Protecting Patients and Stopping Outbreaks

Antibiotic resistance in healthcare settings is a significant threat to public health.  Because almost all Americans will receive care in a medical setting at some point, antibiotic resistance can affect anyone.  By preventing antibiotic resistance in healthcare settings, patients’ lives are better protected and their health can be preserved.  

Antibiotic-resistant infections can happen anywhere.  Data show that most happen in the general community; however, most deaths related to antibiotic resistance happen in inpatient healthcare settings, such as hospitals and nursing homes

Inpatient Healthcare Settings

Inpatient Healthcare Providers

• Know what types of drug-resistant infections are present in your facility and patients.
• Request immediate alerts when the lab identifies drug-resistant infections in your patients.
• Alert receiving facility when you transfer a patient with a drug-resistant infection.
• Protect patients from drug-resistant infections.
• Follow relevant guidelines and precautions at every patient encounter.
• Prescribe antibiotics wisely.
• Remove temporary medical devices such as catheters and ventilators as soon as they are no longer needed.

Health Care CEOs, Medical Officers, and Other Healthcare Facility Leaders

• Require and strictly enforce CDC guidance for infection detection, prevention, tracking, and reporting.
• Make sure your lab can accurately identify infections and alert clinical and infection prevention staff when these bacteria are present.
• Know infection and resistance trends in your facility and in the facilities around you.
• When transferring a patient, require staff to notify the other facility about all infections.
• Join or start regional infection prevention efforts.
• Promote wise antibiotic use.

 Top of Page

Resources for Healthcare

• Get Smart for Healthcare 
• Get Smart: Know when Antibiotics Work for Healthcare Professionals
• Core Elements of Hospital Antibiotic Stewardship Programs
• HICPAC: Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006
• Antibiotic Rx in Hospitals: Proceed with Caution
• Stop Infections from Lethal CRE Germs Now
• Stopping C. difficile Infections
• 2012 CRE Toolkit – Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)
• NEW, March 2017: Interim Guidance for a Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs)

Outpatient Healthcare Settings

Antibiotic-resistant infections outside of the hospital setting were rare until recently.  

• Prescribing antibiotics when they are not needed or prescribing the wrong antibiotic in outpatient settings such as doctors’ offices is common.  
• In some cases, doctors might not order laboratory tests to confirm that bacteria are causing the infection, and therefore the antibiotic might be unnecessarily prescribed.  
• In other cases, patients demand treatment for conditions such as a cold when antibiotics are not needed and will not help.

Resources for Outpatient Healthcare Settings

• Get Smart: Know when Antibiotics Work
• Adult Treatment Recommendations for Outpatient Healthcare Professionals
• Pediatric Treatment Recommendations for Outpatient Healthcare Professionals
• Resources for Community Pharmacists
• Materials and References for Outpatient Healthcare Professionals

   Top of Page

Steps to Combat Antimicrobial Resistance in Outpatient Settings

Steps	Suggestions for implementation
Improve antibiotic prescribing
Use current clinical guidelines to support rational and appropriate antibiotic prescribing	Share unremarkable finding during the examination (e.g., “no inflammation” or “normal breathing”), while acknowledging the patient is sick. Determine the likelihood of a bacterial infection, especially for upper respiratory track infections. Provide a specific diagnosis (e.g., “viral bronchitis” vs “virus”) Weigh benefits vs harms of antibiotics
Communicate with patients about when and why antibiotics may not be necessary	Explain that unnecessary antibiotic use can be harmful (e.g., adverse effects associated with antibiotic use, potential resistance development) Explain that treating viral infections with antibiotics does not work Explicitly plan treatment of symptoms by describing the expected normal course of the illness, and instruct patients to call or come back if symptoms persist or worsen; consider providing care packages with non antibiotic therapies
Educate patients if an antibiotic is needed	Encourage adherence Discuss potential adverse effects
Create an office environment that promotes a reduction in antibiotic use	Start the process in the waiting room with videos, posters, and other materials Hang posters in examination rooms to display a commitment to not prescribe antibiotics for viral infections Involve office personnel in the reinforcement of the physician’s messages
Prevent infections and the spread of resistant bacteria
Ensure that all patients get recommended vaccinations Prevent cross-transmission	Provide pneumococcal and influenza vaccines (to help avoid secondary bacterial infections)., which are particularly important Counsel patients onhow to avoid spreading or becoming infected with resistant pathogens in the community (e.g., methicillin-resistant Staphylococcus aureus) Follow recommendations for infections control in outpatient settings (/hai/settings/outpatient/outpatient-care-guidelines.html)
Monitor antibiotic-resistant infections
Report notifiable diseases	Report to the health department any diseases caused by bacteria on the Centers of Disease Control and Prevention’s list of urgent and serious pathogens (reporting requirements differ by U.S. state and Canadian province); antibiotic-resistant strains of some bacteria (e.g., methicillin-resistant Staphylococcus aureus) are reportable in some states
Be alert for treatment failures	Consider the possibility of antibiotic resistance in cases of treatment failure; obtain laboratory confirmation and notify local public health authorities in case of unusual or unexpected treatment failure

