# Presentation: 075705

## Campaign to PreventAntimicrobial ResistanceDialysis Patients

- Centers for Disease Control and Prevention
-   National Center for Infectious Diseases
-   Division of Healthcare Quality Promotion
**Department of Health and Human Services**

* **Link to: Campaign to Prevent Antimicrobial Resistance Online*
* **Link to:** Federal Action Plan to Combat Antimicrobial Resistance *

**Campaign to Prevent Antimicrobial Resistance in Healthcare Settings**

**Notes:**
The Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) led a task force of 10 agencies to develop a comprehensive plan to address the emerging threat of antimicrobial resistance.  
One of the top priority items in the plan is “ In collaboration with many partners, develop and facilitate the implementation of educational and behavioral interventions that will assist clinicians in appropriate antimicrobial prescribing.”
To address this priority, CDC in conjunction with the CDC Foundation, corporate partners, healthcare organizations, public health agencies, and expert consultants is conducting a nationwide Campaign to Prevent Antimicrobial Resistance.

## Clinicians

* **Link to: Campaign to Prevent Antimicrobial Resistance Online*
* **Link to:** Federal Action Plan to Combat Antimicrobial Resistance *

***Clinicians***
***Hold the***
***Solution!***

**Notes:**
The Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) led a task force of 10 agencies to develop a comprehensive plan to address the emerging threat of antimicrobial resistance.  
One of the top priority items in the plan is “ In collaboration with many partners, develop and facilitate the implementation of educational and behavioral interventions that will assist clinicians in appropriate antimicrobial prescribing.”
To address this priority, CDC in conjunction with the CDC Foundation, corporate partners, healthcare organizations, public health agencies, and expert consultants is conducting a nationwide Campaign to Prevent Antimicrobial Resistance.

## Emergence of Antimicrobial Resistance

**Susceptible Bacteria**

**Campaign to Prevent Antimicrobial Resistance in Healthcare Settings**

**Notes:**
Bacteria have evolved numerous mechanisms to evade antimicrobial drugs.
Chromosomal mutations are an important mechanism of resistance for some antimicrobial agents.
Acquisition of resistance genes or gene clusters, via conjugation, transposition, or transformation, accounts for a significant portion of  antimicrobial resistance among bacterial pathogens. 
Resistance gene transfer also enhances the likelihood of multi-drug resistance.  

## Selection for Antimicrobial-resistant Strains

**Selection for Antimicrobial-resistant Strains**

**Notes:**
Once resistant strains of bacteria are present in a population, exposure to antimicrobial drugs favors their survival. 
Reducing antimicrobial selection pressure is one key to preventing antimicrobial resistance and preserving the utility of available drugs for as long as possible. 

## Antimicrobial Resistance: Key Prevention Strategies

**Pathogen**

**Susceptible Pathogen**

**Notes:**
Once a pathogen produces infection, antimicrobial treatment may be essential. 
However, inappropriate antimicrobial use (wrong drug, inadequate dose, inappropriate duration of therapy) promotes selection of antimicrobial-resistant strains of pathogens.
As the prevalence of resistant strains increases in a population, subsequent infections are increasingly likely to be caused by these resistant strains.
Fortunately, this cycle of emerging antimicrobial resistance / multi-drug resistance can be interrupted.
Preventing infections in the first place will reduce the need for antimicrobial exposure and the emergence and selection of resistant strains.
Effective diagnosis and treatment will benefit the patient and decrease the opportunity for development and selection of resistant microbes; this requires rapid accurate diagnosis, identification of the causative pathogen, and determination of its antimicrobial susceptibility. 
Optimizing antimicrobial use is another key strategy; optimal use will ensure proper patient care and at the same time avoid overuse of broad-spectrum antimicrobials and unnecessary treatment. 
Preventing transmission of resistant organisms from one person to another is the final step in successful prevention efforts. 

## Key Prevention Strategies 

**Prevent infection**
**Diagnose and treat infection effectively**
**Use antimicrobials wisely**
**Prevent transmission **

*Clinicians hold the solution!*

**Notes:**
These 4 strategies – preventing infection, diagnosing and treating infection effectively, using antimicrobials wisely, and preventing transmission -  form the framework for CDC’s Campaign to Prevent Antimicrobial Resistance. 
Clinicians and their patient care partners hold the solution to integrating these strategies into daily practice and optimizing the care and safety of all patients.  

## Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

- General health communication strategy
- Goals:
- - inform clinicians, patients, and other stakeholders
- - raise awareness about the escalating problem of antimicrobial resistance in healthcare settings
- - motivate interest and acceptance of  interventional programs to prevent resistance

**Notes:**
The Campaign to Prevent Antimicrobial Resistance is one of CDC’s health communications priorities.
The Campaign targets frontline clinicians, patient care partners, healthcare organizations, purchasers, patients, and the general public.
The goals are to raise awareness about the important problem of escalating antimicrobial resistance and to motivate involvement of clinicians and others in targeted interventional programs, such as the “12 Steps to Prevent Antimicrobial Resistance in Dialysis Patients”.  

## 12 Steps To Prevent Antimicrobial Resistance

- Targeted intervention programs for clinicians caring for high risk patients
- - *hospitalized adults**	**- dialysis patients*
*- hospitalized children**	**- surgical patients*
*long - term care residents**	*
- Goal: Improve clinician practices & prevent antimicrobial resistance
- Partnership with professional societies; evidence base published in peer-reviewed specialty journals
- Educational tools – web-based / didactic learning modules, pocket cards, slide presentations, etc.

**Notes:**
The “12 Steps to Prevent Antimicrobial Resistance” are new programs that encourage clinicians to engage in actions that will promote patient safety and prevent infections with antimicrobial-resistant bacteria.
The evidence-based action steps are designed to optimize the care of individual patients in the era of widespread antimicrobial resistance.
Each program addresses a specific target patient population, such as hospitalized adults and children, long- term care residents, dialysis patients and surgical patients.
The goals of these intervention programs are to improve clinician practices and prevent antimicrobial resistance. 
The programs are created in close partnership with professional societies and key opinion leaders in the relevant specialty. 
All action steps included in the programs are based on scientific evidence and/or published guidelines. 
The program translates this existing evidence and guidance into ACTION STEPS that can be taken now to prevent antimicrobial resistance.
CDC is working with many public, professional, and private sector partners to market the 12 Steps for each target group and promote their implementation.

