2. AMR AND INFECTION PREVENTION
There are two main ways of tackling AMR:
• To reduce and control consumption of antimicrobial agents in both
human beings and animals
• To prevent the spread of antibiotic resistant microorganisms –
especially among human beings
Both ways have to go hand in hand in order to prevent the further
development and escalation of AMR
Textbox in DANMAP 2018 describing the Danish infection control
program and national guidelines for AMR
Guidelines on AMR, St Petersburg December 2019 2
3. GUIDELINES FOR AMR
2 important national guidelines for infection prevention and control:
• National guideline on universal precautions
• National guideline on isolation precautions
2 important national guidelines on AMR from the Danish Health Authority:
• Guidance on Preventing the Spread of MRSA (3rd edition 2016)
• Guidance on Preventing the Spread of CPO (1st edition 2018)
Appendices to the guidelines with detailed instructions on AMR infection
prevention and control are published on the SSI site at www.ssi.dk
Infection prevention and control guidance on vancomycin-resistant
enterococci (VRE) in National guideline on isolation precautions
Big challenges with VRE – a common AMR-guideline in the future?
Guidelines on AMR, St Petersburg December 2019 3
4. MODE OF TRANSMISSION: CONTACT
Direct contact means a direct physical contact between the
infected person and the susceptible person
Indirect contact, e.g. via hands and equipment
Guidelines on AMR, St Petersburg December 2019 4
5. HOW CAN WE PREVENT CONTACT TRANSMISSION?
By using universal precautions – both in ”peacetime” and during outbreaks
» Hand hygiene – HCW, patients and relatives
» Personal protective equipment (PPE) depending on the task
» Cleaning – cleaning up – and clear agreement on who does what
By using isolation precautions
- In hospitals:
» Isolation in single room with own bathroom or cohort isolation
(outbreak)
» Use of PPE whenever in direct contact with the patient and patient´s
equipment
» Disinfection of contact points with ethanole-based alcohol 70-85% v/v
» Screening strategy – who and when?
- In primary health care:
» Supply universal precautions with increased use of PPE, increased
frequency of cleaning – especially the toilet facilities, disinfection of
contact points etc.
Guidelines on AMR, St Petersburg December 2019 5
6. PERSONAL PROTECTIVE EQUIPMENT
Medical single use gloves
Single use gown/single use apron
Mask (surgical)
Goggles/visor
Guidelines on AMR, St Petersburg December 2019 6
7. HOW CAN WE CREATE AN ISOLATED ISLAND IN A BUSY
HOSPITAL ENVIRONMENT?
Isolation (from italian: isolare, isola, latin: insula - island)
Isolation facility with appropriate location and access, relevant
opportunities for treatment of the patient, interior design and material
selection (single use when possible), ventilation, reprocessing of used
equipment and utensils
Type of room
- (Common room with space for more than one patient)
- Single room
- Single room with front room/lock
- Isolation room with low pressure ventilation and lock
+
Guidelines on AMR, St Petersburg December 2019 7
8. CONTAINMENT
Limit the risk of infection -> contain blood, secretions
and excretions from the patient
Use a closed system when suction of trachea is
perfomed
Use of a closed technique when blood samples are
taken
Suction and drainage bottles, bags for collection of
urine and vomit
Close dressings
Patients receive instructions for:
- How to cough the right way
- Using a container for used handkerchiefs
- How to perform hand hygiene
Change clothes/sheets when contaminated
Technique when handling dirt clothes and garbage
Lid on the bed pan
Change dressings before leaving the room for
transport
Clean clothes and clean bed before leaving the room
for transport
Guidelines on AMR, St Petersburg December 2019 8
9. SEARCH AND DESTROY IS STATE OF THE ART
PREEMPTIVE
Screening in target populations
Sampling from relevant places
Speed-up in diagnostic time
Isolation in single room
Emphasis on universal
precautions
DETECTION OF A CASE
Screening of fellow-patients
MRSA; > 1 case: screening of HCW
Isolation in single room or alternatively
cohorte isolation (outbreak)
Extensive use of PPE
Enhanced cleaning
Follow-up on case(s) including
decolonization if feasible
Monitoring of cases
Alert and Reporting
Documentation
Guidelines on AMR, St Petersburg December 2019 9
10. MRSA CARRIER STATE
Mode of transmission:
• Contact – direct and indirect
• More seldom droplet transmission
Nose, throat, perineum
Individual factors that increase the risk of MRSA:
- Wounds, including recurrent abscesses
- Chronic skin diseases
- Chronic respiratory infections, including sinusitis
- Foreign objects (e.g. urinary catheters, drain)
- Intravenous drug abuse
Guidelines on AMR, St Petersburg December 2019 10
11. GUIDANCE ON MRSA
11
www.sst.dk
• The 1st guidance on MRSA from the
Danish Health Authority was
published in 2006 - revised and
simplified in 2012 - and again in 2016
• Only minor changes compared to the
2012-edition
• Four general and some special high-
risk situations
• IPC appendices to the MRSA
guidance on the SSI site at
www.ssi.dk
Guidelines on AMR, St Petersburg December 2019
12. Risk situations for MRSA
4 general high-risk situations
Patients must be asked in connection with hospitalisation, same-day surgery and relevant
symptomatic infections
1.
