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The Focus Areas: II. Prevention and Control

Prevention and control of drug-resistant infections require measures to promote the appropriate use of antimicrobial drugs and prevent infection transmission. The concept of appropriate use may be expressed in various other ways, e.g., good antimicrobial stewardship or judicious, prudent, or rational use. In this Action Plan, appropriate antimicrobial drug use is defined as use that maximizes therapeutic impact while minimizing toxicity and the development of resistance. In practice, this means prescribing antimicrobial therapy when and only when beneficial to a patient; targeting therapy to the desired pathogens; and using the appropriate drug, dose, and duration. Appropriate antimicrobial drug use should not be interpreted simply as reduced use because these drugs offer valuable benefits when used appropriately. It is overuse and misuse that must be decreased to reduce the selective pressure favoring the spread of resistance.

Appropriate use can be facilitated in various ways, e.g., by promoting informed prescribing by clinicians, informing consumers about the proper use and limitations of antimicrobial drugs, and improving diagnostic techniques. The challenge facing public health organizations is to work with partners to identify effective methods of promoting appropriate antimicrobial drug use and to translate these interventions into routine medical practice.

Measures to prevent infection transmission, whether drug-resistant or not, are also very important in controlling AR. These measures include the appropriate use of vaccines and infection control, sanitation, hygiene measures, and other safe behaviors, e.g., safe sexual practices. Efforts to control drug-resistant infections must become part of everyday practice in healthcare settings across the nation, as well as in other settings (e.g., agriculture and veterinary medicine) in which antimicrobial drugs are used. Partners in many sectors of society and the general public will need to be involved in this effort.

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A. Issue: Appropriate use of antimicrobial drugs can offer great benefits to patients, but overuse and misuse of these drugs can hasten the development of resistance and shorten the drug’s useful life.

1. Goal: Identify effective methods for promoting appropriate antimicrobial use.

a. Action Items

  1. Identify factors that promote or impede appropriate drug use in hospitals, extended care facilities, and outpatient settings in collaboration with partners.b Coordinator: CDC; Collaborators: FDA, AHRQ, DVA, DoD Timeline: Initiated
  2. Develop appropriate drug use policies and evaluate the impact (including on prescribing patterns, resistance rates, patient outcome, and cost) of implementing these policies in hospitals and other healthcare delivery settings. Identify ways to increase adherence to appropriate use policies proven to be beneficial in collaboration with partners.b Coordinator: CDC; Collaborators: AHRQ, FDA, DVA, DoD, HCFA Timeline: Initiated
  3. Evaluate the relationship between prescribing behavior and specific antimicrobial drug marketing and promotional practices. Assess the public health effects of these practices in collaboration with partners.b Coordinators: CDC, FDA Timeline: Begin within three to five years
  4. Help individual hospitals and healthcare systems analyze how the availability of AR data and computer-assisted decision support systems influences prescriber behavior, health outcomes, and costs. This plan may include the provision of computer software and the establishment of projects that involve the Medicare Peer Review Organizations (PROs). Coordinator: CDC; Collaborators: HCFA, DVA, DoD Timeline: Begin within three to five years

2. Goal: Promote appropriate antimicrobial use through educational and behavioral interventions found to be effective.

a. Action Items

  1. TOP PRIORITY ACTION ITEM - Conduct a public health education campaign to promote appropriate antimicrobial use as a national health priority. The campaign should involve many partners.b Elements of this campaign may include:
    • Culturally appropriate educational and behavioral interventions implemented through community-based programs that target patients and selected populations and communities, such as daycare centers and schools;
    • Strategies to improve patient adherence to appropriate therapies;
    • A clearinghouse for educational materials (e.g., booklets and CD-ROM presentations) on appropriate drug use and AR prevention;
    • A periodically updated priority list of drug-resistant microorganisms in humans and animals; and
    • A glossary disseminated through CDC Website that defines technical words commonly used in discussions of AR issues.
      Coordinators: CDC, FDA; Collaborators: USDA, HCFA Timeline: Begin within one to two years
  2. TOP PRIORITY ACTION ITEM - In collaboration with many partners,b develop and facilitate the implementation of educational and behavioral interventions that will assist clinicians in appropriate antimicrobial prescribing. Examples may include:
    • Educational curricula and training modules for all prescribing clinicians, health professions students, trainees, and senior healthcare administrators as part of quality assurance programs;
    • Clinical guidelines that address appropriate antimicrobial use; · Informatics technology (e.g., computer-assisted decision support) to assist in point-of-care prescribing and patient outcome monitoring;
    • Culturally appropriate materials and methods to help clinicians explain to patients the benefits and limitations of antimicrobial drugs and the importance of appropriate use of these drugs; and
    • Material that could be included in licensing, board certification, and credentialing examinations.
      Coordinators: CDC, FDA; Collaborators: DoD, DVA, HRSA, HCFA
      Timeline: Initiated

