# data[].attributes.headline
Issue - Antibiotic Resistance and Infections

# data[].attributes.subject
Issue - Antibiotic Resistance and Infections

# data[].attributes.body
Why is antibiotic resistance a problem?
According to the CDC, antibiotics are among the most commonly prescribed drugs around the world. Antibiotic use is the single most important cause leading to antibiotic resistance. Some additional factors that cause antibiotic resistance that can lead to infection include:

(CDC, 2017a)

Who is affected? Where?
Antibiotic resistant infections can affect anyone from pediatrics to geriatrics; including those in the outpatient setting (doctors offices), nursing homes, those in the hospital setting and even in the community (CDC, 2017b).

How does antibiotic resistance happen?
Antibiotic resistance can develop from even one bacterium becoming resistant to antibiotics, which can then multiply and replace all bacteria that were destroyed, thus further making those surviving bacteria resistant to future antibiotics leading to the development of infections (CDC, 2017a). (CDC, 2017a)

What causes the spread of infection?
Unnecessary antibiotic use; misuse or through person to person transmission via: contact with contaminated hands of hospital staff, contact with contaminated surfaces such as door handles, over the bed tables, furniture, call bells and contact with contaminated equipment such as stethoscopes and blood pressure cuffs. This can occur in both inpatient and in outpatient settings (Victoria State Government, 2017).

# data[].attributes.body
For this presentation, I will be focusing on MRSA and C-diff infections.

Citations for this audio section:
(CDC, 2017c).
(IHI, 2017).

# data[].attributes.body
One EBP intervention already in place in Sentara Hospitals is the utilization of copper infused bed linens to help prevent the spread of HAI such as C-diff and MRSA. This 10 month clinical study demonstrated an 83% reduction in c-diff and a 78% reduction in multi-drug resistant organisms (Sentara Healthcare, 2017). This study could not have happened without the nursing staff participation and implementation. Changing bed linens is a part of nursing practice and nursing care to help keep the patients clean. The use of copper infused bed-linens can be easily incorporated into other hospitals around the country. This is one effective way EBP has been studied, suggested and implemented into the Sentara Healthcare System.

For patients who have suspected or diagnosed c-diff or MRSA, the patients are put on contact precautions. However, the issue may be with how well doctors, nurses and patient visitors adhere to theses contact precautions with respect to putting on gloves and gowns, using disposable equipment and washing their hands before and after patient contact. For example, there have been many times I have seen nurses, patient visitors and doctors walk into a contact precaution room without putting on gowns and gloves and using their own equipment and the other nurses did not say anything to them about it. Other times, nurses and doctors don't gown up because they are "only going in for a second".

Nurses must play an active role in preventing the spread of infections through making sure they practice frequent and appropriate hand hygiene and adhering to standard and contact precautions. According to the CDC, cleaning hands can prevent the spread of germs, including those resistant to antibiotics. On average, healthcare providers comply with recommended hand hygiene procedures less than 50% of the times they should (CDC, 2016). I have seen many nurses not wash their hands before going into patient's rooms,but this is one of the easiest things to do to help prevent the spread of infections.

Additionally, most of the issue with antibiotic resistant infections is contributed to the overuse or misuse of antibiotics. Nurses must advocate for their patients and teach their patients on how to properly take the antibiotics as well as questioning providers use of antibiotics based on the patients clinical presentation. Of course this also must involve collaboration from doctors so the nurses can know the indication for the antibiotic therapy and the intended duration of treatment.

Nurses play a crucial role in the prevention of antibiotic resistant infections, as they need to hold themselves and others accountable for actions such as: adhering to standard and contact precautions, educating patients and visitors on hand hygiene, contact precautions and popper use of antibiotics and reminding doctors that they too must adhere to the same precautions as everyone else. Nurses can and should keep up with current EBP and suggest and implement new ideas into practice that could help improve patient care. Additionally, nurses should be advocating for patients by having a question attitude. Some barriers to these nursing implementations could include: lack of time because it takes so long to gown up and off every time you go into a patients room, lack of resources, lack of communication between the nurse, care providers, non-healthcare employees, patients and visitors,  not properly cleaning the rooms or equipment (or using contaminated equipment) and fear of questioning the providers.

# data[].attributes.body
1. Co-administration of Probiotics with Antibiotics
2. Patient advocacy and education
3. Infection Prevention

# data[].attributes.headline
Recommendation 1: The Power of Probiotics! 

# data[].attributes.subject
Recommendation 1: The Power of Probiotics! 

# data[].attributes.body
A systematic review of studies showed evidence that the administration of probiotics closer to the first dose of antibiotics reduces the risk of antibiotic associated c-diff infections by over 50% in hospitalized adults (Ancy, Crawford, Evans, Maw, Pino, Shen, Simon & Tmanova, 2017).

Probiotics add good bacteria to the digestive system. They don't effect the antibiotic treatment, they only treat the side effects. Probiotics can come in supplemental pill form or from everyday foods we eat. For example, yogurt that contains "active and live cultures" are a great source of probiotics that can be implemented into a persons diet (Cleveland Clinic, 2015).

A study conducted in a Pennsylvania hospital showed that patients on antibiotics  who were given 2 cups a day of yogurt (already available at the hospital), had a dramatic decrease in c-diff infections acquired in the hospital setting (ACP Hospitalist, 2014).

