hospital infection control from a developing country’s perspective · 2018-07-17 · hospital...

Hospital Infection Control From a Developing Country’s PerspectiveDr. Aamer Ikram, National Institute of Health, Islamabad, Pakistan

A Webber Training Teleclass

Hosted by Martin Kiernan [email protected]

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HospitalInfectionControlfromaDevelopingCountry’sPerspective

ProfAamer Ikram,SI(M)MBBS,MCPS,FCPP,FCPS,PhD

FRCP(Edin),FRSTMH,FFPH,FRCPath (UK)DipOSHE,DipDisasterManagement

BSP(UK),IFBACP,CertEID (US),RBP(US)

www.webbertraining.com July17,2018

[email protected]

Background

InfectionControl

Unknown Infections

Known Infections The Iceberg Effect

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Microbes&Humans

•Microbes: 5X1031(50,000,0000,000,000,0000,000,0000,000,000)

• Humans: 6X109(6,000,000,000)

Microbiologyinthe21stcentury,ASM,2004 3

SuperBugs

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FinancialEffects

§ USA $6.65B

§ Europe €7B

§ UK £1B

§ Turkey $1B

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CostEffectiveness

Infection CostSavings

VAP $25,072

Bacteremia $23,242

SurgicalSiteinfection $10,443

UTI $758

Anderson,etal.InfectControlHospEpidem2007;28:767-73 7

Prevalence Developedcountries

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Prevalence Developingcountries

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Device-associatedinfectionratesincriticalcareindevelopingcountries

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EdwardsRJ.AmJInfectControl2007;35:290– GastmeierP.JHospInfect2006;64:16PronovostP.NEnglJMed2006;355:26– RosenthalV.AmJInfControl,2008:36:627-637

Reportedincidencerates

Catheter-associatedbloodstreaminfectionsinsurveillancenetworksinICUs

• NHSN: 2.7per1000catheter-days(1.5/1’000– 6.8/1’000)

• Michigan: 2.7per1000catheter-days(medianbeforeintervention)

• Germany: 2.1per1000catheter-days

• 18developingcountries: 8.9per1000catheter-days

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Infect Control Hosp Epidemiol . 2008 Suppl 1:S41-50.

AJIC 2016

J Hosp Infect. 2007 65 Suppl 1:S1-64

AJIC 2017

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Emergenceofanewantibioticresistancemechanismin India, Pakistan, and the UK: a molecular, biological, and epidemiological study

LancetAugust11,2010

§ Gram-negative Enterobacteriaceae with resistance tocarbapenem conferred by NDM-1 are potentially a majorglobal health problem

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NewDelhiMetalloBetalactamase(NDM)

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NDM-1

§ 25isolatesfrom8citiesofPakistan

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Emergence of Resistance in ClinicalSettings;Community

Neisseriagonorrhea

Neisseriameningitides

SalmonellaTyphi

MTB,MDR-TB,XDR-TB

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EmergenceofResistanceinClinicalSettings;HealthCareSettings

ColistinresistantGNR MRSA/VRE

PanRPs.aeruginosa

MDR&XDRGNR

Candidaauris

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Candidaauris:Arapidlyemergingcauseofhospital-acquiredMDRfungalinfectionsglobally

PLoSPathog.2017May;13(5) 19

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n MeanLOS SD ExtraLOS

Control 236 4.31 +/- 2.66

HAI 120 15.73 +/- 12.69 11.42

VAP 54 21.89 +/- 14.97 17.58

CLABSI 32 25.88 +/- 17.95 21.57

CAUTI 44 18.04 +/- 15.24 13.73

Surveillanceofdevice-associatedinfectionsinintensivecareunitsofatertiarycarehospital.JIH2016

LengthofStayinICU

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MortalityRateinICU

Surveillanceofdevice-associatedinfectionsinintensivecareunitsofatertiarycarehospital.JIH2016 22




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TotalHospitalCostperPatient


ExtraAntibioticCostPerPatient





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AreasofConcern§ Legislativecoverage§ Guidelines,policies§ IPCprograms§ Oversight§ Trainingopportunities§ Infectiouswastemanagement§ Antimicrobialusage§ ClinicalAuditing§ Multifacetedapproach

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Whyinfectioncontrolisimportant?

