Antibiotic Resistance—an Alarming Health Care Issue - Statistical Data Included

Carolyn Twomey

When antibiotics were introduced in the medical arena in the 1940s, many believed they were the definitive answer to infectious disease. Within a few years, however, microbes had begun to exhibit their resistance to antibiotics. At one time, Walt Kelly's comic strip character, Pogo, described pollution, saying, "We have met the enemy and he is us." Today, however, he could have been describing the alarming medical threat of bacterial infections that are resistant to all known antibiotics.

Every year, 17 million people die of infectious diseases. Emerging highly infectious viral agents, resurgent diseases, and mutating bacteria have combined to create a global health care crisis.(1) Despite major strides in prevention and control, infectious diseases continue to take a significant and economic toll on society. The cost to the health care system is enormous. One report estimated the annual cost of antibiotic resistance to a single pathogen, Staphylococcus aureus, was $122 million.(2) In 1995, the annual cost was estimated to be at least $1.5 billion.(3) Organisms that once displayed uniform susceptibility now exhibit resistance to specific antibiotics.

The problem has created a serious concern for patients with prolonged hospital stays. Since the 1980s, the number of reported nosocomial infections, particularly bacterial infections, has increased drastically. The US Centers for Disease Control and Prevention (CDC) estimates that the annual cost of treating patients who acquire nosocomial infections in acute care facilities in the United States is $3.5 billion.(4) The incidence of nosocomial gram-positive infections has continued to rise, and available antimicrobials have become useless against resistant strains (Figure 1). Coagulase-negative staphylococci (CNS), S. aureus, and enterococci now are the three most common nosocomial isolates, comprising 67% of all nosocomial bacteremias.(5) For the preponderance of CNS and S. aureus strains, vancomycin remains the appropriate therapeutic option, it now has been documented, however, that 17% of all enterococci isolates are vancomycin resistant.

[Figure 1 ILLUSTRATION OMITTED]

A SIGNIFICANT PROBLEM

A national surveillance project involving several hundred tertiary care medical centers between 1980 and 1989 revealed a 754% increase in CNS blood infections.(6) This project also revealed a 120% increase in enterococcal infections and a 176% increase in S. aureus infections. A more recent survey examined nosocomial bacteremic infections in more than 4,500 patients between 1995 and 1996 and found

* 67% of infections were caused by gram-positive bacteria,

* 79% of infections were methicillin-resistant CNS,

* 28% were methicillin-resistant S. aureus (MRSA), and

* 17% were vancomycin-resistant enterococci (VRE).

In cases in which pathogens were susceptible to multiple medications, pathogens rapidly were becoming susceptible to vancomycin only or completely nonsusceptible.(7)

NOSOCOMIAL INFECTIONS

Antibiotic resistance can be found in all organisms, including bacteria, fungi, viruses, and parasites. Among these, bacteria are the greatest concern because of their prevalence in both hospital and community settings. Bacterial resistance to antibiotics can result in patients having

* increased severity of illnesses,

* more debilitating diseases,

* longer hospital stays,

* adverse long-term sequelae, and

* higher mortality rates.

Collectively, these factors create great costs for the health care system.

Losing ground. According to the CDC, each year approximately two million people acquire infections while being hospitalized.(8) Microbes that have developed antibiotic or multimedication resistance typically are the primary cause for infections and complicate treatment. Although resistance is possible in all microbes (ie, bacteria, fungi, viruses), bacteria cause the majority of medication-resistant problems. It currently is estimated that 70% of bacteria causing these infections are resistant to at least one of the more commonly used antibiotics.(9) More alarming is that 60% of patient deaths that are attributed to infections are caused by bacteria that now are resistant to at least one antibiotic.(10)

Data collected in 1999 show antibiotics losing ground to certain pathogens. This study of selected antimicrobial-resistant pathogens associated with nosocomial infections in patients in intensive care units revealed an increased resistance in VRE (43%), MRSA (37%), imipenem-resistant Pseudomonas aeruginosa (56%), and quinolone-resistant P. aeruginosa (50%), as compared to data collected between 1994 and 1998.(11) This resistance is driving health care workers to use experimental and potentially toxic medications to combat infection.

Impact of contemporary medicine. Patients' shortened hospital stays and the trend toward outpatient treatment and surgery have contributed to bacterial resistance. It was estimated that 75% of all surgical procedures will be performed in ambulatory, same-day, or outpatient ORs by the turn of this century.(12) As a result, it is critical that health care professionals make no distinction involving infection control and sterile technique between surgical care delivered in conventional inpatient arenas and in outpatient facilities.

The CDC National Nosocomial Infections Surveillance (NNIS) system indicates that surgical site infections (SSIs) are the third most frequently reported nosocomial infection, accounting for 14% to 16% of all nosocomial infections among hospitalized patients.(13) Between 1986 and 1996, SSIs were the most common nosocomial infection found in surgical patients, accounting for 38% of all infections. Of these reported SSIs, two-thirds were confined to the incision, and one-third involved organs or spaces (eg, disc spaces, oral cavities, dural spaces, arteries, veins) accessed during procedures. Seventy-seven percent of patients' deaths were related to infection, and the majority (ie, 93%) were related to serious infection involving organs or spaces accessed during procedures.

In one study, researchers compared the lengths of stays of patients who developed nosocomial surgical wound infections to the lengths of stay of the general surgical population.(14) Between Jan 1, 1990, and Aug 1, 1992--a study period of 19 months--the average length of stay for patients who developed infected surgical wounds was 14.5 days. Patients who did not develop infections spent an average of 4.7 days in the hospital. The mean attributable difference in lengths of stays between these two groups was 5.3 days. This study found nosocomial surgical wound infections added 2,061 inpatient days during the study period--a $1.9 million cost to the facility.

