HOSPITAL PRACTICE

CDC issues guideline for preventing infections

Heightened concerns surrounding the transmission of infectious agents to patients and healthcare workers have prompted the Centers for Disease Control & Prevention to expand its 1996 isolation precaution guideline. The new draft recommendations, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004, include information on emerging pathogens of special concern, including multidrug-resistant organisms (MDROs) and methods to control them in healthcare settings.

"MDROs targeted for control in healthcare facilities include MRSA [methicillin-resistant S. aureus], vancomycin-resistant enterococci [VRE], and certain gram-negative bacilli [GNB], including those producing extended-spectrum beta-lactamases [ESBLs] and others that are resistant to all but one class of antimicrobial agents or that are intrinsically resistant to the broadest-spectrum agents," stated the draft guideline.

According to CDC, the prevalence of MDROs in U.S. hospitals and other healthcare settings has increased steadily over the past several decades. Charles D. Ponte, Pharm.D., CDE, BCPS, BC-ADM, professor of clinical pharmacy and family medicine at West Virginia University, has experienced this trend firsthand. "As a practitioner, I have seen a lot more MDROs recently. They are becoming much more difficult to treat and manage," said Ponte.

MDROs are typically introduced either via colonized or infected patients or as a result of antibiotic-selective pressure that confers advantages to organisms possessing resistance mechanisms gained through either mutation or gene transfer, according to the guideline. The draft cited several recommendations for preventing and controlling MDROs, including enacting campaigns to enhance hand hygiene, computer alerts to identify patients previously known to be colonized or infected with MDROs, limiting the duration of therapy when possible, and restricting the use of broad-spectrum or new, more potent antimicrobials to treat serious infections when no other active ingredients are available.

"All pharmacists are aware that multidrug-resistant organisms exist in the environment due to several reasons that stem from using broad-spectrum antibiotics, whether that type of usage is overuse, misuse, or insufficient use," continued Ponte. "Nonetheless, we are faced with this problem and we see these kinds of bugs popping up in our own patient population."

Jay Rho, Pharm.D., director of inpatient pharmacy at Kaiser Permanente Hospital in Los Angeles, echoed that view and said that using the most narrow spectrum antibiotics is the best route to go in most cases. "Many hospitals have been developing programs that allow for the conversion of intravenous to oral realms," he said. Therefore they are converting a lot of patients from certain drugs to other drugs to combat the occurrence of MDROs.

As part of the care team, there are several take-home messages from the guideline that are important for pharmacists, said Lizzie J. Harrell, Ph.D., FAAM, associate research professor of molecular genetics and microbiology at Duke University Medical Center and a member of the Healthcare Infection Control Practices Advisory Committee (HICPAC), which is overseeing the development of the final guideline. They include:

• Know the multidrug-resistant rates in your hospital or setting.

• Know which antibiotics can be used when highly resistant organisms are present. "There are only a few antimicrobials still left for therapy, and pharmacists need to know what those are," pointed out Harrell.

• Be aware of any new antibiotics for these highly resistant organisms. This includes even those antibiotics that are not approved by the Food & Drug Administration because "sometimes a drug is so resistant, most of the practices we have available will not work," warned Harrell.

• Contribute to your infection control teams. Pharmacists should be involved in surveillance efforts to monitor usage of certain antibiotics and to help limit their use based on emergent resistance patterns.

• Become a "change agent" in your organization. A major role for pharmacists is to become enterprisewide educators about such issues as the appropriate use of antimicrobials.

For a complete set of the five-part guideline, visit the CDC Web site at www.cdc.gov/ncidod/hip/isoguide.htm. Comments on the draft must be received by Aug. 13.

Leah E. Perry

Tthe author is a writer based in the Atlanta area.

Leah Perry. CDC issues guideline for preventing infections.

Drug Topics

Aug. 9, 2004;148:27.