Why do we want to restrain
multiresistant pathogens in our
hospitals?
Uga Dumpis MD, PhD
Stradins University Hospital
Riga, Latvia
[email protected]
Hospitals are institutions where patients go to have
their health problem diagnosed and treated
Hospitals and medical/surgical
interventions may harm a patient’s health
Do you really want to fight
multiresistant pathogens in our
hospital?
Do it, but we are not going to give
you any money for that
Hospital acquired infections
z Prolonged
hospitalization
z Additional morbidity
z Long-term sequelae
z Psychological impact on patients
z Increased costs
z Death
Proportion of MRSA in invasive S. aureus isolates in 2004
http://www.rivm.nl/earss/
What has changed?
In 2004 new MRSA resistance testing
protocol was implemented in most of the
laboratories
z In 2006 MRSA became notifiable pathogen
z In 2007, infection control and screening
procedures were determined by national
guidelines
z In 2007, additional payment for hospitals for
the management of MRSA cases
z
Essentials of MRSA guidelines
z
z
z
z
z
z
Separate room for MRSA positive patients until
discharge from the hospital
Contact transmission prevention measures
Screening (nares and wound, or catheter site) of
high risk patients
Screening of contact patients
Nurse cohorting of patients in ICU
Removal or change of invasive devices if patient
MRSA positive
Discussion
z
Reduction in bacteremia does not always
mean reduction in MRSA cases
z
z
z
z
More patients are being identified early in carrier
state
Not all septic patients ar being cultured in Latvia
Empirical treatment with vancomycin could result in
negative cultures
Less virulent or contageous strain ? (ST368
MRSA III spa type t425)‫‏‬
What did work and what did not?
z
z
z
Increased awareness of MRSA as a particular
pathogen
Increased awareness of healthcare acquired
infections
Hand hygiene
z
z
z
z
Separate rooms and cohort nurses
z
z
z
switch from soap to alcohol
use of gloves and gowns in MRSA patient care
hand washing compliance obviously low
problem for ICU
problem for hospitals in general
Attention to invasive devices
Is it over?
z
z
z
z
z
z
z
Carbapenem resistant Acinetobacter
Carbapenem resistant Enterobacter
ESBL producing Gram negatives
Vancomycin resistant enterococci
Metronidazole resistant Clostridium Difficile?
GISA?
VRSA?
Health care acquired infection
control programme
z
General measures
z
z
z
z
z
surgical prophylaxis
sterilization and desinfection
operation theatres
hand hygiene
surveillance of infections
+ Control of multiresistant pathogens
additional pathogen specific measures
Changes in Nosocomial Infection Rates in
Hospitals with or without Effective Programs
Infection site and Hospitals with very
patient risk
effective programs
Surgical Wound
%
High risk
-48.0
Low risk
-23.6
Urinary Tract
High risk
-35.8
Low risk
-41.6
Pneumonia
Surgical patients
-7.3
Medical patients
-7.7
Bloodstream
All patients
-27.6
SENIC Study, CDC
Hospitals with
ineffective programs
%
+13.8
+21.3
+18.5
+30.7
+9.3
+10.0
+25.5
The role of infection control staff
z Identify
risks
z Understand risks
z Explain risks
z Eliminate or minimize risks
Laboratory
z
Infection
z
z
z
z
+ Colonization
z
z
z
z
z
Bloodstream and CSF
Wound
Urine
Nares
Perineum
Wounds
Invasive devices
+ Environment and engineering in a case of outbreak
z
z
ventilation
equipment
Identify risks
z
Surveillance
z
Pathogens
z
z
z
Disease
z
z
z
z
z
Laboratory based
Laboratory based + epidemiological investigation
Surgical site infections
Ventilator associated pneumonia
Catheter related bloodstream infections
Urinary tract infections
Antibiotic use
z
z
z
Point prevalence studies
Hospital consumption
Department consumption
Understand risks
z Is
the number of cases above normal
range?
z What can be considered outbreak?
z
Veries with different pathogens
z Will
any intervention help?
Explain risks
z
Staff should understand:
z
z
z
z
z
z
z
what does health care associated infection means
what is that particular pathogen you are worried
about
how that pathogen spreads
how dangerous it is for the staff
how dangerous it is for the patients
why do you want to contain the outbreak
what staff should do to contain the outbreak
Explain risks
z Better
be simple than right
Ralf Zinkernagel, Riga, University of
Latvia 12.09.2007
Eliminate or minimize risks
z Introduce
guidelines
Surgical prophylaxis
z Invasive procedures
z Antibiotic guidelines
z
z Target
the interventions
ICU
z Surgical departments
z Hemodialysis departments
z
Bed occupancy rates and MRSA
z Good
infection practices are hampered
in hospitals with high (>82% in England)
bed occupancy rates (Crookson B. 2005)‫‏‬
z Episodes of significant overcrowding,
with occupancy levels in excess of
designated numbers, triggers increases
in infection incidence rates (Borg. et al Infect Control
Hosp Epidemiol. 2008 Jun;29(6):496-502.
Detection of pathogens after exposure
Graham et al Infect Control Hosp
Epidemiol 2008;29:583–589
Roommates exposed for one day to MRSA positive patient
Moore et al. Infect Control Hosp
Epidemiol 2008;29:600–606
Distance between beds
z Dicreasing
the distance between beds
from 2.5 to 1.9 m increases the transfer
of MRSA 3.15 times
Kibbler et al, J Hosp Infect 1998
Pittet D. Infect Control Hosp Epidemiol
2008;29:957–959
Reductions in Hospital Infections Don't Directly
Correlate With Increased Frequency of HandWashing
z Deterministic
Ross-Macdonald model
z Compliance rates of 40% should be
adequate to prevent most outbreaks
occurring
z It should be possible to prevent many
outbreaks of staphylococcal infection
through hand hygiene measures alone
Kerr et al. BMC Infectious Dis
2008;8:114.
The impact of educational interventions on cleaning
performance of staff
Goodman et al. Infect Control Hosp
Epidemiol 2008;29:593–599
Conclusions
z Multiresistant
pathogens can be
restrained by adequate measures even
with limited resources if intervention:
is based on reliable surveillance data
z is evidence or rational based
z is understandable to everybody
z is consistant over the time period
z
Future challanges for Latvia
z To
maintain current practices on the
initial level
z New emerging pathogens with more
complex epidemiological spread
z How to choose and introduce into clinical
practice new diagnostic methods
z What type of surveillance is time and
cost effective