The importance of infection control in the era of multi drug resistance
Dr. Suresh KumarConsultant Infectious Diseases Physician
Hospital Sungai buloh
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Nosocomial infections
§ In Australian acute hospitals – 200,000 HAIs / year§ In US hospitals – 1.7 milion HAIs with 99,ooo
deaths / year§ Most common complication in hospital
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Nosocomial infections and mortality
§ 16 tertiary care hospitals in Northern France (14,222 beds)§ Medical records of patients dying 48hrs after
admission§ 26.6% of 1945 had nosocomial infections§ 14.6% - nosocomial infections contributed to
the death§ 4th most common cause of death
Kaoutar B. et al., Journal of Hospital Infection (2004) 58, 268–275
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Bugs are not what they used to be
5
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MIC 0.5 µg/ml MIC 2 µg/ml
A Norazah et al. MJM, 2009 64; 166-67
Electron microscopy of cell wall of the MRSA
with MIC 2 µg/ml
MRSA is getting too thick skinned
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Carbapenams have been beaten in their own backyard
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Acinetobacter
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Cost of antimicrobial resistance
Attributable mean total cost of patients infected with MDR organism vs non-MDR organism§ Carbapenam resistance nonfermentersú US$ 58,457 and US$85,229
§ ESBL Enterobacteriaceaeú US$ 1584 - US$30,093
§ MRSAú US$1014 – US$40,090
§ In US – cost of MDR pathogens – US$3.5 billion is excess health care cots annually
Tansarli GS., et al., Expert Rev Anti Infect Ther. 2013;11(3):321-31
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Nosocomial infection is an unpredictable complication
But is actually……Potentially preventable adverse events
Common belief in medical field
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How is it handled in other industry?
§ Faulty floormats; accelerator pedal gets stuck§ Between 2007 -10 – Toyota recalls
5.7 million vehicles§ Settles ~ 1 billion claims for
economic loss
§ 89 deaths (as of 2010) –potentially linked to this problem
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Evidence for infection control
Haley RW et al., Am J Epid 1985;121:182-205
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Role of infection control
§ PFGE resultsú Isolates from 64 of
73 patients belonged to a single clone
Hsueh P-R, Teng L-J, Chen C-Y, Chen W-H, Yu C-J, Ho S-W, et al. Pandrug-resistant Acinetobacter baumannii causing nosocomial infections in a university hospital, Taiwan.Emerg Infect Dis 2002 Aug
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Infection control has to be made integral part of clinical care
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Effect of Nonpayment for Preventable Infections
Incidence Rates of Infections Reported by Hospital Units between January 2006 and March 2011.
Lee GM et al., N Engl J Med 2012;367:1428-37.
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Success with MRSA
2007: 28,000
2015: 10,000
2007: 28,000
2015: 10,000
De Kraker, Davey, Grundmann: PLoS Med. 2011 Oct;8(10):e1001104.
2001 2003 2005 2007 2009 2011 2013 2015
0.00
0.25
0.50
0.75
1.00
1.25
1.50
C Trend in the number of MRSA bacteremias
Year
Rel
ativ
e ch
ange
(in
dex=
2007
) Observed MRSAPredicted MRSA95% confidence interval
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Trend of MRSA Incidence Rate
0
0.05
0.1
0.15
0.2
0.25
0.3
2004 2005 2006 2007 2008 2009 2010 2011
No. of new patients infected or
colonised/100 admissions
Malaysian National Surveillance of Antibiotic Resistance
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Decline in MRSA Univ. hospitals of Paris area (n=39) 1993-2007
Jarlier V et al. Arch Intern Med 2010; 170: 552-559
Suresh Grayson L et al. Med J Austr 2011; 195 (10):615-9.
Hand hygiene and MRSA - Australia
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What happened when Semmelweistried to improve hand hygiene?