## 12 Steps to Prevent Antimicrobial Resistance: Dialysis Patients

**Notes:**
The “12 Steps to Prevent Antimicrobial Resistance: Dialysis Patients” intervention program is the second “12-Steps Program” to be launched. The first intervention program was for hospitalized adults. Dialysis patients are at especially high risk for serious antimicrobial-resistant infections.
This slide includes steps for preventing antimicrobial resistance in dialysis patients. In the following slides, the rationale and more details for each step will be provided.

## Disease Burden for Dialysis Patients

- The number of patients with end-stage renal disease treated by maintenance hemodialysis in the US has increased during the past 30 years.1
- In 2001 more than 3,000 hemodialysis centers had greater than 250,000 chronic hemodialysis patients.2
- Annual mortality rate among hemodialysis patients is 23% and infections are the second most common cause, accounting for 15% of deaths.1
- Hemodialysis patients are immunosuppressed and require frequent hospitalization and surgery, which increases their risk for resistant infections.1
- Vascular access infections (in hemodialysis patients) and peritonitis (in peritoneal dialysis patients) are the most common infections.1

- 1 CDC, *MMWR* 2001; 50 (5):13
- 2Unpublished data, Dialysis Surveillance Network

**Notes:**
There is an increased number of chronic hemodialysis patients in the US.
In 2001 more than 3,000 hemodialysis centers had greater than 250,000 chronic hemodialysis patients.
Infections account for a high percentage of the overall mortality rate among hemodialysis patients.
Hemodialysis patients are immunosuppressed, which increases their susceptibility to infection, and they require frequent hospitalization and surgery, which increases their opportunities for exposure to nosocomial infections.
Vascular access infections and peritonitis are the most common infections.

## Fact: Influenza and pneumococcal vaccine given to both staff and patients will help to prevent infections requiring antimicrobial therapy.

***Prevent Infection***
**Step 1:  Vaccinate staff and patients**

**Notes:**
On average, influenza causes approximately 114,000 influenza-related hospitalizations and 20,000 deaths in the United States.
Streptococcus pneumoniae is associated with 12,500 deaths, at least 50% of which are likely to be preventable with vaccination. 
These vaccine-preventable infections and their complications are a major cause of hospitalization and exposure to antimicrobials and create opportunities for the emergence and spread of antimicrobial resistance.

## Vaccination Rates of Dialysis Patients,1999-2001*

*Link to: **Influenza recommendations...*CDC,* MMWR *2003; 52 (RR08):1-36

- * Unpublished data, Dialysis Surveillance Network

**Notes:**
Vaccination of target populations is a high priority for public health agencies, as articulated in Healthy People 2010. 
Nevertheless, national rates of vaccination remain below Healthy People 2010 targeted levels, and additional methods to improve vaccine coverage are needed. 
In 2001, less than 70% of dialysis patients reportedly received influenza vaccination, despite the Advisory Committee of Immunization Practices (ACIP) recommendation for vaccination of dialysis patients. 
Less than 30% of dialysis patients reportedly received pneumococcal vaccination. 
Likewise, influenza vaccination of healthcare providers is recommended but coverage rates are notoriously poor.  

## Need for Healthcare Personnel Immunization

**Need for Healthcare Personnel Immunization**
**Programs: Influenza Vaccination Rates (****1996-97)**

*Source: 1997 National Health Interview Survey*
- Walker FJ, et al.,* Infect Control Hosp Epidemiol *2000; 21:113

* **Link to: *_[ACIP Influenza](http://www.phppo.cdc.gov/cdcrecommends/showarticle.asp?a_artid=1361++++&TopNum=50&CallPg=Adv)__[ Immunization Recommendations](http://www.phppo.cdc.gov/cdcrecommends/showarticle.asp?a_artid=1361++++&TopNum=50&CallPg=Adv)_

**Notes:**
Outbreaks of influenza in healthcare facilities have been linked to transmission from otherwise healthy healthcare personnel and are a major patient safety issue.
The Advisory Committee on Immunization Practices (ACIP) recommends that healthcare personnel with patient care duties receive an annual influenza vaccine.
However, vaccination rates among healthcare personnel are extremely poor; less than 40% of personnel are immunized in most facilities. 

## Actions:
Get influenza vaccine
Give influenza / pneumococcal vaccine to patients
    in addition to routine vaccines (e.g., hepatitis B)

**Actions:**
- Get influenza vaccine
- Give influenza / pneumococcal* *vaccine to patients
-     in addition to routine vaccines (e.g., hepatitis B)

***Prevent Infection***
**Step 1:  Vaccinate staff & patients**

**Fact:****  **Influenza and pneumococcal vaccine given to both staff and patients will help to prevent infections requiring antimicrobial therapy.

* **Link to: *_[ACIP Influenza](http://www.phppo.cdc.gov/cdcrecommends/showarticle.asp?a_artid=1361++++&TopNum=50&CallPg=Adv)__[ immunization recommendations](http://www.phppo.cdc.gov/cdcrecommends/showarticle.asp?a_artid=1361++++&TopNum=50&CallPg=Adv)_
* **Link to: CDC facts** about influenza and pneumococcal vaccine*
* **Link to: ACIP: Vaccine standing orders*

**Notes:**
The Advisory Committee on Immunization Practices (ACIP) recommends standing orders for influenza and pneumococcal vaccinations to improve vaccination of dialysis patients before hospital discharge.
In addition, the Advisory Committee on Immunization practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that healthcare personnel receive an annual influenza vaccine to protect patients and other healthcare personnel. 
Hepatitis B vaccine has been recommended for both hemodialysis patients and staff members since the vaccine became available in 1982.

