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 important for IPs to have a working knowledge of current antibiotics used to treat HAIs, and the local antibiogram, but not at the level of the ID physician, the Laboratorian and the Pharmacist. Not that IPs are not capable of learning those details – they certainly are, and some do – not all in my profession would agree with me here. But the way I look at it is if IPs are spending time doing that, what they are missing in terms of time spent preventing and controlling infections. I think it is super important as an IP to be ever vigilant of time spent on activities not directly contributing to prevention and control of infections, and establishing and defending clear boundaries regarding the role and scope of IP vs. nursing, pharmacy, and other professions. This to me is important, since often the individuals that IPs report to, do not necessarily understand the scope of IP practice. And the line can get blurred when resources in many departments are constrained, and of course everyone is working to keep patients safe.
Kara: OK Sue to be clear, the IP’s primary role in AS programs is prevention and control of infections – Infections prevented means, antibiotics avoided, and resistance risk reduced?
Sue Response: Yes.
Kara: I love that. Thank you for the clarity.
Kara QUESTION 6: Describe an AS Program that you are aware of that would represent best practice?
Sue Response: I saw many best practice programs when I worked for Kaiser Permanente. They included a software program for Pharmacy to expedite the screening of antibiotics that are prescribed for selection, dosing, route of administration, and duration of administration. This helps to automate and reduce the people resources required to identify patients that need some type of intervention – change in antibiotic, change in dose, change in route, or d/c. The pharmacist should also be ID trained. And should work closely with an ID doc who would confer with the pharmacist, and confirm or revise antibiotic intervention recommendations. Depending on local relationships it might be either the ID pharmacist or the ID physician who contacts the treating MDs to recommend the changes in antibiotics. In addition the Pharmacy generates reports to share with the Infection Control Committee and ASP committee if there is a separate one. The report might include outcome metrics such as days of therapy (DOT) or defined daily dose (DDD), as well as analyses on specific antibiotic(s) and hospital locations where stewardship actions are implemented. The IP department would be responsible for sharing the rate and trending of hospital onset CDI, as well as rates of MDRO.
Kara Question: Sue this has been really informative. Any final thoughts?
Sue Response: We have primarily discussed hospital based AS programs, but the majority of antibiotics are prescribed and administered in the community – in outpatient settings. This is an area of great opportunity and increased focus. And just as in the hospital, prevention of community-associated CDI should include focus on reducing inappropriate antibiotic and PPI use.
Kara Response: Sue I completely agree. The outpatient area should be a big focus. For example Emergency Departments and Primary Care Physicians ordering a urine analysis tied to a urine culture order for patients that do not have signs or symptoms of a urinary tract infection. If that culture has growth, they will treat that colonized and not infected patient with unnecessary antibiotics. Which as you alluded to increases community-associated CDI.
We could go on and on about CDI prevention, but that is another show!
Kara Question: Sue, you are a busy lady these days working as an Independent Clinical Consultant, author, and San Francisco APIC Board Member. Can you share with the listeners any new projects you are working on?
Sue Response: Yes absolutely – I am currently preparing for another podcast for August 22 on the C diff Foundation radio show Spores and More. I will be talking about the role of contaminated mobile devices in healthcare HAI risk. Also stay tuned for an article coming out soon on Air contamination and SSI risk in orthopedic surgery recently accepted for publication by AJIC. I’m a co-author on that.
Kara Response: That is so great! Mobile devices are a big issue! I have seen providers on personal cell phones in a contact isolation room with gown and gloves on. I look forward to listening to that show. I also can’t wait to read the AJIC article. The doors in the OR open way too often in my opinion. Great Projects!
Kara Question: Sue, Please let us know the best ways for everyone to connect with you.
Sue Response: The easiest way is by email – mine is simple my name with middle initial a – so it’s firstname.lastname@example.org. I’m on LinkedIn now too - so (LinkedIn, twitter, Facebook, email).
Kara Response: Wonderful, I will have a link in the show notes on how to connect with Sue. Sue, thank you so much for joining me on the Infection Prevention Spotlight Podcast. I’d love to have you back again in the future, you are a wealth of Infection Prevention knowledge. Also, I want to personally thank you for your dedication and contributions to the field of Infection Prevention, really amazing work – Thank you!
Sue Response: It was my pleasure – thanks for the opportunity!
End of Interview