What is a good strategy for helping to prevent the spread of antibiotic resistance
Show Welcome and OverviewThis session will discuss antibiotic resistance and how it develops, existing threats from antibiotic resistant organisms, the opportunities that exist for improving the judicious use of antibiotics, and strategies and resources to decrease the development of antibiotic resistance and prevent the spread of antibiotic resistant bacteria in long-term care organizations. This session is one of a series of six sessions for nursing homes to support implementation of principles and practices of antibiotic stewarship and prevention and management of C. difficile infections. Objectives
How can you use this session?This session focuses on antibiotic resistance in the nursing home setting. The material is intended to be useful for guiding individual practice and as an educational resource for staff involved in the care of nursing home residents. Nursing home leaders can review the content in this session and decide which components would be helpful to staff in their facility. The components can be shared and discussed during staff education sessions, or they can be accessed by staff online at any time. Depending on which components you choose to review and/or share and discuss with staff, this session may take 30-90 minutes. OrientationHere is an outline of what is in this session. You can click on the hyperlinks to go directly to a section or scroll down below the outline to see all section content.
What is antibiotic resistance?Antibiotic resistance is the ability of a bacteria to change so that antibiotics can’t kill it or stop it from reproducing. In other words, the bacteria become "resistant" and continue to multiply in the presence of therapeutic levels of an antibiotic. Antibiotic resistance is a naturally occurring phenomenon; bacteria naturally evolve in order to survive. However, this process can be accelerated or made worse by misuse of antibiotics. Why do bacteria become resistant to antibiotics?Because bacteria are living organisms, they contain specific DNA. Bacteria do not start out sensitive to all antibiotics and then become resistant to them. Rather, certain types of bacteria have what is called innate resistance to certain types of antibiotics. This innate resistance is naturally part of the bacteria genetic make-up or part of the DNA. This is why some antibiotics are not expected to work on certain types of infections. However, bacteria can also acquire genes that allow them to become resistant to antibiotics which they were once sensitive to. This is called becoming resistant through acquisition. The bacteria can acquire resistance genes from other bacteria and add the resistance genes to its DNA in order to increase its chance of survival. There are different ways that bacteria can resist the effects of antibiotics:
How do bacteria become resistant to antibiotics?Anytime an antibiotic is used, bacteria that can resist that antibiotic have a greater chance of survival than those that are susceptible to the antibiotic. Resistant strains of bacteria have a survival advantage. So, simply using antibiotics, even judicious use, can increase the risk of the spread of antibiotic resistance. However, judicious use can have an important impact on slowing this process and limiting the spread of resistance. Therefore, antibiotics should only be used to manage serious bacterial infections, and with the right dose, duration, and route of administration. Click here to see a graphic from the CDC showing how antibiotic resistance happens (click on the graphic to download and print it).How much of a problem is antibiotic resistance?Antibiotic resistance is one of the most important public health threats that we face today. According to the CDC, each year in the United States, at least two million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections. The CDC states that these estimates are based on conservative assumptions and are likely minimum estimates. They are the best approximations that can be derived from currently available data. The CDC has shared information on the top 18 drug-resistant threats to the United States. These threats were categorized based on level of concern: urgent, serious, and concerning. Urgent healthcare threats include:
Serious healthcare threats include:
Discussion question: Which of the urgent or serious resistant organisms have you seen in your facility? NOTE: There are two sessions that focus on C. difficile in this six part series. Are antibiotic resistant infections a problem in nursing homes?Multi-drug resistant organisms (MDROs) are causes of infection and colonization in long-term care residents. Examples include:
Nursing home residents are at increased risk for colonization and infection with resistant organisms (colonization refers to bacteria being in or on the body, but not making you sick). Residents are at an increased risk because of:
