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.

The Overuse of Antibiotics in Food Animal Production Needs to Be Addressed

The Food and Drug Administration (FDA) issued guidelines to curb the non-therapeutic use of antibiotics in food-producing animals last June. The hope is that food producers will reserve these vital antibiotics for disease treatment and prevention.  According to the FDA, in 2009 nearly 29 million pounds of antibacterial drugs (includes 3.7 million kilograms of Ionophores) were sold for animal use, almost four times the amount sold for human use that year. Data released later last year revealed that of all the antibiotics used in the United States, 80% is used in animals and the use is not to treat or prevent disease, but to make the animals gain weight faster and to compensate for the crowded conditions often found in such enormous facilities.

APUA believes that more action needs to be taken on this issue and that these guidelines will have little impact in fighting the growing threat of antibiotic resistance to public health unless the agency halts the practice and establishes a system to monitor compliance.

High-volume use of antibiotics at food animal production sites is a major contributor to the selection and transfer of resistance genes that can end up in human pathogens.

What are your thoughts on the use of antibiotics in food animal production?

For more information please contact Carol Cogliani

Resistant Salmonella Concord from Ethiopia

APUA chapter advisor for sub-Saharan Africa, Dr. Iruka Okeke, Ph.D. and current assistant professor of biology at Haverford College offers her insights on drug-resistant Salmonella Concord infections in Ethiopian adoptees.


There have been a number of worrisome reports in the recent medical literature about drug-resistant Salmonella Concord infections in Ethiopian adoptees.  The reports come from the USA, France, Norway and Denmark, plus a case report from Spain.  Based on global epidemiology of Salmonella, which includes very little information from every country in Africa combined, Salm. Concord is unusual.  The reports about what seems to be an epidemic come from less than two hundred individuals in all over a period of about seven years.  Thus, in a sense, they represent an archetypical example of what University of Virginia’s Richard Guerrant and his co-workers referred to as the ‘eyes of the hippopotamus’  – a mere scratch on the surface of what could be a deeper problem of unimaginable girth. 

 Unfortunately, too much of what we know about pathogens and drug resistance in resource-limited areas still comes from studies performed very distant from those places -  on isolates from returning travelers, or as in the Salmonella Concord case, recent immigrants.  Is it true, as some have suggested, that selection of resistant Salmonella Concord occurs in orphanages that overuse or abuse antibiotics in order to speed up adoption and empty out needed spaces?  Could we nip the problem in the bud by restricting antibiotic use in a few institutions and prescreening international adoptees?  Or is the average Ethiopian child at equal risk of a Salmonella Concord infection, with a significantly lower chance of having it detected and treated appropriately?  And are other, less susceptible individuals transporting Salmonella genomes packed with mobile resistance genes from endemic areas with an efficiency that is analogous to human transport via concord only a decade before?  Should we be developing a Salm. Concord vaccine to deal with the last two possibilities?  Or will the current apparent outbreak burn itself out before we get started?

 Getenet Beyene and co-workers have finally performed a small, but much-needed study to address these vital questions and they’ve done so where it is needed – in Addis Ababa and rural South-West Ethiopia.  The results, published in the January 2011 issue of the Journal of Infections in Developing Countries, are clarifying, if troubling.  Working at Tikur Anbessa Hospital in Addis Ababa and Jimma University Hospital, the researchers looked for Salmonella and other pathogens in the blood of patients with fever and in stool specimens from individuals with diarrhea.  Non-typhoidal Salmonella were isolated from the blood of 26 patients and from the stool of 59 more individuals.  Salmonella enterica serovariety Concord was the most common Salmonella serovar detected, being four times as common as all other Salmonella combined, and it was more invasive than other serovarieties.   The lack of evidence of clonality among the isolates suggests that this is no new epidemic and data from a smaller study published 25 years ago report Salm. Concord from Ethiopia, strongly suggesting that this pathogen has lurked undetected for at least a quarter of a century (Ashenafi and Gedebou, 1985, Trans R Soc Trop Med Hyg 79: 719-721).  Since 1985, Salm. Concord isolates from Ethiopia appear to have become more prevalent, and resistant to more antibiotics.  The isolates in the recent report were resistant to most affordable antibacterial options in Ethiopia.

 Oddly, the literature suggests that this serovar has a narrow geographic range.  However, our perceptions can only be as broad as our vision. There are reasonably good data from Kenya, which suggest that Salm. Typhimurium and Typhi are more important there, but with next to no data from other nearby locations, we cannot be sure that the problem is not extensive. While the endemicity, invasiveness and resistance of Salm. Concord in Ethiopia all give cause for concern, as Beyene et al emphasize in their discussion, the now global problem of multidrug-resistant Salmonella Concord must be addressed from endemic areas.  The very first step is determining where these are, and what exactly are the risk factors for infection.  Everyone is at risk when any part of the world lacks the diagnostic capacity to identify, track and control resistant pathogens. Microbes made the resistance problem a global one decades ago.  To deter them, we need local surveillance worldwide. 

 Iruka N Okeke

Haverford College

The International Society of Chemotherapy's African Network

APUA expert panel member and Secretary General of the International Society of Chemotherapy, Dr. Ian Gould, discusses launching of the ISC African Network.

Recently in South Africa, as Secretary General of the International Society of Chemotherapy, I was very pleased to be able to launch a new initiative- the ISC African network. The network will work in close conjunction with the ISC working group on Antibiotic Stewardship (AS) which is co-chaired by Gabriel Levy Hara (Argentina) and Jim Hutchison (Canada). It will be a working group of the Infection Prevention Control African Network (IPCAN) jointly with ISC.

The aims are to create a worldwide web-based compilation of antimicrobial stewardship efforts and activities, the people involved with them, their products and accomplishments. The website will display the collected information and promote sharing. It will be used as a platform for further Antimicrobial Stewardship Working Group initiatives. We believe that this could really help colleagues of different specialities (physicians, pharmacists, microbiologists and health care managers) in formulating and enacting AS initiatives.

Other aims of the ISC AS working group include:

1. Performing international studies of antimicrobial consumption in all five continents.
2. Distance learning courses to address specific and locally prevalent problems (e.g., rational management of URI, principles and experiences with antimicrobial stewardship programs, frequent problems regarding antimicrobial use in the elderly, etc).
3. To work with pharmacists of the different countries in common aspects (regulation, educational programs) regarding use and misuse of antimicrobials.
4. To advocate for the regulation of sales and distribution of antimicrobials worldwide.
5. To hold meetings to highlight stewardship issues.

We are also in discussion about a first position statement to include critical tips in prescribing. ISC is in regular contact with other groups active in this area such as WHO, APUA, CDDEP and CGD as we need to join forces as much as is possible in this critical area.


I M Gould