European approaches to MDR- GNR prevention and control

European approaches to MDRGNR prevention and control Jon Otter, PhD FRCPath Imperial College Healthcare NHS Trust Blog: www.ReflectionsIPC.com Twitte...
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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

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