Existe una preocupación creciente respecto a que los microorganismos resistentes a los antimicrobianos puedan ser adquiridos en la comunidad o que ellos puedan ser introducidos en la comunidad proveniente de los centros de salud. La resistencia a los antimicrobianos puede además ser adquirida en la comunidad y ser introducida en los centros de salud, donde la infección puede ser ampliamente diseminada (1-6). Las sugerencias presentadas en esta revisión provee una aproximación básica que puede ser aplicada para prevenir la transmisión de los actuales patógenos resistentes a los antimicrobianos y aquellos que podrían llegar a serlos en el futuro.
La prevención es el paso clave para detener la transmisión de estos microorganismos (7-10). Las recomendaciones limitadas existen para prevenir la transmisión de estos microorganismos en la provisión del cuidado de salud en la comunidad y la casa (3,11-20).
Muchas de las recomendaciones existentes seguidas en los centros de salud no pueden fácilmente ser transferidas a la comunidad o la casa debido a las limitaciones en el medio, los recursos o la incapacidad de tomar medidas. Varias sugerencias para prevenir la transmisión de los virus respiratorios incluyen el uso de máscaras y guantes; aunque estas sugerencias son basadas en meta análisis de una gran cantidad de reportes y estudios de intervención, demandan muchos recursos lo cual lo hace impráctico e irreal en el hogar (4,512).
En la casa, la preocupación sobre microorganismos resistentes como Staphylococcus aureus meticilina resistentes (MRSA por sus siglas en inglés), Enterococcus y Clostridium difficile resistente a Vancomicina junto con Mycobacterium tuberculosis, virus respiratorios y gastrointestinales, se relacionada con las implicancias por el paciente y otras personas viviendo o visitando el paciente
people living with or visiting people infected or colonized with these pathogens,1,11,12,21–28 as well as to home-based health care providers. The true prevalence and risk of transmission of MRSA, vancomycin-resistant Enterococcus, extended spectrum
?-lactamase–producing gram negative bacteria, Acinetobacterbaumanii and C. difficile in the community among patients,
their caregivers and family members is not known.
However, the risk of transmission is believed to be low.2,29
This is in contrast to the risk of transmission of respiratory
and gastrointestinal viruses and M. tuberculosis, for which the
attack rate for people living in the same dwelling is much
higher1,3,13–15
Prevention and control of infections
The chain of transmission (Appendix 1, available online at
www.cmaj.ca/cgi/content/full/180/11/E82/DC1) may be similar
in the home to that in health care facilities. It may include
transmission from person to person and from inanimate object
to person. This chain should be considered when determining
principles of infection prevention and control in the community.
12,16,17 As well as being spread from the patient to family
members, health care providers and other patients, these microorganisms
may also spread from family members, health
care providers and pets to the patient. Each of these may be
susceptible hosts.12,16,17
Microorganisms can spread by contact, droplet, airborne
and vector transmission. Contact transmission, which includes
both direct and indirect transmission,8–10,16,17 is the most frequently
encountered mechanism of spread of antimicrobialresistant
microorganisms in the home environment.
The foundation of infection prevention and control in the
health care environment is the use of routine practices.8 Routine
practices include the use of hand hygiene at all times and
the use of personal protective equipment (e.g., gloves,
gowns, masks, eye protection and face protection when indicated)
and environmental controls (e.g., equipment and environmental
cleaning) as required.8 Some of these practices
cannot be readily implemented in the home and should be
tailored to the available resources, individual situation and
potential pathogen.
Hand hygiene is the most important aspect of infection
prevention and control activities because it reduces the bur
den of microorganisms on the hands and minimizes the
chance of transmission to other people.8–10,12,23 Hand hygiene
can be performed by using soap and water or, alternatively,
an alcohol-based hand rub.8–10,18, 30–35 In the home, hands may
be dried with a dry, clean towel.
The use of antimicrobial hand soaps, compared with the
use of regular soaps, provides a greater reduction in the number
of bacteria on the hands. Antimicrobial soaps may decreases
the transmission of microorganisms from the hands to
inanimate objects and food products.36,37 However, the use of
antibacterial soaps may lead to the selection of antimicrobialresistant
bacteria. There appear to be no additional health
benefits to using triclosan-containing consumer soap.38,39 This
is an area of controversy. Therefore, until more data become
available, the only recommendation that can be made is to
continue using regular household soap in the home.
Data are also lacking to support the use of special antibacterial
cleaning products in the home. Concern has been raised
about the potential evolution of bacteria resistant to triclosan.40
In vitro experiments have suggested a link between exposure to
biocides and resistance to antimicrobials; however, this remains
a theoretical concern because there is little evidence showing
that use of biocides in the community has led to the emergence
and spread of antimicrobial-resistant pathogens.41
There is evidence to support the use of alcohol-based hand
rubs to break the chain of transmission of microorganisms.42
For a visitor entering the home of a person who is colonized
or infected with MRSA, vancomycin-resistant Enterococcus
or C. difficile, strict attention should be paid to hand
hygiene before and after the visit, with either soap and water
or an alcohol-based hand rub. These measures will minimize
the risk of acquiring and transmitting these organisms.
