Florida Schools Get Smart Antibiotic use and resistance: the role of the school nurse in promoting proper antibiotic use and reducing antibiotic resistance Bureau of Epidemiology Division of Disease Control Florida Department of Health 2007 Session I ? Unit 1 • Get Smart: Know When Antibiotics Work Campaign ? Unit 2 • Florida Schools Get Smart: Know When Antibiotics Work Program ? Unit 3 • Antibiotic use in Florida ? Unit 4 • Facts about antibiotic use, antimicrobials and antibiotic resistance. • Community Associated- Methicillin Resistant Staphylococcus aureus (CA-MRSA) Skin and Soft Tissue Infections (SSTIs) in the Community: information for school nurses Disclaimer The health and medical information provided in this material is not intended to take the place of advice or treatment from pediatricians or other healthcare professionals. The material provided is designed for educational purposes only. Introduction ? This training has been designed to assist Florida school nurses to implement a strategy to effectively communicate messages and promote behaviors to use antibiotics properly and therefore decrease antibiotic resistance. ? The basic tool of the program is the leadership role and credibility school nurses have. ? To promote behavioral changes, the program relies on the health belief model (HBM). Unit 1 Get Smart: Know When Antibiotics Work Campaign ? Learning objective: • To describe the national campaign to promote proper use of antibiotics and align its objectives with the Florida program and with school initiatives. Unit 1. Get Smart: Know When Antibiotics Work Campaign ? Get Smart: Know When Antibiotics Work is a multi-state campaign funded by the CDC. ? Objectives • To reduce the rate of rise of antibiotic resistance by: • Promoting adherence to appropriate prescribing guidelines among providers. • Decreasing demand for antibiotics for viral upper respiratory infections among healthy adults and parents of young children. • Increasing adherence to prescribed antibiotics for bacterial upper respiratory infections. ? Scope • Otitis media, sinusitis, pharyngitis, bronchitis, and the common cold. ? Target audiences • Patients and providers. Unit 2. Florida Schools Get Smart: Know When Antibiotics Work Program ? Learning objective: • To understand the rationale, scope, goals and objectives of the Florida program to promote proper use of antibiotics and reduce antibiotic resistant infections in the community setting. Unit 2. Florida Schools Get Smart: Know When Antibiotics Work Program ? Statewide program developed in public schools. ? Goals: • To reduce the emergence of resistant infections through the promotion of appropriate use of antibiotics. • To decrease the demand for antibiotics for viral upper respiratory infections. • To increase compliance to prescribed antibiotics by parents, students, teachers and school staff. ? The direction of the program has been based on the Florida Schools Get Smart survey of school nurses. Unit 2. Florida Schools Get Smart: Know When Antibiotics Work Program ? Campaign resources and materials • Posters, brochures, postcards and fact sheets. • Web site: http://www.doh.state.fl.us/disease_ctrl/epi/FGS/FL_GetSmart.html Q&A Fact Sheet “Runny Nose” & “Otitis Media” ? Targets students and parents of middle school students. Posters “Snort. Sniffle. Sneeze. No antibiotics please” ? Target students, parents and school staff of middle and high schools. Poster “Warning: Antibiotics Don’t Work For Viruses Like Cold And The Flu” ? Targets high school students, parents, and school staff. Poster “Self-medication With Antibiotics Can Harm Your Health” ? Targets Spanish speaking students and families. Brochure “Snort. Sniffle. Sneeze. No Antibiotics Please” ? Targets parents and school staff of middle schools. Brochure “Cold Or Flu. Antibiotics Don’t Work For You” ? Targets students and parents from middle and high schools, and staff of the schools. Brochure “Sometimes, The Remedy Is Worse Than The Disease” ? Targets Spanish speaking students and families. Postcard “Virus And Bacteria” ? Targets students, parents and staff of middle and high schools. Unit 3. Antibiotic use in Florida ? Learning objective: • To examine the available information for Florida communities regarding antibiotic use and antibiotic resistance awareness. 2006 Florida Behavioral Risk Factor Surveillance Survey (BRFSS) ? Findings from the 2006 survey have been used to demonstrate the need for education about antibiotic use, and to develop a program in Florida to target middle and high school students from different ethnic groups. ? The BRFSS findings were analyzed for households with children. ? Respondents with low levels of education and members of ethnic minorities were less informed. ? These findings motivate the implementation of a program to target first those people with less than high school education (middle and some high school), high school graduates and members of ethnic minorities. 2006 Florida Behavioral Risk Factor Surveillance Survey (BRFSS) ? 