According to these researchers, 500,000 to one million of the 23 million surgical procedures performed annually in the United States result in surgical wound infections. Nosocomial wound infections have a significant negative human and financial impact. Despite advances in OR ventilation, availability of antimicrobial prophylaxis, sterilization methods, surgical technique, and barriers--especially surgical gloves--SSIs continue to be a significant cause of patient morbidity and mortality.

EMERGING MICROBES

Resistant microbes have emerged in response to various conditions and opportunities. Their growth has been encouraged by multimedication prophylaxis, new surgical procedures of longer duration and greater risk (eg, organ transplantations), the use of indwelling devices, hospitalization of immune-suppressed or immune-compromised patients, serious acute disease or chronic illness in older adult patients, and breakdown in aseptic technique. Community factors, such as clustering and overcrowding, population mobility, and inadequate sanitation, have conspired to give pathogens an evolutionary edge.(15) In the major categories of bacteria responsible for this emergence of resistance, three factors are striking.

* The increased frequency of vancomycin use.

* The increased use of temporary indwelling catheters in patients who are critically ill. One researcher examined the relationship of bacteremia to invasive line status and found that, although there was an enormous range of infections, the number of bloodstream infections per central venous catheter (CVC) use was dramatically higher than the number of infections per nonCVC use.(16)

* An increase in the bed census of patients who are critically ill. Data from NNIS show a 17% increase in intensive care unit (ICU) beds between 1988 and 1995.(17) At the same time, total hospital bed capacity decreased slightly. This indicates that as lengths of hospital stays decrease, the acuity of the remaining inpatient population is rising dramatically. In addition, CDC data reveal a significant and continuing increase in antibiotic-resistant infections in ICUs.(18)

Resistant gram-positive and gram-negative microbes are a frequent cause of nosocomial infections. Enterobacter, S. aureus, Enterococcus faecium, and P. aeruginosa now are commonly encountered in clinical practice. Fungi, such as Candida and Aspergillus, also have become an increasingly important cause of postoperative infections. In the community setting, Streptococcus pneumoniae, Neisseria gonorrhoeae, Mycobacterium tuberculosis, and Haemophilus influenza have emerged as significant pathogens.(19)

RESISTANCE

Like other life forms, bacteria have two main purposes: survival and reproduction. Microbes always have coexisted with mammalian life forms, learning to adapt to hostile environments. To some degree, resistance is an evolutionary survival trait. It is a complex phenomenon involving an interaction among the microorganism, antimicrobial medication, environment, and patient. A resistant microorganism is defined as "one that will not be inhibited or killed by an antimicrobial agent at concentrations of the drug achievable in the body after normal dosage."(20)

Although resistant bacteria are present in the environment, their predominance usually is so small that the chance an individual will contact a medication-resistant infection is unlikely. Resistance only becomes a problem when these bacteria reach a high density in a susceptible host or population.

DIMINISHING THERAPEUTIC OPTIONS

Bacteria adapt quickly to new medications, which has been apparent since the discovery of antibiotics. In 1928, Scottish bacteriologist Alexander Fleming noticed that mold stopped the growth of S. aureus (Figure 2). In 1940, Howard Florey and Ernst Chain isolated the active ingredient of Fleming's mold and called it penicillin. By the mid-1940s, bacteria resistant to penicillin-based antibiotics already had begun appearing in hospitals, and Fleming warned that the misuse of penicillin could lead to the selection and propagation of mutant forms of bacteria that would become resistant to the medication. These early predictions have proven to be true.

[Figure 2 ILLUSTRATION OMITTED]

Physician response to infection has been to use increasingly potent antibiotics. Two to three decades ago, treatment options were much wider. Treatment for E. faecium included ampicillin, penicillin, vancomycin, and aminoglycosides.(21) Between 1970 and 1989, options were reduced to teicoplanin, aminoglycosides, and vancomycin, which was known as the "silver bullet."

Vancomycin. Initially, vancomycin was a powerful alternative to other antibiotics in treating serious infections. It was introduced in 1958, but it remained a secondary antibiotic until the late 1970s and 1980s, when MRSA became increasingly resistant to numerous antimicrobial agents. Vancomycin became the last weapon--the only medication capable of treating multimedication-resistant infections.(22)

Two significant dates paint a vivid picture of where microbe resistance stands today. In 1997, staphylococcal bacteria diagnosed in a Japanese infant withstood 29 days of treatment with vancomycin, the strongest antibiotic available. Then, in February 1999, the development of a vancomycin-resistant strain of S. aureus in the United States was documented.(23) Although vancomycin resistance was not a new phenomenon, this was the first documentation of such cases in this country.

To preserve its effectiveness, the CDC Hospital Infection Control Practices Advisory Committee (HICPAC) outlined several uses of vancomycin that should be discouraged, including as an agent for surgical prophylaxis and as a first-line treatment for patients with Clostridium difficile colitis.(24) According to HICPAC, vancomycin should not be administered indefinitely without establishing specific clinical goals and a finite time frame for its use.

