Round Table: Prevention and control of carbapenem-resistant microorganisms
in healthcare facilities
Carlo Gagliotti - ASSR Emilia-Romagna
EUCIC Local Module: Healthcare Associated Infections Bergamo - 07 May 2019
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Disclosure slide for speaker at EUCIC Advanced module for Infection Prevention and Control Disclosure of speaker’s interests: Carlo Gagliotti (Potential) conflict of interest None
Potentially relevant company
relationships in connection with event 1
None
• Sponsorship or research funding2
• Fee or other (financial) payment3
• Shareholder4
• Other relationship, i.e. …5
Carbapenem-resistance Carbapenem-resistance
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Why carbapenem-resistance is a matter
of international concern?
CR gram-negatives are: ➢ emerging cause of HAI
➢ associated with high potential for transmission (mobile genetic elements)
➢ difficult to treat due to high levels of AMR
➢ associated with high mortality
SIGNIFICANT THREAT TO PUBLIC HEALTH!
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Epidemiological
determinants
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ANTIBIOTIC RESISTANCE
Which are the DRIVERS
?
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➢ ANTIBIOTIC USE
➢ PERSON-TO-PERSON TRANSMISSION
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Key variables to be considered
➢ Undetected ratio
➢ Duration of colonization ➢ Colonisation pressure
(Harris AD et al, CID 2006)
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Undetected ratio
Proportion of patients undetected by clinical
cultures among all patients colonized or infected with a specific antibiotic-resistant organism
UNDERWATER PORTION OF
ICEBERG
SCREENING
The higher the ratio, the more effective active
surveillance culturing will be at detecting patients not known to be colonized
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Duration of colonization
Amount of time that patients remain colonized
with antibiotic-resistant bacteria
Duration of isolation precautions
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Colonization pressure
Prevalence of resistancein the specific context
patient-to-patient transmission
Colonization pressure varies both between locations and over time and therefore needs to be measured in the individual institution (e.g. hospital)
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A lot of question marks……..
➢ What is the importance of colonization pressure in transmission?
➢ Active surveillance culturing is needed? ➢ Once colonized, always colonized?
➢ Antimicrobial stewardship will help?
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AN EXAMPLE OF EFFECTIVE
INTERVENTION
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➢ Implementation of national guidelines
➢ Supervised adherence to GL (site visits by national task force)
➢ Responsability for containment to hospital directors ➢ Active screening to find asymptomatic carriers
➢ Dedicated staffing + Physical separation of hospitalised carriers
➢ Surveillance and timely feedback
(Schwaber MJ et al, CID 2011)
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Israeli CRE outbreak
The national intervention was rapidly effective!
Emphasis on infection control
(Schwaber MJ et al, CID 2011)
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(Schwaber MJ et al, CID 2014) ➢ Extension of the intervention to nursing homes
➢ Improvement of microbiological protocols ➢ Strengthening of outbreak investigation ➢ Enhancement of communication
Further progressive
reduction of cases and invasive infections!
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EFFICACY OF INFECTION PREVENTION AND CONTROL: AVAILABLE EVIDENCE
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➢ Study assessing impact of any IPC measure on transmission
➢ Both endemic and epidemic settings ➢ Standardized approach for study
screening and data abstraction
➢ Risk of bias assessed using
design-specific effective practice and organization of care (EPOC) quality criteria
(Tomczyk S et al, CID 2019)
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➢ 17 EPOC studies ➢ all interrupted time
series (ITS)
➢ none conducted in low-income countries
➢ 15 reasonably well powered
(Tomczyk S et al, CID 2019)
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WHAT INTERVENTIONS
ARE RECOMMENDED?
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Prevention and control of carbapenem-resistant
Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities
➢ WHO Guidelines Development Group ➢ WHO Steering Group
➢ Systematic Reviews Expert Group
➢ WHO Public Health Ethics Consult. Group Based on the same studies as the review by Tomczyk et al, 2019.
WHO guidelines
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The WHO guidelines (2017)
➢Expert consensus document
➢Setting: health care facilities
➢MDROs: Enterobacteriaceae,
Acinetobacter baumannii and Pseudomonas aeruginosa
➢Eight recommendations
➢Very low to low quality of evidence
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1) Implementation of multimodal IPC
➢hand hygiene
➢surveillance
➢contact precautions
➢patient isolation
➢environmental cleaning
•Strong recommendation•Very low to low quality of evidence
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2) Hand hygiene
The panel recommends that hand
hygiene best practices according to the WHO guidelines on hand hygiene in
health care should be implemented.
•Strong recommendation
•Very low quality of evidence
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3) Surveillance of infection and
asymptomatic colonization
The panel recommends that:
a) surveillance of CRE-CRAB-CRPsA
infection(s) should be performed
b) surveillance cultures for asymptomatic
CRE colonization should also be
performed, guided by local epidemiology and risk assessment.
•Strong recommendation
•Very low quality of evidence
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4) Contact precaution
The panel recommends that contact
precautions should be implemented when providing care for patients colonized or
infected with CRE-CRAB-CRPsA.
•Strong recommendation
•Very low to low quality of evidence
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5) Patient isolation
The panel recommends that patients colonized or infected with CRE-CRAB-CRPsA should be physically separated from non-colonized or non-infected
patients using (a) single room isolation or (b) by cohorting patients with the same resistant pathogen.
•Strong recommendation
•Very low to low quality of evidence
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6) Environmental cleaning
The panel recommends that compliance with environmental cleaning protocols of the immediate surrounding area (that is, the “patient zone”) of patients colonized or infected with CRE-CRAB-CRPsA should be ensured.
•Strong recommendation
•Very low quality of evidence
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7) Surveillance cultures of the
environment for colonization/
contamination
The panel recommends that surveillance cultures of the environment for
CRE-CRAB-CRPsA may be considered when epidemiologically indicated.
•Strong recommendation
•Very low quality of evidence
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8) Monitoring, auditing and feedback
The panel recommends monitoring, auditing of the implementation of
multimodal strategies and feedback of results to health care workers and
decision-makers.
•Strong recommendation
•Very low to low quality of evidence
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ANTIMICROBIAL
STEWARDSHIP
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EU guidelines on the prudent use of antimicrobial in humans
European Centre for Disease Prevention and Control
(ECDC, 2017)
Core elements of Hospital
antibiotic Stewardship Programs
Antimicrobial stewardship ➢ Organisational or healthcare
system-wide approach to promoting and monitoring
judicious use of antimicrobials to preserve their future effectiveness ➢ Coordinated programmes that
implement interventions to ensure appropriate antimicrobial
prescribing
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Key elements of a national strategy
➢ national action plan
➢ antimicrobial stewardship programmes at all levels of care (community, hospital, long-term)
➢ integrate stewardship activities with infection prevention/control and vaccination
➢ qualitative and quantitative targets for
improvement of antimicrobial prescribing ➢ data on antimicrobial consumption and on
antimicrobial resistance
➢ development, implementation and monitoring of clinical guidance for infections
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Thank you for your attention!
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DISCUSSION
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MEASURES/STRATEGY CRE CRAB CRPsA Responders
Multimodal IPC
Hand hygiene best practices Active screening
Contact precaution for colonized/infected
Patient isolation (single room/cohorting)
Environmental cleaning (Patient zone)
Surveillance cultures of the environment
Monitoring, auditing and feedback
Antimicrobial stewardship
