Every year, more than two million Americans are infected with antibiotic-resistant bacteria known as superbugs, and as many as 23,000 die, according to statistics from the U.S. Centers for Disease Control and Prevention (CDC). In 2015, the Obama Administration declared war on drug-resistant bacteria, mobilizing multiple federal agencies to strengthen efforts to monitor and combat this growing global threat.
Three years later, medical schools and teaching hospitals remain on the front lines of that war, not only as the primary providers of care for patients sickened by these powerful bugs but also in efforts to curtail the spread of infection within and beyond their institutions.
“Antibiotic resistance is a huge and growing problem,” says Ross McKinney, MD, AAMC chief scientific officer. And while much is already being done to prevent the spread of superbugs, “it’s not enough,” he says. Indeed, better infection control and antibiotic stewardship could prevent 619,000 health care-associated, drug-resistant infections, the CDC estimates.
“Everyone knows about hand hygiene. Many hospitals have set a goal of 100% compliance. Getting there turns out to be a lot more complicated than anyone realized.”
Heather McLean, MD
Duke University Medical Center
While more rapid screening tests and new classes of antibiotics could certainly help meet the threat of antibiotic resistance, the most effective weapons remain time-tested and surprisingly low-tech. “If you look at infection control over the last 100 years, the basic concepts haven’t changed all that much,” says Zachary A. Rubin, MD, medical director of the infection control program at Ronald Reagan UCLA Medical Center. “We know what we need to do. The challenge is finding better ways to do it.”
Creating a culture of compliance
The single most effective way to prevent the spread of hospital-acquired infections and antibiotic-resistant organisms is hand hygiene. Yet studies show that less than half of health care workers comply completely with current standards. “Everyone knows about hand hygiene. Many hospitals have set a goal of 100% compliance,” says Heather McLean, MD, associate professor of pediatrics at Duke University Medical Center. “Getting there turns out to be a lot more complicated than anyone realized.”
Starting in 2013, McLean and her colleagues set out to improve hand hygiene on two pediatric units at Duke. At the time, compliance was good, an average of 87%. To go from good to great, the units focused on a range of interconnected strategies:
- Developing restocking and repair processes to make sure hand hygiene supplies are always available at the point of care.
- Educating all health care workers about when and how to comply with hand hygiene.
- Providing frequent feedback on compliance in a wide range of formats, from emails and posted charts to weekly nursing staff meetings and monthly safety meetings.
- Encouraging families to remind health care workers about hand hygiene before and after visiting a patient’s room.
- Assigning unit leaders committed to improving hand hygiene compliance.
Within nine months of the program’s launch in 2015, hand hygiene compliance rose from an average of 87% to 95%. More important, the improvements have been sustained.
Given the multipronged approach, McLean says it’s difficult to identify which intervention had the biggest impact. But she thinks two stood out: weekly feedback on hand hygiene (including specific details about what kind of health care worker failed to comply, when, and where) and the creation of an interdisciplinary team of hand hygiene champions who were ready in real time to remind other health care workers to comply with protocols.
“You have to do all the basic things – education, reminders, feedback – and you have to stick with them long enough to change the culture, so that great hand hygiene becomes the norm,” says McLean.
Developing checklists and procedures
One of the biggest successes in infection control in the past decade remains one of the simplest: a simple five-item checklist developed by Peter Pronovost, MD, then an acute care physician at Johns Hopkins Hospital, to reduce central line bloodstream infections (CLBSI). In large part because of the checklist’s widespread use, the United States recorded a roughly 50% drop in central line associated bloodstream infections between 2008 and 2016.
“We’ve learned that checklists and bundles are very effective in reducing the rate of central line infections,” says Mary Lou Manning, PhD, a professor at Thomas Jefferson University College of Nursing who studies efforts to reduce antibiotic resistance. “But we haven’t seen anything like the same kind of success yet for other infections.”