If you are not using antibiotics judiciously, you can be promoting the development of resistant strains in your facility. That is why tracking on what antibiotics are being used for what reasons, and using antibiograms (discussed in the next section) to track on resistance and susceptibility patterns helps you to know if you are developing resistance to specific antibiotics in your facility. People that have multi-drug resistant organisms and are being admitted to your facility from hospitals present you with a challenge, as now you need to keep other residents and staff from being infected, in an environment that provides care in a home like setting. Prescribing practices help us to prevent the development of resistant organisms in each facility. Preventing the development and spread of antibiotic resistant organisms is not only about prescribing. It is also about infection control. Poor infection prevention and control practices contribute to further emergence and spread of antibacterial resistance. How can your labs help you to identify resistant bacteria?First, let’s review how the lab identifies bacteria. There are a couple different ways that can be done. First, microbiology labs grow the bacteria. Laboratory personnel plate a sample of the specimen received directly onto culture plates and then incubate them. When bacteria start to grow, the system will flag or the technicians will notice organisms growing on the plate. They will use growth patterns, gram stains and other biochemical testing to say what exactly the bacterial isolate is that’s growing on the plates. There are ways to streamline that process through use of selected culture media and an example of that is CHROMagar. These culture medias are designed to react with certain features of bacteria, and they are a faster way to visually identify what is growing. A different technology and something that’s gaining a lot of use in labs is using DNA to identify bacteria. There are molecular diagnostic tests which take fragments of the DNA or RNA of bacteria and based on those fragments, identify what the organisms are. This technology is called nucleic acid amplification or sometimes is referred to as specific amplification method, polymerase chain reaction (PCR). This is a new technology, and still a very expensive system, so many clinical labs don’t necessarily have this in place yet. Next, let’s review how the lab identifies the susceptibility patterns for organisms identified. In other words, how does the lab identify which antibiotics would be effective in killing the bacteria. In order to do that, the lab tests the growth of these organisms in the presence of different antibiotics, and that’s how they determine which antibiotics inhibit growth and which don’t. They define the susceptibility using something called the minimum inhibitory concentration. That’s the lowest amount of the drug needed to stop growth of the bacteria. A lot of labs now use systems that are automated to help speed up and streamline the process for identification and susceptibility testing and these automated systems can combine the growth and susceptibility into one platform, which means you get the answers much quicker. Some trade names of these systems include: Microscan, Walkaway, VITEK 2, Phoenix, and Sensititre. Laboratories should have procedures to notify you when Carbapenem resistant bacteria are identified. It is important to understand whether and how the lab identifies carbapenamases – enzymes created by bacteria that make the bacteria resistant to the very powerful broad spectrum Carbapenem antibiotics – and how they would flag an organism that shows up in their lab as a Carbapenem resistant organism. The lab should notify you when a Carbapenem resistant bacteria is identified because that is critically important in terms of your clinical management of a resident as well as for your infection prevention program. Carbapenem resistance results in infections which cannot be treated with current antibiotics. Finally, labs can create antibiograms. Your laboratory can provide you with a summary snapshot of antibiotic resistant patterns across all of the organisms (cultures from residents) in your building. This is called an antibiogram which is a summary of the bugs that are frequently identified in culture and the susceptibility to some of the common antibiotics that are used to treat those infections. Typically, on the antibiogram, the organisms are listed down the left column, first listing the gram negative organisms, and then the gram positive organisms. Then across each row, the number of organisms tested is listed, along with the percent of tested organisms that were susceptible to each antibiotic tested. This is a yearly summary and it allows you to trend resistance patterns over time. It also is a tool for clinicians and pharmacist to use to select the best empiric antibiotic treatment when microbiology culture and susceptibility results are pending. Access the resource titled About Antibiograms (Antimicrobial Susceptibilities of Selected Pathogens) from the Minnesota