![Page 1: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/1.jpg)
The importance of infection control in the era of multi drug resistance
Dr. Suresh KumarConsultant Infectious Diseases Physician
Hospital Sungai buloh
![Page 2: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/2.jpg)
Suresh
![Page 3: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/3.jpg)
Suresh
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
![Page 4: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/4.jpg)
Suresh
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
![Page 5: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/5.jpg)
Suresh
Bugs are not what they used to be
5
![Page 6: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/6.jpg)
Suresh
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
![Page 7: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/7.jpg)
Suresh
Carbapenams have been beaten in their own backyard
7
Acinetobacter
![Page 8: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/8.jpg)
Suresh
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
![Page 9: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/9.jpg)
Suresh
Nosocomial infection is an unpredictable complication
But is actually……Potentially preventable adverse events
Common belief in medical field
![Page 10: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/10.jpg)
Suresh
![Page 11: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/11.jpg)
Suresh
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
![Page 12: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/12.jpg)
Suresh
Evidence for infection control
Haley RW et al., Am J Epid 1985;121:182-205
![Page 13: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/13.jpg)
Suresh
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
![Page 14: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/14.jpg)
Suresh
Infection control has to be made integral part of clinical care
![Page 15: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/15.jpg)
Suresh
![Page 16: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/16.jpg)
Suresh
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.
![Page 17: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/17.jpg)
Suresh
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
![Page 18: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/18.jpg)
Suresh
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
![Page 19: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/19.jpg)
Suresh
Decline in MRSA Univ. hospitals of Paris area (n=39) 1993-2007
Jarlier V et al. Arch Intern Med 2010; 170: 552-559
![Page 20: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/20.jpg)
Suresh Grayson L et al. Med J Austr 2011; 195 (10):615-9.
Hand hygiene and MRSA - Australia
![Page 21: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/21.jpg)
Suresh 21
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
![Page 22: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/22.jpg)
Suresh
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
![Page 23: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/23.jpg)
Suresh
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
![Page 24: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/24.jpg)
Suresh
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
![Page 25: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/25.jpg)
Suresh
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
![Page 26: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/26.jpg)
Suresh
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
![Page 27: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/27.jpg)
Suresh
![Page 28: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/28.jpg)
Suresh
![Page 29: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/29.jpg)
Suresh
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
![Page 30: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/30.jpg)
Suresh
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.
![Page 31: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/31.jpg)
Suresh
Acinetobacter in the environment
‘Healthcare planners need to be aware that hospital cleaning is invaluable in controlling outbreaks…..’
P=0.004
![Page 32: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/32.jpg)
Suresh 32
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
![Page 33: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/33.jpg)
Suresh
Care bundles in infection control
Jasper van der Slegt et al., Plos 2013
![Page 34: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/34.jpg)
Suresh
Care bundles in infection control
Jasper van der Slegt et al., Plos 2013
![Page 35: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/35.jpg)
Suresh
![Page 36: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/36.jpg)
Suresh
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
![Page 37: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/37.jpg)
Suresh 37
Hospital practice to introduce new policies vs predicted staff compliance
Seto WH. J Hosp Infect 1995; 30: 107-115.
![Page 38: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/38.jpg)
Suresh
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
![Page 39: Dr. Suresh Kumar Consultant Infectious Diseases Physician ... · The importance of infection control in the era of multi drug resistance Dr. Suresh Kumar Consultant Infectious Diseases](https://reader031.vdocuments.net/reader031/viewer/2022020216/5c81865109d3f2b9438c7dec/html5/thumbnails/39.jpg)
Suresh
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.”