Tracking Trends in Infection Prevention and Antimicrobial Stewardship

By Matt Phillion

Emerging infectious diseases have been increasing in frequency during the past few decades, yet none have tested the U.S. healthcare system’s capacity or resiliency like COVID-19—a pandemic that has forever changed the way we think about surveillance and tracking.

We’ve reached a moment in time where many officials are rolling back mitigation efforts like masking, testing, and rules about gathering. The CDC has updated its guidance to measure community risk for COVID-19 through three primary metrics: new cases, new hospitalizations for COVID-19, and current hospital beds occupied by COVID-19 patients. These metrics underscore the importance of leveraging in-depth data to assemble a more detailed view of near-term risk that goes beyond case numbers.

BD has launched a new blog series, BD Infectious Disease Insights, that examines data from 250 healthcare facilities across the U.S.

“Home testing has become a huge game changer,” says Kalvin Yu, MD, FIDSA, vice president of U.S. medical affairs with BD. “There are pros and cons—easier access in the U.S. is key and critical—but there’s no standardized method of collecting those tests.” That means the true infection rates are thought to be underestimated, as we simply do not have a system in place to capture accurate data. The CDC has tweaked its guidance and safety protocols based on its own data, which does not include the prevalence of home testing.

Meanwhile, variants—omicron BA.4 and BA.5, specifically—are on the rise, thought to be more infectious, and sparking more hospitalizations in different pockets of the world. “The jury is still out on what that means for the U.S.,” says Yu.

Right before COVID-19 hit, Yu says, CMS ruled that to help improve patient safety, organizations would link infection prevention efforts with antimicrobial stewardship programs. This link was added as a Condition of Participation, and organizations without it risked being penalized in their CMS licensing surveys, which could lead to reduced reimbursement.

“I bring this up because COVID highlighted the pre-pandemic problem of increasing antimicrobial resistance,” says Yu. While antibacterials are not used to treat COVID-19 itself, 4%–10% of COVID-19 patients were getting secondary bacterial infections during most of 2020, and those infections tended to be more resistant than community-acquired infections.

“We’ve just published a study showing that as a nation we tend to overuse antibiotics during respiratory virus season—and with that trend, we likewise see more antibiotic-resistant infections during this time. So it’s not a huge surprise that of COVID patients who also had a bacterial infection, if they were placed on inadequate up-front therapy, their clinical outcomes were more severe than those who tested negative for COVID,” says Yu.

Ideally, the teams dealing with these patients make sure the patient is on the right antimicrobial as soon as possible, right when the culture shows it’s needed. But in real life, Yu notes, particularly during a surge capacity situation, that may not happen. A physician who is busy with rounds or with other patients may not get to those results for half a day, which could make an important difference for length of stay, ICU visits, or mortality rates.

Quality initiatives throughout healthcare systems were put on hold to deal with surge capacity, which caused many pre-pandemic infection prevention bundles to fall to the wayside as organizations worked to keep their heads above water.

What are the metrics telling us?

“COVID put a searing spotlight on the importance of using data to track what’s happening, where, and to whom,” says Yu—“not just infection rates, but the severity to which that infection affects crucial organ systems like the heart, liver, and kidney. That more granular information helps you triage your resources—and infection prevention is a low-resourced department, usually, relying on the whole workforce to follow what they recommend. This is hard with patient surges.”
Infection prevention programs do two things, Yu says. One, if there is a person with a contagious condition, the program recommends protocols to mitigate its spread. “That’s the more immediately tangible action,” he says. “The other, more esoteric part often gets the short end of the stick: looking at trends, performing root cause analyses, determining what to do better. That’s the link to stewardship programs. If you have a bad outcome, the infection preventionists will do a root cause analysis and retrospective on what could have been done better.”

Connecting the two as CMS has recommended makes sense, Yu notes. “From the physician standpoint, it’s one continuum. Yes, they should get the best antimicrobial possible,” he says. “But there are silos where infection prevention is separate from antimicrobial stewardship, and now we need to link the two disparate programs in order to improve patient safety and get the patient on the best medications in a more timely fashion.”

That link has been a long time coming, he says. “When you practice medicine, you know there’s a big overlap between what those two programs are trying to do,” says Yu. But infection preventionists are normally nurses or other professionals trained in epidemiology, while antimicrobial stewardship teams are clinicians dealing with infectious diseases, pharmacists, and other team members who are on the treatment end of the spectrum. And this means the two teams have traditionally been funded from different sources, creating an operational silo.