In 1999, President Clinton requested $25 million from Congress to study and monitor antibiotic-resistant microbes. In 1995, the US Office of Technology Assessment estimated that resistant bacteria cost the nation $1.5 billion annually, and it estimated that the number of deaths per year due to resistant bacteria is 77,000.(25) All levels of the US government combined spend $55,455 annually on surveillance of bacterial resistance. Approximately 600 times that amount is spent on AIDS surveillance, which affects a much smaller population.(26)

On April 17, 2000, the US Food and Drug Administration (FDA) approved the first new type of antibiotic in 35 years.(27) Linezolid (ie, Zyvox), an oxazolidinone, is designed specifically to overcome medication resistance. Linezolid blocks bacterial growth by disrupting the initiation of the process that microbes use to make proteins. Protein synthesis is essential to microbial survival. Linezolid, which is available in IV or oral routes, is different from some of the current antibiotics that inhibit protein synthesis after it has begun. In clinical trials of patients with complicated and uncomplicated skin and soft tissue infections, it was reported to have a clinical success rate of 93.2% against organisms such as S. aureus, S. epidermidis, and Enterococcus.(28)

IMPACT OF OVERUSE AND ABUSE OF ANTIBIOTICS

Physicians admit they have overused many existing antibiotics, allowing bacteria to "beat" the medications.(29) People expect that they can call or visit their physicians when they are ill and be prescribed a medication that will quickly cure them. According to one report, pediatricians estimate antibiotics are prescribed inappropriately 20% to 50% of the time, and the CDC estimates that one-third of all antibiotic prescriptions are unnecessary.(30) The prescribing of antibiotics affects society as a whole. In treating individuals, health care workers affect not only the individual's disease-causing organism but also the entire range of flora in the environment.

Health-conscious consumers may be making matters worse in several ways, including noncompliance in the taking of prescribed antibiotics. In 1996, a cross-sectional Gallup survey of 1,010 adults and 100 physicians found that six out of 10 Americans believed antibiotics were effective against viruses. Eight out of 10 physicians believed their patients saved unfinished antibiotics prescriptions to use at a later time.(31) By taking only a portion of prescribed medications and stockpiling them for later use, patients expose flora to subtherapeutic doses, which encourages resistance.

Resistant organism proliferation also is encouraged by the use of antimicrobial-impregnated products, such as soaps, cutting boards, high chairs, and toys. Microorganisms invariably lurk in out-of-the-way areas like these, where the concentration of antibiotics is not high enough to kill them. These survivors pass along their resistance to other generations through a number of sophisticated methods. In fact, evidence now exists that cross-species communication of resistance is occurring.(32)

VETERINARY MEDICINE AND AGRICULTURE

Veterinary and agricultural use of antibiotics is fueling the problem. Veterinary and agricultural antibiotics--many of which were not used in humans when they initially were introduced--now form the core structure of some of medicine's newest antibiotics. Domestic animals and cattle receive 16 million lbs of medications per year--the equivalent of 7.6 billion patient doses.(33) Many of these medications have been used as alternative growth promoters. Antibiotics harbored in animals' intestinal tracts have appeared in meat and eggs and are excreted into the soil. Eventually strains of resistant bacteria are drawn into water tables and foods that are fanned and harvested.

In agriculture, antibiotics are used to treat fruit trees and beehives. This industry alone consumes 50,000 lbs (ie, 22 million patient doses) of antibiotics per day.(34) Despite recommendations, the United States has not discontinued its use of subtherapeutic doses of antibiotics in agricultural or veterinary settings. In Europe, however, legislation restricting the use of antibiotics for animal growth promotion was passed in the late 1970s in response to the spread of a multimedication-resistant organism from animals to people.(35)

Like a resistant strain of bacteria, debates regarding veterinary and agricultural use of antibiotics will not go away. Although many experts fear that routine use of antibiotics in food and animals threatens human health by encouraging resistant bacteria, some caution against underestimating the importance of antibiotics used in the agricultural setting to treat disease and promote growth.

Further issues continue to be documented. The emergence of antibiotic-resistant strains of food-borne bacteria, including salmonella, Campylobacter, and Escherichia coli--all of which cause intestinal infections in humans--have been reported (Figure 3).(36) A new study has reported that children with E. coli 0157:H7 who are treated with antibiotics are at increased risk for developing hemolytic uremic syndrome.(37) The study confirms that children treated with sulfa-containing antibiotics and beta-lactam antibiotics have a similar degree of risk. Researchers recommend against prescribing antibiotics to children who may be infected with E. coli 0157:H7 until a stool culture indicates the responsible pathogen that can be appropriately treated by an antibiotic.

[Figure 3 ILLUSTRATION OMITTED]

The first study to directly connect antibiotic resistance in humans with food has been documented.(38) In addition, one study reported an eightfold increase in a medication-resistant food-poisoning bacteria after the antibiotic--quinolone--was approved to be used in chickens.(39)

Perhaps the most sobering component of this issue surrounds the new antibiotic, quinupristin/dalfopristin (ie, Synercid), which has just been approved by the FDA to treat patients who are infected with bacteria that are resistant to other antibiotics.(40) Quinupristin/dalfopristin is a unique injectable antibiotic composed of two molecules, which some believe hinder bacteria's ability to develop resistance. It is the first in a class of medications called streptogramins and the first streptogramin to be used in humans.(41) Quinupristin/dalfopristin has been approved to treat acutely ill patients who have resistant cases of E. faecium, as well as complex infections caused by Staphylococcus and Streptococcus bacteria.

Some health officials are concerned about veterinary medicine's use of the antibiotic virginiamycin because of its chemical similarity to quinupristin/dalfopristin. Since 1974, virginiamycin has been used in animals. The CDC has raised concerns that the bacteria that have developed a resistance to virginiamycin will transfer that resistance to other bacteria and produce a resistance to quinupristin/dalfopristin, which will affect the human population. In fact, evidence exists that cross-resistance has occurred and that a precious antibiotic for human use may be lost.(42)

In its concern, the FDA has proposed new rules for animal health products, which set finn predetermined guidelines for the use of veterinary antibiotics, including when their use should be restricted or withdrawn.(43) Public health experts praise the proposed rules, as medication use in agricultural animals has advanced the problem of antibiotics losing their power to fight human infections.(44) Critics argue that the government is overreacting, attributing the problem of antibiotic resistance not to the agricultural use of medications, but to inappropriate physician prescribing practices.

