European approaches to MDRGNR prevention and control
Jon Otter, PhD FRCPath Imperial College Healthcare NHS Trust Blog: www.ReflectionsIPC.com Twitter: @jonotter Email:
[email protected]
Disclosures I have research funding from the Guy’s and St. Thomas’ Charity I have given paid lectures for 3M, BD and Society for Applied Microbiology I am a consultant to Gama Healthcare
THE END OF ANTIBIOTICS IS NIGH
What’s the problem? “CRE are nightmare bacteria.” Dr Tom Frieden, CDC Director
“If we don't take action, then we may all be back in an almost 19th Century environment where infections kill us as a result of routine operations.” Dame Sally Davies, Chief Medical Officer
“If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine where treatable infections and injuries will kill once again.” David Cameron, Prime Minister, UK
“The rise of antibiotic-resistant bacteria, however, represents a serious threat to public health and the economy.” Barack Obama, President USA
CRE in the UK and US
Universal or targeted approach?
Evidence-free zone
Guidelines = Policy
Standardise standard precautions. Avoid an acronym minefield Simple outbreak epidemiology. Guideline writing dream team. “Road-test” guidelines.
Curran & Otter. J Infect Prevent 2014;15:193-198.
Acronym minefield CPC CPE
MDR-GNR
CRO
MDR-GNB
ESBL
CRE
CRC
CPE
KPC
CRAB
Risk assessment BBF spillage BBF exposure prevention & management Waste disposal
Patient placement Resp hygiene Linens Care equipment
Care environment Hand hygiene PPE
Safe Injection practices Safe lumbar Puncture practices Resuscitation safety
Safe use and disposal of sharps
Asepsis: optimal use of invasive devices; PVC, CVC, UC Health Protection Scotland: http://www.documents.hps.scot.nhs.uk/hai/infection-control/ic-manual/ipcm-p-v2-3.pdf Centres for Disease Control: http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.html UK Epic3: http://www.sciencedirect.com/science/article/pii/S0195670113600122 WHO: www.who.int/csr/resources/publications/EPR_AM2_E7.pdf
Guideline ESCMID 2014
Organisms / groups included ESBL-Enterobacteriaceae MDR K. pneumoniae
Setting(s) Acute-care facilities, endemic or epidemic
MDR A. baumannii MDR P. aeruginosa Burkholderia cepacia UK Working Party 2015
S. maltophilia ESBL-Enterobacteriaceae
Acute-care facilities
CRE MDR A. baumannii Irish MDRO 2012
MDR P. aeruginosa Resistant Enterobacteriaceae
CRE
Acute-care facilities, longterm care, and community
MDR A. baumannii MDR P. aeruginosa Public Health England CPE 2013 Health Protection Scotland CPE 2013 ECDC Systematic Review 2013
CPE
Acute-care facilities
CPE
Acute-care facilities
CPE
Acute-care facilities
Antibiotic stewardship
Hand hygiene
HCW screening
Cleaning / disinfection Active screening
Decol.
MDRGNR Toolbox Contact precautions
Cohorting staff / patients
Env. screening
Education
Tacconelli et al. Clin Microbiol Infect 2014;20 Suppl 1:1-55.
Note flagging
MDR A. baumannii ESCMID UK Working Party Irish MDRO MDR P. aeruginosa ESCMID UK Working Party Irish MDRO ESBL-E ESCMID UK Working Party
Irish MDRO
CPE* ESCMID UK Working Party Irish MDRO PHE (England) HPS (Scotland) ECDC
1 Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Outbreak
All
Patient decolonisation
HCW screening
Cohort staff
Cohort patients
Note flagging / alert code
Active surveillance cultures
Antimicrobial stewardship
Environmental screening
Cleaning / disinfection
Single room
Contact precautions
Hand hygiene
Antibiotic stewardship
Hand hygiene
HCW screening
Cleaning / disinfection Active screening
Decol.
MDRGNR Toolbox Contact precautions
Cohorting staff / patients
Env. screening
Education
Tacconelli et al. Clin Microbiol Infect 2014;20 Suppl 1:1-55.
Note flagging
Who do I screen? UK PHE CPE Toolkit screening triggers: a) an inpatient in a hospital abroad, or b) an inpatient in a UK hospital which has problems with spread of CPE (if known), or c) a‘previously’positive case. Also consider screening admissions to highrisk units such as ICU, and patients who live overseas.
How do I screen? Rectal swab is the best sample – Insert no more than 2cm into rectum – Twist gently and withdraw – Ideally want to see faeces on swab.
Patient and staff education as to why this is needed in order to overcome taboos Alternate specimen is stool sample, but have to wait for the patient to ‘go’
Does screening and isolation work? All MDROs
MRSA
VRE
ESBLs
Baseline trend
–
↑
–
–
Hygiene intervention step-change
–
–
–
–
Hygiene intervention trend change
↓
↓
–
–
Screening step-change
–
–
–
–
Screening trend change
–
↑
–
–
Rapid vs. conventional step-change
↑
–
–
↑
Rapid vs. conventional trend-change
–
–
–
–
Derde et al. Lancet Infect Dis 2014;14:31-39.
Antibiotic stewardship
Hand hygiene
HCW screening
Cleaning / disinfection Active screening
Decol.
MDRGNR Toolbox Contact precautions
Cohorting staff / patients
Env. screening
Education
Tacconelli et al. Clin Microbiol Infect 2014;20 Suppl 1:1-55.
Note flagging
Hand hygiene
40% Median hand hygiene compliance from 95 studies.
Erasmus et al. Infect Control Hosp Epidemiol 2010;31:283-294.
Antibiotic stewardship
Hand hygiene
HCW screening
Cleaning / disinfection Active screening
Decol.
MDRGNR Toolbox Contact precautions
Cohorting staff / patients
Env. screening
Education
Tacconelli et al. Clin Microbiol Infect 2014;20 Suppl 1:1-55.
Note flagging
Surface survival 7
Log (10) cfu / disc
6 5 C. difficile 4 Acinetobacter
3
K. pneumoniae
2 1 0
0
1
2
3 Time / weeks
Otter & French. J Clin Microbiol 2009;47:205-207.
4
5
Surface survival – strain variation 8 7
Log (10) cfu / disc
6 5
Klebsiella pneumoniae NCTC 9633
4
K. pneumoniae K2
3 K. pneumoniae K41
2 1
0 0
2
4 Time / weeks
Otter & French. J Clin Microbiol 2009;47:205-207.
K. pneumoniae vs. E. coli Conclusion K. pneumoniae seems to be more environmental than E. coli.1,2 Surface contamination on five standardized sites surrounding patients with ESBLproducing Klebsiella spp. (n=48) or ESBL-producing E. coli (n=46).1 35
P