3. Goal: Promote appropriate antimicrobial use through regulatory changes and public policy actions.

a. Action Items

  1. Explore ways to integrate appropriate use information into antimicrobial package inserts and promotional materials, to provide such information to patients with each prescription, and to provide clear guidance to industry to ensure that promotion of antimicrobials directed towards consumers encourages appropriate use and discourages inappropriate use. Coordinator: FDA; Collaborator: CDC Timeline: Initiated
  2. Articulate factors that support the current approach of requiring prescription-only dispensing for all systemic (i.e., nontopical) antimicrobial drugs used in clinical medicine. Coordinator: FDA; Collaborator: CDC Timeline: Begin within one to two years
  3. Periodically review and update antimicrobial drug susceptibility information included in drug labeling, with input from stakeholders and other experts, e.g., the National Committee for Clinical Laboratory Standards (NCCLS) and CDC. Coordinator: FDA Timeline: Begin within one to two years
  4. Convene an advisory panel or other expert group involving stakeholders and partnersb to consider issues related to resistant pathogens that cause serious infections for which available treatment options are very limited or nonexistent. Issues include:
    • Criteria for designating such drug-pathogen combinations;
    • Compiling and updating a list of such drug-pathogen combinations;
    • Recommendations for diagnosis and management of patients with suspected or documented infection, including where appropriate that selected important drugs be preferentially used for the treatment of conditions associated with organisms that are resistant to other drugs;
    • Publicizing and facilitating access to clinical trials or compassionate use of investigational therapies;
    • Recommendations for preventing infection transmission;
    • Recommendations for performance and reporting of susceptibility test results for selected important drugs by clinical laboratories including possibly that they be reported to clinicians only on request if an organism is sensitive to other appropriate drugs;
    • Monitoring the use of selected important drugs, with consideration of changes in product labeling by FDA and in recommendations for use if increased resistance is detected; and
    • Labeling by FDA of selected important drugs with the recommendation that they be preferentially used for the treatment of conditions associated with organisms that are resistant to other drugs. (Related Action Item: This item will also be considered in conjunction with Product Development #80.)
      Coordinators: FDA, CDC
      Timeline: Begin within one to two years
  5. Convene a working group to examine the impact of federal reimbursement policies for home parenteral antimicrobial treatment, appropriate antimicrobial use, and appropriate use of antimicrobial susceptibility testing. Where needed, the working group will make recommendations for modifying these policies.
    Coordinator: HCFA;
    Collaborators: CDC, HRSA
    Timeline: Begin within one to two years
  6. Develop and submit measures for appropriate antimicrobial use to the National Committee for Quality Assurance for inclusion in Health Plan Employer Data and Information Set (HEDIS), which provides comparative data on managed care organizations.
    Coordinator: CDC; Collaborator: HCFA
    Timeline: Initiated

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B. Issue: Improved diagnostic practices can enhance antimicrobial use and patient care.

1. Goal: Identify and promote the widespread use of diagnostic testing and reporting strategies that effectively facilitate appropriate use of antimicrobial drugs in routine practice.

