MGH Institute Faculty Member Working to Avert Health Crisis

People in the coming years who will have surgery, go through cancer treatment, or give birth may be in trouble due to the rise in bacteria that don’t respond to antibiotics.

Antibiotic Awareness Weeks runs November 13-20 across the globe. MGH Institute of Health Professions School of Nursing Assistant Professor Rita Olans, RN, DNP, is one of several health care professionals who are sounding the alarm about decades of the overuse of antibiotics for health issues both large and small.

A combination of over-prescribing antibiotics and bacteria becoming increasingly resistant, says Olans, could become a crisis unless this misuse is reversed.

“This is a looming crisis,” says Olans, who is leading efforts to increase the role of nurses - who comprise 80 percent of the country’s health care workers - to antimicrobial stewardship efforts.

“Despite all we are doing on stewardship, the bacteria will continue to mutate, but will do so more slowly. Our antibiotic use is putting this mutation ‘on steroids,’ making mutation much faster and deadlier. We have to do something about this quickly because if we don’t there is the possibility that without effective antibiotics, surgery becomes more risky, chemotherapy becomes more risky, and even giving birth becomes more risky.”

Olans, who has taught in the MGH Institute’s School of Nursing since 2012, will be among an interdisciplinary panel conducting a workshop on November 15 designed for quality improvement professionals in acute care settings which builds on NQF’s National Quality Partners Playbook: Antibiotic Stewardship in Acute Care, which is based on CDC’s Core Elements of Hospital Antibiotic Stewardship Programs.

According to the Centers for Disease Control, each year in the United States at least 2 million people become infected with bacteria that are resistant to antibiotics. At least 23,000 people die as a direct result of these infections, while many more people die from other conditions that were complicated by an antibiotic-resistant infection. The CDC says antibiotics are among the most commonly prescribed drugs used in human medicine, but estimates up to 50% prescribed for people are not needed or are not optimally effective as prescribed.

In addition, the World Health Organization earlier this month urged countries to restrict the routine use of antibiotics given animals to promote growth and prevent diseases during food production, which it says is the largest use of the drugs and also is causing a rise of antibiotic resistance among bacteria.

Getting Involved

It was 2011, and Olans had just enrolled in the MGH Institute’s Doctor of Nursing Practice program after four years of STD, TB, and HIV prevention work in the Virgin Islands with her husband, Richard. Richard Olans, the co-chair of antimicrobial stewardship at Hallmark Health Systems, was talking with a colleague about national efforts to make stewardship the norm for all hospitals when she cut into the conversation.

“You need to get nurses involved,” she told them. “Nurses monitor patients 24/7. They do the triage and take the cultures. They take that all-important allergy history. It is the nurse that puts the infectious patient in isolation. This is standard nursing practice, so why aren’t nurses included in the planning?”

Alfred DeMaria Jr, MD, the colleague with whom Dr. Olans’ husband had been speaking, is medical director and state epidemiologist at the Massachusetts Department of Public Health. “Rita had this insight that became obvious to us once she identified it,” Dr. DeMaria says. “No one had talked to nurses about the whys and wherefores of stewardship. It was just assumed that nurses would do these things.”

Olans has made the inclusion of nurses in antimicrobial (more commonly known as antibiotic) stewardship programs a cornerstone of her professional work. Using the topic as her capstone project to complete her DNP, she increasingly has pursued her mission to ensure that nurses have a seat at the table as experts work to figure out how to prevent a looming crisis of multidrug resistance.

“Part of what drug companies are in business for is to make money, and they do that making Viagra rather than an antibiotic that could become multi-resistant by the time it comes to market,” says Olans.

Antibiotics revolutionized medicine in the 1940s, providing a cure for infections like tuberculosis and gonorrhea and making complex procedures like organ transplant and open-heart surgery possible. But over time, their healing powers have waned through widespread misuse and overutilization. Superbugs, resistant strains of bacteria impervious to available treatments, have become a serious global threat responsible for 2 million infections and 23,000 deaths in the U.S. each year. The United Nations has compared antibiotic resistance to a slow-motion tsunami. Meanwhile, pharmaceutical companies are devoting ever-fewer resources to developing new antibiotics, citing rising costs and an inability to produce a drug that rapid bacterial mutations don’t render obsolete by the time it is developed.

