Regional Approaches to Lessening Antibiotic Resistance

A symposium at the annual meeting of the Infectious Diseases Society of America in New Orleans, Louisiana, highlighted initiatives designed to curb the spread of antibiotic resistance.

The common theme of the symposium was the value of coordinated efforts involving multiple sites in the particular jurisdiction, instead of the silo approach that has long been canon. It has been recognized that no matter how scrupulous antibiotic control is in any one institution, patients coming from environments where precautions are less stringent will undermine the control efforts.

“Antimicrobial stewardship is a quality improvement initiative that has been proven in multiple, peer-reviewed studies to improve patient outcomes, shorten length of hospital stay, reduce Clostridium difficile infection rates, save money, and reduce antimicrobial resistance. Yet, antimicrobial stewardship and infection control interventions have focused on individual institutions without coordination,” said Keith Hamilton, MD, director of Antimicrobial Stewardship at the Hospital of the University of Pennsylvania, in his talk.

California, which has enacted some of the most stringent regulations requiring antimicrobial stewardship, has provided an example of what can be achieved with a more widely coordinated approach.

“Transformative changes in infection control occurred when all healthcare facilities were required to implement infection control programs and required to report healthcare-associated infection rates. This has reinforced that antibiotics are a shared community resource and that antimicrobial stewardship should be seen as a community effort, said Dr. Hamilton.

The approach taken in Pennsylvania and elsewhere recognizes that patterns of bacterial resistance vary by region and that patient transfer between healthcare facilities causes horizontal spread of antimicrobial resistance. “In many cases, resources are not allocated to the facilities in which they may have the most significant impact on the community,” said Dr. Hamilton in his talk.

The Philadelphia Community Antimicrobial Stewardship Collaborative is comprised of 40 area healthcare facilities. The aim is to propagate knowledge and expertise, and foster the establishment of regional research networks. Surveys have indicated a thirst for knowledge of tangible aspects of antimicrobial stewardship.

“Most literature on antimicrobial stewardship has been performed in university/academic hospitals without clearly defined practical advice to ‘real-world’ solutions. Regional collaborations can identify and highlight tools that are effective at changing local prescribing culture,” said Dr. Hamilton in his talk.

Marion A. Kainer, MD, MPH, FRACP, FSHEA Tennessee Department of Health, Nashville, Tennessee, described regional collaboration between health departments in the state through a regional laboratory network. The state network is one of seven regional networks nationwide. The dissemination of information on cases of antibiotic resistance through shared data has improved resistance surveillance, outbreak response, and communication between health facilities in the state.

“One goal is the early recognition of antibiotic resistance cases and/or clusters of cases that warrant immediate investigation or intervention. We can also monitor epidemiology, epidemiologic trends, and spread of antibiotic resistant pathogens over time and place. We can use the data to drive control and prevention efforts, and to evaluate their effectiveness to guide revisions to response. We can use antibiotic resistance surveillance data to suggest hypotheses and inform research. We can monitor changes in healthcare practices that may have the potential to increase risk for acquisition or spread of resistance. And we can characterize the microbiology of antibiotic-resistant pathogens with the ability to identify rare and novel resistance mechanisms,” said Dr. Kainer in her talk.

Michael Lin, MD, MPH, an associate professor of Medicine at Rush University Medical Center, Chicago, Illinois, described another collaborative initiative— The Illinois XDRO Registry– that provides regional surveillance and, in a pilot study, successfully automatically generated regional alerts when cases involving or suspected to involve carbapenem-resistant Enterobacteriaceae (CRE; also termed extremely drug resistant organisms, or XDRO) are identified. The point-of-care use of amassed data represents ‘smart data,’ according to Dr. Lin.

“Patients move around a lot, but their health information doesn’t move with them. As well, information degrades over time. The XDRO registry addresses two critical gaps. One is the need for improved surveillance. The registry creates CRE surveillance rule and stores patient-specific CRE information. The second gap is the need for improved inter-facility communication. The registry provides efficient CRE information exchange,” said Dr. Lin in his talk.

Patient information entered into the registry is tagged to an identifier code. The information can be obtained by a search of the registry, which allows facilities state-wide access to the patient data. From its inception in October 2013, 5,081 reports representing 3,234 unique patients have been filed in the registry. There have been 8,099 manual queries.

A pilot study involving nine hospitals in the Chicago region has shown the potential for automated CRE alerts. In the study, 204 alerts were generated for 102 unique patients. The alerts detected the right person in 99% of cases. But there is room for improvement, particularly for cases where CRE status is unknown at the time of data entry and no contact precautions are in place.

“Public health-based information exchanges can enhance regional cooperation among healthcare facilities. The Illinois XDRO registry is an example of making public health data available for local action,” said Dr. Lin.

DISCLOSURES: Keith Hamilton, Marion Kainer, and Micahel Lin had no disclosures.

SOURCES:

• Photography and taping of presentations
• Hick LA New Engl J Med 2013 368:1461-1462
• Won SY et al. Clin Infect Dis 2011 53:532-540

Studies Presented:

The Pennsylvania Experience: Regional Approaches to Antimicrobial Stewardship

Keith Hamilton, MD

The Role of the Health Department in Regional Approaches to Resistance

Marion Kainer, MBBS, MPH, FSHEA

The Illinois XDRO Registry: Regional Surveillance for Local Action

Michael Y. Lin, MD, MPH

Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at hoyle@square-rainbow.com.