Bureau of Epidemiology
Bureau of Epidemiology March 2000 Utah Department of Health
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Changes in Clinical Practice Can Reduce Antibiotic Resistance

The discovery of antibiotics was initially hailed as the ultimate solution to the problem of bacterial infections. However, overuse and inappropriate use of antibiotics has led to the development of antibiotic-resistant bacteria. Few guidelines are available for physicians and other health care providers that detail when and when not to prescribe antibiotics in the outpatient setting. Antibiotics are mistakenly prescribed for viral illnesses, allergy-related illnesses, and for patients with “green” sputum or nasal secretions.

Education of health care providers and patients about appropriate antibiotic use can help to curtail the problem of emerging antibiotic resistance. Researchers in rural Alaska provided education to community members and medical providers about the appropriate use of antimicrobials for children with upper respiratory infections.1 Two other areas served as non-intervention controls. Results showed a 22% decrease in antimicrobial prescriptions per respiratory visit in children under five years and a simultaneous 28% decline in pneumococcal isolates that were resistant to penicillin. No significant changes in either antibiotic usage or antibiotic resistance levels were seen in the non-intervention population.

The study in rural Alaska shows that education of health care providers and patients can lead to a change in how antibiotics are prescribed for upper respiratory illnesses. Similar educational efforts might be useful for other conditions. The administration of antibiotics for acute bronchitis has proven to be ineffective in most cases. Researchers have shown that the etiology of acute bronchitis is most often a virus such as adenovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus (RSV), or rhinovirus. Americans make more than 10 million office visits each year for bronchitis, and two-thirds receive antibiotics.2

Antibiotics are also excessively prescribed for patients presenting with pharyngitis. Nearly 70% of all patients with pharyngitis are given antibiotics, however, only 30-40% actually have a bacterial illness.2 According to the 1998 antibiotic use survey conducted in Utah by the Bureau of Epidemiology, primary care physicians in Utah prescribed antibiotics for pharyngitis between 25% and 75% of the time. Seventeen respondents (14%) specifically noted that they prescribed antibiotics only when a positive strep test or culture was available.

Nearly two-thirds of the 13 million patients diagnosed with sinusitis each year are also prescribed antibiotics. In the same 1998 survey conducted by the Bureau of Epidemiology, primary care physicians prescribed antibiotics for sinusitis between 25% and 75% of the time. However, studies have shown that no more than 10% of sinusitis patients have bacterial illness.1 Viruses cause the vast majority of acute sinus inflammation.

To avoid unnecessary treatment for sinusitis, only patients with sinusitis symptoms that persist for more than 10 days should be treated with antibiotics.2 Signs and symptoms of sinusitis may include the following: first, a history of purulent nasal discharge with unilateral predominance; second, a history of facial pain with unilateral predominance; and third, findings of purulent nasal discharge and pus in nasal cavity. When a patient presented with 0-1 of these signs and symptoms, less than 10% had bacteria in their sinuses based on direct sinus puncture. When more than two of these signs and symptoms were present, 67-85% of patients had bacterial sinusitis.3 Other predictors of bacterial versus viral sinusitis may include the following: colored nasal discharge, poor response to decongestants, maxillary toothache, and abnormal sinus transillumination.

The practice of treating the majority of cases of acute bronchitis, pharyngitis, and sinusitis, appears to be widespread despite its questionable clinical effectiveness. In addition, indiscriminate use of antibiotics is contributing to the problem of antibiotic resistance. Education of health care providers and patients has the proven potential to improve the situation. Strong educational efforts need to be undertaken and supported by public and private health care providers to help curb this problem.

References:
1. Petersen, Centers for Disease Control and Prevention, et al. Provider and community education decreases antimicrobial use and carriage of penicillin resistant Streptococcus pneumoniae (PRSP) in rural Alaska communities. IDSA. 1999
2. Gonzales Rand, Sande MA. Uncomplicated acute bronchitis. Submitted for publication. 2000
3. Berg O, Carenfelt C. Analysis of symptoms and clinical signs in the maxillary sinus empyema. Acta Otolaryngol. 1988

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Activities for Addressing Antimicrobial Resistance

As long as antimicrobial drugs are used, drug resistance will remain a challenge. The Centers for Disease Control and Prevention (CDC) vision is a world in which antimicrobial resistance is a manageable problem that does not compromise the availability of safe and effective drugs to treat infectious diseases. In collaboration with many private and public partners, the National Center for Infectious Diseases (NCID) plans the following public health activities to address the problem of antimicrobial resistance:

Surveillance and Response

  • Enhance and coordinate surveillance systems for drug-resistant infections. Data collected through these systems can provide early warnings of outbreaks, identify changing patterns of resistance, guide drug and vaccine development, target prevention and control measures, and assist in targeting and evaluating interventions.

  • Enhance and coordinate surveillance systems for identifying risk factors that lead to drug resistance, including antimicrobial drug use in humans, agriculture, and the environment. These data can be used to assess trends in drug use, the relationship between drug use and the emergence of resistant infections, the appropriateness of drug use, and the extent to which resistance can be reduced through the prudent use of drugs.

