EDITORIAL
The urgent need for nurse practitioners to lead antimicrobial stewardship in ambulatory health care The Centers for Disease Control and Prevention (CDC) recently released several reports highlighting the evolving landscape of healthcare-associated infections (HAIs), the growing threat of antimicrobial resistance in all healthcare settings, and the urgent need to implement antimicrobial stewardship strategies beyond the hospital walls. It is critical for nurse practitioners (NPs) to heed these emerging trends and assume leadership in addressing the implications for their patients, their practice, and the profession. The first report details national HAI estimates derived from a point-prevalence survey of hospitals in 10 geographically diverse states (Magill et al., 2014). While significant progress is being made in controlling several of the most common HAIs, the data indicate that on any given day 1 of every 25 inpatients in U.S. hospitals has at least one HAI. Pneumonia and surgical site infections were the most common infection types, and Clostridium difficile (CDI), a spore-forming bacillus that causes pseudomembranous colitis, was the most common pathogen. A concurrent report, based on an analysis of several national databases, confirms previous studies that the majority of hospitalized patients are prescribed antibiotics, often incorrectly and without proper evaluation and follow-up (CDC, 2014a). The high prevalence of CDI infection and the inappropriate use and misuse of antibiotics underscore the need to improve antibiotic prescribing in all clinical practice environments. Also warranted is a strategy of antimicrobial oversight at care transitions, such as discharge from hospital to home, or long-term care nursing facilities. The third and perhaps most alarming report relates to the complex problem of antibiotic resistance, more specifically carbapenem-resistant Enterobacteriaceae (CRE; CDC, 2014b). The Enterobacteriaceae (e.g., Escherichia coli, Klebsiella species, and Enterobacter species) are a family of bacteria that are normal inhabitants of the human gastrointestinal tract and a common cause of community-acquired and healthcare-acquired infections. Over time, Enterobacteriaceae developed resistance to broad-spectrum antibiotics, leading clinicians to rely on the carbapenems to treat infections caused by these resistant organisms. In recent years, CRE, sometimes called the “nightmare bacteria,” has been detected (and can spread rapidly) in hospitals and long-term acute care
Journal of the American Association of Nurse Practitioners 26 (2014) 411–413 C 2014 American Association of Nurse Practitioners
facilities, with mortality rates of up to 50%. CRE are resistant to virtually all antibiotics and easily transfer their antibiotic resistance genes to other bacteria. CRE have the potential to move from their current niche among healthcare-exposed patients into the community, making it important for NPs working in ambulatory settings (CDC, 2014b).
Antibiotic resistance threats in the United States The CDC’s report, Antibiotic Resistance Threats in the United States, 2013, provides the first comprehensive snapshot of the problem and is a “must read” for every NP (CDC, 2013). Using conservative estimates, the CDC determined that each year over 2 million people in the United States acquire serious infections from organisms resistant to one or more antimicrobial agents. Such infections result in considerable morbidity, mortality, crosstransmission within and between healthcare settings, as well as significant economic cost. Data show that most antibiotic-resistant infections happen in the general community; while most deaths related to antibiotic resistance happen in healthcare settings, such as hospitals and nursing homes. While the underlying cause of antimicrobial resistance is multifactorial, there is a well-documented causal relationship between emergence of resistant pathogens and inappropriate antibiotic use across the spectrum of healthcare settings. For the first time, the CDC categorized the antibiotic resistance threat level of each bacterium as urgent, serious, or concerning. Urgent threats include CDI, CRE, and drug-resistant Neisseria gonorrhoeae. Examples of serious threats are multidrug-resistant Acinetobacter, drugresistant Salmonella Typhi (the serotype causing typhoid fever), drug-resistant Shigella, and methicillin-resistant Staphyloccus aureus (MRSA), among others. Concerning threats comprise vancomycin-resistant Staphylococcus aureus (VRSA), erythromycin-resistant Group A Streptococcus and clindamycin-resistant Group B Streptococcus. The report recommends four core actions for halting resistance: preventing infections and the spread of resistance, tracking resistance patterns, developing new antibiotics and diagnostic tests, and antimicrobial stewardship.
