Post on 31-May-2022
DO WE NEED
ACINETOBACTER SPECIFIC
INFECTION CONTROL
Dr Bijie HU (胡必杰)Department of Infectious Diseases
Zhongshan Hospital of Fudan University
Shanghai ChinaESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
ANTIBIOTIC RESISTANCE THREATS in the United States 2013Urgent Threats
Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Serious Threats
Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus ( VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Concerning Threats
201649 Dr Bijie HU 4
ESCMID eLibrary
by a
uthor
Distribution of pathogens involved in DA-HAI
201649 Dr Bijie HU 5
L Tao et al International Journal of Infectious Diseases 15 (2011) e774ndashe780 ESCMID eLibrary
by a
uthor
TOP 4 Bacteria Isolated from Sputum
in Zhongshan Hospital of Fudan University in 2013
201649 Dr Bijie HU 6
1鲍曼
2铜绿
3金葡
4肺克
Abaumannii271Klebsiella spp
132
S aureus135
Pseudomonas spp193
ESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
ANTIBIOTIC RESISTANCE THREATS in the United States 2013Urgent Threats
Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Serious Threats
Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus ( VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Concerning Threats
201649 Dr Bijie HU 4
ESCMID eLibrary
by a
uthor
Distribution of pathogens involved in DA-HAI
201649 Dr Bijie HU 5
L Tao et al International Journal of Infectious Diseases 15 (2011) e774ndashe780 ESCMID eLibrary
by a
uthor
TOP 4 Bacteria Isolated from Sputum
in Zhongshan Hospital of Fudan University in 2013
201649 Dr Bijie HU 6
1鲍曼
2铜绿
3金葡
4肺克
Abaumannii271Klebsiella spp
132
S aureus135
Pseudomonas spp193
ESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
ANTIBIOTIC RESISTANCE THREATS in the United States 2013Urgent Threats
Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Serious Threats
Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus ( VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Concerning Threats
201649 Dr Bijie HU 4
ESCMID eLibrary
by a
uthor
Distribution of pathogens involved in DA-HAI
201649 Dr Bijie HU 5
L Tao et al International Journal of Infectious Diseases 15 (2011) e774ndashe780 ESCMID eLibrary
by a
uthor
TOP 4 Bacteria Isolated from Sputum
in Zhongshan Hospital of Fudan University in 2013
201649 Dr Bijie HU 6
1鲍曼
2铜绿
3金葡
4肺克
Abaumannii271Klebsiella spp
132
S aureus135
Pseudomonas spp193
ESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
ANTIBIOTIC RESISTANCE THREATS in the United States 2013Urgent Threats
Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Serious Threats
Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus ( VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Concerning Threats
201649 Dr Bijie HU 4
ESCMID eLibrary
by a
uthor
Distribution of pathogens involved in DA-HAI
201649 Dr Bijie HU 5
L Tao et al International Journal of Infectious Diseases 15 (2011) e774ndashe780 ESCMID eLibrary
by a
uthor
TOP 4 Bacteria Isolated from Sputum
in Zhongshan Hospital of Fudan University in 2013
201649 Dr Bijie HU 6
1鲍曼
2铜绿
3金葡
4肺克
Abaumannii271Klebsiella spp
132
S aureus135
Pseudomonas spp193
ESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Distribution of pathogens involved in DA-HAI
201649 Dr Bijie HU 5
L Tao et al International Journal of Infectious Diseases 15 (2011) e774ndashe780 ESCMID eLibrary
by a
uthor
TOP 4 Bacteria Isolated from Sputum
in Zhongshan Hospital of Fudan University in 2013
201649 Dr Bijie HU 6
1鲍曼
2铜绿
3金葡
4肺克
Abaumannii271Klebsiella spp
132
S aureus135
Pseudomonas spp193
ESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
TOP 4 Bacteria Isolated from Sputum
in Zhongshan Hospital of Fudan University in 2013
201649 Dr Bijie HU 6
1鲍曼
2铜绿
3金葡
4肺克
Abaumannii271Klebsiella spp
132
S aureus135
Pseudomonas spp193
ESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
CRBA from one hospital in Shanghai
186 419 322 44 593
2006
2007
2008
2009
2005
681
2010
7
increased risk of deathESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
year
bullresistance(CHINETAcinetobacter)
Resistance rate of A baumannii
against Carbapenem()
ESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Epidemic and Endemic by CRAB in ICU
201649 DrHU Bijie 9
Acinetobacter infection
bull Pneumonia
bull Bacteremia
bull Surgical site infection
bull Skin and soft tissue infection
bull Urinary tract infection
bull wound infection
bull secondary meningitis ESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