Today's consumers keep abreast of these issues in published stories and autobiographies, most frequently related to E coli, that appear almost daily in mainstream publications.(45) Consumers also track these issues on the Internet, where they have access to cutting-edge medical information.

PERIOPERATIVE INTERVENTIONS

Basic infection control is the most important weapon against the spread of antibiotic resistance in the health care environment. Perioperative nurses can take a number of steps to combat antibiotic-resistant bacteria by preventing SSIs before, during, and after surgical procedures. In addition, there are a number of patient and procedure characteristics that may influence the risk of SSI development (Table 1). The following outlines some recommendations contained in the CDC "Guideline for prevention of surgical site infections, 1999."(46)

Table 1

CHARACTERISTICS THAT MAY INFLUENCE SURGICAL SITE INFECTION DEVELOPMENT(1)

Patient

Age Nutritional status Diabetes Smoking Obesity Coexistent infections at a remote body site Colonization with microorganisms Altered immune response Length of preoperative stay

Procedure

Duration of surgical scrub Skin antisepsis Preoperative shaving Duration of procedure Antimicrobial prophylaxis Ventilation in OR Inadequate sterilization of instruments Foreign material in the surgical site Surgical drains Surgical technique

* Poor hemostasis

* Failure to obliterate dead space

* Tissue trauma

NOTE

(1.) Centers for Disease Control and Prevention, "Guideline for the prevention of surgical site infections, 1999." Available from http://www.cdc.gov/ncidod/ hip/SSI/SSI_guideline.htm. Accessed 18 May 2000.

Preoperative. Preoperative antiseptic showers decrease skin microbial colony counts; however, they have not been shown to reduce SSI rates definitively. Shaving immediately before a procedure, compared to shaving within 24 hours preoperatively, is associated with decreased SSI rates (ie, 3.1% versus 7.1%). If shaving is performed more than 24 hours before a procedure, SSI rates exceed 20%. Clipping hair immediately before a procedure is associated with a lower risk of SSI than shaving or clipping the night before surgery. Some studies show that preoperative hair removal by any means is associated with increased SSI rates and suggest that no hair be removed before a procedure.(47)

The optimum antiseptic for scrubbing must have a broad spectrum of activity, be fast acting, and have a persistent effect. Alcohol remains the most effective and rapid-acting skin antiseptic and the standard in several European countries. Its greatest disadvantage is its flammability. No agent is ideal for every situation. A major factor, aside from a product's efficacy, is its acceptability by OR staff members after repeated use.

Most studies that evaluate surgical scrub antiseptics have focused on measuring hand bacterial colony counts and the impact of the choice of scrub agents on SSI.(48) Recent studies suggest that scrubbing for two minutes is as effective as scrubbing for 10 minutes in reducing hand bacterial colony counts.(49) The optimum duration of scrub time is not known. Hand carriage of gram-negative organisms has been known to be greater among health care workers who wear artificial nails than among non-wearers. Although the relationship of SSI and the length of nails is not known, artificial or natural long nails may be associated with tears in surgical gloves.(50)

Surgical personnel who have active infections or who are colonized with certain microorganisms have been linked to outbreaks or clusters of SSI. Health care organizations should implement strategies to prevent transfer of infection from staff members to patients, including management of job-related illnesses, provision of postexposure prophylaxis, and when necessary, exclusion of ill staff members from work duties or patient contact.

Surgical antibiotic prophylaxis refers to a brief course of an antimicrobial agent initiated just before a procedure begins. It is not an attempt to sterilize tissues but a critically timed adjunct to reduce the microbial burden of intraoperative contamination to a level at which it cannot overwhelm host defenses. It does not pertain to the prevention of postoperative contamination. Four principles must be followed to maximize the benefits of antimicrobial prophylaxis (AMP).

* The AMP agent must be used for all procedures for which its use has been shown to reduce SSI rates based on evidence from clinical trials or for which incisional or organ SSI would present a catastrophe.

* The AMP agent must be safe, inexpensive, and bactericidal with an in vitro spectrum that covers the most probable intraoperative contaminants for the procedure.

* Infusion of the initial dose of the AMP agent must be timed so that a bacterial concentration of the medication is established in the serum and tissues by the time the skin is incised.

* Therapeutic levels of the AMP agent must be maintained in both serum and tissues throughout the procedure and until at least two hours after the incision is closed in the OR.

The CDC recommendations also advise against routine use of vancomycin for antimicrobial prophylaxis.

Intraoperative. Air in the OR may contain microbial-laden dust, lint, skin squamae, or respiratory droplets. The microbial level in OR air is directly proportional to the number of people in the room; therefore, efforts should be made to minimize personnel traffic during surgical procedures.

Operating rooms should be maintained at positive pressure with respect to corridors and adjacent areas. Conventional OR ventilation systems must produce a minimum of approximately 15 exchanges of filtered air per hour, three of which (ie, 20%) must involve fresh air. Ultraclean air (eg, laminar airflow) is an additional measure to reduce SSI risk for certain procedures. Most studies on the efficacy of ultraclean air involve only orthopedic procedures.(51) One study compared the effects of ultraclean alone, AMP alone, and ultraclean air in conjunction with AMP on the rate of deep SSI.(52) Findings suggest that both ultraclean air and AMP can reduce the incidence of SSI after orthopedic implant procedures; however, AMP is more beneficial than ultraclean air at reducing incidences of SSI. Environmental surfaces (eg, tables, walls, floors, ceilings, lights) in ORs are rarely implicated as sources of pathogens related to the development of SSI.

