Health at Risk: The Impact of Antimicrobial Resistance From a Global to Local Health Perspective

Antibiotic Resistance

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One potential threat that I lose sleep over is multidrug-resistant organisms (MDROs). If you query frontline health care providers about whether they experience similar feelings of concern, you may find that they disagree. However, what cannot be seen by the naked eye is a global and local health threat.

According to the World Health Organization (WHO), antimicrobial resistance (AMR) is one of the leading global public health and development threats.¹ When considering how AMR affects the planet, you will often receive varying opinions depending on whom you ask. It is a crucial question to consider as an infection preventionist (IP).

When I contemplate this subject, I rely on, similarly to others in my profession, my experiences, knowledge, and awareness of the importance of prevention through implementing clinical evidence-based practices. However, I know all too well the potential impacts of omission of generally accepted practice bundle elements to treat and prevent hospital and community-acquired infections.

In reviewing the previous WHO bacterial priority pathogens list, one of the top global microbes of concern for bacterial resistance is Mycobacterium tuberculosis (MDR-TB).² However, ranking the prioritization of other antimicrobial bacteria of concern relies on collaborative research and development to identify and understand the burden of pathogenicity. Depending on the setting, this may include considerations for food safety, chemical hazards, and noncommunicable diseases.² It is important to note that there is yet to be a consensus regarding the most effective practice to prioritize infectious diseases.2

In reflection, as IPs, epidemiologists, public health specialists, and health care providers, it is vital to be aware of changes in endemicity and incidence of antimicrobial resistance patterns, including differences between populations impacted by drug-susceptible TB, MDR-TB, and extensively drug-resistant TB (XDR TB), as this may or may not apply to prioritizing AMR efforts and collaboration within your local, region, and state.

The more recently published WHO fungal priority pathogen list highlights the significance of particular emerging fungal priority pathogens.³ In addition to knowledge and prevention of other globally critical resistant organisms such as Aspergillus fumigatus and Cryptococcus neoformans is the ever-concerning multidrug-resistant Candida auris, especially cases of invasive fungal disease, C auris fungemia. Generally, fungal microbes are found within our environment, where intact immunity supports homeostasis. A particular emphasis is placed upon fungal pathogens due to the risk to those with underlying health conditions and immunosuppression, both due to treatment or disease process and those who are critically ill.

Additionally, patients with indwelling lines or drains also have an increased risk. According to the WHO, antifungal resistance can be compounded by consequences that can plague one’s health.3 Antifungal resistance commonly results in extended hospital stays and treatment. Additional limiting factors include lack of access to countries with low to middle incomes due to cost, driven by increased necessity globally, and second-line antifungals can be highly toxic.³

Similarly, on a national level, the CDC published the “Antibiotic Resistance Threats in the United States, 2019 Revision.”⁴ This extensive document pinpoints the dynamics of risks associated with and potential burden within our nation concerning antimicrobial stewardship (AS), diagnostics, resistance factors, and support efforts. The CDC notes gaps are still present, limiting progress against the threat.⁴ The 2019 Revision states, “Antibiotics are critical tools for treating common and complex infections among humans, animals, and crops, including infections that can lead to sepsis.” However, the CDC highlights the significance of infection prevention efforts to aid in reducing the incidence of morbidity and mortality caused by microbial resistance through education and awareness, supported by a retrospective review of electronic health data to reduce the burden of [AMR] amongst our population.⁴

The central repository with which many IPs are familiar is the National Healthcare Safety Network (NHSN).⁵ The substantial benefit of NHSN is that the electronic system supports routine reporting, tracking, and benchmarking of health care-associated infections (HAI) based on facility, region, state, and national data. Additionally, NHSN supports surveillance and reporting for other facilities of importance, including psychiatric hospitals, ambulatory surgical centers, and long-term hospitals and -care facilities. All of them collaboratively support the prevention of antimicrobial utilization and, most recently, the addition of an antimicrobial resistance module.

Reporting via NHSN is in response to fulfilling the Center for Medicare and Medicaid (CMS) Hospital Inpatient Quality Reporting and Promoting Interoperability program requirements for acute care hospitals. For CMS NHSN reporting requirements that may apply to your facility, visit https://www.cdc.gov/nhsn/cms/index.html.⁵ The functionality of antimicrobial use through the utilization of the NHSN database is crucial to understanding a facility from a departmental/location and antimicrobial level. Reports that can be generated based on routinely reported data that can be shared and communicated effectively amongst facility subject matter experts diligently working towards frontline antimicrobial diagnostic stewardship and utilization stewardship programs.

To further explore an exciting collaboration as a systematic approach to reducing the overall burden and risk of the threat of MDROs and AMR on a more personal level, Association for Professionals in Infection Control and Epidemiology provides IPs and Epidemiologists a road map through the IP competency model.⁶

Where there are multiple connections to be made within the competency domains and subdomains, IPC Informatics can be utilized by applying surveillance technology, diagnostic testing data, and techniques that can support the utilization of technologies to monitor adherence to transmission-based and standard precautions. If implemented and educated successfully, it can prevent colonization and possible infection in patients and staff by breaking the chain of infection. Through the quality improvement domain, via data utilization subdomain to identify key indicators to measure, analyze, and interpret for presentation with key stakeholders. The AS subdomain falls within the IPC operations domain, where we, as IPs, must have a seat at the table to support AS initiatives and collaborate with other subject matter experts, including partnerships with infectious disease physicians, infectious disease doctors of pharmacy, and others. All these minute efforts taken on at the facility level actively and passively support and drive community, regional, and national efforts. All of these determine the response to both prospective and retrospective global action plans to reduce the risk and burden associated with AMR and, ultimately, the effects on our planet.

References

1. Antimicrobial resistance. World Health Organization. Published November 21, 2023. Accessed March 3, 2024. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
2. Prioritization of pathogens to guide discovery, research and development of new antibiotics for drug-resistant bacterial infections, including tuberculosis. Geneva: World Health Organization; 2017(WHO/EMP/IAU/2017.12). https://www.who.int/publications/i/item/WHO-EMP-IAU-2017.12
3. WHO fungal priority pathogens list to guide research, development and public health action. Geneva: World Health Organization; 2022. https://www.who.int/publications/i/item/9789240060241
4. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019. http://dx.doi.org/10.15620/cdc:82532
5. National Healthcare Safety Network (NHSN). Antimicrobial Use and Resistance (AUR) Options. Accessed March 3, 2024. Atlanta, GA: US Department of Health and Human Services, CDC. https://www.cdc.gov/nhsn/psc/aur/index.html
6. APIC Infection preventionist (IP) competency model. Association for Professionals in Infection Control and Epidemiology, Inc (APIC). Accessed March 3, 2024. Arlington, VA. https://apic.org/professional-practice/infection-preventionist-ip-competency-model/