Multiresistant bacteria

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Old and new insights into multiresistant bacteria

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Multiresistant bacteria

  1. 1. Multiresistant bacteria in conflict between theory and practice 16th September 2011, Düsseldorf Old and new insights into multiresistant bacteria <ul><li> h  m  i  </li></ul><ul><li>hygiene  microbiology  infectious diseases </li></ul><ul><li>Prof. Dr. med. B. Wille </li></ul><ul><li>Doctor of hygiene and environmental medicine </li></ul><ul><li>Doctor of microbiology, virology and the epidemiology of infection </li></ul>16.09.2011 - MRE - Düsseldorf
  2. 2. 16.09.2011 - MRE - Düsseldorf Deaths (per 100 000 citizens) due to infection in the U.S.A., 1900-1996 Influenza Pandemic First use of penicillin
  3. 3. <ul><li>1962: </li></ul><ul><li>“ It‘s time to close the book on infectious diseases“ </li></ul><ul><li>(Quoted by a senior American health official) </li></ul>16.09.2011 - MRE - Düsseldorf
  4. 4. <ul><li>Definition </li></ul><ul><li>of multiresistant </li></ul><ul><li>bacteria? </li></ul>16.09.2011 - MRE - Düsseldorf
  5. 5. <ul><li>List of known viruses according to § 23 Abs. 1 S. 1 </li></ul><ul><li>Types of bacteria: resistance to the following substances has been tested in the framework of clinical-microbiological diagnostics. </li></ul><ul><li>1 S. aureus: </li></ul><ul><li>Vancomycin, Oxacillin , Gentamicin, Quinolone Gr. IV (e.g. Moxifloxacin), Teicoplanin, </li></ul><ul><li>Quinupristin / Dalfopristin </li></ul><ul><li>2 S. pneumoniae: </li></ul><ul><li>Vancomycin, Penicillin (Oxacillin 1 µg), Cefotaxim, Erythromycin, Quinolone Gr. IV </li></ul><ul><li>(e.g. Moxifloxacin) </li></ul><ul><li>3 E. faecalis / E. faecium: </li></ul><ul><li>Vancomycin , Gentamicin (“high level”: Gentamicin 500 mg/l; Streptomycin </li></ul><ul><li>1000 mg/l (Mikrodil.) or 2000 mg/l (Agardil.), Teicoplanin </li></ul><ul><li>E. faecium: zusätzlich Quinupristin / Dalfopristin </li></ul><ul><li>4 E. coli / Klebsiella spp.: </li></ul><ul><li>Imipenem / Meropenem, Quinolone Gr. II (e.g. Ciprofloxacin), Amikacin, Ceftazidim, </li></ul><ul><li>Piperacillin / Tazobactam, Cefotaxim or analogous test substances </li></ul><ul><li>5 Enterobacter cloacae / Citrobacter spp. / Serratia marcescens: </li></ul><ul><li>Imipenem / Meropenem, Chinolon Gr. II (e.g. Ciprofloxacin), Amikacin </li></ul><ul><li>6 P. aeruginosa / A. baumannii: : Imipenem / Meropenem, Quinolone Gr. II </li></ul><ul><li>(e.g. Ciprofloxacin), Amikacin, Ceftazidim, Piperacillin / Tazobactam </li></ul><ul><li>7 S. maltophilia: Quinolone Gr. II (e.g. Ciprofloxacin), Amikacin, Ceftazidim, Piperacillin / </li></ul><ul><li>Tazobactam, Cotrimoxazol </li></ul><ul><li>8 Candida spp. * Fluconazol * </li></ul><ul><li>Only recorded in establishments with haemotological-oncological departments. For the main resistant species the leading resistances are in bold and underlined. </li></ul>Multiresitant bacteria 2010 16.09.2011 - MRE - Düsseldorf
  6. 6. Causes of MRB <ul><li>1. Misuse of antibiotics in medicine </li></ul><ul><li>- MRSA: Gyrase inhibitors </li></ul><ul><li>- ESBL: 3rd generation Cephalosporines </li></ul><ul><li>- VRE: Vancomycin use </li></ul><ul><li>2. Reduced cost of valuable antibiotics </li></ul><ul><li>3. Use of antibiotics in veterinary medicine/ intensive farming </li></ul>16.09.2011 - MRE - Düsseldorf
