Antimicrobial use and multidrug-resistant organisms in community-based healthcare settings – optimising infection control and antimicrobial stewardship

2017-02-16T02:54:05Z (GMT) by Lim, Ching Jou
The emergence of multidrug-resistant (MDR) organisms in the community poses significant threat and burden to community-based healthcare. As the development pipeline of new antibiotics continues to diminish, measures to contain the rising trend of MDR organisms have increasingly relied on effective infection control and antimicrobial stewardship (AMS) strategies. However, these strategies are generally less developed in the community in comparison to the hospital setting. Fundamentally, surveillance activities to monitor the magnitude of infections, antibiotic use and MDR organisms will be crucial to guide timely infection control interventions in high-risk community-based healthcare settings. Two major community-based healthcare settings [residential aged care facilities (RACFs) and emergency departments (EDs)] have been targeted for further research, given their potential as a “reservoir and gateway” for MDR organism transmission into hospitals or other healthcare institutions. To date, a systematic surveillance system for tracking infection rates in Australian RACFs remains to be established. Furthermore, data describing the burden of healthcare-associated infections (HCAIs) and antibiotic use in the Australian RACF setting is limited. A retrospective observational study was initiated to explore the longitudinal trend of infection burden in four co-located Australian RACFs. The average yearly incidence of HCAIs in these facilities (4.16 episodes/1000 occupied bed-days) was found to be comparable to the rates reported in RACFs abroad. However, routine infection surveillance in the absence of more proactive intervention did not result in noticeable reduction of infection burden over time. Importantly, several areas where antibiotic use was likely to be inappropriate have been identified, and up to 37% of antibiotic use was for presumed episodes of infections not meeting the McGeer criteria for symptomatic infections. Evidence from overseas has suggested that residents in RACFs are an important reservoir for transmission of MDR organisms in the community; however, such data are lacking in Australia. The frequent patient transfer between RACFs and acute-care hospitals, and the complexity of their healthcare needs render this population at high-risk for MDR organism transmission. Accordingly, an active surveillance was conducted to explore the carriage of three major groups of MDR organisms in the aforementioned RACFs. The study has revealed significant carriage of various MDR organisms, with 36% of residents carrying at least one type of MDR organisms. Higher prevalence of MDR Gram-negative bacilli (GNB, 21%) colonisation relative to methicillin-resistant Staphylococcus aureus (MRSA, 16%) and vancomycin-resistant enterococci (VRE, 6%) have been shown, proposing that existing infection control strategies that have focused primarily on the containment of MRSA and VRE may need to be modified. Furthermore, these MDR GNB strains were found to have strong clonal relatedness, suggesting the possibility of person-to-person transmission of these organisms within and between RACFs. Specific risk factors for MRSA and MDR GNB colonisation, which may facilitate targeted management of high-risk residents, in particular community-based drivers such as advanced dementia [adjusted odd ratio (AOR) 3.5 [1.2 – 10.2], P=0.02] and prior fluoroquinolone use [AOR 4.3 (1.2 – 15.3), P=0.025], were also identified. The high burden of antibiotic use and MDR organism colonisation among this vulnerable population (as shown in the aforementioned studies) highlights the important role of AMS in the RACF setting. Unfortunately, AMS activities in the RACF setting are substantially behind those in acute-care hospitals. Adopting a comprehensive model of the hospital-based AMS programs into the RACF setting with minimal medical resources is unrealistic. Consequently, the views of general practitioners, executive nurses, nurse unit managers, registered nurses and pharmacists servicing RACFs affiliated with four major public healthcare services within Victoria were explored to understand their perceptions towards AMS interventions in the RACF setting. Using qualitative and observational methods, significant gaps in the RACF organisational workflow and culture in relation to antibiotic prescribing practices were observed, highlighting the unique challenges for the implementation of an AMS program in this setting. Knowledge gaps, especially among nursing staff, in relation to issues of antibiotic over-prescribing and antibiotic resistance were noted. Importantly, the notion of AMS interventions was deemed useful and supported by all key stakeholder groups. This study has identified modifiable factors that will assist resource allocation for potential areas of AMS intervention. The information gathered about the feasibility, barriers and facilitators of various AMS interventions will be useful to guide the development of a feasible model of AMS intervention specifically for the Australian RACFs. ED is another community-based healthcare setting, where surveillance of MDR organisms and identification of high-risk patients (e.g. RACF population) are critical, particularly in severe infections such as bloodstream infections (BSIs). Therefore, a ten-year longitudinal trend, risk factors and clinical outcomes for community-onset (CO) BSI associated with MDR organisms in an Australian ED were studied. Whilst MRSA bacteraemia remained at high levels (20% - 30%) over ten years, the proportion of MDR Escherichia coli causing COBSI was found to be increasing from 9% - 26% (P < 0.001). Previously published healthcare-associated risk factors appeared predictive for MRSA, but were less predictive for MDR GNB. Indeed, being a resident in RACF remained an independent risk factor for acquiring both MRSA and MDR GNB in COBSI, further supporting that the RACF population can serve as an important reservoir for transmission of MDR organisms into hospitals. In summary, the research in this thesis has explored a number of important aspects in relation to antimicrobial use and MDR organisms in two important community-based healthcare settings (RACF and ED). Significantly, this work will provide useful insights into guiding infection control and AMS strategies within these settings.