## Step 2: 

*Link to:** *_[NNIS Online at CDC](http://www.cdc.gov/ncidod/hip/surveill/nnis.htm)_

**Fact:** Indwelling catheters are the single most important factor contributing to bacteremia in hemodialysis patients.

***Prevent Infection***
**Step 2: **
**Get the catheters out**

**Notes:**
Invasive medical devices are a major cause of preventable infections in dialysis patients.
Intravenous catheters, arterial catheters, urinary tract catheters, and many other devices increase the risk of infection in all patient populations. 

## Epidemiology of Catheter Associated Infections

- Estimated attributable mortality for catheter-associated bloodstream infections ranges from 0% to 35%, depending on study design.
- Primary risk factor for access infection is access type (catheters>grafts>fistulas).
- The relative risk for bacteremia in patients with dialysis catheters is sevenfold the risk for patients with primary arteriovenous fistulas.

- CDC, *MMWR* 2002, 51 (RR-10); p.10

**Notes:**
The estimated attributable mortality for catheter-associated bloodstream infections ranges from 0% to 35%, depending on study design. 
The primary risk factor for access infection is access type, with catheters having the highest risk for infection, graft an intermediate risk, and native arteriovenous fistulas the lowest.
The use of catheters for hemodialysis is the most common factor contributing to bacteremia in dialysis patients. The relative risk for bacteremia in patients with dialysis catheters is sevenfold the risk for patients with primary arteriovenous fistulas.

## Biofilm on Intravenous Catheter Connecter 24 Hours After Insertion

**Biofilm on Intravenous Catheter Connecter 24 Hours After Insertion**

- Scanning Electron Micrograph

*Link to:** *_[Biofilms and device-associated infections](http://www.cdc.gov/ncidod/eid/vol7no2/donlan.htm)_

**Notes:**
All invasive medical devices support the development of biofilms.
A biofilm is a complex three-dimensional structure that consists of cells, bacteria, and extracellular matrix materials.
In this scanning electron micrograph, many bacteria are seen in a matrix of material that also contains a red blood cell.
This biofilm developed within 24 hours of catheter insertion.
Biofilms may promote development of antimicrobial-resistant infections in several ways:
- Serving as a nidus for deposition and growth of resistant strains that then are released to cause infection;
- Creating a permeability barrier to antimicrobial diffusion, so that bacteria imbedded in the biofilm may be exposed to sub-inhibitory concentrations of drug that promotes emergence of resistance;
- Providing a matrix in which bacteria can exchange resistance factors.
Biofilms cannot be prevented but some strategies may decrease the rate at which biofilms are formed and decrease bacterial colonization of biofilms.

## Rates of Bacteremia Infection by Access Type - Dialysis Surveillance Network 10/99-05/02

- Tokars et al., *Am J Infect Control* 2002;30:288-295.

**Notes:**
In a study of 109 dialysis centers, 2429 vascular access infections were reported;  of these 45% were from local access infections and 55% were from access-associated bacteremias.
 The rate of access-associated bacteremia was 1.78 per 100 patient-months overall; with substantial variation by vascular access type:  0.3 for fistulas, 0.5 for grafts, 4.8 for cuffed catheters, and 8.7 for noncuffed catheters.

## Fact:  Indwelling catheters are the single most important factor contributing to bacteremia in hemodialysis patients.

Actions:
	   Hemodialysis:	   	
Use catheters only when essential
Maximize use of fistulas/grafts
Remove catheters when they are no longer essential
Peritoneal Dialysis:
Remove/replace infected catheters

**Fact:**** ** Indwelling catheters are the single most important factor contributing to bacteremia in hemodialysis patients.
**Actions:**
***	******   ****Hemodialysis:****	******   ******	***
- Use catheters only when essential
- Maximize use of fistulas/grafts
- Remove catheters when they are no longer essential
*Peritoneal Dialysis:*
- Remove/replace infected catheters

- _[Coming soon...guidelines for preventing catheter-associated bloodstream infections](http://www.cdc.gov/ncidod/hip/default.htm)_

-  *Link to:* _[Urinary catheter infection prevention](http://www.cdc.gov/ncidod/eid/vol7no2/maki.htm)_

***Prevent Infection***
**Step 2:  Get the catheters out**

**Notes:**
The most effective way to decrease catheter-associated infections is to decrease catheter utilization. 
In other words, get the catheters out! 
For hemodialysis patients:
	- Catheters should only be used when essential to patient care, 	not for convenience or as a “routine” practice,.
          	- The need for a catheter should be assessed on a daily basis so 	that unnecessary catheters will be recognized and removed.
 	- The use of fistulas and grafts should be maximized.
For peritoneal dialysis patients, infected catheters should be removed or replaced.

## Fact:  Careful infection control prevents peritoneal dialysis related infections.

*Link to:** NNIS Online at CDC*

**Fact:****  **Careful infection control prevents peritoneal dialysis related infections.

**Notes:**
Permanent and safe access to the peritoneal cavity is a  key to successful peritoneal dialysis.
Since the incidence of peritonitis is declining following the introduction of new connectology, catheter-related complications during peritoneal dialysis have become a major concern.

## Peritoneal Catheter Insertion and Management

- Catheter insertion should be performed under operating room, sterile conditions.
-  Adherence to the principles of catheter insertion, management, and care remain the cornerstone of successful peritoneal dialysis access.
- Despite improvements in catheter survival over the last few years, catheter-related complications still occur, causing significant morbidity and often forcing the removal of the catheter.

- Gokal et al., *Peritoneal Dialysis International *1998;18:11-33.

**Notes:**
Catheter insertion should be performed under operating room, sterile conditions.
Adherence to the principles of catheter insertion, management, and care remain the cornerstone of successful peritoneal dialysis access, which is the  key to successful peritoneal dialysis.
Despite improvements in catheter survival over the last few years, catheter-related complications still occur, causing significant morbidity and often forcing the removal of the catheter.