  7. 7. 16.09.2011 - MRE - Düsseldorf Rate of multiresistant bacteria per 1,000 patient days
  8. 8. Increase in resistance through use of antibiotics <ul><li>Increase in Quinolone use of around 1 % </li></ul><ul><li> After one month, increase in the incidences of nosocomial ESBL infections reached </li></ul><ul><li>4.43 % </li></ul>16.09.2011 - MRE - Düsseldorf
  9. 9. Increase in resistance through antibiotic use <ul><li>Increase in the use of </li></ul><ul><li>3rd Generation Cephalosporins over 12 weeks: </li></ul><ul><li> Doubling of ESBL-related nosocomial infections </li></ul>16.09.2011 - MRE - Düsseldorf
  10. 10. A common wrong interpretation: <ul><li>Out of the 600,000 new incidences per year in Germany </li></ul><ul><li>“ only“ 5-10 % are due to multiresistant bacteria! </li></ul>16.09.2011 - MRE - Düsseldorf
  11. 11. 16.09.2011 - MRE - Düsseldorf Basic principle of MRB MRB are not different from bacterial infections apart from by their RESISTANCE TO ANTIBIOTICS This means: - They transfer from person to person easily - They are capable of surviving (epidemic MRSA strains)? - Disinfection treatments have limitations *Discussion: Is MRSA connected to increased virulence?
  12. 12. <ul><li>New concept for multi-resistent bacteria </li></ul><ul><li>ESKAPE </li></ul><ul><li>(bad bugs, no drugs: </li></ul><ul><li>no ESKAPE) </li></ul>16.09.2011 - MRE - Düsseldorf
  13. 13. <ul><li>E : Enterococcus faecium </li></ul><ul><li>S : Staphyloccocus aureus </li></ul><ul><li>K : Klebsiella pneumoniae </li></ul><ul><li>A : Acinetobacter baumannii </li></ul><ul><li>P : Pseudomonas aeruginosa </li></ul><ul><li>E : Enterobacter species </li></ul>Eskape 16.09.2011 - MRE - Düsseldorf
  14. 14. MRSA-related deaths in Intensive Care Units <ul><li>KISS-Data: 274 ICUs / 505487 Patients </li></ul><ul><li>6,888 Pneumonia 1,851 S. aureus </li></ul><ul><li>2,357 Primary Septicaemia 378 S. aureus </li></ul><ul><li>Pneumonia: </li></ul><ul><li>105 of 1502 MSSA   (  7 %) </li></ul><ul><li>59 of 349 MRSA   (  16.9 %) </li></ul><ul><li>Primary Septicaemia: </li></ul><ul><li>17 of 283 MSSA   (  6 %) </li></ul><ul><li>16 of 95 MRSA   (  16.8 %) </li></ul><ul><li>Gastmeier et al.: Mortality Risk Factors with Nosocimial S. aureus </li></ul><ul><li>Infections in Intensive Care Units </li></ul><ul><li>Infection 2005; 33: 50-55 </li></ul>16.09.2011 - MRE - Düsseldorf
  15. 15. <ul><li>ESBL – clinical significance </li></ul><ul><li>Seoul, Children‘s hospital. Bacteremia with E. coli & K.pneumoniae: </li></ul><ul><li>Lethality ESBL +: 26,7%; ESBL -: 5,7 % p=0.001 </li></ul><ul><li>Kim et al. AAC 2002; 46: 1481-91 </li></ul><ul><li>Los Angeles;  Alter 56y, Bacteremia with E. coli & K. pneumoniae: </li></ul><ul><li>Failure of initial treatment: </li></ul><ul><li>ESBL+: 82 %; ESBL -: 20 %; p=0.009 </li></ul><ul><li>Wong-Beringer et al. CID 2002; 34: 135-46 </li></ul>16.09.2011 - MRE - Düsseldorf
  16. 16. Profile: MRSA / MRSE <ul><li>Omnipotent pyogenic organism </li></ul><ul><li>MRSA: strong tendency to spread, also among out-patients </li></ul><ul><li>Outbreaks are falling </li></ul><ul><li>Large general interest </li></ul>16.09.2011 - MRE - Düsseldorf
