An August, 2015 CDC report includes mathematical modeling that projects increases in drug-resistant infections and Clostridium difficile (C. difficile) without immediate, nationwide improvements in infection control and antibiotic prescribing.
The promising news is that a coordinated approach—that is, health care facilities and health departments in an area working together—could prevent up to 70 percent of life-threatening carbapenem-resistant Enterobacteriaceae (CRE) infections over five years. Additional estimates show that national infection control and antibiotic stewardship efforts led by federal agencies, health care facilities, and public health departments could prevent 619,000 antibiotic-resistant and C. difficile infections and save 37,000 lives over five years.
Antibiotic-resistant germs, those that no longer respond to the drugs designed to kill them, cause more than 2 million illnesses and at least 23,000 deaths each year in the United States. C. difficile caused close to half a million illnesses in 2011, and an estimated 15,000 deaths a year are directly attributable to C. difficile infections.
The report recommends the following coordinated, two-part approach to turn this data into action that prevents illness and saves lives:
- Public health departments track and alert health care facilities to drug-resistant germ outbreaks in their area and the threat of germs coming from other facilities, and
- Health care facilities work together and with public health authorities to implement shared infection control actions to stop the spread of antibiotic-resistant germs and C. difficile between facilities.
“Antibiotic resistant infections in health care settings are a growing threat in the United States, killing thousands and thousands of people each year,” said CDC Director Tom Frieden, M.D., M.P.H. “We can dramatically reduce these infections if health care facilities, nursing homes, and public health departments work together to improve antibiotic use and infection control so patients are protected.”
The CDC report shows that C. difficile and drug-resistant bacteria—like CRE, MRSA (methicillin-resistant Staphylococcus aureus), and resistant Pseudomonas aeruginosa—spread inside of and between health care facilities when appropriate infection control actions are not in place and patients transfer from one health care facility to another for care.
Antibiotic resistance is a threat. Nightmare germs called CRE can cause deadly infections and have become resistant to all or nearly all antibiotics we have today. CRE spread between health care facilities like hospitals and nursing homes when appropriate actions are not taken. MRSA infections commonly cause pneumonia and sepsis that can be deadly. The germ Pseudomonas aeruginosa can cause healthcare associated infections (HAIs), including bloodstream infections. Strains resistant to almost all antibiotics have been found in hospitalized patients. These germs are some of the most deadly resistant germs identified as "urgent" and "serious" threats.
C. difficile infections are at historically high rates. C. difficile, a germ commonly found in health care facilities, can be picked up from contaminated surfaces or spread from a healthcare provider's hands. Most C. difficile is not resistant to antibiotics, but when a person takes antibiotics, some good germs are destroyed. Antibiotic use allows C. difficile to take over, putting patients at high risk for deadly diarrhea.
These infections can lead to serious health complications, including sepsis or death. Even facilities following recommended infection control and antibiotic use practices are at risk when they receive patients who carry these germs from other health care facilities.
The model shows how coordination could reduce CRE over the course of five years after the drug-resistant bacteria enters ten facilities in an area sharing patients. For example, the common approach (or status quo) results in 2,000 patients getting CRE, impacting 12 percent of patients in the area – not enough to protect patients. When a facility acts alone to enhance their infection control practices, the situation improves. This independent effort results in 1,500 patients getting CRE, impacting 8 percent of patients – while an important improvement, it is not enough to fully protect patients. With a coordinated approach where facilities work together to prevent infections and notify each other of CRE issues before transferring patients, the modeling shows far fewer patients at risk. Four hundred patients are predicted to get CRE, impacting only 2 percent of patients—the needed approach to protect patients.
The report also describes the importance of public health departments taking the lead to identify health care facilities in the area and know how they are connected, dedicate staff to improve connections and coordination with health care facilities in the area, and know the antibiotic resistance threats in the area and state. The public health department can work with the CDC to use data for action to prevent infections and improve antibiotic use in health care.
“We must transform our public health response to turn the tide. The coordinated response this Vital Signs report describes is a forward-looking approach,” said Beth Bell, MD, MPH, director of CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “The President’s FY 2016 budget would accelerate efforts to strengthen our response and improve antibiotic stewardship in health care facilities.”
Complementing the public health coordination, the report recommends that hospital owners and health care facility administrators consider steps to implement systems to alert receiving facilities when transferring patients who have drug-resistant germs and review and perfect infection control actions in each facility. They should connect with public health departments to share data about antibiotic resistance and other HAIs and provide clinical staff access to prompt and accurate laboratory testing for antibiotic-resistant germs.
Prescribers and healthcare staff can prescribe antibiotics correctly. Get cultures first, and then start the right drug promptly at the right dose for the right duration. Know when to stop antibiotics. They can be aware of antibiotic resistance patterns in their facility and area to protect patients and ask patients if they have recently received care in another facility. All caregivers should follow hand hygiene and other infection control measures with every patient.
“Patients and their families may wonder how they can help stop the spread of infections,” says Michael Bell, M.D., deputy director of CDC’s Division of Healthcare Quality Promotion. “When receiving health care, tell your doctor if you have been hospitalized in another facility or country, wash your hands often, and always insist that everyone have clean hands before touching you. Ask your health care providers what they and the health care facility in your area do to coordinate with others to protect you and your family from an antibiotic-resistant or C. difficile infection.”
The data in the CDC report come from both mathematical modeling and analysis estimates. The CDC used two mathematical simulation models to estimate the impact of the coordinated approach in preventing the spread of antibiotic-resistant germs within a group of health care facilities in an area. Data from CDC’s National Healthcare Safety Network and Emerging Infections Program informed projections of the number of infections and deaths in the United States.
During the next five years, with investments, the CDC’s efforts to combat C. difficile infections and antibiotic resistance under the National Strategy to Combat Antibiotic Resistant Bacteria, in collaboration with other federal partners, will enhance national capabilities for antibiotic stewardship, outbreak surveillance, and antibiotic resistance prevention. These efforts hold the potential to cut the incidence of C. difficile, health care CRE, and MRSA bloodstream infections by at least half.
The proposed State Antibiotic Resistance Prevention Programs (Protect Programs) would implement this coordinated approach. These Protect Programs would be made possible by the funding proposed in the President’s FY 2016 budget request, supporting work with health care facilities in all 50 states to detect and prevent both antibiotic-resistant germs and C. difficile infections. The FY 2016 budget would also accelerate efforts to improve antibiotic stewardship in health care facilities.
The nation is at a tipping point: an increasing number of germs no longer respond to the drugs designed to kill them. Inappropriate prescribing of antibiotics and lack of infection control actions can contribute to drug resistance and put patients at risk for deadly diarrhea (caused by C. difficile). Now more than ever is the time for public health authorities and health care facilities to work together, sharing experiences and connecting patient safety efforts happening across the state.
See the CDC Announcement
See the CDC Report
See the CDC Telebriefing Transcript
See also Medical Law Perspectives, January 2012 Report: Hospital-Acquired Infections: Who Is Liable and Why?
See the Medical Law Perspectives March 11, 2015, Blog: Uncleanable ERCP Duodenoscopes: Manufacturer, Hospital, and Physician Liability?