21C Antimicrobial Stewardship

Antimicrobial resistance contributes to 2.8 million infections and 35,000 deaths each year in the US alone (CDC, 2019). The inappropriate administration of antimicrobials not only compromises the benefit of essential pharmacologic therapies but also increases susceptibility to the spread of multidrug-resistant organisms (Moody et al., 2012). Coordination across all professional disciplines and universally adopted processes in hospitals, including optimal selection, dose, and duration of treatment, can significantly reduce the burden of antimicrobial resistance in hospitals (SHEA, 2015).

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

Executive Summary Checklist
Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
Performance improvement plan to follow if improvements are necessary
Clinical workflow for preoccupation with workflow for areas of improvement
How to educate patients and family members about the significance of their role throughout the continuum
Guidance on how to measure outcomes

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APSS are revised annually and available free of charge on our website for download.

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Sabina Paradi

Patient Stories

Sabina Paradi

As told by Sabina's mother, Bodo Paradi

I would like to introduce my daughter Sabina Paradi.

She was a dietetic fellow at Columbia University, New York Hospital, in 2007 when she sustained traumatic brain injury after being struck by a truck in New York’s Lower West Side on the way from a play.

The system worked perfectly when she was assisted immediately by a passing nurse. In minutes she was dispatched via ambulance by a fine paramedical team and was brought for evaluation in the hospital.

This is where the system broke down. The immediate reaction by the team was to attempt to relieve acute elevated intracerebral pressure. The method chosen, hemicraniectomy, and the anesthetic (propofol) were both inappropriate to her care. Hemicraniectomy has been shown in a later study to be inappropriate in most cases. Propofol has been banned by the FDA in the treatment of pediatric traumatic brain injury patients because of various complications. My daughter was very slight of build, under 100 lbs, easily smaller than many pediatric cases. She was also athletic, which may have increased the tendency for higher intracerebral pressure. She had been ill for over a week, having contracted a resistant infection from one of her patients, and was taking antibiotics.

How would systems improvement have helped at this stage? Her condition should have been evaluated by a higher level of expertise, and used tools like teleconferencing and remote medicine to get the opinion of a nationwide team of experts. The hospital throughout her care lacked access to medical expertise other than what appeared to be a very overworked neurosurgeon. Traumatic brain injury cases in the first hours require extraordinary care in their evaluation.

What happened next? What happened next, I believe, is responsible for her death. She contracted a resistant pneumonia which was identified with her respirator. Complicating everything was that she was taking antibiotics, and therefore immunosuppressed; she had a head injury and was therefore immunosuppressed; she sustained extensive neurosurgery and was therefore immunosuppressed; and she was sedated and therefore immunosuppressed. The infections deepened her coma, along with the sedation.

Risking surgery and sedation in her case was very much contraindicated. There were and are many alternate protocols for handling cases like hers. Greater knowledge and the use of artificial intelligence might have led to an entirely different treatment regime. Other items needed were immediately accessible MRI, preferably state of the art; real-time polymerase chain reaction tests for the detection of microbial infections, in particular fungal infections which seem to plague the immunosuppressed; and a modern neurological intensive care facility. The facility at my daughter’s hospital had a ward shared among four neurologically impaired patients, all quite likely immunosuppressed.

In the end, what killed my daughter was a complete lack of knowledge of her condition which instrumentation and broader, specialized knowledge would have alleviated. Facilities like the US military traumatic brain injury facility at Ramstein, Germany, are more appropriate to the treatment of moderate to severe traumatic brain injury than hospital emergency rooms. It is my view that all such patients should be evacuated to very large specialty hospitals that treat only severe neurological conditions such as stroke, TBI, encephalitis, and the like. Air transport systems and stabilization protocols need to follow the military model.

Nile Moss

Patient Stories

Nile Moss

Nile Moss took his first breath of air in a California hospital on August 23, 1990. His parents welcomed Nile with hope and great joy.

Fifteen years later, Nile Moss struggled for his last breath of air in a California hospital, the victim of a hospital-acquired infection. A deadly form of bacteria called MRSA had invaded Nile’s bloodstream and led to deadly pneumonia. Nobody knew that at the time.

Nile said good-bye just before midnight on Easter Sunday. He lost consciousness and died the next morning. His parents were stunned and confused. What went wrong? What could have been done to save Nile’s life? Their confusion turned into a quest for answers.

Tragically, the information provided did not quiet the concern for the parents, or lessen their pain. Nile’s death should not have occurred. Like 100,000 other patients who died that year from hospital-acquired infections, Nile’s death could have—and should have—been prevented.

Nile was born with a treatable condition called hydrocephalus. That condition required two brain surgeries and annual MRIs to monitor his condition. Each visit produced a report of good health. At no time did Nile’s parents fear harm would come to him through routine hospital screens. They were never informed about the dangerous bacteria that accumulate on surfaces in our nation’s best hospitals, and are inherent in many medical facilities.

Seventy-two hours before Nile died, he developed symptoms that looked like the flu—a fever, deep cough, dark mucus, headache, shortness of breath, and fatigue. Pediatric doctors tested Nile for strep bacteria. The test came back negative, but no other tests were performed. He went home with antibiotics that were appropriate for strep and ineffective for MRSA. Nile’s fever peaked at 104.5 and his breathing was labored. Nile was taken back to the doctor early Easter morning. An x-ray confirmed pneumonia. Nile was in a medical emergency, but the truth of his condition had not yet been diagnosed. A rapid two-hour test for MRSA existed at the time, but was not the standard practice.

Five hours passed before Nile was admitted to the hospital, as his fever continued to rise, and his breathing worsened. Five additional hours passed before he received his first antibiotics. His heart began to fail. His parents saw urgency in the faces of the doctors. Nile was dying and the doctors knew it. He was pronounced dead at 5:30 the next morning.

The official cause of death was recorded as sepsis, but later identified as MRSA bacteria that Nile had acquired from simply lying down on a contaminated MRI bed. CDC estimates more than two million people per year will contract one of a growing number of deadly infections while visiting the hospital. Many will pay the ultimate cost for the lack of urgency that has allowed this epidemic to go untreated for decades.

Upon learning these statistics, Nile’s Project was launched to help bring awareness to other families. In 2008, California passed SB1058, called Nile’s Law, requiring hospitals to screen, measure, and report hospital infections.

Please see http://www.nilesproject.com/ to learn more about Nile’s Project, Nile’s Law, and the dangers of MRSA.

Actionable Patient Safety Solutions (APSS)

<img src="https://psmf.org/wp-content/uploads/2021/02/Antimicrobial-Stewardship.svg" alt="" /> 21C Antimicrobial Stewardship

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Sabina Paradi

Nile Moss

21C Antimicrobial Stewardship