10
Fatal rate of BSI by pathogen specific (2013)
CRAB 50
ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
MDRO Bundlebull Hand Hygiene
bull Contact precautions
bull Minimize shared equipment
bull Environmental cleaning
bull HAI Preventive Bundles
bull Active surveillance cultures
bull Chlorhexidine baths
bull Antimicrobial stewardship
12
ESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
MDROs
Prevention Strategies
Core Measures
1 Administrative support
2 Surveillance
3 Patient placement
4 Patientstaff cohorting
5 Hand hygiene
6 Contact precautions
7 Protocol for lab notification
8 Dedicated equipment
9 Device use
10 Environmental measures
11 Monitor compliance
12 Education
13 Antimicrobial stewardship
Supplemental Measures
1 Preemptive isolation
2 Active surveillance culture
3 Chlorohexidine bathing
13
ESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Active Surveillance Controls MRSA BSIs
Huang et al CID 200643971-8ESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
15
Soap and ABHR consumption
in Shanghai (70 hospitals)
201649 15
Reference ICU ABHR 24~75mlptd
year kind department averagePercentile
25 50 90
2009
soapICU 3764 229 3395 6412
wards 863 646 857 1206
ABHRICU 1807 1027 1862 2683
wards 395 135 343 851
2010
soapICU 3797 2528 3453 5920
ward 850 649 843 1253
ABHRICU 2064 1393 1903 3606
ward 445 206 385 970
ESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Effect of computer keyboard covers on reduction of
microbial contaminationbull the bacterial colony counts were 3493
CFU10 keys before the cleaning 2262 CFU10 keys after the cleaning the difference was statistically significant (Plt 005)
bull The median bacterial colony counts in the SICU were 1735 CFU10 keys after the cleaning significantly less than 4586 CFU10 keys before the cleaning(P=001) and there was no significant difference in the bacterial colony counts in the SICU between before and after the cleaning ESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Trends of antimicrobial resistance
among major nosocomial pathogens in China
Drug Resist Updat (2011) doi101016jdrup201107001 Chin J Nosocomiol 2011 234896ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Special characteristics
bull Live on dry surface long time
bull Spread via air
ESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Environmental survival
bull Use of various substrates for growth
bull Biofilm formation on surfaces
bull Resistance to desiccation disinfectants and antibiotics
bull Quorum sensing for regulation of for example biofilm formation
Colonizationbull Adherence to host cells
bull Resistance to inhibitory agents andconditions of skin and mucosalsurfaces
bull Biofilm formation
bull Quorum sensing
Infectionbull Elicitation of inflammatory responses
bull Cytotoxicity
bull Iron acquisition
bull Resistance to serum and complementactivation
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
What makes Acinetobacter an enemy
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95
Common source with respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Ventilator spirometers
bull Wright respirometers
bull Demand valve reservoir of ventilator
bull In-line temperature and oxygen monitor probes
bull Suction catheter and bottle
bull ldquoYrdquo piece of ventilator
45
19
30
48
9
23
Adult ICUs
Multiple ICUs
Surgical ICU
Adult mixed ICU
Neonatal ICU
Adult ICU
6 mo
1 mo
9 mo
6 mo
2 wk
7 moESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Common source without respiratory site predominance
No of Patients
Hospital Setting
Duration
bull Bedside humidifiers
bull Warming bath water
bull Bedpan and urine jugs
bull Patient mattresses
bull Feather pillows
bull Reusable pressure transducers in arterial lines
24
14
8
63
128
75
Medical wards Medical ICU
Urology ward
Burn unit
Hspital wide
Multiple ICUs
4 mo
4 mo
2 wk
21 mo
26 mo
17 mo
Reservoirs of Acinetobacter
Villegas MV Infect Control Hosp Epidemiol 2003 Apr24(4)284-95 ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull Feather pillows
bull Surrounding curtains
bull Bedrails
bull Bedside tables
bull door handles
bull computer keyboards
bull Sinks
Weernink A J Hosp Infect 199529189-199
Das I J Hosp Infect 2002 50 110ndash14
Catalano M J Hosp Infect 1999 42 27ndash35
Wang SH J Hosp Infect 2003 53 97ndash102
Roberts SA J Hosp Infect 2001 48 228ndash32
