AMR PREVENTION AND CONTROL

Despite a lack of solid evidence base, infection control is vital when it comes to antibiotic resistance, writes Dr Elaine Cloutman-Green.

The impact of antimicrobial resistant (AMR) microorganisms has been felt in the healthcare setting for over 20 years.

Historically, the focus of infection prevention and control (IPC) teams has been on reducing the spread of AMR microorganisms from patients that are colonised to other patients.

Most interventions were based on the prevention of person-to-person spread and have included direct interventions,
such as hand hygiene. However, both the number of AMR species and the impact on antibiotic choices has led to a change in the way that infection control is undertaken. Focusing purely on prevention of person-to-person spread is no longer sufficient.

AMR is something that is diffi cult to define, but the most frequent definition is that of the Centers for Disease Control
and Prevention (CDC) for multidrug resistant gram-negative bacteria of “nonsusceptible to at least one agent in three
or more antimicrobial categories” (1).

The scale of AMR The CDC estimates that over two million people a year acquire AMR bacteria. These can either colonise a patient or can be responsible for causing infection. It is thought that in Europe 25,000 people die a year from infections caused by AMR bacteria, with a further 23,000 dying in the US, where the economic impact of patient colonisation and death is significant, with $9.8bn a year attributed to the five most common infections (2).

The rise in AMR bacteria is particularly problematic, as there have been no new classes of antibiotics discovered since
1987, leading to an ever-decreasing list of available antibiotics to treat severe infections caused by resistant bacteria.

This, combined with an aging population, increasingly complex patients, medical tourism and increased travel, means
that we have an increasingly large group of vulnerable patients who are being exposed to a spectrum of AMR bacteria. In 2015, the European Centre for Disease Prevention and Control asked experts from 38 European countries to return data on carbapenemase producing Enterobacteriaceae (CPE).

UK data showed that across resistance mechanisms, there were outbreaks occurring in the UK from sporadic to inter-regional spread (3).

More concerning than the distribution of CPE was that only 11 of the 38 countries surveyed had implemented a national plan for containment/preparedness to contain CPE by 2015, with a further nine countries having plans to implement a containment strategy (4).

The risk associated with AMR bacteria has therefore resulted in it being placed upon the Cabinet Office’s national risk register, putting drug resistance on a par with pandemic flu and terrorism as a significant civilian threat.

The Chief Medical Officer addressed the threat of AMR bacteria in her annual report in 2011, which led to the production of the UK Five Year Antimicrobial Resistance Strategy 2013–2018.

The role of infection control

Currently, control of antimicrobial resistance within the healthcare environment relies on two key strategies:

■ Patients colonised with AMR bacterial flora require interventions to prevent that flora changing site, where it could result in an infection.

■ Patients who do not have any AMR bacterial flora require interventions to prevent them acquiring resistant flora during their stay in healthcare, due to selection or exogenous acquisition.

These are based on two assumptions:

■ Most AMR bacteria positive patients are asymptomatic carriers with high risk of spreading before identification.

■ Standard or contact precautions do not reliably halt AMR bacterial transmission in all circumstances (5).

IPC guidelines on the control of CPE were published by Public Health England in 2014 (6). These include: hand hygiene,
contact precautions, single room isolation, cleaning and disinfection, antimicrobial stewardship, active surveillance and
note flagging. Additionally, in outbreak situations, the guidance advocates cohorting of patients and staff.

Interestingly, the English guidance has areas in opposition to guidelines from Ireland, Scotland and Europe as a whole,
including the recommendation against decolonising patients and healthcare worker screening during outbreak situations (7).

This demonstrates how difficult it is to gain a consensus.

AMR in a hospital setting

Even within a single hospital it can be difficult to comply with the PHE guidelines. Control of AMR bacteria means decisions that can directly impact both individual patients and staff in order to protect the wider patient population. Strategies such as isolation have been demonstrated to directly impact the mental wellbeing of patients and lead to delays in patients reaching key developmental milestones (7).

Isolation has also been shown to result in a decrease in the quality of clinical care by increasing risk of drug errors and decreasing time spent with healthcare workers. (8)

Therefore, managing the provision of high-quality care, while balancing the needs of the patient population, is an incredibly challenging task. Hand hygiene, the intervention for which most evidence base exists, can have a significant impact on staff.

Studies have shown that on average an intensive care nurse should be washing their hands 60 times per shift, for two minutes each time. This means that during a 12-hour shift, a nurse should spend two hours washing their hands (9).

The skin damage associated with this level of hand hygiene is why it is difficult to ensure compliance among workers. However, despite the lack of evidence base and the cost to both patients and staff, the need to control AMR bacteria in
health care is essential.

The implications for the population as a whole, mean that the needs of the many really do outweigh the needs of the individual.

Dr Elaine Cloutman-Green is an Infection Prevention and Control Practitioner at Great Ormond Street Hospital.

REFERENCES

1. Otter JA, Mutters NT, Tacconelli E, Gikas A, Holmes AH. Controversies in guidelines for the control of multidrug-resistant Gram-negative bacteria in EU countries. Clinical Microbiology and Infection. 2015;21(12):1057-66

2. Simões AS, Couto I, Toscano C, Gonçalves E, Póvoa P, Viveiros M, et al. Prevention and Control of Antimicrobial Resistant Healthcare-Associated Infections: The Microbiology Laboratory Rocks! Frontiers in Microbiology. 2016;7

3. Lee Howell. Global Risks 2013. World Economic Forum. Eighth Edition. 2013

4. Albiger B, Glasner C, Struelens MJ, Grundmann H, Monnet DL. Carbapenemase-producing Enterobacteriaceae in Europe: assessment by national experts from 38 countries, May 2015. Eurosurveillance. 2015;20(45)

5. Birgand G, Leroy C, Nerome S, Luong Nguyen LB, Lolom I, Armand-Lefevre L, et al. Costs associated with implementation of a strict policy for controlling spread of highly resistant microorganisms in France. BMJ Open. 2016;6(1)

6. England PH. Carbapenemase-producing Enterobacteriaceae: early detection, management and control toolkit for acute trusts. London: Public Health England; 2014

7. Tarzi S, Kennedy P, Stone S, Evans M. Methicillin-resistant Staphylococcus aureus: psychological impact of hospitalization and isolation in an older adult population. The Journal of hospital infection. 2001;49(4):250-4

8. Palmore TN, Henderson DK. Managing Transmission of Carbapenem-Resistant Enterobacteriaceae in Healthcare Settings: A View From the Trenches. Clinical Infectious Diseases. 2013;57(11):1593-9

9. Kleypas Y, McCubbin D, Curnow ES. The Role of Environmental Cleaning in Health Care-Associated Infections. Critical Care Nursing Quarterly. 2011;34(1):11-7