  17. 17. MRSA in Germany (2008) <ul><li>Resistance (in %) against other selected antibiotics </li></ul>16.09.2011 - MRE - Düsseldorf 2006 2007 2008 Ciprofloxacin 93.8 97.8 91.1 Moxifloxacin - 94.4 89.6 Clindamycin 65.4 72.0 73.4 Gentamycin 13.3 9.8 10.5 Oxytetrazyklin 7.4 6.8 7.8 Rifampicin 2,5 1,1 0.4 Cotrimoxazol 3.1 2.0 10.8 Fosfomycin 3.3 0.6 1.1 Linezolid 0.04 0.11 0.1 Muporizin 2.6 3.3 5.3
  18. 18. MRSA and other multiresistant bacteria <ul><li>Frequency of multiresistant bacteria in German hospitals </li></ul><ul><li>MRSA: </li></ul><ul><ul><li>1990: 1.7 % </li></ul></ul><ul><ul><li>1998: 15.2 % </li></ul></ul><ul><ul><li>2001: 20.7 % </li></ul></ul><ul><li>(MRSA proportion of all S. aureus isolates) </li></ul><ul><li>ICUs: 2003 > 30 % </li></ul><ul><li>Retirement and care homes: 1-3% of patients </li></ul><ul><li>(Source PEG, 2003) </li></ul>16.09.2011 - MRE - Düsseldorf
  19. 19. <ul><li>Breakdown of MRSA </li></ul><ul><li>ha-MRSA (hospital acquired-MRSA) </li></ul><ul><li>ca-MRSA: community acquired (community associated MRSA) </li></ul><ul><li>la-MRSA: lifestock-associated MRSA </li></ul><ul><li>(presumably low infectivity und pathogenicity from la-MRSA ST 398) </li></ul>16.09.2011 - MRE - Düsseldorf
  20. 20. <ul><li>Saarland (from 18/10 to 12/12/2010) </li></ul><ul><li>All registered in-patients during this time period </li></ul><ul><li>Results: </li></ul><ul><li>More than 80%, 90% in some hospitals </li></ul><ul><li> around 20,000 patients with a total of 405 positive results </li></ul><ul><li>corresponding prevalence around 0.52 % </li></ul>New data from MRSA screening 16.09.2011 - MRE - Düsseldorf
  21. 21. 16.09.2011 - MRE - Düsseldorf Reduction of nosocomial MRSA infections after the introduction of MRSA screening with the LightCycler MRSA advanced test in the Southwest clinical network, Germany (colours correspond with areas within the network), Number of ha-MRSA infections/colonisations New screening implemented
  22. 22. An increased risk for an MRSA colonisation in line with RKI* recommendations exists for: <ul><li>Patients with known MRSA anamnesis </li></ul><ul><li>Transfers from regions/establishments with a known high MRSA prevalence </li></ul><ul><li>In-patients who have stayed in hospital for more than 3 days in the last 12 months </li></ul><ul><li>Patients who have direct (occupational) contact with animals and agricultural animal feed (pigs) </li></ul><ul><li>In-patients who during their stay have had contact with MRSA carriers (e.g. by staying in the same room) </li></ul>16.09.2011 - MRE - Düsseldorf * Robert Koch Institute, Germany
  23. 23. An increased risk for an MRSA colonisation in line with RKI recommendations exists for: <ul><li>6. Patients with two or more of the following risk factors: </li></ul><ul><li>They are in need of constant care </li></ul><ul><li>They have had a course of antibiotics in the last 6 months </li></ul><ul><li>They have a catheter (e.g. bladder catheter, PEG tube) </li></ul><ul><li>They have dialysis </li></ul><ul><li>They have skin ulcers/ gangrene/ chronic wounds/ deep infection of soft tissues </li></ul><ul><li>They have burns </li></ul>16.09.2011 - MRE - Düsseldorf