Rigorous adherence to the principles of asepsis by all scrub personnel is the foundation of SSI prevention. All those who work in close proximity to the sterile surgical field, including anesthesia care providers, must abide by these principles. Lack of adherence to the principles of asepsis during procedures (eg, placement of intravascular devices and endotracheal tubes, administration of IV medications, use of common syringes, assembly of equipment and solutions in advance of procedures) have been associated with outbreaks of postoperative infections including SSIs.

Excellent surgical technique (eg, minimizing tissue trauma, effective hemostasis) is widely believed to reduce the risk of SSI. Any retained foreign body (eg, suture materials, prosthetic devices, drains) may promote inflammation at the surgical site and increase the probability of SSI despite otherwise benign levels of tissue contamination.

Postoperative. Postoperative care is determined by whether the incision is closed primarily, left open to be closed later, or left open to heal by second intention. When a surgical site is closed primarily, the incision usually is covered with a sterile dressing for 24 to 48 hours. Beyond 48 hours, it is unclear whether an incision must be covered or whether bathing is detrimental to healing. The American College of Surgeons, the CDC, and others have recommended using sterile gloves and equipment (ie, sterile technique) when changing dressings on any type of surgical incision.(53)

LEGAL ISSUES

Infectious disease is a global issue. Control at the national level is encumbered, and the United States' response to infectious diseases is governed by jurisdictional boundaries. Worldwide microbial resistance issues, however, are creating the need for an international legal role. Despite the fact that surveillance and reporting of resistance are critical, efforts are underfunded at local, state, and national levels. Moreover, legal duty does not necessarily result in compliance.

Surveillance and reporting have to be balanced with patient privacy issues. Different legal systems handle such issues in vastly different ways. Although patient confidentiality is a significant issue in the United States, Europe strictly forbids the processing of health information without patients' written permission. In addition, European law permits states to withhold personal data from those who cannot comply with the protection of this data. This difference between the United States and European reporting is an example of how complicated the international approach to microbial resistance issues will be.

Another frightening component of infectious disease is biological warfare. Considerable concern exists about the potential use of resistant microorganisms in warfare because resistance inhibits defenses against a biological attack. The US Department of Defense monitors suspicious outbreaks of resistant infectious disease because of its concern about biological weapons.(54)

Many other legal issues are at stake, including the

* ability to detain or isolate infected people,

* judicious use of antimicrobial agents,

* widescale funding of research and development of new antimicrobial agents,

* pharmaceutical company concerns of loss of intellectual property rights,

* regulatory approval procedures, and

* antitrust law limitation on collaborative research and development.

Achieving the public health objectives of antimicrobial resistance involves legal considerations and decisions. National and international laws are imperative to the public health mission in every country.(55)

CONCLUSION

Correct identification of infectious strains is critical. Reporting of MRSA, VRE, and vancomycin intermittent-resistant S. aureus to the CDC is essential. Scientists need to implement the latest CDC recommendations for detecting staphylococci with reduced vancomycin susceptibility. The CDC defines its role as frontline observers waiting to sound the alarm.(56)

Although a large complement of federal agencies (eg, the US Department of Defense, Heath Care Financing Administration) are becoming involved in the effort to fight antibiotic resistance, a newly formed antibiotic resistance task force has been headed by three key agencies: the CDC, the National Institutes of Health, and the FDA. Their impact likely will reach well beyond the warnings and guidelines that have been issued in recent years.(57)

Another recent trend that must be addressed is the growing use of antibacterials in individual homes. This includes products (eg, soaps, kitchenware) that have been impregnated with antibacterials. Some researchers believe there is no evidence that these products prevent infection. Moreover, these products may alter the natural bacteria population by killing susceptible bacteria and encouraging the growth of resistant strains. Resistant strains are abundant in hospitals where these antibacterials are truly necessary.(58)

Basic infection control is the most important weapon in the health care environment. Proper hand washing, glove selection, gloving and ungloving, infection isolation, and aseptic and sterile technique must be consistent. Universal training of all health care workers in basic infection control techniques and the issues of resistance is essential to controlling resistance. Until newer, improved antimicrobials are available, infection control and surveillance will remain the crucial defenses.(59) To preserve antibiotics for future generations, health care workers must ensure their effectiveness against medication-resistant microorganisms and limit the emergence of additional multimedication-resistant pathogens.

NOTES

(1.) J C Pechere, "Prevention: Toward a golden age," Infection Control and Hospital Epidemiology 19 (August 1998) 537-538.

(2.) Centers for Disease Control and Prevention, Hospital Infectious Program. "Antimicrobial resistance: A growing threat to public health." Available from http://www.cdc.gov/ncidod/hip/Aresist/am_res.htm. Accessed 22 May 2000.

(3.) M D Uehling, "Superbugs," Popular Science (May 1999) 64-68.

(4.) Centers for Disease Control and Prevention, Hospital Infectious Program. "Mission statement and the National Nosocomial Infections Surveillance System." Available from www.cdc.gov/ncidod.hip/@HIP.htm. Accessed 31 May 2000.

(5.) J Hodnett, "Nosocomial infection: The changing bugs and drags," ADVANCE for Medical Laboratory Professionals (Sept 14, 1998) 30-31.

(6.) Ibid.

