RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCES KARNATAKA, BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / NAME AND ADDRESS OF THE CANDIDATE / SHINY. K.PVETTUVAZHIYIL(HOUSE)
KEEZHOORP.O,THALAYOLAPARAMBU
KOTTAYAM(DT),KERALA
PIN-686605
2 / NAME OF THE INSTITUTION / ACHARYA COLLEGE OF NURSING, CHOLANAGAR R.T.NAGAR POST, BANGALORE- 32.
3 / COURSE OF THE STUDY AND SUBJECT / M. Sc NURSING 1st YEAR
MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION TO COURSE / 12-07-2011
5 / STATEMENT OF THE PROBLEM / A STUDY TO EVALUATE THE EFFECTIVNESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDINGANTIMICROBIAL RESISTANCE AMONG NURSES IN SELECTED HOSPITAL, BANGALORE
BRIEF RESUME OF THE INTENDED WORK
“No stronger condemnation of any hospital or ward could be pronounced than the single fact that infectious diseases has originated in it”
-Florence Nightingale
6. INTRODUCTION
Bacteria are integral part of the world, inseparable from life or earth. They are found everywhere in the environment, cover the skin and mucous membranes, and line the intestinal tracts of human and animals. Most bacteria are harmless some bacteria are beneficial to their host and provide nutrients or protection from pathogens and disease by limiting the ability of more harmful bacteria to colonise.Because they have a short generation time –from minutes to hours-they can respond rapidly to changes in their environment. Thus as, antimicrobial agents were introduced into the environment, bacteria responded by becoming resistant to these agents1
Antimicrobial resistance (AMR) is a resistance of a micro organism to an antimicrobial medicine to which it was previously sensitive.Antimicrobial resistance is the ability of bacteria or other microbes to resist the effects of an antibiotic. Antibiotic resistance occur when bacteria change in some way that reduces or eliminates the effectiveness of drugs, chemicals or other agents designed to cure or prevent infections. The bacteria survive and continue to multiply causing more harm.
Resistant organism is able to with stand attack by anti microbial medicines such as antibiotics, antivirals, and antimalarials, so that standard treatments become ineffective and infections persist and may spread to others. AMR is a consequence of the use , particularly the misuses of antimicrobial medicines and develops when a micro organism mutates or acquires a resistance gene.2
WHO has selected combating antimicrobial resistance as the theme for world health day 2011.On this day, WHO issues an international call for concerted action to halt the spread ofantimicrobial resistance and recommends a 6 point policy package for the governments.
A high percentage of hospital acquired infections are caused by highly resistant bacteria such as methicilin –resistant staphylococcus aureus (MRSA). MRSA is a strain of staphylococcus aureus which is resistant to methicillin and other antibiotics.MRSA is revalent in health care environments because individuals tend to be older, sicker and weaker than the general population, which heightens their vulnerability to infection through weakened immunity.3
Infection caused by resistant microorganisms often fails to respond to conventional treatment, resulting in prolonged illness and greater risk of death About 44,0000 new cases of multi drug resistant tuberculosis (MDRTB)emerge annually causing at least 1500000 deaths.4
The use of antimicrobial agents has increased dramatically in the past 50 years.Whether or not a prescription from a medical professional is required. There is no guarantee that doses, or for an inadequate or inappropriate length of time, antimicrobial agents can not only be ineffective, but lead to the development of resistence.5
There is increasing concern about the medical and public health problems directly associated with the development and spread of antimicrobials resistant organism in hospitals, communities and the environments. Resistant bacteria cause infections that are more difficult to treat, requiring drugs that often less readily available, more expensive and more toxic. In some cases strains of bacteria have become resistant to all available antimicrobial agents.Without effective agents to hold them in check, these infections spread through hospitals and communities causing epidemics that are difficult to control 6
Prevention is better than cure so there is an important role to educate nurses about antimicrobial resistance.
