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Prävention postoperativer Infektionen WHO Implementierungs - Empfehlung

Andreas F. Widmer

Core member Patient Safety WHO Geneva

President of the Swiss National SSI Surveillance Programm

And Swiss Reference Center for Prevention of Nosocomial Infektions

www.swissnoso.ch

¨

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Minimal Standards WHO in der Chirurgie

30 Standards

5 vital

10 sehr wichtig

15 Empfehlungen

«use» ist gleich ein MUSS, evidenz hoch

«Consider»: Evidenz nicht perfekt

Übersicht

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USB: Chlorhexidine, documentation

USB: cardiac surgery only

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WHO Preparation under review

Weber W. Marti W. & Widmer AFInfect Control Hosp Epidemiol 2009

WHO Guideline on Surgical Hand AntisepsisWidmer AF. J Hosp Infect 2009

N=32 in jeder Gruppe

A Clinical Cross-Over Trial on Surgical Hand Rub: 1.5 vs 3 minutes

n=32 (sample: n=64)

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60

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

0100200300400500600700800900

<=

-80

-79

to 7

0

-69

to -

60

-59

to -

50

-49

to -

40

-39

to -

30

-29

to -

20

-19

to -

10

-9 t

o 0

1 to

10

>10

% S

SIs

# In

terv

en

tio

ns

Time of Prophylaxis (minutes)

Incidence of SSIs and Time of Antimicrobial Prophylaxis prior to Incision with Cefuroxime

1.5g iv

# Interventions SSI (%)

-

30 to -60 min

Incisionp<0.0001

Weber WP & Widmer AF. Ann.Surg. 247 (6):918-926, 2008.

• 4‘557 patients included. Data set complete in 98.8% • Overall rate of SSIs: 224 / 4‘557 (4.9%)

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GuidelineWHO Jan 2009

Early versus late administration of surgical antimicrobial prophylaxis on SSIs: 0 – 30 vs 30- 60 min

Weber WP.. Widmer AF. Marti W. .Lancet Infect Dis. 2017 Mar

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Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of SSIs: A systematic review and meta-analysis

De Jonge. Medicine (Baltimore). 2017 Jul;96(29):e6903. doi: 10.1097/MD.0000000000006903

Sommerstein R & Widmer AF. European Journal of Cardio-Thoracic Surgery, 22 February 2019, , https://doi.org/10.1093/ejcts/ezz039

Antimicrobial prophylaxis in cardiac surgery: an analysis of 21 007 patients in Switzerland

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0-30 minutes ???

Swissnoso SSI InterventionData from University Hospital Basel

Bereich 0-60min>90%

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Second point prevalence survey (PPS) of healthcare‐associated infections and antimicrobial use, 2016 to 2017

ReportedStandards of SurgicalAntibioticProphylaxis in 28 European countries

Plachouras D & Suetens Carl,Euro Surveill. 2018 Nov;23(46). doi: 10.2807/1560-7917.

0 % perfect25 % optimal60 % acceptable75% Fail to meet

WHO standard

Single-shot

1 day> 1 day

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Sommerstein R et al Emerg Infect Dis 2016

Airborne transmission of mycobacteria in the OR

Fan without contact to contaminated water!

National alerting in Switzerland

https://www.news.admin.ch/message/index.html?lang=de&msg-id=53774

Airborne outbreak in the OR

Kuehl R & Widmer AF. Infect Control Hosp Epidemiol. 2018 Jul;39(7):834‐840. doi: 10.1017/ice.2018.102.

Wassereinlass

Water to Air to Patient during cardiac suergy

Samples positive with M. chimaera

3T HCU30 HCU40

Water (HCU) 10/97  7/12  0/64 

Air during

operation ���65  0/4  0/50 before/afteroperation ����  0/2  n.a. 

Water from the tap: no M. chimaera detected (0/71)

Kuehl R & Widmer AF. Infect Control Hosp Epidemiol. 2018 Jul;39(7):834-840. doi: 10.1017/ice.2018.102.

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2018 WHO Guideline

PREVENTING SSIs:IMPLEMENTATION

APPROACHESFOR EVIDENCE-BASEDRECOMMENDATIONS

22.03.2018

http://apps.who.int/iris/bitstream/handle/10665/273154/9789241514385-eng.pdf?ua=1

www.clinicaltrials.gov

SWKI; laminar air flowCDC

US wässeriges IOD vs Europa

12 x höhere freie Iod KonzentrationIn europäischen Produkten als in USA

Warm up during Transport to OR as well

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Monofiles not proven

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METHODS

INTRODUCTIONRESULTS

1. FMH Swiss Medical Association (www.fmh.ch)

2. SLF Swedish Medical Association (www.slf.se)

3. German Medical Association (www.bundesaerztekammer.de)

4. MSc Infection Prevention and Control. University of West London. Infection Prevention Society (IPS) (www.ips.uk.net/education-events/courses)

