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Guidelines to prevent spread of resistance.

This slide is by CDC. Avoid overuse. Some of these are pretty straightforward when you think of this issue. Surveillance, tough. Could we be keeping track of how the resistant patterns are going on in your hospitals. If you had the record of the antibacterial resistance patterns seen in a hospital, you could almost could predict what antibiotics they used in that hospital or certainly those that were misused. Housekeeping. This appears to be a simple approach to put in practice. Simply having medical staff wash their hands, as appropriate times would probably make a significant difference. This extends to proper disinfection of instruments, floors, walls, bedding, etc. Isolation of Patients. The fact that certain patients should be isolated. There is some good things to that. Actually, the Danish, they've had trouble with resistant organisms coming into the country. They have very low levels of resistance in these populations within their country, i.e. the bacterial populations isolated from infection. We're trying to figure out how to prevent spread of resistance. Wait a minute. We're doing that with surveillance and the Danes are telling us they don't have much resistance. Why don't we do what the Danes are doing? That makes sense. Well, apparently this is what they're doing. They found that travelers coming in to their country were a source of resistant organisms into the country. So it caused them problems. So now they've established protocols that require isolation of foreign infectious disease patients when they first enter a hospital. Once they identify that the pathogen is not resistant, okay, they can leave isolation. That's the control their used to. Fortunately, they can do it. I doubt if we could adopt that in this country.

Health care workers, protective clothing, treating patients, harboring, particularly vancomycin resistant organisms. This is similar to housekeeping practices, but this is focused particularly on use of protective clothing that is dedicated to this use. That is such clothing should not be worn out of a particular area in an effort to control the potential spread of organisms throughout the hospital. Not to prescribe a low dose or short treatment regimes. Use of low dose regimens reminds me of the laboratory setting in which we are intentionally trying to select for resistant organisms. We'll repetitively expose organisms to low sub-inhibitory concentrations to keep viable. Eventually, we can increase the concentration at which the bacterium will grow. That's the way we show emergence of resistance. So no, prescribe the proper dose. Don't just go for a couple days. Don't prescribe antibacterials on patient request or for viral illnesses. Enough said on this issue; this thing with the viral, common cold, adenoidal virus and patients expectations.

Immediate Actions

Wiser use. We talked about this and again using the hospital laboratory to direct use of appropriate antibiotic. This one (use of appropriate agent; no overkill, panic) actually has been tried. It has had some success but I'm not sure how much. That is, if you use penicillin and they're effective, you don't have to go through the real hot stuff like vancomycin very frequently. Rotation of antibiotics is reasonable in theory and has also been tried. As I indicated, the types of antibiotics used will give you a fingerprint of the hospital use by resistance patterns seen in that hospital. The notion is to terminate use of certain classes of agents followed by reintroduction of agents not currently in wide use in a particular hospital. Maybe a switch back to tetracyclines or common penicillins that may not have been used in the hospital. In theory it should work, but in practice to try to get that type of shift probably is going to be a very difficult one.

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