Has the person previously been
diagnosed with MRSA?
And has not been declared MRSA-free
2.
Has the person within the past 6
months lived together with or had
household-like contact with a
person who has been tested
positive for MRSA?
3.
Has the person within the past 6
months received treatment at a
hospital or clinic abroad (outside
the Nordic countries)?
AND
1) The stay at the hospital or clinic lasted for more than 24
hours or
2) The patient underwent an invasive procedure regardless
of the duration of the stay.
4.
Has the person himself/herself or a
household member had weekly or
more frequent contact with live pigs
within the past 6 months?
RISK SITUATIONS FOR MRSA MRSA GUIDANCE 2016
Guidelines on AMR, St Petersburg December 2019 12
13. Special risk situations for MRSA
Questions concerning high-risk situations are only asked if the doctor (typically the patient´s
general practitioner) believes them to be relevant, e.g. on the basis of his/her knowledge of the
patient. The person may also know about a high-risk situation, e.g. due to his/her work.
Within the last six
months, the
person has:
• Lived or resided on a daily basis in assisted living facilities or similar
institutions (e.g. for disabled persons) with MRSA outbreaks or been
admitted to a hospital with an outbreak of MRSA
• Worked (including had a student job or internship with patient contact) at:
• A foreign hospital, assisted living facility or similar institutions
outside the Nordic countries
• A department at a hospital, assisted living facility or similar
institutions in Denmark and other Nordic countries, such department
having experienced an outbreak of MRSA.
• Has resided or stayed in confined spaces under poor hygienic conditions
(e.g. asylum centre, hostel for the homeless, war zones, refugee camps or
in foreign children´s homes)
• Worked on mink farms or is a household member of a person who has
worked on mink farms
• Had household-like contact with people who live/have lived outside the
Nordic countries within the past 6 months (e.g. foreign adopted children,
au pair or household members who have been on a long trip abroad
outside the Nordic countries)
• Been abroad and displays signs/symptoms of a staphylococcal infection,
especially if the person has had a tattoo or piercing, shared equipment
(e.g. diving) or has been in prison.
RISK SITUATIONS FOR MRSA MRSA GUIDANCE 2016
Guidelines on AMR, St Petersburg December 2019 13
14. SCREENING, TREATMENT AND POST-TREATMENT FOLLOW-UP
Outside hospital swab from:
- nose and throat; wounds, foreign objects etc.
At hospital swab from:
- nose, throat, perineum; wounds, foreign objects etc.
Treatment of carrier state with:
- Mupirocin nasal ointment 2%, apply in both nostrils twice a day for 5
days
- Daily whole-body washing, including hairwash, using chlorhexidine
soap 4% with glycerol for 5 days
- Treatment can be extended to 10 days (throat carriers)
Control swabs after treatment:
- Outside hospital: 1 month and 6 months
- At hospital: day 7, 14, 21 and 6 months
- Health care workers: day 1, 7, 14, 21 and 6 months
Guidelines on AMR, St Petersburg December 2019 14
15. CPO CARRIER STATE AND CPO INFECTIONS
Mode of transmission:
• Contact – direct and indirect
• Fecal – oral
Colonisations/infections:
• Carrier (asymptomatic) in the gut
• Infections in urinary tract, abdomen, bacteremia/septicemia
• Foreign object related infections
- Catheter related UTI
- Catheter related bacteremia
- Ventilation associated pneumonia
Risk factors for a longlasting carrier state: repeated antibiotic treatments,
frequent admissions to hospital, foreign objects.
