Infection control and antimicrobial...
Transcript of Infection control and antimicrobial...
Infection control and antimicrobial
stewardship
Janos Sinko PhD
South-Pest Central Hospital
Budapest
What is infection control?
• Surveillance : (monitoring: collect data
using standardized methods - intervention)
• Estimate risk factors, critical points of care
» intervene to minimize
Nosocomial surveillance
Monitoring by standardized methods
Whom to monitor?
• Hospital, department, unit, risk groups
• Instrumentation, interventions, surgery
• Sporadic, clustered or epidemic nosocomial
infections/pathogens
– internally monitored,
– background-checked,
– prevented/eliminated by specific measures and
interventions
Infection control activity
• Collaborating to develop antimicrobial
stewardship policies, based on
– Antimicrobial resistance
– Antibiotic consumption
– Perioperative prophylaxis
• Theoretic and practical education and training
of health care personnel
Infection control
PREVENTION
Anticipate infections threatening health care
workers (visitors) and patients
• Specific measures
–Vaccination
–Chemoprophylaxis
• Aspecific measures
–Hand hygine
–Isolation, protective equipment
–Disinfection, sterilization
Interventions
• Isolation
• Quarantine
• Work management, patient routes
• Disinfection
• Prophylaxis
• Ongoing monitoring
1st principle of infection prevention
at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:
• Use and care of urinary catheters
• Use and care of vascular access lines
• Therapy and support of pulmonary functions
• Surveillance of surgical procedures
• Hand hygiene and standard precautions
Pittet D
Standard precautions
• Hand hygiene
• Protective equipment: gloves, masks, gown
etc.
• Hazardous material management (waste)
• Linen disinfection
• Disinfective cleaning
Transmission specific precautions
• GOAL: To prevent transmission
• METHODS:
– Contact isolation
– Droplet isolation
– Airway isolation
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Healthcare workers’ hands: potentially
important tools of infection transmission
• Hand hygiene: conscious behaviour
– Education (theory and practice)
– Appropriate conditions (material and individual, shifts, personnel)
• Permanent monitoring,
• Bacterial cultures
• Observing compliance
• Results
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How?
• Single phase hand disinfectant: in case of
visible contaminations (+ C. difficile infection)
• Apparently clean hands: alcohol based rub
Single phase disinfectant
Both cleaning and disinfecting hands
(containing both soap and disinfectant)
Apply to dry hands, add water to foam, then rinse
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Alcohol based hand rub
• Only disinfecting, not cleaning.
• Should be applied to dry hands free of visible contamination. Rub until dry.
• Should not be wiped. Do not apply water.
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What is appropriate antibiotic use?
• If given according to guidelines.
• In general: Order…
– To those
– Then
– That compound
– That formulation
– That frequently
– That long
As it works the
best
Multifactorial background
• HUMAN USE
• Adequate
• INADEQUTE
• Agricultural utilisation
• Environment, water
• Remnants of antibiotics
• Resistance genes
• Lack of monitoring and regulation
• No alternative therapies developed
Regulation? Whose job?
• Yours: do you have a clear view on that?
• Institution: how is it managed in your
hospital?
• Profession: what do groups and societies do?
• Country: any governmental strategy?
• Regional: EU administration, organizations
• Global: WHO?
How are antimicrobials used?
• Seemingly a medical question, in fact
determined by factors of behavioural, societal
and cultural anthropologic background
Illustration
Some cultural elements Power distance (PDI) relates to the extent to which the
less powerfulmembers of organizations and institutions
accept and expect that power is distributed unequally. It
suggests that a society‟s level of inequality is endorsed by
the followers as much as by the leaders.
Uncertainty avoidance (UAI) indicates to what extent a
society tolerates uncertainty and ambiguity, and it shows
how comfortable its members feel in unstructured
situations which are novel, unknown, surprising or different
from usual.
Individualism (IDV) is the degree to which individuals are
integrated into tight groups (collectivist) or loose groups
(individualist).
Could this be you?
