PREVENTION AND CONTROL OF

ANTIMICROBIAL RESISTANCE
IN HOSPITAL
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Masalah resistensi di Rumah Sakit
Eksposur tinggi
terhadap antibiotika
Densitas
populasi tinggi
Frekuensi kontak tinggi
terhadap staf RS
Risiko tinggi
cross infeksi
High risk
environment
Masalah penggunaan antibiotika
Exessive/overuse
Inappropriate
Cara pemberian
Dosis
Frekuensi Lama pemberian
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100.00%
32.69% - Others
3.85% Ciprofloxacin Ciprofloxacin
5.76% Cefotaxim Cefotaxim
9.62% Cefotaxim Taxegram
23.08% Ceftriaxone Terfacef
25.00% Ceftriaxone Ceftriaxone
% Generics Antibiotics
Relationship between antibiotic use, resistance, treatment
failure and healthcare burden
Increase in
antibiotic use
Increase in
resistant strains
Ineffective empiric
therapy
increased morbidity
more antibiotics
Increased
hospitalisation
more antibiotics
Increased
use of
healthcare
resources
Limited treatment
alternatives
more antibiotics
increased
mortality
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Optimize Use
Prevent
Transmission
Prevent
Infection
Effective
Diagnosis
& Treatment
Pathogen
Antimicrobial-Resistant
Pathogen
Antimicrobial Antimicrobial
Resistance Resistance
Antimicrobial Use
Infection
Infection
Susceptible Pathogen
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Prevent infection
Diagnose and treat
infection effectively
Use antimicrobials
wisely
Prevent transmission
Clinicians hold the solution!
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12 Steps
12 Contain your contagion
11 Isolate the pathogen
10 Stop treatment when cured
9 Know when to say no to vanco
8 Treat infection, not colonization
7 Treat infection, not contamination
6 Use local data
5 Practice antimicrobial control
4 Access the experts
3 Target the pathogen
2 Get the catheters out
1 Vaccinate
Prevent Transmission
Use Antimicrobials Wisely
Diagnose and Treat Effectively
Prevent Infection
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Vancomycin-resistant
enterococci
Non-Intensive Care Unit Patients
Intensive Care Unit Patients
Antimicrobial Resistance Among Pathogens
Causing Hospital-Acquired Infections
Source: National Nosocomial Infections Surveillance (NNIS) System
8 Link to: NNIS Online at CDC
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resistant Klebsiella pneumoniae
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Fluoroquinolone-resistant
Pseudomonas aeruginosa
Non-Intensive Care Unit Patients
Intensive Care Unit Patients
Antimicrobial Resistance Among Pathogens
Causing Hospital-Acquired Infections
Source: National Nosocomial Infections Surveillance (NNIS) System
8 Link to: NNIS Online at CDC
8 Link to: NNIS Online at CDC
Fact:
Catheters and other invasive devices are the #1
exogenous cause of hospital-acquired infections.
Prevent Infection
Step 2:
Get the catheters out
Biofilm on Intravenous Catheter Connecter
24 Hours After Insertion
Scanning Electron Micrograph
8 Link to: Biofilms and device-associated infections
Fact: Catheters and other invasive devices are the #1
exogenous cause of hospital-acquired infections.
Actions:
-use catheters only when essential
-use the correct catheter
-use proper insertion and catheter-care
protocols
-remove catheters when not essential
Coming soonguidelines for preventing catheter-associated bloodstream infections
8 Link to: Urinary catheter infection prevention
Prevent Infection
Step 2: Get the catheters out
Fact:
Appropriate antimicrobial therapy (correct
regimen, timing, dosage, route, and duration)
saves lives.
Diagnose and Treat
Infection Effectively
Step 3:
Target the pathogen
Inappropriate Antimicrobial Therapy:
Prevalence Among Intensive Care Patients
Source: Kollef M, et al: Chest 1999;115:462-74
0%
10%
20%
30%
40%
50%
Community-acquired infection
Hospital-acquired infection
Hospital-acquired infection after
initial community-acquired infection
Inappropriate
Antimicrobial Therapy
(n = 655 ICU patients with infection)
Patient Group
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17.1%
34.3%
45.2%
Inappropriate Antimicrobial Therapy:
Impact on Mortality
Source: Kollef M, et al: Chest 1999;115:462-74
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42.0% mortality
17.7% mortality
Relative Risk = 2.37
(95% C.I. 1.83-3.08; P < .001)
# Deaths
# Survivors
Inappropriate
Therapy
Appropriate
Therapy
Fact: Appropriate antimicrobial therapy saves lives.
