SOON AFTER ANTIBIOTICS went into wide use in the 1940s, bacteria began finding ways to thwart them. Today, preventing and managing infection from antibiotic-resistant bacteria is a major challenge.
Recently, the Centers for Disease Control and Prevention (CDC) issued guidelines for preventing the transmission of multidrug- resistant organisms (MDROs) in various health care settings.1 These organisms include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain Gram-negative bacteria.
Hand hygiene, standard precautions, and other basic infection control practices are the first line of defense against the spread of any type of bacteria. In an MDRO outbreak, however, enhanced control efforts may be necessary. The CDC's new guidelines spell out seven guiding principles:
1. Administrative support to make the recommended changes and to foster a team effort to implement changes. Support also is needed for the financial and personnel costs involved with making these changes.
2. Education to encourage behavior changes that reduce the threat from MDROs. Educational efforts should involve everyone at all levels: facility administrators, medical and nursing staff, support staff, patients and families, and the general public.
3. Judicious use of antibiotics to reduce MDRO emergence. Examples of judicious antibiotic use include preferring narrow-spectrum antibiotics over wide-spectrum antibiotics, not prescribing antibiotics for patients who are colonized but not infected, and avoiding long-term antibiotic therapy.2
4. Surveillance, or tracking resistance patterns for the facility and community. This includes monitoring trends (such as disease recurrence in specific units or among certain patients), and calculating infection rates by service.Facilities may also initiate a program of active surveillance cultures, in which target populations are cultured on admission to determine MDRO colonization. The facility will need to determine which populations to culture, which organisms to target, who collects and pays for the cultures, and what to do with the patients until results are known. Surveillance culturing of asymptomatic patients can reduce the overall prevalence of MDRO colonization and the transmission of MDROs to susceptible patients.3
5. Implementing standard precautions. You can't know with certainty which patients have an MDRO, so always observe standard precautions. Contact precautions are a useful adjunct if certain organisms are a concern within the facility.
6. Environmental measuressuch as cleaning and disinfection. This reduces the overall bacterial burden in the environment. Adherence to environmental measures must be monitored, and housekeeping personnel must be educated about routinely cleaning frequently touched surfaces. Clinicians must be educated about not sharing equipment between patients who have an MDRO and those who don't and should have input into prioritizing room cleaning assignments. Dedicated caregiver and ancillary personnel should be assigned in MDRO areas and during outbreaks.
7. Decolonization, or treating patients who are colonized but not infected. This measure may not be effective against all MDROs, but has had some success in MRSA outbreaks. When surveillance cultures of patients and staff show MRSA colonization, the recommended decolonization treatment was daily bathing with antimicrobial soap and combination regimens such as topical mupirocin, alone or with oral antibiotics such as rifampin, trimethoprim-sulfamethoxazole, or ciprofloxacin. In the absence of an outbreak or an epidemiologic link to cases, health care providers colonized with MRSA shouldn't require decolonization.
By knowing and adhering to the CDC's seven principles (as well as standard precautions and facility policies), you can help protect patients from dangerous and difficult-to-control MDRO infections.