Surgeons who prescribe to the C.Y.A. method of patient care are at least partially responsible for the spread of antimicrobial-resistant strains of bacteria, says Phenelle Segal, RN, CIC, president of Infection Control Consulting Services in Delray Beach, Fla. She's had surgeons tell her, "I'd much rather give patients extra doses of post-op antibiotics than have them get a surgical site infection." In fact, that's what Ms. Segal's surgeon admitted to her when complications from an unnecessary post-op dose of cefazolin contributed to the Clostridium difficile infection she suffered in 2013. Ms. Segal survived the potentially fatal bug, but your patients might not be so lucky.
Efforts to prevent the spread of "superbugs" the widely used catchphrase for antibiotic-resistant bacteria begin in your facility with a rather simple premise: Create standardized infection control policies based on national guidelines and best practices, develop a consistent approach to implementing them and stick with it.
"The more infections we prevent, the less likely we are to see infections related to antimicrobial-resistant bacteria," says Richard Martinello, MD, medical director of infection prevention at Yale New Haven (Conn.) Hospital, which completely revamped its infection prevention protocols to reduce the risk of SSIs and, by extension, superbugs. The multifaceted effort involved a host of surgical professionals, and the same team-based approach is required at your facility to address these pillars of good infection control practice.
1. Tackle low-hanging fruit. The first step of Yale New Haven's program involved the basics: ensuring patients were properly warmed, pre-op skin preps were standardized (staff created an in-house video that shows the correct way to apply various preps), surgical attire was worn properly, foot traffic in ORs was minimized and staff practiced proper hand hygiene.
Have written policies and procedures in place for preventing the transmission and acquisition of multidrug-resistant organisms in patients and staff, suggests Ms. Segal. Those efforts should begin at the time of the pre-op phone call, when the right screening questions can indicate which patients might be carriers of dangerous infections. Ask patients if they have a current antibiotic-resistant infection or have a history of such infections. Have they had a recent infection of any kind? Have they ever been treated for Methicillin-resistant Staphylococcus aureus (MRSA is the culprit for most SSIs, notes Ms. Segal)?
2. Practice antibiotic stewardship. Ensure the appropriate antibiotic is administered at the appropriate time to the appropriate patient and don't prolong the use of post-op antibiotics, says Linda Fan, MD, a female pelvic medicine specialist and director of Yale Medicine Gynecology at Yale New Haven Hospital. For example, Dr. Fan looked at the evidence and reviewed guidelines issued by the American College of Obstetricians and Gynecologists, which indicate antibiotics don't have to be administered before clean laparoscopic procedures, because the risk of infection at the skin level is so low.
Cefazolin is the primary pre-op antibiotic used at Yale New Haven (and at most surgical facilities). The idea of giving vancomycin, potentially on top of other antibiotics, is overkill in patients who do not test positive for infection. It exposes the patient to risks associated with taking a powerful antibiotic, and it unnecessarily increases the likelihood of antibiotic resistance.
Focus on using antibiotics that show activity against bacteria that are known to cause infections during the types of procedures you host, says Dr. Martinello. He says it's important to base your antibiotic regimens on national guidelines, but it's equally important to consider the types of bacteria that are causing infections at your facility, or at other healthcare facilities within your community, and adjust your protocols accordingly.
The patient care team at Yale New Haven adjusted its antibiotic protocols on a specialty-specific manner. For example, they administer metronidazole to GYN patients, because metronidazole has a greater activity against anaerobic bacteria, which is often the cause of infections in gynecologic surgery. Dr. Martinello says the hospital is considering extending coverage of gram-negative bacteria which include Escherichia coli and pseudomonas for its joint replacement patients. He says hip replacement patients are particularly susceptible to infection because the complex procedures require manipulation of deep tissue. Plus, says Dr. Martinello, the body has a more difficult time fighting off infection caused by bacteria or fungus that grows on implants than it would if the infection-causing organisms grew in native tissue. Yale New Haven is also considering adding gentamicin to cefazolin as the standard antibiotics administered to the majority of surgical patients in order to provide broad prophylactic coverage against the bacteria that's causing infections seen at the hospital.
Dr. Martinello says cefazolin is re-dosed after the initial pre-op dose at the 3-hour mark of longer surgeries, but care teams avoid giving post-op antibiotics whenever possible. "Studies performed over the last decade have shown limited benefit in continuing antibiotics after surgery," he adds. "Antibiotics that don't provide benefit only provide risk by selecting out bacteria that may be resistant and increasing risk of antibiotic-related complications such as Clostridium difficile infection."
3. Perform nasal prophylaxis. "There's some promising research about the effectiveness of povidone-iodine nasal swabs in preventing Staphylococcus aureus infections and we're waiting to see more data regarding the efficacy of the alcohol-based nasal decolonization application," says Dr. Martinello.
Patients receive either form of nasal prophylaxis during the immediate pre-op period, a factor that supports efficient workflow, says Dr. Martinello. "But we don't have a full understanding of how Staphylococcus aureus infections occur," he says. "We do know the bacteria are found in nasal passages, so treating the nose is important. But the bacteria are also present in other areas of the body, so it's unknown if treating the nose with nasal povidone-iodine or the alcohol-based application offers sufficient protection against infection."
Yale New Haven's surgical patients are prescribed 5-day treatments of mupirocin nasal ointment and chlorhexidine gluconate baths to eliminate or minimize the risk of SSIs due to S. aureus. But Dr. Martinello acknowledges that it's difficult to coordinate delivery of the prepping products to patients at least a week before surgery and ensure full compliance, which is needed for the regimens to be completely effective.
"It's not yet clear if we're able to transition to the simpler regimen of treating the nasal passages on the day of surgery, but we look forward to seeing more data on the effectiveness and durability of both options," says Dr. Martinello. OSM