Hot issues in infection prevention€“ Safer Care Victoria ... –All had HCU in the OR •UK •USA • Isolates genetically related • Point source outbreak in the factory of

Hot issues in infection prevention

Philip Russo BN MClinEpid PhD

Research FellowSchool of Nursing and Midwifery, Faculty of HealthCentre for Quality and Patient Safety Research - Alfred Health PartnershipDeakin University

@PLR_aus

Declarations

• VICNISS Coordinating Centre (Vic HAI surveillance)

• Hand Hygiene Australia

• National Centre for Antimicrobial Stewardship

• Australian Commission for Safety and Quality in Health Care

• NHMRC IC Guidelines Advisory Committee

• Australasian College for Infection Prevention and Control

Outline

• Australia's response to antimicrobial resistance – Australian data

• Hand Hygiene– Where is the elephant?

• What do we know about HAIs in Australia?

The World Health Organization (WHO) has described antimicrobial resistance as a

key global health issues

“...this serious threat is no longer a prediction for the future; it is

happening right now in every region of the world and has

the potential to affect anyone, of any age, in any country.”

WHO, 2014

MROs – Why are they important?

• Significant costs to healthcare systems

– Extended LOS

– Toxic treatments

– Diagnostic testing

– Additional healthcare visits


• Significant costs to healthcare systems

– Extended LOS

– Toxic treatments

– Diagnostic testing

– Additional healthcare visits

• Increased morbidity and mortality


• Now– 700,000 die annually directly from MROs

Review on AMR - UK Health 2016



• Do nothing, by 2050– > 10,000,000 will die annually

Review on AMR - UK Health 2016



• Do nothing, by 2050– > 10,000,000 will die annually

– > $100,000,000,000,000 USD (i.e one hundred trillion) cost to world

economy Review on AMR - UK Health 2016

Victorian Outbreak

Victorian Outbreak

Jan 2012 – June 2015

• 57 patients with Carbapenem producing Enterobacteriaceae (CPE)

• Increase noted in 2014, triggered a look back and increased surveillance

• Epidemiology and genomic investigation

– All cases hospital acquired

• Almost all patients treated within a single health service

Victorian Outbreak

Issues

• Multiple laboratories receiving specimens

• No statewide systematic surveillance

• CPE not reportable to Dept of Health

• No established pathways for communication to

– Other Victorian facilities

– Other State and Territories

Victorian Outbreak

Response

• CPE Incident Management Team was formed to oversee investigations and

responses to cases

– Communicable Diseases Branch – Safer Care Victoria– Surveillance systems (VICNISS and the Microbiological Diagnostic Unit), – Infectious diseases physicians and – Infection control practitioners

• Developed and revised statewide guidelines

One Health

Ant

AMR - What are we doing?

1. Communication, education and training

2. Antimicrobial stewardship

3. Surveillance

4. Infection prevention and control

5. National research agenda

6. Strengthen international partnerships

7. Clear governance arrangements

What are we doing?

AMR Strategy

1. Increase awareness and understanding of antimicrobial resistance, its

implications and actions to combat it, through effective communication,

education, and training

2. Implement effective antimicrobial stewardship practices across human

health and animal care settings to ensure the appropriate and judicious

prescribing, dispensing and administering of antimicrobials

AMR Strategy

3. Develop nationally coordinated One Health surveillance of antimicrobial

resistance and antimicrobial usage

4. Improve infection prevention and control measures across human health and

animal care settings to help prevent infections and the spread of resistance

5. Agree a national research agenda and promote investment in the discovery

and development of new products and approaches to prevent, detect and

contain antimicrobial resistance

AMR Strategy

6. Strengthen international partnerships and collaboration on regional and

global efforts to respond to antimicrobial resistance

7. Establish and support clear governance arrangements at the local,

jurisdictional, national and international levels to ensure leadership,

engagement and accountability for actions to combat antimicrobial

resistance

COAGHealth Council

AHMAC

All JursidictionsVarious AMR and AU

Strategies

ACSQHCNational AMR &AU Surveillance

Standard 3 Accreditation

DoH DoA

Federal Minister for Health

Federal Minister for Agriculture

Antimicrobial Resistance Prevention and Control Steering Group

Australian Strategic and Technical Advisory Group (ASTAG AMR)