a. Action Items

  1. Evaluate the potential impact of improved diagnostic tests, including rapid point-ofcare tests on antimicrobial drug use and patient care, and assess their financial implications. Take into account tests that distinguish between bacterial and viral infections, tests that identify resistant pathogens, and tests that distinguish common clinical entities such as bacterial sinusitis and acute bacterial otitis media from illnesses with similar manifestations for which antimicrobials are not beneficial. (Related Action Item: Research #76) Coordinators: CDC, FDA, NIH; Collaborators: DVA, DoD, Timeline: Begin within one to two years
  2. Identify economic and other barriers in the healthcare system (e.g., reimbursement policies by third-party payers, managed care practices, cost considerations, empiric treatment recommendations, etc.) to diagnostic testing that promotes appropriate use of antimicrobials. Develop recommendations that remove disincentives or promote incentives to such testing. Coordinator: HCFA; Collaborators: CDC, HRSA; AHRQ Timeline: Begin within three to five years
  3. In collaboration with professional societies, industry, health departments, and other stakeholders and partners,b develop guidelines for clinicians and clinical microbiology laboratories that address:
    • Appropriate specimen collection;
    • Performance, interpretation, and reporting of antimicrobial (including antibacterial, antifungal, antiviral, and antiparasitic) susceptibility tests performed on clinical specimens; and
    • Use of in-office (point-of-care) tests for infection, including AR infections. Coordinator: CDC; Collaborators: FDA, DoD, DVA, HCFA, HRSA Timeline: Begin within three to five years
  4. In collaboration with professional societies, industry, health departments, and other stakeholders and partners,b develop guidelines that address the use of clinical microbiology laboratories for use by healthcare delivery organizations. The guidelines will:
    • Promote access to clinical microbiology services by clinicians;
    • Promote access to appropriate on-site microbiology services in acute care facilities;
    • Allow physicians to submit specimens to clinical laboratories other than those designated by their healthcare delivery organization or the patient’s insurance company, with appropriate justifications; and
    • Facilitate direct consultation between clinicians and laboratory personnel with appropriate expertise and authority.
      Coordinator: CDC; Collaborator: HCFA for bullet 2.
      Timeline: Begin within one to two years
  5. Promote the increased performance of direct examination of microbiological specimens (e.g., by Gram stain or other rapid method), in circumstances where appropriate, clinically relevant, and reliable information can be garnered, as a readily available point-of-care diagnostic test. This step will require working within the framework of the Clinical Laboratory Improvement Amendment (CLIA) regulations and involving medical education and healthcare delivery organizations. Coordinator: CDC; Collaborator: HCFA Timeline: Begin within one to two years

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C. Issue: Preventing infection transmission through improved infection control, behaviors that prevent infection (e.g., safe sexual practices), and use of vaccines can help prevent the spread of antimicrobial resistance.

1. Goal: Identify ways to reduce disease transmission in healthcare settings and in the community.

a. Action Items

  1. Identify factors that promote transmission of drug-resistant pathogens in healthcare facilities, in extended care facilities, and in community settings including daycare centers and in the community at large. These may include characteristics of the facilities and of the populations that they serve. Coordinator: CDC; Collaborators: DVA, DoD Timeline: Initiated
  2. TOP PRIORITY ACTION ITEM - Evaluate the effectiveness (including costeffectiveness) of current and novel infection-control practices for healthcare and extended care settings and in the community. Promote adherence to practices proven to be effective. Coordinator: CDC; Collaborators: DoD, DVA, HCFA, HRSA Timeline: Initiated
  3. Evaluate the cost-effectiveness and impact on patient care and drug resistance of medical devices that incorporate anti-infective compounds to prevent infection (e.g., anti-infective urinary catheters and prosthetic heart valves). Where appropriate (e.g., shown to be effective and not induce resistance), encourage the clinical use of these devices. (Related Action Item: Product Development #82) Coordinator: CDC; Collaborators: AHRQ, DoD, DVA, FDA, HRSA, HCFA Timeline: Begin within three to five years
  4. Encourage the development and implementation of clinical alternatives to those invasive medical procedures and devices that increase the risk of infection in hospitals and other healthcare settings, e.g., substitution of transcutaneous monitoring of blood oxygen levels of indwelling catheters. Coordinator: CDC; Collaborators: FDA, DVA Timeline: Begin within three to five years
  5. Evaluate the benefits and risks of incorporating antimicrobial, disinfectant, or antiseptic chemicals into consumer products (e.g., soap, toys, kitchen utensils, clothes, paints, plastics, and film preservatives) and of applying disinfectants and sanitizers to hard, non-porous surfaces such as food-contact surfaces, hospital premises, bathrooms, etc. Consider whether they have any efficacy in reducing infection and/or may play a role in promoting drug resistance. Coordinators: CDC, EPA; Collaborator: FDA Timeline; Initiated