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58Podnos YD Surg Infect 2001 2 297ndash301
Environmental sites
ESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Reservoirs of Acinetobacter
Drosos E Karageorgopoulos Lancet Infect Dis 2008 8 751ndash62
Common source References
bull mechanical ventilation
bull suctioning
bull infusion pumps
bull pressure transducers
bull blood pressure cuffs
bull pulse oximeters
bull laryngoscope blades
Bernards AT nfect Control Hosp Epidemiol 200425 1002ndash04Wroblewska MM J Hosp Infect 2004 57 300ndash07Wang SH J Hosp Infect 2003 53
Beck-Sague CM Am J Epidemiol 1990 132 723ndash33Bureau-Chalot F J Hosp Infect 2004 58 91ndash92Aygun G J Hosp Infect 2002 52 259ndash62
Wilks M Infect Control Hosp Epidemiol 2006 27 654ndash58
Devices
ESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Dijkshoorn L Nature reviews Microbiology 2007 5(12)939-951
3D focus 4D focus
1Providers Air2Patients
3Environmental surfaces
Transmission mode
contact or airborne route
ESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Acinetobacter spp can be transmitted
through the airborne route
bull Outbreaks was transmitted by the airborne route Allen KD J Hosp Infec 19879 110ndash119
Bernards AT Am J Infection Control 199826544ndash551
Gervich DH Am J Infect Control 198513210ndash5
bull The micro-organism could remain viable in the airborne state Jawad A J Clin Microbiol 1998July1938ndash1941
bull Ability of surviving on fingertips and on dry surfaces under environmental conditions typically found in hospitals
Musa EK J Hospital Infection 199015219ndash227
Jawad A J Clin Microbiol 1996342881ndash2887 CBBeggs Indoor Built Environ 2003129ndash18 ESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Outline
bull Acinetobacter urgent or serious threats
bull Current prevention measures is effective enough
bull Acinetobacter has special characteristic from
other MDRO
bull Do we need Acinetobacter specific measures for
infection prevention
ESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Preventing Healthcare-Associated Infections
Examples of Vertical and Horizontal Approaches bull Vertical approaches reduce risk of infections due to specific
pathogensbull Active surveillance testing to identify asymptomatic carriersbull Contact precautions for patients colonized or infected with specific organisms bull Decolonization of patients colonized or infected with specific organisms
bull Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific
bull bull Standard precautions (eg hand hygiene)bull Universal use of gloves or gloves and gownsbull Universal decolonization (eg chlorhexidine gluconate bathing)
bull bull Antimicrobial stewardshipbull Environmental cleaning and disinfection
201649 Dr Bijie HU 28
Infect Control Hosp Epidemiol 201435(7)797-801ESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
bull baseline periodJan 1 - Dec 31 2009
bull intervention periodApr 8 2010-Sep 30 2011
bull group 1 screening and isolation
bull group 2 targeted decolonization (known to have MRSA underwent a
5-day decolonization regimen consisting of twice daily intranasal
mupirocin and daily bathing with chlorhexidine-impregnated cloths)
bull group 3 universal decolonization (Contact precautions were similar
to those in group 1 All patients received twice-daily intranasal
mupirocin for 5 days plus daily bathing with chlorhexidine-
impregnated cloths for the entire ICU stay)
201649 DrHU Bijie 29
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
201649 DrHU Bijie 30
N Engl J Med 2013 DOI 101056NEJMoa1207290ESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 31
ESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
32
CDAD prevention and control bull Hand hygiene
bull Personal protective equipment (PPE)
bull Environmental cleaning
bull Use of care equipment
Hand washing with soap and water or chlorhexidine recommended
Alcohol-based hand rubs are not effective in removing C difficile spores
from handsnot be the only hand hygiene measure when caring CDAD
patients
Patients and visitors strongly encouraged to wash their hands with soap
and water especially before eating and after using the toiletESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
201649 Dr Bijie HU 33
ESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
B Special approaches[A] Active surveillance testing (AST)
bull 1 Implement an MRSA AST program as part of a multifaceted strategy to control and prevent MRSA (II)
