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ANTIBIOTIC RESISTANCEWhat you should KNOW
What you should DO
Seth Johnson, RN,MSN,CNN May 7, 2014
Test Your Knowledge
1. How do you put a giraffe into a refrigerator?
The correct answer is: Open the refrigerator, put in the giraffe and close the door
This question tests whether you tend to do simple things in an overly complicated way
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
Test Your Knowledge
2. How do you put an elephant into a refrigerator?
Wrong Answer: Open the refrigerator, put in the elephant and close the refrigerator.
Correct Answer: Open the refrigerator, take out the giraffe, put in the elephant and close the door.
This tests your ability to think through the repercussions of your actions
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
Test Your Knowledge
3. The Lion King is hosting an animal conference. All the animals attend except one. Which animal does not attend?
Correct Answer: The Elephant. The Elephant is in the refrigerator
This tests your memory
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
Test Your Knowledge
OK, even if you did not answer the first three questions, correctly, you still have one more chance to show your abilities.
According to Andersen Consulting Worldwide, around 90% of the professionals they tested got all questions wrong. But many preschoolers got several correct answers.
Anderson Consulting says this conclusively disproves the theory that most professionals have the brains of a four year old.
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
Test Your Knowledge
4. There is a river you must cross. But it is inhabited by crocodiles. How do you manage it?
Correct Answer: You swim across. All the Crocodiles are attending the Animal Meeting.
This tests whether you learn quickly from your mistakes
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
At the completion of this presentation participants will be able to:
◦Identify the treat of antibiotic resistance
◦Identify patients at high risk for antibiotic resistance
◦Identify the safe use of antibiotics
◦Identify measures to prevent or reduce antibiotic
resistance
Objectives
Antibiotic resistance is a worldwide problem
New forms of antibiotic resistance can cross international boundaries and spread between continents with ease
World health leaders have described antibiotic resistant microorganisms as “nightmare bacteria” that “pose a catastrophic threat” to people in every country in the world.
Introduction
The ability of bacteria or other microbes to resist the effects of an antibiotic.
Antibiotic resistance occurs when bacteria change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections.
The bacteria survive and continue to multiply causing more harm.
What is antibiotic resistance?
When bacteria are exposed to antibiotics, they start learning how to outsmart the drugs.
This process occurs in bacteria found in humans, animals, and the environment.
Resistant bacteria can multiply and spread easily and quickly, causing severe infections.
They can also share genetic information with other bacteria, making the other bacteria resistant as well.
Each time bacteria learn to outsmart an antibiotic, treatment options are more limited, and these infections pose a greater risk to human health.
How Bacteria Become Resistant
Each year in the United States, at least 2 million people acquire serious infections with bacteria that are resistant to one or more of the antibiotics designed to treat those infections.
At least 23,000 people die each year as a direct result of these antibiotic-resistant infections.
Many more die from other conditions that were complicated by an antibiotic-resistant infection.
The United States
In addition, almost 250,000 people each year require hospital care for Clostridium difficile (C. difficile) infections.
In most of these infections, the use of antibiotics was a major contributing factor leading to the illness.
At least 14,000 people die each year in the United States from C. difficile infections.
Many of these infections could have been prevented.
Clostridium Difficile
Antibiotic Safety
Antibiotic Prescriptions per 1000 Persons of All Ages According to State, 2010
Antibiotic-resistant infections add considerable and avoidable costs to the already overburdened U.S. healthcare system.
Total economic cost of antibiotic resistance to the U.S. economy - difficult to calculate.
Estimates vary -ranged as high as $20 billion in excess direct healthcare costs, with additional costs to society for lost productivity as high as $35 billion a year (2008 dollars)
Cost
http://www.youtube.com/watch?v=RpKZvnJwicA&feature=youtu.be
The Threat of Antibiotic Resistance
Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Urgent Threats
Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum β-lactamase producing
Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus (VRE)
Multidrug-resistant Pseudomonas aeruginosa
Serious Threats
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
◦ occurs most frequently among persons in hospitals and healthcare
facilities (such as nursing homes and dialysis centers) who have
weakened immune systems.
