4-prevention and control of antimicrobial resistance

7/27/2019 4-Prevention and Control of Antimicrobial Resistance

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PREVENTION AND CONTROL OF

ANTIMICROBIAL RESISTANCEIN HOSPITAL


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Masalah resistensi di Rumah Sakit

Eksposur tinggi

terhadap antibiotika

Densitaspopulasi tinggi

Frekuensi kontak tinggi

terhadap staf RS

Risiko tinggicross infeksi

High risk

environment


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Masalah penggunaan antibiotika

Exessive/overuse

Inappropriate

Cara pemberian

Dosis

Frekuensi Lama pemberian


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100.00%32.69%-Others

3.85%CiprofloxacinCiprofloxacin

5.76%CefotaximCefotaxim

9.62%CefotaximTaxegram

23.08%CeftriaxoneTerfacef

25.00%CeftriaxoneCeftriaxone

%GenericsAntibiotics


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Relationship between antibiotic use, resistance, treatment

failure and healthcare burden

Increase inantibiotic use Increase in

resistant strains

Ineffective empirictherapy

increased morbidity

more antibiotics

Increasedhospitalisation

more antibiotics

Increaseduse ofhealthcare

resources

Limited treatmentalternatives

more antibiotics

increasedmortality


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Optimize Use

PreventTransmission

PreventInfection

EffectiveDiagnosis& Treatment

PathogenAntimicrobial-ResistantPathogen

AntimicrobialAntimicrobialResistanceResistance

Antimicrobial Use

InfectionInfection

Susceptible Pathogen


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Prevent infection

Diagnose and treatinfection effectively

Use antimicrobialswisely

Prevent transmission

Clinicians hold the solution!


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TULUNGAGUNG

TRENG

GALEK

NGAWI

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ISPA Balita

ISPA Dewasa


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12 Steps12 Contain your contagion

11 Isolate the pathogen10 Stop treatment when cured

9 Know when to say no to vanco8 Treat infection, not colonization

7 Treat infection, not contamination6 Use local data

5 Practice antimicrobial control4 Access the experts

3 Target the pathogen2 Get the catheters out

1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose and Treat Effectivel

Prevent Infection


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0

10

20

30

40

50

60

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

Perce

ntResistance

Methicillin (oxacillin)-resistantStaphylococcus aureus

0

5

10

15

20

25

30

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

Per

centResistance Vancomycin-resistantenterococci

Non-Intensive Care Unit PatientsIntensive Care Unit Patients

Antimicrobial Resistance Among PathogensCausing Hospital-Acquired Infections

Source: National Nosocomial Infections Surveillance (NNIS) System

Link to: NNIS Online at CDC


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0

2

4

6

8

10

12

14

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

Perce

ntResistance

3rd generation cephalosporin-resistant Klebsiella pneumoniae

0

5

10

15

20

25

30

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

PercentResistance

Fluoroquinolone-resistantPseudomonas aeruginosa

Non-Intensive Care Unit PatientsIntensive Care Unit Patients

Antimicrobial Resistance Among PathogensCausing Hospital-Acquired Infections

Source: National Nosocomial Infections Surveillance (NNIS) System



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Fact:

Catheters and other invasive devices are the #1

exogenous cause of hospital-acquired infections.

Prevent Infection

Step 2:Get the catheters out


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Biofilm on Intravenous Catheter Connecter24 Hours After Insertion

Scanning Electron Micrograph

Link to: Biofilms and device-associated infections


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Fact: Catheters and other invasive devices are the #1exogenous cause of hospital-acquired infections.

Actions:

6use catheters only when essential

6use the correct catheter

6use proper insertion and catheter-careprotocols

6remove catheters when not essential

Coming soonguidelines for preventing catheter-associated bloodstream infections Link to: Urinary catheter infection prevention

Prevent Infection

Step 2: Get the catheters out


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Fact:Appropriate antimicrobial therapy (correct

regimen, timing, dosage, route, and duration)saves lives.

Diagnose and TreatInfection Effectively

Step 3:Target the pathogen


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Inappropriate Antimicrobial Therapy:Prevalence Among Intensive Care Patients

Source: Kollef M, et al: Chest 1999;115:462-74

0%

10%

20%

30%

40%

50%

Community-acquired infectionHospital-acquired infection

Hospital-acquired infection afterinitial community-acquired infection

InappropriateAntimicrobial Therapy(n = 655 ICU patients with infection)

Patient GroupPercentIn

a

ppro

priate

17.1%

34.3%

45.2%


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Inappropriate Antimicrobial Therapy:Impact on Mortality

Source: Kollef M, et al: Chest 1999;115:462-74

0

100

200

300

400

500

600

No

.In

fe c

te d

Pa

t i e n

ts

42.0% mortality

17.7% mortality Relative Risk = 2.37(95% C.I. 1.83-3.08; P< .001)

# Deaths

# Survivors

Inappropriate

Therapy

Appropriate

Therapy


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Fact: Appropriate antimicrobial therapy saves lives.

