Infection Control and Antibiotic Stewardship
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Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur. CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
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Infection Control and Antibiotic Stewardship
- 1. Hopital Sacre Coer Infectious Diseases Symposium 2011 Infection Control and Antimicrobial Stewardship Helen Boucher MD FACP FIDSA Associate Professor of Medicine Division of Infectious Diseases and Geographic Medicine
- 26. Sharp Objects Associated with 51 Percutaneous Injuries Resulting in HIV Seroconversion in 50 Healthcare Personnel* June 2001 * http://www.cdc.gov/hiv/pubs/facts.htm#Transmission
- 37. INFECTION CONTROL IS EVERYBODY’S RESPONSIBILITY!
- 42. The Discovery of Antibiotics
- 43. Evolution of Drug Resistance in Staphylococcus aureus S. aureus Penicillin [1950s] Penicillin-resistant S. aureus [2002] Vancomycin-resistant S. aureus (VRSA) Methicillin [1970s] Methicillin-resistant S. aureus (MRSA) Vancomycin-resistant Enterococci (VRE) Vancomycin [1990s] [1997] Vancomycin intermediate- resistant S. aureus (VISA)
- 45. MRSA
- 46. Progression of resistant Staphylococcus aureus McDonald LC. Clin Infect Dis. 2006;42:S65-S71. Penicillinase-producing S aureus 0 25 50 75 100 1940 1960 1980 2000 Year Resistant isolates (%) Methicillin-resistant S aureus 0 25 50 75 100 1940 1960 1980 2000 Year Resistant isolates (%) A similar trend in the increase in nosocomial infections caused by antimicrobial-resistant S aureus isolates can be observed in community-acquired infections Nosocomial infection Community-acquired infection
- 47. Source: National Nosocomial Infections Surveillance (NNIS) System Methicillin-Resistant Staphylococcus aureus (MRSA) Among Intensive Care Unit Patients, 1995-2004
- 48. Incidence of Nosocomial Pneumonia Caused by S. aureus Pujol et al. Eur J Clin Microbiol Infect Dis . 1998;17:622; Germaud et al. Rev Pneumol Clin . 1999;55:83.
- 49. VRE
- 50. Source: National Nosocomial Infections Surveillance (NNIS) System Vancomycin-Resistant Enterococci (VRE) Among Intensive Care Unit Patients, 1995-2004
- 51. Resistant Gram-Negatives Resistant Gram-Negatives
- 52. Source: National Nosocomial Infections Surveillance (NNIS) System 3 rd Generation Cephalosporin-Resistant Klebsiella pneumoniae Among Intensive Care Unit Patients, 1995-2004
- 53. Annual evolution of antimicrobial resistance in invasive Escherichia coli isolated by Spanish laboratories participating in European Antimicrobial Resistance Surveillance System, 2001-2003.
- 54. Source: National Nosocomial Infections Surveillance (NNIS) System Fluoroquinolone-Resistant Pseudomonas aeruginosa Among Intensive Care Unit Patients, 1995-2004
- 62. Antimicrobial Therapy A Balancing Act Appropriate initial antibiotic while improving patient outcomes and healthcare Unnecessary Antibiotics, adverse patient outcomes and increased cost
- 68. Efforts to Improve Antimicrobial Prescribing and Control Resistance Antimicrobial Stewardship Develop New Drugs and Vaccines Improved Diagnostics Infection Control Reduce Resistance Reservoirs Research & Pubic Policy Education
- 69. Efforts to Improve Antimicrobial Prescribing and Control Resistance Antimicrobial Stewardship Develop New Drugs and Vaccines Improved Diagnostics Infection Control Reduce Resistance Reservoirs Research & Pubic Policy Education
- 70. Questions?
- 90. Antibiotics Feeding tube Ventilator Environment Catheters Colonized Patient Dynamics of Nosocomial Multi-Drug Resistance Pathogen Transmission Risk factors Infection Control Infection Control Cleaning
Notas do Editor
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- Main Efficacy Main Efficacy Main Efficacy The key elements of postexposure management are listed here. Over the next few slides, wound management, exposure reporting, assessment of the infection risk by type and severity of exposure, determination of the bloodborne status of the source person, and appropriate treatment, follow-up, and counseling are explored in more detail.
- Main Efficacy Main Efficacy Main Efficacy The first element in postexposure management is wound care. Wounds should be cleaned with soap and water. Mucous membranes should be flushed with water. Eyes should be flushed with eye irrigant or clean water. There is no evidence that application of antiseptics or disinfectants, or squeezing (or milking) puncture sites provides any benefit. The use of bleach and other agents that are caustic to the skin should be avoided.
