Fed plan faces a complex problem

Multiagency group hones ambitious plan

While emerging multidrug resistant gram negative rods are a prime topic of current concern, there is a sobering reminder that longstanding foes have not exactly been vanquished. Consider, for example, methicillin-resistant Staphylococcus aureus (MRSA), long the tyrant king of healthcare associated infections (HAIs). The Centers for Disease Control and Prevention estimates that 15,000 patients die every year due to infection with MRSA.

Overall, some 90,000 Americans annually acquire serious infections caused by antibiotic resistant pathogens, according to Steve Solomon, MD, director of antimicrobial resistance in the CDC's Division of Healthcare Quality Promotion.

A broad collaboration of federal agencies is being brought to bear on the issue, with the spear point being Federal Government's Interagency Task Force on Antimicrobial Resistance, he explains. The task force recently published the latest draft of its "Public Health Action Plan to Combat Antimicrobial Resistance" (http://1.usa.gov/uBLgNA), which outlines the government's national strategy for preventing infections with antibiotic resistant pathogens.

"The federal plan has four main sections — surveillance, prevention and control, research and product development," Solomon tells Hospital Infection Control & Prevention. "Certainly there are issues relevant to healthcare epidemiology and infection control. A lot of the focus of the plan is on resistance problems in the healthcare environment — both from the standpoint of surveillance and from the various intervention initiatives, including the importance of antimicrobial stewardship."

A commonly lamented problem is that there are not sufficient profit incentives to entice the private sector to develop new antibiotics for resistant pathogens. Thus the research goals of the plan include supporting "the development of novel broad spectrum antimicrobials with dual indications for community-acquired infections and biodefense threat agents. Conduct and support clinical research to evaluate the safety and efficacy of novel drugs and vaccines for pathogens where resistance threatens effective treatment."

Indeed, with no new drugs expected to alleviate the problem any time soon, the primary strategies are antibiotic controls and infection prevention.

"You want to prevent the emergence of resistance — which is where the stewardship comes in — and you want to do an excellent job with infection control," Solomon says. "It prevents the transmission of these resistant pathogens to patients and it helps prevent the spread of colonization. That is the other big problem. These patients get colonized, they go out and go home or they go to other health care settings."

Attacking problem on all fronts

Some of the federal plan's overarching goals in the area of prevention and control of antibiotic resistance (AR) include the following. The goals are in various stages of planning and implementation.

Implement and evaluate the impact of community-based interventions, such as vaccination campaigns and the promotion of appropriate antibiotic use to reduce the spread of AR microorganisms, rates of disease, and antimicrobial use, and to improve patient outcomes.
Estimate the effectiveness of pneumococcal and influenza vaccines on drug-resistant infections caused by those pathogens.
Evaluate factors that influence the prescribing practices of primary care physicians, including academic detailing and benchmark analysis.
Identify and promote successful AR prevention and control programs in healthcare settings that utilize existing recommendations for preventing transmission of AR organisms.
Establish state-based MDRO and Clostridium difficile prevention collaborative in at least 10 states.
Evaluate impact of the CMS-Quality Improvement Organization MRSA prevention.
Evaluate impact of the Department of Veterans Affairs National MRSA prevention initiative Explore the expansion of prevention initiatives to include other MDRO including C. diff and multidrug-resistant gram-negative pathogens.
Facilitate initiation of at least one regional, multi-center prevention collaborative in which acute and long-term care facilities address prevention of multi-drug resistant infections in a coordinated manner.
Identify factors that reduce transmission of drug-resistant pathogens, including infection control, in veterinary, agriculture and aquaculture settings.
Identify factors important for assuring that antimicrobial drugs are used judiciously in veterinary, agriculture and aquaculture environments.
Promote infection control education at all stages of training and practice for healthcare workers in human and veterinary medicine.
Complete basic infection control curriculum for posting on the CDC website.
Develop a plan for infection control education of veterinary medicine workers.
Develop interagency programs in collaboration with regulators, payers, professional societies and other stakeholders to promote effective hand hygiene strategies in communities and healthcare settings and to foster the use of biomedical devices and behaviors that prevent the transmission of infectious organisms in community settings.
In collaboration with academic partners, complete research studies that evaluate the impact of novel technologies for measuring hand hygiene adherence in the healthcare setting.
Identify factors and strategies that promote appropriate antimicrobial use (i.e., best practices) or discourage inappropriate use in all types of healthcare settings, including inpatient and outpatient facilities, clinics and offices. Facilitate the implementation of these strategies.
Examine the impact of improved antimicrobial use on adverse events associated with antimicrobials, especially C. diff infections.
Evaluate the benefits and potential unintended consequences of clinical guidelines and policies that bear on antimicrobial use and affect patient care, reimbursement, or other areas of medical practice (e.g., increased use of antimicrobial agents in emergency rooms for unconfirmed community-acquired pneumonia).
Develop, implement, and evaluate treatment algorithms for management of common clinical syndromes frequently treated with antibiotics (e.g., ventilator-associated and community-acquired pneumonia, acute bronchitis and sinusitis, and asymptomatic bacteriuria and sexually transmitted diseases.)