Interview with Sue Barnes on IP's Role in Antibiotic Stewardship Programs

 

 

Kara Mullane: – Intro to Podcast: Hello everyone and welcome to the Infection Prevention Spotlight Podcast. I’m am so excited about today’s show we have an Industry Icon with us today, Sue Barnes. For those of you who may not be familiar with Sue let me tell you about Sue’s contribution to Infection Prevention:

 

Kara: Sue Barnes is an independent clinical consultant, as of October 2016 when she retired as National Infection Prevention Leader for Kaiser Permanente’s 38 hospitals and 673 medical offices. She is Board certified in Infection Control and Prevention, and was granted the designation of Fellow of APIC in 2015 (FAPIC). She has been in the field of Infection Prevention since 1989. She has participated in the development of a number of APIC guides, and served as a speaker for organizations including AORN and APIC. In addition Sue has been published in journals including AORN Journal, American Journal of Infection Control and the Joint Commission Source for Compliance Strategies. She served on the National APIC Board of Directors from 2010 to 2012, and the San Francisco chapter board of directors for the past 10 years.

Kara: Welcome Sue, I’m delighted to have you join me today!

Sue Barnes: Glad to be here.

Kara: Let’s dive in. Today we are spotlighting: The Infection Preventionists Role in Antibiotic Stewardship.

Kara QUESTION 1: So Sue, for anyone listening who might not know, why is antibiotic stewardship so important?

Sue Response: The CDC estimates that at least 30% of all antibiotics prescribed in this country are unnecessary – that is 1 in every 3 antibiotics is actually not needed. The World Health Organization (WHO) considers misuse and overuse of antimicrobials one of the top three threats to human health. This is such a big concern because with every dose of antibiotics prescribed and ingested, bacteria are continuing to develop mechanisms to resist those antibiotics. This leads to antimicrobial resistance – bacteria that are resistant to antibiotics. And infections caused by these drug resistant organisms such as MRSA, are more difficult and sometimes impossible to treat. So in general the rate at which bacteria are becoming resistant to antibiotics and losing their effectiveness, is far exceeding the rate at which new antibiotics are being developed.

 

 

Antibiotic stewardship has been an organized effort since the late 1990s. To date it has been primarily implemented in hospitals and has largely been voluntary with self-regulation. In hospitals, this often takes the form of an antimicrobial stewardship program and committee. As of 2014, only the state of California has made this type of AMS mandatory by law.

 

In addition to causing bacterial resistance, the inappropriate use of antibiotics increases the risk of Clostridium difficile infections. This infection is caused in part by the disruption of helpful intestinal bacteria such as that caused by ingestion of antibiotics. For anyone listening who is not familiar with Clostridium difficile, often called C. difficile, C. diff, it is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long-term care facilities and typically occurs after use of antibiotic medications. However, studies show that there are increasing rates of C. difficile infection among people traditionally not considered high risk, such as younger and healthy individuals without a history of antibiotic use or exposure to health care facilities. Each year in the United States, there are half a million cases of C diff infection and more than 29,000 deaths. In recent years, C. difficile infections have become more frequent, severe and difficult to treat. Consequently antibiotic monitoring and control is critical – which is what antimicrobial stewardship programs or ASP for short - are all about.

Kara QUESTION 2: What about PPI medications – proton pump inhibitors used to prevent and treat gastric ulcers. I understand they can disrupt intestinal flora as well and contribute to the increased risk of C.difficle infection also known as CDI.

Sue Response: Great question – Proton pump inhibitor (PPI) use has been reported to be associated with an increased risk of CDI, and PPIs are frequently over prescribed. There are two reasons for why PPI causes this increased risk: first, by raising pH, PPIs may prevent gastric contents from killing C. difficile spores; second, gastric contents of PPI-treated patients may promote germination and outgrowth of C. difficile spores. FDA reviewed a total of 28 observational studies. Twenty-three of the studies showed a higher risk of C. difficile infection or disease, associated with PPI exposure compared to no PPI exposure. So in addition to antibiotics, this category of drugs is really important to monitor and control. In some hospitals, PPI utilization is included in the Antibiotic Stewardship Program.

Kara QUESTION 3: Since ASP is a multi-disciplinary endeavor, can you describe who should be involved?