## Fact:  Careful infection control prevents peritoneal dialysis-related infections.
Actions:	 
Follow established guidelines for access care
Use proper insertion and catheter-care protocols
Remove access device when infected
Use the correct catheter

**Fact:****  **Careful infection control prevents peritoneal dialysis-related infections.
**Actions:*****	****** ***
- Follow established guidelines for access care
- Use proper insertion and catheter-care protocols
- Remove access device when infected
- Use the correct catheter

*Guidelines for preventing catheter-associated bloodstream infections, CDC, MMWR 2002 51 (RR10)*

-  *Link to:* *Peritoneal Catheters and Exit-Site Practices 1998 Update*

**Notes:**
Adherence to Kidney Disease Outcomes Quality Initiative and CDC guidelines for access care will prevent infections and help ensure successful dialysis access.
Use proper insertion and catheter-care protocols.
When the catheter device is infected, it should be removed to prevent further infection from  occurring. 
Use of the correct catheter is important for both controlling infections  and  successful vascular access.

## Fact:  Identifying the pathogen using microbiologic cultures and antimicrobial susceptibility testing allows for targeted antimicrobial therapy.

**Notes:**
Antimicrobial therapy can be life saving and represents one of the greatest medical achievements in the past century. 
It is essential that efforts to prevent antimicrobial resistance do not compromise the effective treatment of infections in individual patients.

## Importance of Utilizing Cultures and Antimicrobial Susceptibility Testing Results

-                                     No. (%) Susceptible
- _____________________________________________________
-                                          **Cefazolin      Vanco         Cefazolin and    Vanco and**
**	****	****	****                                   ****	****           ****Gentamicin       Gentamicin**
- ___________________________________________________
- Blood Cultures          14 (78)     16 (89)        16 (89)        17 (94)
- (n=18)
- Clinically Significant
- Cultures (n=146)	  87 (60)    100 (68)      132 (90)      142 (97)

- Fogel et al., *Am J Kidney Dis* 1998;32:401-409

**Notes:**
The antimicrobial susceptibility patterns of organisms obtained from patients at a hemodialysis center were analyzed to determine the optimal antimicrobial regimens for empiric therapy of blood and wound infections.
The combination of cefazolin and gentamicin was equivalent to vancomycin alone, while adding gentamicin into vancomycin was even more effective.
Thus, it is possible to reduce vancomycin usage in a hemodialysis center without compromising therapeutic efficacy.

## CDC’s M.A.S.T.E.R. Improving Antimicrobial Susceptibility Testing Proficiency

**CDC’s *****M.A.S.T.E.R.***** ****Improving Antimicrobial Susceptibility Testing Proficiency**

**Notes:**
CDC has developed a new tool to assist laboratory personnel.
“MASTER” provides case studies, updates about important methods, reviews of important publications, and many other resources to promote laboratory proficiency in assessing antimicrobial susceptibility. 
MASTER is accessible online through the CDC website. 

## Fact:  Identifying the pathogen using microbiologic cultures and antimicrobial susceptibility testing allows for targeted antimicrobial therapy.

Actions: 
Obtain appropriate cultures 
Target empiric therapy to likely pathogens 
Target definitive therapy to known pathogens 
Optimize timing,regimen,dose,route and duration

**Fact:****  **Identifying the pathogen using microbiologic cultures and antimicrobial susceptibility testing allows for targeted antimicrobial therapy.
**Actions:**
- Obtain appropriate cultures
- Target empiric therapy to likely pathogens
- Target definitive therapy to known pathogens
- Optimize timing,regimen,dose,route and duration

*Link to:** *_[IDSA guidelines for evaluating fever in critically ill adults](http://www.journals.uchicago.edu/CID/journal/issues/v26n5/my56_1042/my56_1042.web.pdf)_

**Notes:**
Correct diagnosis of the causative pathogen is necessary to ensure appropriate antimicrobial therapy. 
Hence, microbiologic cultures are indicated when managing patients with known or suspected infection. 
Empiric antimicrobial therapy should be selected to target likely pathogens and should be consistent with local antimicrobial susceptibility data.
Definitive therapy should target known pathogens once they are identified and their antimicrobial susceptibility patterns are known.  
For individual patients, appropriate antimicrobial therapy includes choosing the correct antimicrobial drug or combination; proper timing, dosage, and route of administration; and proper treatment duration based on culture and susceptibility test results.

## Fact:Input from infectious diseases experts improves the outcome of serious infections.

**Notes:**
Input from professionals with infectious diseases expertise can improve patient outcomes, optimize antimicrobial use, and decrease treatment costs.

## Infectious Diseases Expert Resources

**Infectious Diseases **
**Specialists**

**Optimal **
**Patient Care**

- Infection Control
- Professionals

- Healthcare
- Epidemiologists

- ClinicalPharmacists

- Clinical
- Pharmacologists

- Surgical Infection
- Experts

- Clinical
- Microbiologists

**Notes:**
Infectious diseases professionals help optimize care of patients with infections. 
Like all patient safety endeavors, multidisciplinary collaboration is key! 

## Fact:  Input from infectious diseases experts improves the outcome of serious infections.

Action:
Consult the appropriate experts for complicated infections

**Fact:**** ** Input from infectious diseases experts improves the outcome of serious infections.
**Action:**
- Consult the appropriate experts for complicated infections

* **Link to:** SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance*
*in Hospitals*

***Diagnose & Treat Effectively*** **Step 5:  Access the experts**

**Notes:**
There are no performance standards that define when input from professionals with infectious diseases expertise should be obtained.
Consultation should be considered for patients with complicated underlying illnesses, those who are receiving complicated antimicrobial treatment regimens, those who fail to respond to therapy as expected, and those at increased risk for drug interactions or other adverse events associated with treatment.
Early surgical consultation is essential when there is any suspicion of infection requiring surgical drainage or remediation. 