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Serious Threats-cont’d
Vancomycin-resistant Staphylococcus aureus (VRSA)
Erythromycin-resistant Group A Streptococcus
Clindamycin-resistant Group B Streptococcus
Concerning Threats
Categories
DIALYSIS FOR END-STAGE RENAL DISEASE
CANCER CHEMOTHERAPY
COMPLEX SURGERY
RHEUMATOID ARTHRITIS
ORGAN AND BONE MARROW TRANSPLANTS
Who is at risk
There are four core actions that will help fight these deadly infections:◦ preventing infections and preventing the spread of
resistance
◦ tracking resistant bacteria
◦ improving the use of today’s antibiotics
◦ promoting the development of new antibiotics and developing new diagnostic tests for resistant bacteria
Action
Infections prevention reduces the amount of antibiotics that have to be used and reduces the likelihood that resistance will develop during therapy
Ways that drug-resistant infections can be prevented:◦ Immunization◦ safe food preparation◦ handwashing, and ◦ using antibiotics as directed and only when necessary.
Preventing infections also prevents the spread of resistant bacteria
Infection Prevention & spread of resistant bacteria
CDC gathers data on antibiotic-resistant infections, causes of infections and whether there are particular reasons (risk factors) that caused some people to get a resistant infection.
With that information, experts can develop specific strategies to prevent those infections and prevent the resistant bacteria from spreading.
Tracking
Single most important action needed - to greatly slow down the development and spread of antibiotic-resistant infections is to change the way antibiotics are used
Up to half of antibiotic use in humans is unnecessary and inappropriate and makes everyone less safe
Antibiotic stewardship - always use antibiotics appropriately and safely, only when they are needed to treat disease, and to choose the right antibiotics and to administer them in the right way in every case
Improving antibiotic prescribing/stewardship
Because antibiotic resistance occurs as part of a natural process in which bacteria evolve, it can be slowed but not stopped.
Need for new antibiotics to keep up with resistant bacteria as well as new diagnostic tests to track the development of resistance
Developing new drugs & diagnostic tests
Increased risk for getting a bloodstream infection
Bloodstream infections are the second leading cause of death in dialysis patients
Infections also complicate heart disease, the leading cause of death in dialysis patients
Infection risk is higher ◦ weakened immune systems ◦ catheters
Dialysis Patients & Antibiotic Resistance
Infection Prevention in Dialysis Settings
A Continuing Education (CE) Training Course forOutpatient Hemodialysis Healthcare Workers
Infection prevention and control◦ Hand hygiene – observations◦ Proper catheter /vascular care and reduction in catheters◦ Proper cleaning measures
Safe medication management◦ Preparation◦ Handling◦ Storage◦ administration
Vaccination – patients and staff Staff education and competency Patient education and engagement
What dialysis care providers can do to protect patients from drug-resistant infections
Follow all necessary infection control recommendations, including hand hygiene, standard precautions, and contact precautions.
Diagnose and treat resistant infections quickly and efficiently
Treatment options change often because resistance is complex
Make sure to follow the latest recommendations to ensure you are prescribing appropriately.
Only prescribe antibiotics when likely to benefit the patient, and be sure to prescribe the right dose and duration.
What dialysis care providers can do to protect patients from drug-resistant infections
When transferring patients, ensure the other facilities are notified of any infection or known colonization.
Keep tabs on resistance patterns in your facility and in the area around your facility.
Encourage prevention methods with your patients.
