Mark A. DeSorbo
ATLANTA, GA-It happens all too often: A person goes to the hospital for something as simple as a sprain and they catch a hospital-borne illness that pummels their immune system.
Federal health officials estimate that nearly two million patients in the United States alone catch a hospital-borne illness during a stay, and about 90,000 of them die.
The crisis has become so severe that the U.S. Centers for Disease Control and Prevention (CDC) has launched a campaign, “Prevent Antimicrobial Resist ance,” an urgent crusade that comes at a time when bacteria is considered a weapon that defies the very drugs designed to kill them.
The CDC did not return calls placed by CleanRooms magazine, but many in the medical and contamination-control industries say federal steps to curb antimicrobial resistance have been a long-time coming.
Dr. Richard Brown, chief of infectious disease at Baystate Medical Center (Springfield, MA) recently told The Boston Globe that it is a “constant rat race” to stay ahead of bacteria that morph over time and become resistant to drugs that at one time used to kill them.
“It's like going back to 1920 when there were no antibiotics at all,” he says.
Resistance to antimicrobials is nothing new, says Robert W. Powitz, principal consultant at R.W. Powitz & Associates (Old Saybrook, CT).
“We created this problem with the idea that we shoot them full of juice and they'll be fine,” he says. “But because we did that we now have staphylococcal viruses that are resistant to antibiotics.”
The CDC campaign centers around four strategic goals to battle bacteria in healthcare settings. They are: 1) prevent infection; 2) diagnose and treat infection; 3) use antimicrobials wisely and 4) prevent transmission of infection.
Within these areas are 12 specific action steps derived from evidence-based guidelines and recommendations already developed by the CDC and other organizations that clinicians can take to prevent antimicrobial resistance in hospitalized adults. In the future, the CDC will develop action steps for clinicians that care for dialysis, critical care, long-term care and pediatric patients.
Under the “prevent infection” goal are two action steps, one of which calls for administering influenza and pneumonia vaccines to at-risk patients before they are discharged from the hospital.
Even before a patient is discharged, however, the “diagnose and treat infection effectively” goal calls for targeting and beating back pathogens.
The third and fourth action steps call for targeting therapy to like pathogens, taking cultures from the patient, identifying therapy and monitoring response to treatment. The action steps also ask healthcare professionals to seek the advice of contamination-control experts.
The goal of using antimicrobials wisely, Powitz says, is an attempt to get physicians to write fewer prescriptions for antibiotics.
“The environmental end is minimal. Right now we're creating people who have not been exposed to anything, so they are not building a natural immunity to illnesses,” he adds. “The person who works in a sewer plant, or a school teacher who is surrounded by kids is usually sick for a week, but after that they build a natural immunity.”
Powitz has long been a proponent of using antibiotics as well as cleanroom disinfectants rationally.
A balanced approach to disinfectants must be practiced and based upon “good science.”
In a January 1999 article for the CleanRooms Life Sciences supplement, Powitz encourages contamination-control professionals to adopt many of the same objectives found in the recently drafted CDC campaign. [See “A rational approach to disinfectants,” Life Sciences supplement, January 1999, p. S4.]
“Of greatest importance, however, is to consider the primary objectives of contamination control,” he writes. “The first objective is to keep the contaminants out. The second objective is to eliminate the contaminants that found their way to the hard surface, in spite of all preventive efforts. This (latter) objective characterizes disinfection.”
One size, Powitz adds, does not fit all, and selecting a single cleaning agent for all applications may obstruct the cleaning process or add an additional cost factor with few benefits, if any.
“You have to minimize bacteria, you can't eliminate it, and wide use of broad-spectrum disinfections can cause mutations,” he says. “We have to use this stuff, but we have to use it judiciously. We have to look at disinfectants and be smart about them. The CDC initiative may be different from a cleanroom perspective, but that's not to say that we shouldn't use it with due diligence. We need to examine what we are doing and why we are using them.”
And that's just what the CDC initiative calls for: to use antimicrobials wisely and require medical professionals to practice contamination control through “appropriate use programs and local data.”
“Know your antibiogram, know your formulary and know your patient population,” the sixth action step indicates.
The seventh step denotes “treat infection, not contamination,” while the eight step says “treat infection, not colonization.”
“Treat pneumonia, not the tracheal aspirate. Treat bone infection, not the skin flora,” the steps say. “Treat staphylococcal infection, not contaminants or colonization.
Steps 10 through 12 are perhaps the most important. “Stop antimicrobial treatment when infection is treated; when infection is not diagnosed [and] when infection is unlikely,” step 10 indicates.
Steps 11 and 12, which embody the fourth and final goal, “prevent transmission,” require the use of standard infection control precautions; the containment of bodily fluids and the consultation of experts “when in doubt.”
“Break the chain of contagion,” decrees step 12. “Stay home when you are sick. Keep your hands clean. Set an example.”
Still, there are many who believe the battle of antimicrobial resistance is a losing one.
Dr. Robert C. Moellering Jr., physician in chief at Beth Israel Deaconess Medical Center (Boston) and a specialist in infectious disease also told The Boston Globe that even the very best efforts in infection control is not enough to keep organisms under wraps.
“You can't sterilize everybody's nose everyday,” he adds.