The presentation is solely meant for Academic purpose

Capital of Gram negative resistance Poor to absent infection control but

burgeoning private healthcare industry with technological advances such as transplants

Newer drugs available abroad take time to come

What is available is often not affordable Irrational combinations abound due to poor

regulatory control Antibiotic pipeline empty

Parameters Western world India

Common Isolates prevalent in ICUs Gram+ves Gram-ves

ESBL prevalence in gram –ves Much less Very high

Prevalence of ESBLs in last few years Slow increase Rapidly increasing

ICU type Mostly closed ICUs Mostly open ICUs

Generics Very few Hundreds of generic

Restriction of antibiotic prescription Strict Relaxed

Guidelines made by western world keeping their issues in mind may not suitable for India. 1

1. Soong JH et al. Am J Infect Control 2008;36:S83-92.

Reinert RR, Low DE, Rossi F, et al. J Antimicrob Chemother (2007) 60:1018–29.

A global study on prevalence of ESBL in K.pneumoniae of over 86,000 isolates from 266 centers

Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study: ◦ 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in

the UK, and 73 in other sites in India and Pakistan. ◦ NDM-1 was mostly found among Escherichia coli (36) and

Klebsiella pneumoniae (111) ◦ Highly resistant to all antibiotics except tigecycline &

colistin ◦ Several of the UK source patients had undergone elective,

including cosmetic, surgery while visiting India or Pakistan

◦ “We would strongly advise against such proposals…for UK patients to opt for corrective surgery in India”

Lancet Infect Dis 2010;10:597-602

While other countries tackle the problem ◦ US FDA banned off label

use of cephalosporins in cattle, swine, chickens, and turkeys effective 5 April 2012.

◦ Since April 2011, in Brazil the use of antimicrobials is no longer allowed without a prescription

◦ Israel implemented a nationwide plan to monitor and control carbapenemase resistant Enterobacteriaceae with an 80% reduction in rates (Clin Infect Dis 2011;52:848)

Our health ministry came out with an excellent document to prevent antimicrobial resistance in April 2011

Shelved it in October 2011!

We have started taking baby steps

OTC use banned for drugs in this category

Warning boxes that advice against taking except in accordance with medical advice

91 drugs added including most antibiotics and anti-TB drugs

May be pruned down to 20-25 drugs

Will it be rationally decided?

Will it be implemented?

What’s the MRSA rate here, I asked? ◦ What’s that

Where’s the hospital antibiogram, I asked? ◦ Anti-what?

April 2001 -establishment of IC program and IC committee

-surveillance and hospital antibiogram initiated

-one infection control advisor (ID physician) and 3

part time IC nurses appointed

-policy on contact isolation of MDRO (MRSA,

ESBL, carbapenem resistant Pseudomonas) including

one on one nursing approved

-respiratory isolation for TB started

-500ml alcohol dispensers for hand hygiene approved

for installation in all rooms and in other nursing areas

-surveillance for central line infections and VAP

initiated

-needlestick registry and PEP initiated

July 2001 -lecture on infection control to all hospital

consultants

-puncture proof container for sharps at each

bedside provided

-towels replaced with disposable tissue paper for

drying after handwashing

-infection control manual for hospital written and

adopted August

2001 -meeting with all surgeons on antibiotic

prophylaxis guideline formulation

-antibiotic protocol for surgical prophylaxis

introduced with emphasis on starting antibiotic

within one hour of skin incision

-antibiotics specified for each type of surgery

-duration of post-op antibiotics reduced from 7 to

2-4 days with aim of long term movement

towards a single dose

October 2001 -provisional adoption of a surgical prophylaxis policy

-infection control week for health care workers organized

-free administration of 3 doses of HBV vaccine for all

nurses started

-standardized protocol for ventilator management introduced

-disposable gowns introduced for contact isolation

-typhoid vaccine introduced for all food handlers

-color coded bins for waste segregation introduced

January 2002 -glutaraldehyde storage of forceps on dressing trays

eliminated, forceps to be sterilized and packed

-formalin tablet fumigation eliminated

March 2002 -mandatory wearing of gloves for phlebotomists

-finalization of surgical prophylaxis policy

-antibiotic prophylaxis duration reduced to 48 hrs

April 2002 -one full time IC nurse appointed

-elimination of flimsy plastic gloves, replacement by latex

gloves

June 2002 -lab to stop reporting ceftazidime sensitivities, consultants advised not

to prescribe drug

-single room isolation for all MRSA patients approved

-administration of pre-op antibiotic started in OT, not in ward

July 2002 -IC committee to be notified whenever building works are carried out

-same day or previous day admission for elective surgery advised

-Staph aureus screening by nasal swabs pre-op initiated for elective

surgery

-previous day pre-op shaving eliminated for surgery, clipping

introduced

November

2002 -central line protocol introduced (sterile placement, removal of femoral

lines by day 5, use of antiseptic impregnated catheters for high risk

cases)

