There is no silver bullet for patients with such antibiotic-resistant superbugs as MRSA and VRE. The overuse of antibiotics is the main reason these potentially deadly infections exist. That's why it's critical for you and your team to avoid spreading the bacteria and why, infection prevention experts say, the basic practices of hand hygiene and surface disinfection are still so important in the fight against superbugs.

Cause and crisis
The problem was decades old and widespread before it became a common concern. The effects of antimicrobial agents such as antibiotic drugs had been dulled against organisms that had built up resistance to them, likely due to the agents' overuse or misuse.

"The No. 1 drug used to treat Staphylococcus aureus was methicillin. In the late 1960s, researchers started to notice the emerging resistance," says Phenelle Segal, RN, CIC, of Infection Control Consulting Services in Blue Bell, Pa. "When vancomycin was used against staph, that's where Enterococcus picked up a resistance." By the late 1970s, researchers had begun to see these pathogens as a growing threat deserving of aggressive action in healthcare environments. "And then it exploded," says Ms. Segal.

Spreading through the 1980s and 1990s, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) have since been joined on the superbug front by carbapenem-resistant Enterobacteriaceae (CRE), which includes a resistant strain of Klebsiella pneumoniae; extended spectrum beta lactamases (ESBL), which produce an enzyme that induces resistance; and Acinetobacter baumannii, also known as "Iraqibacter" after its infections were observed among wounded American soldiers stationed in the Middle East.

These and other pathogenic hazards were sufficient evidence to convince healthcare leadership to ramp up investment in infection prevention efforts. "We've gotten administrators to understand that supporting an infection control program, while it's not a revenue-generating area, can significantly reduce morbidity and mortality," says Ms. Segal.

Tools at hand
Infection preventionists facing an increase in infections from multi-drug resistant organisms (commonly abbreviated MDROs) were armed with the same tools they'd had before. Their clinical practices hadn't changed and no new antimicrobial agents had been developed in response. But 2 trends reshaping the culture of health care coincided with and complemented the need to prevent the threat of transmission.

The first was the surfacing of blood- and body-fluid-borne pathogens such as HIV in the 1980s, which established the use of personal protective equipment as a precaution by every healthcare provider with every patient. These "universal precautions" later became the core of what is now known as the standard precautions of patient care, says Ms. Segal.

The second was QI. "At the same time these MDROs emerged, we saw an industry-wide initiative toward patient safety management and quality improvement management," says Jan E. Patterson, MD, MS, a professor of medicine in infectious diseases and pathology and the director of the Center for Patient Safety and Health Policy at the University of Texas Health Science Center at San Antonio.

Together, preventing direct transmission and striving for consistent compliance emphasized and expanded clinical efforts. "The basic, proven infection prevention practices were in place for many years," says Julia Moody, MS, SM-ASCP, director of infection prevention for Hospital Corporation of America in Nashville, Tenn. "This was an acknowledgment of how effective they were across all the MDROs, instead of seeking to combat each organism separately."

MDROs may not have changed the way that perioperative staff conduct infection prevention practices, but they have increased the frequency with which they are carried out.

"What primarily has changed the way we practice infection control is applying standard procedures to every patient," says Jan Davidson, MSN, RN, CNOR, manager of ambulatory products for AORN. "Proper hand hygiene before and after patient contact, wearing gloves when there will be any contact with patients' fluids, such as drawing blood, starting an IV, emptying a bedpan."

Depending on the situation, a gown, mask, and eye or face shield may also be warranted. "Healthcare workers need to be knowledgeable about the different ways in which an infection can be transmitted," says Dr. Patterson. While MRSA can be spread by skin contact, for instance, the flu is spread by sneezed or coughed droplets and tuberculosis is airborne.

Staff must know what precautions need to be taken in which situations. A step above the standard precaution emphasis on consistent hand hygiene and environmental cleaning are contact precautions, such as patient isolation and providers donning barrier protection just to enter the room. This higher level of protection would be used with patients who are actually infected with MDROs or Clostridium difficile, not technically classified as an MDRO but considered an epidemiologically significant organism, says Dr. Patterson.

Hand hygiene helps
Since many MDROs transmit by hand, and since proper hand hygiene is a proven method of reducing the skin's microbial burden, hand washing is a practice "we must do without fail," says Ms. Moody.