Be sure they understand how to protect themselves with vaccines, treatment, and infection control practices such as hand washing and safe food handling
What dialysis care providers can do to protect patients from drug-resistant infections
Basic Steps in Fistula/Graft Care
Decannulation Procedure:1. Perform hand hygiene2. Put on a new, clean pair of gloves3. Wear proper face protection4. Remove needles using aseptic technique5. Apply clean gauze/bandage to site6. Compress the site with clean gloves7. Remove gloves and perform hand hygiene
Basic Steps in Catheter Care
Catheter Connection Procedure:1. Perform hand hygiene2. Put on a new, clean pair of gloves3. Wear proper face protection4. Apply antiseptic to catheter hub and allow it to dry5. Connect the catheter to blood lines using aseptic technique6. Unclamp the catheter7. Remove gloves and perform hand hygiene
Basic Steps in Catheter Care
Catheter Disconnection Procedure:1. Perform hand hygiene2. Put on a new, clean pair of gloves3. Wear proper face protection4. Disconnect the catheter from blood lines using aseptic
technique5. Apply antiseptic to catheter hub and allow it to dry6. Replace caps using aseptic technique7. Make sure the catheter remains clamped8. Remove gloves and perform hand hygiene
Catheter Exit Site Care
1. Perform hand hygiene2. Put on a new, clean pair of gloves3. Wear a face mask if required4. Apply antiseptic to catheter exit
site and allow it to dry5. Apply antimicrobial ointment6. Apply clean dressing to exit site7. Remove gloves and perform hand
hygiene
Photo provided by Stephanie Booth, used with permission
Separate Clean Areas from Contaminated Areas
• Clean areas should be used for the preparation, handling and storage of medications and unused supplies and equipment– Your center should have clean medication and
clean supply areas• Contaminated areas are where used supplies
and equipment are handled• Do not handle or store medications or clean
supplies in the same area as where used equipment or blood samples are handled
Remember: Treatment stations are contaminated areas!
Clean area
Photo provided by Stephanie Booth, used with permission
Dedicate Supplies to a Single Patient
• Any item taken to a patient’s dialysis station could become contaminated
• Items taken into the dialysis station should either be:– Disposed of, or– Cleaned and disinfected before being taken
to a common clean area or used on another patient
• Unused medications or supplies taken to the patient’s station should not be returned to a common clean area (e.g., medication vials, syringes, alcohol swabs)
Photo provided by Marshia Coe and Teresa Hoosier, used with permission
Safe Use of Medication Vials
• Prepare all individual patient doses in a clean area away from dialysis stations
• Prepare doses as close as possible to the time of use
• Do not carry medications from station to station
• Do not prepare or store medications at patient stations
• CDC recommends that dialysis facilities:– Use single-dose vials whenever possible and
dispose of them immediately after use
Guidelines for Carrying Medications
Do not use the same medication cart to deliver medications to multiple patients
Do not carry medication vials, syringes, alcohol swabs, or supplies in pockets
Be sure to prepare the medication in a clean area away from the patient station and bring it to the patient station for that patient only at the time of use
Cleaning and disinfection reduce the risk of spreading an infection
Cleaning is done using cleaning detergent,water and friction, and is intended toremove blood, body fluids, and othercontaminants from objects and surfaces
Disinfection is a process that kills manyor all remaining infection-causinggerms on clean objects and surfaces◦ Use an EPA-registered hospital disinfectant◦ Follow label instructions for proper dilution
Wear gloves during the cleaning/disinfection process
Cleaning and Disinfecting theDialysis Station
All equipment and surfaces are considered to be contaminated after a dialysis session and therefore must be disinfected
After the patient leaves the station,disinfect the dialysis station(including chairs, trays, countertops,and machines) after each patienttreatment◦ Wipe all surfaces◦ Surfaces should be wet with disinfectant and allowed to air dry◦ Give special attention to cleaning control panels on the dialysis machines
and other commonly touched surfaces◦ Empty and disinfect all surfaces of prime waste containers
Disinfecting the Dialysis Station
Photo provided by Stephanie Booth, used with permission
Safe Handling of Dialyzers andBlood Tubing
• Before removing or transporting used dialyzers and blood tubing, cap dialyzer ports and clamp tubing
• Place all used dialyzers and tubing in leak-proof containers for transport from station to reprocessing or disposal area
• If dialyzers are reused, follow published methods (e.g., AAMI standards) for reprocessing
AAMI is the Association for the Advancement of Medical Instrumentation
Photo provided by Stephanie Booth, used with permission
Infection Control Policies and Practicesfor Dialysis Facilities
