infection prevention
infection prevention
By Teri Hulett , RN , BSN , CIC , FAPIC
Reducing patient harm , improving patient outcomes and preserving a decreasing resource in our antibiotic armamentarium as more and more antibiotics develop resistance is key to maintaining effective antibiotics in our tool box of treatments in the future .”
Bugs Gone Wild
We ’ ve all heard about antibiotic stewardship ( ABS ). It ’ s been a buzzword within the healthcare world for decades . The Centers for Disease Control and Prevention ( CDC ) identifies ABS as a core strategy to combat antimicrobial resistance ( AMR ) by optimizing antibiotic use . In this article , we will review best practices to reduce AMR by preventing bugs from going wild and developing resistance , which leads to suboptimal patient outcomes .
Antibiotic stewardship was first discussed in 1996 . The Society for Healthcare Epidemiology of America ( SHEA ) published seminal stewardship guidelines in 1997 for the prevention of antimicrobial resistance . These guidelines provided criteria for infection prevention and control programs to focus on appropriate antibiotic selection , appropriate antibiotic dosing , and prescribing for the appropriate duration of time . Effective , robust antibiotic stewardship requires a multi-disciplinary team approach that includes the infection preventionist ( IP ). The role of the physician and pharmacist is to review providers ’ prescribing practices and provide timely audit and feedback . The role of the IP and nurse on the ABS team is to take the lead on diagnostic testing with respect to chart review for clinical indication for the ordered test and reviewing the culture and sensitivity report for any resistant organisms , communicating with the provider to ensure they review lab results in a timely manner , and for those on IV antibiotics , moving from IV to PO once the patient meets the criteria .
The CDC moved forward next with developing the Core Elements of Antibiotic Stewardship with setting-specific guidelines ; Core Elements of Hospital Antibiotic Stewardship Programs : 2019 , Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals , Core Elements of Outpatient Antibiotic Stewardship , Core Elements of Antibiotic Stewardship for Nursing Homes , and Core Elements of Antibiotic Stewardship Programs in Resource-Limited Settings : National and Hospital Levels . The core elements provided a formalized structure for the work moving forward .
Universal core element interventions included , as noted above , appropriate antibiotic selection , appropriate antibiotic dosing , and appropriate antibiotic duration . Chart review identified new challenges ; in some cases , antibiotics were ordered without a culture being obtained , which made it impossible to ensure the appropriate antibiotic was prescribed for the appropriate organism – checking for the bug / drug match . The next challenge identified was that often cultures were being ordered in an attempt to identify if a patient was admitted to a facility with an active infection ; the best example of this is the patient presenting to the emergency department ( ED ) and as part of the admission orders , a urinalysis ( UA ) and / or urine culture ( UC ) are ordered . The risk in this situation is for the patient who presents without any clinical indication for a urinary tract infection ( UTI ) but the lab results identify dirty urine and the provider inappropriately treats the patient with an antibiotic for a UTI , which is identified as a diagnostic error .
This led to a focus on diagnostic stewardship identified in a 2017 Journal of the American Medical Association article Diagnostic Stewardship- Leveraging the Laboratory to Improve Antimicrobial Use . The article states the decision to order a test should be “ guided by clinical evaluation , recognition of a clinical syndrome , and estimation of the pre-test likelihood of the condition for which the test is obtained .” Benefits of diagnostic stewardship are improved clinical care , fewer false-positive test results and less overdiagnosis – increased accurate diagnostic results which allow for appropriate antibiotic prescribing and decreased antibiotic exposure which decreases the risk for AMR .
The positive outcomes of diagnostic stewardship have led the CDC to release recently the Core Elements of Hospital Diagnostic Excellence Assessment Tool Priority Examples and Core Elements of Hospital Diagnostic Excellence Assessment Tool Additional Examples . The CDC advises hospitals to “ set aside resources for a diagnostic excellence team and committee ; to track and report any incorrect diagnoses ; to involve patients in care decisions and to put protocols in place to ensure the right diagnostic tests are ordered , interpreted , communicated and acted upon .” This supports the need to commit necessary resources to this work . While at a conference on antimicrobial resistance this month , there was an IP attendee from a foreign country who shared that she just received approval for a full-time nurse whose job will be to take the lead on this work .
It ’ s time we as infection preventionists start developing a business case for the same thing here in the United States . Reducing patient harm , improving patient outcomes and preserving a decreasing resource in our antibiotic armamentarium as more and more antibiotics develop resistance is key to maintaining effective antibiotics in our tool box of treatments in the future .
Teri Hulett , RN , BSN , CIC , FAPIC , has been in nursing for 44 years . Her experience includes 27 years as a bedside nurse with her area of specialty being neonatal ICU . She transitioned from the bedside to infection prevention in 2006 . Over her tenure as an IP , she has served in multiple leadership roles at the local level to include president of the APIC Mile High Colorado Chapter , and at the national level as chair of the APIC Education Committee . She has been involved in multiple projects and initiatives at the local , regional , and national level , and has co-authored multiple articles published in peer-reviewed journals . Infection prevention and control areas of focus include antimicrobial and diagnostic stewardship to include co-leading a 2-year statewide antibiotic stewardship collaborative for Colorado in 2016 . She continues to partner with and mentor colleagues in antimicrobial stewardship across the continuum of care .
10 • www . healthcarehygienemagazine . com • november 2024