Presentation given during Cost AMiCI meeting in Tallinn Nov 2017 by Pille Märtin Infection control doctor West-Tallinn Central Hospital Chief specialist Dep. Of Communicable Diseases surveillance and control Health Board of Estonia

1. Trends on Health-Care Associated
Infections and Infection Control in
Estonia and in Europe
Pille Märtin
Infection control doctor
West-Tallinn Central Hospital
Chief specialist
Dep. Of Communicable Diseases surveillance and control
Health Board of Estonia
2017

2. Backround
• West-Tallinn Central Hospital
2016
– 475 acute care beds (+ 47 day
care beds), 18 920 admissions
(+ 4703 day care patients)
– Head of the infection control
department
• Health Board
– Chief specialist (AMR and HAI)
– Department of Communicable
Diseases Surveillance and
Control
• National Focal point for ECDC-
HAI (ICU, SSI, PPS)
03.02.2018 2PMärtin

3. Topics
• Healthcare- associated infections (HAI)
• Epidemiology in EU
• Epidemiology in Estonia
• Infection control
• Opinion of AMC in health-care settings
03.02.2018 3PMärtin

4. Healthcare-associated infections
• Definitions
• ≥ day 3 or later (day of admission = Day 1) of
current admission
• Readmission with infection <2 days after
discharge from acute hospital
• With SSI, following surgery incl day 1, 2
• 30 days post OP or 3 months post implantation
• With C. difficile infection <28 days post
discharge from acute hospital
• With device-associated infection
(pneumonia, UTI, bloodstream infection)
following insertion of device (incl day 1, 2 if
post-insertion) or following device removal…
Multifactorial
Very different locations
Usually MDR mibrobes
involved
ECDC, HAI-Net definitions, 2016

5. • Healthcare-associated infections (HAI)
– approximately 4 million per year
– Directly attributable deaths: approx. 37,000 each
year
– Extra hospital days: approx. 16 million each year
– Direct costs: approx. €5.5 billion per year (average €334 per
day)
HAI in Europe
Source: ECDC Annual Epidemiological Report 2008 and Monnet DL, ECDC (preliminary
estimate)

6. Surveillance of HAI in Europe
ECDC role
Source: IPSE Technical Implementation Report 2005–2008
 Several ongoing HAI surveillance
activities (The Healthcare-
Associated Infections Surveillance
Network (HAI-Net) :
 Surgical site infections
 HAI in intensive care
 HAI in long-term care facilities
(2009)
 Structure & process indicators
infection control
 PPS since 2010
 Surveillance of Clostridium difficile
infections

7. Point prevalence survey
 A survey carried out during one short period of time,
according to a specific protocol (“one shot” of one
ward per day).
 Examines the use of AB and the occurence of hospital
infections.
 The aim: to change the quality of the use of
antibiotics and to define problems in HAI incidences.
 Two (2) successive studies are more informative (e.g. one
year apart).
 Enables the finding of problems that need
improvement:
 In the presence of HAI trends;
 Regarding the causing microbes;
 In risk factors;
 In the area of using antibiotics.
03.02.2018 PMärtin 7

8. History
• During 2001-2009 the point prevalence surveys
were coordinated by ESAC (European
Surveillance of Antimicrobial Consumption)
• Since 2010 ECDC (European Centre for Disease
Prevention and Control) has been organizing:
– Pilot research (2010)
• 23 countries, 66 hospitals, 17 900 patients.
– First EU wide PPS 2011-2012
• 30 countries, 1149 hospitals, 231 459
patients
• HAI prevalence 5,7% (95% confidence
interval 4,5-7,4%)
• Second PPS 2016-2017(preliminary results 2018)
03.02.2018 PMärtin 8

9. EU data (2011-2012)
• 15 000 HAIs
• Estimated HAI
prevalence 5,7%(CI 4,5-
7,4%)
– Highest ICU: 19,5% at
least one HAI
– All other specialties
5,2%
• Number of patients on
any given day in
European acute care
hospitals- 81 089

10. PPS 2011-2012
03.02.2018 PMärtin 10
Europa PPS 2011-2012 Estonia 2011 (2076 pt)
Prevalence of HAI 13 829pt/6,0% 118/5,7%
N of HAI 15 000 128
N of HAI with
microorganisms
54,1 % 47,7%
Pneumonia 19,4% 24%
Urinary tract infections 19,0% 13%
Surgical site infections 19,6% 32%
Bloodstream infections 10,6% 5,5%
C.difficile infections 3,6% 1,6%
European Centre for Disease Prevention and Control. Point prevalence survey of health care
associated infections and antimicrobial use in European acute care hospitals. Stockholm:
ECDC; 2013.

11. Device assoctiated infections (PPS data
for EU)
European Centre for Disease Prevention and Control. Point prevalence survey of health care associated
infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013.

