Antibiotic usage in nosocomial infections in hospitals

Dr. Birgit Ross

Hospital Hygiene

University Hospital Essen

Infection control in healthcare settings - Isolation - Hand Hygiene - Environmental Hygiene

Usage control Appropriate Use -Human -Animal -Environment

Surveillance Antibiotic policy and guidelines - Management programmes

Prevention Reduction

IFIC Basic Concepts

A nosocomial infection — also called “hospital acquired infection” can be defined as: 1. An infection acquired in hospital by a patient who was admitted for a reason other than that infection. 2. An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.

WHO 2002 Prevention of hospital-acquired infections - A practical guide; 2nd edition

Epidemiology of hospital acquired Infections (HAI)

Benedetta Allegranzi et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis; Lancet 2011; 377: 228–41

US: about 4,5 % HAI 1.7 million affected patients Europe: about 7.1 % HAI 4.5 million affected patients Low and middle income countries: varies between 5.7 % and 19,1 %

Epidemiology of hospital acquired Infections (HAI)

WHO Health care associated infections FACT SHEET http://www.who.int/entity/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf

Respiratory tract infection as an example for nosocomial infection (1,3 % respiratory tract infection in the study conducted by Ider et al)

Ca 5.4 % of hospital admissions due to pneumonia 1,2 % of specimen tested for pathogens

Cause of death 6,2 % (list of total death by cause)

Prevalence of hospital-acquired infections and antibiotic use in two tertiary Mongolian hospitals B.-E. Ider et al. Journal of Hospital Infection Volume 75, Issue 3, July 2010, Pages 214–219 Prof. P.Nymadawa, MD, PhD, DSc(Med) Published online globe-network.org/.../hospital-based-pneumonia-surveillance-in-mongolia http://www.worldlifeexpectancy.com/country-health-profile/mongolia

Pneumonia is a relevant disease: Cave: Hospital environment may include other bacteria than community So in some cases you will have to treat in different ways (especially if you do not know the pathogen) Example: Community acquired pneumonia (CAP) Vs. Hospital acquired pneumonia (HAP)

Most common pathogens Streptococcus pneumoniae Haemophilus influenzae Others: M. pneumoniae, Enterobacteriacae, Legionella spp., S. aureus, respiratorische Viren

What is suspected:

Antibiotic therapy 1. Empirical therapy Therapy of a probable infection. Culture of the pathogen is not available. For targeted therapy the most likely pathogens and its resistance profiles

should be known. 2. Pathogen directed therapy Therapy guided by the results of a microbiological investigation. (Kind of pathogen/resistance profile) 3. Prophylaxis Use of antibiotics for prevention of infections, eg surgery The most common pathogens in the special situation should be considered

Suspected pathogen recommends therapy of that pathogen

Recommended Antibiotic Therapy:

Amoxicilline 3 x 1000 mg (< 70 kg 3 x 750 mg)

(or Doxycycline or Azithromycine)

In hospital: Cefuroxime 3 x 1,5 g i.v.

Duration: 5 – 7 Tage, Azithromycin 3 days

Suspectec pathogens in hospital acquired pneumonia

Inzidenzdichte und Erregerspektrum der Beatmungsassoziierten Pneumonie nach dem Typ der Intensivstation. Daten aus 586 Intensivstationen 2005-2009 [25*]. Meyer E, Schwab F, Gastmeier P. Nosocomial methicillin resistant Staphylococcus aureus pneumonia - epidemiology and trends based on data of a network of 586 German ICUs (2005-2009). Eur J Med Res 2010; 15: 514-524

Data from Germany!

If you expect other pathogens: Cefotaxime/Cefuroxime are recommend, If you expect pseudomonas: Ciprofloxacine and/or Ceftazidime for 7 to 8 days Cave: Hospital environment depends on your antibiotic treatment Antibiotic exposure increases the risks of resistance

Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106

Zaoutis TE et al. Pediatrics 2005;114:942-9

Talon D et al. Clin Microbiol Infect 2000;6:376-84

Resistenzen

susceptible

less susceptible

Selection Pressure of Antibiotics

The problem of selection pressure

About 60 % of all patients received Antibiotics, 92,1 % without sensitivity testing (similar to U.S., eg*, but big differences)

Polk, Ronald E., et al., Measurement of Adult Antibacterial Drug Use in 130 US Hospitals: Comparison of Defined Daily Dose and Days of Therapy. Clin Infect Dis, 2007. 44(5): p. 664-670. de With, K., et al., Is There Significant Regional Variation in Hospital Antibiotic Consumption in Germany? Infection, 2006. 34(5): p. 274-277.

Antibiotics are misused in a variety of

ways

• Given when they are not needed

• Continued when they are no longer necessary

• Given at the wrong dose

• Broad spectrum agents are used to treat very

susceptible bacteria

• The wrong antibiotic is given to treat an infection

1. Obtaining an accurate Infectious Disease Diagnosis

An infectious disease diagnosis is reached by determining the site of infection, defining the host (eg, immunocompromised, diabetic, of advanced age), and establishing, when possible, a microbiological diagnosis.

„Look at you patient“ 2. Timing of Initiation of Antimicrobial Therapy

General Principles of Antimicrobiological Therapy

Anand Kumar, Optimizing antimicrobioal therapy in sepsis and septic shock, Critical Care Clinics Volume 25, Issue 4, October 2009, Pages 733–751

The timing of initial therapy should be guided by the urgency of the situation.

„hit hard“ (if urgent) „get the point“

3. Empiric vs. Definitive Antimicrobial Therapy Initial therapy is usually empiric – treat the possible pathogens If microbiological results are available: try to narrow antibiotic spectrum For example: if you find Streptococcus pneumoniae in nosocomial pneumonia, Amoxicilline may be the right choice

4. Duration of antibiotic Therapy Use the right time – „look at your patient again“ For the example of pneumonia 5 – 8 days are supported by most studies.

Stewardship optimizes patient safety:

decreased patient-level resistance

Cipro Standard

Antibiotic

duration

3 days 10 days

LOS ICU 9 days 15 days

Antibiotic

resistance/

superinfection

14% 38%

Study terminated early because attending

physicians began to treat standard care group

with 3 days of therapy

Singh N et al. Am J Respir Crit Care Med. 2000;162:505-11.

5. Response to therapy Ensure that patient is better – if not, this can be associated with antimicrobial resistance

6. Antibiotic Management Programme Try to initiate Antibiotic Stewardship Programme

Fishman N. Am J Med. 2006;119:S53.

Prophylaxis of nosocomial pneumonia: Respiratory muscles training!

Avoid Aspiration! HAND HYGIENE!

Conclusions : Nosocomial infections are common Nosocomial pneumonia (as a part of it) is common Nosocomial infections may require other treatment than community

acquired infections „Get the point“

Good hygiene is a basic tool of prophylaxis!

Vielen Dank für Ihre Aufmerksamkeit und viele Grüße aus Essen!

Thank you for your attention…

…and best regards from Essen