Colleagues dismissed his observations
His contract in Vienna was not renewed
Returned to his home country – HungaryMade the same observations
Got the same response
Admitted to a insane asylumDied there miserably
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Challenge with gram negatives
§ Higher bacterial burden in the gut§ Fecal excretion§ Transferable resistance genes§ No effective decolonisation regimes§ Substantial role of antibiotic selection pressures
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Where do these bugs come from?
§ Sources of pathogens causing HAI in ICUsú 40 – 60% - patients’ endogenous floraú 20-40% - cross infections via HCWs handsú 20-25% - antibiotic driven changes in floraú 20% - others including environmental contamination
Weisnstein RA, Am J Med 1991; 91; 179S-184S
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Contact precaution adherence
§ On room entryú Hand hygiene – 19.4%ú Gloves – 67.5%ú Gowns – 67.9%
§ On room exitú Hand hygiene – 48.4%ú Gloves – 63.5%ú Gowns – 77.1%
Clock SA. et al., AJIC 2010;38:105-111
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Equipment associated adherence
§ Signagesú Gloving on entry 67.5% vs 22.7%
ú Gowning on entry 67.9% vs 2.2%
§ Gloves of all sizesú 49.4 – 72.1% had all glove sizesú In rooms with all glove sizes Adherence to gloving on entry higher 72% vs 63.4%; p=0.032
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Steps to isolation1. identifying an at-risk patient;
2. obtaining a specimen for culture or PCR;
3. testing the specimen for multi-resistance;
4. providing the nurse or physician with the result
5. placing the patient in a private room or cohorting the patient with other carriers;
6. posting signs indicating that the patient is in isolation
7. stocking the patient’s room with isolation supplies;
8. requiring visitors and HCWs who care for the patient to wear gloves and gowns;
9. enforcing strict hand hygiene;
10. providing for adequate environmental hygiene, including waste removal
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Where do these bugs come from?
§ Sources of pathogens causing HAI in ICUsú 40 – 60% - patients’ endogenous floraú 20-40% - cross infections via HCWs handsú 20-25% - antibiotic driven changes in floraú 20% - others including environmental contamination
Weisnstein RA, Am J Med 1991; 91; 179S-184S
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Role of environment
Independently predictive of healthcare worker contamination with multidrug-resistant bacteria
Morgan DJ et al., Crit Care Med. 2012; 40(4): 1045–1051.
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Acinetobacter in the environment
‘Healthcare planners need to be aware that hospital cleaning is invaluable in controlling outbreaks…..’
P=0.004
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Prevent Pressure UlcersReduce Methicillin-Resistant Staphylococcus aureus (MRSA) InfectionPrevent Harm from High-Alert MedicationsReduce Surgical ComplicationsDeliver Reliable, Evidence-Based Care for Congestive Heart FailureGet Boards on BoardDeploy Rapid Response TeamsPrevent Adverse Drug Events (Medication Reconciliation)Improve Care for Acute Myocardial InfarctionPrevent Surgical Site InfectionsPrevent Central Line-Associated Bloodstream InfectionsPrevent Ventilator-Associated Pneumonia
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Care bundles in infection control
Jasper van der Slegt et al., Plos 2013
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Care bundles in infection control
Jasper van der Slegt et al., Plos 2013
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Sequence of Behaviour Change
Knowledge Attitudes Behaviour
Why Don’t Physicians Follow Clinical Practice Guidelines?JAMA. 1999;282:1458-65
Lack of agreementLack of outcome expectancyLack of self-efficacyLack of motivationInertia of previous practice
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Hospital practice to introduce new policies vs predicted staff compliance
Seto WH. J Hosp Infect 1995; 30: 107-115.
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Summary
§ We need to be more serious about nosocomial infection prevention
§ How to create local ownership?§ Hand hygiene is alone not enough§ Identify and isolate patients with MDR pathogensú Checklists
§ Emphasis is required on environmental cleanliness§ Use bundles for infection prevention§ Use behavioral tools to increase compliance
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Thank you
Hospital Sungai Buloh
“We'll be remembered more for what we destroy than “We'll be remembered more for what we destroy than what we create.” what we create.”
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