§ Preventstransmissionofinfections

§ Shortenspatient’sstayinthehospital

§ Decreaseshospitalizationcost

§ Reducesmorbidityandmortality

§ ContainmentofAMR

§ Anindicatorofsafecaretopatient

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FactorsinvolvedinHAI

§ Themicro-organisms

§ Thehost(patient)

§ Thecarriers(Staff)

§ Theenvironment

§ Treatment

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InfectionControlComponents

LocalSurveillanceBestPractices

SterilisationandDisinfection29




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?Responsibility

§ InfectionControlCommittee• InfectionControlteam

•Coregroup§ HCW§ Medicalofficers§ Nursingstaff

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PreventiveMeasures

• Interruptionoftransmissionofmicroorganisms

• Careofequipment

• Interruptionofpersontopersontransmission

• Handwashing

• Barrierprecautions

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WhyWeWashOurHands?

Clean Hands are HealersDirty Hands are Killers

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§ Antibioticprescribing• 35%ofthetotalhealthcarebudgetisspentonantimicrobialsindevelopingcountriesversus11%indevelopedcountries

§ Antibioticsarenow“endangeredspecies”facingextinctionduetotheworldwideemergenceofantibioticresistance

Harsh Fact

Microbiol., 23 November 2016 https://doi.org/10.3389/fmicb.2016.01881 42




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Years

Resistance

New

A

ntim

icro

bial

s

We are here

Wherearewe?

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Compliance < 40%

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An approach to infection control indevelopingcountries

EvidenceBasedPractice

Costeffective

DivertresourcesWastefulpractices

Toreduceinfectionrateto‘irreducibleminimum’

Unsafepractices

InfectionControlTeam/InfectionControlProgrammeAudit (process)&outcomeSurveillance

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Prioritizingrisks

High severityLow frequency

(Blood stream infections)

High severityHigh frequency

(Blood-borne Infections from re-use of syringes & needles)

Low severityLow frequency

(Infections from linen)

Intermediate severity High frequency

(Surgical site infections)

FREQUENCY

SEVERITY

Low High

High

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Cost Saving Measures § Routine

• MicrobiologicalSwabbingofenvironment• Disinfectantsforenvironmentalcleaninge.g.floors&walls• Fumigationofisolationroomwithformaldehyde

§ Unnecessary• Useofovershoesanddustattractingmatt• PersonalProtectiveEquipmentintheIntensiveCare,&NeonatalUnit

§ Excessive/unnecessaryuseof• IM/IVinjections• Insertionofindwellingdevicese.g.IVlines,urinarycatheters,nasogastrictube

• Antibioticsbothforprophylaxisandtreatment

Damani NN. Journal of Hospital infection 2007; 65(S1): 151-154. 48




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Cost Effective Practices§ Educationandpracticaltrainingin

• Handhygiene• Aseptictechnique• AppropriateuseofPPE• Sharpuseanddisposalinrobustcontainers

§ Provisionofalcoholichandrubandhandwashingfacilitiesforhandhygiene

§ Useofadequatelysterileitemsforinvasiveprocedures§ Useofsingle-usedisposablesterileneedlesandsyringes§ Adequatedecontaminationofitems/equipmentbetween

patients§ ProvisionofHepBvaccinationforhealthcareworkers§ Postexposuremanagementofhealthcareworkers

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ContainmentofAMR

Internationallevel§WHOContainmentofAMR2015

§ (GlobalActionPlanforAMR)