5. Master online based on Clinical Cases. ComplutenseUniversity of Madrid. (www.iras.es)

6. Graduate Certificate in Infection Prevention and Control. Griffith University. (www.griffith.edu.au)

7. APIC. Online Learning. (www.apic.org)

8. European Centre for Disease Prevention and Control ecdc (www.ecdc.europa.eu)

Effective HAI prevention and control in healthcare organisations relies on specialised infection control staff inchargeof elaborating, implementing and monitoring local preventive measures such as hand hygiene and patientisolation. Training in infection control and the epidemiology of healthcare-associated infections was also the topic of one ofthework packages of the Improving Patient Safety in Europe project (IPSE), Education of Infection Control nurses or Practitioners (ICP) is commonly well organized and regulated, and in some countries federally regulated with number of credit hours and final exam.In Switzerland, ICPs training is federally regulated since 2009, and all ICPs must pass a final national exam. In contrast, there is no formal training for hospital epidemiologist.

I therefore provided the background to create a concept for training to receive a diploma/title “hospital epidemiologist”

For the Swiss Society for Infectious diseases (president: Nicola Mueller).

Post-doc training for physician is organized by Schweizerische Institut für ärztliche Weiter- und Fortbildung (SIWF)

(https://www.fmh.ch/siwf/siwf/ueber-das-siwf/portraet.cfm). Swissnoso is the current association of the Swiss hospital epidemiologist who have earned a board certification in internal medicine as well as infectious diseases, and are mainly working as head of hospital epidemiology at large hospitals. However, there is a need for mid-size hospital as well as smaller hospitals to have an in-house or an associated physician with specific training in HE.Therefore, I have created a proposal for SIWF) for hospital epidemiology, that requires a training in Infectious disease and at least one year specific training in hospital epidemiology at a university hospital.

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In most European and non-European countries including the USA, there is no formal training requirements for hospital epidemiologist. In Northern European countries, HEs are mainly trained as clinical microbiologist, in the USA as Infectioius disease specialists.(Table 2)

In 2018, The Swiss association for training of physicians (SWIF) accepted the training program for HE, as subspeciality of Infectious Diseases. In includes 3 years of internal medicine, 3 years for infectious diseases with at least 18 clinical services, 2 peer-reviewed papers, and one year of hospital epidemiology at a university hospitals with specific division of hospital epidemiology.

CONCLUSIONS

REFERENCES

Lack of standardized education for hospital epidemiologists (HE) in Europe: Creation of federally regulated HE in Switzerland in 2019Andreas F. Widmer, University Hospital Basel

#P2575

Federally regulated and structured Training for in Infection Control in Europe ( Physicians only)

Country Institution Residency Program Year Duration

Switzerland Swiss Medical Association (FMH) Schweizerische Institut für

ärztliche Weiter- und Fortbildung (SIWF)

Subspecialty in Infection Prevention and Control Requiremen

3 years Internal Medicine3 years Infectious diseases (board exam for ID)1 year infection control (final exam for accreditation “infection control”)

2019 7 years

10 years (with internal med board

Sweden Swedish Medical Association(SLF)

Specialty in Infection Prevention and Control of Healthcare- associated infections (HAIs)

2019 6 years

Germany Federal Medical Association Additional advanced training hospital hygiene - 6 years

Academic Training for Infection prevention (MDs, Nurses and Pharmacists and others)

University/ Institution Program/ Training Target population Duration Year Exam Certificate

EUCIC (ESMID) EUCIC Infection Prevention and Control Certificate

medical doctors and pharmacists, nurses or other healthcare professionals with a MSc or PhD

2 years 2018 ‐ ESCMID 

Complutense University of Madrid (Spain) Online Master based on Clinical Cases

MDs or other graduates healthcare 2 years 2018 Yes MSc

University of West London (UK) MSc Infection Prevention and Control (IPC)

Students with a degree or equivalent and be working in an infection prevention role

3 years 2018 - MSc

Griffith University (Australia) Online Graduate Certificate in Infection Prevention and Control

Related Bachelor degree or higher, work experience

6 months full time1 year part time

2019 - Professional recognition

Association for Professionals in Infection Control and Epidemiology (APIC) (America)

Online learning- Full Course Catalog

- 12 months 2019 - -

• Most countries including the USA lack a federally regulated training program for physicians for hospital epidemiology (HE)

• 2 of 3 European countries just recently accepted a formal title with defined requirements for HE

• In contrast to physicians, training for infection control nurses and practitioners is much more advances compared to similar training for physician

AcknowledgementsI thank the society for infectious diseases and their board for their help. Additional input from- Petra Gastmeier, Germany- Nicco Mutters, Germany- Stephan Erb, Switzerland

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Zusammenfassung

WHO Präventionsmassnahmen heute weitgehend klar

Umsetzung eine weltweite Herausforderung

Swissnoso Intervention unterstützt finanziell und personell die Umsetzung

Ohne Intervention – bisher keine Verbesserung in CH erreichbar

Ziel: Schweizer Standard in CH Spitälern im detaildefinieren und umsetzen