  24. 24. The microbiological screening rules include: - A swab of the nose, mouth and - A swab of wounds if necessary 16.09.2011 - MRE - Düsseldorf If the MRSA results are positive (ICD-10: U 80.0): Take hygiene measures (see text) Recommended measures include isolation If the MRSA results are negative: Standard hygiene practices Source: Epi. Bull. 46/2004
  25. 25. <ul><li>Isolation in a single room: 84.5 % </li></ul><ul><li>Protective overalls: > 90 % </li></ul><ul><li>Gloves: > 90 % </li></ul><ul><li>Covered mouth or nose: > 85 % </li></ul><ul><li>Covered head: 40-50 % (more nurses than doctors) </li></ul><ul><li>Surface disinfection: daily, almost without exception </li></ul>New MRSA results (Results of a survey from the DGKH* and the BVÖGD**, Autumn 2010) 16.09.2011 - MRE - Düsseldorf *Deutsche Gesellschaft f ür Krankenhaushygiene (German Society for Hospital Hygiene) **Bundesverband der Ärztinnen und Ärzte des Öffentlichen Gesundheitsdienstes (German Federal Association of Doctors in the Public Health Service)
  26. 26. <ul><li>Sanitation of MRSA positive patients: 60% antiseptic washes/showers </li></ul><ul><li>Mupirocin nose salve: 52 % </li></ul><ul><li>antiseptic mouthwash: 43 % </li></ul><ul><li>Entry screening: 38 % refer to the KRINKO* recommendations! </li></ul>New MRSA results (Results of a survey from the DGKH and the BVÖGD, Autumn 2010) 16.09.2011 - MRE - Düsseldorf *Kommision f ür Krankenhaushygiene und Infektionsprävention (The Commission for Hospital Hygiene and Infection Control)
  27. 27. <ul><li>Summary: </li></ul><ul><li>In 8-12 % of hospitals the MRSA patient recommendations were not satisfactorily applied. </li></ul><ul><li>78 % carry out the risk-based screening with at least 50% of the KRINKO recommendations. </li></ul><ul><li>Source: Hyg. Med. 2011; 36-6, pp. 254-255 </li></ul>New MRSA results (Results of a survey from the DGKH and the BVÖGD, Autumn 2010) 16.09.2011 - MRE - Düsseldorf
  28. 28. MRSA <ul><li>General characteristics of MSSA and MRSA </li></ul><ul><li>Transfer: Predominately through </li></ul><ul><ul><ul><ul><li>physical contact (particularly hands!) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Aerogens (dust, droplets) </li></ul></ul></ul></ul><ul><li>Virulence </li></ul><ul><ul><ul><ul><li>depends on the strain! </li></ul></ul></ul></ul><ul><li>Contagiousness: depends on the strain and the patient </li></ul><ul><li>Mode of infection: both endogenous and exogenous </li></ul>16.09.2011 - MRE - Düsseldorf
  29. 29. MRSA and other multiresistant bacteria <ul><li>Bacteria-related measures for MRSA </li></ul><ul><li>Strict isolation (including “just“ colonisation cases) </li></ul><ul><li>Adequate therapy </li></ul><ul><li>Sanitisation </li></ul><ul><li>Prevent re-colonisation </li></ul><ul><li>Avoid postponments in hospital </li></ul><ul><li>Epidemiological recording/ analysis </li></ul>16.09.2011 - MRE - Düsseldorf