411
Editorial
Antibiotic resistance has become one of the most serious and growing threats to public health. To stem the rapidly growing threat to our nation and the world, the CDC has requested $30 million in President Obama’s fiscal year 2015 budget specifically for the Detect and Protect Against Antibiotic Resistance Initiative.
Antimicrobial stewardship The concept of antimicrobial stewardship emerged in the 1970s and gradually took root as a growing body of evidence demonstrated its effectiveness. Antimicrobial stewardship is intended to ensure patient safety and the public’s health through the implementation of combined, coordinated interventions to improve and measure the appropriate use of antimicrobials. This is achieved by promoting the selection of the optimal antimicrobial drug regimen, including dosing, duration of therapy, and route of administration. According to the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society (2012), the major objectives are to achieve the best clinical outcomes related to antimicrobial use while minimizing toxicity and other adverse events, thereby limiting the emergence of antimicrobial resistant bacterial strains. According to the 2007 Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship, and the 2014 CDC Core Elements of Hospital Antibiotic Stewardship Programs, programs should include leadership commitment, accountability via an interprofessional team, processes to monitor antimicrobial use and resistance patterns, prospective audit with prescriber feedback, prescriber education, guidelines for management of common infection syndromes, clinical pathways, and computer decision support (CDC, 2014c; Dellit et al., 2007). Although both guidelines were initially intended for acute care hospitals, the principles can be applied to any healthcare setting. Historically, antimicrobial stewardship efforts have focused on acute care hospitals and targeted the practices of physicians and pharmacists. Although these programs are described as using an interprofessional approach, registered nurse involvement has been limited. As health care increasingly shifts to nonacute care settings, and as recognition that most antibiotic use occurs in outpatient settings, there is growing interest to apply antimicrobial stewardship strategies across the healthcare continuum, including ambulatory care. As trusted professionals, advocates of their patients’ health, quintessential problemsolvers, and relationship builders, NPs are uniquely qualified and well-positioned to seize the opportunity to collectively lead antimicrobial stewardship in ambulatory care. 412
M. L. Manning
Call to action According to the American Association of Nurse Practitioners (2014), there are over 189,000 NPs licensed in the United States, the large majority holding graduate degrees, practicing in primary care, and averaging almost 12 years of experience. Approximately 45% hold hospital privileges and 15% have long-term care privileges. Most NPs have independent prescriptive authority and write on average 19 prescriptions a day, often for antibiotics. These facts alone make it clear that NPs must play a key role in improving antimicrobial management in ambulatory care. It is time to harness the collective education and experience of this group of advanced practice nurses to make antibiotic stewardship a core part of everyday practice. It is time to unleash an NP movement to own and lead antimicrobial stewardship in ambulatory care. Stewardship of antimicrobials can occur at many levels. Listed are five stewardship activities NPs can do immediately. ■
■
■
Advance your knowledge. Read the articles and CDC reports cited in this editorial. Participate in educational opportunities (e.g., seminars, webinars) to advance your antimicrobial drug expertise, optimize antimicrobial prescribing performance, and use of relevant clinical guideline updates. Contact the American Association of Nurse Practitioners and encourage them to offer periodic updates on antimicrobial resistance, infectious disease guidelines, and antimicrobial prescribing. Learn together by starting an antimicrobial stewardship journal club at your practice. Optimize your antibiotic prescribing performance and practice. Consistently use the principles of appropriate antimicrobial prescribing, including standards of care, available guidelines, and diagnostic testing. If you determine a patient needs an antimicrobial, take care to prescribe the most appropriate one, and clearly specify the dose, duration, and indication/s. On a regular basis audit your patterns of antimicrobial prescribing to determine appropriateness. Know the level of antimicrobial resistance in your community and geographic region. Advocate for the adoption of at least one antimicrobial stewardship recommended action in your practice setting. Work closely with your practice colleagues to select antimicrobial stewardship interventions based on the needs of your practice setting as well as the availability of resources and content expertise. Adapt and customized antimicrobial stewardship principles to “fit” your practice setting. Be careful not to implement too many interventions
Editorial
M. L. Manning
■
at once. Clinician education is known to be most effective when coupled with personalized audit and feedback of antibiotic prescribing. Reach out and connect with NPs in your local region. Create a network to share experiences and support the work. Explore strategies to remove real and perceived obstacles and barriers. Partner with the local health department to explore opportunities for providing education related to antimicrobial resistance and its consequences in your community and region.