Methicillin-resistant Staphylococcus aureus
A number of reports summarize Canada’s experience with
MRSA; however, this experience is limited primarily to health
care facilities and clusters in northern communities.43–45 MRSA
has been characterized into health care–associated MRSA
strains and community-associated strains.46 Communityassociated
MRSA can affect otherwise healthy people, such as
athletes, those who are incarcerated, soldiers, injection drug
users, men who have sex with men and those in specific ethnic
populations, such as Aboriginal people.46–52 There are many reports
of the isolation of MRSA from domestic pets and farm
animals, with the possibility for cross-transmission to
humans.53–56 Community-associated MRSA strains produce thePanton–Valentine leukocidin.46,48–57 These microorganisms are
frequently associated with skin and soft tissue infection and
necrotizing pneumonia.
In contrast, MRSA associated with health care typically
affects residents of long-term care facilities, individuals who
have extensive exposure to health care facilities, as well as
people with underlying medical problems.46
Prevention and control
There are a limited number of reports of the spread of MRSA
in the home.2,22 Proper hand hygiene (Box 1),8 as well as
cleaning of equipment and the environment, is important in
both the home and institutions where health care is provided.
In the home, it is neither realistic nor practical to attempt to
isolate a family member who is colonized or infected with
MRSA. Because MRSA is transmitted by direct person-toperson
contact, particularly on the hands of caregivers, hand
hygiene among all family members, visitors and health care
providers is key in the prevention of transmission.16,17
Because domestic pets may serve as a reservoir of MRSA,
hands should always be washed thoroughly with soap and water
after contact with animals or their feces.57,58 In cases of outbreaks
within a family of an infection caused by communityassociated
MRSA that cannot be arrested, a colonized pet
may need to be temporarily removed from the home.57 However,
it may be prudent to re-emphasize the importance of
personal hygiene before taking such a drastic measure. Skinto-
skin contact should be minimized by avoiding sports and
play in which close contact occurs.16,17,57 Given that this may
be difficult, particularly for children, keeping open and draining
wounds covered may be a prudent more approach.57 It is
also important to have good personal hygiene and to cover
cuts and abrasions.
Some recommend that articles, such as clothing, towels,
face cloths and linens, that come into close contact with the
body should not be shared among family members.16,17,57
Clearly, these recommendations may be difficult to implement,
particularly in close quarters and where resources are
limited. Clothes, household linens, including cleaning cloths,
should be washed on a regular basis. The home should be
cleaned regularly with standard household cleaners that do
not contain antibacterial agents.16,17
There are no specific recommendations for home nursing.
However, routine practices, specifically the use of hand hygiene
and gloves, should be used if there is the potential for
the hands to become soiled.8
Environmental contact surfaces should be kept as clean as
possible with the use of a disinfectant cleaner. Objects for
personal hygiene should not be shared. Intimate apparel,
towels, linens, and sports clothing, should be washed at 40°C
using a bleach-containing laundry detergent, or at 60°C if a
bleach-containing laundry detergent is not used.17
People infected or colonized with MRSA should pay
strict attention to hand hygiene to minimize transmission.
Children may attend school and adults may attend work or
educational venues; however, the principles of hand hygiene
need to be reinforced and any open or draining wound
should be covered.
Vancomycin-resistant Enterococcus
Vancomycin-resistant enterococci are infrequently observed in
the community. They are transmitted in health care facilities
by the hands of health care workers59–61 and by contaminated
equipment and surfaces.61–67 In Canada, the incidence of infection
and colonization with vancomycin-resistant Enterococcus
is very low but has been slowly increasing.68
Prevention and control
There are no published reports on how to manage the care of
patients infected or colonized with this microorganism in the
community. General infection prevention and control principles
should be followed, and it is critical that strict attention
be paid to hand hygiene (Box 1). In addition, contact by family
members with potentially infectious material should be
avoided at all times. The person infected or colonized with
vancomycin-resistant Enterococcus should also pay strict attention
to hand hygiene to prevent transmission within the
household.
Those providing health care in the home should adhere to
the routine practices and pay specific attention to hand hygiene
and, when necessary, environmental cleaning.8 The
home needs to be cleaned regularly, and clothes and linens
should be washed as for the prevention of MRSA transmission.
12,17
Clostridium difficile
The ease with which C. difficile has spread within health care
facilities has been attributed to the spores produced by the organism,
suboptimal housekeeping practices, the widespread
use of antimicrobial agents and inadequate hand hygiene.69
Although C. difficile transmission has not been reported in
the home, the uniforms of health care workers can become
contaminated by C. difficile spores,70 and people with symptomatic
and asymptomatic C. difficile infections can shedspores.