Actions:6 culture the patient

6 target empiric therapy to likely pathogens and

local antibiogram6 target definitive therapy to known pathogens

and antimicrobial susceptibility test results

Link to: IDSA guidelines for evaluating fever in critically ill adults

Diagnose and Treat Infection Effectively

Step 3: Target the pathogen


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Nosocomial infections


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Fact:

Infectious diseases expert input improves

the outcome of serious infections.

Diagnose and TreatInfection Effectively

Step 4:Access the experts


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Infectious Diseases Expert Resources

Infectious Diseases

Specialists

OptimalPatient CareOptimalPatient Care

Infection ControlProfessionals

HealthcareEpidemiologists

ClinicalPharmacists

ClinicalPharmacologists

Surgical InfectionExperts

ClinicalMicrobiologists

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 4: Access the experts


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Fact: Infectious diseases expert input improves the

outcome of serious infections.

Action:

6 consult infectious diseases expertsabout patients with serious infections

Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistancein Hospitals

Diagnose and Treat Infection Effectively

Step 4: Access the experts


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Fact:

Programs to improve antimicrobial use

are effective.


Step 5: Practiceantimicrobial control


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Methods to Improve Antimicrobial Use

Passive prescriber education

Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue

Pharmacy substitution or switch Multidisciplinary drug utilization evaluation (DUE) Interactive prescriber education

Provider/unit performance feedback Computerized decision support/online ordering

Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance

in Hospitals


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Computerized Antimicrobial Decision Support Local clinician-derived consensus guidelines embedded in

computer-assisted decision support programs

62,759 patients receiving antimicrobials over 7 years

1988 1994

Medicare case-mix index 1.7481 2.0520Hospital mortality 3.65% 2.65%

Antimicrobial cost per treated patient $122.66 $51.90

Properly timed preoperative antimicrobial 40% 99.1%

Stable antimicrobial resistance

Adverse drug events decreased by 30%

Source: Pestotnik SL, et al: Ann Intern Med 1996;124:884-90


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Step 5: Practice antimicrobial control

Fact: Programs to improve antimicrobial use are effective.

Action:6 engage in local antimicrobial use quality

improvement efforts

Link to: Methods to improve antimicrobial use and prevent resistance

Source: Schiff GD, et al: Jt Comm J Qual Improv 2001;27:387-402


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Fact:The prevalence of resistance can vary

by time, locale, patient population,hospital unit, and length of stay.


Step 6: Use local data



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Trimethoprim/Sulfamethoxazole (TMP/SMX)Resistance Among Bacterial Patient Isolates*

San Francisco General HospitalMartin JN, et al: J Infect Dis 1999;180:1809-18

* 30,886 patient isolatesStaphylococcus aureusEscherichia coli

Enterobacterspp.Klebsiella pneumoniae

Morganellaspp.Proteusspp.Serratiaspp.Citrobacterspp.

0

10

20

30

40

50

60

1988 1989 1990 1991 1992 1993 1994 1995Percen

tResistantP

atientIsolates Non-HIV units (n = 28,966 patient isolates)

HIV units (n = 1,920 patient isolates)

Prevalence of TMP/SMX useamong AIDS patients





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Prevalence of Fluoroquinolone-ResistantEscherichia coli: Variability Among PatientPopulations

0

10

20

30

40

50

HIV/AIDS

Trauma

COP

D

Diabetes

Dialy

sis

Homeless

InjectionDrugUse

Pediatric

Patient Characteristics

Percen

tResistant

Patien

tIsolates

San Francisco General Hospital 1996-1997





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Fact: The prevalence of resistance can vary by locale, patient

population, hospital unit, and length of stay.

Actions:

6know your local antibiogram6know your patient population

Link to: NCCLS Proposed Guidance for Antibiogram Development

p p


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Interpreting a Positive Blood Culture

True Bacteremia:

Unlikely Uncertain Likely

S. aureus

S. pneumoniae

Enterobacteriaceae P. aeruginosa

Candida albicans

Corynebacteriumspp.