Vaccination of dialysis staff and patients Preventing the spread of hepatitis B Preventing the spread of bacterial infections
Influenza◦ Influenza or the “flu” is a respiratory infection that
infects the nose, throat, and lungs◦ The flu is spread mainly by droplets that are made
when people with flu cough, sneeze or talk◦ The single best way to prevent the flu is to get a flu
vaccine each year Hepatitis B
◦ Hepatitis B is a serious infection that affects the liver. It can cause acute (short-term) or chronic (long-term) infection and liver cancer
◦ Hepatitis B virus is easily spread through contact with the blood or other body fluids of an infected person
◦ Hepatitis B vaccine can prevent hepatitis B infection
Vaccine-Preventable Infections
Vaccination and Routine Testingof Hemodialysis Patients
• Vaccinate all susceptible patients against:– Hepatitis B
• Recommended vaccines for patients include:– Influenza (inactivated)– Pneumococcal
• Conduct routine testing for:– Hepatitis B virus– Hepatitis C virus
Preventing the Spread of Hepatitis B
Dialyze hepatitis B (HBsAg+) patients in a separate room using separate machines, equipment, instruments, and supplies◦ Be sure to use a separate gown when treating these
patients Staff members caring for patients with hepatitis B
(HBsAg+) should not care for HBV-susceptible patients at the same time (e.g., during the same shift or during patient changeover)
• HBsAg+ means hepatitis B surface antigen (a lab test for hepatitis B virus) was positive
• HBV-susceptible means anyone who has never been infected and lacks immunity to hepatitis B virus
Patients with catheters:◦ 1.Hand hygiene◦ 2.General access care at home (e.g., bathing with a catheter) ◦ 3.Signs and symptoms of infection◦ 4.How to respond if problems with catheter develop outside of
the dialysis center ◦ 5.Risks associated with catheters/importance of permanent
access ◦ 6.Basic infection control practices during catheter accessing
process (as a means to engage patients)
Key areas for patient education
Patients with other access types: ◦ 1.Hand hygiene ◦ 2.Washing the access site prior to treatment ◦ 3.General access care at home (e.g., don’t scratch or pick at
the site) ◦ 4.Signs and symptoms of infection ◦ 5.How to respond if problems with access develop outside
of the dialysis center ◦ 6.Basic infection control practices during cannulation
process (as a means to engage patients)
Key areas for patient education
Basic steps clinicians can take to prevent infections in hemodialysis patients include:◦ Promote fistula use◦ Get catheters out◦ Improve catheter care◦ Clean hands before and after every patient contact◦ Talk to patients about good vascular access care
Facility Action Steps
Follow Policies & Procedures Heighten awareness on hand hygiene Empower staff to own infection prevention practices Create infection prevention / control team including
patients Conduct unannounced audits / checks Utilize toolkits from CDC, WHO, AHQR
Facility Action Steps
The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work
QSEN define quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics
QSEN Competencies: OVERVIEW
Patient-centered Care
Teamwork and Collaboration
Evidence-based Practice (EBP)
Quality Improvement (QI)
Safety
Informatics
QSEN building blocks
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs
Patient-centered Care
Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care
Teamwork and Collaboration
Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
Evidence-based Practice (EBP)
Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
Quality Improvement (QI)
Minimizes risk of harm to patients and providers through both system effectiveness and individual performance
Safety
Use information and technology to communicate, manage knowledge, mitigate error, and support decision making
Informatics
http://www.cdc.gov/cdctv/SnortSniffleSneeze/index.html
Snort! Sniffle!! Sneeze. No Antibiotics Please!
What is the biggest room we all have?
ROOM FOR IMPROVEMENT
Question
Conclusion
preventing infections and preventing the spread of resistance tracking resistant bacteria improving the use of today’s antibiotics promoting the development of new antibiotics and developing
new diagnostic tests for resistant bacteria Infections that patients can get while receiving dialysis are
serious but preventable Healthcare workers following infection control precautions and
other safe care practices are the key to prevention Infection prevention is everyone’s responsibility
1 CDC. Active Bacterial Core Surveillance Methodology (2012). http://www.cdc.gov/abcs/index.html [Accessed 5/23/2013].
2 CDC. Active Bacterial Core Surveillance (ABCs) Report, Emerging Infections Program network, Group B Streptococcus (2011). http://www.cdc.gov/abcs/reports-findings/ survreports/gbs11.pdf [Accessed 7/23/2013].
3 CDC. Antimicrobial Susceptibilities Among Group B Streptococcus Isolates, Active Bacterial Core Surveillance (ABCs) (2010). http://www.cdc.gov/abcs/reports-findings/survreports/gbs10-suscept.html [Accessed 7/23/2013].
4. http://www.cdc.gov/nhsn/
5. http://www.cdc.gov/dialysis/monitoring/Data-reports.html
6. http://www.qsen.org/
References
Questions
