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Pathogen and Treatment Paradigms for Multidrug-Resistant Infections
Cookies facilitate the functioning of this site including a member login and personalized experience. Cookies are also used to generate analytics to improve this site as well as enable social media functionality. Join IDSA. A recent survey of infectious diseases consultants attests to the diversity of hospital approaches to control of multidrug-resistant organisms [ 16 ]. This lack of consistency in practice hinders local and national efforts to control multidrug-resistant organisms and is addressed by both new guidelines.
Both guidelines strive to overcome negative attitudes and perceptions about control efforts toward multidrug-resistant organisms, especially the pessimistic notion that problems with these organisms will progress relentlessly no matter what is done. Reports in the literature attest to a number of successful control efforts—some in special care units, some in hospitals, and some in all health care facilities of a geographic region [ 2 ].
These reports are not without flaws. Controversies regarding interpretation and application have arisen in large part because of quasi experimental or weak study designs, use of multiple interventions at the same time, short periods of follow-up, and, often, inadequate statistical analysis [ 2 , 17 , 18 ]. Nevertheless, these reports provide the evidence base for control measures for multidrug-resistant organisms and highlight measures that have been associated temporally with reduced rates of transmission of multidrug-resistant organisms.
In health care facilities, person-to-person transmission of multidrug-resistant organisms by indirect and, in some cases, direct contact constitutes the major route of transmission and dissemination [ 1 , 2 ]. Health care workers may acquire multidrug-resistant organisms on their hands or clothing while rendering care to an infected or colonized patient. Without observing recommended precautions, staff members may then transfer bacteria acquired from these patients or their immediate environment to other patients, who then become colonized and at risk for infection.
This process can repeat indefinitely. Disruption of this cycle requires recognition of sources of multidrug-resistant organisms—predominantly infected and colonized patients—and consistent use of hand hygiene, physical isolation, barriers, personal protective equipment, designated equipment, and environmental measures to prevent both contamination of health care workers and their transmission of multidrug-resistant organisms to other patients and staff members.
Major Infectious Diseases. 3rd edition.
Both guidelines recommend a combination of effective measures to disrupt the cycle of transmission. However, the peer-reviewed literature contains few randomized controlled trials; consequently, recommendations lack the kind of support required by other evidence-based guidelines [ 19 ]. Despite the controversy that these documents have fomented, they are strikingly similar: they share a common goal; they offer a comprehensive review of relevant literature and evidence-based recommendations, with ratings determined by the strength of evidence, using the same HICPAC rating system; they recommend similar control measures; and they emphasize the importance of monitoring of adherence and giving feedback to caregivers, support from organizational leadership for fiscal and human resources, and incorporation of control of multidrug-resistant organisms into institutional priorities.
They provide relevant citations for the evidence underlying each recommendation so that readers can understand the rationale and present such information to others, including administrators. The groups of preventive measures recommended for control of multidrug-resistant organisms—administrative action, education, surveillance, use of active surveillance cultures, analysis of and provision of feedback to caregivers about surveillance data, use of personal protective equipment, standard precautions including hand hygiene , contact precautions, and environmental decontamination—constitute the basic elements of infection-control programs to prevent transmission of most epidemiologically important infectious agents; however, the guidelines differ in their recommendations for application of some measures.
Understanding the development and approval processes of the 2 documents provides useful insights. The SHEA consensus paper was written by a select group of experts, including 3 past presidents of the organization, whose professional experience has been primarily in acute care hospitals. There was no opportunity for written input from the infection-control community, and the final approval process consisted of a vote by SHEA board members in a closed meeting.
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These authors included persons with experience in acute care hospitals, long-term care facilities, and home care services. During the development process, HICPAC members reviewed and discussed the evolving guideline at many public committee meetings and obtained reviews from outside experts in infection control. More than written comments were received and processed, leading to revisions. Clearance by relevant divisions and leaders of CDC and 3 outside experts will be required before publication.
The SHEA consensus paper is a stand-alone document and acknowledges the importance of multidrug-resistant gram-negative bacilli but provides guidance only for control of MRSA, vancomycin-intermediate S. The recommendations for control of multidrug-resistant organisms are generic and intended for control of MRSA, vancomycin-intermediate S. This guideline notes the applicability of these recommendations for control of other epidemiologically important bacteria and viruses—for example, Clostridium difficile and noroviruses. The SHEA document acknowledges the role of judicious antimicrobial use and of health care settings other than hospitals and notes that recommendations may require modification in other settings, but it does not provide specific guidance.
