National Program on Prevention and Control of Infection and Antimicrobial Resistance – PPCIRA / PORTUGAL

José Artur Paiva, Elaine Pina, Maria Goreti Silva, Paulo André Fernandes, Anabela Coelho, José Alexandre Diniz, Francisco George Manuela Caniça, Jorge Machado, Ana Silva

Where were we in 2011-2012 ?

Before PPCIRA……

Prevalence of HAI AM use

Portugal EU Portugal EU

Men 12,4% 7,2% 48,3% 39,2%

Women 8,8% 5,4% 42,3% 33,2%

Global population

10,5%

6,1%

45,3%

35,8%

PPS DGH 2012

High prevalence of hospital acquired infection and high antimicrobial consumption

High hospital consumption of carbapenems

“ In 2012, consumption of carbapenems varied by a factor of 14, from 0.01 (Bulgaria) to 0.14 DDD per 1 000 inhabitants and per day (Portugal)“ “The proportion of consumption of carbapenems out of antibacterials for systemic use ranged from 0.8% (Latvia) to 9.8% (Portugal) with an EU/EEA population-weighted mean of 2.9%.”

2010

Carbapenems

ECDC; ESAC Net 2012

High antibiotic consumption in the ambulatory setting

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ECDC; ESAC Net 2012

Global consumption Quinolone consumption

6

High ESKAPE composed index of resistance Extracted from ECDC PPS 2011-2012

Growing resistance of Staphylococcus aureus to methicillin in Portugal (2001-2011)

ECDC – EARS Net

Weaknesses and threats

• Low level of integration and synergy of the several processes; no holistic vision; too many process leaders

• Understaffing underpowerment of the central and peripheral structures

• Absence of focus in the most relevant issues: MRSA, CRE, carbapenems, quinolones, Standard precautions campaign

• Problems of data sharing among state institutions and of data feedback to the providers

• Difficulties in implementing a collaborative model, increasing capacity building and maximizing participation.

• Reimbursement system not reflecting the indicators and targets and not boosting motivation

What has been done in 2013-2014?

PPCIRA initiatives

PROGRAM ON PREVENTION AND CONTROL OF INFECTION AND ANTIMICROBIAL RESISTANCE

NATIONAL PROGRAM

OF INFECTION CONTROL

NATIONAL PROGRAM ON PREVENTION OF ANTIMICROBIAL

RESISTANCE +

8 Feb 2013

1999 2008

PPCIRA: one lidership

PPCIRA management structure: law 15423/2013 Directorate

General of Health (DQS)

Regional Health Authority (RHA)

Health Units

94% H; 25% PC

PPCIRA central direction

PPCIRA Regional

Coordination Group

PPCIRA Local

Coordination Group

Pharmacy and Therapy Regional Committee

RHA Administrator on Quality

Local Comission on Quality and Safety

Pharmacy and Therapy Hospital Comission

Depart. Of Quality in Health - DNH

PPCIRA Scientific Council

Reduce HCAI Reduce antimicrobial consumption

To reduce the emergence of antimicrobial resistance

Evict antibiotics when there is no

infection

Reduce transmission of antimicrobial

resistance

Shorten antibiotic treatment duration

To reduce the incidence of resistant bacteria

STANDARD PRECAUTIONS

CAMPAIGN

ANTIBIOTIC STEWARDSHIP

PROGRAM

Epidemiological surveillance

Adhesion to the main interventions

Launching 2012 2014 Epidemiological surveillance of antimcrobial resistance (Microbiology Lab)

Guideline NRL/DGH

21 February 2013

22

70

Epidemiological surveillance of at least one of the HAI

Law 15423/2013

18 November 2013

85%

Antimicrobial Stewardship Program

Law 15423/2013

18 November 2013

0

40% hospitals

Standard Precautions Campaign

5 May 2014

-

70% hospitals

24% PCC

September 2014 PPCIRA /DGH

PPCIRA “bundles”

Hand hygiene Adequate use of gloves • Patient/clinical environmental hygiene “Anti-MRSA” policy Surgical antibiotic prophylaxis for no more than 24 h Duration of antibiotic duration limited to 7 days (with exceptions) • Reduction of quinolone and carbapenem prescription Antimicrobial stewardship program in the first 96 h

