Chapter 1 - Antibiotic Resistance: Patients and Hospitals in Peril
Case Study 1:
In the intensive care unit (ICU) of a large academic medical center, a nurse noticed a number of insects crawling on the open surgical wound of a patient. Expert consultation revealed that the
insects were common houseflies at various stages of development. After investigation, the organization determined that the infestation was probably the result of a single housefly that passed
through the hospital’s entrance and made its way to the ICU.
Although the affected patient suffered no clinical consequences of the infestation and ultimately made a full recovery from his surgery, his family was upset and demanded action. Nursing,
physician, and administrative leadership held an emergency meeting, and the chief executive officer (CEO) ordered a full investigation to ensure that this would not happen again.
On the same day the nurse observed the houseflies, two other patients in the ICU were battling bloodstream infections caused by methicillin-resistant Staphylococcus aureus (MRSA), another had
been placed on precautions because of the isolation of vancomycin-resistant Enterococcus (VRE), and a fourth died of overwhelming sepsis caused by a highly resistant gram-negative bacterium. No
complaints were received from these patients or their families, no special meetings were called, the CEO was not informed, and no new measures were implemented.
Could this happen at your institution?
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Chapter 2 - The Clinical Consequences of Antibiotic Resistance
Case Study 2:
Ms. Jones and Ms. Smith, both 56-year-old women with a history of diabetes mellitus, undergo elective total knee replacements at your facility on the same day. Both procedures are reportedly
uneventful and there are no intraoperative complications. Postoperatively, both patients have a central venous catheter (CVC) placed to deliver fluids and pain medication. On hospital day 4, the
planned discharge date for both patients, they both develop a high fever and elevated white blood cell count. Later that day, although Ms. Jones remains clinically stable, Ms. Smith’s blood pressure
drops, requiring transfer to the surgical intensive care unit (ICU). Blood cultures drawn at the time of the initial fever return positive for each patient. Cultures from Ms. Jones grow methicillin-susceptible Staphylococcus aureus (MSSA), a strain that is susceptible to most of the antibiotics to which it is tested. Blood cultures from Ms. Smith, however, grow methicillin-resistant Staphylococcus aureus (MRSA).
Following a course of intravenous (IV) antibiotics and removal of her CVC, Ms. Jones is discharged home 7 days post-procedure, where she has a complete recovery. Ms. Smith, despite IV antibiotics
and removal of her CVC, requires continued support for low blood pressure and is placed on a ventilator for respiratory distress. Blood cultures from Ms. Smith continue to grow MRSA. After 6 days
in the ICU, Ms. Smith’s condition worsens, as she develops renal failure requiring hemodialysis and progressive ventilatory support. On hospital day 12, she sustains cardiac arrest and dies.
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Chapter 3 - The Financial Impact of Antibiotic Resistance
Case Study 3:
Mr. Johnson, a 65-year-old man, was admitted to your institution from a rehabilitation facility with chest pain. He had been at the rehabilitation facility for two weeks after suffering an acute stroke. He underwent cardiac catheterization followed by a coronary artery bypass graft on hospital day 7. On hospital day 9, he became septic and required blood pressure support. Multidrug-resistant (MDR)
Klebsiella pneumoniae were found in his blood and from the tip of his central venous catheter, and he was started on three antibiotics—the only three active against the pathogen.
On the same day, Mr. Andrews, a patient in the medical intensive care unit, developed a catheter-related bloodstream infection, and the following day Mr. McDonald, a patient in the telemetry unit,
developed hospital-acquired pneumonia. The pathogens isolated from the cultures of Mr. Andrews and Mr. McDonald was also MDR Klebsiella pneumoniae.
Mr. Johnson—the index patient—died three weeks after his bloodstream infection of acute respiratory distress syndrome. Mr. Andrews and Mr. McDonald were discharged to a rehabilitation
facility three and four weeks, respectively, after infection with MDR Klebsiella pneumoniae. At the facility, both patients experienced acute renal failure as a result of their antibiotic therapy. The cost
of hospital care for the three patients at the institution exceeded $1 million.