Of note, level I ratings in the HICPAC grading system, which was used in both guidelines, do not require data from randomized, controlled trials. Both approaches are likely to raise awareness of the urgent need to reduce the prevalence of multidrug-resistant organisms.
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Which approach will lead to better control throughout the community, be more cost-effective, reduce the burden of resistance, and improve patient safety remains to be determined by carefully designed studies such as the ongoing National Institutes of Health—sponsored multicenter study of adult intensive care units. In this study, adult intensive care units are randomized either to practice standard precautions or use routine active surveillance cultures and contact precautions for persons harboring MRSA or VRE [ 21 ].
Six issues that have considerable impact on implementation of recommendations from either guideline are discussed below. Goal for control program. Reports of successful control of multidrug-resistant organisms in the medical literature suggest that goals vary among institutions. In addition, such goals may apply only to a specific unit with high-risk patients, to an individual facility, or to a group of related facilities. In the United States, selection of goals resides with leadership of health care organizations, which vary considerably in structure.
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Because individual leaders may interpret the evidence differently or have contrasting philosophical approaches or other competing priorities, a broad consensus on specific goals has not been reached, thereby hampering control efforts. Allocation of resources for control program. Silence about the financial issues does not reflect a failure of the guidelines but rather the limitations of the evidence and the varying conditions of health care delivery in the United States. A number of authors have argued that control efforts aimed at multidrug-resistant organisms are cost-effective, even those using active surveillance cultures [ 1 , 24 , 28 ].
However, the assumptions and projections used and the estimates of attributable costs of infections due to multidrug-resistant organisms may make it difficult to achieve consensus on this point. Failure to match patients for duration of stay and failure to account for delayed administration of appropriate antimicrobial therapy often confound cost estimates [ 14 , 29 , 30 ].
Studies comparing the benefits and costs of different control strategies for multidrug-resistant organisms directly have not yet appeared in the medical literature.
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In contrast, many well-conducted studies suggest that prevention of device-related infections should be a major focus for control of multidrug-resistant organisms. Of importance, this strategy reduces the likelihood of bloodstream infections, ventilator-associated pneumonia, and surgical site infections caused by MRSA, VRE, and other multidrug-resistant organisms.
Adoption and adherence to well-established performance measures for preventing device-associated infections may provide the best return on investment for controlling multidrug-resistant organisms [ 33 , 34 ]. Enforcement of infection control measures. Indeed, several reports have indicated that this practice contributed to successful control efforts [ 2 , 35—37 ].
Even so, the guidelines do not recommend specific measures to enforce adherence by health care workers or sanctions for repeated nonadherence. Regrettably, failure to adhere to recommendations for contact precautions and hand hygiene remain commonplace [ 38 ] and undoubtedly contribute to the burgeoning case load of infections due to multidrug-resistant organisms. Coordination of control efforts with programs outside the facility. The Siouxland experience with control of VRE, success of other coalitions, and 2 reports from other countries undergird these recommendations [ 26 , 39 , 40 ].
However, the guidelines have no specific recommendations on the process of developing such partnerships, and there is no evidence regarding optimum ways of establishing such alliances. Balancing consequences of control efforts. For the most part, the recommendations do not attempt to balance concerns about decreasing transmission of multidrug-resistant organisms with related personal, institutional, and societal concerns, which may lead in opposite directions.
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In the past few years, several reports have identified unintended negative consequences incurred by patients under contact precautions. These include less attention from nurses and physicians, increased scores on depression and anxiety scales, and a higher frequency of adverse events [ 2 , 41—43 ].
Practitioners and authors of guidelines await future studies to assess the tradeoff between these negative outcomes and the benefits derived as well as methods to mitigate the negative effects. Existing guidelines for control of multidrug-resistant organisms are based largely on an experiential scientific literature.
Although many of the studies used to inform the guidelines are suboptimal methodologically [ 17 , 18 ], health care facilities are faced with growing numbers of multidrug-resistant organisms to which they must respond. The guidelines offer and grade recommended infection-control measures and recommend an assessment of each facility's challenges posed by multidrug-resistant organisms.