Question 20

Antibiotic Stewardship

• Review antibiotic usage.
• Assess community rate of MRSA

KPIs and Re assessment

• Audit and review that changes are improving habits

Higher marks were allocated to answers which gave a structured approach consisting of

• Identifying the problem
• Instituting change measures, which must include hand washing
• Measuring the effect of the change.

Examiners Comments:

Generally answered well; generic answers without reference to the specific issue were marked poorly.

Discussion

Normally this sort of "organisational approach to MRO spread" question has stereotypical elements. Even though the examiners remark that "generic answers without reference to the specific issue were marked poorly", what they gave was in fact a fairly generic looking answer, in terms of its structure. 

Thus:

Commence active surveillance cultures to determine the extent and source of the problem:

• Identifies the "reservoir" for spread
• Allows precautions to be cost-effectively focused on the reservoir.
• The health care workers themselves may become colonised reservoirs.
• Performed on all patients, on admission, and then periodically (eg. weekly).
• In facilities found to have a high prevalence on initial sampling, a facility-wide culture survey is indicated.

Control the outbreak:

• Contact precautions to prevent new cases
  • Hand hygiene
    • Soap and water for visibly contaminated hands
    • Alcohol-based rub for routine pre-and-post-contact hygiene
    • Monitoring of compliance should be performed
  • Disposable gloves
  • Disposable gowns
  • Patients colonised by the same MRO may be cohorted together.
  • Contaminated areas should be identified by obvious cautionary signs
• Decontamination of existing sources
  • Decontamination ("decolonisation") of MRSA/VRE patients
  • Decontamination of colonised health care workers
  • Environmental disinfection
  • Routine disinfection of equipment between patient contacts
  • Wherever possible, individualised equipment for every patient

Coordinate a response and empower a team to execute the response:

• Infection control specialty team, composed of ICU specialists, infectious diseases specialists, senior nursing staff, laboratory staff and administration staff.
• Allocated resources to MRO surveillance, compliance monitoring and education
• "Champions" - staff allocated to promote the existing policies and monitor adherence

Promote adherence to the new policies

• "Widespread campaign"
• Awareness-rasing posters
• Lunchtime meetings
• Promulgated reading material
• Education bundle as a part of mandatory employee training

Collect data regarding MRSA colonisation and the effect of your new strategies

• Data collection and MRO colonisation record
  • Records of MRO results allow colonised patients to be identified early
• Regular review of collected information, resistance and transmission patterns
• Regular audit of the efficacy of implemented strategies
• Regular comparison of policies to those of peer hospitals
• Regular reevaluation and amendment of infection control policies