Mr. McDonald’s family learned about the outbreak of MDR Klebsiella pneumonia and sued the hospital, charging that poor hygiene led to the spread of the identical pathogen from other patients
to their family member. The local newspaper published a three-part series on your hospital, describing how an “untreatable resistant killer bug” had spread uncontrollably throughout the
institution. Government and regulatory bodies began intensive investigations. The hospital suffered huge losses in patient referrals and millions of dollars in legal fees.
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Chapter 4 - Transmission Control to Prevent the Spread of MDROs
in Health Care Facilities
Case Study 4:
Ms. Wilson was admitted in transfer to your long term acute care hospital (LTACH) for skilled wound care to treat a slowly healing abdominal wound. She had a negative nasal screening culture for
methicillin-resistant Staphylococcus aureus (MRSA) on admission, appeared to be progressing well, and was scheduled for discharge the following week. However, 24 hours later she developed fever, tachycardia, and hypotension and was transferred back to her original acute care facility where she was found to have an MRSA bloodstream infection.
Subsequent molecular analysis of her MRSA isolate confirmed that the strain of MRSA that had caused her infection had been isolated from several other inpatients at the LTACH. Subsequent
surveillance cultures revealed unacceptably high rates of MRSA cross-transmission among LTACH inpatients, and direct observation of LTACH care staff revealed suboptimal adherence to
recommended hand hygiene and contact isolation procedures. Intensive education of staff, coupled with an ongoing system for monitoring adherence with recommended hand hygiene and isolation
practices, was followed by a sustained reduction in rates of MRSA cross-transmission.
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Chapter 5 - Antibiotic Stewardship
Case Study 5:
Dr. Anderson admitted an elderly nursing home patient to your hospital with pneumonia. He ordered blood cultures and an antibiotic (moxifloxacin), which the patient began three hours after
admission. In spite of the antibiotic, the patient’s condition worsened. The microbiology reports were returned the next day and showed that the blood cultures were growing Pseudomonas
aeruginosa resistant to moxifloxacin but susceptible to imipenem.
Dr. Anderson changed the antibiotic to imipenem as soon as the test results became available. The patient was transferred to the intensive care unit (ICU) where she worsened and required mechanical
ventilation. She spent two weeks in the ICU before being transferred to the internal medicine service.
The patient was finally transferred back to her nursing home after a 24-day hospital stay. The total cost of her admission was more than $100,000. During a subsequent morbidity and mortality
conference, Dr. Anderson learned that nearly all of the patients admitted from that particular nursing home with infection ended up requiring treatment with broad-spectrum antibiotics (such
as imipenem) because of a high frequency of multidrug-resistant organisms (MDROs). Dr. Anderson wondered whether his patient’s course might have been less complicated had he been aware of this
problem and used the more powerful antibiotic from the start.
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Chapter 6 - Challenges on the Path to Higher Performance
Case Study 6:
Hospital A is an average community hospital with a new CEO. Recognizing that having a new CEO is an opportunity to impact culture, the CEO decides to make an early statement about quality and safety being a high priority. Two patient safety projects are selected to demonstrate alignment with the CEO’s efforts to send a message about safety. Weekly walk-rounds are implemented. During these walk-rounds, the CEO asks the staff about their roles in improvement, how they make use of the QI model used in improvement, and what help they need to better apply the QI model. Staff is also asked about their ideas for the projects, and if they have none, they are asked to look for improvements that they could share on the next week’s walk-rounds. In senior staff meetings, department heads are asked how they support the QI projects. Each department is expected to be able to explain their role in major, hospital-wide initiatives, and how they are using current projects to strengthen their capability for the next project. The impact of these efforts is measured using selected scales from the AHRQ Safety Culture survey as indicators of improvement in the quality and safety culture.
CEO, chief executive officer; QI, quality improvement; AHRQ, Agency for Healthcare Research and Quality.
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