bull 2 Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections (III)
[B]MRSA decolonization therapy
bull 1 Provide targeted decolonization therapy to MRSA- colonized patients in conjunction with an AST program (II)
bull 2 Provide universal decolonization to ICU patients (I)
[C]Use of gowns and gloves for all contact with patients and the patient care environment
bull 1 Use gowns and gloves when providing care to or entering the room of adult ICU patients (II)
201649 Dr Bijie HU 34
ESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Contact Precaution is not effective for all MDROs--Reservoirs for MDROs
Organism Reservoir Colonizes In hospital environment
Staphylococcus aureus Nares skin Nares skin Stethoscopes pagers bed spaces linens wheelchairs doorknobs workstations telephones hellip
Enterococcus species Intestines Intestines Bed rails linens doorknobs bedpans urinals blood pressure cuffs stethoscopes monitoring equipment
Pseudomonas aeruginosa
Soil water plants
Axilla ear perineum respiratory tract
Drains toilets showers water in patient equipment
Acinetobacter species Soil water food Pharynx especially tracheostomy
Tap water peritoneal dialysate bath urinals washcloths soap dispensers
Enterobacteriaceae(Klebsiella
Intestines Oropharynx genitourinary tract
Sinks ultrasonography gel bath soap water baths
35
ESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
ESCMID guidelines for the management of the infection control measures to reduce transmission of MDR- Gram-negative bacteria in hospitalized patients bull The Role of Hand Hygiene to Prevent Spread of MDR-GNB
bull The Role of Contact Precautions to Prevent Spread
bull The Role of Active Screening Cultures to Prevent Spread
bull The Role of the Environmental Cleaning to Prevent Spread
bull The Role of Antimicrobial Stewardship to Prevent Spread
bull The Role of Decolonization and Topical Chlorhexidine to Reduce
Spread
bull The Role of Infrastructure and Education to Reduce the Spread
201649 DrHU Bijie 36
Clin Microbiol Infect 2014 20 (Suppl 1) 1ndash55
Some special measures may need to
apply for MDR-ABhelliphellipESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
A Multifaceted Intervention
Rates of pandrug-resistant Acinetobacter baumanii infection and colonization in 3 intensive
care units Period 1 was the baseline period period 2 was the intervention period and
period 3 was the follow-upCID 200847 (15 September) bull Apisarnthanarak et alESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Effects of various antimicrobial stewardship
programs remained controversal
Lai CC J Microbiol Immunol Infect 2016 Feb49(1)74-82
Hospit
al
ASP strategy Piperacillintazo
bactam
Fluoroquinol
ones
Class 2
carbapenems
Extended-spectrum
cephalosporins
Total
A Preprescription
approval hospital-
wide
213 228 122 530 1093
B Preprescription
approval except
ICUs
275 264 224 1028 1792
C Postprescription
review437 323 425 499 1685
Average consumption of broad-spectrum antibiotics (defined daily doses1000 patient-days) at three
medical centers from July 2005 to December 2011
bull the total amount of broad-spectrum antibiotic use was similarly high at Hospitals B and
C whereas their use was considerably lower in Hospital A (average 10925 DDDs1000
patient-days)ESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Specific infection control measures
bull Vaporized Hydrogen peroxide
bull Monitoring the effectiveness of cleaning
bull Ultraviolet light-C
bull Negative air ionisation
bull Microaerosolization of liquid disinfectants into the air
bull Bacteriophage
bull Vaccines specific to Acinetobacter baumanniiESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
VHP FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Author Year HP System Pathogen Before HPV After HPV Reduction
French 2004 VHP MRSA 6185-72 185-1 98
Bates 2005 VHP Serratia 242-5 024-0 100
Jeanes 2005 VHP MRSA 1028-36 050-0 100
Hardy 2007 VHP MRSA 729-24 029-0 100
Dryden 2007 VHP MRSA 829-28 129-3 88
Otter 2007 VHP MRSA 1830-60 130-3 95
Boyce 2008 VHP C difficile 1143-26 037-0 100
Bartels 2008 HP dry mist MRSA 414-29 014-0 100
Shapey 2008 HP dry mist C difficile 48203-24 7203-3 88
Barbut 2009 HP dry mist C difficile 34180-19 4180-2 88Falagas et al J Hosp Infect 201178171ESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
bull Environmental cultures were negative immediately after VHP decontamination and
