1. Ensuring Quality of Care 
             
2. Optimizing Vancomycin for MRSA Infections
      
3. Selecting Appropriate Therapy for ESBL- and KPC-Producers
      
4. Dosing Strategies for MDR P. aeruginosa/A. baumannii Infections
      
5. Adjusting Antimicrobial Regimens for Efficacy and Safety
      

Ensuring Quality of Care

Quality of Care and HAIs:
The Implications

Today’s healthcare environment is characterized by an emphasis on improving patient quality of care and increasing transparency for hospital-acquired conditions. Institutions failing to abide by federal mandates will likely face financial consequences, notably non-reimbursement for conditions considered preventable. In 2009, the Centers for Medicare & Medicaid Services announced 8 hospital-acquired conditions that would no longer be reimbursed, and of these, 3 are infection-related. Other HAIs being considered for addition to this list include ventilator-associated pneumonia and C. difficile infections. A renewed focus on improving quality of care has placed emphasis on preventing HAIs.

CR-BSI: Keystone ICU Project

The Keystone ICU Project evaluated the effectiveness of a state-wide multidisciplinary program in reducing the incidence of catheter-related bloodstream infections (CR-BSIs).[1,2] This study involving 103 of the 108 ICUs in Michigan assessed the impact of implementing a bundled approach of care for all patients requiring a catheter. Following its implementation, the median rate of CR-BSIs significantly decreased from 2.7 to 0 per 1000 catheter-days (P>.002) within 3 months and remained at 0 per 1000 catheter-days during the 16–18-month sustainability period.

VAP: Institute for
Healthcare Improvement

To reduce the incidence of ventilator-associated pneumonia (VAP) the Institute for Healthcare Improvement (IHI) in its “5 Million Lives Saved” program recommends a respiratory bundle be used for all patients requiring mechanical ventilation.

VAP: University Hospital in France

In a report recently published in Critical Care Medicine, a French institution implemented a multifaceted program to improve adherence on 8 targeted measures aimed to reduce the incidence of VAP.[4] The program included a multidisciplinary task force, educational sessions, direct observations with performance feedback, technical improvements, and the use of reminders. Compliance for each of the targeted measures improved at the 1-, 6-, and 12-month periods while the prevalence of VAP decreased by 51%.

References

1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
2. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter-related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309.
3. Weireter LJ Jr, Collins JN, Britt RC, Reed SF, Novosel TJ, Britt LD. Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project. J Am Coll Surg. 2009;208:700-4; discussion 704-5.
4. Bouadma L, Mourvillier B, Deiler V, et al. A multifaceted program to prevent ventilator-associated pneumonia: impact on compliance with preventive measures. Crit Care Med. 2010;38:789-796.

Suggested Reading
Vincent JL, Rello J, Marshall J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302:2323-2329.
This one-day, prospective, point-prevalence study involved 1265 ICUs in 75 countries to provide an up-to-date international picture of the extent and patterns of infections in the ICU. On the day of the study, over 50% of 13,796 ICU patients were infected and 71% were receiving antimicrobials.

Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49:1175-1184.
This study was performed to measure the medical and societal cost attributable to antimicrobial-resistant infection (ARI). Of the 1391 high-risk hospitalized patients included in the study, 13.5% had an ARI. ARI presence resulted in significantly higher medical costs, LOS, and attributable mortality. Studies such as this can help support the clinical and economic benefits of prevention programs.

Wip C, Napolitano L. Bundles to prevent ventilator-associated pneumonia: how valuable are they? Curr Opin Infect Dis. 2009;22:159-166.
This review carefully evaluates the effectiveness of various components of care bundles in preventing ventilator-associated pneumonia. Though some components were shown to not directly impact the incidence of VAP (such as prophylaxis for peptic ulcer disease and deep vein thrombosis), several others were found to be effective and should be considered for inclusion in a modified or expanded VAP bundle.