Department of Health. Access AHRQ's Concise Antibiogram Toolkit. How can you prevent the development and spread of antibiotic resistance?You cannot prevent the development of all resistance, as it is a naturally occurring phenomenon. Your real job is to slow development and reduce the spread of antibiotic resistant bacteria. Effective diagnosis and treatment, including the judicious use of antibiotics, is a key part of preventing antibiotic resistance. Refer to the session Antibiotic Stewardship for strategies to support the judicious use of antibiotics. Another key component to prevent further emergence and spread of antibacterial resistance is through infection prevention and control practices. While much broader than the spread of antibiotic resistance, read SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility. The guideline from SHEA and APIC describes the elements of a Long-Term Care Facility Infection Control Program, including infection control activities such as establishing and implementing routine infection control policies and procedures and infection identification. Also included are identification, investigation, and control of outbreaks such as organism-specific infection control policies and procedures, disease reporting, antibiotic stewardship, monitoring of patient care practices, facility management issues, product evaluation, resident health programs, and employee health programs. Key examples provided by SHEA and APIC of infection control and prevention activities include hand hygiene, standard precautions, organism-specific isolation, employee education, developing case definitions of infections, reviewing antibiotic use, and facility maintenance and cleaning and sanitation procedures. Also see the four-part webinar series in the session Clostridium difficile Part Two: Strategies to Prevent, Track, and Monitor C. difficile that discusses how MDROs and C. difficile emerge and spread and actions that caregivers can take to minimize their spread. ActivityDiscussion questions: To gain situational awareness of antibiotic resistance in your organization, discuss the following questions with your laboratory:
Take Home Messages
Optional Tools and ResourcesThe Minnesota Department of Health These education modules were developed for nurses and for nursing assistants on antibiotic use and antibiotic resistance:
What Do We Do When Antibiotics Don’t Work Anymore? by Maryn McKenna (16:59) Watch this TED Talk with Maryn McKenna, public health journalist. Guidance for Preventing Transmission of Carbapenem-Resistant Enterobacteriaceae (CRE) in Skilled Nursing Facilities Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE): November 2015 Update, CRE Toolkit Preventing the Spread of Carbapenem-resistant Enterobacteriaceae in LTCFs Watch this recorded webinar presented by Dr. Nimalie Stone, a medical officer at the Centers for Disease Control and Prevention (CDC) (1:00:29). This webinar is presented by the Lake Superior Quality Innovation Network. Presentation objectives:
For the presentation slides: PDF The Basics of Antibiotic Resistance: Focus on Carbapenem-Resistant Enterobacteriaceae (CRE) For more information on CRE, watch this recorded webinar presented by Dr. Nimalie Stone, a medical officer at the Centers for Disease Control and Prevention (CDC) (56:54). This webinar is presented by the Lake Superior Quality Innovation Network. Presentation objectives:
For the presentation slides: PDF Environmental Hygiene: Best Practices to Use When Cleaning and Disinfecting Patient Rooms This video, available in English and Spanish, is intended to compliment the infection prevention education program in healthcare organizations. It was developed by the Oregon Patient Safety Commission and the Oregon Healthcare-Associated Infection Program at the Oregon Health Authority. Watch the video in English (8:42). Watch the video in Spanish (10:16). What are 2 strategies the US is using to combat antibiotic resistance?Implementing evidence-based infection control practices can prevent the spread of resistance. Encouraging development of more therapies and drugs to treat infections.
What is being done to prevent antibiotic resistance?The best way to prevent antibiotic resistance is to use antibiotics correctly. Take them only when needed. Here are some of the ways you can help: Don't take an antibiotic for a virus.
How can healthcare providers help prevent the spread of antibiotic resistance?Ensure your patients receive recommended vaccines. Alert receiving facilities when transferring patients who are colonized or infected with antibiotic-resistant germs. Educate patients on ways to prevent spread. Stay informed of current outbreaks.
What is the best way to prevent contributing to antibiotic resistance in bacteria?Taking antibiotics only when they are needed is an important way you can protect yourself and your family from antimicrobial resistance. Talk to your doctor about the best treatment if you are sick.
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