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Incorporating antimicrobial stewardship into hospital infection control programs
Incorporating antimicrobial stewardship into hospital infection control programs: a video by Professor Fosalade Ogunsola
We’ll be talking about integrating antimicrobial stewardship into hospital infection control programmes today. The objectives of this lecture are to recognise links and areas of partnership between infection control and antimicrobial stewardship, to describe practical steps to incorporating antimicrobial stewardship into the existing hospital infection control programmes, and to contribute to developing a national antimicrobial stewardship programme. Before we begin, let me share with you a seminal study by Levi, et al. in 1976, which shows the ease with which resistant genes can be spread in the environment. 300 chickens were hatched from pathogen-free eggs and divided into two groups. One group was fed with feed that was laced with low doses of tetracycline, while the other set was not.
By 48 hours, the tetracycline-fed chickens were excreting some tetracycline-resistant E. coli, while the control group was not. At seven days, all E. coli excreted were tetracycline-resistant in the group being fed low dose tetracycline. At three months, all excreted E. coli had become multidrug resistant, with resistance to sulphonamides, ampicillin, streptomycin, and carbenicillin. In addition, humans living on the farm and surrounding farms were also excreting increasing numbers of multidrug resistant E. coli. This study therefore demonstrates a number of things.
First, that low dose non-therapeutic amount of antibiotics can select for and help to spread multidrug resistant bacteria at high levels, that it can also select for resistance to other antibiotics not being taken, and that antibiotic resistance genes can be transferred to those not taking the antibiotics, but are in the environment of those so doing. And most importantly, it shows the environmental impact of antibiotics. In fact, antibiotics are the only drugs which when given to an individual affects others as well. Therefore, addressing antimicrobial resistance must be collectively done. Otherwise, we will not be able to reduce the rates. No continent can be left behind. There are only three ingredients required for the spread of antibiotic resistance genes.
Two of them are primary, which is the presence of resistance genes, and two, the extent of antibiotic use, while the third, which is secondary, are the factors that aid their transmission in the environment. Looking at the WHO action plan to reduce antimicrobial resistance, which stands on five pillars, which are effective communication and education, surveillance, infection, prevention, and control, antimicrobial stewardship, and research and development, it is clear that it’s only pillars three and four, which is IPC and antimicrobial stewardship, that fall into our immediate sphere of influence.
Once resistance genes have been selected for by antibiotic use, an effective infection, prevention, and control programme prevents or reduces their transmission to new hosts or sites during health care delivery, which ultimately leads to a reduced need for antibiotic use, which then also reduces the selection pressure. IPC is therefore an important component in the war against antimicrobial-resistant organisms because every breech in the IPC practice is an opportunity for the transmission of multidrug resistant organisms.
This third pillar in the WHO action plan for antimicrobial resistance can be achieved in three ways– by ensuring the IPC programme in the hospital is effective, by ensuring that the antimicrobial stewardship team have basic training in infection, prevention, and control, and maintaining good communication flow between the antimicrobial stewardship team and the IPC team. So let’s look at ensuring IPC programmes are effective. To ensure the programme is effective, it’s important to implement the eight core components of an IPC programme.
And this would include educating health care workers on standard and transmission-based precautions, and ensuring that these precautions are observed every time that health is practised, and to also support health care workers to do their tasks properly by providing standard operating procedures, and job manuals, and job aids, as well as regularly auditing and giving feedback. But all these cannot be done effectively if you do not carry management along because they will be required to help in preventing overcrowding, for the provision of adequate water supply, and good sanitation.
Other thing is that the day-to-day work of IPC is useful and assists antimicrobial stewardship through the analysis and reporting of hospital-acquired infections, the identification, monitoring, and reporting of multidrug resistant organism trends and newly emerging resistant strains, the use of effective aseptic procedures, and the adoption of antibiotic treatment and prophylaxis guidelines in the facilities. It’s also important that members of the antimicrobial stewardship team understand the role of IPC and understand standard and transmission-based precautions and WASH. These they must be able to do. And they also require to understand the governance structure of IPC so that they can key in to what they are doing and also may be able to use some of their personnel, e.g.
Link nurses on the wards who may also collect useful information for the antimicrobial stewardship team. The Link nurse is a particularly useful and well-positioned to work with antimicrobial stewardship teams because nurses are coordinators of care and tend to monitor patients throughout the day. And they monitor their safety and response to antibiotic therapy. And more importantly, they are central to communication between patients and other health care workers. Finally, the IPC team and the AMS teams must maintain good communication flow to ensure that both programmes remain effective and are not duplicating effort or infringing on other staff perceived areas of influence, which may result in increased costs and interpersonal friction.
The AMS and IPC team must share findings of resistance strains found during IPC rounds, have joint meetings regularly. And the IPC team must share outbreak information with antimicrobial stewardship teams, and also help to create awareness of the antimicrobial stewardship programme. In creating awareness, it’s so necessary that the antimicrobial stewardship team is visible. They must have spokespersons or a person. And this person or persons must be respected. They must try to give talks on IPC and AMR at seminars and grand rounds. They must engage the hospital administration frequently through sending reports or through meetings that are face-to-face. In all these interactions, it’s important to use local data as much as possible so that you can continue to push their objectives.
It’s also important to always keep the goal in mind that it’s about reducing antibiotic use and reducing transmission. In working and starting an antimicrobial stewardship, it’s also good to start with units where there will be the least resistance to change and work with them. And in all that you do, give feedback on resistance levels in the units and the impacts of interventions, which help to encourage people to continue to work. So what can we do at a facility level? You do need champions. And the more diverse these are, the better because then they can talk with– you have the different with nurses talking to nurses, doctors to doctors.
You must do a situational analysis to identify the gaps, get as much data as possible, identify what barriers there are to implementation, set your goals, get training if you need them, and work with groups under pressure, especially people in the intensive care unit, the neonatal unit. These groups tend to be very receptive. Be visible and give feedback regularly. In low and middle-income countries, IPC and AMR using the internet might be difficult. But software such EPI-info, WHONET, Microsoft Excel lend themselves to use. So at the national level, how does IPC work with AMR? A lot of that is through advocacy, working together to promote both IPC and AMS.
And it’s important that you work with groups with similar objectives so that you form strong advocacy groups. Veterinary surgeons are useful, pharmacies, environmentalist, patient groups. And in doing this, you must use local data so that they can identify with it. Then you must create awareness. You can use or adapt available international IEC materials, e.g. from the WHO, CDC, or develop locally to educate and inform the public. Work with NGOs. Hold national multidisciplinary seminars, workshops, and conferences, and share local data with relevant authorities. There’s a lot to do and it can be daunting. It is important to start from wherever you can. You cannot afford to do nothing. Thank you.
You may now have questions such as:
What are the links between Infection Prevention (IPC) and Antimicrobial Stewardship (AMS)?
What practical steps can we take to incorporate AMS into existing IPC programmes?
How can we help develop a national programme as outlined by Professor Shaheen Mehtar in step 2.8.
In this video Professor Fosalade Ogunsola, Clinical Microbiologist, Chair Nigerian Infection Control Association, Chair Elect ICAN, through her role promoting IPC and AMR prevention in Nigeria and Africa, answers these questions.
You may also wish to read the paper “Education and management of antimicrobials amongst nurses in Africa—a situation analysis: an Infection Control Africa Network (ICAN)/BSAC online survey” by Bulbula et al, 2016 (available below) which assessed the involvement of nurses in the use and management of antimicrobials and their training in antimicrobial stewardship (AMS) across Africa.
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