(7.) Hodnett, "Nosocomial infections: The changing bugs and drugs," 30-31.

(8.) Centers for Disease Control and Prevention, Hospital Infectious Program. "Antimicrobial resistance: A growing threat to public health."

(9.) Ibid.

(10.) R Gaynes, "Surveillance of antibiotic resistance: Learning to live with bias," Infection Control and Hospital Epidemiology 16 (November 1995) 623-626; S D Holmberg, S L Solomon, P A Blake, "Health and economic impact of antimicrobial resistance," Review of Infectious Disease 9 (November/December 1987) 1065-1078.

(11.) Centers for Disease Control and Prevention, "Antimicrobial Resistance, 1999 NNIS ICU Report." Available from www.cdc.gov/ncidod/hip/NNIS/ar_surv99.pdf. Accessed 20 May 2000.

(12.) A D Hecht, "Creating greater efficiency in ambulatory surgery," Journal of Clinical Anesthesia 7 (November 1995) 581-584.

(13.) Centers for Disease Control and Prevention, "Guideline for the prevention of surgical site infections, 1999." Available from http://www.cdc.gov/ncidod/hip/SSI/SSI_guideline.htm. Accessed 18 May 2000.

(14.) "Nosocomial surgical infections extend LOS," Wound Care (December 1998) 141-142.

(15.) S B Levy, The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle (New York: Plenum Press, 1992).

(16.) W R Jarvis et al, "Nosocomial infection rates in adult and pediatric intensive care units in the United States. National Nosocomial Infections Surveillance System," American Journal of Medicine 91 no 3B suppl (September 1991) 185-191.

(17.) S K Fridkin, R P Gaynes, "Antimicrobial resistance in intensive care units," Clinics in Chest Medicine 20 (June 1999) 303-316.

(18.) Centers for Disease Control and Prevention, "Antibiotic-resistant bugs on rise in ICUs," Patient Focus Care Satisfaction 7 (May 1999) 54-55.

(19.) D R Schaberg, D Cluver, R P Gaynes, "Major trends in microbial etiology of nosocomial infection," American Journal of Medicine 91 no 3B suppl (September 1991) 72-75.

(20.) Centers for Disease Control and Prevention, "Guideline for the prevention of surgical site infections, 1999."

(21.) Hodnett, "Nosocomial infection: The changing bugs and drugs," 30-31.

(22.) J W Brown, A Grilli, "An emerging superbug. Staphylococcus aureus becomes less susceptible to vancomycin," MLO 30 (January 1998) 26-35.

(23.) T L Smith et al, "Emergence of vancomycin resistance in Staphylococcus aureus," New England Journal of Medicine 340 (Feb 18, 1999).

(24.) J M Davis, "A wake-up call: VR/MRSA arrives in the US," Contemporary Surgery 54 (June 1999) 332.

(25.) Hecht, "Creating greater efficiency in ambulatory surgery," 581-584.

(26.) Ibid.

(27.) C Laino, "Novel antibiotic combats superbugs." Available from www.msnbc.com/news/316438.asp. Accessed 31 May 2000.

(28.) "Zyvox is the first in a new class of antibiotics." Available from http://pharminfo.com/pubs/druginfo line/druginfo1_14.html. Accessed 31 May 2000.

(29.) D A Goldman et al, "Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals," JAMA 275 (Jan 17, 1996) 234-240.

(30.) Division of Health Sciences Policy, Institute of Medicine, Antimicrobial Resistance: Issues and Options, ed F Harrison, J Lederberg (Washington, DC: National Academy Press, 1998); Centers for Disease Control and Prevention, "Antibiotic resistance: A new threat to you and your family's health." Available from http://www.cdc.gov/ncidod/_vti_bin/shtml.dll/dbmd/ antibioticresistance/faqs.htm. Accessed 26 May 2000.

(31.) Survey Shows Half of Americans Never Complete Antibiotic Therapy (press release, New York: Presence-Euro, Oct 12, 1995).

(32.) Levy, The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle.

(33.) S B Levy, G B Fitzgerald, A B Macone, "Changes in intestinal flora of farm personnel after introduction of tetracycline-supplemented feed on a farm," New England Journal of Medicine 295 (September 1976) 583-588.

(34.) Ibid.

(35.) S B Levy, "Multidrug resistance--a sign of the times," New England Journal of Medicine 338 (May 7, 19981.

(36.) S H Cody et al, "Two outbreaks of multidrug-resistant salmonella serotype typhimurium DTI04 infections linked to raw-milk cheese in northern California," JAMA 281 (May 19, 1999) 1805-1810; R G Villar et al, "Investigation of multidrug-resistant salmonella serotype typhimurium DT104 infections linked to raw-milk cheese in Washington state," JAMA 281 (May 19, 1999) 1811-1816.

(37.) C S Wong et al, "The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli 0157:H7 infections," New England Journal of Medicine. Available from http://www.nejm.org/content/wong/1 .asp Accessed 31 May 2000.

(38.) D Thompson, "Drugged chicks hatch a menace," Time (May 31, 1999) 81.

(39.) Ibid.

(40.) "Antibiotic gets FDA approval: New class of medication to target bacteria resistant to other drugs," Healthcare Purchasing News 23 (November 1999) 3-4.

(41.) "Risk assessment of the public health impact of streptogramin resistance in Enterococcus faecium attributable to the use of streptogramins in animals; request for comments and for scientific data and information," Federal Register 65 (April 19, 2000) 20992.

(42.) "Livestock drug could ruin human antibiotic," USA Today, 15 June 1999, sec 6D.

(43.) A Manning, "Like a resistant strain, the debate won't go away," USA Today, 15 June 1999, sec 6D.