As nurses, we can use this EBP and recommend to the doctor to prescribe the patients probiotics or the doctor can make suggestions of OTC probiotic supplements to patients receiving antibiotic treatment to help prevent antibiotic resistant associated diarrhea when applicable. Nurses can use this EBP and recommend/advocate for the patients to consume yogurt with active and live cultures as part of the patients dietary meal plans to help prevent occurrence of c-diff infections both in the hospital setting and outpatient. Yogurt may also be a more cost effective means of introducing good bacteria as opposed to supplementation.

# data[].attributes.headline
Recommendation 2: Patient Education and Advocacy 

# data[].attributes.subject
Recommendation 2: Patient Education and Advocacy 

# data[].attributes.body
The American Nurses Association suggests five ways to help prevent future emergence of antibiotic resistance through the influence of antibiotic management decisions:

1. Ensure pertinent information about antibiotics is available at the point of care
-all healthcare team members should have access to key information about a patients antibiotic therapy to help influence antibiotic management decisions.

2. Question the antibiotic route of administration
-Advocating: PO vs. IV route

3. Reassess antibiotic therapy in 2-3 days
-broad spectrum antibiotic use vs. narrow-spectrum

4. Review antibiotic therapy when your patient develops new c-diff infections
-are the antibiotics still indicated at this point?

5. Review antibiotics during all patient care transitions
-re-evaluate antibiotic use between care settings such as hospitals and outpatient as well as between different care points in the facility (ICU floor to step down).

(American Nurse Today, 2016)

Nurses should also emphasis patient education with antibiotic use in the outpatient setting:
(WHO, 2017)

# data[].attributes.body
1. Hand hygiene: Alcohol based vs. soap and water
Antimicrobial soap and water are recommended for visibly soiled hands, hands that have been exposed to bodily fluids or those after contact with a patient who has c-diff, and then followed by an alcohol based rub. Alcohol based gels are the preferred routine for decontaminating hands after patient contact. These products rapidly kill bacteria and viruses and are actually gentler on the hands than repeated use of soap and water (IHI, 2017). To encourage frequent hand washing, alcohol rub dispensers should be easily and readily accessible. Nursing input could give guidance into where theses dispensers should be placed to help encourage and reminding staff to wash their hands. Nurses must also have self-awareness of their own hand hygiene practices, always keeping infection prevention and patient safety in mind.
2. Adherence to standard and contact precautions

3. Environmental measures
Thorough and frequent cleaning of the rooms and equipment is critical in keeping infections at bay. Patients on contact precautions should have frequent room cleanings with a particular focus on high touch areas such as bed rails and door knobs (IHI, 2017). Ensuring proper disposal of bed linens is also essential in preventing the spread of infection. Additionally, the hospital room floors may be an overlooked source of infection.  A study found that limited attention is paid to disinfection of contact precaution room floors because they are not frequently touched. However, items in the patients room may touch the floors, these pathogens can move rapidly to hands and high touch surfaces in a hospital room. The floors were found to be heavily contaminated with MRSA, VRE and c-diff in contact precaution patient rooms (APIC, 2017). This is where education and collaboration with environmental services can be helpful.
4. Team effort
Both medical and non-medical personnel should involved in the prevention of spread of infections. Nurses, doctors, environmental services, patient transporters and dietary services should all be educated and aware of protocols for c-diff and MRSA and to take appropriate infection control measures (IHI, 2014). Nurses can take a role in facilitating collaboration, communication and education among other hospital staff to ensure appropriate infection prevention strategies.

# data[].attributes.body
The main concepts in this presentation that are reflective of the role of the nurse are: the utilization of evidence based practice, patient advocacy and education, infection prevention and inter-professional collaboration. Nurses are leaders in the aspect that they ultimately patient advocates and are in charge of overall patient care and safety. Nurses use their knowledge and utilize research to incorporate the best and most evidence based practice into their care. As a nurse, I can take a leadership role in suggesting/implementing new practices and ideas based of EBP that could help enhance patient care and outcomes (exp. introducing yogurt into meal plans to help with antibiotic resistant c-diff and effective sanitation measures to help prevent spread of infection). For example, becoming a member of a research or quality improvement council is a great way to suggest ideas and get involved in a leadership position and influence patient care.

As previously mentioned, nurses take a leadership role in patient advocacy, this means having a questioning attitude and communicating with the providers to ensure patients get prescribed antibiotics appropriately. Additionally, being a leader means being aware of hospital policies, protocols and adhering to infection prevention guidelines. Additionally, ensuring sufficient hand washing and cleaning personal equipment comes from a nurses own self awareness and personal practice (leading by example). Nurses must also ensure everyone adheres to theses same precautions; from doctors, to visitors to other hospital staff.

Nurses can take a leadership role in the facilitation of inter-professional collaboration and education. Inter-professional collaboration takes place between healthcare personnel (doctors, nurses, PTs)  and non healthcare personnel (dietary and environmental services) to ensure the safety and well being of patients.

Lastly, nurses are responsible for patient education. Patient education is an essential part of nursing practice. We use our nursing knowledge to lead, guide and teach patients how to best care for themselves to ensure they remain safe and healthy when they are not being cared for in the hospital setting. Patient education on appropriate antibiotic use is essential to help reducing antibiotic resistant infections. This helps to promote patient self-sufficiency and empowerment as they know how to properly care for themselves.

Through utilization of EBP, communicating with doctors, adhering to and maintaining infection prevention protocols (and holding others accountable as well), inter-professional collaboration and patient education- nurses are leaders in patient care, safety and advocacy!