“It’s hard to marry the two, but CMS has made it so that you’re going to have a stewardship committee that purposefully has an infection prevention lead on it and a quality executive so you can execute on findings the stewardship team finds with infection prevention,” says Yu.

What are infection preventionists talking about now?

After living through the worst respiratory pandemic in 100 years, infection preventionists have a lot to talk about, and antimicrobial resistance is top of that list, Yu says. While the industry was bucking the trend pre-pandemic, healthcare-acquired infections climbed over the past two years as organizations struggled to meet the needs of patients during COVID-19.

“We’re at an inflection point where antimicrobial resistance is on the rise, and the U.S. is a nation that uses antimicrobials liberally. We have to get better at that,” says Yu. “I think infection preventionists are seeing that on their end, trends of resistance. It was a theme before COVID and it’s not going anywhere.”

The one upside to COVID-19, Yu says, is that systems, physicians, and researchers are talking about antimicrobial resistance. “Before, we’d call it the silent epidemic. Nobody was talking about it. But worldwide it’s getting more traction.” Antimicrobial use was even a key topic at the G7 summit.

“If you’re a glass half-full person, this is generally an issue everyone can agree on,” he says. “COVID kicked the ball up higher, and that’s why I’m hopeful we’ll see grassroots movement that’s stronger than before the pandemic.”

Technology and tracking trends

With the majority of healthcare systems on electronic records, infection prevention data can be collated via the different aggregate sources, enabling better comparison of infection rates. “It’s what we’ve done with our 250-hospital database,” says Yu.

According to Yu, healthcare systems face a future of managing not only routine respiratory viruses, but also the “x-factor” of continued COVID-19 surges. To understand how antimicrobial resistance may impact this challenge, BD analyzed hospital admissions to compare how inadequate antimicrobial treatment varied before and during the COVID-19 pandemic. Having access to that kind of national data enables BD to highlight trends and make the knowledge available to those who need it.

Take urinary tract infections (UTI), for example. “We looked at UTIs because it’s one of the biggest drivers in antibiotic use and overuse,” says Yu. “If you have a UTI, you may have all the three recommended antibiotics available, but depending on community resistance patterns, you may be resistant to two or even all three, so it’s a crapshoot. If the clinician isn’t aware of the community resistance trends, you may be at more risk for treatment failure; the patient may end up in the ED. You don’t want this kind of scenario running in the background if we’re going to be facing COVID, colds, and flu every season. We’ll be setting up a surge capacity situation all over again.”

We need to be able to learn from this, Yu says. “We need to aggregate data to help clinicians make the right choices; [to show] the impact of inadequate empiric therapy and what it can do in terms of deleterious outcomes and the benefits of visibility of resistance patterns. What we’re trying to show here is that resistance patterns matter,” he says. “We have an infection surveillance platform where we can gather these insights, shine a flashlight on the data and how it matters. It could make a dent in these negative outcomes.”

With infection prevention often underfunded, where does the money for this kind of change come from?

“There’s a question I’ve been asked: how do we talk to a CFO versus a CMO” on this, says Yu. “If you talk about increases in length of stay, readmissions, mortality rates, the CMO thinks about it as bad outcomes from the patient standpoint, and the CFO looks at it from the dollar amount,” such as cost of care or risk of lawsuits. But regardless of where they start from, the benefits to improving these numbers will lead both C-suite roles to the same conclusion.

“It behooves healthcare systems to support their infection prevention and antimicrobial stewardship teams to get the best therapy upstream so those downstream, more costly interventions can be mitigated,” says Yu. “Bring home the fact that everyone should be paying attention to data-informed care.”

Pandemic-era budget cuts have squeezed infection prevention programs not just financially, but also spiritually, Yu says, with discouragement leading to heavy turnover. Younger faces are joining the profession, but there’s a need to empower and educate newer infection preventionists to help make up for the loss of institutional knowledge that comes from turnover. According to Yu, that’s where real-time data can play a critical role.

“One of the reasons we decided to launch the BD Infectious Disease Insights blog series was to show tangible examples of emerging trends that teams can help articulate at their own hospitals, to help steer the spotlight toward them so they can be empowered to make their case,” he says. “We need to sit down and see what COVID has shown us and then lead the discussion about how we can better prepare for the next time through infection prevention and stewardship programs. Healthcare systems should be doubling down on stewardship and infection prevention teams moving forward, and not have these programs be disassembled during surge capacity.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.