One practical application that rose from the need to keep washing hands was the development and widespread acceptance in the 1990s of alcohol-based antiseptic hand sanitizers, which Ms. Moody sees as a revolution in infection prevention. "It made hand hygiene more convenient, even at the point of care. Staff could even carry personal-sized bottles of sanitizer. All of which increased compliance, with less dermatitis than washing with soap and water."

That's not to say everyone's at 100%. With regard to hand hygiene, says Ms. Segal, "there will always be areas for improvement. Some facilities have high compliance, and some don't."

Plus, says Ms. Davidson, there's the challenge of managing the hand hygiene component of standard precautions among patients' family members and other visitors, who may be colonized, asymptomatic and unaware they're carrying and spreading infectious bacteria.

Another challenge is the awareness that hand hygiene is one of the few defenses healthcare providers have against the most tenacious, relatively infrequent (as yet), resistant-to-everything organisms such as Acinetobacter baumannii, and it's only a pre-emptive defense at that. "That's what keeps infection preventionists up at night," says Ms. Moody. "Because if we get one of those in a hospital, we're solely reliant on basic precautions such as hand hygiene and wearing PPEs. And it's always a challenge to keep those things compliant. We know we're not perfect."

Environmental science
Healthcare providers' hands may be a major source of transmission for MDROs, but they pick up and pass on the bugs by touching environmental surfaces. "Particularly high-touch surfaces: door handles, bed rails, nightstands, keyboards, reused items like blood pressure cuffs and blood glucose monitors," says Ms. Segal. "Environment plays more of a role than we ever thought it did. Contamination of the environment is a very easy way for organisms to spread."

As with hand hygiene, environmental cleaning and surface disinfection were always part of infection control protocols, but the spread of MDROs emphasized their importance. "Terminal cleaning ramped up in the late '90s and early 2000s," says Ms. Segal.

"People are monitoring environmental cleaning at many hospitals," says Dr. Patterson. "Is it being done correctly? Is the surface clean? Double-checking that, for example, the same mop water isn't being used from room to room."

"The biggest challenge in environmental cleaning is C. diff.," says Ms. Segal. Dr. Patterson agrees: "C. diff. is still creeping up as SSIs and bloodstream infections have been going down." A spore-forming organism that can live 5 to 6 months unchecked, it takes the addition of bleach in the mop water to neutralize it. If detected, contact precautions are necessary. All equipment that enters or leaves a room in which C. diff. exists must be disinfected, and its high-touch surfaces should be cleaned at least 2 times a day.

Environmental cleaning products have improved to meet the need, says Ms. Moody. While quaternary ammonia has traditionally been used for mopping OR floors, newer agents incorporate hydrogen peroxide or peracetic acid, which are more effective against resistant organisms, not to mention faster-acting. "Per human behavior, a faster-acting solution is desirable," she says. The mops themselves are also the beneficiaries of technological advances, with heads made from fibers that clean more effectively.

The future of environmental cleaning, though, might be no-touch, says Ms. Moody. "The really exciting area that we're looking at is room cleaning with UV light or vaporized hydrogen peroxide, for terminal cleaning or outbreak management."

For the future
According to infection prevention experts, one of the key strategies in combating MDROs is making sure the situation doesn't worsen. The Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America recently published a joint position paper (tinyurl.com/7k2wfxz) advising the healthcare industry to adopt a stance of antimicrobial stewardship.

Antimicrobial stewardship means the judicious use and measured management of the available antibiotic drugs and other options in an attempt to prevent further resistance, says Ms. Moody, one of the paper's authors. It depends on "a multi-disciplinary partnership that employs the skill sets of all personnel — infection prevention, environmental services, pharmacy — at a facility to work together to minimize the risk of developing and transmitting resistance," she says. "There's a great amount of work to be done across the continuum of care."

Of course, the future of infection prevention in the age of MDROs doesn't have to be a complex global undertaking. It starts at every individual facility, says Dr. Patterson. "We've had the evidence for prevention for a long time," she says. "We need to teach our teams to speak up if they see a problem. Building a culture of safety, with visible leadership from administrators and buy-in from clinical staff, is even more important than education on wearing gowns and gloves. There are fewer healthcare-associated infections now than there were a decade ago, but we still want to see it even lower."