• “To stay on the safe side… let‟s add
antibiotics”
• “ The patient forced me to prescribe…”
• “What will the boss say when this guy with
that fever won‟t be on antibiotics”
• “Do not change your winning team, go on for
one more week”
• “Nobody has ever been convicted for giving
antibiotics. Only for not giving them in time.”
Antimicrobial stewardship
Antimicrobial stewardship refers to coordinated
interventions designed to improve and measure
the appropriate use of antimicrobials by
promoting the selection of the optimal
antimicrobial drug regimen, dose, duration of
therapy, and route of administration.
(Infectious Society of America)
www.idsociety.org
Goals
• To improve infection outcome
• Ameliorate toxicity
• Prevent C. difficile infections
• Decrease antibiotic-resistant strains
• Optimizing resource utilization
Clinical Infectious Diseases® 2016;62(10):e51–e77
• 27 recommendations
• Intervention.Optimalization.Benchmark.
Special populations..
• Moderate/low level of evidence: few
evidence based data from studies (USA).
Pros and cons Authorization Control and feedback
Less unnecessary therapy Stewardship including all
Improved empirical choice More flexible
Based on previous microbiology data No need for daily management
Less costly Broadening knowledge
Direct guidance Spearing autonomy
Only affecting some drugs Labour intensive
Hurting autonomy Need for co-operation of parties
Can delay therapy Need for technical background
Manipulation possible Success method dependent
Drugs under regulation might be
avoided
Success coming only later
+
-
Clinical Infectious Diseases® 2016;62(10):e51–e77
Interventions
• How are antimicrobials ordered?
– Authorization?
– Prospective control and feedback?
• What is appropriate?
– Education OK but not sufficient
– Institutional and disease-specific
recommendations
– Clostridium difficile risk groups: restriction of
antibiotics
• What is appropriate?
– Self-control (eg. Stop rules)
– Computer based decision augmentation
– Cycling of antibiotics: NOT recommended
Intervention
Optimalization
• Pharmacokinetics
–Drug levels
–Alternative dosing
–Sequential oral therapy
–De-ecalation
Optimalization
• Pharmacokinetics
– Drug levels
– Alternative dosing
– Sequential oral therapy
– De-ecalation
• Testing drug allergies
• Pre-specified duration of therapy
Optimalization
• Co-operation with microbiology
– Stratified, selective reporting
– Speeding-up diagnostics (viruses, blood
cultures)
– Non-cultural fungal diagnostics
• Procalcitonin
Key players
• Pharmacist dedicated for antibiotic
therapy
• Antimikrobial stewardship team
–Minimal: clinician + pharmacist
–Multidisciplinary
Ten commandments
1. Get appropriate microbiological samples before antibiotic
administration and carefully interpret the results: in the absence of
clinical signs of infection, colonisation rarely requires antimicrobial
treatment.
2. Avoid the use of antibiotics to „treat‟ fever: investigate the root cause of
fever and treat only significant bacterial infections.
3. When indicated, start empirical antibiotic treatment after taking
cultures, tailoring it to the site of infection, risk factors for multidrug-
resistant bacteria, and the local microbiology and susceptibility patterns.
4. Prescribe drugs at their optimal dose, mode of administration and for
the appropriate length of time, adapted to each clinical situation and
patient characteristics.
5. Use antibiotic combinations only in cases where the current evidence
suggests some benefit.
International Journal of Antimicrobial Agents 48 (2016) 239–246 alapján
Ten commandments
6. When possible, avoid antibiotics with a higher likelihood of promoting
drug resistance or hospital-acquired infections, or use them only as a last
resort.
7. Drain the infected foci quickly and remove all potentially or proven
infected devices: control the infection source.
8. Always try to de-escalate/streamline antibiotic treatment according to
the clinical situation and the microbiological results; switch to the oral
route as soon as possible.
9. Stop antibiotics as soon as a significant bacterial infection is unlikely.
10. Do not work alone: set up local teams with an infectious diseases
specialist, clinical microbiologist, hospital pharmacist, infection control
practitioner or hospital epidemiologist, and comply with hospital
antibiotic policies and guidelines.
International Journal of Antimicrobial Agents 48 (2016) 239–246 alapján