both 24 hours and 1 week after VHP decontamination
AdvantagesbullPortability
bullLow vapor temperature
bulllack of harmful residue
bullDoes not afford any
residual biocidal effect
bulla broad-spectrum
disinfectant
Vaporized Hydrogen Peroxide
Amy RayInfect Control Hosp Epidemiol 2010ESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Vaporized Hydrogen Peroxide
Chmielarczyk A J Hosp Infect 2012 Aug81(4)239-45
bull An outbreak investigation 28 patients between January 2009 and September 2010 in two ICUs
bull A combination of rigorous infection control and surface decontamination using VHP halted the outbreak
Arrow 1 closure units and Steris VHP intervention (20 December 2009) arrow 2 Steris VHP
interventionESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
UV-C radiation
Study organism Baseline
infection
count
Intervention
infection count
Baseline
incidence rate
Intervention
incidence rate
Incidence rate
change
P
A baumannii 7 2 039 011 -7180 005
C difficile 22 12 123 066 -4620 lt001
K pneumoniae 8 0 044 0 -10000 lt001
MRSA 7 7 039 038 -120 1
VRE 18 16 1 088 -1230 14
Napolitano NA Am J Infect Control 2015 Dec 143(12)1342-6
bull Actericidal doses of UV-C radiation (254 nm) were delivered through a UV-C based mobile
environmental decontamination unit
bull The intervention period spanned October 1 2012 to March 31 2013
bull Significant reductions was identified including a 714 decrease for Acinetobacter
baumannii a 427 decrease for Clostridium difficile and a 1000 decrease for Klebsiella
pneumoniae
bull The dedicated service model dramatically reduced HAIsESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Effect of negative air ionisers
Kerr KG et al Intensive Care Med 2006
bull Negative air lonisers may have a role in the prevention of Acinetobacter infections
bull The airborne route of transmission is important in the Acinetobacter infectionsESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Shepherd et al BMC Infectious Diseases 2010
Ventilator
tubing
Face mask
Nebulizer tubing Unometer tubing
Effect of negative air ionisers
bull The action of negative air ionizers significantly alters the electrostatic landscape of the clinical
environment causing Acinetobacter-bearing particles in the air to be strongly repelled from
some plastic surfaces therefore prevent critical items of equipment from becoming
contaminated
ESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Bacteriophage
A new disinfectant agent for the control of MDRAB
bull Rapid adsorption (gt99 adsorbed in 6 min)
bull A short latent period (lt10 min)
bull A large burst size (ca 200)
bull Capable of infecting a wide spectrum of A baumannii
strains causing virtually complete lysis φAB2 a good
candidate as a therapeuticdisinfectant agent to control
nosocomial infections caused by MDRAB
N-T Lin et al Research in Microbiology 161 (2010) 308e314ESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
bull Bactericidal effect of different concentrations of A baumannii M3237 in a liquid suspension The
addition of φAB2 at a concentration of at least 105 PFUml to an A baumannii M3237 suspension
killed gt999 of A baumannii M3237 after 5 min regardless of A baumannii M3237 concentration
bull φAB2 bactericidal effect showed a dose-response
Chen et al BMC Microbiology 2013 13154
Bactericidal effect of φAB2
ESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Michael J etc Vaccine Volume 29 Issue 34 2011 5705ndash5710
An outer membrane complex vaccine
Meta J Kuehn and Nicole C
Kesty Genes Dev 2005192645-2655
bull Outer membrane vesicles (OMVs)
non-viable vesicles that contain multiple antigenic proteins from the
bacterial outer membrane
bull A mouse model of disseminated sepsis
Produced a robust antibody response against multiple bacterial
antigens which consisted of antigen-specific IgG IgM IgG1 and IgG2c
subtypes
Had lower tissue bacterial loads and lower serum levels of the pro-
inflammatory cytokines IL-6 and IL-11113248 post-infectionESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor
Summary
bull Classic Interventions to prevent the spread of MDR-AB
bull hand hygiene measures (HH)
bull active screening cultures (ASC)
bull contact precautions (CP)
bull environmental cleaning (EC)
bull antimicrobial stewardship (ABS)
bull New measures such as air interventions should beconsidered more and morehellip
Thank youESCMID eLibrary
by a
uthor