Health Care Assiciated Infections and Antibiotic Resistance: an increasing threat to Patient Safety in Europe Aftab Jasir, European Centre for Disease Prevention and Control (ECDC)

European public health microbiology training program (EUPHEM)

Objectives of the lecture

To learn and understand about:

Basic of antibiotics and resistant among bacteria

Health care associated infections

Relevant terminologies

Story of glory

1945

Fleming, Florey and Chain

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Antibiotics

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Antimicrobial drugs

Natural antibiotics

Synthesized antibiotics

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Natural antibiotics

Penicillium notatum

Knowledg about killing

Do we need to use antibiotics for killing of pathogens?

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Hip replacement

Organ transplants

Cancer chemotherapy

Intensive care

Care of preterm babies

Modern medicine is not possible without effective antimicrobials

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TerminologyTerminologyAntisepticsAntiseptics

• Topical substances (e.g. Topical substances (e.g. skin) skin)

• e.g. iodine or 70% e.g. iodine or 70% alcoholalcohol• “ “reduce” bacterial loadreduce” bacterial load

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AntibioticsAntibiotics

• Selectively toxic for bacteriaSelectively toxic for bacteria• bactericidal (killing) bactericidal (killing) • bacteriostatic (growth inhibition)bacteriostatic (growth inhibition)

• no harm to patient (???)no harm to patient (???)

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Prophylaxis

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Minimal inhibitory concentration/ Minimal inhibitory concentration/ minimal bactericidal concentration minimal bactericidal concentration

(MIC/MBC)(MIC/MBC)

lowest level stopping lowest level stopping growth/killinggrowth/killing

e. g. zone of inhibition around a e. g. zone of inhibition around a diskdisk

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MIC/MBC

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Most important targets in bacteria 1. Attack bacterial cell wall synthesis.

2. Interfere with protein synthesis.

3. Interference with nucleic acid synthesis (RNA and DNA)

4. Inhibition of an essential metabolic pathway that exists in the bacterium but does not exist in the host

5. Membrane inhibition or disruption doesn't work too well because of the similarities

between and bacterial membranes.

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Drug usage = Drug resistance

Basis of Antibiotic Resistance

The antibiotic resistance is guided by Genomic changes

Spread of R plasmids or other genetic elements among the Bacteria

Do remember Antibiotics are used in veterinary medicine

The discovery of antibiotic resistance was discovered with spread of R plasmids from animal sources

Plasmids and Transposons

RTF

R determina

nt

Tn 8

Tn 10

Tn 9

Tn 21

Superbugs

Multi drug-resistantacquired non-susceptibility to at least one agent in three or more antimicrobial categoriesExtensively drug-resistantnon-susceptibility to at least one agent in all but two or fewer antimicrobial categoriesPandrug-resistance (PDR)non-susceptibility to all agents in all antimicrobial categories

Welcome to the hospital!Bugs are waiting for you!!!

NIIIIIICE! I am getting something good here

Terminology

Nosocomial • Traditional meaning “originating in hospital”

Hospital-acquired/associated

Healthcare-acquired/associated

HAI or NI or HCAI

Definition

An infection occurring in a patient/staff/visitor in a

healthcare facility not present or incubated at the

time of admission.

- includes infections that do not become apparent until after discharge and occupational infections among staff of the facility

Healthcare-associated infections

Community-acquired

infections

Antimicrobial resistance

Healthcare-associated infections, antimicro-bial resistance: Overlapping, but not identical

Antimicrobial resistance

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Burden of Healthcare-Associated Infections and Multidrug Resistance (preliminary estimate)

Healthcare-associated infections (HCAI)• approximately 4 million per year• approx. 37,000 directly attributable deaths

each year

Multidrug-resistant bacteria • approximately 1/2 of the deaths attributable to

HCAI

are due to the 7 most common multidrug-resistant bacteria

in the 4 main types of HCAI: bloodstream infection, pneumonia, skin and soft tissue infection, urinary tract infection

This is an underestimate!Source: Suetens C & Monnet DL, ECDC(preliminary estimate)

Risk factors

External/none host• Catheters and other

invasive devices• Surgeries• Invasive procedures• Antibiotic exposure• Inadequate staff and

overcrowding

Internal/Host • Extremes of age• Immune status• Illness severity• Comorbidities • Colonization status

New challenges

http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=740

Challenges in developing Case-Definitions for HAI

Assumptions: >48 or >72 hours after admission Not incubating at the time of admission Can manifest after discharge Acquired in healthcare setting

Use both clinical and lab criteria

Examples of potential for misclassificationCase 1 80 y.o. patient, multiple medical problems,

lives at home, visited by grandchildren who have colds

2 days later, admitted for hip fracture

4 days after admission she develops RSV (respiratory syncytial virus) pneumonia

What you think?

Examples of potential for misclassificationCase 2 55 y.o. patient, admitted for work-up and

management of chest pain, cared for by healthcare worker taking care of another patient who has MRSA

Discharged after 2 days in hospital

Develops an MRSA soft tissue infection 3 weeks later while in the community

What now???

Incubation periods

C.difficile unknown MRSA unknown VRE unknown Influenza 1-4 days RSV 2-8 days Norovirus 24-48 hours

Conclusions

There are always outbreaks going on at the hospitals. However they might not be detectable

Hospitals are a suitable place for outbreak investigation

It is not always easy to define the cases

Outbreaks agents circulating frequently. Therefore you need good microbiological evidence to confirm your cases.

Hands are the most common public transport of microorganisms

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