12. Microorganisms and HAI for EU
• For 54,1% of HAI a
microorganims was
reported
– 38,5% for PN
– 43,7% for SSI
– 66,9% for UTI
– 94,7% for BSI
Microorganism
E.coli 15,9%
S.aureus 12,3%
Enterococcus sp. 9,6%
P.aeruginosae 8,9%
Klebsiella 8,7%
CONS 7,5%
Candida sp. 6,1%
C.difficile 5,4%
Enterobacter sp 4,2%
Proteus sp. 3,8%
Acinetobacter sp. 3,6%
European Centre for Disease Prevention and Control. Point prevalence survey of health care associated
infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013.

13. Antimicrobial resistance markers for
EU
Microorganism N with known result % NS
S.aureus(MRSA) 1071 41,2%
Enterococci, VAN-R(VRE) 755 10,2%
E.coli(3GC-NS) 1292 23,5%
Klebsiella spp, (3GC-NS) 726 53%
E.coli (CAR-NS) 1267 3,6%
Klebsiella spp., (CAR-NS) 719 19,3%
P.aeruginosae CAR-NS 756 31,8%
A.baumanni CAR-NS 292 81,2%
European Centre for Disease Prevention and Control. Point prevalence survey of health care associated
infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013.

14. ICU related infections
• Infections occuring after
48h in the ICU
– 87 337 pt (2014)
– 6995 (8%) at least one
HAI
• Of all patsients staying
more then 2 days
– 6% will have PN
– 4% will have BSI
– 3% will have UTI
ECDC Annual Epidemiological report 2016

15. Intubation associated pneumonia
Mean incidence density per ICU was 3,86 PN episodes per 1000 pateint-days
ECDC Annual Epidemiological report 2016

16. Number of isolates and percentage of the most
frequently isolated microorgnism in ICU aquired
PN (2014 EU data)
Microorganism Estonia(N=63) Total(N=9434)
Pseudomonas aeruginosae 15,9% 18,8%
Staphylococcus aureus 17,5% 17,6%
Klebsiella spp. 22,2% 14,1%
Escherichia coli 15,9% 13,4%
Enterobacter spp. 9,5% 9,2%
Candida spp. 7,9% 8,2%
Serratia spp. 1,6% 5,3%
S.maltophila 6,3% 4,9%
Haemophilus spp. 3,2% 4,4%
ECDC Annual Epidemiological report 2016-HAI in ICU, data retrieved from TESSy 22.05.2017

17. ICU-acquired bloodstream infections
• ICU –acquired BSI occures 3,5% of patients
staying more then 2 days in ICU
• Catheter related 48,3 %
• Central vascular catheter utilisation rate was
on average 70,5 CVC-days per 100 pt. days
– Highest in Estonia: 83,0
– Lowest in Slovakia:57,0
– Most frequent isolate: CONS (both in Estonia and
in EU)

18. SSI
• 7 types of surgical
operations incl. hip and
knee prosthesis
• 313 255 HPRO
– SSI 1,1%(0,3-3,5%)
• 189 239 KPRO
– SSI 0,6%(0,0%-3,4%)
No data from Estonia (only
CSEC and CABG)
ECDC Annual Epidemiological report 2013-2014

19. Infection control in EU and in Estonia
Infection control doctors/250
beds
Infection control nurses/250
beds
European Centre for Disease Prevention and Control. Point prevalence survey of health care
associated infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC;
2013.

20. Alcohol hand rub consumption
(l/1000 pateint –days, )
European Centre for Disease Prevention and Control. Point prevalence survey of health care associated
infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013.

21. Single-room beds in EU
European Centre for Disease Prevention and Control. Point prevalence survey of health care associated
infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013.

22. Are HAI preventable?
• Cathter-associated urinary tract infections
(CAUTI) reduced by 70 %
• Surgical site infections by 55 %
• Sepsis due to central lines by > 99 %
Umscheid, C. A., ICHE 2011;32 (2):101-114

23. Multimodal strategy
http://www.who.int/infection-prevention/tools/core-components/en/
Guidelines on core components of infection prevention and control programmes at the national
and acute health care facility level. WHO 2016

24. How ?
Infection control policies
• Adequate staff resources
• Hand hygiene!
• Other standard precautions, enhanced when necessary
• Sufficient isolation facilities
• Epidemiological typing of ‘outbreak’ strains
• Decontamination of patients (MRSA)
• Decontamination of medical equipment (instruments),
environment
• Audit / feedback
• Education and reinforcement
• Environment, materials

25. Infection control department in WTCH
• Surveillance of MDR pathogenes
• Surveillance of nosocomial infections
• Monitoring of AB use
• Monitoring of hospital environment, staff
behaviour in different situations
• Education of staff (AB usage, nosocomial
infections, isolation precautions)
• Consultations in different departments
• Participation in public procurements for hospital
(e.g. gloves, AB, desinfectants)
03.02.2018 25PMärtin

26. Conclusion
• Cornerstone of the HAI prevention is
surveillance
• HAI are related to MDR microbes
• Very few options to treat if HAI and MDR
• Possible solutions?
– Multimodal strategies incl. materials