The presentation is solely meant forAcademic purpose
Capital of Gram negative resistance Poor to absent infection control but burgeoning private healthcare industry with technological advances such as transplants Newer drugs available abroad take time to come What is available is often not affordable Irrational combinations abound due to poor regulatory control Antibiotic pipeline empty
Parameters Western world IndiaCommon Isolates prevalent in ICUs Gram+ves Gram-ves ESBL prevalence in gram –ves Much less Very highPrevalence of ESBLs in last few years Slow increase Rapidly increasing ICU type Mostly closed ICUs Mostly open ICUs Generics Very few Hundreds of genericRestriction of antibiotic prescription Strict Relaxed Guidelines made by western world keeping their issues in mind may not suitable for India. 1 1. Soong JH et al. Am J Infect Control 2008;36:S83-92.
A global study on prevalence of ESBL in K.pneumoniae ofover 86,000 isolates from 266 centers Reinert RR, Low DE, Rossi F, et al. J Antimicrob Chemother (2007) 60:1018–29.
Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study: ◦ 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in the UK, and 73 in other sites in India and Pakistan. ◦ NDM-1 was mostly found among Escherichia coli (36) and Klebsiella pneumoniae (111) ◦ Highly resistant to all antibiotics except tigecycline & colistin ◦ Several of the UK source patients had undergone elective, including cosmetic, surgery while visiting India or Pakistan ◦ “We would strongly advise against such proposals…for UK patients to opt for corrective surgery in India” Lancet Infect Dis 2010;10:597-602
While other countries tackle the problem ◦ US FDA banned off label use of cephalosporins in cattle, swine, chickens, and turkeys effective 5 April 2012. ◦ Since April 2011, in Brazil the use of antimicrobials is no longer allowed without a prescription ◦ Israel implemented a nationwide plan to monitor and control carbapenemase resistant Enterobacteriaceae with an 80% reduction in rates (Clin Infect Dis 2011;52:848)
Our health ministry came out with an excellent document to prevent antimicrobial resistance in April 2011 Shelved it in October 2011!
OTC use banned for drugs in this category Warning boxes that advice against taking except in accordance with medical advice 91 drugs added including most antibiotics and anti-TB drugs May be pruned down to 20-25 drugs Will it be rationally decided? Will it be implemented?
What’s the MRSA rate here, I asked? ◦ What’s that Where’s the hospital antibiogram, I asked? ◦ Anti-what?
April 2001 -establishment of IC program and IC committee -surveillance and hospital antibiogram initiated -one infection control advisor (ID physician) and 3 part time IC nurses appointed -policy on contact isolation of MDRO (MRSA, ESBL, carbapenem resistant Pseudomonas) including one on one nursing approved -respiratory isolation for TB started -500ml alcohol dispensers for hand hygiene approved for installation in all rooms and in other nursing areas -surveillance for central line infections and VAP initiated -needlestick registry and PEP initiated
July 2001 -lecture on infection control to all hospital consultants -puncture proof container for sharps at each bedside provided -towels replaced with disposable tissue paper for drying after handwashing -infection control manual for hospital written and adoptedAugust -meeting with all surgeons on antibiotic2001 prophylaxis guideline formulation -antibiotic protocol for surgical prophylaxis introduced with emphasis on starting antibiotic within one hour of skin incision -antibiotics specified for each type of surgery -duration of post-op antibiotics reduced from 7 to 2-4 days with aim of long term movement towards a single dose
October 2001 -provisional adoption of a surgical prophylaxis policy -infection control week for health care workers organized -free administration of 3 doses of HBV vaccine for all nurses started -standardized protocol for ventilator management introduced -disposable gowns introduced for contact isolation -typhoid vaccine introduced for all food handlers -color coded bins for waste segregation introducedJanuary 2002 -glutaraldehyde storage of forceps on dressing trays eliminated, forceps to be sterilized and packed -formalin tablet fumigation eliminatedMarch 2002 -mandatory wearing of gloves for phlebotomists -finalization of surgical prophylaxis policy -antibiotic prophylaxis duration reduced to 48 hrsApril 2002 -one full time IC nurse appointed -elimination of flimsy plastic gloves, replacement by latex gloves