## Fact:The prevalence of resistance varies by locale

***Use Antimicrobials Wisely***
**Step 6:  Use local data**

**Notes:**
Antimicrobial susceptibility data are often aggregated into “antibiograms,” which provide a summary picture of common organisms and their susceptibility to many antimicrobial agents.
Local antibiograms (e.g., by unit, hospital, or facility) provide a starting point for making decisions about empiric antimicrobial treatment, but do not necessarily predict susceptibility of pathogens from a given patient because the data are not stratified by relevant characteristics that may affect the prevalence of resistance. 

## Percent of S. aureus Blood Isolates Resistant to Methicillin, by Dialysis Center

**Dialysis Surveillance Network 1999-2002****3**

**11 Centers, Canada, 10%****1**

**10 Centers, Connecticut, 43%****2**

- 1Taylor et al., *Infect Control Hosp Epidemiol*  2002;23:716-720
- 2 Dopirak et al., *Infect Control Hosp Epidemiol* 2002;23:721-724
- 3 Unpublished data, Dialysis Surveillance Network

**Notes:**
As seen in the slide set, the percent of blood isolates with MRSA varied among centers enrolled in the Dialysis Surveillance Network. In two other studies, the proportions of S. aureus isolates resistant to methicillin were 10% to 43%.

## Use Antimicrobials Wisely Step 6:  Use local data

***Use Antimicrobials Wisely*** **Step 6:  Use local data**

**Fact:****	**The prevalence of resistance varies by locale.
**Actions:**
- Know your local antibiogram
- Get previous microbiology results when patients transfer to your facility

*Link to:** NCCLS Proposed Guidance for Antibiogram Development*

**Notes:**
Local antimicrobial susceptibility data are the most relevant for predicting the probability of resistance and selecting empiric therapy. 
Furthermore, it is recommended that microbiology results be obtained for each patient when transferred in to your facility.

## Fact: 
Reduction of vancomycin use is one of the most important strategies to limit the emergence, selection, and spread of vancomycin resistant bacteria.

- Reduction of vancomycin use is one of the most important strategies to limit the emergence, selection, and spread of vancomycin resistant bacteria.

**Notes:**
The importance of judicious use of antimicrobial agents has been emphasized for many years. 
Dialysis patients have played a prominent role in the proliferation of vancomycin resistant organisms because this drug is used commonly in this patient population. Vancomycin can be conveniently administered to patients when they come in for hemodialysis treatments.

## Evolution of Drug Resistance in S. aureus

***S. aureus***

**Penicillin**

**[1944]**

**Penicillin-resistant**
***S. aureus***

**Evolution of Drug Resistance in *****S. aureus***

**Methicillin**

**[1962]**

**Methicillin-resistant**
***S. aureus *****(MRSA)**

**Vancomycin-resistant**
**enterococci (VRE)**

**Vancomycin**

**[1990s]**

**[1997]**

**Vancomycin**
**intermediate**
***S. aureus***
**(VISA)**

**[2002]**

**Vancomycin-**
**resistant**
***S. aureus***

- CDC, *MMWR* 2002;51(26):565-567

**Notes:**
The introduction of every new class of antimicrobial agents is followed by emergence of resistance. 
By 1962, penicillin-resistant S. aureus were a major threat in hospitals and nurseries.
By the 1970s, methicillin-resistant S. aureus had emerged and spread, a phenomenon that encouraged widespread use of vancomycin. 
In the 1990s, vancomycin-resistant enterococci emerged and rapidly spread; most of these organisms are resistant to other traditional first-line antimicrobial drugs.
In 1997, the first S. aureus strains with reduced susceptibility to vancomycin were documented, prompting concerns that S. aureus fully resistant to vancomycin may be on the horizon.
In June 2002, the first case of vancomycin-resistant S. aureus was detected; the patient was receiving chronic hemodialysis.

## VRE Colonization Among Dialysis Patients Who Received Vancomycin

_**Received Vancomycin    **__**	**__**Developed VRE**_
-                   No			   0/29 (0%)
-                   Yes			   16/61 (26%)
- 				              p<.001

- Atta et al., *Kidney International* 2001;59:718-724

**Notes:**
VRE colonization is a relatively common and underrecognized problem among chronic hemodialysis patients. It is strongly and independently associated with the use of vancomycin, which should be avoided whenever possible.
During a 2- year prospective cohort study, rectal swabs were obtained from patients during periodic intervals to determine VRE colonization.
Sixteen of 90 patients became colonized with VRE, an incidence rate of one case per 9.8 patient years of follow-up. None of the 29 patients who did not receive vancomycin developed VRE.

## First Case of Vancomycin - Resistant S. aureus (VRSA) 

- First fully vancomycin resistant clinical isolate of *S. aureus*
- Michigan, June 2002
- 40-year old black female with diabetes mellitus, peripheral vascular disease,on chronic hemodialysis
- VRSA from foot ulcer and catheter exit site
- During the 6 months preceding VRSA:
- patient experienced 6 hospitalizations, totaling 18 days
- patient received multiple antimicrobial therapy, including
- 5.5 weeks of vancomycin

- Chang S et al, *New England J of M*ed 2003; 348:14,1342-3447

**Notes:**
The first clinical isolate of S. aureus fully resistant to vancomycin was detected in Michigan in June 2002 in a 40- year- old black female with diabete mellitus, peripheral vascular disease, and hemodialysis. The VRSA was cultured from a foot ulcer and her catheter exit site.
The emergence of VRSA underscores the need for programs to prevent the spread of antimicrobial-resistant microorganisms and control the use of antimicrobial agents, particularly vancomycin in healthcare settings.

## Vancomycin- Intermediate S. aureus (VISA)

- _State, Year_	_Site_	_PD/HD*_
- Michigan, 1997	Peritonitis	Chronic PD
- New Jersey, 1997	Blood	Recent PD
- New York, 1998	Blood	Chronic HD
- Illinois, 1999	Endocarditis	Chronic HD
- Minnesota, 2000	Bone	Chronic HD
- Nevada, 2000	Liver	-----
- PD=peritoneal dialysis ,  HD=hemodialysis

- Fridkin, *Clin Infect Diseases* 2001;32:111

**Notes:**
Several strains of Vancomycin- Intermediate S. aureus (VISA)  associated with a clinical infection have been reported.
The spectrum of underlying illnesses is remarkably similar among these patients.
Among the first 8 US patients with VISA, most had ongoing or recent dialysis and most had recurrent methicillin-resistant S. aureus (MRSA) central venous catheter- or prosthetic material- associated bacteremias that were treated with vancomycin.
Many had prolonged vancomycin exposure in the 3-6 months preceding the infections.

