APUA Webinar on Antimicrobial Stewardship

Get Smart About Antibiotics Week

November 12-18, 2012

APUA is proud to have been a national partner of the CDC's Get Smart About Antibiotics Week since 2010. Get Smart About Antibiotics Week is an annual effort to coordinate the work of CDC’s Get Smart: Know When Antibiotics Work campaign, state-based appropriate antibiotic use campaigns, non-profit partners, and for-profit partners during a one week observance of antibiotic resistance and the importance of appropriate antibiotic use.

This year, for Get Smart About Antibiotics Week APUA produced a webinar about Antibiotic Stewardship.

Containing Healthcare Associated Infections Through Antibiotic Stewardship Live event: Wednesday, November 14, 2012  1:00 PM EST PACE® credit available until May 13, 2013 There is no charge to view this webinar.
Presenters:
Stuart Levy, M.D. Professor of Medicine Tufts University School of Medicine President, APUA	Shira Doron, M.D., M.S. Assistant Professor of Medicine Tufts University School of Medicine

A recent APUA study found that antibiotic-resistant infections can add nearly 13 hospital days per patient, and up to $26 billion in annual US healthcare costs*. The number of hospitalizations associated with C. difficile infections has tripled to 335,000 annually, while the number of deaths has quadrupled in the past decade.

New ESBLs have evolved dramatically in the recent decades, such that few treatment options remain for infections caused by these exceptionally resistant pathogens. And of the estimated 478,000 US hospitalizations with S. aureus infection, approximately 58% were related to MRSA. Antimicrobial Stewardship Programs (ASPs) are recommended by the CDC and IDSA as essential in controlling these most problematic infections. This webinar will describe the nature of antimicrobial resistance, identify trends of major resistant infections, and delineate the important components of successful antimicrobial stewardship.

This webinar will:
• Describe trends of major HAIs including MRSA, ESBLs and C. difficile
• Review the causes and mechanisms driving antibiotic resistance problems
• Explain the link between antibiotic overuse and the emergence of resistant infections
• Review effective ASP practices and the importance of diagnostics in improving antibiotic treatment and minimizing resistance
• Illustrate specific examples to enhance hospital-based antimicrobial stewardship

* (CIDOct 2009)

This webinar is produced by the Alliance for the Prudent Use of Antibiotics in conjunction with the Tufts Medical Center and is funded by an unrestricted grant from Alere.

To learn more about Antimicrobial Stewardship please see our recent APUA Clinical Newsletters:

Volume 29 No. 3
December 16, 2011
"Enhancing Infection Control with Antibiotic Stewardship" (PDF)

Volume 29 No.1
June 14, 2011
"Anitbiotic Stewardship Gaining Traction: Recommended Models and Resources" (PDF)

About the CDC Campaign
How to Become a CDC Get Smart Partner
CDC Daily Fact Sheets
APUA Fact Sheets
CDC Brochures
CDC Podcasts

Multidrug-Resistant Staphylococcus aureus in US Meat and Poultry

Dr. Lance Price is a Senior Scientist, Office of Wellness and Healthy Communities, at the Interdisciplinary Health Policy Institute as well as a Senior Science Advisor at the Pew Charitable Trusts. He is a molecular microbiologist and public health researcher. Lance is also the director of the Center for Metagenomics and Human Health at the Translational Genomics Research Institute (TGen). 

A couple weeks ago we published the first US-based, multi-state study of antibiotic resistant Staphylococcus aureus in retail meat and poultry. We revealed that 47% of the samples were contaminated with S. aureus and that more than half of the isolates were multidrug resistant (i.e., resistant to three or more classes of antibiotics).

