Nov 18, 2019
Nurses are critical in effective antimicrobial stewardship
Take away messages:
- Antimicrobials are losing their power to fight infections, largely due to inappropriate or excess use.
- Assessing antimicrobial use and recommending caution when using them, including when determining the duration of the treatment, are within all nurses’ scope of practice.
- You have an essential role as an antimicrobial “resistance fighter”!
Imagine a future where a common infection, such as pneumonia, cannot be treated because the antibiotics simply no longer work.
Mr. H is an 87-year-old-man who has been having increasing challenges managing his own care in the house he has lived in for the past 40 years. He required a hospital stay this past winter to treat pneumonia and ended up in the ICU when his condition deteriorated. He has recovered sufficiently to be discharged to long-term care (LTC)/reactivation, but unfortunately, he is now colonized with carbapenemase-producing Enterobacteriaceae (CPE). Because of this resistant organism, local LTC homes are extremely reluctant to accept Mr. H for admission. How did this happen? How can a nurse help to prevent this situation in the future?
Mrs. P is a 75-year-old woman with mild dementia who has been living independently in the community. Her family is concerned because her ability to care for herself has deteriorated recently. She has a reported history of recurrent urinary tract infections (UTIs), and her daughter has brought her to see the family doctor to request antibiotics as she seems more anxious and agitated today. Is there a role for the practice nurse in effective antibiotic use here?
Mrs. P was recently admitted to a LTC home. Her behavioural changes have resulted in the family again requesting antibiotics for a presumed UTI. A personal support worker also notes that Mrs. P’s urine is quite dark and “smelly.” What can a nurse do to help Mrs. P receive best care?
These scenarios highlight the serious impact of antimicrobial resistance on our patients and communities. Nurses are in a unique position to advocate for their patients and influence practice change in relation to antimicrobial use.
- What is antimicrobial resistance?
Antimicrobial resistance (AMR) is the ability of a microorganism (e.g., bacteria, viruses, fungi, and some parasites) to stop an antimicrobial (e.g., antibiotic, antiviral, antifungal, or antiparasitic) from working against it. As standard treatments become ineffective, infections become harder to treat and may spread to others (PHAC, 2015; WHO, 2019a). The World Health Organization includes antimicrobial resistance as one of the top 10 threats to global health in 2019 (WHO, 2019b)—not just for developing countries, but for us all. A recent projection by the Organisation for Economic Co-operation and Development predicts that by 2050, drug-resistant infections will lead to an estimated 2.4 million avoidable deaths in developed countries, including Canada (OECD, 2018).
- How does antimicrobial resistance affect my patient/my practice/me?
Antimicrobial resistance affects not just the person receiving antimicrobials, but the larger society as well. Your patients infected with resistant organisms will need to be treated with alternative antibiotics which are sometimes less effective or cause more side effects. In addition, infections by drug-resistant organisms have been associated with poor health outcomes, including increased length of stay in hospital, complications, and death (WHO, 2014).
Most people with a resistant organism are colonized, meaning that it is present in or on their bodies but not causing symptoms. Being colonized greatly increases the risk of developing an infection, with signs and symptoms of illness. Whether colonized or infected, the patient will be cared for using contact precautions, which include, at minimum, use of gloves for direct care, and likely gowns as well, adding to the nurses’ workload. Precautions and separation can also result in stigma and social isolation, as well as making mobilization or transfer to a more appropriate setting (e.g., LTC or a retirement home) more difficult.
While healthcare providers very rarely acquire antimicrobial-resistant organisms (AROs) (Decker et al., 2017), they can carry them on their hands, equipment, or clothing to the next patient. As resistance grows, more antimicrobials become less effective, and with fewer new antimicrobials being developed (Boucher et al., 2009), untreatable infections may develop. In Canada, the government has identified three antibiotic-resistant illnesses of concern: gonorrhea, pneumonia, and tuberculosis (PHAC, 2014), and now new resistant organisms, such as CPE and Candida auris, are on the rise (Schwartz, 2018).
- What is antimicrobial stewardship?
Antimicrobial stewardship (AMS) is the cautious use of antimicrobials to decrease unnecessary exposure to them and improve infection cure rates, reduce adverse drug reactions, minimize the emergence of antibiotic resistance, and lower health care costs (ANA & CDC, 2017). Antimicrobial stewardship programs (ASPs) promote using antimicrobial drugs only when necessary and then selecting the appropriate antimicrobial at the right dose, route, frequency, and duration to optimize outcomes while minimizing adverse effects. ASP is part of hospital-based patient safety and an Accreditation Canada Required Organizational Practice (Accreditation Canada, 2017). ASP principles apply wherever antimicrobial agents are used, including hospitals, LTC facilities, community medicine, agriculture and veterinary use, and in the home and community (WHO, 2019a).
- What role can nurses play in antimicrobial resistance, and how can I be a steward?
As role models: We all play a personal role in antimicrobial stewardship, starting as simply as not seeking antibiotics for illnesses that are likely viral (e.g., colds and coughs) and making conscious consumer decisions, such as choosing antibiotic-free foods and avoiding antimicrobial cleaning products.
As patient educators: Nurses have a unique and vital role to play in antimicrobial stewardship that has not yet been fully recognized or tapped (ANA & CDC, 2017; Carter et al., 2018; Olans, Olans, & Witt, 2017). We are often the first point of contact for patients/residents/clients and their families when there is a health-related issue, and they look to us for guidance. Nurses can promote prevention, including immunization to prevent infection and subsequent need for antibiotics (Bloom, Black, Salisbury, & Rappuoli, 2018). We can explain the difference between colonization and infection and recommend strategies to prevent or relieve symptoms, such as increasing fluid intake and mobilization. We can provide reassurance that those in our care will be effectively assessed (ANA & CDC, 2017) and carefully monitored, and their care will not be diminished by holding off starting an antibiotic. We can educate others that antibiotics do not work against viral infections (such as the cold and flu), advise on symptom management for coughs and colds, and good hand hygiene to prevent their spread - all of this will help to reduce demand for antimicrobials.
