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1/25/2019
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Biosecurity in an equine hospital with special reference to
multi‐drug resistant bacteria
Brandy A. Burgess, DVM, MSc, PhD, DACVIM‐LA, DACVPM
Assistant Professor | Department of Population Health
Director of Infection Control | Veterinary Teaching Hospital
College of Veterinary Medicine | University of Georgia
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Session Objectives
Describe key components of an infection control program.
Describe strategies that may be used in an antimicrobial
stewardship program.
Gain perspective on the prevalence of AMR‐bacteria in
equine practice.
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Semmelweiss & Cadaverous Poisoning
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What is biosecurity and infection control?
All efforts designed to reduce the risk of introduction and dissemination of infectious
agents in a population or facility
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What are we trying to do when we implement infection control practices?
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Chain of Infection
Etiologic Agent
Reservoir
Portal of Exit
Mode of Transmission
Portal of Entry
Susceptible Host
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Why should we care?
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How common are HCAIs in human hospitals?
Study on Efficacy of Nosocomial Infection Control*
Site Infection Rate (per 100 admissions)
Urinary Tract 2.39
Surgical Site (per 100 sx) 1.39
Lower Respiratory Tract 0.60
Bacteremia 0.27
Other Sites 1.07
All Sites 5.72
Haley RW, et al., Am J Epidem 1985; 121:182‐205*Conducted in 1974
Comprehensive infection control
program
Trained personnel
Surveillance
Reporting
32% ↓ in NI rates
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HAIs are in top 10 causes of death in the US (accounting for ~98,000 deaths in 2002).
Annu. Rev. Med. 2012. 63:359–71
National Nosocomial Infection Surveillance
(CDC, 2002)
An estimated 1.7 million HAIs occur each year in human hospitals
~5% of admissions develop HAI
duration of hospitalization
morbidity & mortality
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How common are nosocomial or healthcare‐associated infections in
veterinary medicine?
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People Patients Hospital
50% of VTHs recognized
zoonotic infections in the previous 2
years
Crypto 68%MRSA 16%Salmonella 16%
82% of VTHs reported outbreaks
of nosocomial infections in the previous 5 years
58% of VTHs restricted patient admissions for
outbreak mitigation in the previous 5
yearsSalmonella 67%MRSA 40%E. Coli 16%Crypto 13%EHV‐1 10%
S. enterica the most commonly isolated
organism
Benedict KM, et al. JAVMA 2008; 233:767‐773
Healthcare‐associated infections in veterinary medicine
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Ruple‐Czerniak et al., JVIM 2013; 27:1392‐1399
1. IV catheter site inflammation2. Urinary tract catheterization inflammation3. Respiratory disease4. Gastrointestinal disease5. Surgical site inflammation6. Fever of unknown origin7. Septicemia
SYNDROMIC EVENTS
Ruple‐Czerniak et al., EVJ 2013©2019BABurgess
Reported Nosocomial Syndromic Events Among Critical Care Patients
Incidence per 100 hospitalization days
Incidence Risk
Canine 6.0 19.4%
Feline 4.9 16.1%
Equine 4.2 21.9%
Total 5.5 19.1%
Participants: Colorado State University, University of Minnesota, University of Missouri, University of Pennsylvania, Tufts University
Ruple‐Czerniak et al., JVIM 2013; 27:1392‐1399 Ruple‐Czerniak et al., EVJ 2013©2019BABurgess
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Why is this important?
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‘Optimal patient care cannot be realized without effectively managing risks related to healthcare‐
associated infections’
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‘Veterinarians must be universally cognizant that there is a minimum standard of care regarding infection control’
Morley PS, et al. EVJ 2013; 45: 131‐136
i.e., substandard infection control is recognizable – you can do to little
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‘All facilities and patient populations are unique –therefore specific practices within an ICP will vary’
Surveillance Patient Contact
Education & AwarenessHygiene
Definable standards – as opposed to identifying specific practices.
General Areas of ICP Activity
Morley PS, et al. EVJ 2013; 45: 131‐136
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‘Infection control programs are dynamic and should rely upon organized surveillance efforts’
Program efficacy cannot be assessed without monitoring, summarizing findings, and reporting to stakeholders.
Surveillance = gathering information + plan of action
• Rigoro minimal vs. comprehensive
• Typeo active vs. passiveo all patients vs. targetedo laboratory‐based vs. syndromic
General Considerations
Morley PS, et al. EVJ 2013; 45: 131‐136
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Is environmental contamination important?