Actions:
-culture the patient
-target empiric therapy to likely pathogens and
local antibiogram
-target definitive therapy to known pathogens
and antimicrobial susceptibility test results
8 Link to: IDSA guidelines for evaluating fever in critically ill adults
Diagnose and Treat Infection Effectively
Step 3: Target the pathogen
Nosocomial infections
Fact:
Infectious diseases expert input improves
the outcome of serious infections.
Diagnose and Treat
Infection Effectively
Step 4:
Access the experts
Infectious Diseases Expert Resources
Infectious Diseases
Specialists
Optimal
Patient Care
Optimal
Patient Care
Infection Control
Professionals
Healthcare
Epidemiologists
Clinical
Pharmacists
Clinical
Pharmacologists
Surgical Infection
Experts
Clinical
Microbiologists
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 4: Access the experts
Fact: Infectious diseases expert input improves the
outcome of serious infections.
Action:
-consult infectious diseases experts
about patients with serious infections
8 Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals
Diagnose and Treat Infection Effectively
Step 4: Access the experts
Fact:
Programs to improve antimicrobial use
are effective.
Use Antimicrobials Wisely
Step 5: Practice
antimicrobial control
Methods to Improve Antimicrobial Use
Passive prescriber education
Standardized antimicrobial order forms
Formulary restrictions
Prior approval to start/continue
Pharmacy substitution or switch
Multidisciplinary drug utilization evaluation (DUE)
Interactive prescriber education
Provider/unit performance feedback
Computerized decision support/online ordering
8 Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals
Computerized Antimicrobial Decision Support
Local clinician-derived consensus guidelines embedded in
computer-assisted decision support programs
62,759 patients receiving antimicrobials over 7 years
1988 1994
Medicare case-mix index 1.7481 2.0520
Hospital mortality 3.65% 2.65%
Antimicrobial cost per treated patient $122.66 $51.90
Properly timed preoperative antimicrobial 40% 99.1%
Stable antimicrobial resistance
Adverse drug events decreased by 30%
Source: Pestotnik SL, et al: Ann Intern Med 1996;124:884-90
Use Antimicrobials Wisely
Step 5: Practice antimicrobial control
Fact: Programs to improve antimicrobial use are effective.
Action:
- engage in local antimicrobial use quality
improvement efforts
8 Link to: Methods to improve antimicrobial use and prevent resistance
Source: Schiff GD, et al: Jt Comm J Qual Improv 2001;27:387-402
Fact:
The prevalence of resistance can vary
by time, locale, patient population,
hospital unit, and length of stay.
Use Antimicrobials Wisely
Step 6: Use local data
Trimethoprim/Sulfamethoxazole (TMP/SMX)
Resistance Among Bacterial Patient Isolates*
San Francisco General Hospital
Martin JN, et al: J Infect Dis 1999;180:1809-18
* 30,886 patient isolates
Staphylococcus aureus
Escherichia coli
Enterobacter spp.
Klebsiella pneumoniae
Morganella spp.
Proteus spp.
Serratia spp.
Citrobacter spp.
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Non-HIV units (n = 28,966 patient isolates)
HIV units (n = 1,920 patient isolates)
Prevalence of TMP/SMX use
among AIDS patients
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 6: Use local data
Prevalence of Fluoroquinolone-Resistant
Escherichia coli: Variability Among Patient
Populations
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12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 6: Use local data
Use Antimicrobials Wisely
Step 6: Use local data
Fact: The prevalence of resistance can vary by locale, patient
population, hospital unit, and length of stay.
Actions:
-know your local antibiogram
-know your patient population
8 Link to: NCCLS Proposed Guidance for Antibiogram Development
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Fact:
A major cause of antimicrobial overuse
is treatment of contaminated cultures.
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Use Antimicrobials Wisely
Step 7: Treat infection,
not contamination
Interpreting a Positive Blood Culture
True Bacteremia:
Unlikely Uncertain Likely
S. aureus
S. pneumoniae
Enterobacteriaceae
P. aeruginosa
Candida albicans
Corynebacterium spp.
Non-anthracis Bacillus spp.
Propionibacterium acnes
Coagulase-negative
staphylococci
Source: Kim SD, et al: Infect Control Hosp Epidemiol 2000;21:213-7
Pre-test probability
patient risk factors
prosthetic devices
clinical evidence
Post-test probability
# positive/# cultures
compare antibiograms
compare genotypes
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 7: Treat infection, not contamination
Use Antimicrobials Wisely
Step 7: Treat infection, not contamination
Fact: A major cause of antimicrobial overuse is treatment of
contaminated cultures.