71 Spores can be transmitted by the hands of health care
workers72 and by dogs used for hospital visitation.73,74
One of the key elements for the transmission of C. difficile
is the alteration of the gastrointestinal flora. Although
the microorganism may be shed asymptomatically in the
stool of carriers, susceptible hosts are required for the
pathogen to cause disease. Thus, although the risk of transmission
of C. difficile exists in the home and community,the risk is likely quite low.16,17 However, steps should be
taken to minimize the risk of transmission in the home and
institutions.
Prevention and control
Because C. difficile spores are not effectively killed by
alcohol-based hand rubs, mechanical cleaning with soap and
water is required to remove spores. C. difficile spores may
contaminate the home and serve as a potential source of infection
for family members and reinfection of the patient.
The use of routine practices should prevent the transmission
of C. difficile within the home. Careful attention must bepaid to hand-washing practices.8 Clothes and linens should be
washed as for the prevention of MRSA transmission.
Good personal hygiene is essential. The home, especially
the bathroom, should be cleaned regularly with standard
household cleaners.16,17 Health care workers who provide care
in the home should pay strict attention to hand hygiene when
caring for patients infected or colonized with C. difficile.
Gloves should be worn if there is a chance of soiling of the
hands.8
Conclusions
Hand hygiene, with soap and water or alcohol-based hand
rubs, is the most important strategy for preventing transmission
of antibacterial-resistant organisms in the home. It is neither
realistic nor practical to expect people who are infected
or colonized to be kept in isolation or that family members
and health care providers wear personal protective equipment
for direct or indirect contact.
Available recommendations for the prevention and control
of infections16–20 are clear, well-written and based on
available reports. Hand hygiene and routine practices can
serve as a basis to prevent the transmission of these
pathogens between colonized or infected family members
and other family members or health care providers. In the absence
of specific recommendations, the basics of infection
prevention and control (Box 1) can be used as templates to
help prevent the transmission of antimicrobial-resistant microorganisms
in the home.
Family members and those who provide home health
care for people infected or colonized with antimicrobialresistant
microorganisms should understand the chain of
transmission of infection and should apply the measures
outlined here to prevent transmission of these microorganisms
in the home.
Bibliografía: En el artículo original del CMAJ
http://www.cmaj.ca/cgi/reprint/180/11/E82
Durante el proceso de diagnóstico y tratamiento, los pacientes deben recibir la información más completa. Tal como lo describiera en los post de Superar barreras para reportar RAM Parte 1 y Superar barreras para reportar RAM Parte 2 se debe trabajar para informar a los pacientes sobre las reacciones adversas que ellos presentan a los medicamentos.
Cuando hace varios meses comentábamos sobre el uso indiscriminado de los medicamentos de la familia del Sildenafilo en el post 
Existe la preocupación creciente que la resistencia antimicrobiana puede ser adquirida en la comunidad o que ellas pueden ser introducidas en la comunidad desde los centros de salud. La resistencia antimicrobiana podría además evolucionar o ser adquirida en la comunidad y ser introducida a los centros de salud, donde la infección puede ser diseminada (1-6).
El avance del cuidado de pacientes durante la hospitalización por parte de los Farmacéuticos es un logro muy notorio, haciendo que se reconozca el trabajo que se desarrolla. Sin embargo, existe un aspecto que falta trabajar y es aquel que asegure que todos los cuidados hacia el paciente que se da en el hospital, continuen en el ambulatorio durante la vuelta a casa.
El lanzamiento por parte de National Health and Hospitals Reform Commission (NHHRC por sus siglas en inglés) del reporte enfocado en la “e-salud” y la introducción de un “registro de salud controlado por cada persona” ha sido bien recibido por la Pharmaceutical Society of Australia (PSA). El reporte recomienda que para el 2012 cada Australiano debe tener un registro personal de salud que será llenado por las mismas personas.
Vitamina D
La American College of Rheumatology (ACR) ha actualizado su guía para el uso de medicamentos no-biológicos antirreumáticos para la artritis reumatoidea (AR), la cual ahora incluye el uso de agentes biológicos. Las recomendaciones actualizadas fueron presentadas en la revista Arthritis Care and Research. “La mayoría de los pacientes con diagnóstico confirmado de AR usan medicamentos no-biológicos aunque la tasa de uso de biológicos esta aumentando rápidamente” dice Kenneth G. Saag, de la University of Alabama, Birmingham.
La American Society of Health-System Pharmacists (ASHP) ha publicado un nuevo manifiesto sobre los criterios apropiados para una categoria intermedia de medicamentos que podrían estar disponibles en el medio ambulatorio sin la exigencia de una receta médica. Los medicamentos apropiados para esta categoría intermedia deberán haber probado beneficios en la salud pública y deberían ser identificados por procesos que incluyen el consejo de expertos en el medicamento como Farmacéuticos, Médicos y otros profesional con las competencias necesarias. Los medicamentos de esta categoría estarían solo disponibles para los pacientes después de una evaluación y consulta con el Farmacéutico.
Los incentivos económicos ofrecidos por empleadores incrementó la tasa de deshabituación tabáquica, de acuerdo a los resultados de un ensayo clínico aleatorio publicado recientemente en la revista New England Journal of Medicine.