VTH environmental isolates can be phenotypically linked to
patient isolates
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Salmonella Newport 2003
25% of environmental samples were positive©2019BABurgess
LIVESTOCK HOSPITAL
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Hygiene
• Environment– Proper facility design– Proper protocols
• Equipment– Segregation– Use and cleaning protocols
• Personnel– Hand hygiene– Footwear– Clothing
• Patients
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Disinfectant comparison and exam room cleaning effectiveness of a Small Animal Hospital
Counter Sample
Door Sample
Before Cleaning
After Cleaning
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Burgess BA, et al., in preparation
SiteMean baseline count
(cfu per 10 cm2)SD
Floor 12.5 14.3
Door 7.8 9.7
Counter 6.9 11.9
Table 5.3 9.4
Disinfectant Comparison and Cleaning Effectiveness
Hand‐contact Surfaces Critical Limit in
Human Healthcare
<25 cfu per 10 cm2
(Mulvey, et al. J Hosp Infect 2011;77:25)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Mean red
uction in
cfu per 10 cm
2
Mean Bacterial Reduction
Site
Disinfectant
Crew Member
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Cleaning is a multi‐step process
Removal of visible debris
Scrub with detergent
Rinse
Disinfectant application
US$4.1 million in mitigation
Case fatality 36.1%
Biofilm Formation
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Patient Contact
• Barrier nursing
• Segregation
• Isolation
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Barrier Nursing
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SMALL ANIMAL SERVICES
EMER
GEN
CY
IMAGING
SMALL ANIMAL
SURGERY
LARGEANIMAL
SURGERY
EQUINEINPATIENT
EQUINEICU
EQUINEEMERGENCY
FOOD ANIMAL
TREATMENT
EQUINERECEIVING
PHARMACY
CENTRALSUPPLY
ISO
IMC
ICU
SA LOBBY
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‘To achieve long‐term behavior change – there must be a universal understanding about why ICPs are necessary’
Education & Awareness
• Education• Training/re‐training• Interactive review of protocols
Crucial for Program Success
It is much easier to implement new rules and protocols than it is to implement effective training.
Morley PS, et al. EVJ 2013; 45: 131‐136
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Common Opportunistic Pathogens
Methicillin‐resistant Staph. aureus
Extended spectrum beta‐lactamase E. coli
Acinetobacter baumannii
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MDR‐organism incursion into hospital environment
Patient population
Hospital size and medical services
Hospital connectedness
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Antimicrobial Stewardship Programs
Prospective surveillance,
intervention, & feedback
Audit and report use of specific drugs and patient
outcomes to stakeholders
Antimicrobial restriction
Restrict use of drugs considered to be 'critically
important' to public health to approved indications
o Formulary restriction, and/or
o Pre‐authorization with justification
Education
Providing foundational knowledge can influence
prescribing practices, increase compliance, and
improve program buy‐in
Combine in‐service trainings and e‐mail alerts with
written guidelines and data from active surveillance
Core Strategies
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Guidelines and
clinical pathways
Evidence‐based practice guidelines based on local
microbiology and resistance patterns;
Incorporate with education and use reporting
Streamlining and de‐
escalation of therapy
Discontinue empirical therapy based on clinical
response or culture results;
Eliminate redundant combination therapy
Automatic stop
orders
Evidence‐based discontinuation of therapy to limit
therapy duration
Dose optimization Base dosing on patient characteristics, causative
organism, site of infection, and pharmacokinetics
Clinical‐decision
making computerized
support system
Provide local epidemiological information and its
potential impact on courses of therapy;
Provide warnings regarding intended therapy based on
guidelines and local patterns
Supplemental Strategies
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44% of healthy adult horses shed MRD E. coli
Medical treatment within past 3‐months
Staff numbers > 5
Activity (e.g., riding school vs breeding facility)
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Hospital personnel are at risk for carriage of MDR & ESBL‐producing bacteria
6% carriage rate of ESBL‐producing E. coli
32% carriage rate of MDR‐E. coli
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High prevalence of AMR‐bacteria in equine community
69.5% fecal carriage rate of resistant E. coli
6.3% fecal carriage rate of ESBL‐E. coli
0.6% nasal carriage rate of MRSA
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High prevalence of AMR‐bacteria in equine patients with signs of colic or open wounds
10.7% fecal carriage rate of MDR‐Gram negative bacteria
0.9% fecal carriage rate of A. baumannii
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Key Points
There is a recognizable standard of care with respect to
infection control in veterinary practice.
Infection control programs are unique to each facilities
structural and operational limits.
Prevention of AMR‐bacteria includes infection control and
antimicrobial stewardship.
©2019BABurgess
Thank you for your attention!
Questions?