## Guidelines for Appropriate Vancomycin Use (HICPAC/CDC)

- _Selected situations in which the use of vancomycin is appropriate or acceptable: _
- For treatment of serious infections caused by beta-lactam-resistant gram-positive microorganisms.
- For treatment of infections caused by gram-positive microorganisms in patients who have serious allergies to beta-lactam agents.
- When antibiotic-associated colitis fails to respond to metronidazole therapy or is severe and potentially life-threatening.

- CDC, *MMWR* 1995;44(RR12):1-13

**Notes:**
 Situations in which the use of vancomycin is appropriate or acceptable: 
- For  treatment of serious infections caused by beta-lactam-resistant gram-positive microorganisms. Vancomycin may be less rapidly bactericidal than are beta-lactam agents for beta-lactam-susceptible staphylococci. 
- For treatment of infections caused by gram-positive microorganisms in patients who have serious allergies to beta-lactam antimicrobials. 
- When antibiotic-associated colitis fails to respond to metronidazole therapy or is severe and potentially life-threatening. 

## Guidelines for Appropriate Vancomycin Use (HICPAC/CDC)

- _Selected situations in which the use of vancomycin should be discouraged: _
- Treatment in response to a single blood culture positive for coagulase-negative staphylococcus, if other blood cultures taken during the same time frame are negative.
- Continued empiric use for presumed infections in patients whose cultures are negative for beta-lactam resistant gram-positive microorganisms.
- Eradication of MRSA colonization.
- Systemic or local prophylaxis for infection or colonization of indwelling central or peripheral intravascular catheters.
- Primary treatment of antibiotic-associated colitis.
- Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis.
- Treatment (chosen for dosing convenience) of infections caused by beta-lactam-sensitive gram-positive microorganisms in patients who have renal failure.

**Notes:**
 Situations in which the use of vancomycin should be discouraged: 
- Treatment in response to a single blood culture positive for coagulase-negative staphylococcus, if other blood cultures taken during the same time frame are negative (i.e., if contamination of the blood culture is likely). 
- Continued empiric use for presumed infections in patients whose cultures are negative for beta-lactam- resistant gram-positive microorganisms.
Eradication of MRSA colonization.
 Systemic or local prophylaxis for infection or colonization of indwelling central or peripheral intravascular catheters.
- Primary treatment of antibiotic-associated colitis.
- Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis.

## Use Antimicrobials WiselyStep 7: Know when to say “No” to vanco

***Use Antimicrobials Wisely*****Step 7: Know when to say “No” to vanco**

**Fact:****  **Reduction of vancomycin use is  one of the most
- important strategies to limit the emergence, selection, and
- spread of vancomycin resistant bacteria.
**Action:**
- Follow CDC guidelines for vancomycin use
- Consider 1st generation cephalosporins instead of vancomycin

*Link to:** Methods to improve antimicrobial use and prevent resistance*

**Notes:**
Regardless of the options available for improving antimicrobial use, the commitment and participation of the prescribing clinician and the institution are essential. 

## Fact: 
A major cause of antimicrobial overuse is treatment of contamination or colonization.

- A major cause of antimicrobial overuse is treatment of contamination or colonization.

**Notes:**
Contamination of blood culture specimens and other patient specimens often leads to unnecessary antimicrobial use.
Positive cultures may reflect merely colonization of the patient without invasive infection.
Clinical evaluation is needed to differentiate true infection from contamination or colonization.

## Interpreting a Positive Blood Culture

*True Bacteremia:** ** *
- Unlikely	                      Uncertain                  Likely

*S. aureus*
*S. pneumoniae*
*Enterobacteriaceae*
*P. aeruginosa*
*C. albicans*

*Corynebacterium *spp.
- Non-anthracis *Bacillus *spp.
*Propioniobacterium acnes*

- coagulase-negative
-    staphylococci

**Notes:**
The presence of some organisms, such as Propionibacterium acnes, in blood culture is unlikely to indicate true bacteremia, unless the patient is at special risk.
The presence of some organisms, such as Staphylococcus aureus, should be assumed to indicate true bacteremia unless proven otherwise.
Identification of coagulase-negative staphylococci in blood is one of the major reasons for vancomycin use in the United States, but often these organisms are contaminants.
The first stepin interpreting blood culture results when coagulase-negative staphylococci are identified is to assess the pre-test probability of true bacteremia. Some patients, including those with endovascular implants and other prosthetic devices and neurotopenic pateints, are at increased risk for coagulase-negative staphylococcal bacteremia. 
Vascular catheters also increase the risk, but most coagulase-negative cultures in catheterized  patients without other risk factors are contaminants.
In patients who are critically ill, treatment is usually indicated until true bacteremia is excluded in the differential diagnosis.  
Additional information can help assess the post-test probability of true bacteremia. If more than one specimen is growing coagulase-negative staphylococci, then true bacteremia is more likely than when only a single specimen is positive. 
If more than one culture is positive, comparing the antibiograms can help determine if they are similar (more likely to represent true bacteremia) or different (less likely).
The best method for assessing true bacteremia is to compare genotypes of the suspect strains. However, this method is not widely available and results are usually not timely enough to guide therapy. 

