Infection control and antimicrobial

stewardship

Janos Sinko PhD

South-Pest Central Hospital

Budapest

Healthcare related infections

By 2050 300M deaths

GDP down 2 %- 3.5 %

Infection control Antimicrobial stewardship

PREVENTION OF INFECTIONS =PATIENT SAFETY

1. Infection control

PATHOGEN

SUSCEPTIBLE

HOST

PORT OF

ENTRY

TRANS-

MISSION

PORT OF

EXIT

RESERVOIR

INFECTION CIRCLE

What is infection control?

• Surveillance : (monitoring: collect data

using standardized methods - intervention)

• Estimate risk factors, critical points of care

» intervene to minimize

Nosocomial surveillance

Monitoring by standardized methods

Whom to monitor?

• Hospital, department, unit, risk groups

• Instrumentation, interventions, surgery

Surveillance and infection control

Effectiveness of surveillance

Efficacy of infection control

• Sporadic, clustered or epidemic nosocomial

infections/pathogens

– internally monitored,

– background-checked,

– prevented/eliminated by specific measures and

interventions

Infection control activity

• 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

PREVENTION

Anticipate infections threatening health care

workers (visitors) and patients

• Specific measures

–Vaccination

–Chemoprophylaxis

• Aspecific measures

–Hand hygine

–Isolation, protective equipment

–Disinfection, sterilization

Interventions

• Isolation

• Quarantine

• Work management, patient routes

• Disinfection

• Prophylaxis

• Ongoing monitoring

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

Standard precautions

• Hand hygiene

• Protective equipment: gloves, masks, gown

etc.

• Hazardous material management (waste)

• Linen disinfection

• Disinfective cleaning

Transmission specific precautions

• GOAL: To prevent transmission

• METHODS:

– Contact isolation

– Droplet isolation

– Airway isolation

An infection control tool of

paramount importance…

Ignaz Philipp Semmelweis

(1818-1865)

Az infekciókontroll

jelentősége a

gyakorlatban Kertész Adrienne

28

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

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

30

31

Kézhigiénia WHEN?

(WHO five moments of hand hygiene)

How?

• Single phase hand disinfectant: in case of

visible contaminations (+ C. difficile infection)

• Apparently clean hands: alcohol based rub

Single phase disinfectant

Both cleaning and disinfecting hands

(containing both soap and disinfectant)

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

33

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.

34

2. Antimicrobial stewardship

http://www.ecfr.gov/

PUBLIC ENEMIES

http://ecdc.europa.eu/

http://ecdc.europa.eu/

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

Paucity of new antibiotics

E

S

C

A

P

E

A useful alternative: use available antimirobials in a

prudent and responsible way

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

Multifactorial background

• HUMAN USE

• Adequate

• INADEQUTE

• Agricultural utilisation

• Environment, water

• Remnants of antibiotics

• Resistance genes

• Lack of monitoring and regulation

• No alternative therapies developed

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?

133 countries, 34 having some strategy

Is this by chance?

How are antimicrobials used?

• Seemingly a medical question, in fact

determined by factors of behavioural, societal

and cultural anthropologic background

Illustration

Decision environment

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).

J Antimicrob Chemother 2014; 69: 1142–1144

UNCERTAINITY

AVOIDANCE AND

PERIPERATIVE

PROPHYLAXIS

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.”

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

Goals

• To improve infection outcome

• Ameliorate toxicity

• Prevent C. difficile infections

• Decrease antibiotic-resistant strains

• Optimizing resource utilization

INFECTION

CONTROL

EPIDEMIOLOGY

ANTIMICROBIAL

STEWARDSHIP

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).

Intervention

• How are antimicrobials ordered?

– Authorization?

– Prospective control and feedback?

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

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

• What is appropriate?

– Self-control (eg. Stop rules)

– Computer based decision augmentation

– Cycling of antibiotics: NOT recommended

Intervention

Optimalization

• Pharmacokinetics

–Drug levels

–Alternative dosing

–Sequential oral therapy

–De-ecalation

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

Optimalization

• Pharmacokinetics

– Drug levels

– Alternative dosing

– Sequential oral therapy

– De-ecalation

• Testing drug allergies

• Pre-specified duration of therapy

Optimalization

• Co-operation with microbiology

– Stratified, selective reporting

– Speeding-up diagnostics (viruses, blood

cultures)

– Non-cultural fungal diagnostics

• Procalcitonin

Key players

• Pharmacist dedicated for antibiotic

therapy

• Antimikrobial stewardship team

–Minimal: clinician + pharmacist

–Multidisciplinary

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

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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