Mostly missing. I’ll take Obama’s initiative to combat antibiotic resistance–there’s a lot of good stuff in there, though, as always, on certain regulatory issues (e.g., reducing antibiotic use in agriculture, and reporting standards for antibiotic use in the NHSN) the devil is in the details. I have some minor quibbles about which current programs should be emphasized (NAHMS is specifically mentioned, while NARMS is not–and this is not an issue of non-rhotic accents).

Nonetheless, I like these goals:

This effort holds the potential to:

•Reduce the incidence of carbapenem-resistant Enterobacteriaceae (CRE) infections by 60 percent.
•Reduce the incidence of Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections by 50 percent.
•Reduce the incidence of multidrug-resistant Pseudomonas infections acquired during hospitalization by 35 percent.
•Spur at least a 25 percent reduction in the rate of multi-drug resistant Salmonella infections and pediatric and geriatric antibiotic-resistant invasive pneumococcal disease.

(an aside: I’m not sure Salmonella per se is a major issue, but if it serves as a mechanism to focus on farm-to-fork spread of antibiotics antibiotic resistance, I’m on board)

What you’ll note is that the outcomes are defined in infection control terms. This is important, as too often, proposed solutions to antibiotic resistance are posed as a combination of drug discovery and smarter use of antibiotics (which, to be clear, are critical). However, the only part of the initiative that explicitly deals with infection control that I can find is this:

Improving the health and well-being of veterans. VA will improve the implementation and effectiveness of the VA Antimicrobial Stewardship Program. This program fosters the judicious use of antimicrobials through education, direct provider-to-provider stewardship, and surveillance, and supports and expands ongoing efforts to prevent emergence of multidrug-resistant organisms. All of these actions are focused on improving the health and well-being of our veteran population.

The VA Antimicrobial Stewardship Program has some very good infection components, but the lack of emphasis on preventing unnecessary infections, whether they be susceptible or resistant to antibiotics, should be (and hopefully, is) part of the solution. To put this another way, every time we have to treat an unnecessary infection, we use antibiotics when we shouldn’t have. At the same time, we potentially create an asymptomatic carrier (‘MRSA Mary’) of either the disease-causing resistant organism (obviously, only if it was resistant), or potentially enable the transfer of resistance into another organism (or strain) which can then serve as a reservoir of resistance.

At this year’s ICAAC meeting, there was a very interesting, debate-oriented symposium about hand hygiene* and decolonization (the latter is the attempt to prevent patients from being asymptomatic carriers). We need to figure out what the best practices are, and then get those into hospitals. Infection prevention is a key component of protecting the power of antibiotics.

The obvious locus for this research is AHRQ, but I can understand why the administration didn’t mention AHRQ at all: the Republicans want to kill AHRQ because they believe evidence-based assessment will lead to death panels.

Overall, it’s a very good proposal, but there should have been–and still could be–a greater emphasis on the unsexy business of infection control.

Related post: Scary Disease Woman (aka ‘Maryn McKenna’) has some interesting thoughts about the initiative here.

*At least one hospital has essentially moved to gloving up every time a healthcare provider enters a patients room or pod, as opposed to trying to increase hand washing compliance.