2. Goal: Promote infection control through behavioral and educational interventions.

a. Action Items

  1. Conduct a public health campaign to promote hand hygiene and other hygienic practices, as well as other behaviors that prevent the transmission of infectious organisms, in collaboration with professional societies and stakeholders. This campaign may be coordinated with the public health education strategy to promote appropriate antimicrobial use described in Action Item #25: Prevention and Control. Components will include developing, evaluating, and facilitating the implementation of school-based and other programs that promote hand hygiene and other behaviors that prevent infection, building on previous campaigns (e.g., American Society of Microbiology’s Operation Clean Hands).
    Coordinator: CDC
    Timeline: Begin within one to two years
  2. Facilitate and support the activities of infection control programs in healthcare settings as a component of medical care. Promote infection control education at all stages of training and practice for all healthcare workers who have contact with patients.
    Coordinator: CDC; Collaborators: DVA, HCFA, DoD, HRSA
    Timeline: Initiated
  3. Support ongoing public health education campaigns on food safety, such as FDA and USDA’s Fight Bac program,28 whose aims are to educate food producers, suppliers, retailers, and consumers about food safety practices that reduce foodborne infections (including AR infections).
    Coordinators: USDA, CDC, FDA Timeline: Initiated
  4. Educate the public about the merits and safety of irradiation as one tool to reduce bacterial contamination of food.
    Coordinator: CDC Timeline: Begin within one to two years

3. Goal: Optimize the use of vaccines to prevent drug-resistant infections and reduce antibiotic use.

a. Action Items

  1. Support community-based programs that promote and facilitate availability of recommended vaccinations for adults and children. Coordinator: CDC Timeline: Initiated
  2. Identify vaccines useful in preventing drug-resistant infections and reducing antimicrobial drug use, and evaluate novel methods for improving coverage with these vaccines. For example:
    • Evaluate the risks and benefits of allowing certain vaccines for adults (e.g., for pneumococci and influenza virus) to be dispensed by pharmacists without prescription and
    • Review and evaluate methods to promote administration of pneumococcal vaccines (e.g., offering vaccination when patients are discharged from the hospital), and encourage the use of methods found to be effective. Coordinator: CDC; Collaborators: DVA, FDA, HCFA Timeline: Begin within three to five years

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D. Issue: Prevention and control of drug resistance in agriculture and veterinary medicine is important to promoting animal and plant health, as well as in preventing AR transmission to humans through the food supply or through contact with infected animals or the environment.

1. Goal: Improve understanding of the risks and benefits of antimicrobial use, and ways to prevent the emergence and spread of drug resistance, in agricultural and veterinary settings.

a. Action Items

  1. Evaluate the nature and magnitude of the impact of using various antimicrobial drugs as growth promotants in different species, using current animal husbandry practices. Use this information to assist in risk-benefit assessments of such use. Coordinator: USDA; Collaborators: CDC, FDA Timeline: Begin within one to two years
  2. Conduct additional research to further define the effects of using various veterinary drugs on the emergence of resistant bacteria that infect or colonize food animals of different species, using various animal husbandry practices. Identify risk factors and preventive measures. Assess the associated risk of:
    • Transmission of AR infections to humans;
    • Clinical disease in humans;
    • and Transfer of resistance factors from animal flora to human flora.
    Coordinators: CDC, USDA, FDA Timeline: Initiated
  3. Conduct epidemiologic and laboratory studies to assess the risk of development and transfer of resistance related to the use of antimicrobial drugs in food and nonfood plants, and identify risk factors and potential preventive measures. Coordinator: USDA; Collaborators: CDC, FDA, EPA Timeline: Initiated
  4. Develop rapid tests for inspecting fresh commodities like fruit for evidence of contamination with bacteria that are resistant to antibiotics. Coordinator: USDA; Collaborators: EPA, FDA, CDC Timeline: Begin within one to two years
  5. Evaluate the effect of current food processing and distribution methods on the emergence and spread of drug-resistant organisms. Coordinator: USDA; Collaborators: CDC, FDA Timeline: Begin within one to two years
  6. Identify and evaluate new food pasteurization strategies. Coordinator: USDA; Collaborators: FDA, CDC Timeline: Begin within three to five years
  7. Assess the risk of AR emergence and spread due to environmental contamination by antimicrobial drugs or by resistant bacteria in animal and human waste. Collect information on whether environmental contamination by antimicrobial drugs can lead to the development of resistance in bacteria that live in the soil or in water. (Related Action Item: Surveillance #19) Coordinators: USDA, CDC, EPA, FDA Timeline: Initiated
  8. Assess the impact of antimicrobial use in companion animals (pets) on colonization and infection with drug-resistant organisms in the animals and their human household contacts. Coordinator: CDC Timeline: Begin within three to five years

