Patient safety goal 4 : Tackling Antimicrobial Resistance

To implement WHO’s 3rd Global Patient Safety Challenges-

“Tackling Antimicrobial Resistance”

Patient Safety Goal (PSG) No 4

1PSG4 :Tackling Antimicrobial Resistance

WHO 3rd Global Patient Safety Challenge: Tackling Antimicrobial Resistance

RATIONALE

Antimicrobial resistance poses a growing threat to the treatment and control of infections


Antimicrobial misuse puts community at risk of severe illness / death due to untreatable infections, and

wastes limited healthcare resource for future generations.

HAI with MDRO are major causes of death in the world.

Inappropriate use of antimicrobials by patients, healthcare providers, and food producers is an issue of patient safety.

PSG 4: Tackling Antimicrobial Resistance



Antibiotic exposure increases the risks of

resistancePathogen and Antibiotic Exposure Increased

Risk

Carbapenem Resistant Enterobactericeae and Carbapenems

15 fold

ESBL producing organisms and Cephalosoprins

6- 29 fold

Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106Zaoutis TE et al. Pediatrics 2005;114:942-9Talon D et al. Clin Microbiol Infect 2000;6:376-84

More usage, more resistance!!

Increasing resistant rate of E.coli & K.Pneumo to 3rd GEN cephalosporins

Institute for Medical Research


MultiDrug Resistant Organism (MDRO)

MDRO (MultiDrug-Resistant Organism) : microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents.


Must fulfill all 3 criteria:

i. Isolation of an MDRO from any body sites

ii. The patient must be admitted to the ward

iii. The case must be “Newly Identified”

“Newly identified” include:

i. MDRO identified for the first time during current hospital admission

ii. Cases that have been identified at our site but acquired “new infection “

( Infection with organism having different antibiogram 0r as defined “new infection” by clinician)

Definition: MDRO Case


• Population under surveillance : all in patients• Exclusion:i.Cases from Emergency department, clinic, or other outpatient servicesii.Cases previously identified at other acute care facilities/hospitalsiii.Cases re-admitted with same MDROs within one yeariv.Cases with insufficient information on healthcare exposurev.Cases from screening culturevi.Coloniser

PSG 4:Tackling Antimicrobial Resistance- Methodology


Indicators 1.Incidence rate of MRSA infection

2. Incidence rate of ESBL- Klebsiella Pneumoniae infection

3. Incidence rate of ESBL-E.coli infection

PSG4 :Tackling Antimicrobial Resistance - 3 Indicators


Indicators 1.Incidence rate of MRSA infection

Type of Indicator

Outcome indicator

Numerator (N)

Number of MRSA infection (new cases) in the hospital

Denominator (D)

Total number of hospital admissions

Formula (N/D) x 100

Target ≤ 0.4%

1.Incidence rate of MRSA infection


MRSA (Methicillin-resistant Staphylococcus Aureus )

MRSA : a bacteria that is resistant to many antibiotics.

In the community, most MRSA infections are skin infections.

In medical facilities, MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections.


Indicators 2) Incidence rate of ESBL- Klebsiella Pneumoniae infection

Type of Indicator

Outcome indicator

Numerator (N)

Number of patients with ESBL-Klebsiella Pneumoniae infection (new cases) in the hospital

Denominator (D)


Formula (N/D) x 100Target ≤ 0.3% 13

Extended-Spectrum β-Lactamases (ESBLs) Klebsiella Pneumoniae

PSG4 :Tackling Antimicrobial Resistance

Indicators 3) Incidence rate of ESBL-E.coli infection Type of Indicator

Outcome indicator

Numerator (N)

Number of ESBL-E.coli infection (new cases) in the hospital

Denominator (D)


Formula (N/D) x 100

Target ≤ 0.2%

Data collection at facility level

Monthly

Reference Alert Organism Surveillance Manual, MOH 201214


ESBL (Extended-Spectrum β-Lactamases)

Are enzymes that mediate resistance to extended-spectrum (3rd generation) cephalosporins (e.g., ceftazidime, cefotaxime, and ceftriaxone) and monobactams (e.g., aztreonam).

• Why should clinician be concerned about detecting ESBL?

Presence of an ESBL-producing organism in a clinical infection can result in treatment failure if one of the above classes of drugs is used.


• Meta-analysis of mortality in ESBL-producing versus non-ESBL-producing Enterobacteriaceae bacteraemia

• Having an ESBL bacteraemia confers almost 2x risk of dying compared to a non-ESBL bacteraemia !!