January 2003 -standard precautions and routine protocols for HIV infected patients

undergoing surgery introduced

-post-exposure prophylaxis emphasized

-educational program for HIV introduced

June 2003 -nasal swab screening for Staph aureus eliminated for elective surgery

-surveillance for CRBSI and VAP commenced

November

2003 -closed bag system for IV fluids introduced on

selected basis

-removal of femoral lines by day 5 recommended

-single use vials recommended for all

medications

-puncture proof bedside sharps container

introduced

December

2003 appropriate barrier precautions introduced

whenever building works carried out to prevent

Aspergillus outbreaks March 2004 -N-95 masks for respiratory isolation introduced

-10% povidone iodine to replace lower strengths

-antibiotic prophylaxis for surgery reduced to

24hrs May 2004 switch to collapsible bags for IV fluids hospital

wide, elimination of vented plastic bottles

July2004

August 2004:

-use of 2% chlorhexidine for skin preparation prior to

bedside procedures introduced

-varicella vaccination for nurses treating high risk

neutropenic patients introduced

-infection control junior officer appointed to assist infection

control advisor

-nasal swab screening selectively for MRSA introduced for

ICU, with follow up contact isolation and decolonization

with mupirocin

October 2004 100ml handrub dispenser mounted on each bedrail instead of

500ml in each room

January 2005 policy for neutropenic patients introduced (ultra-violet light

for room disinfection before use after construction, sign

outside door, N-95 masks for patients when transported,

elimination of surgical masks for staff)

May 2005 -ESBL accepted as a hospital wide problem, isolation

discontinued for ward patients

-early Foley catheter removal emphasized

October 2005 ESBL isolation discontinued hospital wide

February

2006

-notifiable diseases list drawn up and submitted to Govt

periodically

-MRSA screening at admission extended for high risk

neutropenic patients and step down ICUs

March 2006 -antimicrobial stewardship initiated by restricting

carbapenems and linezolid with pharmacy tracking of use

of these antibiotics, and IC officer feeding back to

consultants after 48 hrs of use

-adherence to hand hygiene monitored in ICU

July 2006 MRSA screening extended to Neurology ICU and high

risk neutropenic patients November

2006 intensive cleaning of ICU surfaces commenced

February

2007 MRSA screening extended hospital wide

March 2007 circular issued mandating ID consultation when restricted

antibiotics used beyond 48hrs

August 2007 tigecycline, vancomycin, teicoplanin added to restricted

antibiotics January 2008 chlorhexidine bathing for all patients in ICU and oral

decontamination for ventilated patients introduced

August 2008 -elimination of white coats and recommendation against

long sleeves, ties and wrist watches

-teicoplanin and vancomycin removed, polymyxins added

to restricted antibiotics list

Antibiogram

Antibiogram formulated for E.coli, Klebsiella, Staph aureus, Pseudomonas, Enterococcus

Updated every 3 months

Circulated to all clinicians

Surveillance initiated ◦ VAP, CRBSI,

CAUTI ◦ Rates of MDR-O

monitored

Most Indian hospitals not constructed with plumbing at each bedside

Greater the distance to basin, lazier we all get to hand wash!

