Infection Prevention and Control at Sentara Health

Tracey Odachowski

As the country adapts to the ‘new normal’ of infection prevention and control after the height of the COVID pandemic and its ongoing impact, more focus is necessary on the negative impacts of antibiotic use, antimicrobial resistance, and healthcare-associated infections (HAIs). Advances in prevention prior to the pandemic, with reductions in antimicrobial-resistant infections and deaths related to them, have seen a setback since 2020. The world was unprepared for the onset of COVID-19, and responses during that time included antibiotic administration in a ‘try anything’ approach to improve patient outcomes. The Centers for Disease Control and Prevention (CDC) report ‘COVID-19: US Impact on Antimicrobial Resistance, Special Report 2022’ confirmed that antimicrobial-resistant infections have worsened in recent years, showing more infections and increased antibiotic use. The surge of antifungal-resistant infections, such as Candida auris, in hospitals, confirms the need to reverse this trend. CDC also reported similar increases in HAIs during the first two years of the pandemic, including central-line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated events (VAE), and Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Patients were sicker and required more devices, and staffing and supply shortages led to practices contrary to our typical infection prevention techniques. So, how do we alter the course back to pre-pandemic improvements?

" It is time to double down on prioritizing practices and interventions to improve patient outcomes and to slow the spread of MDROs "

Re-Focus on Prevention

Getting ‘Back to the Basics’ has never been more important. Hardwired prevention strategies incorporating hand hygiene, cleaning and disinfection, vaccinations, and standard precautions are impactful in reducing the risk of HAIs and improving outcomes. However, on the tail end of the pandemic peak, many organizations are identifying opportunities to reengage the team in these basic but necessary principles. Hand hygiene programs such as the World Health Organization’s (WHO) 5 Moments for Hand Hygiene or CDC’s Clean Hands Count offer simple educational products for patients and healthcare workers. Personal protective equipment (PPE) is no longer in critical supply and should be used as single use only with standard and transmission-based precautions as guidance. Respiratory hygiene and cough etiquette are still of very high importance as COVID and other respiratory illnesses such as influenza and respiratory syncytial virus (RSV) continue to circulate; ensuring facilities have simple, posted reminders and easily available masks and tissues can go a long way in improving compliance. Lastly, care should be taken to clean and disinfect patient equipment and the environment to aid in reducing the transmission of infectious organisms. Infection prevention education for patients and the community should be cognizant of health equity and hygiene poverty or lack of availability or access to products to clean oneself or their environment.

Scrutinize Culture Collection Techniques

Poor culture collection techniques continue to be of concern, potentially exposing patients to unnecessary antibiotics and increased length of stay. It is important to practice diagnostic stewardship and obtain cultures only on patients that require them and based on the signs and symptoms displayed and source potential. 'Pan culturing' practices should be avoided. For blood cultures, stewardship includes hand hygiene, proper skin antisepsis, blood culture bottle disinfection, proper fill volume of culture bottles, collection before antibiotic administration, and venipuncture collection versus collection via central venous or peripheral catheters. Diversion devices have become commercially available to decrease contamination potential, as well. Urine cultures are of further concern due to contamination risk and the prevalence of asymptomatic bacteriuria (ASB) that is common in women, the elderly, and certain comorbid populations and tends to lead to unnecessary use of antibiotics to treat this benign condition. Additional principles of urine culture stewardship include proper cleansing of the perineum prior to collection and, for patients with indwelling catheters, changing of the catheter prior to collection unless contraindicated to avoid culturing of biofilm.

Examine Antibiotic Use and Necessity

Healthcare facilities are responsible for tracking, monitoring, and reporting antibiotic use. Prescribers, nurses, pharmacists, and patients should receive education about antibiotics and antibiotic resistance but cannot be used alone as a strategy. Regular distribution of facility antibiotic use and resistance summaries should occur along with prescriber-specific details and comparisons to promote accountability. Additionally, patient and staff education is essential to improve antibiotic prescribing practices and usage and is most effective when tailored to the individual. Maintaining a strong partnership and engagement with pharmacists can identify and improve prescribing practices. Key actions incorporating audit and feedback, preauthorization, facility-specific treatment guidelines, and utilization of common treatment interventions for lower respiratory tract infections, urinary tract infections, and skin and soft tissue infections improve antibiotic prescribing and usage.

Conclusion

It is time to double down on prioritizing practices and interventions to improve patient outcomes and slow the spread of MDROs. The advances made in antibiotic use, antimicrobial resistance, and HAI prevention before the pandemic are recoverable, and small changes can greatly impact overall infection prevention and safety.