6.1NEED FOR STUDY
Antimicrobial resistance has been called one of the world’s most pressing public health problems Almost every type of bacteria has become stronger and less responsive to antibiotic treatment when it is really needed.7
The number of death certificates in England and Wales mentioning MRSA has increased from 734 in 2001 to 1,629 in 2005, with an increase of 39% from 2004 to 2005. Now the UK has one of the highest rates within Europe and the need for improved intervention has been highlighted by experts in infection control.8
About 70% of hospital isolates of staphylococcus aureus are now resistant to all beta-lactuam antibiotics which had been the first line of treatment.By 2001, two-third of hospitals reported increasing rate of methicillin- resistant S.aureus (MRSA), AND 24%reported MRSA outbreaks with in the previous year.9
According to Centres for disease control(CDC), up to 250,000 hospital associated catheter related blood stream infection(CR-BSIs) occur annually in US hospitals, with approximately 80,000 of these occurring in ICUs.Central venous catheters(CVCs) are frequently used in hospitalized patients and they carry associated risks, the most common being blood stream infection(BSI).10
Health care associated infection occurs in about 2 million people annually, about 90,000 of whom die. The annual costs of the infection are approximately 4.5 billion and the rate of HAI has increased to 36%over the past 20 years. As the incidence of laboratory-confirmed bloodstream infection was 13.9% (255/1828) of all admissions, 15.9% (85/535) among neonates and 13.1% (170/1293) among older children. A single pathogen was recovered from 224 children (12.3%), while 31 (1.7%) had polymicrobial infection with two (n = 26), three (n = 2) or four isolates (n = 3). In total, 294 pathogenic bacterial and fungal isolates were recovered (Table 2). Among all laboratory-confirmed bloodstream infections, half (128/255) were defined as potentially hospital-acquired.11
The problem of antimicrobial resistance requires a multipronged research strategy. NAID supports and conducts research on many aspects of antimicrobial resistance, from basic research on how microbes develop resistance to clinical trials that translate research from lab findings to potential treatments .12
The emergence of AMR is a complex problem a driven by many interconnectedfactors, singleisolated interventions have little impact A global and national multispectral response is urgently needed to compact the growing threat ofAMR.13
These antibiotic resistant bacteria can quickly spread to family members, schoolmates and co-workers. Threatening the community with new strain of infectiousdisease that is more difficult to cure and more expensive to treat For this reason antibiotic resistance is among CDC’s top concerns.14
MRSA is a major cause of nosocomial infection in hospitals throughout the world. In particular, MRSA is a significant contributor to prolonged hospital stay, poor clinical outcomes and increased healthcare costs amongst surgical patients.15
One study calculated that 10-70% of Hospital acquired infection (HAI) is preventable.Unfortunately, with the introduction of antimicrobial agents has come poor compliance with other preventive strategies such as barrier precautions and hand hygiene, which has also contributed to the problem of resistance. This represents a 29%increase in resistance over 4 years, 1995-99.16
Most hospitals (87%)reported implementing measures to rapidly detect resistance, but only about half reported providing appropriate resources to prevent antimicrobial resistance or having implemented antimicrobial use guidelines17
Each year, an estimated 126000 hospitalisations are attributed to MRSA, with 94,000 being invasive leading to approximately 19,000 deaths. Since the late 1990s, there has been a significant increase in MRSA infection- a500 percentage increase since 2003 alone.18
Current hospital practice to control antimicrobial resistance is inadequate.Infection control is everyone’s business but nurses but, as the largest single occupational group in health care, have a key role to play.19
Central venous catheters(CVCs) are frequently used in hospitalized patients and they carry associated risks, the most common being blood stream infection(BSI). 20
The RCN wipe it out campaign is providing nurses, with the information and resources to promote better and safer practice around MRSA and health care associated infections {HCAIs} amongst nurses and other health professionals across the UK health services.21
The potential contributionnursescan make to the management of antimicrobials within an in-patient setting could impact on the development ofantimicrobialresistance(AMR) and healthcare associated infections (HCAIs). Current initiatives promoting prudentantimicrobialprescribing and management have generally failed to includenurses, which subsequently limits the extent to which these strategies can improve patient outcomes. Forantimicrobialstewardship (AS) programmes to be successful, a sustained and seamless level of monitoring and decision making in relation toantimicrobialtherapy is needed.22
Asnurseshave the most consistent presence as patient career, they are in the ideal position to provide this level of service. However, fornursesto truly impact on AMR and HCAIs through increasing their profile in AS, barriers and facilitators to adopting this enhancedrolemust be contextualised in the implementation of any initiative.Nurses see the effects of HCAIs including MRSA on patients every day. They carry a high cost in terms of extra resources used, as well as the pain, disability and even death which can result. Working in partnership, we can help wipe it out.23
All these above mentioned factors urged the researcher to assess and educate the staff nurses about prevention of antimicrobial resistance
6.2 REVIEW OF LITERATURE
A review of literatureenables one to get an insight into various aspects of the problem under study. It covers promising methodological tools, throws light on ways to improve the efficiency data collection and suggest how to increase effectiveness of data analysis and interpretation. Review of literature is an essential step in the development of the research project.