  30. 30. Psychological aspects of isolation <ul><li>- Measures: </li></ul><ul><li>Keep isolated patients better informed </li></ul><ul><li>Show understanding for the unusual situation </li></ul><ul><li>For longer periods of isolation: a room with a toilet </li></ul><ul><li>A bathroom for shared rooms </li></ul><ul><li>Adequate number of staff on wards </li></ul><ul><li>Daily contact with the ward‘s doctor (very important!) </li></ul><ul><li>Facilitate flexible visiting hours </li></ul><ul><li>Aim for individual isolation (thereby protecting personal space) </li></ul><ul><li>When entering the room, staff should always introduce themselves </li></ul><ul><li>Always maintain hygiene measures </li></ul>16.09.2011 - MRE - Düsseldorf C. Hartmann: Wie erleben Patienten die Isolation im Krankenhaus aufgrund einer Infektion o. Kolonisation mit MRSA* Hyg. Med. 30. Jg. 2005 - Issue 7/8, S. 234 - 243 *How patients experience isolation in hospital due to MRSA infection or colonisation
  31. 31. c-MRSA <ul><li>Occurs along with: </li></ul><ul><li>Deep skin infection (USA, Australia) </li></ul><ul><li>Invasive infections such as Septicaemia, Endocarditis, Osteomyelitis </li></ul><ul><li>in prisons, homosexual scenes, sailors </li></ul><ul><li>It is possibly brought into hospitals </li></ul><ul><li>USA: Puerperal Mastitis </li></ul>16.09.2011 - MRE - Düsseldorf
  32. 32. Profile: VRE <ul><li>VR-E. faecalis </li></ul><ul><li>VR-E. faecium </li></ul><ul><li>among others </li></ul><ul><li>No marked virulence </li></ul><ul><li>Found in the bowels </li></ul><ul><li>Survival ability: high environmental resistance </li></ul><ul><li>Not particularly adhesive </li></ul><ul><li>Immunodeficient patients at risk </li></ul><ul><li>Nevertheless: outbreaks (oncology) </li></ul>16.09.2011 - MRE - Düsseldorf
  33. 33. MRSA and other multiresistant bacteria <ul><li>Epidemiology Glycopeptide-Resistant Enterococci </li></ul><ul><li>(VRE - GRE) </li></ul><ul><li>USA: from 1989 0.4 % general wards / 0.6 % ICUs </li></ul><ul><ul><li>2002 : 76.3 % with E. faecium / 4.5 % with E. faecalis </li></ul></ul><ul><li>Europe: high rates in England, Italy, Portugal, Greece </li></ul><ul><li>Germany: E. faecium 5 % maximum </li></ul><ul><li>E. faecalis < 1 % </li></ul>16.09.2011 - MRE - Düsseldorf
  34. 34. VRE <ul><li>Strains/ mechanisms </li></ul><ul><li>of Glycopeptid-Resistence 1 </li></ul><ul><li>5 strains </li></ul><ul><li>“ Acquired resistance“: VanA, VanB, VanD, VanE </li></ul><ul><li>“ Natural resistance“: VanC with 3 subdivisions </li></ul><ul><ul><ul><li>VanC1 (E. gallinarum) </li></ul></ul></ul><ul><ul><ul><li>VanC2 </li></ul></ul></ul><ul><ul><ul><li>VanC3 (E. casselliflavus / E. flavescens) </li></ul></ul></ul><ul><ul><ul><li>Cross-resistance between VAN and TPL </li></ul></ul></ul>16.09.2011 - MRE - Düsseldorf
  35. 35. Profile: ESBL ( Extended-Spectrum Beta-Lactamases ) <ul><li>Concerning Enterobacteria (E. coli, Klebsiella spp., among others) but also non-fermenters (P. aeruginosa, Acinetobacter sp., Stenotrophomonas maltophilia, among others) </li></ul><ul><li>= not a uniform group </li></ul><ul><li>Resistance: particularly against 3rd and 4th generation cephalosporine </li></ul><ul><li>Survival ability: love humid environments </li></ul><ul><li>Bowels, humid biotop </li></ul><ul><li>Not particularly adhesive (except for P. aeruginosa -> biofilms) </li></ul>16.09.2011 - MRE - Düsseldorf
