Chapter 125. Health Care– Associated Infections (Part 10) Table 125-3 Controlling Antibiotic Resistance: Approaches to Consider Conduct surveillance for antibiotic resistance. Perform molecular typing (e.g., pulsed- field gel electrophoresis) when rates increase. For clonal expansion (e.g., single- strain outbreaks): Stress hand hygiene (alcohol hand rub and universal gloving); monitor adherence and give feedback. For polyclonal expansion (e.g., multistrain outbreaks): Stress antibiotic prudence (conside r antibiotic rotation for ICUs); monitor adherence and give feedback. For continued problems: Obtain patient- surveillance cultures and isolate or provide cohort nursing for colonized/infected patients. Control device-related infections. Enlist administrative support proactively. Source: Adapted from: RA Weinstein, Emerg Infect Dis 7:188, 2001; see also www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Currently, several antibiotic resistance problems are of particular health care concern. First, the emergence of community-acquired MRSA has been dramatic in many countries, with as many as 50% of community-acquired "staph infections" in some U.S. cities now caused by strains resistant to β-lactam antibiotics (Chap. 129). The potential incursion of these strains into hospitals and the resulting impact on control of nosocomial MRSA infections are of enormous concern. Second, in the ongoing global reemergence of nosocomial multidrug- resistant gram-negative bacilli, new problems include plasmid-mediated resistance to fluoroquinolones, metallo-β-lactamase-mediated resistance to carbapenems, and panresistant strains of Acinetobacter. Many of these multidrug-resistant strains are susceptible only to colistin, which has led to a "rediscovery" and renewed use of this drug. Finally, clinical infections with MRSA strains exhibiting high-level vancomycin resistance due to VRE-derived plasmids have been reported in several patients in the United States, often in the setting of prolonged or repeated treatment with vancomycin and/or VRE colonization. The detection of any of these current problems should trigger an epidemiologic investigation and aggressive infection-control measures. Because the excessive use of broad-spectrum antibiotics underlies many resistance problems, aggressive antibiotic-control policies must be considered a cornerstone of resistance-control efforts. Recommendations for "antibiotic stewardship" are being promulgated by the Infectious Diseases Society of America. Although the efficacy of antibiotic-control measures in reducing rates of antimicrobial resistance has not been proven in prospective controlled trials, it seems worthwhile to restrict the use of particular agents to narrowly defined indications in order to limit selective pressure on the nosocomial flora. Bioterrorism and Other "Surge-Event" Preparedness The horrific attack on the World Trade Center in New York City on September 11, 2001; the subsequent mailings of anthrax spores in the United States; and recently exposed terrorist plans and activities in the United Kingdom and elsewhere have made bioterrorism a prominent source of concern to hospital infection-control programs. The essentials for hospital preparedness (Table 125-4) entail education, internal and external communication, and risk assessment. Up-to- date information on a variety of bioterrorism-associated issues is available from the CDC (see www.bt.cdc.gov). Table 125- 4 Highlights of Hospital Preparedness for Bioterrorism and Other "Surge Events" Emergency Department: Educate (bioterrorism diagnoses, case definitions, and appropriate syndrome-based isolation precautions) Laboratory: Identify protocols and laboratory safety procedures for agents of bioterrorism Pharmacy: Develop medication and vaccine par stock, allocation, and delivery plans Nursing: Assess bed and isolation surge capacity; help develop contingency plans to free bed space (e.g., early discharges) Hospital Police: Plan for responsibilities as first responders and providers of risk assessment Engineering/Buildings and Grounds: Evaluate air- handling systems and ensure familiarity with shutoffs and controls; educate about environmental decontamination Outpatient Areas: Develop plans for delivery of prophylactic medications and/or vaccines Public Health: Open lines of communication, education, and surveillance The Community: Plan for infection- control practitioners to serve as liaisons for emergency departments, laboratories, and community providers Administration: Perform resource assessment (e.g., medical supplies, transpo rtation capabilities, potable water, sanitation facilities, provider backup, bed-space backup); oversee development of an incident command system "Morale Officer": Keep staff functioning . Chapter 125. Health Care– Associated Infections (Part 10) Table 125- 3 Controlling Antibiotic Resistance: Approaches to Consider . of particular health care concern. First, the emergence of community-acquired MRSA has been dramatic in many countries, with as many as 50% of community-acquired "staph infections& quot;. hospital preparedness (Table 125- 4) entail education, internal and external communication, and risk assessment. Up-to- date information on a variety of bioterrorism -associated issues is available