Non-anthracis Bacillusspp.

Propionibacterium acnes

Coagulase-negative

staphylococci

Source: Kim SD, et al: Infect Control Hosp Epidemiol 2000;21:213-7

Pre-test probabilitypatient risk factorsprosthetic devicesclinical evidence

Post-test probability# positive/# culturescompare antibiogramscompare genotypes

Step 7: Treat infection, not contamination


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Fact:

A major cause of antimicrobial overuseis treatment of colonization.



Step 8: Treat infection,not colonization



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Fact:

Vancomycin overuse promotes

emergence, selection, and spreadof resistant pathogens.

Steps to e e t t c ob a es sta ce osp ta ed du ts


Step 9: Know when tosay no to vanco


St 9 K h t t


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S. aureus

Penicillin

[1950s]

Penicillin-resistant

S. aureus

Evolution of Drug Resistance in S. aureus

Link to: CDC Facts about VISA Link to: CDC Facts about VRE

Methicillin

[1970s]

Methicillin-resistant

S. aureus(MRSA)

Vancomycin-resistant

enterococci (VRE)

Vancomycin

[1990s]

[1997]

Vancomycin

intermediate-

resistantS. aureus(VISA)

Vancomycin-

resistant

S. aureus

Step 9: Know when to say no to vanco



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Step 9: Know when to say no to vanco

Fact: Vancomycin overuse promotes emergence, selection, andspread of resistant pathogens.

Actions:

6treat infection, not contaminants or colonization

6fever in a patient with an intravenous catheteris not a routine indication for vancomycin

Link to: CDC guidelines to prevent vancomycin resistance


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US $ 17 Milyar

25%

32%

33%

10%

25%

27%

28%

20%


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Fact:

Failure to stop unnecessaryantimicrobial treatment contributesto overuse and resistance.

Use AntimicrobialsWisely

Step 10: Stop treatmentwhen infection is cured

or unlikely


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Fact: Failure to stop unnecessary antimicrobial treatmentcontributes to overuse and resistance.

Actions:6when infection is cured

6when cultures are negative and infection

is unlikely6when infection is not diagnosed


Step 10: Stop antimicrobial treatment


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Fact:

Patient-to-patient spread ofpathogens can be prevented.


Step 11:Isolate the pathogen


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Step 11: Isolate the pathogen

Fact: Patient-to-patient spread of pathogens can beprevented.

Actions:

6use standard infection control precautions6contain infectious body fluids (use approved

airborne/droplet/contact isolation precautions)

6when in doubt, consult infection controlexperts

Link to: A VRE prevention success story

Link to: CDC isolation guidelines and recommendations


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Fact:

Healthcare personnel can spread

antimicrobial-resistant pathogens frompatient to patient.


Step 12:Contain your contagion


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Improved Patient Outcomes AssociatedWith Proper Hand Hygiene

Ignaz Philipp Semmelweis(1818-1865)

Chlorinated lime hand antisepsis

Link to: Ignaz Semmelweis


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Impact of Hand Hygiene on HospitalInfections

Year Author Setting Impact on Infection Rates

1977 Casewell adult ICU Klebsielladecreased1982 Maki adult ICU decreased

1984 Massanari adult ICU decreased

1990 Simmons adult ICU no effect1992 Doebbeling adult ICU decreased with one versus

another hand hygiene product

1994 Webster NICU MRSA eliminated

1995 Zafar nursery MRSA eliminated1999 Pittet hospital MRSA decreasedICU = intensive care unit; NICU = neonatal ICU

MRSA = methicillin-resistant Staphylococcus aureus.

Link to: Improving hand hygiene

Source: Pittet D: Emerg Infect Dis 2001;7:234-240


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How are Patients Exposed to HospitalWater?

Handwashing (cross-contamination) Bedpans

Enteral feedings

Respiratory equipment

Drinking

Showering Bed bathing


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Prevent TransmissionStep 12: Break the chain of contagion

Fact: Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient.

Actions:

6stay home when you are sick

6contain your contagion

6keep your hands clean6set an example!

Link to: Health guidelines for healthcare personnel Coming soonnew guidelines for hand hygiene


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Hypodermic syringeswith Self-Sheathing safetyf t

Hypodermic syringes with RetractableTechnology safety feature


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feature

Self-sheathedprotected position

gy y

Retracted protected position

Phlebotomy needle withSelf-Blunting safety feature

Blunted protected position

Attached to syringe needle

Attached to blood tube holder


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4-prevention and control of antimicrobial resistance

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