  36. 36. MRSA and other multiresistant bacteria <ul><li>ESBL </li></ul><ul><li>( Extended-Spectrum Beta-Lactamases ) show </li></ul><ul><li>resistance to 2nd and 3rd generation Gephalosporins: </li></ul><ul><ul><li>Germany < 1 -5 % </li></ul></ul><ul><ul><li>Southern European countries up to 30 % </li></ul></ul><ul><ul><li>India up to 70 % </li></ul></ul><ul><ul><li>20 recorded cases of outbreaks in retirement and care homes </li></ul></ul><ul><li>No data for: </li></ul><ul><li>Pseudomonas aeruginosa / </li></ul><ul><li>Stenotrophomonas maltophilia, Acinetobacter sp. </li></ul>16.09.2011 - MRE - Düsseldorf
  37. 37. 16.09.2011 - MRE - Düsseldorf Development of the rate of 3 rd Generation Cephalosporin resistant E. coli Average ESBL strains make up a growing proportion of E. coli-isolates in German ICUs Month/Year y axis: percent of resistant bacteria
  38. 38. 16.09.2011 - MRE - Düsseldorf <ul><li>ESBL – clinical significance </li></ul><ul><li>Seoul, Children‘s hospital. Bacteremia with E. coli & K.pneumoniae: </li></ul><ul><li>Lethality ESBL +: 26,7%; ESBL -: 5,7 % p=0.001 </li></ul><ul><li>Kim et al. AAC 2002; 46: 1481-91 </li></ul><ul><li>Los Angeles;  Alter 56y, Bacteremia with E. coli & K. pneumoniae: </li></ul><ul><li>Failure of initial treatment: </li></ul><ul><li>ESBL+: 82 %; ESBL -: 20 %; p=0.009 </li></ul><ul><li>Wong-Beringer et al. CID 2002; 34: 135-46 </li></ul>
  39. 39. <ul><li>Costs due to multiresistant gram-negative bacteria vs. MRSA </li></ul><ul><li>F. Dachsböck, Medizinische Universität Wien (Medical University Vienna) </li></ul><ul><li>Hyg. Med. 31. Jahrgang 2006 – Issue 6, pp. 284-285 </li></ul><ul><li>n/MRGRN: 99 </li></ul><ul><li>n/MRSA: 74 </li></ul><ul><li>Length of stay in both groups: </li></ul><ul><li>+ 6 days compared with normal patients </li></ul><ul><li>Cost per patient with MRGN:  12,429 EUR </li></ul><ul><li>Cost per patient with MRSA:  4,545 EUR </li></ul>16.09.2011 - MRE - Düsseldorf
  40. 40. ESBL Principles <ul><li>ESBL is considerably less persistent on surfaces, appliances, hands and protective clothing than MRSA and VRE. </li></ul><ul><li>The airborne transmission of ESBL plays a secondary role as it does for nosocomial infection bacteria generally. </li></ul>16.09.2011 - MRE - Düsseldorf
  41. 41. <ul><ul><li>3rd generation Cephalosporin-resistant Enterobacteria (CRE) </li></ul></ul><ul><ul><li>Quinolone and 3rd generation Cephalosporin-resistant Enterobacteria (Chin-CRE) </li></ul></ul><ul><ul><li>Carbapenem-resistant Enterobacteria (Carb-CRE) </li></ul></ul><ul><ul><li>Consensus recommendation, Baden-Württemberg: Umgang mit Patienten mit hochresistenten Enterobakterien inkl. ESBL-Bildnern*, Hyg.-Med. 2010; 35 (1/2), pp. 40-45 </li></ul></ul>Management of antibiotic resistant Enterobacteria 16.09.2011 - MRE - Düsseldorf *Dealing with patients with high resistant Enterobacteria including ESBL-producers
  42. 42. <ul><li>Infected patients </li></ul><ul><ul><ul><li>Stool </li></ul></ul></ul><ul><ul><ul><li>Urine </li></ul></ul></ul><ul><ul><ul><li>Anogenital region </li></ul></ul></ul><ul><ul><ul><li>Respiratory tract (rarer) </li></ul></ul></ul><ul><li>Colonisation of the bowels of staff of healthcare establishments </li></ul>Sources of infection for CRE: 16.09.2011 - MRE - Düsseldorf
  43. 43. <ul><li>Longer patient stays, particularly in ICUs </li></ul><ul><li>Stays in long-term care facilities </li></ul><ul><li>Antibiotic use (3rd generation Cephalosporins, SXT, Ciprofloxacin) </li></ul><ul><li>Transurethral catheter, intubation, tracheotomy, gastrostomy </li></ul><ul><li>Decubital ulcers </li></ul><ul><li>Heavy need for care </li></ul>Risks from CRE: 16.09.2011 - MRE - Düsseldorf