I’ve done countless media interviews since the paper appeared online, and the most frequent question that I hear is “What can we do to protect ourselves?” Unfortunately, there’s no straightforward answer to this simple question. We found S. aureus strains with MLST sequence types identical to those of strains that colonize and infect people, but we don’t know if they’re the exact same strains. Even if they were the same strains, we don’t know if meat is a good vehicle for S. aureus infection—anyone who says “it is” or “it is not” is not making their statement based on robust science, because we don’t have good data on this subject yet. Industry groups and the media have largely focused on the risk from ingestion, but we should also be concerned about skin infections from handling the contaminated products. Does having a cut on your hand increase your risk? Maybe. We need to answer this.

I have also read a few statements from people saying that if this were really a problem, we would have seen outbreaks of foodborne infections from contaminated products. I disagree. With such high prevalence rates, we would not expect outbreaks, but rather routine sporadic infections. Campylobacter spp. is a good example of this type of observation. More than 40% of fresh chicken products in the US are contaminated with Campylobacter spp. and a couple million Americans are sporadically infected each year. It’s entirely possible that some of the hundreds of thousands of S. aureus infections that occur in the US each year are from foodborne exposure. So, with all these knowledge gaps, I answer the question, “What can we do to protect ourselves?” by saying what every good public health person would say: “wash your hands repeatedly when handling raw meat and poultry; wash your cutting boards and other equipment; separate meats from vegetables that will be eaten raw; and, definitely cook your food properly.” I also add that people should treat their meat and poultry as potential biohazards and never let children handle these products when helping out in the kitchen.

Unfortunately, almost everyone has focused on the consumer end of the food chain, when the problem clearly starts with the food animal producer. The prevalence of antibiotic-resistant S. aureus antibiotic use in food animal production. on meat and poultry is most likely a result of largely unregulated

While doctors are told to use antibiotics sparingly for their patients, millions of pounds of antibiotics—many of which are important for clinical medicine—are used as common production tools to improve feed efficiency, stimulate growth, and prevent diseases in food animals. I was once told “antibiotics is a crutch for poor animal husbandry” by the owner of a major US poultry production company. I am not a veterinarian, but I can say with confidence that any animal production system that requires the routine input of antibiotics to keep animals from becoming sick is a broken system. There is no justification for this flagrant antibiotic abuse while doctors and scientists are working frantically to preserve the utility of these drugs to treat sick people.

So what’s next? Now that we know that multidrug resistant S. aureus is common in our food supply, we need to define the risk to consumers. Occupational studies are probably the most powerful place to start. Studying food animal workers will tell us about the infectious potential of the strains that we’re finding on our food. Looking at prep cooks and butchers will move us even closer to the risk posed by handling meat and poultry. But, we’ll eventually have to bring these studies to the consumer’s kitchen to see how and how often consumers are exposed to S. aureus from food.

All that said, our future research shouldn’t follow the lead of the media and focus exclusively on the consumer end of the food chain. We also need to better understand the situation in the CAFO and slaughterhouse. How can we decrease antibiotic-resistant S. aureus colonization among food animals in CAFOs? How can we reduce meat contamination in the slaughter facilities? And one urgent question in my mind is: What is the relationship between ceftiofur use and MRSA colonization among food animals? Ceftiofur is a third generation cephalosporin and has been shown to kill off other S. aureus and select directly for MRSA in the laboratory. Are the new MRSA strains—such as ST398—that we are seeing in food animals a direct result of ceftiofur use? We need to answer all of these questions, but we’ll need cooperation by the food animal industry to do so.

Anyway, there are lots of import questions to answer here, and I’d be interested in hearing your thoughts…

Lance

Evidence-Based Strategies for the Containment of Antibiotic Resistance

Professor Sabiha Essack (B. Pharm., M. Pharm., PhD), Dean of the Faculty of Health Sciences and Professor in the School of Pharmacy and Pharmacology at the University of KwaZulu-Natal is a Welcome Trust Research Fellow who completed research towards her PhD in Pharmaceutical Microbiology at St Bartholomew’s and the Royal London School of Medicine and Dentistry in the United Kingdom. She is also the president of APUA-South Africa.