National AMR Strategy

Resistance data

Collect and analyse data,

coordinate reporting from

existing systems, and develop

reports needed to target and

inform action on AU & AMR

Resistance data

• improve data quality

• analyse relationships between AU and AMR

• centralised national reporting

• timely identification of the emergence AMRs

Australian antimicrobial usage data

National Antimicrobial Prescribing Survey

• facilitate effective audit and review of

antimicrobial use, including compliance with

prescribing guidelines and prescribing

appropriateness

• benchmarking within hospitals across units

and wards, and between hospitals and

jurisdictions

• 2014 – 151 hospitals participated

Antimicrobial prescribing – hospitals 2015

N=281

NCAS – NAPS 2016 report

Antimicrobial prescribing –2015

Key Indicator Hospitals survey n=281

Indication documented in medical notes 72.5%

Review or stop date documented 35.5%

Surgical prophylaxis given for >24 hours 27.4%

Compliant with TGA or local guidelines 55.9%

Appropriate antimicrobial given 73.2%

NCAS – NAPS 2016 report

Aged Care NAPS

Antimicrobial prescribing –2015

Key Indicator Hospitals survey n=281

Aged Care n=186

Indication documented in medical notes 72.5% 68.4%

Review or stop date documented 35.5% 35.1%

Surgical prophylaxis given for >24 hours 27.4% -

Compliant with TGA or local guidelines 55.9% -

Appropriate antimicrobial given 73.2% -

NCAS – NAPS & AC NAPs 2016 report

Antimicrobial prescribing – Aged Care 2015

Prolonged duration of prescriptions

• 31.4% of prescriptions prescribed for longer than six months; of these – 49.0% had NO indication documented

– 2.0% had a review or stop date recorded

NCAS – AC NAPs 2016 report

Antimicrobials and infection in Aged Care

NCAS – AC NAPs 2016 report

Surgical antibiotic prophylaxis

Procedure Hospitals Number of procedures

Correct timing Correct drug & dose

24hr cease

Hip prosthesis

26 2743 91.8%

Knee prosthesis

22 3377 95.1%

CABG 6 653 89.0%

LSCS 12 3806 85.9%

ACHS Clinical Indicator Report 2016




24hr cease

Hip prosthesis

26 2743 91.8% 81.3%

Knee prosthesis

22 3377 95.1% 87.4%

CABG 6 653 89.0% 90.6%

LSCS 12 3806 85.9% 81.9%





24hr cease

Hip prosthesis

26 2743 91.8% 81.3% 77.4%

Knee prosthesis

22 3377 95.1% 87.4% 83.1%

CABG 6 653 89.0% 90.6% 68.7%

LSCS 12 3806 85.9% 81.9% 84.9%


N=886

• 22% had an antimicrobial use policy

• Poor compliance with guidelines for neutering

• Recent graduates had lower compliance than older graduates

Antimicrobial use guidelines need to be expanded and promoted to improve the responsible use of antimicrobials in small animal practice in Australia

AMR

National strategyAURANAPs

Challenges• Central coordination • Response• Animal health

Hand Hygiene

Hand Hygiene

Hand Hygiene

Number of Hospitals

TotalMoments

ComplianceRate

March 2017 951 684,327 84.6%

hha.org.au

HH compliance by HCW

hha.org.au

Correlation between hand hygiene and HAIs

25 50 75

% Compliance

Infection rate

25 50 75

% Compliance

Infection rate

Correlation between hand hygiene and HAIs

Systematic review HH studies 2009-2014

Kingston JHI 2016


Kingston JHI 2016


Kingston JHI 2016

Is 100% Compliance required?

25 50 75

% Compliance

Infection rate

At what cost?

• $2.9M per year

• Most costs related to auditing

• Do we know if it is cost effective

• Are HAI rates decreasing?