§ UNgeneralAssemblyhighlevelmeetingonAMR2016

§ Collaborationbetweencountries;GARP

RequiresGlobalEfforts

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WHOInitiatives

§ Increasedcollaborationbetweengovernments,nongovernmentalorganizations,professionalgroupsandinternationalagencies

§ NetworkingthatundertakesurveillanceofantimicrobialuseandAMR

§ Internationalapproachforcontrolofcounterfeitdrugs

§ IncentivesforR&Dfornewdrugsandvaccines

§ Formingnew,andreinforcingexistingprogrammestocontainAMR

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§ RegionalCommitteemeetinginTimorLeste 2015• Memberstatespassedakeyresolutionforsteadfastpoliticalcommitmentandmulti-sectoralcoordinationtotackleAMR

§ JaipurDeclaration2011onAMR• Callsforcomprehensiveactionagainsttheirrationaluseofantibiotics

§ Berlindeclaration2017§ G20healthministersin2017recognizedtheincreasingthreatofAMR

§ MemberspledgedtodevelopnationalactionplanstotackleAMR,inlinewiththeOneHealthapproach,withinterventionsaimedatagriculture,livestock,andhumanhealth

RegionalInitiatives

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Containment of AMR

§ National§ Jointpolicies/guidelinesfromhealthministry,agriculture&environment

§ Nationalpolicyimplementation§ Advocacyanddisseminationofinformation

§ Roleofprofessionalbodies§ CommunityandIndividual§ PublicPrivatePartnership

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National Strategies

NationalCommitteetoworkincoordinationwithregulatorybodies:§ AMRsurveillance&antimicrobialutilization§ EvaluatetheimpactofAMRpreventiveandcontrolstrategies§ Registeralldispensingoutlets§ Ensureavailabilityofantimicrobialswithprescriptiononly§ Bindlegallyallmanufacturerstoreportdataonantimicrobial

distribution§ Enhancecoverageofimmunization§ Developnationalactionplansandallocateresources

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Community Level

§ ICincommunity(PublicHealth)

§ Handwashing§ Sanitation§ Cleandrinkingwater(chlorination)§ Immunization

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LaboratoryanditsRoleinContainmentofAMR

Earlyidentificationofmicroorganismsandfastreportingofantimicrobialsusceptibilityresult

LaboratoryQualityManagementSystemLaboratoryInformationSystemDataManagementandAnalysisGo

odLab

oratoryPractice

AMRSurveillance

Laboratory Level

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Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 23, No. 2, February 2017

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ChallengestoOvercome

§ Infectionsbeyondhealthcarefacilities

§ Congregatesettingsandincommunity

(carriersofMDRorganisms)

§ Lackofresponsibilityandaccountability

§ DeficientIPCsupportincongregatesettings

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WayForward

§ InfectionPrevention&ControlProgram§ DiagnosticStewardship§ AntibioticStewardship§ Risk assessment of AMR in the food chain,environment in a public health perspective

§ A higher profile research on IC and AMRin health care settings

§ Enough funding for research to addresscurrent gaps

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Good Infection Control Practices

§ Aseptictechniqueforallsterileprocedures§ Removeindwellingdeviceswhennolongerneeded

§ Isolationofpatientwithcommunicablediseases/multi-resistantorganism

§ Placingmechanicallyventilatedpatientsinasemi-recumbentposition

§ MinimizenumberofpeopleinOT§ Staffeducationandtraining

62Damani NN. Journal of Hospital infection 2007; 65(S1): 151-4




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Policies

§ Policyforhandhygiene§ PolicyofHepatitisBvaccination§ Disinfectantpolicy§ Needlestickinjurypolicy§ Wastemanagementpolicy

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Impact of Staff Education Programme onVentilator-associatedPneumonia

ReductioninincidenceofVAPfrom12.6to5.7episodes/1000ventilatordays

Zack JE, Crit Care Med. 2002;30:2407-2412

ReductioninincidenceofVAPfrom13.2to6.5

episodes/1000ventilatordays

SalahuddinNetal.JHospInfect2004;57:223-227

ImpactofStaffEducation




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SENICStudyontheEfficacyofNosocomialInfectionControl