Antimicrobial resistance is currently the greatest challenge to the effective treatment of infections globally. Resistance adversely affects both clinical and financial therapeutic outcomes with effects ranging from the failure of an individual patient to respond to therapy and the need for expensive and/or toxic alternative drugs to the social costs of higher morbidity and mortality rates, longer durations of hospitalisation, increased health care costs and the need for changes in empirical therapy. Resistance may emerge by selection pressure (overuse/indiscriminate antimicrobial use in developed vs under-use/misuse in developing countries) but is perpetuated by diverse risk factors and maintained within environments as a result of poor infection control. Population-specific drug pharmacokinetics and pharmacodynamics also play a role. The WHO, US, UK and EU have initiated strategies for the containment of resistance, with surveillance critical to all.

Surveillance in South Africa should be disease-based, establishing sensitivity profiles of common causative organisms to inform the development of or amendment to standard treatment guidelines and essential drugs lists adopted within national drug policies in developing countries globally. The manner of antimicrobial use (overuse, underuse, inadequate dosing) associated with resistance must be established for appropriate intervention in terms of rational drug use, a reduction in use and dosing regimens based on population-specific pharmacokinetics and pharmacodynamics. Risk factors unique to South African communities (poverty, HIV) and hospitals (duration of hospitalisation, location within the hospital, intensive care unit stay, surgery, wounds, previous and current antimicrobial therapy, mechanical ventilation, urinary catherterisation, nasogastric intubation, central venous and peripheral catheters, previous hospitalisation and transfer from another unit or hospital) must be determined and due vigilance exercised in patients exhibiting classical risk factors for the acquisition of or colonisation with resistant pathogens.

 

Hygiene and sanitation (in communities) and infection control (in hospitals) status must be determined and interventions initiated to prevent the spread of resistance. Pharmacokinetics and pharmacodynamics specific to diverse populations must be devised to optimise antimicrobial therapy. Evidence-based treatment of infections guided by local susceptibility/resistance would ensure productive, economically viable individuals capable of fulfilling their social roles. Efficacious treatment would assure sustainable livelihoods in all populations (healthy and otherwise) as infections are the most frequently encountered health problem even in the absence of HIV/AIDS. While one infection will ultimately be fatal, the efficacious use of antibiotics will successfully treat several infections in the lifetime of the AIDS patient even in the presence of a compromised immune system sustaining the economic viability of the country and preventing the economic collapse portended by the World Bank. South Africa has unique needs in the antimicrobial resistance arena, needs to be addressed in the context of severe financial, human resources and technological challenges.

Infection Prevention + Optimal Antibiotic Use = Zero Infections

Julia Moody, MS SM (ASCP), Clinical Director, Infection Prevention, Clinical Services Group, HCA, Inc, APIC Antimicrobial Stewardship Task Force

Antibiotics are the second most common medication prescribed in the US. Although the discovery of antibiotics advanced the treatment of infections, excessive use frequently occurs. Bacteria easily adapt to become resistant, often at an alarming rate, posing a threat to public health safety, because new, more powerful antibiotic development is limited. This threat to public health safety was recognized on World Health Day, April 7, 2011, and endorsed by Centers for Disease Control and Prevention (CDC) and healthcare professional organizations in the U.S. To address the threat, antimicrobial stewardship programs are instituted to optimize antibiotic use and improve patient outcomes, while decreasing the development of resistance.

Antibiotic exposure is the single most important risk factor in C. difficile infection, a cause of severe diarrhea, serious intestinal complications and death. In some parts of the U.S., C. difficile is more common than MRSA. New cases of C. difficile infection occurring during a hospital stay are an indicator of adverse drug events as there is growing evidence that the risk for infection drops with antimicrobial stewardship.

What is the science of infection prevention and the value for hospitalized patients? Hospitals are where the most vulnerable patients in intensive care units, those with chronic health conditions and whose immune systems are unable to fight infection, rely totally on antibiotics to treat life-threatening infections. Resistant bacteria can leave these patients without an effective antibiotic for their infections.