  44. 44. <ul><li>Dependent on details about antibiotic resistance </li></ul><ul><li>Dependent on the type of ward </li></ul><ul><li>First requirement: a series of Chin-CRE und Carb-CRE negative swabs </li></ul><ul><li>Carb-CRE: always placed in single room </li></ul><ul><li>Chin-CRE: room isolation if necessary </li></ul><ul><li>(Consensus recommendations, Baden-Württemberg) </li></ul>Proposed measures for CRE 16.09.2011 - MRE - Düsseldorf
  45. 45. MBL-producers = Metallo-Beta-Lactamase-producers <ul><li>For infections with ESBL-producers regular therapy with Carbapenems is recommended: </li></ul><ul><li>Imipenem </li></ul><ul><li>Meropenem </li></ul><ul><li>Doripenem </li></ul><ul><li>Ertapenem </li></ul><ul><li>Start educating about </li></ul><ul><ul><ul><li>Carbapenemases and </li></ul></ul></ul><ul><ul><ul><li>Metallo-Beta-Lactamases </li></ul></ul></ul>16.09.2011 - MRE - Düsseldorf
  46. 46. MBL 16.09.2011 - MRE - Düsseldorf Carbapenemase-producers discovered so far The phenomenon of Carbapenem resistance is not new; 4 different resistance mechanisms are currently known Italy Turkey India
  47. 47. MBL <ul><li>Cabapenemase/ Metallo-Beta-Lactamase Development </li></ul><ul><li>VIM, 1999 Italy </li></ul><ul><li>KPC, 2001 USA </li></ul><ul><li>OXA 48, 2004 Turkey </li></ul><ul><li>NDM-1, 2008, India </li></ul><ul><li>Affected bacteria: </li></ul><ul><li>Klebsiellen, A. baumannii, E. coli, </li></ul><ul><li>E. cloacae, P. aeruginosa u.a. </li></ul><ul><li>Actual data from Germany: </li></ul><ul><li>NRZ* 1/1/11 to 28/2/11 </li></ul><ul><li>66 strains nationwide, particularly Berlin, North Rhine-Westphalia, Baden-W ürttermberg </li></ul><ul><li>- At the time, no recommendations made regarding screening or specific measures </li></ul>16.09.2011 - MRE - Düsseldorf * Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen (National Reference Centre for the Surveillance of Nosocomial Infections)
  48. 48. ESBL / MBL <ul><li>Applicable antibiotics: </li></ul><ul><li>Tigecycline </li></ul><ul><li>Colistin </li></ul><ul><li>Fosfomycin </li></ul><ul><li>Combinations </li></ul><ul><li>Pharmacokinetics and side effects! </li></ul><ul><li>Pan-resistance possible </li></ul><ul><li>(Tigecycline: higher mortality rate) </li></ul>16.09.2011 - MRE - Düsseldorf
  49. 49. <ul><li>Hygiene measures for patients with </li></ul><ul><li>MBL colonisation/infection </li></ul><ul><li>Generally the same as ESBL: </li></ul><ul><ul><li>Gloves/overalls </li></ul></ul><ul><ul><li>Hygenic disinfection of hands </li></ul></ul><ul><ul><li>Basic hygiene measures! </li></ul></ul><ul><ul><li>Individual treatment only if high risk of pathogens spreading (diarrhoea, large open wounds, tracheotomy etc.) </li></ul></ul>16.09.2011 - MRE - Düsseldorf
  50. 50. Measures for ESBL <ul><li>Isolation </li></ul><ul><li>Customised solution for every house </li></ul><ul><li>In unproblematic cases no isolation </li></ul><ul><li>Screening </li></ul><ul><li>Use not yet established, possibly to be considered for selected situations </li></ul><ul><li>(Eich, 2006) </li></ul>16.09.2011 - MRE - Düsseldorf
