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Infection Control
and antimicrobial resistance
Evelina Tacconelli
Infectious Diseases
Tuebingen University
Germany
Preventing MDR-Gram positive
Open or closed issues?
• Targeted screening vs universal screening
• PCR vs conventional cultures (screening)
• Room isolation / contact precaution vs no CP
• Target vs universal decolonisation
Preventing MDR-Gram negative
Open or closed issues?
• Best combination of interventions
• CP for patients colonised or infected with ESBL-E. coli • Chlorexidine bath
• Decolonisation
Preventing MDR
Open or closed issues?
• Antimicrobial stewardship programme
• Impact of the increase of elderly population
• Outcome assessment
• PUBLIC-PRIVATE COLLABORATIVE RESEARCH
Quezada, AAC 2012
Schinasi L, (2013)
Fuller, Plos One Sept 2013
Fuller, Plos One Sept 2013
Tacconelli, Lancet Infect Dis, 2009
Type of tests
Molecular vs Cultures
1. Isolation + decolonization
reduces transmission by
64%
2. Undetected MRSA-positive
patients were estimated to
be the source of 75% of total
transmission events.
3. Isolation measures
combined with
decolonization treatment
were strongly associated
with a reduction in MRSA
transmission in hospital
general wards.
Worby, Am J Ep April 2013
Universal decolonisation
Huang, NEJM, June 2013
3 groups
universal screening
+ isolation
universal screening
+ isolation +
decolonisation
universal
decolonisation
(chlorexidine +
mupirocin)
One BSI infection
was prevented per
54 patients who
underwent
decolonisation
Shweizer, BMJ 2013
• 5726 patients included
• BSI due to MRSA
• 1.8 x 1,000 hospital-admission
• BSI due to ESBL+
Enterobacteriaceae
• 3.1 x 1,000 hospital-admission
Tacconelli, ECCMD 2012, 2013
http://www.saturn-project.eu/
Chairperson: Evelina Tacconelli (Tuebingen, Germany)
• Barry Cookson (Health Protection Agency, London, UK)
• Stephanie Dancer (Hairmyres Hospital, East Kilbride,
Lanarkshire, UK)
• Uwe Frank (Heidelberg University Hospital, Heidelberg,
Germany)
• Gunnar Kahlmeter (Central Hospital, Växjö, Sweden)
• Jesus Rodrigues Bano (Hospital Universitario Virgen
Macarena, Sevilla, Spain)
• Nalini Singh / Deborak Yokoe (USA)
Tacconeli, CMI, under publication (free access)
Multifaceted strategy effectiveness for MDR-GN
Tacconelli et al, under revision
HH
Education
CP
Combinations of interventions significantly
associated with effectiveness
HH
Education
CP
Isolation room
OR = 6.1 OR = 8.3
Chlorexidine bathing
Climo NEJM 2013
Tacconelli, AAC, 2009
Risk of MRSA new acquisition after antibiotic therapy in hospitalized patients
Cochrane review (P. Davey 2013)
• The main comparison was between persuasive and
restrictive methods.
• Overall, the 89 studies showed that the methods improved
prescribing.
• 21 studies showed that the methods decreased the number
of infections in hospital.
• The restrictive methods appeared to have a larger effect
than persuasive methods.
ESCMID Guidelines
to control the spread of MDR-GNB 2013
• Epidemic setting: 17 interventions
• Endemic setting: 7 interventions
• Moderate level of evidence / strong recommendations for:
• MDR-A. baumannii (epidemic setting)
• ESBL-producing Enterobacteriaceae (endemic setting)
1. University Hospital
Freiburg, Germany (WP
1-3, 8)
2. Mater Dei Hospital,
Msida, Malta (WP 4)
3. Institute of Public Health,
Brussels, Belgium (WP
5)
4. Università Cattolica,
Rome, Italy (WP 6)
5. Radboud University
Nijmegen Medical
Centre, The Netherlands
(WP 7)
Only 56% of ICU have an ATBS
Definition of effectiveness of ATBS
New parameters
• resistance rate x 1000 HA / DH
• mortality attributable to infection
• overall length of hospitalization
• periods spent in specific care areas such as the ICU’s
• hospitalisation within 1 months
• rates of recurrent infection
• the frequency with which specific laboratory
studies are performed
• antibiotic usage patterns, and institutional
antimicrobial resistance patterns.
Lack of agreement about outocome indicators / heterogeneity of reports
Decolonisation
• 6 CT
• 2 RCT
• 1 KRKP
• No evidence to recommend decolonisation to reduce the
spreading of ESBL-producing bacteria
Major comments
a) International networking and societies should play an
“homogenizing” role
b) Revision and improvement of STROBE items for
epidemiological studies on ARI to improve the quality level of
evidence
c) New studies and agreement on outcome indicators
d) Consensus among clinicians, researchers, epidemiologists,
pharmacologists, pharma companies, governative entities,
control entities on new outcome indicators for clinical
evaluation of new antibiotics
Preventing MDR-Gram positive
Open or closed issues?
• Targeted screening vs universal screening
• PCR vs conventional cultures (screening)
• Room isolation / contact precaution vs no CP
• Target vs universal decolonisation
• Decolonisation
Preventing MDR-Gram negative
Open or closed issues?
• Best combination for best effectiveness
• CP for patients colonised or infected with ESBL-E. coli
• Chlorexidine bath
• Decolonisation
Preventing MDR
Open or closed issues?
• Antimicrobial stewardship programme
• Impact of the increase of elderly population
• Outcome assessment
• PUBLIC-PRIVATE COLLABORATIVE RESEARCH
Is there any country doing good?