Guidelines on AMR, St Petersburg December 2019 15
16. GUIDANCE ON CPO
1st guidance on CPO from the Danish Health Authority in 2018
IPC appendices to the CPO guidance on the SSI site at www.ssi.dk
The CPO guidance is built on the MRSA guidance
The CPO guidance differs from the MRSA guidance
- No treatment for carriers
- No screening of health care workers
- No CPO freedom
- More complex with several bacteria that can be divided in 2 main
groups: environmental and gut bacteria
Guidelines on AMR, St Petersburg December 2019 16
17. Risk situations for CPO
4 general high-risk situations
Patients must be asked in connection with hospitalisation
1.
Has the person previously been
diagnosed with CPO?
2.
Has the person within the past 6
months lived together with or had
household-like contact with a
person who has been tested
positive for CPO?
3.
Has the person within the past 6
months received treatment at a
hospital or clinic abroad (outside
the Nordic countries)?
AND
1) The stay at the hospital or clinic lasted for more than 24
hours or
2) The patient underwent an invasive procedure regardless
of the duration of the stay.
4.
Has the person been abroad
(outside the Nordic countries)
within the past 6 months and
received antibiotic treatment during
the stay?
RISK SITUATIONS FOR CPO CPO GUIDANCE 2018
Guidelines on AMR, St Petersburg December 2019 17
18. Special risk situations for CPO
Questions concerning high-risk situations are only asked if the doctor (typically the patient´s
general practitioner) believes them to be relevant, e.g. on the basis of his/her knowledge of the
patient. The person may also know about a high-risk situation, e.g. due to his/her work.
Within the last six
months, the
person has:
• Been admitted to a hospital with an outbreak of CPO
• Lived or resided on a daily basis in assisted living facilities or similar
institutions (e.g. for disabled persons) with CPO outbreaks
• Has resided or stayed in confined spaces under poor hygienic conditions
(e.g. war zones, refugee camps or in foreign children´s homes)
• Been in dialysis treatment or received anti-neoplastic medical treatment
RISK SITUATIONS FOR CPO CPO GUIDANCE 2018
Guidelines on AMR, St Petersburg December 2019 18
19. VRE CARRIER STATE
Mode of transmission:
• Contact – direct and indirect
• Fecal – oral
Colonisations/infections:
• Carrier (asymptomatic) in the gut
• Infections in urinary tract, abdomen, bacteremia/septicemia
• Foreign object related infections
Risk factors for a longlasting carrier state: repeated antibiotic treatments,
frequent admissions to hospital, foreign objects.
IPC precautions:
- Single room with own bathroom/toilet facilities
- PPE and disinfection of contact points as described for MRSA and
CPO
Guidelines on AMR, St Petersburg December 2019 19
20. SUMMARY OF AMR
MRSA VRE ESBL CPE
Mode of
transmission
Contact Fecal/oral
Contact
Fecal/oral
Contact
Fecal/oral
Contact
Carrier Nose, throat
etc.
Gut Gut Gut
Risk factors Antibiotic
treatment, foreign
objects, wounds
Antibiotic
treatment, foreign
objects, hospital
admission
Antibiotic
treatment, foreign
objects, travelling,
food
Antibiotic
treatment, foreign
objects, hospital
admission
Screening Yes Outbreak Outbreak Yes
Treatment,
carrier state
Yes No No No
Guidelines Guidance on
MRSA
National IPC
guideline
National IPC
guideline
Guidance on
CPO
Guidelines on AMR, St Petersburg December 2019 20
21. QUESTIONS
What are the Russian experiences with guidelines for infection prevention
and control?
- Are there common national guidelines?
- Are there regional/local guidelines?
Guidelines on AMR, St Petersburg December 2019 21
22. THANKS FOR ATTENTION – ANY QUESTIONS?
22Guidelines on AMR, St Petersburg December 2019
