CDC: Drug-resistant bugs are on the rise in ICUs
Hospital infection control steps may need boosting
Recent news from the front lines in the war against hospital-borne bacterial infections is not encouraging. In January, the Centers for Disease Control and Prevention (CDC) in Atlanta quietly reported a disturbing increase in antibiotic-resistant nosocomial infection rates in intensive care units.
The surveillance data hardly surprised some hospital infection control workers. They’ve known for years about the need for stronger infection control measures.
But the CDC data and the hospital community’s response to it seemed to beg two important questions: Why aren’t existing infection controls working and what can be done about it?
Some infection control experts say that effectively managing endogenous (patient-borne) and exogenous (environment-related) pathogens, the two main causes of nosocomial infections, may be more complex than faulting human error or ineffective policies. In fact, advancements in medical care may be partly responsible for the growing rates, some experts say.
The difficulty with attacking infection rates in ICUs has coincidentally risen with the trend toward better ICU care, according to Janet M. Serkey, JD, RN, an infection control officer and attorney at The Cleveland Clinic Foundation in Ohio.
Medical advancements, better technology, and stronger antibiotics have improved outcomes and reduced mortality rates. Sicker patients are being kept alive longer today than in the past. The trend has saved lives but indirectly has contributed to a higher incidence of pathogen growth, Serkey says.
"We have bypassed the body’s natural defense mechanism to fight off these pathogens" by an over-dependence on antibiotics, she explains. Antibiotics alone have contributed to the problem by effectively quashing one type of infection only to lay the foundation for another, often stronger pathogen, she adds.
As a result, "we actually end up selecting in favor of drug-resistant pathogens in the ICU," she concludes.
The subject is gaining importance because studies have shown that infections are a major determinant of both morbidity and mortality rates in critical care units (CCUs), and they prolong the length of stay in both the CCU and hospital.1
In its surveillance data, which the CDC has regularly published since the 1980s, the agency identified rates of antimicrobial resistance in a group of pathogens commonly responsible for nosocomial infections in ICU patients.
The rate of resistance showed an alarming rise in an 11-month period between January and November 1998 when compared with the average rate over the previous five-year period (1993-1997).
The highest percentage rates of increase involved quonolon-resistant P. aeruginosa (89%), vancomycin-resistant enterococci (55%), and methicillin-resistant S. aureus (31%).
The pathogens were selected for study because of their known public health risk and link to nosocomial infections in ICUs, according to the CDC data. (The above chart shows the growth rate for the whole pathogen group.)
The surveillance is just one of several initiatives under way by the agency to determine the prevalence of uncontrolled infection rates within health care facilities, according to Scott Fridkin, MD, medical epidemiologist with the CDC’s National Nosocomial Infections Surveillance (NNIS) system.
In a separate report, the agency singled out vancomycin-resistant enterococci (VRE) as one of the most difficult pathogens to eradicate. The difficulty of identifying the epidemiology of VRE is one of the problems associated with its eradication.2
The CDC report suggested that patient- to-patient contact and inconsistent hospital infection control policies may be contributing factors. VRE has also shown to be resistant to drugs such as aminoglycosides and ampicillin, normally used to treat the infection.
In its report, the CDC recommended hospitals carefully and regularly screen ICU patients for the presence of VRE. Additional recommendations included:
• determining when vancomycin use is appropriate, for example, when specific infection-related conditions such as colitis don’t respond to conventional therapy and become life-threatening;
• regular monitoring of vancomycin use through the hospital’s quality assurance and improvement process;
• better screening methods involving regular testing for the pathogen in urine, wounds, clinical specimens, stool, and rectal swabs (The pathogen is found in the normal gastrointestinal and female genital tracts.);
• isolating infected patients;
• careful disposal of potentially contaminated supplies such as gloves, patient gowns, and fibrous materials.
For nursing staff, constant monitoring for drug-resistant infection growth and faithful adherence to hospital control policies are paramount to managing the problem, according to the CDC. Major endogenous indicators, or priorities, first identified in the 1980s by the Joint Commission on Accreditation of Health Care Organizations, are still relevant, according to most researchers.
They include indicators for: 1) surgical wound infections; 2) post-operative pneumonia; 3) urinary catheter usage; 4) ventilator-associated pneumonia; 5) concurrent surveillance of primary bloodstream infections; and 6) medical record abstraction for the retrospective determination of primary bloodstream infections.
But nurses should remember that external passage from health care workers or contaminated line catheters to the patient is a constant threat, Serkey says. Simple hand washing regimens and frequent changes in resuscitation bags and ventilator circuits are effective precautions that nurses should be reminded about, says Frederick J. Tasota, RN, MSN, a clinical instructor at the University of Pittsburgh (PA) School of Nursing. "A lot of it involves simple, direct precautions," he notes.
So why are these steps so often missed? They’re not intentionally, says Serkey. But ICUs are busy places. Then, "the major thrust in health care today is in managing resources. Infection control tends to be a resource consumer. These things cost money," she observes.
But no one is indicating that hospitals are lax in their efforts. Fridkin cautioned that the NNIS data isn’t suggesting that current hospital infection control measures aren’t working. "What it does say is that in this patient population — the ICU patient — the problem of resistance is continuing despite some warnings and revised recommendations," he told Critical Care Management.
References
1. Osguthorpe SG, Ormond L. Management constraints on infection control. Crit Care Nurs Clin N Am 1995; 7:703-712.
2. Centers for Disease Control and Prevention. Recommendations for Preventing the Spread of Vancomycin Resistance — Recommendations of the Hospital Infection Control Practices Advisory Committee. Atlanta; 1998.
(Editor’s note: For the full text of the CDC report, go to the agency’s Web site at: www.cdc.gov. Click on: About CDC, then National Center for Infectious Diseases, then Hospital Infections. Click on either Antimicrobial Resistance or Surveillance links.)
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