41% of respondents believe (incorrectly) that antibiotics are good medication for colds. • 61% have less than high school education • 54% of high school graduates • 34% have some college or technical school • 24% of college graduates. ? 49% of respondents have heard about antibiotic resistance. • 28% have less education than high school have heard about this • 32% of high school graduates • 56% have had some college or technical school • 69% of college graduates 2006 Florida Behavioral Risk Factor Surveillance Survey (BRFSS) ? In total, 20% of respondents said that health care providers have discussed antibiotic resistance when prescribing antibiotics. • 11% of respondents who have less than high school said that their health care providers have discussed antibiotic resistance when prescribing antibiotics • 15% of high school graduates • 29% have some college or technical school • 69% of college graduates Unit 4. Facts about antibiotic use, antimicrobials and antibiotic resistance ? Learning objective: • To review information about antibiotics, resistance mechanisms, and antibacterials. ? Credits: • The Alliance for the Prudent Use of Antibiotics has granted permission to use information from http://www.tufts.edu to create this section. • Alliance for the Prudent Use of Antibiotic, APUA. (1999). Practitioner information, Q & A’s. Retrieve from http://www.tufts.edu/med/apua/. Antibiotics ? What is an antibiotic? ? How do antibiotics work? ? How are antibiotics used? Antibiotic Resistance ? What is antibiotic resistance? ? Why do bacteria become resistant to antibiotics? ? How do bacteria become resistant? Antibiotic Resistance ? How does antibiotic resistance spread? ? Can bacteria lose their antibiotic resistance? Antibiotic Resistance ? Why is antibiotic resistance a public health problem? ? Why is antibiotic resistance an ecological problem? ? How serious is the problem of antibiotic resistance? Antibiotic Resistance ? Can the effectiveness of existing antibiotics be preserved? ? Can new antibiotics be developed? Antibacterials ? What is an antibacterial? ? How are antibacterials classified? ? How common are antibacterials in consumer products? ? Is the use of antibacterial agents regulated in the US? Antibacterials ? What is the difference between bacteriostats, sanitizers, disinfectants and sterilizers? ? How beneficial are antibacterials? ? Do antibacterials create resistant bacteria? ? Can the widespread use of antibacterial agents lead to more resistant bacteria? ? When are antibacterials useful? Community Associated- Methicillin Resistant Staphylococcus aureus (CA-MRSA) ? Learning objective: • To provide information to help school nurses to educate students, parents, teachers and school staff and to address CA- MRSA in school settings. ? Credits • Gorwitz, R.J., Jernigan, D.B., Powers, J.H., & Jernigan, J.A. ,and Participants in the CDC-Convened Experts’ Meeting on Management of MRSA in the Community. Strategies for clinical management of MRSA in the community: Summary of an experts’ meeting convened by the Centers for Disease Control and Prevention 2006. Available at http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html. • The Nursing and Wellness Program of San Diego Unified School District has granted permission to use information for educational purposes from Methicillin resistant Staphylococcus aureus (MRSA) at school. The Nursing and Wellness Program: resources for school nurses at http://www.sandi.net/depts/nursing_wellness/resources.html CA-MRSA ? MRSA are S. aureus strains which have acquired resistance to the antibiotics methicillin, oxacillin, nafcillin, cephalosporins, imipenem, and/or other beta-lactam antibiotics. ? Community-associated MRSA (CA-MRSA) refers to an MRSA infection with onset in the community in an individual with no risk factors. CA-MRSA ? Manifestations • Furuncles • Carbuncles • Abscesses • MRSA skin lesions are frequently confused with spider bites ? Population at risk and factors for transmission • Children and young adults • Individuals from racial minority groups or low socioeconomic status CA-MRSA ? Transmission: • Among inmates in correctional facilities • Competitive sports participants • Military recruits • Day care attendees • Men who have sex with men • Native Americans CA-MRSA ? Factors that facilitate the spread of infection: • Crowding • Frequent skin-to-skin contact between individuals • Participation in activities that result in compromised skin surfaces • Sharing of personal items that may become contaminated with wound drainage • Difficulty to maintain personal cleanliness and hygiene • Limited access to health care • Frequent antibiotic exposure CA-MRSA ? Culture and antimicrobial susceptibility • Abscesses or purulent skin lesions. ? Therapy - Incision and Drainage • Primary therapy for furuncles and other abscesses in individuals with no systemic signs of infection. • For small furuncles moist heat may be satisfactory to promote drainage. ? Antimicrobial combined with Incision and Drainage • For some patients with purulent skin lesions, empiric antimicrobial therapy may be administered in addition to incision and drainage. At the physician’s discretion or because of lack of