Review of literature for the present study is organised under the following
6.2.1Review of literature regarding antimicrobial resistance.
6.2.2Review of literature regarding structured teaching programs on antimicrobial resistance among staff nurses.
6.2.1Review of literature regarding antimicrobial resistance.
A study was conducted to determine the current antimicrobial susceptibility patterns of the most frequent multi-resistant bacteria and to analyze any possible changes with respect to the two VIRA studies carried out in 2001 and 2004 among 40 participating hospitals.. Among MRSA, we detected one isolate nonsusceptible to linezolid, four resistant to quinupristin-dalfopristin and one strain with a vancomycin MIC of 4 microg/mL. The prevalence of extended-spectrum beta-lactamase-producing E. coli was 12.1%. Resistance of A. baumannii to imipenem varied from 27% in the 2001-2004 period to 47.8% in 2006 (p < 0.005).They concluded thatresistance surveillance systems are an important tool for preventing the emergence and spread of multi-resistant pathogens.24
AViriato study was updated on antimicrobial susceptibility in which 30 microbiology laboratories throughout Portugal are asked to isolate, identify and submit to a central laboratory for testing Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis responsible for communityacquired lower respiratory tract infections and Streptococcus pyogenes from tonsillitis to monitor changes in antimicrobial resistance patterns of these frequent respiratory pathogens. The result was among S. pneumoniae penicillin non-susceptibility decreased from 25% in 1999 to 18% in 2007 (p = 0.002). . They concluded that penicillin remains the most active antimicrobial agent against S.pyogenes causing tonsillitis25. SRING
A Study was conducted to investigate the antimicrobial resistance of clinical isolates of Staphylococcus aureus during a 2 period of 1999-2000.usingDisc diffusion test (K-B method) the frequency of MRSA was 59.2%(161/ 272) and 39.9%( 105/263) in Beijing and Hubei, respectively; The results also revealed that the major multiresistant profiles of MRSA were (chloramphenicol, ciprofloxacin, enythromycin, gertamicin, sulfamethoxazole,CCpEGSt) (20.6%) and CCpESt (9.1 %) in Hubei province, and CCpEG (14.4%)and CCpEGSt (8.4%)in Beijing city; . They concluded that multiresistant phenotypes of MRSA were different,and also antimicrobial resistance of MRSA and MSSA was some differences between Beijing and Hubei regions.26
A prospective cohort study was conducted to predict death in Tanzanian children with blood stream infections among 1828 consecutive admissions .The result wasthe incidence of laboratory-confirmed bloodstream infection was 13.9% (255/1828) of admissions.. The most frequent isolates were klebsiella, salmonellae, Escherichia coli, enterococci and Staphylococcus aureus. One third (34.9%) of the children with laboratory-confirmed bloodstream infection died. The mortality rate from Gram-negative bloodstream infection (43.5%) was more than double that of malaria (20.2%) and Gram-positive bloodstream infection (16.7%). They concluded that Bloodstream infection causes more deaths. 27
A study was conducted to assess MRSA prevalence in hospitals and other healthcare institutions in non-outbreak situations in Western Europe.
Surveillance screening of MRSA was performed in long-term care (11 studies) and acute care (20 studies). Prevalence rates varied over a wide range, from less than 1% to greater than 20%. The prevalence of MRSA was expressed in various ways - the percentage of MRSA among patients (range between 1% and 24%), the percentage of MRSA among S. aureus isolates (range between 5% and 54%), and as the prevalence density (range between 0.4 and 4 MRSA cases per 1,000 patient days). 28
6.2.2Review of literature regarding structured teaching programs on antimicrobial resistance among staff nurses.