June 2002 -lab to stop reporting ceftazidime sensitivities, consultants advised not to prescribe drug -single room isolation for all MRSA patients approved -administration of pre-op antibiotic started in OT, not in wardJuly 2002 -IC committee to be notified whenever building works are carried out -same day or previous day admission for elective surgery advised -Staph aureus screening by nasal swabs pre-op initiated for elective surgery -previous day pre-op shaving eliminated for surgery, clipping introducedNovember -central line protocol introduced (sterile placement, removal of femoral2002 lines by day 5, use of antiseptic impregnated catheters for high risk cases)January 2003 -standard precautions and routine protocols for HIV infected patients undergoing surgery introduced -post-exposure prophylaxis emphasized -educational program for HIV introducedJune 2003 -nasal swab screening for Staph aureus eliminated for elective surgery -surveillance for CRBSI and VAP commenced
November -closed bag system for IV fluids introduced on2003 selected basis -removal of femoral lines by day 5 recommended -single use vials recommended for all medications -puncture proof bedside sharps container introducedDecember appropriate barrier precautions introduced2003 whenever building works carried out to prevent Aspergillus outbreaksMarch 2004 -N-95 masks for respiratory isolation introduced -10% povidone iodine to replace lower strengths -antibiotic prophylaxis for surgery reduced to 24hrsMay 2004 switch to collapsible bags for IV fluids hospital wide, elimination of vented plastic bottles
July2004 -use of 2% chlorhexidine for skin preparation prior toAugust 2004: bedside procedures introduced -varicella vaccination for nurses treating high risk neutropenic patients introduced -infection control junior officer appointed to assist infection control advisor -nasal swab screening selectively for MRSA introduced for ICU, with follow up contact isolation and decolonization with mupirocinOctober 2004 100ml handrub dispenser mounted on each bedrail instead of 500ml in each roomJanuary 2005 policy for neutropenic patients introduced (ultra-violet light for room disinfection before use after construction, sign outside door, N-95 masks for patients when transported, elimination of surgical masks for staff)May 2005 -ESBL accepted as a hospital wide problem, isolation discontinued for ward patients -early Foley catheter removal emphasizedOctober 2005 ESBL isolation discontinued hospital wideFebruary -notifiable diseases list drawn up and submitted to Govt2006 periodically -MRSA screening at admission extended for high risk neutropenic patients and step down ICUs
March 2006 -antimicrobial stewardship initiated by restricting carbapenems and linezolid with pharmacy tracking of use of these antibiotics, and IC officer feeding back to consultants after 48 hrs of use -adherence to hand hygiene monitored in ICUJuly 2006 MRSA screening extended to Neurology ICU and high risk neutropenic patientsNovember intensive cleaning of ICU surfaces commenced2006February MRSA screening extended hospital wide2007March 2007 circular issued mandating ID consultation when restricted antibiotics used beyond 48hrsAugust 2007 tigecycline, vancomycin, teicoplanin added to restricted antibioticsJanuary 2008 chlorhexidine bathing for all patients in ICU and oral decontamination for ventilated patients introducedAugust 2008 -elimination of white coats and recommendation against long sleeves, ties and wrist watches -teicoplanin and vancomycin removed, polymyxins added to restricted antibiotics list
Antibiogram formulated for E.coli, Klebsiella, Staph aureus, Pseudomonas, Enterococcus Updated every 3 months Circulated to all clinicians Surveillance initiated Antibiogram ◦ VAP, CRBSI, CAUTI ◦ Rates of MDR-O monitored
Most Indian hospitals not constructed with plumbing at each bedside Greater the distance to basin, lazier we all get to hand wash! Microbiologically superior to hand washing unless hands visibly soiled Less skin damage than soap Have to have one per patient
