Infection control and antimicrobial stewardshipAntimicrobial stewardship . Antimicrobial stewardship...

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Infection control and antimicrobial stewardship Janos Sinko PhD South-Pest Central Hospital Budapest

Transcript of Infection control and antimicrobial stewardshipAntimicrobial stewardship . Antimicrobial stewardship...

Page 1: Infection control and antimicrobial stewardshipAntimicrobial stewardship . Antimicrobial stewardship . refers to coordinated interventions designed to improve and measure the appropriate

Infection control and antimicrobial

stewardship

Janos Sinko PhD

South-Pest Central Hospital

Budapest

Edina
Szövegdoboz
Dr. János Sinkó Semmelweis University 3rd Department of Internal Medicine Infectious Disease Group South-Pest Central Hospital
Edina
Szövegdoboz
4th Year, Faculty of Medicine 2018/2019 Academic Year
Edina
Szövegdoboz
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Healthcare related infections

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By 2050 300M deaths

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GDP down 2 %- 3.5 %

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Infection control Antimicrobial stewardship

PREVENTION OF INFECTIONS =PATIENT SAFETY

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1. Infection control

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PATHOGEN

SUSCEPTIBLE

HOST

PORT OF

ENTRY

TRANS-

MISSION

PORT OF

EXIT

RESERVOIR

INFECTION CIRCLE

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What is infection control?

• Surveillance : (monitoring: collect data

using standardized methods - intervention)

• Estimate risk factors, critical points of care

» intervene to minimize

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Nosocomial surveillance

Monitoring by standardized methods

Whom to monitor?

• Hospital, department, unit, risk groups

• Instrumentation, interventions, surgery

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Surveillance and infection control

Effectiveness of surveillance

Efficacy of infection control

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• Sporadic, clustered or epidemic nosocomial

infections/pathogens

– internally monitored,

– background-checked,

– prevented/eliminated by specific measures and

interventions

Infection control activity

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• Collaborating to develop antimicrobial

stewardship policies, based on

– Antimicrobial resistance

– Antibiotic consumption

– Perioperative prophylaxis

• Theoretic and practical education and training

of health care personnel

Infection control

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PREVENTION

Anticipate infections threatening health care

workers (visitors) and patients

• Specific measures

–Vaccination

–Chemoprophylaxis

• Aspecific measures

–Hand hygine

–Isolation, protective equipment

–Disinfection, sterilization

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Interventions

• Isolation

• Quarantine

• Work management, patient routes

• Disinfection

• Prophylaxis

• Ongoing monitoring

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1st principle of infection prevention

at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

• Use and care of urinary catheters

• Use and care of vascular access lines

• Therapy and support of pulmonary functions

• Surveillance of surgical procedures

• Hand hygiene and standard precautions

Pittet D

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Standard precautions

• Hand hygiene

• Protective equipment: gloves, masks, gown

etc.

• Hazardous material management (waste)

• Linen disinfection

• Disinfective cleaning

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Transmission specific precautions

• GOAL: To prevent transmission

• METHODS:

– Contact isolation

– Droplet isolation

– Airway isolation

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An infection control tool of

paramount importance…

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Ignaz Philipp Semmelweis

(1818-1865)

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Az infekciókontroll

jelentősége a

gyakorlatban Kertész Adrienne

28

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024681012141618

1841

1842

1843

1844

1845

1846

Maternal

Mortality

First

Second

(%)

Semmelweis IP, 1861

Maternal mortality rates, First and Second Obstetric Clinics,

GENERAL HOSPITAL OF VIENNA, 1841-1850

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Healthcare workers’ hands: potentially

important tools of infection transmission

• Hand hygiene: conscious behaviour

– Education (theory and practice)

– Appropriate conditions (material and individual, shifts, personnel)

• Permanent monitoring,

• Bacterial cultures

• Observing compliance

• Results

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Kézhigiénia WHEN?

(WHO five moments of hand hygiene)

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How?

• Single phase hand disinfectant: in case of

visible contaminations (+ C. difficile infection)

• Apparently clean hands: alcohol based rub

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Single phase disinfectant

Both cleaning and disinfecting hands

(containing both soap and disinfectant)

Apply to dry hands, add water to foam, then rinse

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Alcohol based hand rub

• Only disinfecting, not cleaning.

• Should be applied to dry hands free of visible contamination. Rub until dry.

• Should not be wiped. Do not apply water.

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2. Antimicrobial stewardship

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http://www.ecfr.gov/

PUBLIC ENEMIES

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http://ecdc.europa.eu/

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http://ecdc.europa.eu/

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http://ecdc.europa.eu/ http://ecdc.europa.eu/

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Paucity of new antibiotics

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E

S

C

A

P

E

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A useful alternative: use available antimirobials in a

prudent and responsible way

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What is appropriate antibiotic use?

• If given according to guidelines.

• In general: Order…

– To those

– Then

– That compound

– That formulation

– That frequently

– That long

As it works the

best

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Multifactorial background

• HUMAN USE

• Adequate

• INADEQUTE

• Agricultural utilisation

• Environment, water

• Remnants of antibiotics

• Resistance genes

• Lack of monitoring and regulation

• No alternative therapies developed

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Regulation? Whose job?

• Yours: do you have a clear view on that?

• Institution: how is it managed in your

hospital?

• Profession: what do groups and societies do?

• Country: any governmental strategy?

• Regional: EU administration, organizations

• Global: WHO?

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133 countries, 34 having some strategy

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Is this by chance?

