Setting the scene: Part 2

So we were surprised that Mr. Smith hadn’t responded to our standard antimicrobial treatment. He was recovering from surgery, he was expected to do very well. We’re very pleased when the ward nurse actually escalated the problem to us and told us that he hadn’t been responding to treatment. Unfortunately, they didn’t send blood cultures or urine samples before they started a short course of antibiotics, so these had to be delayed for three or four days until it was apparent he wasn’t responding to treatment.

Once we had the samples into the laboratory, we put them up on our usual culture plates, and unfortunately it’s turned out that this patient has managed to acquire a much more resistant bacterial infection than we would normally see. This necessitates the use of much more broad-spectrum antibiotics and introduces risks such as needing to have intravenous therapy, and it has got very limited oral options. As soon as we knew it was one of these more resistant organisms, we had to take some infection control precautions. So what we did was to put Mr. Smith into a single room, and we asked everybody who was going into that single room to wear gloves and aprons, be very careful with hand hygiene.

And we also put in a disinfectant clean of the environment and also the equipment. We have seen this strain appear in the ward over the past couple of years with increasing regularity, so we’re going to send it off to the reference laboratory to see if it’s the same strain or related to the other patients as well. Because of this– and because it was an ongoing problem– we thought it very important to have a multi-disciplinary team meeting with the antimicrobial prescribing team and the medical director and the clinical staff, just to sit down and assess whether there was good compliance with the antimicrobial prescribing and also with the standard and transmission-based infection prevention and control precautions.

So we’ve now had an opportunity to discuss the key issues in relation to infection control and adherence to standards in transmission-based infection control precautions, and I’m very grateful to all of you for that. I think it’s been very helpful. Perhaps this is a good time now to move on to some of the prescribing issues and what we need to do about them. I am assuming one of the surgeons is joining us?

No they’re not, I’m sorry to say. We’ve asked. We asked the clinical director. He sadly is busy today. I did, and I think Gabby also was going to, ask just one of the attending surgeons who looked after the patient, but he’s busy in theatre. And despite me suggesting how important this meeting is, he just said he was just too busy to come. So, I’m sorry. Given the significance and the importance of what we’re discussing, that is really disappointing. Clearly we’ll need to pick that up with the meeting. Maybe this is the point if you could help him understand what information we have in relation to the antibiotic prescribing within the ward.

Well, As you will know– and as you would expect– we have an antibiotic policy in place now for quite some time that addresses treatment as well as prophylaxis issues. But when we were developing the antibiotic policy, we did consult with many of the urologists. But unfortunately, they were not very happy with many of the agents that we were recommending as part of our policy, in keeping with national guidelines. They’re particularly keen on cephalosporins and certain similar broad-spectrum antibiotics including ciprofloxacin, and they feel that these are the powerhouse broad-spectrum antibiotics that really are required for the sick patients.

And their patients are always sicker, and they felt that many of the things we were recommending were not good enough for their sick patients. We tried very hard for them to get to attend many of the meetings around the making of the policy, but ultimately– I’m sorry to say– I just got so fed up that I just put the policy out and hoped for the best. I see. So, do we know that they use it? That’s a good question. I can’t tell you all the time, but we have medical students which we have persuaded to do some more, they’re always looking for a project.

In fact, I remember one now around 18 months ago, when we did a project with one of our medical students. And she measured in a compliance rate of around 30% for the treatment bit of the guideline. I do remember sharing it with one of the urologists who happens to be a friend of mine. We sometimes go out together, so he was quite keen to hear. And he said to me that he would let his colleagues know that they were doing at that. But when I said to him, well 30% percent is not very good, he said well, it doesn’t seem to be affecting or harming his patients.

They seem to be doing very fine with the treatment that they’re currently using. We have, on numerous occasions, pointed out that they’re not compliant with what we would usually recommend. Really? The registrar usually tells us not to interfere with the clinical decision because they know what’s best for the patient. Yeah, I remember you mentioning that to me. Do you think this has impact upon resistance? I just thought it was all down to bad hand hygiene. No. I think over the past couple of years we have seen a gradual increase in resistance in this unit. I’m pretty certain that poor antimicrobial prescribing will be contributing to that.

I think it demonstrates that it’s important to have prudent antimicrobial prescribing as well as the standard and transmission-based infection control precautions. One of the difficulties, of course, is that now we’ve got limited oral options. You’ve got to give it IV, and that introduces devices and can increase our risk of things like Staph aureus, bacteremias, and Clostridium difficile infections. So, I think this is part of the whole problem. I see. So, what about prophylaxis? And that’s an indicator that we’re now being asked to monitor, and clearly I’m accountable for that. Are we doing any better there? Well, our performance is around 45% to 60% at best.

We kind of can’t measure it on a regular basis because we can never find anybody, I’m afraid. And also the types of antibiotics they like to use, they particularly like a drug called piperacillin tazobactam, called tazocin. They love it. They think it’s the best for their sick patients for prophylaxis. I think Heather would remember telling me that the stock in theatre is out on a regular basis, because they use this for prophylaxis. I don’t believe it’s what we recommend as part of our guideline, but our colleagues in urology– and even the anaesthetists who actually often administer the prophylaxis– don’t like what we recommend. They just don’t like gentamicin because they think it harms patient’s kidneys and it’s dangerous.

And they are not prepared to use it. I am concerned about what we have in terms of a policy, compliance with that policy, and engagement with that policy. We need to sort this out.

Sadly, what you have seen is not an unusual scenario in many hospitals and departments across the world. As your warm up exercise, I would like you to consider the following questions and post your responses. Firstly, is the outbreak of a resistant infection an unusual scenario in your hospital? Secondly, what are the key deficiencies in infection control and clinical practise that you have highlighted in this film? Thirdly, can you identify the key drivers for resistance in this film? One of the key actions– as you have seen– that came from this outbreak was to set up an urgent meeting of the infection control or prevention team with the antimicrobial management or stewardship team. I would like you to consider some additional questions.

Four, do you have an antimicrobial management or stewardship team in your hospital? Five, what are the key prescribing issues worthy of investigation in the scenario described? Six, and importantly, how would you measure this? Finally, in this incident outbreak meeting, can you identify the clear strengths and weaknesses of the stewardship response of the team we have described?