Microbiologically superior to hand washing unless hands visibly soiled

Less skin damage than soap

Have to have one per patient

Infectivity

after stick

Prevention Perceived

threat

Hepatitis B 30% Vaccine Low

Hepatitis C

3% None None

HIV 0.3% Post exposure

prophylaxis

High

Recombinant DNA vaccine given in 3 doses at 0, 1 & 6 mths

Gluteal administration contra-indicated

Successful vaccination indicated by antibody to HbsAg>10 mIU/ml

Consists of zidovudine 300 mg bd & lamivudine 150 mg bd for 4 weeks

Second drug necessary only to cover the possibility of zidovudine resistance

Of 18 documented failures of zidovudine, 8 involved source patients on zidovudine

Usually not warranted for mucosal and intact skin exposures

Start ASAP, definitely within 24 hrs

Standard precautions

Isolation (syndrome and disease specific) ◦ Contact

MRSA

Resistant non-fermenters

VRE

◦ Droplet

◦ Airborne

For patients with multi-resistant bacteria

Consists of standard precautions plus unsterile gloves whenever patient is touched, then handwashing or hand rub immediately

Plastic gowns if extensive patient contact

Dedicated equipment eg stethoscope, BP apparatus and thermometer

Sign at head of bed

Single room or cohort nursing for MRSA

One on one nursing essential

SARS in 2003 was when we introduced N-95 mask concept

H1N1 in 2009 was a challenge ◦ Treated a large no of

patients without a hospital outbreak

◦ Vaccination of employees introduced

Outbreak of XDR-TB in South Africa was mainly nosocomial

Healthcare workers get active TB at rate of 5.8% annually in developing countries, well above general population

Smear negative TB is also transmissible though 4 times less likely, accounts for 13% of all cases (Clin Infect Dis 2008;47:1135)

MDR-TB 5-6 times more infectious than historical controls (PLoS Med 2008;5:e188)

Three types of strategies: ◦ Administrative controls eg Mantoux for HCW ◦ Environmental controls ◦ Personal protection eg N-95 masks

Mechanical ventilation delivering negative pressure and 12 air changes per hour ◦ Costly, needs maintenance, may function poorly ◦ Needed for inpatient rooms, bronchoscopy

Natural ventilation ◦ High ceilings, large windows, open doors & windows ◦ Can provide up to 40 air changes per hour ◦ Applicable to OP settings and HIV settings ◦ Fails in extreme climates when windows closed

Upper room ultra-violet light ◦ Reduces airborne transmission by 70% ◦ Applicable to waiting room areas

Intubation for

mechanical

ventilation

increases the

risk for

pneumonia

3x to 21x !

AJRCCM 2002; 165:867-903

Common, seen in 10-20% of patients ventilated for >48 hrs

Ventilator Associated Pneumonia

Semi recumbent posture

Avoid routine stress ulcer prophylaxis; sucralfate is better (when needed)

Subglottic suctioning

Avoid tubing change q 24 hours

Selective decontamination of the digestive tract

Avoid nasal intubation Ref: N Engl J Med 1999;340:627-34

Catheter Related Bloodstream Infection:

(CRBSI)

Clinical catheter site infection (or)

Systemic signs of sepsis (c no other source)

AND

Positive catheter culture

(quantitative / semi quantitative)

AND

Same organism cultured in peripheral blood

Hand hygiene

Full Sterile barrier @ placement

Chlorhexidine is better than

povidone iodine site prep

Prefer subclavian site, avoid femoral

Antibiotic-impregnated catheters

Remove catheter when not required

MMWR 2002; 51: RR-10

N Engl J Med 2003;348:1123-33.

N Engl J Med 2006;355:2725

Contamination rates in one study from 1974: ◦ bottle: 13% ◦ burette: 7% ◦ bag: 0.7%

Switched to viaflex collapsible bags Avoided micro-infusion sets and vents Used infusion pumps instead

Am J Hosp Pharmacy 1974;31:961

Use viaflex collapsible bags which do not need vents in preference to vented plastic or glass bottles

Drops infection rate from 6.52 to 2.36 per 1000 line days

West switched 30 years ago

Am J Infect Control 2004;32:135

Clinical

Culture based

Outpatient follow-up

Feedback

Can reduce SSI rates by 35-50%

Stratify monitoring to high risk group

Admission immediately pre-op

Same day clipping instead of shaving

Avoiding hypothermia

Giving 1st dose antibiotic within 1 hr pre-incision

Stopping antibiotics within 24 hrs

Prospective audit, intervention and feedback is the cornerstone

Antibiotic forms introduced

Special focus on surgical prophylaxis

Better implementation of antimicrobial stewardship

Better adherence to hand hygiene regulations

Checklist approach

Need tighter regulatory control by authorities ◦ Antibiotics

◦ Hospital infection control programs

◦ Accreditation

Motion-activated video cameras were strategically located throughout a medical intensive care unit

Clin Infect Dis 2012 54: 1-7