Question 14

College Answer

More focus on techniques for prevention and control:
•  hand washing practice, placement of hand basins, use of gloves, use of protective clothing
•  isolation  techniques  (standard  precautions,  transmission  based   precautions  [airborne, dropJet, contact])
•  increasing need for surveillance

More focus on judicious use of antibiotics (individual versus community needs)
•  appropriate initial cover, tailor quickly according to results of investigations, stop as soon as no longer  needed
•  reserve/restrict use of some  antibiotics (eg. vancomycin) with use of alternatives whenever possible

Need to alter antibiotic prescribing habits:
•  initial antibiotic regimen may not cover infecting organism
•  community acquired  organisms have more resistance eg. penicillin no longer always useful against streptococcus or haemophilus
•  third generation cephalosporios lose value after first week. in hospital
•  may have to use uncommonly used antibiotics (intravenous cotrimoxazole)
•  broader antibiotic use may increase superinfection (C difficile, fungi, etc.)
• antibiotics used for prophylaxis may  need to change  accordingly (? vancomycin for cardiac surgery)

Increased cost:
• newer antibiotics or combinations used to treat some resistant infections                          
•  additional susceptibility  testing required
•   invasive lines impregnated (antibacterial) or changed more frequently
•  ? prolonged ICU and hospital stay of nosocomial infections

Have no available antibiotics to treat infections with some resistant organisms.

Discussion

This is another very broad question. The candidate ought to have prepared a prefabricated rant in reponse to this. A solid basis for such a rant may be derived from articles such as this 2011 paper, which discuss the burden of multidrug resistance in the ICU. This question was from 2000, and the authors probably had something like this 1999 paper in mind.

In point form:

Preventative measures

• Routine barrier and infection control process needs complicance monitoring and regular review.
• Surveillance for MROs must be proactive.
• Patient isolation should be practiced.

Antibiotic stewardship

• Use of some antibiotics should be restricted/reserved
• Broad spectrum antibiotics must be deployed intelligently
• Antibiotics must be reviewed daily, and narrowed or discontinued when appropriate
• Infectious diseases physicians should have greater input into prescribing practices
• Perioperative prophylaxis needs to be rationalised
• Antibiotic cycling may be helpful in preventing the emergeance of resistant strains

Healthcare costs

• Increased cost of increased surveillance
• Increased cost of extended spectrum susceptibility testing
• Increased cost of increased use of consumables (eg. gloves, gowns, single room terminal cleaning)
• Increased cost of exotic antibiotics
• Increased cost of increased duration of hospital and ICU stay
• Cost of developing and testing new antimicrobial agents

Elliott, T. S. J., and P. A. Lambert. "Antibacterial resistance in the intensive care unit: mechanisms and management." British medical bulletin 55.1 (1999): 259-276.

Brusselaers, Nele, Dirk Vogelaers, and Stijn Blot. "The rising problem of antimicrobial resistance in the intensive care unit." Annals of intensive care 1.1 (2011): 1-7.

Niederman, Michael S. "Impact of antibiotic resistance on clinical outcomes and the cost of care." Critical care medicine 29.4 (2001): N114-N120.