- Main Efficacy Main Efficacy Main Efficacy It is important to collect and record information about the exposure on an exposure report, and to maintain the confidentiality of both the worker and the source patient. An exposure report should include the date and time that the exposure occurred, as well as details of what procedure was being performed, where, how, and what device (if any) was involved. If a device was involved, OSHA requires that the brand and manufacturer of the device be recorded. Details such as the route of exposure, body substance involved, and volume or duration of contact also should be included. Additionally, information about the source person and exposed person, if known, is critical, along with exposure management details, which will be discussed later.
- Main Efficacy Main Efficacy Main Efficacy As mentioned earlier, one factor to consider in assessing the risk of infection is the body substance to which healthcare personnel are exposed. This shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus. Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat.
- Main Efficacy Main Efficacy Main Efficacy For the 50 documented cases of HIV infection associated with the 51 percutaneous injuries from the previous slide, the types of sharp objects implicated are shown on this pie chart. The largest portion of the pie, in red, represents hollow-bore needles. Other sharp objects represented on this chart include scalpels, in peach, and broken vials, in green. The purple slice represents cases where the sharp object causing the injury was unknown.
- Main Efficacy Main Efficacy Main Efficacy The risk of HBV transmission after a percutaneous exposure to HBV-infected blood, without postexposure treatment, varies, depending on the e-antigen status of the source. If the source is e-antigen positive, the risk of transmission will be up to 30%, whereas if the source is e-antigen negative, the risk is from 1-6%. The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%, with a range of 0-7%. The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%, or 1 in 300 exposures (with a 95% confidence interval of 0.2%-0.5%). The average risk is based on aggregate data, and may not apply to specific exposure events.
- Main Efficacy Main Efficacy Main Efficacy In a retrospective case-control study of healthcare personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a larger quantity of blood from the source person as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein. An increased risk was also associated with exposure to blood from source persons with terminal illness, possibly reflecting either a higher titer of HIV in blood late in the course of AIDS or other factors. Postexposure use of zidovudine was associated with a decreased risk of HIV transmission.
- Main Efficacy Main Efficacy Main Efficacy HIV exposures should be regarded as urgent medical concerns, and, if indicated after evaluating the source patient status and type and severity of the injury, postexposure prophylaxis should be initiated as soon as possible after exposure, i.e. within hours rather than days. The interval after which postexposure prophylaxis is no longer likely to be effective in humans is unknown. Initiating postexposure prophylaxis days or weeks after an exposure might be considered if warranted for a higher exposure risk.
- Main Efficacy Main Efficacy Main Efficacy Preventing transmission of bloodborne viruses in healthcare settings requires a multifaceted approach, including promoting hepatitis B vaccination of all healthcare personnel who may have contact with blood, considering all patients as potentially infectious, using appropriate barriers to prevent blood and body fluid contact, and preventing percutaneous injuries, by eliminating unnecessary needle use, implementing safety devices (devices with safety features), using safe work practices when handling needles and other sharp devices, and safely disposing sharps and blood-contaminated materials.
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- Cut to the 1940s and the introduction of penicillin, discovered by Alexander Fleming. We now had a weapon against infection.
- Unfortunately, as it turns out, the Introduction of every new class of antimicrobial drug is followed by emergence of resistance. By the 1950s, penicillin-resistant S. aureus were a major threat in hospitals and nurseries. Methicillin was developed. By the 1970s, methicillin-resistant S. aureus (or MRSA) had emerged and spread, a phenomenon that encouraged widespread use of vancomycin. In the 1990s, vancomycin-resistant enterococci emerged and rapidly spread; most of these organisms are resistant to other traditional first-line antimicrobial drugs. At the end of the century, the first S. aureus strains with reduced susceptibility to vancomycin (the so-called VISA) were documented, prompting concerns that S. aureus fully resistant to vancomycin may be on the horizon. In June 2002 the first case of vancomycin-resistant S. aureus was detected.
- Here are some abbreviations that I will be using for those of you that are not familiar with these terms.
- Progression of resistant Staphylococcus aureus Key Points: Changes in the epidemiology can be observed in both nosocomial and community-acquired infections caused by antimicrobial-resistant strains of S aureus Methicillin resistance is increasing in both nosocomial and community-acquired strains of S aureus The trend of increasing prevalence of methicillin resistance among S aureus strains mirrors the evolution observed with penicillin resistance following the introduction of penicillin If the trend continues, methicillin resistance may become widespread among S aureus strains in the hospital and community settings Reference: McDonald LC. Clin Infect Dis . 2006;42:S65-71.
