CDC Foundation with support from
Pharmacia Corporation, Premier, nc., and the
Sally S. Potter Endowment Fund.
Endorsed by the American Society for Microbiology,
the nfectious Diseases Society of America, and the
National Foundation for nfectious Diseases.
Link to: CDC Foundation
Protect patients.protect healthcare personnel.
promote quality healthcare!
Division of Healthcare Quality Promotion
National Center for nfectious Diseases
Prevent|on
|8 PR|HARY!
Link to: Division of Healthcare Quality Promotion Home Page

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Campaign to Prevent

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