infection control and antimicrobial resistance

Infection Control

and antimicrobial resistance

Evelina Tacconelli

Infectious Diseases

Tuebingen University

Germany

Preventing MDR-Gram positive

Open or closed issues?

• Targeted screening vs universal screening

• PCR vs conventional cultures (screening)

• Room isolation / contact precaution vs no CP

• Target vs universal decolonisation

Preventing MDR-Gram negative

Open or closed issues?

• Best combination of interventions

• CP for patients colonised or infected with ESBL-E. coli • Chlorexidine bath

• Decolonisation

Preventing MDR

Open or closed issues?

• Antimicrobial stewardship programme

• Impact of the increase of elderly population

• Outcome assessment

• PUBLIC-PRIVATE COLLABORATIVE RESEARCH

Quezada, AAC 2012

Schinasi L, (2013)

Fuller, Plos One Sept 2013

Fuller, Plos One Sept 2013

Tacconelli, Lancet Infect Dis, 2009

Type of tests

Molecular vs Cultures

1. Isolation + decolonization

reduces transmission by

64%

2. Undetected MRSA-positive

patients were estimated to

be the source of 75% of total

transmission events.

3. Isolation measures

combined with

decolonization treatment

were strongly associated

with a reduction in MRSA

transmission in hospital

general wards.

Worby, Am J Ep April 2013

Universal decolonisation

Huang, NEJM, June 2013

3 groups

universal screening

+ isolation

universal screening

+ isolation +

decolonisation

universal

decolonisation

(chlorexidine +

mupirocin)

One BSI infection

was prevented per

54 patients who

underwent

decolonisation

Shweizer, BMJ 2013

• 5726 patients included

• BSI due to MRSA

• 1.8 x 1,000 hospital-admission

• BSI due to ESBL+

Enterobacteriaceae

• 3.1 x 1,000 hospital-admission

Tacconelli, ECCMD 2012, 2013

http://www.saturn-project.eu/

Chairperson: Evelina Tacconelli (Tuebingen, Germany)

• Barry Cookson (Health Protection Agency, London, UK)

• Stephanie Dancer (Hairmyres Hospital, East Kilbride,

Lanarkshire, UK)

• Uwe Frank (Heidelberg University Hospital, Heidelberg,

Germany)

• Gunnar Kahlmeter (Central Hospital, Växjö, Sweden)

• Jesus Rodrigues Bano (Hospital Universitario Virgen

Macarena, Sevilla, Spain)

• Nalini Singh / Deborak Yokoe (USA)

Tacconeli, CMI, under publication (free access)

Multifaceted strategy effectiveness for MDR-GN

Tacconelli et al, under revision

HH

Education

CP

Combinations of interventions significantly

associated with effectiveness

HH

Education

CP

Isolation room

OR = 6.1 OR = 8.3

Chlorexidine bathing

Climo NEJM 2013

Tacconelli, AAC, 2009

Risk of MRSA new acquisition after antibiotic therapy in hospitalized patients

Cochrane review (P. Davey 2013)

• The main comparison was between persuasive and

restrictive methods.

• Overall, the 89 studies showed that the methods improved

prescribing.

• 21 studies showed that the methods decreased the number

of infections in hospital.

• The restrictive methods appeared to have a larger effect

than persuasive methods.

ESCMID Guidelines

to control the spread of MDR-GNB 2013

• Epidemic setting: 17 interventions

• Endemic setting: 7 interventions

• Moderate level of evidence / strong recommendations for:

• MDR-A. baumannii (epidemic setting)

• ESBL-producing Enterobacteriaceae (endemic setting)

1. University Hospital

Freiburg, Germany (WP

1-3, 8)

2. Mater Dei Hospital,

Msida, Malta (WP 4)

3. Institute of Public Health,

Brussels, Belgium (WP

5)

4. Università Cattolica,

Rome, Italy (WP 6)

5. Radboud University

Nijmegen Medical

Centre, The Netherlands

(WP 7)

Only 56% of ICU have an ATBS

Definition of effectiveness of ATBS

New parameters

• resistance rate x 1000 HA / DH

• mortality attributable to infection

• overall length of hospitalization

• periods spent in specific care areas such as the ICU’s

• hospitalisation within 1 months

• rates of recurrent infection

• the frequency with which specific laboratory

studies are performed

• antibiotic usage patterns, and institutional

antimicrobial resistance patterns.

Lack of agreement about outocome indicators / heterogeneity of reports

Decolonisation

• 6 CT

• 2 RCT

• 1 KRKP

• No evidence to recommend decolonisation to reduce the

spreading of ESBL-producing bacteria

Major comments

a) International networking and societies should play an

“homogenizing” role

b) Revision and improvement of STROBE items for

epidemiological studies on ARI to improve the quality level of

evidence

c) New studies and agreement on outcome indicators

d) Consensus among clinicians, researchers, epidemiologists,

pharmacologists, pharma companies, governative entities,

control entities on new outcome indicators for clinical

evaluation of new antibiotics

Preventing MDR-Gram positive

Open or closed issues?

• Targeted screening vs universal screening

• PCR vs conventional cultures (screening)

• Room isolation / contact precaution vs no CP

• Target vs universal decolonisation

• Decolonisation

Preventing MDR-Gram negative

Open or closed issues?

• Best combination for best effectiveness

• CP for patients colonised or infected with ESBL-E. coli

• Chlorexidine bath

• Decolonisation

Preventing MDR

Open or closed issues?

• Antimicrobial stewardship programme

• Impact of the increase of elderly population

• Outcome assessment

• PUBLIC-PRIVATE COLLABORATIVE RESEARCH

Is there any country doing good?