Why Are Antibiotic-Resistant Nosocomial Infections Spiraling Out of Control?

For as long as the Centers for Disease Control and Prevention (CDC) has measured the prevalence of hospital-acquired infections caused by multidrug-resistant organisms, it has been increasing.1-4 According to the CDC, more than 70% of the bacteria now causing hospitalacquired infections are resistant to at least one of the drugs most commonly used to treat them.5 It seems important to control these infections because they have been more costly and more deadly than those due to antibiotic-susceptible strains of the same species.6-9 Nevertheless, despite decades of discussing the control of antibiotic-resistant nosocomial infections, there has been little evidence of control in most healthcare facilities in most countries.1-3 Several articles in this issue of Infection Control and Hospital Epidemiology evaluate the efforts that have been made by hospitals to control them and may help to explain this failure.10-14 The first of these, by L’Heriteau et al.,10 reports the findings of a nationwide, prospective study designed to describe methods used for diagnosis and surveillance of nosocomial infections and multidrug-resistant organisms in French intensive care units (ICUs). They sought to survey all 573 French ICUs, but only 252 (44%) responded to the written survey. Follow-up telephone interviews of personnel in 143 (47%) of the initially nonresponding ICUs allowed them to increase the overall response rate to 69%. Despite the existence of clearly stated French national guidelines,15 the authors found that there were “profound differences” in the way that ICUs had implemented the recommendations for surveying for various nosocomial infections. They concluded that great caution must be exercised when comparing data regarding ICU infections among French hospitals. Regarding surveillance for multidrug-resistant organisms, they found that 70% of the respondents performed active surveillance cultures to detect these organisms on admission, whereas 60% did so during the stay; 88% of the responding ICUs flagged carriers of multidrug-resistant organisms so that isolation could be maintained consistently. This indicates important variation among hospitals, and inconsistent use of an effective control measure could help to explain difficulties in controlling multidrug-resistant organisms (ie, approximately one-third of the time active surveillance cultures were not being performed to identify contagious patients). A second national survey in this issue of Infection Control and Hospital Epidemiology was designed to examine the extent of implementation of strategies to control multidrug-resistant organisms in U.S. hospitals based on recommendations from a 1994 workshop co-sponsored by the National Foundation for Infectious Diseases and the CDC.16 Ward et al.11 surveyed hospitals for compliance with five goals to optimize antibiotic use and five goals to detect, report, and prevent spread of multidrug-resistant organisms. From approximately 7,000 U.S. hospitals, 108 hospitals (1.5%) were randomly selected to receive a survey (excluding Veterans’ Affairs hospitals and smallto medium-sized teaching hospitals). The survey response rate was 60%. Approximately half of the responding hospitals were classified as large (> 200 beds) and an equal proportion of those remaining as small (50 to 99 beds) and medium (100 to 199 beds). Survey responses were recorded using a 5-point Likert scale. The mean response regarding