  51. 51. Measures for ESBL <ul><li>Decolonisation: </li></ul><ul><li>No sustained success documented </li></ul><ul><li>Problems: </li></ul><ul><ul><ul><li>Quinolone resistance </li></ul></ul></ul><ul><ul><ul><li>General development of resistance </li></ul></ul></ul><ul><ul><ul><li>Other areas with colonisation (Nasopharynx: Iodopovidone: J Hosp Infect 2001; 48: 207-213.) </li></ul></ul></ul>16.09.2011 - MRE - Düsseldorf
  52. 52. Aspects of hospital hygiene for outbreaks of multiresistant bacteria <ul><li>Measures to avoid MRB </li></ul><ul><li>1. General antibiotic therapy </li></ul><ul><li>2. Antibiotic therapy for patients with MRE in accordance with regulations </li></ul><ul><li>3. Quick sanitisation (Example: MRSA) </li></ul><ul><li>4. Discharge patients quickly if possible </li></ul><ul><li>5. BASIC HYGIENE!!! </li></ul>16.09.2011 - MRE - Düsseldorf
  53. 53. <ul><li>Increase in the use of alcoholic hand disinfectants of around 1 % </li></ul><ul><li> after 4 months </li></ul><ul><li>Reduction in incidences of infection by around </li></ul><ul><li>7 % </li></ul>Basic hygiene/ Disinfection of hands 16.09.2011 - MRE - Düsseldorf
  54. 54. MRSA <ul><li>Measures </li></ul><ul><li>Sanitisation </li></ul><ul><li>Skin: </li></ul><ul><li>Most important principle: Wash when possible! </li></ul><ul><li>Varied handwashes ( no antiseptics!) </li></ul><ul><ul><li>Reduces skin irritation </li></ul></ul><ul><li>Complete body wash </li></ul><ul><ul><li>Alternative: “wash“ without water with wipes impregnated with active agents. </li></ul></ul>16.09.2011 - MRE - Düsseldorf
  55. 55. MRSA <ul><li>Measures </li></ul><ul><li>Sanitisation </li></ul><ul><li>Mouth: </li></ul><ul><li>Various solutions </li></ul><ul><li>(Polyhexanide/ PVP-I/ Octenidine/ others) </li></ul>16.09.2011 - MRE - Düsseldorf
  56. 56. MRSA <ul><li>Measures </li></ul><ul><li>Preventing recontamination in the area </li></ul><ul><li>Change clothing/ underwear daily </li></ul><ul><li>Change beds daily </li></ul><ul><li>Electric tootbrushes/ razers (wet) </li></ul><ul><li>Disinfect dentures </li></ul><ul><li>Disinfect personal belongings and everyday items </li></ul>16.09.2011 - MRE - Düsseldorf
  57. 57. MRSA <ul><li>Measures </li></ul><ul><li>Take action on failures in hygiene </li></ul><ul><li>Most recontamination in same areas! </li></ul><ul><li>Switch to other agents? </li></ul><ul><li>Second attempt is worth it but have a more stringent course of action </li></ul>16.09.2011 - MRE - Düsseldorf
  58. 58. <ul><li>Not enough staff: more deaths </li></ul><ul><li>ICUs with high staff numbers: </li></ul><ul><li>17 % patient deaths </li></ul><ul><li>ICUs with low staff numbers: </li></ul><ul><li> 45 % patient deaths </li></ul><ul><li>Increase in staff numbers monitored over 4 years: </li></ul><ul><li> Number of patient deaths dropped from 34 to 18 % </li></ul><ul><li>Tarnoff-Mordi WO, How C, Warden A, Shearer AJ: Hospital mortality in relation to staff work </li></ul><ul><li>load: 4-year-study in adult intensive-care unit Lancet 2000; 356: 185-189 </li></ul>Prospects and limitations of hygiene 16.09.2011 - MRE - Düsseldorf
  59. 59. Louis Pasteur 1895: <ul><li>“ The microbes always have the last word!“ </li></ul>16.09.2011 - MRE - Düsseldorf

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