## Use Antimicrobials Wisely Step 8:  Treat infection, not  contamination or colonization

**Fact:**  A major cause of antimicrobial overuse is treatment of contamination or colonization.
**Actions:**
- Use proper antisepsis for drawing blood cultures
- Get one peripheral vein blood culture, if possible
- Avoid culturing vascular catheter tips
- Treat bacteremia, not the catheter tip
- Culture the blood, not the skin or catheter hub

*Link to:** CAP standards for specimen collection and management*

**Notes:**
Optimizing skin antisepsis is the first critical step in obtaining blood cultures.
If possible, get one peripheral vein blood culture.
Avoid culturing the vascular catheter tips.
Proper specimen collection and management are key to preventing contaminated cultures. 
Improving the specificity of diagnostic criteria for infection can help reduce unnecessary antimicrobial use.

## Fact: 
Stopping empiric therapy when cultures are negative can significantly reduce antimicrobial use.

- Stopping empiric therapy when cultures are negative can significantly reduce antimicrobial use.

***Use Antimicrobials Wisely***
**Step 9:  Stop antimicrobial treatment**

**Notes:**
Once antimicrobial therapy is started, it is often difficult to stop, even when there is no indication for ongoing treatment.
However, in some cases, unnecessary antimicrobial treatment may actually harm patients and add to treatment costs.

## Short-course Antimicrobial Treatment of New Pulmonary Infiltrates in an ICU

**Short-course Antimicrobial Treatment of New Pulmonary Infiltrates in an ICU**

- 	Standard	Experimental
- _Variable__	__Therapy (n=42)__	__Therapy (n=39)_
- Regimen	clinician discretion	ciprofloxacin 400mg
- 	(all treated; 18 drugs)	(IV bid x 3 days)
- Treatment  > 3 days	97%	28%
- Antimicrobial resistance 	35%	15%
- Length of stay
-    mean/median	14.7/9 days	9.4/4 days
- Mortality (30 day)	31%	13%
- Antimicrobial cost
-     mean/total	$640/$16,004	$259/$6,484

*Link to: *Singh N, et al*.,Am J Respir Crit Care Med *2000;162:505-511

**Notes:**
This randomized unblinded clinical trial of patients in a Veteran’s Administration Medical Center was designed to assess a pragmatic approach to use of antimicrobials in the intensive care unit (ICU).
Eligible patients had new-onset pulmonary infiltrate and a low clinical pulmonary infection score (CPIS <= 6), indicating that pneumonia was unlikely.
Clinicians selected treatment for those in the standard group; 18 different antimicrobials were prescribed alone or in combination to those in this group.
Patients in the experimental group were treated with ciprofloxacin monotherapy for 3 days; after 3 days, treatment was stopped unless the CPIS was > 6 or infection at another site was documented.
Patients in the experimental group had less antimicrobial exposure and less emergence of antimicrobial resistance / superinfection. Their length of stay was shorter and their antimicrobial treatment cost was lower.
The difference in 30-day mortality rates for the 2 groups was not statistically significant, highlighting that shorter courses of antimicrobial treatment may not be necessary.
Over time, the participating clinicians began to choose new approaches for patients in the standard therapy arm and the study was stopped. 

## Use Antimicrobials WiselyStep 9:  Stop antimicrobial treatment

***Use Antimicrobials Wisely*****Step 9:  Stop antimicrobial treatment**

**Fact:  **Stopping empiric therapy when cultures are negative can significantly reduce antimicrobial use.
**Actions:**
- Stop when infection is treated
- Stop when clinical and laboratory data rule out infection

*Link to:** IDSA guideline for evaluating fever in critically ill adults*

**Notes:**
Stopping treatment when infection is unlikely or ruled out by clinical and laboratory data is safe and benefits patients by reducing the chance of emergence of resistant organisms.

## Fact: 
Following the recommended infection control precautions for hemodialysis patients can prevent transmission of infections from patient to patient. 

**Fact:**** **
- Following the** **recommended infection control precautions for hemodialysis patients can prevent transmission of infections from patient to patient.

***Prevent Transmission***
**Step 10:  Follow infection control precautions**

**Notes:**
Isolation practices and other measures to prevent transmission of infections from one patient to another are effective but too often ignored. These practices are important components of antimicrobial resistance prevention.
The infection control practices recommended for hemodialysis units reduce opportunities for patient-to-patient transmission of infectious agents directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel.

## Infection Control Precautions for Hemodialysis Patients

- In the hemodialysis setting, contact transmission plays a major role in transmission of bloodborne and other pathogens.
- Infection Control Precautions for hemodialysis patients include:
- Strict attention to hand hygiene
- using gloves for patient care and when handling patients medical equipment and devices.
- Dedicating nondisposable items for use on a single patient.
- Cleaning and disinfection of items taken into a dialysis station that will be used for more than one patient.
- For patients at increased risk for transmission of pathogenic bacteria, including antimicrobial-resistant strains, additional precautions also might be necessary in some circumstances. For example, staff treating the patient should a) wear a separate gown over their usual clothing and b) dialyze the patient at a station with as few adjacent stations as possible.

**Notes:**
In the hemodialysis setting, contact transmission plays a major role in transmission of bloodborne and other pathogens.
Contact transmission occurs most commonly when microorganisms from a patient are transferred to the hands of a healthcare worker who does not comply with infection control precautions, then touches another patient.
Infection Control Precautions for patients include:
- Strict attention to hand hygiene
- Using gloves for patient care and when handling patients medical         equipment and devices. 
- Dedicating nondisposable items for use on a single patient.
- Cleaning and disinfection of items taken into a dialysis station that  will be used for more than one patient.
.
For patients at increased risk for transmission of pathogenic bacteria, including antimicrobial-resistant strains, additional precautions also might be necessary in some circumstances.

## Prevent Transmission Step 10:  Follow infection control procedures

***Prevent Transmission*** **Step 10:  Follow infection control procedures**

**Fact: **** **Following recommended** **infection control precautions for hemodialysis patients can prevent transmission of infections from patient to patient.
**Actions:**
- Use standard infection control precautions for dialysis centers
- Consult local infection control experts

*Link to:** A VRE prevention success story*
*Link to:** CDC isolation guidelines and recommendations*

**Notes:**
Adherence to common-sense measures to isolate antimicrobial-resistant organisms before they are transferred to other patients or become endemic in a facility is essential. 
When in doubt about appropriate isolation procedures, consult with an infection control professional.