response to initial treatment with incision and drainage alone. CA-MRSA ? Antimicrobials with activity against MRSA • Clindamycin • Tetracyclines (doxycycline and minocycline) • Trimethoprim-sulfamethoxazole (TMP-SMX) • Rifampin (used only in combination with other agents) • Linezolid ? Treatment Limitations • Presence of resistance or potential for rapid development of resistance • Not optimal choices for the empiric treatment of SSTIs • Fluoroquinolones (Ciprofloxacin, levofloxacin moxifloxacin and gatifloxacin) • Macrolides/ azalides (Erythromycin, clarithromycin) CA-MRSA ? Parenteral Antimicrobial • For patients with severe staphylococcal infections, particularly patients requiring hospitalization. • Vancomycin CA-MRSA ? Colonization / Decolonization • Colonization is the presence of S. aureus in an individual with growth and multiplication, but without tissue invasion or damage. MRSA commonly colonizes the anterior nares. • Nasal colonization with S. aureus is a risk factor for infection. • MRSA colonization also occurs at sites other than the nose (e.g., pharynx, axilla, rectum, and perineum). • Decolonization has been used in MRSA outbreaks in community settings. CA-MRSA ? Infection Control • Standard infection control precautions • Hand hygiene ? Outbreaks • Notify the county health department should be notified. CA-MRSA Public Education ? Prevention messages for individuals with SSTIs and their close contacts • Keep wounds that are draining covered with clean, dry, bandages. • Clean hands regularly with soap and water or alcohol-based hand gel (if hands are not visibly soiled). Always clean hands immediately after touching infected skin or any item that has come in direct contact with a draining wound. • Maintain good general hygiene with regular bathing. CA-MRSA Public Education ? Prevention messages for individuals with SSTIs and their close contacts • Do not share items that may become contaminated with wound drainage, such as towels, clothing, bedding, bar soap, razors, and athletic equipment that touches the skin. • Launder clothing that has come in contact with wound drainage after each use and dry thoroughly. CA-MRSA Public Education ? Prevention messages for individuals with SSTIs and their close contacts • If you are not able to keep your wound covered with a clean, dry bandage at all times, do not participate in activities where you have skin to skin contact with other persons (such as athletic activities) until your wound is healed. CA-MRSA Public Education ? Prevention messages for individuals with SSTIs and their close contacts • Clean equipment and other environmental surfaces with which multiple individuals have bare skin contact with an over the counter detergent/disinfectant that specifies Staphylococcus aureus on the product label and is suitable for the type of surface being cleaned. CA-MRSA Public Education ? Prevention messages for individuals with SSTIs and their close contacts • Individuals that cannot maintain adequate hygiene and keep wounds covered with clean, dry bandages should be excluded from activities where close contact with other individuals occurs, such as athletic practice, until their wounds are healed. Addressing MRSA in schools settings ? Persons (staff and students) who are MRSA carriers are likely protected from discrimination by the Americans with Disabilities Act. ? Contamination of MRSA can occur whenever there are body fluids being exchanged. Universal precautions are adequate to prevent MRSA exposure. ? Wash common-used objects with detergent and disinfect with a diluted bleach solution. ? Students who have MRSA wound or skin infections should follow wound care precautions. ? Promote good hygiene and frequent hand washing. Addressing MRSA in schools settings ? Prevention measures for school athletic departments • Participants in competitive sports that involve physical contact, skin damage, and sharing of equipment or clothing can be at risk for MRSA. It is important for schools to implement prevention measures. • Maintain clean facilities and adequate supplies of soap and towels. • Establish routine cleaning schedules for shared equipment • Encourage good hygiene, including showering and washing with soap after all practices and competitions. Addressing MRSA in schools settings ? Prevention measures for school athletic departments • Discourage sharing of towels and personal items (e.g., clothing or equipment). • Train athletes and coaches in first aid for wounds and recognition of wounds that are potentially infected. • Encourage athletes to report skin lesions and encourage coaches to assess athletes regularly for skin lesions. • Instruct athletes to cover all wounds. If a wound cannot be covered adequately, exclude players from practice and competition until the lesion is healed or can be covered adequately. Please Ask Your Questions Contact information: Sonia Clavijo McNelis, MD, MPH. Tel: (850) 245-4444 x2422 or 245 4401 4052 Bald Cypress Way, BIN # A-12. Tallahassee, FL 32399. Sonia_Clavijo-McNelis@doh.state.fl.us Division of Disease Control Bureau of Epidemiology Antimicrobial Resistance Program