2. Goal: Promote appropriate antimicrobial use in agricultural and veterinary settings.

a. Action Items

  1. Work with veterinary and agricultural communities to help educate users of veterinary and agricultural antimicrobials about AR issues, and promote the implementation and evaluation of guidelines that address these issues:
    • Appropriate antimicrobial use in agricultural and veterinary settings;
    • Performance and interpretation of antimicrobial susceptibility tests performed on specimens from different species of animals; and
    • Point-of-care tests for infection, including AR infections.
      Coordinators: USDA, CDC, FDA; Collaborator: EPA
      Timeline: Initiated
  2. TOP PRIORITY ACTION ITEM - In consultation with stakeholders, refine and implement the proposed FDA framework30 for approving new antimicrobial drugs for use in food-animal production and, when appropriate, for re-evaluating currently approved veterinary antimicrobial drugs. The proposed framework includes the following major steps:
    • Categorize antimicrobial drugs according to their importance in human medicine. Timeline: Initiated
    • Develop an approach to the establishment of thresholds for drug resistance in selected pathogens. Timeline: Initiated
    • Revise requirements for the industry’s submission of drug use data. Timeline: Initiated
    • Develop procedures to assess microbial safety of antimicrobial drug use in food-producing animals. Timeline: Initiated In support of the concepts articulated in the framework document:
    • Conduct risk assessments on the human health impact of using selected antimicrobials important in human medicine in food-producing animals Timeline: Initiated
    • Initiate appropriate steps to address any unacceptable human health impact, if identified by the risk assessments, for drugs categorized as being of critical importance in human medicine Timeline: Begin within one to two years Coordinator: FDA
  3. Strongly encourage involvement of veterinarians in decisions regarding the use of systemic antimicrobial drugs in animals, regardless of the distribution system through which the drug is obtained (e.g., regardless of whether a prescription is required to obtain the drug). Coordinators: FDA, USDA Timeline: Initiated
  4. Evaluate the potential impact of making all systemic veterinary antimicrobial drugs available by prescription only. Coordinators: FDA, USDA Timeline: Begin within three to five years
  5. Convene an expert group to consider how to incorporate AR issues into regulations governing the registration and use of antimicrobials and antibiotic pesticides. Invite external experts, stakeholders, and the public to provide input. Coordinator: EPA Timeline: Begin within one or two years

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E. Issue: Efforts to prevent and control AR emergence and spread must be comprehensive and multifaceted, involve a wide variety of nonfederal partners and the public, and become a part of routine practice nationwide.

1. Goal: Ensure input from nonfederal experts on federal efforts to combat antimicrobial resistance.

a. Action Item

  1. Establish an ongoing mechanism to obtain periodic input from external experts on AR issues. This process will include ensuring input from stakeholders and partnersb (e.g., state and local health agencies, the private sector, and the public) in developing and reviewing federal efforts to address antimicrobial resistance.
    Coordinators: CDC, FDA, NIH; Collaborators: USDA, EPA, DoD, DVA, AHRQ, HRSA, HCFA Timeline: Begin within one to two years

2. Goal: Develop and evaluate comprehensive demonstration programs to prevent and control AR.

a. Action Item

  1. TOP PRIORITY ACTION ITEM - Support demonstration projects to evaluate comprehensive strategies that use multiple interventions to promote appropriate drug use and reduce infection rates. These projects will include the following steps:
    • Assess how interventions found effective in research studies can be applied routinely and most cost-effectively on a large scale;
    • Evaluate the use of these programs in healthcare systems (federal and nonfederal), in the community, and in agricultural and veterinary settings; and
    • Involve partnerships with local and state agencies, healthcare systems, professional societies, community organizations, schools, private industry, and the public. Coordinator: CDC; Collaborators: FDA, DVA, DoD, HRSA, HCFA, Timeline: Initiated

3. Goal: Incorporate into routine clinical practice AR prevention strategies and programs that have been found to be beneficial in research and demonstration projects.

a. Action Items

  1. Utilize federal healthcare systems (e.g., DoD, DVA) as models for AR surveillance and prevention and control activities involving appropriate drug use, optimized diagnostic testing, infection control, and vaccination practice. Coordinators: CDC, DVA, DoD, HCFA, HRSA Timeline: Begin within three to five years
  2. For all healthcare systems for which federal funds are provided, identify and promote strategies to establish AR prevention and control activities as part of quality monitoring programs. Coordinators: CDC, DVA, DoD, HCFA, HRSA Timeline: Initiated
  3. Encourage nationally recognized accrediting agencies such as the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to include accreditation standards that promote efforts to prevent and control AR, including appropriate antimicrobial use, infection control, vaccine use, and diagnostic testing. These standards may draw on the findings of existing data and demonstration programs and AHRQ Evidence-Based Practice Centers. Coordinator: CDC; Collaborators: HCFA, AHRQ Timeline: Begin within one to two years

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