- The proportion of hospital-onset infections that are due to a resistant organism has increased at an alarming rate. The next four slides show trends in antimicrobial resistance among pathogens causing infections in ICU patients. These trends are based on data from the CDC’s National Nosocomial Infections Surveillance (NNIS) system. Shown on this slide are trends in the proportion of Staphylococcus aureus infections caused by methicillin-resistant strains. From 1995 through 2004, the percent of S. aureus infections caused by methicillin-resistant strains increased from approximately 40% to 60%.
- Over the 10-year period from 1995-2004, the proportion of enterococcal infections among ICU patients that were resistant to vancomycin doubled from less than 15% to 30%.
- During the same time period, there also was a significant increase in the proportion of gram-negative pathogens (e.g., Klebsiella spp. and Enterobacteriaceae) that had acquired extended-spectrum beta-lactamases (ESBLs). Shown above are trends in 3 rd generation cephalosporin resistance among Klebsiella pneumoniae . As of 2004, approximately 25% of K. pneumoniae isolates causing infections in ICUs were resistant to 3 rd generation cephalosporins.
- Resistance to fluoroquinolones also has emerged among nosocomial pathogens. In 1995, approximately 15% of Pseudomonas aeruginosa infections in ICUs were due to fluoroquinolone-resistant strains, but by 2004, approximately 25% of such infections in ICU patients were resistant to fluoroquinolones.
- Antibiotic treatment of nosocomial pneumonia is a balancing act. Clinicians need to treat patients with these potentially life-threatening infections with an appropriate initial antimicrobial regimen while also trying to minimize the emergence of resistant pathogens.
- 1997: Initail goals CDC's campaign was the development and distribution of principles for appropriate antibiotic use for pediatric and adult upper respiratory tract infections produced a series of health education and behavioral change materials for both patients and providers to promote appropriate antibiotic use. CDC distributes federal funds to state and local health departments for the development, implementation, and evaluation of local
- Since 2003 CDC has developed a national media campaign in partnership with the Food and Drug Administration (FDA) to provide a coordinated message on appropriate antibiotic use and create a foundation for local efforts across the country 4 HEDIS( Healthcare Effectiveness Data and Information Set) measures, incorporated into in 2004, are: Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection (URI) Avoidance of Antibiotic Treatment in Adults with Acute Antibiotic Utilization: This measure summarizes data on outpatient utilization of drug prescriptions, stratified by age.
- Despite success sin the outpatient setting , antimicrobial resistance continues to increase in healthcare settings 50 % of patients in a hospital receive an antibiotic and of those about 50% are in appropriate or unnecessary. iOM report estimated that the total cost to U.S. society of antimicrobial resistance was at least $4 billion to $5 billion
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- The correct answer is #4, to prevent infections that patients acquire in the hospital. All answers are good reasons to practice good hand hygiene. Improved adherence to hand hygiene has been shown to terminate outbreaks in healthcare facilities, reduce the transmission of antimicrobial resistant organisms, and reduce overall infection rates.
- 01/25/12
- Main Efficacy Main Efficacy Main Efficacy Hepatitis B virus (HBV), hepatitis C virus (HCV), and the human immunodeficiency virus (HIV) are all bloodborne viruses that can produce chronic infection and are transmissible in healthcare settings. Data from multiple sources, including surveillance, observational studies, and serosurveys are used to assess the risk of occupational transmission.
- Main Efficacy Main Efficacy Main Efficacy The prevalence of bloodborne virus infection varies. It is generally higher in hospitalized patients than in the general population, but also varies with geographic area and patient group. For example, in Iowa, the prevalence of HIV may be lower than in San Francisco. The prevalence varies with patient group and the presence or absence of such risk factors as injecting drug use, multiple sex partners, and so on.
- Main Efficacy Main Efficacy Main Efficacy This chart shows the number of U.S. healthcare personnel with documented and possible occupationally acquired AIDS/HIV infection reported to CDC, by occupation, as of June 2001. Fifty-seven workers had documented HIV seroconversion temporally associated with an occupational exposure. An additional 137 episodes are considered possible occupational HIV transmissions. These workers report a history of occupational exposure to blood, other infectious body fluids, or laboratory solutions containing HIV, and report no other risk for HIV infection, but HIV seroconversion after a specific exposure was not documented. The occupational group with the most documented and possible transmissions is nurses.
- Why are our long term care patients particularly susceptible to this problem? Before they become infected, they become colonized with these bacteria. A number of risk factors specific to this patient population predispose these patients to becoming colonized with multidrug resistant organisms. In addition, the environment (such as the bedrails, the IV pumps, light switches, phones, faucets), becomes contaminated with these organisms. Cleaning and infection control are essential but often not enough to prevent colonization of the patient with these bacteria.