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How are antimicrobials used?

• Seemingly a medical question, in fact

determined by factors of behavioural, societal

and cultural anthropologic background

Illustration

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Decision environment

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Some cultural elements Power distance (PDI) relates to the extent to which the

less powerfulmembers of organizations and institutions

accept and expect that power is distributed unequally. It

suggests that a society‟s level of inequality is endorsed by

the followers as much as by the leaders.

Uncertainty avoidance (UAI) indicates to what extent a

society tolerates uncertainty and ambiguity, and it shows

how comfortable its members feel in unstructured

situations which are novel, unknown, surprising or different

from usual.

Individualism (IDV) is the degree to which individuals are

integrated into tight groups (collectivist) or loose groups

(individualist).

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J Antimicrob Chemother 2014; 69: 1142–1144

UNCERTAINITY

AVOIDANCE AND

PERIPERATIVE

PROPHYLAXIS

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Could this be you?

• “To stay on the safe side… let‟s add

antibiotics”

• “ The patient forced me to prescribe…”

• “What will the boss say when this guy with

that fever won‟t be on antibiotics”

• “Do not change your winning team, go on for

one more week”

• “Nobody has ever been convicted for giving

antibiotics. Only for not giving them in time.”

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Antimicrobial stewardship

Antimicrobial stewardship refers to coordinated

interventions designed to improve and measure

the appropriate use of antimicrobials by

promoting the selection of the optimal

antimicrobial drug regimen, dose, duration of

therapy, and route of administration.

(Infectious Society of America)

www.idsociety.org

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Goals

• To improve infection outcome

• Ameliorate toxicity

• Prevent C. difficile infections

• Decrease antibiotic-resistant strains

• Optimizing resource utilization

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INFECTION

CONTROL

EPIDEMIOLOGY

ANTIMICROBIAL

STEWARDSHIP

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Clinical Infectious Diseases® 2016;62(10):e51–e77

• 27 recommendations

• Intervention.Optimalization.Benchmark.

Special populations..

• Moderate/low level of evidence: few

evidence based data from studies (USA).

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Intervention

• How are antimicrobials ordered?

– Authorization?

– Prospective control and feedback?

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Pros and cons Authorization Control and feedback

Less unnecessary therapy Stewardship including all

Improved empirical choice More flexible

Based on previous microbiology data No need for daily management

Less costly Broadening knowledge

Direct guidance Spearing autonomy

Only affecting some drugs Labour intensive

Hurting autonomy Need for co-operation of parties

Can delay therapy Need for technical background

Manipulation possible Success method dependent

Drugs under regulation might be

avoided

Success coming only later

+

-

Clinical Infectious Diseases® 2016;62(10):e51–e77

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Interventions

• How are antimicrobials ordered?

– Authorization?

– Prospective control and feedback?

• What is appropriate?

– Education OK but not sufficient

– Institutional and disease-specific

recommendations

– Clostridium difficile risk groups: restriction of

antibiotics

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• What is appropriate?

– Self-control (eg. Stop rules)

– Computer based decision augmentation

– Cycling of antibiotics: NOT recommended

Intervention

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Optimalization

• Pharmacokinetics

–Drug levels

–Alternative dosing

–Sequential oral therapy

–De-ecalation

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http://clincalc.com/Vancomycin/Default.aspx

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Optimalization

• Pharmacokinetics

– Drug levels

– Alternative dosing

– Sequential oral therapy

– De-ecalation

• Testing drug allergies

• Pre-specified duration of therapy

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Optimalization

• Co-operation with microbiology

– Stratified, selective reporting

– Speeding-up diagnostics (viruses, blood

cultures)

– Non-cultural fungal diagnostics

• Procalcitonin

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Key players

• Pharmacist dedicated for antibiotic

therapy

• Antimikrobial stewardship team

–Minimal: clinician + pharmacist

–Multidisciplinary

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Ten commandments

1. Get appropriate microbiological samples before antibiotic

administration and carefully interpret the results: in the absence of

clinical signs of infection, colonisation rarely requires antimicrobial

treatment.

2. Avoid the use of antibiotics to „treat‟ fever: investigate the root cause of

fever and treat only significant bacterial infections.

3. When indicated, start empirical antibiotic treatment after taking

cultures, tailoring it to the site of infection, risk factors for multidrug-

resistant bacteria, and the local microbiology and susceptibility patterns.

4. Prescribe drugs at their optimal dose, mode of administration and for

the appropriate length of time, adapted to each clinical situation and

patient characteristics.

5. Use antibiotic combinations only in cases where the current evidence

suggests some benefit.

International Journal of Antimicrobial Agents 48 (2016) 239–246 alapján

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Ten commandments

6. When possible, avoid antibiotics with a higher likelihood of promoting

drug resistance or hospital-acquired infections, or use them only as a last

resort.

7. Drain the infected foci quickly and remove all potentially or proven

infected devices: control the infection source.

8. Always try to de-escalate/streamline antibiotic treatment according to

the clinical situation and the microbiological results; switch to the oral

route as soon as possible.

9. Stop antibiotics as soon as a significant bacterial infection is unlikely.

10. Do not work alone: set up local teams with an infectious diseases

specialist, clinical microbiologist, hospital pharmacist, infection control

practitioner or hospital epidemiologist, and comply with hospital

antibiotic policies and guidelines.

International Journal of Antimicrobial Agents 48 (2016) 239–246 alapján

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REPROGRAM YOUR MIND