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