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.”