How does the role of infection preventionists decrease the risk of infections and slow the pace of antibiotic resistance in healthcare settings? Infection prevention uses scientifically proven concepts to (1) identify trends and occurrences of drug resistant bacteria [MDROs], like MRSA, and new, emerging resistance in gram negative bacteria; (2) apply practices to prevent transmission of these MDROs to other patients, using bundles of hand hygiene before and after patient contact, isolation precautions placing patients in private rooms, where caregivers wear gowns and gloves, and environmental cleaning to ensure that surfaces and equipment are completely cleaned to reduce the presence of bacteria in the environment; (3) implement care bundles – like checklists – that when consistently performed, reduce the risk of getting an infection from use of catheters or after undergoing a surgical procedure; and (4) share findings of MDRO-related infections with the antimicrobial stewardship team members to identify successes and improvement opportunities.

What have been the outcomes? In the past 10 years, healthcare epidemiologists and infection preventionists – in collaboration with their direct care co-workers – have documented dramatic reductions in the frequency of infections, especially among patients in ICUs, as reported into the CDC’s National Healthcare Safety Network (NHSN) database.

What can you do today to prevent infections and save antibiotics for their intended use? Practice good hand hygiene with alcohol based hand rubs or soap and water, know what common infections do not respond to antibiotics, like the common cold, viral sore throats and influenza, take the full dose of antibiotics when prescribed for true infections, and keep current on vaccinations.

Why Urgent Action is Needed to Safeguard Drug Treatments for Future Generations

Dr Mario Raviglione is Director of the WHO Stop TB Department. He is leading preparations for World Health Day 2011.

The World Health Organization (WHO) is marking World Health Day – April 7 - this year with a call to Combat Drug Resistance and protect vital antimicrobial drugs the effectiveness of which is increasingly under threat. We believe that concerted action under the stewardship of governments, and engaging health professionals such as prescribers and pharmacists. Civil society and the pharmaceutical industry is needed to slow down the impact of drug resistance and preserve medical advances for future generations.

Every year, WHO uses the anniversary of its founding to draw the world’s attention to an urgent health problem. Clearly, drug resistance fits the definition. It’s not a new problem, but it still needs urgent action across the health sector and beyond it.

In her message to governments around the world, the WHO Director-General, Dr Margaret Chan, spelled out the problem: "The message on this World Health Day is loud and clear. The world is on the brink of losing these miracle cures." In the absence of urgent corrective and protective actions, the world is heading towards a post-antibiotic era, in which many common infections will no longer have a cure and, once again, kill unabated.

On Thursday, WHO will publish a policy package that spells out the measures governments and their national partners need to take to safeguard these vital medicines.

We know that the discovery and use of antimicrobial drugs to treat diseases such as leprosy, tuberculosis, malaria, gonorrhea, syphilis, pneumonias and other killer diseases has changed the course of our history as a species. We must act now to prevent those discoveries from being put at risk.

Tuberculosis, malaria and HIV all face severe constraints due to rising levels of resistance, and resistant strains of gonorrhea and shigella are limiting treatment options. Serious infections acquired in hospitals are now often fatal because they are so difficult to treat and drug-resistant strains of microorganism are spread overnight from one geographical location to another in today's interconnected and globalized world. Resistance is also emerging to the antiretroviral medicines used to treat people living with HIV.

Over the last decade, WHO has established many initiatives to understand and address drug resistance - particularly in relation to some of the world's most deadly infectious diseases. Those measures must now be further strengthened and implemented. New collaborations, led by governments working alongside civil society, health professionals and the private sector are essential if we are to halt the public health threat of drug resistance.

APUA has been a leader in promoting rational use of drugs and prevention and containment of antimicrobial resistance for many years. WHO looks forward to an intensified collaboration with APUA and all its chapters.