(44.) J Bernick, "Resisting resistance," Dairy Today (March 1999) 16.

(45.) R Davis, "Corralling the causes of a growing disease risk. Medicine," USA Today, 15 June 1999, sec 6D; V O Smith, "The new E. coli nightmare," Good Housekeeping (April 1998) 66-67; P Ola, E D'Aulaire, "Haylee's ordeal," Readers Digest (July 1999) 95-101.

(46.) Centers for Disease Control and Prevention, "Guideline for the prevention of surgical site infections, 1999."

(47.) Ibid.

(48.) Ibid.

(49.) Ibid.

(50.) Holmberg, Solomon, Blake, "Health and economic impact of antimicrobial resistance," 1065-1078.

(51.) Centers for Disease Control and Prevention, "Guideline for the prevention of surgical site infections, 1999."

(52.) Ibid.

(53.) Holmberg, Solomon, Blake, "Health and economic impact of antimicrobial resistance," 1065-1078.

(54.) R P Kadlec, A P Zelicoff, A M Vrtis, "Biological weapons control: Prospects and implications for the future," JAMA 278 (August 1997) 351-356.

(55.) D P Fidler. "Legal issues associated with antimicrobial drug resistance," Emerging Infectious Diseases 4 (April-June 1998) 169-77.

(56.) Centers for Disease Control and Prevention, "Interim guidelines for prevention and control of Staphylococcal infection associated with reduced susceptibility to vancomycin," Morbidity and Mortality Weekly Report 46 (July 11, 1997) 626-635.

(57.) "Feds may put regulatory `teeth' into national antibiotic resistance plan," Hospital Infection Control 26 (September 1999) 113-124.

(58.) M Vos Savant, "Ask Marilyn," The Seattle Times, Parade, 25 April 1999.

(59.) "Nosocomial surgical infections extend LOS," 141-142.

Examination

ANTIBIOTIC RESISTANCE--AN ALARMING HEALTH CARE ISSUE

1. A current alarming medical threat to our population is bacterial infections

a. resulting from hepatitis C. b. that are responsible for hearing impairments. c. that are resistant to antibiotics. d. that cause infectious diseases.

2. Antimicrobial resistance has resulted because of an increase in

a. HIV. b. nosocomial gram-positive infections. c. viral isolates. d. people carrying bacteria.

3. Which categories of resistant organisms are causing the greatest concern?

a. Bacteria. b. Fungi. c. Viruses. d. Parasites.

4. Prevalence of bacterial resistance to antibiotics in both the health care and community settings is resulting in

a. increased transmission to children and adolescents. b. increased illnesses in the older adult population. c. rapid transmission throughout the population. d. increased costs for the health care system.

5. What is the one complicating factor in caring for patients with nosocomial infections?

a. More debilitating diseases. b. Adverse long-term sequelae. c. Multimedication-resistant organisms. d. Fungal infections.

6. Sixty percent of the patient deaths attributed to nonfatal infections are caused by

a. fungi. b. viruses. c. toxicity. d. bacteria.

7. What are the three most common nosocomial isolates? a. Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus faecium. b. Coagulase-negative staphylococci, Staphylococcus aureus, enterococci. c. Enterobacter, Candida, coagulase-negative staphylococci. d. Staphylococcus aureus, Staphylococcus pneumoniae, Haemophilus influenza.

8. What could be done to prevent medication-resistant infections in surgical patients?

a. Treat patients in outpatient centers. b. Recognize differences in inpatient and outpatients treatment. c. Decrease lengths of stay in the intensive care unit. d. Provide surgical care consistently.

9. What is one of the factors that is responsible for emergence of bacterial resistance?

a. 75% of procedures being performed in ambulatory, same day, or outpatient ORs. b. Poor ventilation systems commonly found in health care settings. c. Discovery of new significant pathogens. d. Increased frequency of vancomycin use.

10. When does microbial resistance become a problem?

a. When patients are transferred to the intensive care unit. b. When bacteria reaches high density in a susceptible host. c. When new therapeutic options are available. d. When the pathogen in question is Neisseria gonorrhoeae.

11. Antibiotic resistance was discovered as early as the a. 1920s. b. 1930s. c. 1940s. d. 1950s.

12. When methicillin-resistant Staphylococcus aureus became increasingly resistant to antimicrobial agents, it resulted in the increased use of

a. penicillin. b. vancomycin. c. ampicillin. d. aminoglycocides.

13. The Hospital Infection Control Practices Advisory Committee identified which situation in which vancomycin use should be discouraged?

a. Food poisoning. b. Viral infections. c. Bacterial infections. d. Surgical prophylaxis.

14. What can patients do to manage problems associated with antibiotic resistance?

a. Encourage physicians to prescribe antibiotics. b. Ensure that family members are taking antibiotics simultaneously. c. Visit Internet sites to find information about the correct antibiotics for a problem. d. Use medications as prescribed.

15. What is causing patients to experience subtherapeutic dosages and develop resistance to antibiotics?

a. Taking medications as prescribed. b. Increases in viral infections. c. Eating products of animals that are given growth promoters. d. Stockpiling medications.

16. What is one problem associated with the use of the antibiotic virginiamycin in animals?

a. Long-term use in animals could result in transfer of bacterial resistance. b. Confusion between appropriate uses of quinupristin/dalfopristin and virginiamycin. c. Expense of the medications when used in humans. d. Viral overload caused by subtherapeutic dosages.

