The document discusses various challenges with infection control in healthcare settings. It describes the spread of antibiotic-resistant pathogens through environmental contamination and between food animals, meat, and humans. Travel to certain regions is associated with higher rates of antibiotic-resistant infections. Proper cleaning, sterilization, use of protective equipment, and hand hygiene are important but not always consistently implemented by healthcare workers. New strategies may be needed to change behaviors and improve compliance with infection control guidelines.

1. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Welcome to the hospital
Despite our best intentions … Control of antibiotic use
1
in
10
pa&ents
“gets
hurt”
… not all problems are preventable
Control of antibiotic use Spread of multi-resistant pathogens
New
MDR-­‐MO’s
New
an&bio&cs
Andreas
Voss,
MD,
PhD
1

2. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Environmental dissemination of NDM-1
Walsh
et
al.
Lancet
ID
2011;11:355
Environmental dissemination of NDM-1: Environmental dissemination of NDM-1:
NDM-1 positive samples NDM-1 positive samples
used
for
drinking
• 20
NDM-­‐1-­‐posi&ve
strains
were
present
in
and
food
prepara&on
the
samples,
including:
– Enterobacteriaceae,
Citrobacter
freundii,
E
coli,
and
K
pneumoniae
(commonly
carry
blaNDM-­‐1)
– Shigella
boydii,
V
cholerae,
Aeromonas
caviae.
blaNDM-­‐1-­‐posi&ve
bacteria
were
recovered
from
12
of
– Various
non-­‐fermenters
not
previously
reported
171
seepage
samples
and
2
of
50
water
samples.
to
carry
blaNDM-­‐1:
Green
squares
=
Pseudomonas
aeruginosa
(and
other
P.
spp),
51
seepage
samples
where
Sutonella
indologenes,
Stenotrophomonas
genes
were
found
(underes&ma&on)
maltophilia,
Achromobacter
spp,
and
Kingella
denitrificans.
Walsh
et
al.
Lancet
ID
2011;11:355
Walsh
et
al.
Lancet
ID
2011;11:355
New Delhi metallo-beta-lacatamse
Estimated income for India by 2012:
US$2 billion
Not
a
“superbug”
(=
single
bacterial
species)
but
a
transmissible
gene1c
element
encoding
mul&ple
resistance
genes
Connell Tourism Mangement 2006;27:1093
Andreas
Voss,
MD,
PhD
2

3. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
ESBL bacteria in patients with
Do you enjoy traveling? travellers’ diarrhoea
• ESBL
significantly
more
frequent
in
travelers
returning
from
Middle
EAST,
India
or
Asia
Tham,
SJID,
2010,
275
Food as a source of MDR-mo’s
Yes,
I
am
mul&-­‐drug
resistant!
L
+
ESB
ESBL in chicken, meat and humans New sources of MRSA
• A
high
prevalence
of
ESBL
genes
was
found
in
raw
chicken
meat
(79.8%).
Pigs & calves
• Gene&c
analysis
showed
that
the
predominant
ESBL
genes
in
chicken
meat
and
human
rectal
swab
specimens
from
the
same
area
were
iden&cal.
These
genes
were
also
frequently
found
in
human
blood
culture
isolates.
• Typing
results
of
Escherichia
coli
strains
showed
a
high
degree
of
similarity
with
strains
from
meat
and
humans.
Overdeveste
et
al
EID
2011;17:1216
Andreas
Voss,
MD,
PhD
3

4. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Personnel Protective Equipment
In the post SARS era … MRSA: import vs acquired
first
MRSA
isolate
was
recovered
within
72
h
of
ICU
admission
P
<
0.01
first
MRSA
isolated
ager
72
h
of
ICU
admission
SARS
Pre-­‐SARS
Post-­‐SARS
…
we
tend
to
forget
while
more
might
come
!
Clin
Infect
Dis
2004;39:511-­‐516
Multi-vial device: re-capping
Andreas
Voss,
MD,
PhD
4

5. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Multi-vial device: sealed ? Meet your new surgical team
Jane
Leonardo
Tom
Hospital Cleaning
Disinfec&on
and
steriliza&on
• In-­‐
or
out-­‐sourced
• Detergent
vs
disinfectants
• Standardized
vs
manual
(beds,
scopes,
…)
• Costs
vs
quality
HCWs & Infection Control
Infec&on
control
Andreas
Voss,
MD,
PhD
5

6. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
HH compliance in the Netherlands What is the problem?
Disregard
to
guidelines
If hospital bugs would look like this – compliance
a
with hand hygiene would be 100% Dangerous micro-organism: MRHW
Mul&-­‐Resistant
Health-­‐care
Worker
MRHW How to change HCWs behavior?
• Resistant
to
good
advice
• Just
presen&ng
something
“new”
or
“beker”
will
not
change
their
behavior
…
• Allergic
to
(professional)
guidelines
• We
should
learn
from
marke&ng
professionals
• Non-­‐compliant
with
IC
measures
• “
People
are
willing
to
change
of
they
feel:
• Blind
to
HAIs
(especially
their
own)
good,
flakered,
powerful
or
sexy”
not
when
bombareded
with
facts
(Hodgkin
1999)
• Other
prioro&es
Andreas
Voss,
MD,
PhD
6

7. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Gimme an Rx! … my new infection control nurses
Cheerleaders Pep Up Drug Sales
Onya,
the
Redskins
cheerer
(who
asked
that
her
last
name
be
withheld,
ci&ng
team
policy),
has
her
picture
on
the
team's
Web
site
in
her
official
bikini-­‐
like
uniform
and
also
reclining
in
an
actual
bikini.
Onya,
27,
who
declined
to
iden&fy
the
company
she
works
for,
is
but
one
of
several
drug
representa1ves
who
have
cheered
for
the
Redskins
A&F stole my idea … Try to find out what your customer wants!
² Many
&mes
we
offer
our
help
assuming
that
we
know
what
HCWs
need
and
how
we
can
help
them
…
whereas
our
assump&ons
and
reality
frequently
differ
!
They old measures work !
Hand
hygiene
With
bed-­‐side
dispensers
and
pocket-­‐bokles
any
excuse
to
not
reach
out
for
the
alcoholic
handrub
is
gone.
Thus,
….
“Just
do
it!”
Furthermore,
hand
hygiene
should
be
seen
as
only
one
of
the
classical
preven&ve
measures
all
of
which
deserve
our
aKen1on
and
HCW’s
compliance.
Poli&cally
incorrect,
biased
and
personal
Andreas
Voss,
MD,
PhD
7

8. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Surveillance GI Infections
HAI-­‐surveillance
GI-­‐tract
infec&ons
Internal
quality
versus
public
repor&ng.
Increasing
rates
of
C.
difficile
and
Repor&ng
real
HAI
rates
(e.g.
VAP)
instead
of
norovirus.
With
regard
to
norovirus:
low
public
rates
and
crea&ng
new
diseases
impact
on
the
pa&ent
outcome
as
well
such
as
ven&lator-­‐associated
trachea-­‐
bronchi&s
as
the
overall
possibility
to
deliver
care
is
frequently
underes&mated
Fighting community and
The
unnecessary
and
wrong
use
of
an&bio&cs
needs
to
stop.
In
the
light
of
the
zoonotic pathogens
emergence
of
MDR-­‐m.o.’s
we
can
not
afford
to
booster
the
trend
by
selec&ng
more
CA-­‐MRSA,
LA-­‐MRSA,
NDM-­‐1
&
Co.
resistance
and
waist
the
limited
Emerging
pathogens
and
mobile
an&microbials
we
have
during
indica&ons
transmissible
elements
through
the
food-­‐
that
need
no
or
other
an&bio&cs.
chain/bio-­‐industry
or
from
travellers
to
countries
with
poor
sanita&on
will
be
a
major
challenge
to
infec&on
control
Influencing public and political
expectations
YES
to
“zero
tolerance”
but
NO
to
zero
infec&ons!
Zero
HAIs
is
impossible.
This
gives
consumers
a
completely
wrong
picture
and
encourages
poli&cians
&
insurances
to
come
up
with
unwanted
rules.
Andreas
Voss,
MD,
PhD
8

9. Infec&on
Control
in
Healthcare
09-­‐05-­‐12
Hospital-structure Commerce
Outsourcing
of
clinical
microbiology
and
Up-­‐hold
and
improve
hospital
structure
infec&ous
diseases
services
are
contra-­‐
and
“HCW
to
pa&ent
ra&o’s”
to
allow
produc&ve
to
what
makes
Infec&on
infec&on
control
measures
to
be
Control
work
in
countries
like
the
NL:
applied,
and
improve
hospital
design
to
direct
accessibility
and
integra&on
allow
op&mal
workflow.
(within
the
healthcare
sevng)
of
all
infec&ous
diseases
services
Culture change Behavioral science
How
to
integrate
behavioral
science
into
infec&on
control
educa&on?
Why
do
healthcare
workers
believe
that
We
will
not
change
HCWs
behavior
by
if
they
adhere
to
70%
of
the
rules
that
con&nuously
blaming
them
for
what
they
are
doing
an
outstanding
job?
In
they
do
wrong.
other
industries
that
is
a
reason
to
get
fired!
Final wisdom of behavioral science
“Before
you
cri&size
someone
you
should
walk
a
mile
in
their
shoes
…
…
that
way,
if
he
gets
angry,
he'll
be
a
mile
away,
and
you
have
their
shoes
”
Homer
Simpson
Andreas
Voss,
MD,
PhD
9