In nursing practice: There are a number of ways nurses can incorporate antimicrobial stewardship into their routine practice. For example, nurses can avoid sending urine cultures for patients without specific symptoms of UTI, thereby preventing unnecessary antibiotic use (Miller, 2016). Nurses also serve as a gateway to safe medication practice and AMS across settings. We are required to understand the indication, action, normal dose and duration, interactions, and side effects of any medications we administer. We can monitor lab reports for sensitivity (that the organism is susceptible to the antibiotic), and participate in clinical decision-making for an antibiotic that is narrow spectrum, prescribed orally if at all possible, and for the shortest period of time (most uncomplicated infections can be treated for 7 days or less) (PHO, 2018).
As interprofessional practice/patient advocates: As a communications hub between patients and families and the larger health care system, nurses should seize opportunities to help build collaborative relationships between disciplines that promote learning, shared understanding, and organizational change related to AMS (ANA & CDC, 2017). Educators can ensure that AMS is included in nursing education (Carter et al., 2018) and create educational tools (e.g., practice guidelines and algorithms) that nurses could readily reference at the point of care.
A 2017 White Paper recommended nurse-driven antibiotic stewardship activities, including questioning the medical necessity of urine cultures; ensuring proper urine and blood culturing techniques; initiating the switch from intravenous (IV) to oral (PO) antibiotics; obtaining and recording an accurate penicillin drug allergy history; and initiating an antibiotic timeout prompting the clinical team to assess and re-assess antibiotic treatment (ANA & CDC, 2017; Raybardhan et al. 2017).
In summary: “Nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy” (Olans et al., 2017).
Here are some essential links to organizations that provide information about the fight against antimicrobial resistance and the important role that nurses can play.
Antimicrobial Resistance Fighters
BC Centre for Disease Control and Alberta Health
Chief Public Health Officer of Canada’s Spotlight Report 2019
Choosing Wisely Canada
- Using Antibiotics Wisely
- Nine Things Nurses and Patients Should Question
- Seven Things Nurses and Patients Should Question
Public Health Ontario
Public Health Agency of Canada
- Antibiotic (antimicrobial) resistance web-page.
Sinai Health System – University Health Network
Accreditation Canada. (2017). Required organizational practice handbook.
American Nurses Association/Centers for Disease Control and Prevention (ANA & CDC). (2017). Redefining the antibiotic stewardship team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the role of registered nurses in hospital antibiotic stewardship practices. Silver Springs, MD: American Nurses Association.
Bloom, D. E., Black, S., Salisbury, D., & Rappuoli, R. (2018). Antimicrobial resistance and the role of vaccines. Proceedings of the National Academy of Sciences of the United States of America, 115(51), 12868–12871.
Boucher, H. W., Talbot, G. H., Bradley, J. S., Edwards, J. E., Gilbert, D., Rice, L.B. … Bartlett, J. (2009). Bad bugs, no drugs: No ESKAPE! An update from the Infectious Diseases Society of America. Clinical Infectious Diseases, 48(1), 1–12.
Carter, E. J., Greendyke, W. G., Furuya, E. Y., Srinivasan, A., Shelley, A. N., Bothra, A., … Larson, E. L. (2018). Exploring the nurses’ role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists. American Journal of Infection Control, 46(5), 492–497.
Decker, B. K., Lau, A. F., Dekker, J. P., Spalding, C. D., Sinaii, N., Conlan, S., … Palmore, T. N. (2017). Healthcare personnel intestinal colonization with multidrug-resistant organisms. Clinical Microbiology and Infection. 24(1), 82.e1-82.e4. doi: 10.1016/j.cmi.2017.05.010
Miller, J. M. (2016). Poorly collected specimens may have a negative impact on your antibiotic stewardship program. Clinical Microbiology Newsletter, 38(6), 43–48.
Olans, R. D., Olans, R. N., & Witt, D. J. (2017). Good nursing is good antibiotic stewardship. American Journal of Nursing, 117(8), 58-63 doi: 10.1097/01.NAJ.0000521974.76835.e0.
Organisation for Economic Co-operation and Development (OECD). (2018.) Stemming the superbug tide: Just a few dollars more. Paris: OECD Publishing. doi: 10.1787/9789264307599-en
Public Health Agency of Canada (PHAC). (2014). Antimicrobial resistance and use in Canada: A federal framework for action.
Public Health Agency of Canada (PHAC). (2015). Federal plan on antimicrobial resistance and use in Canada: Building on the federal framework for action.
Public Health Ontario (PHO). (2018). Evidence brief: Duration of antibiotic treatment for pneumonia in long-term care residents.
Raybardhan S., Chung B., Ferreira D., Bitton M., Shin P., Kan T. & Das P. (2017.) Nurse prompting for prescriber-led review of antimicrobial use in the critical care unit: a quality improvement intervention with controlled interrupted time series analysis. Open Forum Infect Diseases, 4(Suppl 1): S278. doi: 10.1093/ofid/ofx163.624
Schwartz, I. S., Smith, S. W., & Dingle, T. C. (2018). Something wicked this way comes: What health care providers need to know about Candida auris.
World Health Organization (WHO). (2014). Antimicrobial resistance: Global report on surveillance.
World Health Organization (WHO). (2019a). Fact sheet: Antimicrobial resistance.
World Health Organization (WHO). (2019b). Ten threats to global health in 2019.