§ 1infectioncontrolnurseper200to250beds

§ 1hospital epidemiologist perhospital (1000beds)

§ Organized surveillancefornosocomialinfections

§ Feedbackofnosocomialinfectionrates

HaleyRWetal.AmJEpidemiol1985;121(2):182-205 65

IC– QuarterlyReport

1. Period : _____________________2. Hospital/Institute: _____________________3. HospitalClassifiedas: _____________________4. InCharge _____________________

5. InfectionControlCommittee:Composition

President: ______________________No.ofMembers: ______________________AdministrativeOfficermemberICC: ______________________NursingOfficermemberICC: ______________________Isanyofthesanitarystaffmember: ______________________

Lastinfectioncontrolmeetingheldon: ______________________

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INFECTION CONTROL – QUARTERLY REPORT

1. Period : _____________________ 2. Hospital / Institute: _____________________ 3. Hospital Classified as: _____________________ 4. Commandant / Commanding Officer _____________________ 5. Infection Control Committee:

a. Composition 1) President: ______________________ 2) No. of Members: ______________________ 3) Is 2 IC/ Adm Offr member of ICC: ______________________ 4) Is any AFNS offr member of ICC: ______________________ 5) Is any of the sanitary staff member: ______________________

b. Last infection control meeting held on: ______________________ 6. Diagnostic Facilities:

a. Facilities adequate for bacteriological culture: _______________________ b. No. of specimens processed for culture during the qtr: _______________________ c. Number of overall positive culture s: _______________________ d. Can MRSA be detected in the lab: _______________________ e. If yes, no. of MRSA isolated during the qtr: _______________________ f. Can ESBL be detected in the lab: _______________________ g. If yes, no. of ESBL isolated during the qtr: _______________________ h. Can VRE be detected: _______________________ j. If yes, no. of VRE isolated during the qtr: _______________________

7. Infectious cases:

a. No. of infectious (notifiable) cases admitted: _______________________ b. No. of hospital acquired infections: _______________________ c. Isolation facilities adequate: _______________________ d. Number of isolation beds available in the hosp _______________________

8. Antimicrobials

a. Total LP expenditure on antimicrobials: _______________________ b. Expenses incurred on purchase of:

1) Vancomycin/Teicoplanin _______________________ 2) Imipenem / Meropenem _______________________ 3) Sulzone / Tazocin _______________________

c. Is there any antibiotic policy: _______________________ 9. Infection Control Measures:

a. MRSA protocol available with wards/lab: _______________________ b. Adequate hand washing facilities exist:

1) In wards _______________________ 2) In OPDs _______________________

c. Alcohol scrub/hand disinfectant avail at washing area: _______________________

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Nosocomial infections in NICU

§ Activeinvolvementofmother inregularmonitoringofbabies

§ Stricthandwashing beforeandafterhandlingbabies

§ Co-beddingofmotherandinfant(useofaheatedcotasrequired&minimumuseofincubators)

§ Encouragebreastfeeding (lessneedforParenteralfeeding)

§ Allprocedureswereundertakenbytrainednurse

§ Minimalvisitors

68BhuttaZA.etal.1997&BhuttaZA.etal.BMJ2004;329:1151-5




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InfectionControl&QualityHealthcareintheNewMillenium

Multidisciplinaryteamapproach1847

1958

1970

1980

1990

2000

1863

PittetD,AmJInfectControl2005,33:258 69

Message

BEWAREContinuoussurveillanceJudiciousantibioticmonitoringProperinfectioncontrolpoliciesStrictimplementationStringentsterilization&disinfectionRegularauditingEfficientInfectioncontrolnetworkAppositewastedisposal 70




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Profoundlyindebted

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hospital infection control from a developing country’s perspective · 2018-07-17 · hospital...

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