 Top of Page

Biggest Antibiotic Resistance Threats in Healthcare

Microorganism	Notable information
Urgent
Clostridium difficileA1,A2	Deaths related to C. difficile increased 400% between 2000 and 2007, in part because of a stronger strain Most infections are connected to receiving medical care Hand sanitizer does not kill C. difficile, and hand washing may not be sufficient
Carbapenem-resistant EnterobacteriaceaeA3	Difficult to treat and, in some cases, untreatable Kills up to one-half of patients who get bloodstream infections Easily spreads antibiotic resistance to other bacteria
Drug-resistant Neisseria gonorrhoeaeA4	Cases in the United States are more prevalent in the West and among men who have sex with men All patients treated for gonorrhea should routinely be offered condoms, referred for risk-reduction counseling, and retested for gonorrhea three months later
Serious
Multidrug-resistant AcinetobacterA5	Increasingly common in U.S. health care facilities; hard to treat Noted in U.S. service members wounded in Iraq and Afghanistan
Drug-resistant CampylobacterA6	Most cases are sporadic and not part of outbreaks Ciprofloxacin (Cipro) resistance to Campylobacter increased from 12% in 1997 to 24% in 2011
Fluconazole- (Diflucan-) resistant Candida (fungus)A7-A9	Antifungal resistance in mucosal candidiasis varies by species
Extended spectrum ß-lactamase producing EnterobacteriaceaeA10,A11	Infections have become more common in recent years Once confined largely to hospitals, these bacteria, especially Escherichia coli, are increasingly common in community-acquired infections, particularly urinary tract infections
Vancomycin-resistant EnterococcusA12-A14	Enterococci are the fifth most common cause of health care–associated infections Most likely to be found in urine and in wounds; may pose a risk for spreading in the outpatient setting
Multidrug-resistant Pseudomonas aeruginosaA15,A16	About 8% of all health care–associated infections are caused by P. aeruginosa; about 13% of severe P. aeruginosa health care–associated infections are multidrug resistant P. aeruginosa may be isolated from outpatients with otitis, skin rash, and urinary tract infections
Drug-resistant non-typhoidal SalmonellaA17,A18	Estimated 1.2 million cases occur each year in the United States; most go unreported About 100,000 of cases (8%) are caused by drug-resistant Salmonella Outbreaks occur each year; some involve multiple states and/or national distribution
Drug-resistant Salmonella serotype TyphiA19	Estimated 5,700 cases annually in the United States Most (up to 75%) are acquired during international travel Increasing resistance to antibiotics, especially fluoroquinolones
Drug-resistant ShigellaA20	High-risk groups include children in day care centers (younger than five years) and their caregivers, men who have sex with men, international travelers, and persons in custodial institutions Increasing resistance to ciprofloxacin and azithromycin (Zithromax) is of particular concern
MRSAA21-A23	Although overall cases of invasive MRSA are declining, the proportion of community-associated infections has increased MRSA should be considered in the differential diagnosis of skin and soft tissue infections
Drug-resistant Streptococcus pneumoniaeA24	The increasing threat of antibiotic resistance makes vaccination according to the Advisory Committee for Immunization Practices’ recommendations for children and adults more important
Drug-resistant TBA25,A26	The number of TB cases is declining in the United States 63% of TB cases in the United States occur among foreign-born persons The proportion of primary multidrug-resistant TB cases occurring among foreign-born persons has been increasing
Concerning
Vancomycin-resistant Staphylococcus aureusA27	Rare; 13 cases have been identified in the United States since 2002 The severity of the consequences of S. aureus resistance to vancomycin require continued vigilance for this pathogen
Erythromycin-resistant Group A StreptococcusA28	Penicillin remains the drug of choice, but the resistance to other drugs needed for patients allergic to penicillin is worrisome Of samples tested by the CDC, 10% were erythromycin-resistant and 3.4% were clindamycin-resistant
Clindamycin-resistant Group B StreptococcusA29	Neonates, pregnant women, and persons older than 65 years with underlying conditions are at highest risk Penicillin remains the drug of choice, but the resistance to other drugs needed for patients allergic to penicillin is worrisome

NOTE: Additional information on the microorganisms in this table can be found in the CDC’s antibiotic threats report at https://www.cdc.gov/drugresistance/drugresistance/threat-report-2013/index.html (accessed March 27, 2014).
CDC = Centers for Disease Control and Prevention; MRSA = methicillin-resistant Staphylococcus aureus; TB = tuberculosis.

 Top of Page