Be bold. Be brave. Advocate for the health of your patients and your community and seize the moment to preserve the effectiveness of antibiotics. Mary Lou Manning PhD, CRNP, CIC, FAAN Associate Professor, Thomas Jefferson University School of Nursing President-elect, Association for Professionals in Infection Control and Epidemiology
References American Association of Nurse Practitioners. (2014). Fact sheet. Retrieved from http://www.aanp.org/images/documents/about-nps/npfacts.pdf
Centers for Disease Control and Prevention (CDC). (2013). Antibiotic resistance threats in the United States, 2013. Retrieved from http://www.cdc.gov/drugresistance/threat-report-2013/pdf/arthreats-2013–508.pdf. Centers for Disease Control and Prevention (CDC). (2014a). Vital signs: Improving antibiotic use among hospitalized patients. MMWR. Morbidity and Mortality Weekly Report, 63(9), 194–200. Retrieved from http://www.cdc. gov/mmwr/pdf/wk/mm6309.pdf Centers for Disease Control and Prevention (CDC). (2014b). Vital signs: Carbapenem-resistant Enterobacteriaceae. MMWR. Morbidity and Mortality Weekly Report, 62(9), 165–170. Retrieved from http://www.cdc.gov/mmwr/ PDF/wk/mm6209.pdf Centers for Disease Control and Prevention (CDC). (2014c). Core elements of hospital antibiotic stewardship programs. Retrieved from http://www.cdc. gov/getsmart/healthcare/pdfs/core-elements.pdf Dellit, T. H., Owens, R. C., McGowan, J. E., Gerding, D. N., Weinstein, R. A., Burke, J. P., & Hooton, T. M. (2007). Infectious Disease Society of America and the Society for Healthcare Epidemiology of America guideline for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 44,159–177. Magill, S. S., Edwards, J. R., Bamberg, W., Beldavas Z. G., Dumyati, G., Kainer, M. A., & Fridkin, S. K. (2014). Multistate point-prevalence survey of health care-associated infections. New England Journal of Medicine, 370(13), 1198–1208. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. (2012). Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 33(4), 322–327.
413
The urgent need for nurse practitioners to lead antimicrobial stewardship in ambulatory health care The Centers for Disease Control and Prevention (CDC) recently released several reports highlighting the evolving landscape of healthcare-associated infections (HAIs), the growing threat of antimicrobial resistance in all healthcare settings, and the urgent need to implement antimicrobial stewardship strategies beyond the hospital walls. It is critical for nurse practitioners (NPs) to heed these emerging trends and assume leadership in addressing the implications for their patients, their practice, and the profession. The first report details national HAI estimates derived from a point-prevalence survey of hospitals in 10 geographically diverse states (Magill et al., 2014). While significant progress is being made in controlling several of the most common HAIs, the data indicate that on any given day 1 of every 25 inpatients in U.S. hospitals has at least one HAI. Pneumonia and surgical site infections were the most common infection types, and Clostridium difficile (CDI), a spore-forming bacillus that causes pseudomembranous colitis, was the most common pathogen. A concurrent report, based on an analysis of several national databases, confirms previous studies that the majority of hospitalized patients are prescribed antibiotics, often incorrectly and without proper evaluation and follow-up (CDC, 2014a). The high prevalence of CDI infection and the inappropriate use and misuse of antibiotics underscore the need to improve antibiotic prescribing in all clinical practice environments. Also warranted is a strategy of antimicrobial oversight at care transitions, such as discharge from hospital to home, or long-term care nursing facilities. The third and perhaps most alarming report relates to the complex problem of antibiotic resistance, more specifically carbapenem-resistant Enterobacteriaceae (CRE; CDC, 2014b). The Enterobacteriaceae (e.g., Escherichia coli, Klebsiella species, and Enterobacter species) are a family of bacteria that are normal inhabitants of the human gastrointestinal tract and a common cause of community-acquired and healthcare-acquired infections. Over time, Enterobacteriaceae developed resistance to broad-spectrum antibiotics, leading clinicians to rely on the carbapenems to treat infections caused by these resistant organisms. In recent years, CRE, sometimes called the “nightmare bacteria,” has been detected (and can spread rapidly) in hospitals and long-term acute care
Journal of the American Association of Nurse Practitioners 26 (2014) 411–413 C 2014 American Association of Nurse Practitioners
facilities, with mortality rates of up to 50%. CRE are resistant to virtually all antibiotics and easily transfer their antibiotic resistance genes to other bacteria. CRE have the potential to move from their current niche among healthcare-exposed patients into the community, making it important for NPs working in ambulatory settings (CDC, 2014b).