Cost effectiveness

Graves N. 2016. PLOS ONE 11(2): e0148190. https://doi.org/10.1371/journal.pone.0148190

Cost effectiveness

Graves N. 2016. PLOS ONE 11(2): e0148190. https://doi.org/10.1371/journal.pone.0148190

“The pressing question for policy makers is whether cheaper

health returns could have been achieved by allocating scarce

infection prevention budgets to programs that were displaced by

the National Hand Hygiene Initiative.”Graves N et al 2016 PLoS ONE

But then there is also…

• Patient hand hygiene

• Environmental cleaning

• Management of invasive devices

• Compliance with SP, CP and PPE

• Placement of patients

• Infections in the community

• One Health…

Bare below the elbows

Bare below the elbows

“I think the chief executive has taken this ‘bare below the elbows’ a bit far ...”

“I think the chief executive has taken this ‘bare below the elbows’ a bit far ...”

Glove use

Non-alcohol hand rubs

Lose the handshake?

Hand hygiene

• Needs to become more embedded

• Important part of the infection prevention “bundle”

Surveillance is the cornerstone of infection control

If we don’t have HAI data, how do we know what to do?

Infection prevention priorities for Australia?

• How many HAIs are there?

• Where are they happening?

• Who is at greatest risk?

• What interventions will we implement?

• How will we know if they work?


• How many HAIs are there? Don’t know

• Where are they happening? Don’t know

• Who is at greatest risk? Don’t know

• What interventions will we implement? Don’t know

• How will we know if they work? We don’t know!


• How many HAIs are there? Don’t know

• Where are they happening? Don’t know

• Who is at greatest risk? Don’t know

• What interventions will we implement? Don’t know

• How will we know if they work? We don’t know!

Australia is one of the few OECD countries without a

national HAI surveillance system

How many HAIs occur in Australia?

“Estimated at 200,000 HAIs per annum” Graves 2009

175,000 HAIs

2004 - 2005 data from 2 hospitals in one state

HAI in AustraliaSix states: Mandatory requirements

Differences

• Definitions

• Methods of data collection

• Risk adjustment

• Reporting

• Skill

HAI NSW QLD SA TAS VIC WA

TKR/THR Y Y N N Y Y

CABGS Y Y N N Y N

C-Sect N N N N Y N

PDS N O N N O O

CLABSI ICU Y Y Y N Y Y

HW-BSI N Y Y N N N

NHSN M M Y N Y M

Staphylococcus aureus bacteraemia (SAB)

National Safety and Quality Health Service Standards “…surveillance systems…in place”

Do we need national HAI surveillance?

Public reporting of HAI data?

• Transparency instils confidence in consumers

• May inform consumer decision

• Beware of financial penalties

The English MRSA ‘miracle’

European CDC

Victorian data

DHS website?

National HAI data will improve patient safety and quality

M.Chimera endocarditis outbreak

• July 2014 Switzerland – 6 pts with M.chimera endocarditis over 4 years– Valve replacement surgery

– Same brand Heater-Cooler unit

– M.chimera cultured from HCU water and from OR air when HCU on


• July 2015

– 11 patients from 4 Euro countries

– Valve replacement

– immunocompetent

– 6 deceased

– All had HCU in the OR

• UK

• USA

• Isolates genetically related

• Point source outbreak in the factory of the manufacturer– Supported by environmental investigations at factory

• July 2017– 108 patients worldwide

– 5 Australian (3 NSW, 1 Vic, 1 QLD)


Recommended action

– Enhanced testing of HCUs

– Cleaning

– Distance between HCU and patient

– Exhaust facing away

– Documentation, machine, patients, cleaning, testing

– High suspicion for pts returning with unexplained S & S

Lancet Infect Dis 2017;17

Procedure # studies OR P value

TKA 8 1.29 0.07

THA 6 1.08 0.65

Abdo 3 0.75 0.33

Lancet Infect Dis 2017;17

Procedure # studies OR P value

TKA 8 1.29 0.07

THA 6 1.08 0.65

Abdo 3 0.75 0.33

Evidence demonstrates no benefit from laminar flow compared with conventional turbulent ventilation in reducing risk of SSI’s in these procedures.

Laminar flow is not a preventative measure for SSI

Take home

AMR• Post antibiotic era is “emerging”

• Non-antimicrobial prevention

• AURA, NAPs

Hand hygiene• is not a fad

• Contributes to the prevention “bundle”

National Surveillance• Inform national prevention strategy

The end!

Documents

Hot issues in infection prevention€“ Safer Care Victoria ... –All had HCU in the OR •UK •USA • Isolates genetically related • Point source outbreak in the factory of