War on superbugs isn't over

21 APRIL 2016

In the battle on antibiotic resistant bacteria—or superbugs—the tide is turning but the war is far from over.
Despite a 50% reduction in central line-associated blood stream infections (CLABSIs) since 2008, there was no change in the rate of catheter-associated urinary tract infections (CAUTIs), and just an 8% decline in both surgical site infections (SSIs) and laboratory-identified Clostridium difficile infection (CDI) events.
The Centers for Disease Control and Prevention (CDC) is urging healthcare workers to be more vigilant is employing the standard infection prevention strategies already in place to help reduce the number of superbug infections.
Clifford McDonald, MD, associate director for science at CDC’s Division of Healthcare Quality Promotion, says even though healthcare associated infection (HAI) numbers are on a downward trend, the bacteria causing most of those infections are virulent.
For example, he says 1 in 7 catheter- and surgery-related infections in acute care hospitals can be caused by a number of antibiotic-resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and the “nightmare bacteria” carbapenem-resistant Enterobacteriaceae (CRE). That number increases to 1 in 4 infections in long term acute care hospitals, which treat patients who are generally very sick and stay, on average, more than 25 days. While physicians are doing a better job at limiting these types of infections, they still pose a big threat to patients due to the nature of the infection.
“We are seeing progress in the reduction of healthcare-associated infections. However our concern is that many of these infections are caused by antibiotic resistant bacteria—difficult, if not impossible to treat,” says McDonald.
To combat the development of these infections, CDC is asking physicians to crack down on practices that spread bacteria between patients, and that can include washing hands or disinfecting tools such as stethoscopes between patients. The CDC also wants physicians to prevent infections related to surgery and/or catheter placement, and prescribe antibiotics carefully to prevent resistance.
“Physicians have the ability to change the destiny of their patients, and we are calling on them to combine 3 critical efforts, every time and with every patient, to prevent HAIs,” McDonald says. “This means isolating patients when necessary. It also means being aware of antibiotic resistance patterns in their facilities, following recommendations for preventing infections that can occur after surgery or from central lines and catheters placed in the body, and prescribing antibiotics correctly.”
In a report outlining the prevalence of HAIs, CDC states that 1 in 6 CLABSIs, 1 in 10 CAUTIs, and 1 in 7 SSIs are caused by serious antibiotic resistance organisms. Additionally, 9 out of 10 cases of C Difficile are related to healthcare.
Another CDC report revealed that 6 strains of resistant bacteria were the cause of about 12% of HAIs in inpatient rehabilitation facilities and 29% of HAIs in long term acute care hospitals, according to the report. Overall, CDC says 1 in 4 HAIs—excluding C difficile—were caused by antibiotic resistant bacteria. However, CDC also notes that these infections could be reduced by more strictly following protocols that should already be in place.
“Physicians, nurses, and healthcare leaders need to consistently and comprehensively follow all recommendations to prevent catheter- and procedure-related infections and reduce the impact of antibiotic resistant bacteria through antimicrobial stewardship and measures to prevent spread,” the report concludes.
Of the 18 top antibiotic resistant bacteria the CDC outlined as top threats in 2013, 7 are primarily acquired in healthcare settings. In 2014, CDC notes that 14% of all HAIs were caused by one of the top 6 antibiotic resistant bacteria overall, including 18% of all CLABSIs, 15% of all SSIs, and 10% of CAUTIs in short term acute care hospitals. In long term care hospitals, antibiotic resistant bacteria were responsible for 28% of CLABSIs, and 29% of CAUTIs.
Despite continued prevalence of these HAIs, progress is being made.
The decrease in CLABSIs is significant, given the high morbidity, mortality, and cost associated with treated those infections, says CDC. Also, CDC says short term acute care hospitals reduced the CAUTI rates by 5% overall from 2013 to 2014 alone, and non-intensive care units decreased CAUTI rates during the same period by 24%. Catheter-associated urinary tract infections are of particular concern because of their prevalence, but CDC says a number of interventions—including payment and reporting requirements—have aided in the reduction in these types of infections.
Still, other trends are concerning, including a more recent rise in CDIs after a previous downward trend.
C difficile is one of the most common HAIs and a big problem in hospitals, with 94% of all CDIs related to various healthcare exposures. Clostridium difficile infections can be fatal, too, with 29,000 dying within 30 days of diagnosis in 2011—a year that saw a total of 453,000 CDIs. The CDC says while CDIs saw an 8% overall decrease from 2011 to 2014, there was a 4% increase from 2013 to 2014 alone.
Prevention can occur by simply following previously established guidelines, such as in the case of CAUTIs, CDC says.
“Preventing catheter- and procedure-related infections can be accomplished by always following recommended indications and guidelines for insertion, maintenance, and removal of vascular and bladder catheters,” CDC notes, adding that more guidance is coming. “CDC and its partners are implementing new US Department of Health and Human Services-proposed HAI targets for December 2020, using 2015 National Healthcare Safety Network data as its new baseline. A key strategy for reaching these goals is the Targeted Assessment for Prevention strategy to identify gaps in infection control in facilities with a disproportionate number of HAIs. In addition to reducing the need for antibiotics used in treatment, preventing HAIs prevents complications of infection, including sepsis, a major cause of death.”
In terms of preventing HAI through good antibiotic stewardship, CDC says physicians should always obtain cultures when starting antibiotics; using culture results to assess the continued need for antibiotics; and discontinuing the antibiotics once they are no longer needed and before an antibiotic resistant infection can develop. Monitoring administration, with the right drug at the right dose, is also important, says CDC, noting that antibiotic exposure is the “most important modifiable risk factor for CDI, and antibiotic stewardship is potentially the most effective CDI prevention strategy.”
The CDC points to the role increased use of fluoroquinolones had in the emergence and spread of CDIs, and how the reduction in these medications has helped to control fluoroquinolones-resistant CDIs.
Healthcare workers and facilities also need to be vigilant with cleanliness, from hand hygiene to room cleaning and the use of personal protective equipment. Particularly in cases involving CDIs—which can form spores and withstand some basic cleaning and disinfecting protocols—special measures might have to be taken to prevent transmission, CDC says.
The CDC says it is working on additional efforts to prevent HAIs with a number of other agencies, including the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. Additionally, Congress approved $160 million in funding to CDC to implement a number of interventions listed in its National Action Plan for Combating Antibiotic-resistant Bacteria, which aims to accelerate outbreak detection and prevention; enhance tracking or antibiotic resistant infections; support new research; and improve antibiotic use.

Article appeared in CONTEMPORARY PEDIATRICS:,0