Antibiotic resistance threats in the United States The CDC’s report, Antibiotic Resistance Threats in the United States, 2013, provides the first comprehensive snapshot of the problem and is a “must read” for every NP (CDC, 2013). Using conservative estimates, the CDC determined that each year over 2 million people in the United States acquire serious infections from organisms resistant to one or more antimicrobial agents. Such infections result in considerable morbidity, mortality, crosstransmission within and between healthcare settings, as well as significant economic cost. Data show that most antibiotic-resistant infections happen in the general community; while most deaths related to antibiotic resistance happen in healthcare settings, such as hospitals and nursing homes. While the underlying cause of antimicrobial resistance is multifactorial, there is a well-documented causal relationship between emergence of resistant pathogens and inappropriate antibiotic use across the spectrum of healthcare settings. For the first time, the CDC categorized the antibiotic resistance threat level of each bacterium as urgent, serious, or concerning. Urgent threats include CDI, CRE, and drug-resistant Neisseria gonorrhoeae. Examples of serious threats are multidrug-resistant Acinetobacter, drugresistant Salmonella Typhi (the serotype causing typhoid fever), drug-resistant Shigella, and methicillin-resistant Staphyloccus aureus (MRSA), among others. Concerning threats comprise vancomycin-resistant Staphylococcus aureus (VRSA), erythromycin-resistant Group A Streptococcus and clindamycin-resistant Group B Streptococcus. The report recommends four core actions for halting resistance: preventing infections and the spread of resistance, tracking resistance patterns, developing new antibiotics and diagnostic tests, and antimicrobial stewardship.
411
Editorial
Antibiotic resistance has become one of the most serious and growing threats to public health. To stem the rapidly growing threat to our nation and the world, the CDC has requested $30 million in President Obama’s fiscal year 2015 budget specifically for the Detect and Protect Against Antibiotic Resistance Initiative.
Antimicrobial stewardship The concept of antimicrobial stewardship emerged in the 1970s and gradually took root as a growing body of evidence demonstrated its effectiveness. Antimicrobial stewardship is intended to ensure patient safety and the public’s health through the implementation of combined, coordinated interventions to improve and measure the appropriate use of antimicrobials. This is achieved by promoting the selection of the optimal antimicrobial drug regimen, including dosing, duration of therapy, and route of administration. According to the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society (2012), the major objectives are to achieve the best clinical outcomes related to antimicrobial use while minimizing toxicity and other adverse events, thereby limiting the emergence of antimicrobial resistant bacterial strains. According to the 2007 Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship, and the 2014 CDC Core Elements of Hospital Antibiotic Stewardship Programs, programs should include leadership commitment, accountability via an interprofessional team, processes to monitor antimicrobial use and resistance patterns, prospective audit with prescriber feedback, prescriber education, guidelines for management of common infection syndromes, clinical pathways, and computer decision support (CDC, 2014c; Dellit et al., 2007). Although both guidelines were initially intended for acute care hospitals, the principles can be applied to any healthcare setting. Historically, antimicrobial stewardship efforts have focused on acute care hospitals and targeted the practices of physicians and pharmacists. Although these programs are described as using an interprofessional approach, registered nurse involvement has been limited. As health care increasingly shifts to nonacute care settings, and as recognition that most antibiotic use occurs in outpatient settings, there is growing interest to apply antimicrobial stewardship strategies across the healthcare continuum, including ambulatory care. As trusted professionals, advocates of their patients’ health, quintessential problemsolvers, and relationship builders, NPs are uniquely qualified and well-positioned to seize the opportunity to collectively lead antimicrobial stewardship in ambulatory care. 412
M. L. Manning