17. What is the best method and time for hair removal that will lower the risk of surgical site infections, as recommended by the US Centers for Disease Control and Prevention?

a. Shaving during an antiseptic shower within 24 hours of a procedure. b. Preoperative shaving with a razor within 24 hours of a procedure. c. Preoperative hair clipping more than 24 hours before a procedure. d. Clipping hair immediately before a procedure.

18. What is the recommended optimum duration of a surgical hand scrub that is most effective in reducing surgical site infections?

a. This is unknown. b. Two minutes. c. Five minutes. d. 10 minutes.

19. According to this article--in addition to broad spectrum activity, fast acting and persistent effects--one major consideration by OR staff members for using a specific surgical scrub is

a. reduced potential flammability. b. reduction of hand bacterial colony counts. c. acceptability after repeated use. d. optimum duration of surgical scrub.

20. It has been documented that gram-negative organisms are greater in

a. scrub personnel who single glove. b. health care workers who wear artificial fingernails. c. health care workers who scrub for five minutes. d. people taking antibiotics.

21. Surgical antibiotic prophylaxis refers to

a. antibiotic administration beginning 24 hours before a procedure. b. antibiotic administration before the incision is made until 24 hours postoperatively. c. a brief course of antibiotics initiated immediately before a procedure begins. d. 48 hours of antibiotic administration.

22. What is the purpose of performing surgical antibiotic prophylaxis?

a. To sterilize the patient's tissues. b. To reduce microbial burden. c. To prevent postoperative contamination. d. To provide broad spectrum therapy.

23. What principle must be followed to maximize benefits of antimicrobial prophylaxis?

a. Use of antimicrobial prophylaxis for all procedures. b. Use of vancomycin as the agent of choice. c. Timing of the infusion is critical. d. Antimicrobial prophylaxis is administered at the surgeon's discretion.

24. Minimizing personnel traffic and maintaining positive pressure airflow in the OR is important for what reason?

a. It results in a minimum of 15 air exchanges per hour. b. It provides ultraclean air. c. It maintains patient privacy. d. It decreases the microbial level in the OR.

25. What has been associated with outbreaks of postoperative infections, including surgical site infections?

a. Placing intravascular devices. b. Administering IV medications. c. Pathogen sources on floors and ceilings. d. Lack of rigorous adherence to principles of asepsis.

26. The probability of surgical site infections can be reduced for every procedure by following which key principle?

a. Administering antimicrobial prophylaxis. b. Minimizing tissue trauma. c. Placing closed wound drains. d. Prepping the skin with alcohol.

27. Mr J has undergone a traditional inguinal hernia repair; he might expect his dressing to remain in place

a. less than 12 hours. b. 12 to 24 hours. c. 24 to 48 hours. d. no specified amount of time.

28. Legal issues surrounding infectious diseases include

a. educating enough public health nurses. b. jurisdictional boundaries and funding. c. patient confidentiality. d. restricted antibiotics for growth promotion.

29. Which of the following has contributed to opportunities for the emergence of resistant microbes?

a. Ambulatory care procedures. b. Overcrowding and population mobility. c. New types of sterilization methods. d. Multiple procedures during one surgical case.

30. Soaps, cutting boards, toys, and other antimicrobial-impregnated products used in the home are known to

a. pass resistance to other generations of microbes. b. prevent transfer of infection. c. decrease the concentration of bacteria that accumulates. d. serve as a first line of defense in preventing proliferation of organisms.

AORN, Association of periOperative Registered Nurses, is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. AORN recognizes this octivity as continuing education for registered nurses. This recognition does not imply that AORN or the ANCC's Commission on Accreditation approves or endorses any product included in the activity. AORN maintains the following provider numbers: Alabama ABNPO075, California CPE13019, Florida FBN 2296, Kansas LTO 114-0316. Check with your state board of nursing for acceptability of education activity for relicensure.

Professional nurses ore invited to submit manuscripts for the Home Study Program. Manuscripts or queries should be sent to Editor, AORN Journal, 2170 S Porker Rd, Suite 300, Denver, CO 80231-5711. As with all manuscripts sent to the Journal, papers submitted for Home Study Programs should not hove been previously published or submitted simultaneously to any other publication.

Answer Sheet

ANBIOTIC RESISTANCE--AN ALARMING HEALTH CARE ISSUE

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail to:

AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711

Or fax with credit card information to (303) 750-3212

A score of 70% correct is required for credit.

Event #01020 Session #6037 Contact hours: 1.5 Fee: Members $7.50; Nonmembers $15

Program offered July 2000 The deadline for this program is Aug 31, 2001.

1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. Record the time required to complete the program

4. Enclose fee if information is mailed.

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Learner Evaluation

ANTIBIOTIC RESISTANCE--AN ALARMING HEALTH CARE ISSUE

The following evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate the following items on a scale of 1 to 5.

OBJECTIVES

To what extent were the following objectives of this Home Study Program achieved?

(1) Discuss factors that result in antibiotic resistance. (2) Identify variables that interfere with therapeutic options for use of antibiotics. (3) Describe measures during perioperative patient care for prevention of surgical site infections. (4) Discuss future implications of antibiotic use.

PURPOSE/GOAL

To increase the perioperative nurse's knowledge of antibiotic resistance.

CONTENT

(5) Did this article increase your knowledge of the subject matter? (6) Was the content clear and organized? (7) Did this article facilitate learning? (8) Were your individual objectives met? (9) How well did the objectives relate to the overall purpose/goal?

TEST QUESTIONS/ANSWERS

(10) Were they reflective of the content? (11) Were they easy to understand? (12) Did they address important points?

What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s):

Author names and addresses:

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Carolyn Twomey, RN, BSN, is a clinical nurse consultant for Regent Medical, Norcross, Ga.

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