Hand hygiene Adequate use of gloves • Patient/Clinical environmental hygiene Compliance with the vaccination program • Adquate tretment of wounds • Reduction in the prescription of quinolones • Guideline for the treatment of RTI Guideline for the treatment of UTI Antimicrobial stewardship program

Hospital Bundle

Comunity Bundle

Education and Pedagogy

• “Train the trainers” course • In all RHA (7 health regions) • Topics: strategy, implementation and science • Two modules, hospital and ambulatory, in two

consecutive days • 4 trainers per course; a total of 8 trainers • In October 2014, more than 600 doctors and

nurses were trained as trainers

Citizen’s awareness Winter 2013

What has been achieved ?

PPCIRA results

Reduction of large spectrum antibiotic consumption in the ambulatory setting

Quinolones: Higher consumption among ECDC

countries in 2010 Improvement to 7th place in 2013 European median= 1,81

GUIDELINES: - Duration of antibiotic

therapy - Treatment of UTI

INFARMED, 2014

Quinolone consumption

Large spectrum over small spectrum antbiotic consumption

Reduction of antibiotic consumption in the hospital setting

GUIDELINES: - Duration of antibiotic treatment - Treatment of UTI - Surgical antibiotic prophylaxis

INFARMED, 2014

Feedbacking data to

hospitals

Hospital antibiotic consumption in the 1st semester of the year

Reduction of the rate of Staphylococcus aureus resistance to methicillin (MRSA)

ECDC / EARS Net

% of the invasive Staph aureus isolates resistant to methicillin

CRE alert surveillance system 1.8% of all Enterobacteriaceae

Mechanisms of carbapenem resistance Number of isolates (%)

Production of acquired carbapenemase GES-type 5 KPC-type 195 VIM-type 9 KPC-type, GES-type 2

NDM-type 1 Subtotal 212 (40%)

Other mechanisms ESBL and/or AmpC production associated with impermeability mechanism

214

Imipenem resistance mechanism inherent to te species 23

Probable impermeability mechanism 3 Subtotal 240 (45,3%)

Isolates susceptible to the carbapenems 76 Non-viable isolates 2

Subtotal 78 (14,7%) TOTAL 530

CR-BSI (per 1000 CVC days): 2003-2013

3.1 3.0

2.5

2.1 1.9 1.9

0.9

1.4

1.9

2.4

2.9

3.4

2002-2004 2005-2007 2010 2011 2012 2013

Variação da taxa de INCS associada a CVCLinear (Variação da taxa de INCS associada a CVC)

Reduction of some of the HAI

Density of nosocomial BSI due to Staphylococcus aureus and by MRSA

Infections in Adult ICUs

Reduction of some of the HAI

Infections in Neonatal ICUs

Surgical site

infections

HCAI in long term care institutions

GUIDELINES: - Standard

precautions - Prevention of

surgical site infection

- Prevention of chronic wound infection

Next months……..

Strategy

1. Structure consolidation: 4 instead of 3 at DNH 2. Standard precautions campaign 3. Mandatory epidemiological surveillance 4. Mandatory antimicrobial stewardship program 5. Guidelines 6. Education of citizens and professionals 7. Intersectorial Alliance (joint effort) 8. Finantial motivation / Contract-programs

Keep the momentum

PPCIRA institutional assessment

1. To have PPCIRA-Local Coordinating Group in accordance with 15423/2013 law 2. To participate in the epidemiollogical surveillance of antimicrobial resisitance,

through LCG and Microbiology Labs. 3. To participate in the 4 epidemiological surveillance programs on HAI 4. To analyse institution’s data on antimicrobial consumption,

relating them to antimicrobial resistance patterns 5. To have a Antimicrobial Stewardship Program 6. To participate in the Standard Precautions Campaign 7. To reduce mean duration of antibiotic treatment course 8. To reduce to zero surgical antibiotic prophylaxis > 24h 9. To increase antibiotic free days 10. To reduce carbapenem consumption in hospitals 11. To reduce % patients that acquire colonization or infection by MDR in hospitals 12. To reduce hospital MRSA rate 13. To avoid increase in CRE rate 14. To reduce % of patients on antibiotic treatment for chronic wound 15. To reduce quinolone consumption in the ambulatory setting

ppcira@dgs.pt

Thanks !