Chapter 126. Infections in Transplant Recipients (Part 17) doc

Infections in Transplant Recipients Part 17 Table 125-3 Controlling Antibiotic Resistance: Approaches to Consider Conduct surveillance for antibiotic resistance.. Currently, several a

Chapter 126 Infections in Transplant Recipients

(Part 17)

Table 125-3 Controlling Antibiotic Resistance: Approaches to Consider

Conduct surveillance for antibiotic resistance

Perform molecular typing (e.g., pulsed-field gel electrophoresis) when rates increase

For clonal expansion (e.g., single-strain outbreaks): Stress hand hygiene (alcohol hand rub and universal gloving); monitor adherence and give feedback

For polyclonal expansion (e.g., multistrain outbreaks): Stress antibiotic prudence (consider antibiotic rotation for ICUs); monitor adherence and give feedback

For continued problems: Obtain patient-surveillance cultures and isolate or provide cohort nursing for colonized/infected patients

Control device-related infections

Enlist administrative support proactively

Source: Adapted from: RA Weinstein, Emerg Infect Dis 7:188, 2001; see

also www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

Currently, several antibiotic resistance problems are of particular health care concern First, the emergence of community-acquired MRSA has been dramatic in many countries, with as many as 50% of community-acquired "staph infections" in some U.S cities now caused by strains resistant to β-lactam antibiotics (Chap 129) The potential incursion of these strains into hospitals and the resulting impact on control of nosocomial MRSA infections are of enormous concern Second, in the ongoing global reemergence of nosocomial

multidrug-resistant gram-negative bacilli, new problems include plasmid-mediated resistance

to fluoroquinolones, metallo-β-lactamase-mediated resistance to carbapenems, and

panresistant strains of Acinetobacter Many of these multidrug-resistant strains are

susceptible only to colistin, which has led to a "rediscovery" and renewed use of this drug Finally, clinical infections with MRSA strains exhibiting high-level vancomycin resistance due to VRE-derived plasmids have been reported in several patients in the United States, often in the setting of prolonged or repeated treatment with vancomycin and/or VRE colonization The detection of any of these current problems should trigger an epidemiologic investigation and aggressive infection-control measures

Because the excessive use of broad-spectrum antibiotics underlies many resistance problems, aggressive antibiotic-control policies must be considered a cornerstone of resistance-control efforts Recommendations for "antibiotic stewardship" are being promulgated by the Infectious Diseases Society of America Although the efficacy of antibiotic-control measures in reducing rates of antimicrobial resistance has not been proven in prospective controlled trials, it seems worthwhile to restrict the use of particular agents to narrowly defined indications in order to limit selective pressure on the nosocomial flora

Bioterrorism and Other "Surge-Event" Preparedness

The horrific attack on the World Trade Center in New York City on September 11, 2001; the subsequent mailings of anthrax spores in the United States; and recently exposed terrorist plans and activities in the United Kingdom and elsewhere have made bioterrorism a prominent source of concern to hospital infection-control programs The essentials for hospital preparedness (Table 125-4) entail education, internal and external communication, and risk assessment Up-to-date information on a variety of bioterrorism-associated issues is available from the CDC (see www.bt.cdc.gov)

Table 125-4 Highlights of Hospital Preparedness for Bioterrorism and Other "Surge Events"

Emergency Department: Educate (bioterrorism diagnoses, case

definitions, and appropriate syndrome-based isolation precautions)

Laboratory: Identify protocols and laboratory safety procedures for agents

of bioterrorism

Pharmacy: Develop medication and vaccine par stock, allocation, and

delivery plans

Nursing: Assess bed and isolation surge capacity; help develop

contingency plans to free bed space (e.g., early discharges)

Hospital Police: Plan for responsibilities as first responders and providers

of risk assessment

Engineering/Buildings and Grounds: Evaluate air-handling systems and

ensure familiarity with shutoffs and controls; educate about environmental decontamination

Outpatient Areas: Develop plans for delivery of prophylactic medications

and/or vaccines

Public Health: Open lines of communication, education, and surveillance

The Community: Plan for infection-control practitioners to serve as

liaisons for emergency departments, laboratories, and community providers

Administration: Perform resource assessment (e.g., medical supplies,

transportation capabilities, potable water, sanitation facilities, provider backup,

bed-space backup); oversee development of an incident command system

"Morale Officer": Keep staff functioning