“This is a looming crisis,” Olans says, her normally smiling face becoming serious. “We have to do something about this quickly because if we don’t there is the possibility that without effective antibiotics, surgery becomes more risky, chemotherapy becomes more risky, and even giving birth becomes more risky.”

Misuse Runs Deep

The roots of antibiotic misuse stretch far and wide, into physician’s offices and nursing homes. But some of the most lethal forms of resistance proliferate in hospitals. Up to half of all patients in U.S. hospitals receive antibiotics, but the Centers for Disease Control and Prevention has determined that more than a third of those prescriptions are inappropriate or unnecessary. “The organisms we’re most concerned about, the ones that have no treatment options, occur in hospitals,” says Arjun Srinivasan, MD, the CDC’s associate director for health care-associated infection prevention programs in its Division of Healthcare Quality Promotion.

This is where antimicrobial stewardship comes in. It is an interdisciplinary approach that engages key players throughout the hospital— infectious disease specialists, pharmacists, microbiologists, physicians— to ensure antibiotics are used thoughtfully, with a close eye on patients’ changing conditions, to prevent resistant strains from developing or spreading.

In 2015, Olans drew on her capstone research in an article for nurse educators. Her co-authors included DeMaria, School of Nursing faculty colleague Dr. Patrice Nicholas, and Diane Hanley, associate chief nursing officer at Hallmark. Later that same year, Olans, her husband, and DeMaria published an article, “The Critical Role of the Staff Nurse in Antimicrobial Stewardship—Unrecognized, but Already There,” in the journal Clinical Infectious Diseases. It caught the eye of Dr. Srinivasan.

“I read her article and thought it was fantastic,” says Srinivasan, who was heading up a two-year project with the National Quality Forum to develop recommendations for hospitals to implement antimicrobial stewardship programs. “We’d engaged pharmacists, physicians, infectious disease specialists, but not nurses. The article did a wonderful job outlining all the things nurses were already doing on a daily basis.”

Srinivasan emailed Olans and subsequently invited her to Washington, D.C. to participate in a meeting, which culminated in the creation of the National Quality Forum’s landmark “Playbook: Antibiotic Stewardship in Advanced Care.”

Olans speaks regularly to infectious disease physicians, pharmacists, microbiologists, hospital associations, administrators, and nurses across the nation. In 2016, she spoke to the Pew Charitable Trusts and the Colorado Hospital Association about nurses’ roles in stewardship programs, presented at the annual conference of the Association for Professionals in Infection Control and Epidemiology, and led a meet-the-professor session at the annual scientific meeting of the Infectious Diseases Society of America. She also spoke at the annual meeting of the Society of Healthcare Epidemiology of America this past spring, and continues to be involved with other efforts

She also has joined forces with the American Nurses Association, which had been doing its own work to raise awareness around antibiotic resistance. “Dr. Srinivasan brought Rita’s work to the ANA’s attention,” says Sharon Morgan, the ANA’s senior policy advisor. Morgan considers Olans a kindred spirit: “We are both very interested and outspoken about how nurses can be a bridge between all aspects of care.” With funding from the CDC, the ANA convened an antimicrobial stewardship working group and is using Olans’ work as a framework to better define nurses’ contributions to stewardship efforts. The CDC/ANA will soon publish the joint white paper defining nurses’ role in antimicrobial stewardship.

All of this momentum is good news for health professionals and their patients. “Every time I give a talk, I close it with a photo of my grandson,” says Olans. “Antibiotic resistance is not just a health hazard, it threatens our future. It is going to take every health professional, whether working in acute, long-term care or outpatient care, to address this crisis. This is a local, national, and global imperative. We need to make sure future generations will have ways to manage infections successfully.”