VA Looks at New Weapons in War Against Antibiotic Overuse, Resistant Infections

by U.S. Medicine

November 1, 2011

The war against overuse of antibiotics and the resulting resistant infections is constantly being fought at the VA.

Sometimes battles are won – such as a successful program that decreased rates of healthcare associated MRSA infections 67% – and sometimes they are not. A recent study of antibiotic use in VA showed a 102% increase in the use of carbapenems, often the last treatment option for severe infections with multi-drug resistant pathogens) between 2005 and 2009.

“It’s never easy to find a solution to the question of why antibiotic resistance exists,” says Gary A. Roselle, MD, national director Infectious Diseases Program, VA Central Office, Washington, and chief, Medical Service, Cincinnati VA Medical Center, and professor of medicine in the Department of Internal Medicine, Division of Infectious Diseases, at the University of Cincinnati College of Medicine. “From the very early days of penicillin and vancomycin, whenever antibiotics have been used, resistance develops.” He points out that with improvements in medical care, especially in intensive care, the use of antibiotics has grown and resistance continues.

“This is happening globally – in the private sector and the military,” adds Allison A. Kelly, MD, MSOH, infectious diseases staff physician, Infectious Diseases Program Office, Washington, and assistant professor of medicine, Department of Internal Medicine, Division of Infectious Diseases, at the University of Cincinnati College of Medicine. “It’s reflective of the nature of bacteria building resistance and having fewer options to treat those infections.”

But the campaign continues. For example, the successful “MRSA” bundle program is being extended to other pathogens, according to Roselle. The program was implemented in 2007 in acute care VA hospitals nationwide. The “bundle,” or set of best practices, included universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene and culture change that made infection control the responsibility of everyone who had contact with patients.

Roselle said that VA is looking at Clostridium difficile for a similar approach, noting, “Beta test sites are now at work, and, once we see a protocol in proper order, it will be expanded across the country,” Roselle shares.

VA also has started a generalized antimicrobial stewardship program, one that is not necessarily organism-specific, he added.

“We already have had three educational conferences, starting in May 2010,” said Roselle, adding that an Antimicrobial Stewardship Task Force was chartered, and its sub-groups have already been meeting to look at other components of a national program. Plans for another national conference – “Antimicrobial Stewardship in VA” – are also moving forward.

“We began by looking at individual bacteria, are moving out to more and more antibiotic-resistant bacteria, and then, to a larger extent, we’ll look to the general situation in VA. So, it’s a multi-pronged approach,” Roselle explained.

VA Looks at New Weapons in War Against Antibiotic Overuse, Resistant Infections Cont.

Monitoring Progress

Future progress for all VA programs related to healthcare-associated infections (HAIS) will be easier with the introduction of a comprehensive electronic surveillance system to monitor organism resistance trends. The Spring 2011 edition of Public Health Matters, published by VA’s Public Health Strategic Health Care Group, notes that, while VA healthcare facilities are already paying a tremendous amount of attention to monitoring antimicrobial stewardship programs, these programs are able to address concerns only at the facility level. “With its national formulary and fully electronic health record, VHA is in position to create the first national, integrated antimicrobial stewardship program,” say the article’s authors.

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VA Looks at New Weapons in War Against Antibiotic Overuse, Resistant Infections Cont.

Stewardship is the key

The key to better management of antibiotic use, said Roselle, is proper antimicrobial stewardship – which means treating the right patient with the right dose at the right time. VA’s efforts in this area have been much more global than addressing one drug or one class of drugs – and they have met with some success.

“We probably started full force with a program to decrease MRSA in VA in 2006 with education modules,” Roselle recounted, noting that the effort has increased and spread nationwide and has culminated in the paper that was recently published in the New England Journal of Medicine.

From October 2007 to June 2010, the period of the study, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. While the rates of healthcare–associated MRSA infections in ICUs had not changed in the two years before October 2007, they declined 62% with the implementation of the bundle, dropping from 1.64 infections per 1,000 patient-days in October 2007 to 0.62 per 1,000 patient-days in June 2010. During the same period, the rates of healthcare–associated MRSA infections in non-ICUs fell from 0.47 per 1,000 patient-days to 0.26 per 1,000 patient-days, or a decrease of 45%.

“That’s what I call a dramatic decrease in MRSA,” Roselle asserted.

Identifying Best Practices

One of the challenges going forward, he said, is that there is not necessarily a single set of best practices that can be used to address all drug-resistant bacteria. “The program for MRSA concluded that emphasis on hand-washing, nasal cultures on admission and proper isolation were effective, but it’s not entirely clear that each of those would be necessary for other organisms,” he says. For example, he noted, routine cultures are not necessary for C. difficile, so there will clearly be differences in best practices when looking at specific organisms.

On the other hand, he continued, the antibiotic-stewardship program takes a more global approach and is not organism-specific. “Rather, it deals with appropriate use,” he explains. “But it’s too early yet for us to identify the keys to appropriate use.”

“Antibiotic organism resistance and usage is very important to the National Infections Program Office, and we are very actively putting programs in place to have better stewardship of antimicrobial practices and reduced resistance,” added Kelly.


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