Applied Research

  • Investigate the molecular basis of antimicrobial resistance and the epidemiologic factors associated with its emergence and spread.

  • Develop and evaluate new laboratory tests to improve the accuracy and timeliness of antimicrobial resistance detection in clinical settings.

  • Develop, implement, and evaluate appropriate infection control strategies in diverse settings (e.g., hospitals, child care centers, long-term care facilities, and outpatient settings) to prevent transmission of resistant infections.

  • Develop, implement, and evaluate educational and behavioral approaches for improving health care provider adherence to practical recommendations and guidelines for the prudent use of antimicrobial drugs.

  • Develop, implement, and evaluate educational and behavioral interventions that limit the emergence and spread of drug resistance by modifying the drug-prescribing practices of health care providers and educating patients on the appropriate use of drugs.

  • Evaluate vaccine use in preventing drug-resistant infections.

  • Evaluate the effectiveness of formulary controls, reimbursement policies, and regulatory activities in reducing the development and spread of drug resistance.

  • Evaluate the impact of drug resistance, including clinical outcomes and economic costs of treating resistant infections.

Infrastructure and Training

  • Strengthen the capacity of public and private health agencies, health care delivery organizations, and clinical laboratories to detect and report drug-resistant infections, isolate and identify resistant microorganisms, and implement prevention and control strategies.

  • Promote professional education and training in the epidemiology, detection, and prevention and control of diseases that are resistant to antimicrobial drugs, both in the United States and abroad.

Prevention and Control

  • Implement public health programs that prevent the emergence and spread of drug-resistant microorganisms. Such public health programs would include:

  1. infection control strategies in diverse settings;

  1. behavioral and educational interventions for modifying drug-prescribing practices of health care providers;

  1. behavioral and educational interventions for patients on the appropriate use of drugs and adherence to prescription instructions;

  1. health education programs to promote the use of new vaccines for infectious diseases; and

  1. feedback of antimicrobial resistance data to health care providers to reinforce and evaluate intervention programs.

  • Develop and disseminate practical recommendations and guidelines for the prudent use of antimicrobial drugs.

  • Develop and disseminate recommendations and guidelines for laboratory tests to improve the accuracy and timeliness of drug-resistance detection in clinical settings.

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Emerging Antimicrobial Drug Resistance in Hospitals:
A 12 Step Program for Control

The following information is adapted from a presentation by Julie L. Gerberding, M.D., MPH, at the “Advances in Internal Medicine” conference held in Park City, Utah, February 2000.

Dr. Gerberding outlines a 12 step program for controlling antimicrobial resistance in hospitals, including:

Prevent Infection

  1. Vaccinate

  • Get influenza vaccine

  • Give influenza/strep pneumonia vaccine to at-risk patients

  1. Get the catheter out!

  • Use catheters/invasive devices only when essential

  • Maintain proper catheter care

  • Remove catheters/invasive devices

Eradicate Infection ASAP

  1. Get some culture(s)!

  • Diagnose the infection

  • Diagnose the pathogen

  • Diagnose antimicrobial susceptibility

  1. Treat to cure

  • Optimize regimen, dose, duration to eradicate the infection/pathogen

  • Monitor response

Use Antimicrobials Wisely

  1. Accept help

  • Seek expert input from infectious disease/pharmacy consultants

  • Support your local antimicrobial control programs

  1. Use local data to select treatment

  2. Target the pathogen and only the pathogen

  • Less is often best

  • Use/switch to narrow spectrum regimen ASAP

  1. Quit when you are ahead

  • Stop antimicrobials when infection is not diagnosed

  • Stop antimicrobials when cultures are negative

  1. Just say “no” to vanco.

  • Know the epidemiology of MRSA in your hospital

  • Fever and IV is NOT a routine indication for vancomycin treatment.

  1. . Don’t treat contaminants

  • Use proper antisepsis for blood cultures

  • Don’t culture catheter tips

  • Don’t culture through lines

Prevent Transmission

  1. .  Isolate infection at the source

  • Use standard infection control precautions

  • Isolate patients with uncontained infectious body fluids (e.g. diarrhea, exudative wounds)

  • When in doubt, use common sense

  1. .  Wash your hands!

  • Studies show that washing hands for 5 seconds with just water shows no decrease in VRE titer. Handwashing for 30 seconds with warm, soapy water, however, eradicated the VRE.

VRE Survival on Hands and Environmental Surfaces

Source

VRE Survival Time

Gloved Fingers

>60 Minutes

Ungloved Fingers

>60 Minutes

Stethoscope

30 Minutes

Countertops

5-7 days

Telephone

60 Minutes

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Quarterly Report of Diseases of Low Frequency
Year-to-Date January 1 - March 31, 2000
(including a comparison for same time period 1996 –1999)

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Utah Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary
March 2000 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to: The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104 or call (801) 538-6191

Approval 8000008:  Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology
Gerrie Dowdle, MSPH, Managing Editor
Connie Dean, Production Assistant

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