The document discusses strategies for improving antibiotic use and reducing healthcare-associated infections (HAIs) in hospitals. It recommends forming an improvement team to select and implement interventions, monitor compliance with interventions, and check outcomes. Specific interventions discussed include controlling use of reserve antibiotics, standardizing empiric treatment, promoting intravenous to oral switching, educating on antibiotic use, and requiring infectious disease consultation for certain high-risk patients. Real-time surveillance of local resistance trends and guidelines on antibiotic use and infection control are also recommended.

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International Society of Chemotherapy
for Infection and Cancer
www.ischemo.org

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People who say that zero HAIs are possible …
¤ Redefined HAIs
² CLABSI = 2 sets of bloodcultures and Fp with
genoFpically idenFcal pathogen and bloodculture
drawn (not via the catheter) negaFve
¤ Use mean staFsFcal methods e.g. “median”
¤ People who have never seen a hospital from the
inside and make wild assumpFons

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Swiss cheese accident model
Swiss cheese accident model
Hand hygiene
AnFbioFc
misuse
Lacking skills
Under staffing
Cross transmission
Bad luck

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Hand hygiene
AnFbioFc
misuse
Lacking skills
Under staffing
Cross transmission
Bad luck
NI
outbreak

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BIG-FAT Guideline
Even beUer Guideline
Very long super Guideline
Local RecommendaFon
NaFonal RecommendaFon
Tiny overlooked Guideline
RecommendaFon
More RecommendaFon

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Fasces = bundle = strength
¤ A bundle is a structured way of improving the
processes of care and paFent outcome
² a small set of evidence-based pracFces
² generally three to five
² performed collecFvely and reliably
¤ Proven to improve paFent outcomes

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² Evidence based
² Achievable in all
paFents
² Cover the relevant
aspects of the
procedure
Evidence based
Cover relevant aspects
Achievable in all pa?ents
¤ Create a culture of safety
¤ Create a mulF-disciplinary improvement team
¤ Ensure full commitment with the bundle
elements
² No more discussions about the effecFveness of
the bundle elements once started
¤ Agree upon the length of the improvement
period and level of adherence with measures
² If that is not possible à Don’t start !

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1 2 3 4 5 6 7 8 Element
compliance
Element 1 Y Y N Y Y Y Y Y 87.5%
Element 2 Y N Y N Y Y Y Y 75%
Element 3 N Y Y Y Y Y N Y 75%
Element 4 Y Y Y Y Y N Y Y 87.5%
Element 5 Y Y Y Y Y Y Y N 87.5%
PaFents/procedures
Bundle
Compliance
12.5%
Surgical Site Infections

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No influence possible
¤ Age
¤ Underlying disease
¤ Malignancy
¤ Wound classificaFon
¤ ProstheFc material
Influence not probable
• Laminar air-flow
• SterilizaFon
• Pre-op hospitalization
Influence by others
• BMI >30
• Nicotine use
• Malnutrition
• Infection at remote site
Can & should be influenced
• Surveillance
• S. aureus colonization
• Normothermia/hyperoxia
• Glucose levels
• Hair-removal
• Antimicrobial prophylaxis
• Skin disinfection/decolonization
¤ Hair removal
¤ AnFmicrobial prophylaxis
¤ Normothermia
¤ Disciplin in the OR ?

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Bundle
Compliance
SSI
Rate

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¤ Built improvement team
(A-team)
¤ Select intervenFons
¤ Implement inter-
venFons
¤ Check compliance
with intervenFons
¤ Check outcome

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PhamD
ClinMicro/ID
ICT

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¤ Control/restrict use of reserve-anFbioFcs
¤ Select and measure indicators for adequate
anFmicrobial use
¤ Standardize empiric treatment and foster iv-oral
switch
¤ EducaFon and training with regard to
anFmicrobial use
¤ Define all paFents categories that need bed-
side ID consultaFon
Control/restrict use of reserve-an?bio?cs.
¤ An$bio$c guideline
¤ Checks by A-team
¤ Automa$c reports on DDD’s per 1000 pat-days
¤ Pre-use authoriza$on
¤ Restric$ve repor$ng

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Select and measure indicators for adequate
an?microbial use.
¤ Check “use according to guideline” by
² point-prevalence studies
² daily consulta$ons
² audits
Standardize empiric treatment and foster
iv-oral switch.
¤ On-line AB-guideline
¤ “5 x S” as part of consulta$on & teaching
² start, safety, streamline, switch, stop

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Educa?on and training with regard to
an?microbial use
¤ Con$nuous effort of ID & Clin Micro
² own fellows
² part of hospital fellow educa$on
² part of rounds
² “switch of the week”
Define all pa?ents categories that need bed-side
ID consulta?on
¤ All pa$ents with meningi$s, endocardi$s, using
an$bio$cs for longer than 2 weeks, suffering an S.
aureus bacteremia, and receiving reserve an$bio$cs
are seen at bed-side by ID/CM

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¤ Real-Fme surveillance (including feedback) of
local resistance trends and resistance related
problems in the region/country
¤ AnFbioFc/treatment guidelines
¤ InfecFon control guidelines
¤ NaFonal or regional resistance surveillance
¤ NaFonal or regional HAI surveillance
¤ AnFmicrobial use surveillance
¤ Audits based on professional standards (IGZ)
¤ CM/ICP/ID specialists in all major healthcare
senngs and regional co-operaFon