•The pooled RR, represented by the diamond at the bottom of the figure, is 1.85 (95% CI 1.39–2.47, P , 0.001). •There was significant heterogeneity among the study results (P = 0.001).

Journal of Antimicrobial Chemotherapy (2007) 60, 913–920.

Mortality Associated with ESBL-Producing Bacteremia


What happens when antibiotics no longer work?

<20% chance of survival in pneumococcaemia if no antibiotic is available for treatment !! 17PSG4 :Tackling Antimicrobial Resistance

“Tackling Antimicrobial Resistance”

18

Strategies & Implementation

1.Implement Malaysia National Antibiotic Guidelines

2.National & State campaign on containment of Antimicrobial resistance

3.Antibiotic Stewardship Programme



Benefits of prudent use of antibiotics• Prudent use of antibiotics can prevent the emergence and selection of

antibiotic-resistant bacteria.19-23

• Decreasing antibiotic use have also been shown to result in lower incidence of Clostridium difficile infections.24-26

Rates of Vancomycin-resistant Enterococci in hospital before and after implementation of the antibiotic management program compared with rates in National Nosocomial Infections Surveillance (NNIS) System* hospitals of similar size.27

*NNIS is now the National Healthcare Safety Network (NHSN).

Rates of nosocomial Clostridium difficile, expressed per 1,000 patient-days, before and after implementation of the antibiotic management program.28

19, 24. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4):CD003543.20. Lepper PM, Grusa E, Reichl H, Hogel J, Trautmann M. Consumption of imipenem correlates with beta-lactam resistance in Pseudomonas aeruginosa. Antimicrob Agents Chemother. 2002 Sep;46(9):2920-5. 21, 25, 27, 28. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706. 22. Bradley SJ, Wilson AL, Allen MC, Sher HA, Goldstone AH, Scott GM. The control of hyperendemic glycopeptide-resistant Enterococcus spp. on a haematology unit by changing antibiotic usage. J Antimicrob Chemother. 23. De Man P, Verhoeven BAN, Verbrugh HA, Vos MC, Van Den Anker JN. An antibiotic policy to prevent emergence of resistant bacilli. Lancet. 2000;355(9208):973-8. 26. Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia. Clin Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.


Antimicrobial Stewardship Programme

• Promotes appropriate use of antimicrobials by selecting – Appropriate indication– Dose – Duration – Route of administration.

• Has potential to– Improve efficacy– Minimize drug-related adverse events– Limit the emergence of antimicrobial resistance – Reduce treatment-related costs.

Multidisciplinary; teamwork essential!


Remember to USE

guidelines


Stewardship optimizes patient safety:

decreased patient-level resistance

Evaluate at 3 days

Standard care

Antibiotic duration

3 days

10 days

LOS ICU 9 days

15 days

Antibiotic resistance/ superinfection

14% 38%

Study terminated early because attending physicians began to treat standard care group with 3 days of therapySingh N et al. Am J Respir Crit Care Med.

2000;162:505-11.

72 hour re-evaluation works!!

A positive culture from a sterile site (blood, CSF, pleural fluid, peritoneal fluid) unless determined to be contaminantOR

A positive culture for the selected organisms isolated from a non-sterile site isolate AND presence of clinical signs and symptoms OR determined by attending physician

Infection


Data Collection

Infection Control Personnel (ICP) shall collects data on MDRO on a daily basis from the laboratory.

The ICP will liaise with staff in the relevant clinical area to ensure that the infection control practices are implemented.


Cont - Data Collection

Upon isolation of MDRO, the ICP should investigate and complete the MDRO Surveillance Form and Line-listing Form

The specific type of infection is determined based on the CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting.


Numerator MDRO from HCAI cases, own facility

DenominatorTotal number of hospital admissions

The classification of infection in relation to the health care facility is detailed in appendix 1

Data Analysis And Reporting


Appendix 1Classification Of MDRO Infection In Relation To The Healthcare Facility





RATE = Total no. of HCAI cases x 100%

Total admission of the month

Data Analysis And Reporting


SUMMARY

Patient Safety Goal No 4


To implement WHO’s 3rd Global Patient Safety Challenges-

“Tackling……………………………………”

Patient Safety Goal No 4


Indicators 1.Incidence rate of ……..infection (< 0.4%)

2. Incidence rate of ESBL- ………………infection (< 0.3%)

3. Incidence rate of ESBL-……….. infection (< 0.2%)

3 Indicators :Patient Safety Goal No 4



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Health & Medicine

Patient safety goal 4 : Tackling Antimicrobial Resistance