Sue Response: Within the AS program oversight group whether it is part of another committee or free standing, representatives should be included from key physician specialties such as surgery and medicine who are the ones prescribing the antibiotics. And most typically it is an Infectious Disease physician(s) who takes a co-leadership role in ASP programs, along with an Infectious Disease trained Pharmacist. Laboratory should be represented as well, to share the local antibiogram and any trends in resistance. Nursing leaders such as Dr. Mary Lou Manning have recommended that support is needed from nursing as well. What this would entail might be actions such as adding an assessment of antibiotic necessity to daily nursing huddles and rounds, much as nurses currently do with daily assessment of urinary catheter necessity.

The ASP committee or overview group typically review reports of trends in antibiotic prescribing, utilization and adverse events including antimicrobial resistance and C difficile infection. The IP department should of course be represented on the committee or group as well. And in the absence of a committee, should serve as a consultant to the AS program.

Kara QUESTION 4: Can you describe the role that the IP or IP department should play in ASP?

Sue Response: In my opinion the primary role of IPs in AS programs is prevention and control of infections – Infections prevented means, antibiotics avoided, and resistance risk reduced. To me this is what should be considered the central role for IPs in AS programs, though I rarely hear this when AS programs and the role of the IPs is discussed. Prevention and control of infections is what our jobs are focused on entirely through ensuring compliance with the use of evidence based products and practices to reduce all types of healthcare associated infections. And of course also by supporting early adoption of new products and practices to further support prevention of infections. Another function IPs could and do serve that supports AS programs, which I also rarely if ever hear discussed, is to influence providers to use antiseptics instead of antibiotics where efficacy is equivalent. Examples are surgical irrigation solutions, and nasal decolonization for prevention of SSI and ICU device associated infections. Currently antibiotic surgical wound irrigation is commonly used for orthopedic procedures such as joint replacements. However, this is an off label use of antibiotics, and they have been shown to be ineffective in reducing SSI, as well as contributing to the growing antibiotic resistance. There are antiseptic containing surgical irrigation solutions available. The one that is FDA approved contains 0.05% chlorhexidine, which is a very effective antiseptic, with a broad range of efficacy and a sustained effect for at least 48 hours after application. As for nasal decolonization which is performed to suppress bacteria in the patient nasal passage in advance of high risk surgical procedures, the most commonly used agent is mupirocin which is an antibiotic ointment. While it is generally effective, there are increasing cases of mupirocin resistant bacteria, and it requires 5 days of application at home by patients. Patients are not always compliant with this protocol. There are nasal antiseptic products available now, which are alternatives to mupirocin antibiotic ointment, that are easy to use, require one application one hour prior to surgery, are cheap and equally if not more effective than mupirocin and have no associated risk of antibiotic resistance development.

I have seen many suggested functions for the IP in AS programs which are all important, but in many cases (at least in my opinion) not necessarily in the scope of IPs, or even very closely related to the overarching goal of reducing inappropriate antibiotic administration.

Kara QUESTION 5: What are some examples of these functions that are sometimes proposed as part of the role of IPs in AS programs that you are thinking should not be?

Sue Response: To me it seems that often in an effort to include IPs in AS programs (which they should be), there sometimes seems to be a kind of grasping at activities for which they should be responsible for. I am perhaps overly sensitive to the assigning of functions to IPs which are outside of their scope because in my career this has happened quite often. But specific to AS programs some examples of activities I don’t believe are in the scope of IP’s, that I have seen suggested include:

 

1. Questioning MDs regarding antibiotic choice – this is an MD or ID pharmacist role.

2. Educating front-line workers on antibiotic stewardship – unless very general, this should more appropriately be the individuals in charge of AS programs – ID physicians and pharmacists. 

3. Educational efforts related to facility specific antibiogram – although certainly IPs should be knowledgeable about the antibiogram and resistance patterns, it is Laboratorians who are the experts there.

4. Reevaluating antibiotic therapy after 48 hours in light of lab reports – this is an MD or ID pharmacy role.

5. Support pharmacy-led ASP interventions such as switching from IV to oral route of administration during unit visits – again this would seem to be an MD or ID pharmacy role, as would: 

6. Identification of bug-drug mismatches, and identification of excessive use of broad-spectrum antibiotics.

Don’t get me wrong – I think it is impor