As a case in point, consider catheter-related urinary tract infections (UTIs). In 2009, the Department of Health and Human Services set a goal of reducing the rates of catheter-associated UTIs by 25% by 2013. That didn’t happen. In fact, between 2009 and 2013, rates actually climbed by 6%. The stubborn persistence of catheter-associated UTIs is particularly frustrating because “the technical protocols to prevent it have been known for a long time,” as Susan S. Huang, MD, wrote in a 2016 editorial in the New England Journal of Medicine. What’s more, urinary catheters are a route for the spread of some of the most worrisome antimicrobial-resistant organisms, including carbapenem-resistant enterobacteriaceae (CRE) and escherichia coli.
A recent effort, sponsored by the Agency for Healthcare Research and Quality, sheds light on an approach that can help bring UTIs down. Modeled on the checklist strategy for preventing CLBSI, the program, conducted in 926 units in 603 hospitals around the country, included four key interventions:
- Assessing the presence and necessity of an indwelling urinary catheter on a daily basis.
- Evaluating alternatives to indwelling urinary catheters (such as intermittent straight catheterization).
- Educating health care workers on the importance of aseptic technique during insertion and proper maintenance after insertion.
- Providing feedback to the units’ nurses and physicians on catheter use and catheter-associated UTI rates.
After the interventions were implemented, inpatient units (excluding ICUs) saw a steady drop in catheter-associated UTI rates from 2.28 infections per 1000 catheter-days to 1.54 infections. The success of the program, according to Huang, “highlights the very real potential for reductions nationally.”
Sharing information across networks
Pathogens, microbiologists have learned, have clever ways of sharing genes for antimicrobial resistance – one reason superbugs can spread so fast. In 2015, the CDC launched an initiative to encourage health care facilities to establish networks for sharing information about antimicrobial resistance.
The idea is simple enough. Instead of working alone to prevent infections, hospitals and other health care facilities in a given region are encouraged to alert others whenever an antibiotic resistant infection has been diagnosed – and especially when a patient with a resistant infection is being transferred from one facility to another.
“We see communication as critically important to infection control at every level, between members of a health care team, between different areas of a hospital, and among networks of hospitals.”
Keith S. Kaye, MD, MPH
University of Michigan Medical School
After an outbreak of carbapenem-resistant enterobacteriaceae (CRE) in South Dakota, the state’s Department of Health implemented a comprehensive program that included mandatory reporting and educational efforts to increase CRE prevention knowledge among health providers. According to the CDC, the coordinated effort resulted in a statewide decrease in CRE infections, from 24 in 2012 to four in 2014.
Nationwide, the benefits of more effective networking could be enormous. Using mathematical modeling, researchers demonstrated that if hospitals and nursing homes in the same area coordinated their efforts, infection rates could be reduced by as much as 74%.
“We see communication as critically important to infection control at every level, between members of a health care team, between different areas of a hospital, and among networks of hospitals,” says Keith S. Kaye, MD, MPH, professor in the division of infectious diseases at the University of Michigan Medical School and current president of the Society for Healthcare Epidemiology of America (SHEA). “It’s a crucial part of our defense against the spread of antimicrobial-resistant pathogens.”
That doesn’t mean it’s easy. “Putting lots of disparate pieces together, even within a hospital, is very challenging,” says Rubin. “The task has become even more complex and time-consuming with the addition of all kinds of quality metrics, both at the state and federal level.” Metrics are essential, of course. “But more and more, doctors and nurses are being asked to do all kinds of things that they weren’t asked to do before. And we have to make sure that doesn’t get in the way of the basic prevention efforts they do at the patient’s bedside.”
Still, there’s evidence that these efforts and others to stem the rise of resistance are beginning to pay off. In early 2018, the CDC reported a decrease in the number of antibiotic resistant strains of enterobacteria between 2006 and 2015. And when researchers in a 2017 study in the Journal of Preventive Medicine and Hygiene examined infection rates in four New York-based hospitals between 2006 and 2012, they found that hospital-acquired infections fell for all organisms, all infection types, and within all four hospitals.
Unfortunately, the study also found that one organism, P. aeruginosa, was gaining resistance to four powerful classes of antibiotics – a sobering reminder that even with our best efforts, antibiotic-resistant bugs remain a formidable adversary.