Call to action According to the American Association of Nurse Practitioners (2014), there are over 189,000 NPs licensed in the United States, the large majority holding graduate degrees, practicing in primary care, and averaging almost 12 years of experience. Approximately 45% hold hospital privileges and 15% have long-term care privileges. Most NPs have independent prescriptive authority and write on average 19 prescriptions a day, often for antibiotics. These facts alone make it clear that NPs must play a key role in improving antimicrobial management in ambulatory care. It is time to harness the collective education and experience of this group of advanced practice nurses to make antibiotic stewardship a core part of everyday practice. It is time to unleash an NP movement to own and lead antimicrobial stewardship in ambulatory care. Stewardship of antimicrobials can occur at many levels. Listed are five stewardship activities NPs can do immediately. ■
■
■
Advance your knowledge. Read the articles and CDC reports cited in this editorial. Participate in educational opportunities (e.g., seminars, webinars) to advance your antimicrobial drug expertise, optimize antimicrobial prescribing performance, and use of relevant clinical guideline updates. Contact the American Association of Nurse Practitioners and encourage them to offer periodic updates on antimicrobial resistance, infectious disease guidelines, and antimicrobial prescribing. Learn together by starting an antimicrobial stewardship journal club at your practice. Optimize your antibiotic prescribing performance and practice. Consistently use the principles of appropriate antimicrobial prescribing, including standards of care, available guidelines, and diagnostic testing. If you determine a patient needs an antimicrobial, take care to prescribe the most appropriate one, and clearly specify the dose, duration, and indication/s. On a regular basis audit your patterns of antimicrobial prescribing to determine appropriateness. Know the level of antimicrobial resistance in your community and geographic region. Advocate for the adoption of at least one antimicrobial stewardship recommended action in your practice setting. Work closely with your practice colleagues to select antimicrobial stewardship interventions based on the needs of your practice setting as well as the availability of resources and content expertise. Adapt and customized antimicrobial stewardship principles to “fit” your practice setting. Be careful not to implement too many interventions
Editorial
M. L. Manning
■
at once. Clinician education is known to be most effective when coupled with personalized audit and feedback of antibiotic prescribing. Reach out and connect with NPs in your local region. Create a network to share experiences and support the work. Explore strategies to remove real and perceived obstacles and barriers. Partner with the local health department to explore opportunities for providing education related to antimicrobial resistance and its consequences in your community and region.
Be bold. Be brave. Advocate for the health of your patients and your community and seize the moment to preserve the effectiveness of antibiotics. Mary Lou Manning PhD, CRNP, CIC, FAAN Associate Professor, Thomas Jefferson University School of Nursing President-elect, Association for Professionals in Infection Control and Epidemiology
References American Association of Nurse Practitioners. (2014). Fact sheet. Retrieved from http://www.aanp.org/images/documents/about-nps/npfacts.pdf
Centers for Disease Control and Prevention (CDC). (2013). Antibiotic resistance threats in the United States, 2013. Retrieved from http://www.cdc.gov/drugresistance/threat-report-2013/pdf/arthreats-2013–508.pdf. Centers for Disease Control and Prevention (CDC). (2014a). Vital signs: Improving antibiotic use among hospitalized patients. MMWR. Morbidity and Mortality Weekly Report, 63(9), 194–200. Retrieved from http://www.cdc. gov/mmwr/pdf/wk/mm6309.pdf Centers for Disease Control and Prevention (CDC). (2014b). Vital signs: Carbapenem-resistant Enterobacteriaceae. MMWR. Morbidity and Mortality Weekly Report, 62(9), 165–170. Retrieved from http://www.cdc.gov/mmwr/ PDF/wk/mm6209.pdf Centers for Disease Control and Prevention (CDC). (2014c). Core elements of hospital antibiotic stewardship programs. Retrieved from http://www.cdc. gov/getsmart/healthcare/pdfs/core-elements.pdf Dellit, T. H., Owens, R. C., McGowan, J. E., Gerding, D. N., Weinstein, R. A., Burke, J. P., & Hooton, T. M. (2007). Infectious Disease Society of America and the Society for Healthcare Epidemiology of America guideline for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 44,159–177. Magill, S. S., Edwards, J. R., Bamberg, W., Beldavas Z. G., Dumyati, G., Kainer, M. A., & Fridkin, S. K. (2014). Multistate point-prevalence survey of health care-associated infections. New England Journal of Medicine, 370(13), 1198–1208. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. (2012). Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 33(4), 322–327.
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