Actions:
-use proper antisepsis for blood and other cultures
-culture the blood, not the skin or catheter hub
-use proper methods to obtain and process
all cultures
8 Link to: CAP standards for specimen collection and management
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Fact:
A major cause of antimicrobial overuse
is treatment of colonization.
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Use Antimicrobials Wisely
Step 8: Treat infection,
not colonization
Fact:
Vancomycin overuse promotes
emergence, selection, and spread
of resistant pathogens.
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Use Antimicrobials Wisely
Step 9: Know when to
say no to vanco
S. aureus
Penicillin
[1950s]
Penicillin-resistant
S. aureus
Evolution of Drug Resistance in S. aureus
8 Link to: CDC Facts about VISA
8 Link to: CDC Facts about VRE
Methicillin
[1970s]
Methicillin-resistant
S. aureus (MRSA)
Vancomycin-resistant
enterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin
intermediate-
resistant
S. aureus
(VISA)
Vancomycin-
resistant
S. aureus
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 9: Know when to say no to vanco
Use Antimicrobials Wisely
Step 9: Know when to say no to vanco
Fact: Vancomycin overuse promotes emergence, selection, and
spread of resistant pathogens.
Actions:
-treat infection, not contaminants or colonization
-fever in a patient with an intravenous catheter
is not a routine indication for vancomycin
8 Link to: CDC guidelines to prevent vancomycin resistance
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Fact:
Failure to stop unnecessary
antimicrobial treatment contributes
to overuse and resistance.
Use Antimicrobials
Wisely
Step 10: Stop treatment
when infection is cured
or unlikely
Fact: Failure to stop unnecessary antimicrobial treatment
contributes to overuse and resistance.
Actions:
-when infection is cured
-when cultures are negative and infection
is unlikely
-when infection is not diagnosed
Use Antimicrobials Wisely
Step 10: Stop antimicrobial treatment
Fact:
Patient-to-patient spread of
pathogens can be prevented.
Prevent Transmission
Step 11:
Isolate the pathogen
Prevent Transmission
Step 11: Isolate the pathogen
Fact: Patient-to-patient spread of pathogens can be
prevented.
Actions:
-use standard infection control precautions
-contain infectious body fluids (use approved
airborne/droplet/contact isolation precautions)
-when in doubt, consult infection control
experts
8 Link to: A VRE prevention success story
8 Link to: CDC isolation guidelines and recommendations
Fact:
Healthcare personnel can spread
antimicrobial-resistant pathogens from
patient to patient.
Prevent Transmission
Step 12:
Contain your contagion
Improved Patient Outcomes Associated
With Proper Hand Hygiene
Ignaz Philipp Semmelweis
(1818-1865)
Chlorinated lime hand antisepsis
8 Link to: Ignaz Semmelweis
Impact of Hand Hygiene on Hospital
Infections
Year Author Setting Impact on Infection Rates
1977 Casewell adult ICU Klebsiella decreased
1982 Maki adult ICU decreased
1984 Massanari adult ICU decreased
1990 Simmons adult ICU no effect
1992 Doebbeling adult ICU decreased with one versus
another hand hygiene product
1994 Webster NICU MRSA eliminated
1995 Zafar nursery MRSA eliminated
1999 Pittet hospital MRSA decreased
ICU = intensive care unit; NICU = neonatal ICU
MRSA = methicillin-resistant Staphylococcus aureus .
8 Link to: Improving hand hygiene
Source: Pittet D: Emerg Infect Dis 2001;7:234-240
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How are Patients Exposed to Hospital
Water?
Handwashing (cross-contamination)
Bedpans
Enteral feedings
Respiratory equipment
Drinking
Showering
Bed bathing
Prevent Transmission
Step 12: Break the chain of contagion
Fact: Healthcare personnel can spread antimicrobial-
resistant pathogens from patient to patient.
Actions:
-stay home when you are sick
-contain your contagion
-keep your hands clean
-set an example!
8 Link to: Health guidelines for healthcare personnel
8 Coming soonnew guidelines for hand hygiene
Hypodermic syringes
with Self-Sheathing safety
feature
Self-sheathed
protected position
Hypodermic syringes with Retractable
Technology safety feature
Retracted protected position
Phlebotomy needle with
Self-Blunting safety feature
Blunted protected position
Attached to syringe needle
Attached to blood tube holder