management of an outbreak of a multi-drug resistant pathogen professor kevin rooney infection...
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![Page 1: Management of an outbreak of a multi-drug resistant pathogen Professor Kevin Rooney Infection Prevention & Control in the ICU Seminar 10 th November 2014](https://reader036.vdocuments.net/reader036/viewer/2022062713/56649ce05503460f949aadab/html5/thumbnails/1.jpg)
Management of an outbreak of a multi-drug resistant pathogenProfessor Kevin RooneyInfection Prevention & Control in the ICU Seminar10th November 2014
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SBAR - Situation• Director or SCN of
General ICU• Infection Control• Potential outbreak of
a carbapenem-resistant Klebsiella Pneumonia (KPC) • Adjacent CTX ICU• 2 new cases of KPC
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SBAR - Background• 10 bedded ICU• 650 Level 3 patients• Level 3• 25% Mortality• Immunocompromised• At risk of HAI• Adjacent CTX ICU• Same staff pool• KPC patient 2 weeks
ago
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SBAR - Assessment• KP • 15% of G-ve infections• Immunocompromised
• KPC• Few options• Prevent / Mitigate• Hidden Killer (>50%)• Silently colonises GIT• Transmission• Environmental• Staff• Both
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SBAR - Recommendation• Probable outbreak• ≥2 with KPC• More expected• Outbreak Control
Team• Establish Severity• HIIA Tool
• Prevent spread• Prevent further
resistance
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Driver Diagram
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Leadership & Culture
• Transparency• Just Culture (No Blame) Early Reporting to ICT
• Outbreak Control Team• Identify all patients• Control the outbreak• Prevent further disease• Investigate the cause & identify factors
that contributed• Disseminate the learning • Communication (patients, public & staff)
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Severity of the Outbreak• The Hospital Infection Incident Assessment (HIIA) Tool• Impact on patients, services, public health & anxiety• Openness & Transparency• Effective Communication (case notes)• Senior Management Support• Occupational Health• Support policy implementation• Support / advise staff & OCT• Coordinate screening• Treatment & Fitness to work
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Staff Screening Programme
• Beware unintended consequences• Clearly documented in minutes of OCT
• Reasons for staff screening• To characterise the epidemiology of the outbreak –
time, person, place.• To identify the likely source and index case, with a
view to control.• To assist with interrupting the chain of transmission of
an outbreak.• To confirm eradication of the outbreak.
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Mitigation
Mitigation
Containment
Eradication
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Containment• Close the ICU to all new admissions• Discharge to cohorted areas
• Enhanced contact isolation regardless of colonisation status• Hand hygiene, gowns & gloves for staff / visitors
• Cohort the colonised ICU & non-ICU patients (geography)• Staff cohorting for nurses & AHP’s• Not possible for medics, germ theory of disease
• Hand hygiene monitors 24/7• If asymptomatic 3 x Resp & Rectal culture surveillance• More frequent if near a colonised patient
• Trace outbreak (modes / routes of transmission)• Patient tracking, genomic sequencing
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Eradication• Extinction of KPC is the main aim of OCT• Dedicating equipment for single-patient use • Extensive cleaning of shared equipment with bleach• Environmental culture of surfaces prior to next patient• Increase the frequency of environmental cleaning (shift)• Daily patient baths with 2% Chlorhexidine• Double-cleaning of vacated rooms equipment with bleach or
hydrogen peroxide vapour • Staff Education (How, Why, What)• Modes of transmission• Contact precautions• Cohorting
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Disease Prevention
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Antimicrobial Stewardship • The aim of good antimicrobial stewardship• Decrease in antibiotic use ✓• Not targeting a specific antimicrobial class ✗
• Every Patient gets the Right Drug, at the Right Dose, at the Right Time for the Right Duration
• Start Smart and Then Focus (structured response)• Also includes clinical infection management and improving
patient outcomes ✓• Best structure• Prescription (initiation)• Therapeutic Failure (dosing)• Review
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Prescription & InitiationNo in the absence of clinical
suspicion ✗Sepsis Screening Tool ✓
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Antibiotics within the hourSurvival in Septic Shock Sepsis Six
1. Deliver O2 (94 -98% SpO2 or 88-92% in COPD)
2. Take blood cultures and consider source control
3. Give IV antibiotics according to local protocol
4. Start IV fluid resuscitation (min 500ml) and reassess
5. Check lactate & FBC
6. Commence accurate urine output measurement and consider urinary catheterisation
All within one hour
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Antibiotics• At least blood cultures x2• Consideration of cultures from other sites • Potential infective sources (PVC, CVC, CAUTI) should be sought
• Source control ideally within 12 hours of diagnosis • Give for surgical prophylaxis only in cases where antibiotics
have been shown to be effective (<60 mins KTS)• Prolonged operation or significant haemorrhage, repeat the
dose
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Antimicrobial Stewardship: Therapeutic Failure• Antibiotic dosage• According to the patient’s bodyweight (aminoglycosides)• Fixed pre-determined dosage for a 60-80kg man (macrolide)• Insufficient dosing in the obese
• Lipohilic or Hydrophilic antibiotic• Lipophilic: dose according to actual body weight • Hydrophilic: dose according to ideal body weight
• Insufficient concentration of drug at the site of infection • Increased volume of distribution due to hypoalbuminaemia and
rapid administration of fluids • Shock causing a decrease in blood supply to the infected tissues
and organs
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Therapeutic Failure (contd)• Enhanced plasma clearance of antibiotics • Improved renal excretion from a hyperdynamic circulation• Increased drug extraction (CVVHF)
• Therapeutic Drug monitoring • Minimise potential unintended consequences • Ensure optimal treatment
• Antibacterial cycling or rotation• Mitigate or limit bacterial resistance • Antibiotic heterogeneity• Limited use• Mixing classes provides greater heterogeneity
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Antimicrobial Stewardship: Therapeutic Review & Focus• Clinical picture is an evolving process• Daily review of diagnosis and de-escalation prevents
resistance and reduces toxicity and costs • 4 clinical questions• Stop, Switch, Change or Continue
• Multidisciplinary ward rounds• Procalcitonin ( Surviving Sepsis Recommendation)• De-escalation • Absence of positive microbiology• Multiresistant organisms preventing de-escalation• Lack of bottle as still critically ill
• IV to oral switch (removal of PVC)
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In summary
To prevent spread of an
outbreak
Leadership & Culture Mitigation
Prevention & Antimicrobial Stewardship
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Any questions?