Infectivity Prevention Perceived after stick threatHepatitis B 30% Vaccine LowHepatitis C 3% None NoneHIV 0.3% Post exposure High prophylaxis
Recombinant DNA vaccine given in 3 doses at 0, 1 & 6 mths Gluteal administration contra-indicated Successful vaccination indicated by antibody to HbsAg>10 mIU/ml
Consists of zidovudine 300 mg bd & lamivudine 150 mg bd for 4 weeks Second drug necessary only to cover the possibility of zidovudine resistance Of 18 documented failures of zidovudine, 8 involved source patients on zidovudine Usually not warranted for mucosal and intact skin exposures Start ASAP, definitely within 24 hrs
For patients with multi-resistant bacteria Consists of standard precautions plus unsterile gloves whenever patient is touched, then handwashing or hand rub immediately Plastic gowns if extensive patient contact Dedicated equipment eg stethoscope, BP apparatus and thermometer Sign at head of bed Single room or cohort nursing for MRSA One on one nursing essential
SARS in 2003 was when we introduced N-95 mask concept H1N1 in 2009 was a challenge ◦ Treated a large no of patients without a hospital outbreak ◦ Vaccination of employees introduced
Outbreak of XDR-TB in South Africa was mainly nosocomial Healthcare workers get active TB at rate of 5.8% annually in developing countries, well above general population Smear negative TB is also transmissible though 4 times less likely, accounts for 13% of all cases (Clin Infect Dis 2008;47:1135) MDR-TB 5-6 times more infectious than historical controls (PLoS Med 2008;5:e188) Three types of strategies: ◦ Administrative controls eg Mantoux for HCW ◦ Environmental controls ◦ Personal protection eg N-95 masks
Mechanical ventilation delivering negative pressure and 12 air changes per hour ◦ Costly, needs maintenance, may function poorly ◦ Needed for inpatient rooms, bronchoscopy Natural ventilation ◦ High ceilings, large windows, open doors & windows ◦ Can provide up to 40 air changes per hour ◦ Applicable to OP settings and HIV settings ◦ Fails in extreme climates when windows closed Upper room ultra-violet light ◦ Reduces airborne transmission by 70% ◦ Applicable to waiting room areas
Common, seen in 10-20% of patients ventilated for >48 hrs Intubation for mechanical ventilation increases the risk for pneumonia 3x to 21x !AJRCCM 2002; 165:867-903
Ventilator Associated PneumoniaSemi recumbent postureAvoid routine stress ulcer prophylaxis;sucralfate is better (when needed)Subglottic suctioningAvoid tubing change q 24 hoursSelective decontamination of the digestivetractAvoid nasal intubationRef: N Engl J Med 1999;340:627-34
Catheter Related Bloodstream Infection:(CRBSI)Clinical catheter site infection (or)Systemic signs of sepsis (c no other source)ANDPositive catheter culture(quantitative / semi quantitative)ANDSame organism cultured in peripheral blood
Hand hygieneFull Sterile barrier @ placementChlorhexidine is better thanpovidone iodine site prepPrefer subclavian site, avoid femoralAntibiotic-impregnated cathetersRemove catheter when not requiredMMWR 2002; 51: RR-10N Engl J Med 2003;348:1123-33.N Engl J Med 2006;355:2725
Contamination rates in one study from 1974: ◦ bottle: 13% ◦ burette: 7% ◦ bag: 0.7% Switched to viaflex collapsible bags Avoided micro-infusion sets and vents Used infusion pumps instead Am J Hosp Pharmacy 1974;31:961
Use viaflex collapsible bags which do not need vents in preference to vented plastic or glass bottles Drops infection rate from 6.52 to 2.36 per 1000 line days West switched 30 years ago Am J Infect Control 2004;32:135
Clinical Culture based Outpatient follow-up Feedback Can reduce SSI rates by 35-50% Stratify monitoring to high risk group
Admission immediately pre-op Same day clipping instead of shaving Avoiding hypothermia Giving 1st dose antibiotic within 1 hr pre-incision Stopping antibiotics within 24 hrs
Prospective audit, intervention and feedback is the cornerstone Antibiotic forms introduced Special focus on surgical prophylaxis
Better implementation of antimicrobial stewardship Better adherence to hand hygiene regulations Checklist approach Need tighter regulatory control by authorities ◦ Antibiotics ◦ Hospital infection control programs ◦ Accreditation
Motion-activated video cameras were strategically located throughout a medical intensive care unit Clin Infect Dis 2012 54: 1-7