## Fact: 
Hand hygiene is the single most important infection control measure for preventing the spread of antimicrobial resistant organisms.

- Hand hygiene is the single most important infection control measure for preventing the spread of antimicrobial resistant organisms.

***Prevent Transmission***
**Step 11:  Practice hand **
**hygiene**

**Notes:**
Healthcare personnel are important components of the chain of transmission of resistant organisms in healthcare facilities, including dialysis centers.
Antimicrobial-resistant pathogens are transmitted from one patient to another when lapses in proper hand hygiene or other infection control practices occur.
Healthcare personnel can also transmit their own flora and infectious pathogens to patients. 
Hand hygiene is the single most important infection control measure because it prevents transmission of pathogens via hands of healthcare personnel.

## Hand Hygiene Adherence in Hospitals

- 1. Gould D, *J Hosp Infect* 1994;28:15-30  2. Larson E, *J Hosp Infect* 1995;30:88-106
- 3. Slaughter S, *Ann Intern Med* 1996;3:360-365  4. Watanakunakorn C, *Infect Control Hosp *
*Epidemiol* 1998;19:858-860   5. Pittet D,* Lancet* 2000;356:1307-1312

- Year of Study  Adherence Rate	Hospital Area
-  	(1)		29%   		General and ICU
- 1995	(2)		41%			General
- 1996	(3)		41%			ICU
- 1998 	(4)		30%			General
-  	(5)		48%			General

**Notes:**
In general, adherence of healthcare workers to recommended hand hygiene procedures has been poor.
Studies shown here are representative of the overall adherence rates, which average about 40%.
Adherence rates vary by occupation.

## Effectiveness of Hand Hygiene Agents in Reducing Bacteria on Hands

- Adapted from: *Hosp Epidemiol Infect Control*, 2nd Edition, Philadelphia: Lippincott & Williams,1999.

**Time after disinfection**

**Bacterial Reduction**

- Plain soap

- Antimicrobial soap(4% Chlorhexidine)

- Alcohol-based handrub
- (70% Isopropanol)

- Baseline

- 0

- 60

- 180 minutes

**%**
- 99.9

- 99.0

- 90.0

- 0.0

**log**
- 3.0

- 2.0

- 1.0

- 0.0

**Notes:**
This graph shows that alcohol-based handrub is better than plain soap at killing bacteria. 
Shown across the top of this graph is the amount of time after disinfection with the hand hygiene agent.
The left axis shows the percent reduction in bacterial counts. 
The three lines represent alcohol-based handrub, antimicrobial soap, and plain soap.

## Fact:  Hand hygiene is the single most important infection control measure for preventing the spread of antimicrobial resistant organisms.
Actions:
Wash your hands or use alcohol-based handrub
Set an example!

**Actions:**
- Wash your hands or use alcohol-based handrub
- Set an example!

*Link to:** Health guidelines for healthcare personnel*
*Coming soon...new guidelines for hand hygiene** *

***Prevent Transmission***
**Step 11:  Practice hand hygiene**

**Notes:**
Washing your hands or using an alcohol-based handrub is effective in infection control, as recommended in the CDC Guideline for Hand Hygiene in Healthcare Setting published in 2002.
Set an example -  your example can make a difference.

## Fact: 
Dialysis patients share in the responsibility for preventing access-related infections

- Dialysis patients share in the responsibility for preventing access-related infections

***Prevent Transmission***
**Step 12:  Partner with **
**your patients**

**Notes:**
 Dialysis patients play a role in preventing antimicrobial- resistant infections and are an essential partner in both prevention and control efforts in healthcare facilities.

## Poor Patient Hygiene is a Risk Factor for Infection

- 	                  _**No.(%) with Poor Hygiene**_
- 	       Patients 	     Patients not     p-value
- 	                              Infected          Infected
- All Infections	              17/23 (74%)      12/48 (25%)      0.0004
- Access site
- Infections	                   8/9 (89%)           21/62 (34%)     0.002

- Kaplowitz et al., *Infect Control Hosp Epidemiol* 1988;9:534-541

**Notes:**
There is a strong relationship between poor patient hygiene and increased rates of infections in dialysis patients.
A prospective study of chronic hemodialysis patients has shown that a patient’s hygiene practices have an important effect upon infection rates, especially access site infections. The infection rate was 89% for access site infections and 74%  for all infections in patients with poor hygiene.
Logistic regression showed that only poor hygiene was significantly correlated with the development of all infections, and in particular with access site infections.
Good personal hygiene can prevent infections in hemodialysis patients.

## Educating  Patients About Infection Control Practices

- Patients should be educated about the importance of their role in infection control upon admission to a dialysis center/hospital and at least annually thereafter.
- Educational materials should include personal hygiene, hand hygiene, proper care of access lines, and recognition of signs of infection.

- CDC, *MMWR* 2001;50 (5): 31

**Notes:**
Patients have a responsibility in infection control and should be educated about their responsibilities, including :
	- The importance of personal hygiene and hand hygiene for 	infection control.
- The importance of proper care of the access lines  and recognition of signs of infection. These should be reviewed each time the patient has a change in access type.

## Fact:  Dialysis patients share in the responsibility for preventing access-related infections.

Actions:
Educate patients about proper access care and infection control measures
Re-educate regularly

**Actions:**
- Educate patients about proper access care and infection control measures
- Re-educate regularly

*Link to:** Health guidelines for healthcare personnel*
*Coming soon...new guidelines for hand hygiene** *

***Prevent Transmission***
**Step 12:  Partner with your patients**

**Notes:**
Dialysis patients share in the responsibility for preventing access- related infections.
Patients should be educated on access care and infection control measures.
These prevention principles should be reinforced whenever possible.

## PREVENTION  

- IS PRIMARY!

*Protect patients...protect healthcare personnel...*
*promote quality healthcare!*

**Campaign to Prevent Antimicrobial Resistance in Healthcare Settings**