A study was conducted on clinical outcomes of antimicrobial control program(ACP).The ACP was associated with a 2.4-day decrease in length of stay and a reduction in mortality from 8.28% to 6.61%. rates of readmission for infection within 30 days of discharge remained about the same. In patient pharmacy costs other than intravenous antimicrobials decreased an average of only 5.7% over the 2 programme years, but the acquisition cost of intravenous antimicrobials for both programme years yielded a total cost saving of 291,885 dollar, a reduction of 30.8%. the institution’s average daily census fell 19% between the second base line year and the second programme year. This was associated with improvements in impatient length of stay and mortality.29
A prospective study of methicillin resistant staphylococcus Aureas will prospectively evaluate the prevalence and incidence (over a two year period) of MRSA colonization and infection among HIV-infected military beneficiaries to determine predictors for the development of MRSA colonization and infection. This study will also investigate the utility of decolonization procedures for clearance of MRSA carriage and prevention of MRSA infections.30
A total of 120 urine samples from apparently healthy students were analysed for the prevalence of Pseudomonas aeruginosa and Klebsiella pneumonia using the Kirby-Bauer technique. The P. aeruginosa isolates exhibited high resistance to streptomycin, sparfloxacine and ciprofloxacine (39-74%), and moderate resistance to ofloxacine, gentamicin and perfloxacine (19-35%). The K. pneumoniae isolates exhibited moderate resistance to augumentin, co-trimoxazole and amoxicillin (22-29%). P. aeruginosa was more prevalent (80%) in the samples than K. pneumoniae (55%). The isolates also occurred more with the female students than the males. Resistances to the antimicrobials for both isolates were equally higher in the females than in the males. The results infers a great measure of abuse (overuse or mis - use) of antimicrobials among the student population.31
A study was conducted to suggest that infection control practises aimed at preventing horizontal transmission of antibiotic resistant nosocomial infection may lack success unless they are also coupled with antimicrobial intervention. An intensive program of barrier precautions for patients with vacomycin-resistant entrococci (VRE) that nearly 50%of the inpatients at their hospital where found to have gastrointestinal colonization with VRE. The average monthly use of ceftazidime and vancomycin decreased by 55%and34% respectively, after six months of implementation. This was associated with a decrease in the point prevalence of faecal colonization with VRE from 47%to15%(p<0.001) as well as a decreased in the number of patients with clinical isolates positive for VRE32
A study was conducted on surveillance screening of MRSA was performed in long term care(11 studies) and acute care (20 studies) prevalence rates varied over a wide range, from less than 1% greater than 20%. The prevalence of MRSA was expressed in varies ways –the percentage of MRSA among patients(range between 1% and 24%)the percentage of MRSA among S.aureus isolates (range between 5% and 54%)and as the prevalence density(range between 0.4 and 4MRSA cases per 1000 patient days)33
A study was conducted to examine the prevalence of antibiotic resistance in the strains of bacteria isolated from patients with suspected urinary tract infection. A total of 348 bacterial isolates were grown from semi quantitative urine culture and were of significant bacteriuria. The antibiotic susceptibility testing was performed on Muller-Hinton agar by disc diffusion method according to the standard criteria of the National Committee for Clinical Laboratory Standards, Antibiotic susceptibility testing revealed a high prevalence of resistance to ampicillin (55.4%) followed by nitrofurantoin (45.4%), gentamicin (45.1%), amikacin (41.4%) and co-trimoxazole (30.5%). E. coli and Klebsiella pneumonia showed 78.8 % and 75.3 % resistance to three or more drugs respectively. Cefotaxime (87.1%) appeared to be the most active antibiotic against the majority of isolates, followed by Norfloxacin (83.3%).34
This study was undertaken to find out the prevalence of methicillin resistant Staphylococcus aureus (MRSA) infection in our hospital and to compare their antibiotic susceptibility pattern with methicillin sensitive Staphylococcus aureus (MSSA). 100 strains of Staphylococcus aureus isolated from various clinical samples were screened for MRSA by disc diffusion method using 1 gm oxacillin disc. Antibiotic sensitivity testing was done by Kirby-Bauer's disc diffusion method. Out of these, 43% were identified as MRSA and the remaining 57% were MSSA. There was a marked difference in antibiotic sensitivity pattern of these M RSA versus the MSSA isolates. Amongst the aminoglycosides like gentamicin and amikacin, the sensitivity of MRSA was found to be 18.6% and 46.5% and that of MSSA was 98.2% and 94.7% respectively. Sensitivity to cephalosporins like cephalexin and cefotaxime was seen in 23% and 25.5% of MRSA.35
6.3STATEMENT OF THE PROBLEM:
A study to evaluate the effectiveness of self instructional module on knowledge regarding antimicrobial resistance among nurses in selected hospital, Bangalore.