The document discusses the challenges of antibiotic resistance in India, including a high prevalence of gram-negative infections and ESBLs compared to the Western world. It notes the rapid increase in ESBL prevalence in India in recent years. The document also outlines steps taken between 2001-2007 at a hospital in India to implement infection control measures and antibiotic stewardship programs to help address this issue, such as restricting certain antibiotics, screening for MRSA/ESBL, and emphasizing appropriate hand hygiene and barrier precautions.

1. The presentation is solely meant for
Academic purpose

4.  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

5. Parameters Western world India
Common Isolates prevalent in ICUs Gram+ves Gram-ves
ESBL prevalence in gram –ves Much less Very high
Prevalence of ESBLs in last few years Slow increase Rapidly increasing
ICU type Mostly closed ICUs Mostly open ICUs
Generics Very few Hundreds of
generic
Restriction 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.

7. A global study on prevalence of ESBL in K.pneumoniae of
over 86,000 isolates from 266 centers
Reinert RR, Low DE, Rossi F, et al. J Antimicrob Chemother (2007) 60:1018–29.

8.  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

10.  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)

11.  Our health
ministry
came out
with an
excellent
document to
prevent
antimicrobial
resistance in
April 2011
 Shelved it in
October
2011!

12. We have started taking baby steps

13.  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?

15.  What’s the MRSA rate here, I asked?
◦ What’s that
 Where’s the hospital antibiogram, I asked?
◦ Anti-what?

27. 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

28. 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
adopted
August -meeting with all surgeons on antibiotic
2001
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

29. 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 introduced
January 2002 -glutaraldehyde storage of forceps on dressing trays
eliminated, forceps to be sterilized and packed
-formalin tablet fumigation eliminated
March 2002 -mandatory wearing of gloves for phlebotomists
-finalization of surgical prophylaxis policy
-antibiotic prophylaxis duration reduced to 48 hrs
April 2002 -one full time IC nurse appointed
-elimination of flimsy plastic gloves, replacement by latex
gloves

30. 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 ward
July 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
introduced
November -central line protocol introduced (sterile placement, removal of femoral
2002 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 introduced
June 2003 -nasal swab screening for Staph aureus eliminated for elective surgery
-surveillance for CRBSI and VAP commenced

31. November -closed bag system for IV fluids introduced on
2003 selected basis
-removal of femoral lines by day 5 recommended
-single use vials recommended for all
medications
-puncture proof bedside sharps container
introduced
December appropriate barrier precautions introduced
2003 whenever building works carried out to prevent
Aspergillus outbreaks
March 2004 -N-95 masks for respiratory isolation introduced
-10% povidone iodine to replace lower strengths
-antibiotic prophylaxis for surgery reduced to
24hrs
May 2004 switch to collapsible bags for IV fluids hospital
wide, elimination of vented plastic bottles

32. July2004 -use of 2% chlorhexidine for skin preparation prior to
August 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 mupirocin
October 2004 100ml handrub dispenser mounted on each bedrail instead of
500ml in each room
January 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 emphasized
October 2005 ESBL isolation discontinued hospital wide
February -notifiable diseases list drawn up and submitted to Govt
2006 periodically
-MRSA screening at admission extended for high risk
neutropenic patients and step down ICUs

33. 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 ICU
July 2006 MRSA screening extended to Neurology ICU and high
risk neutropenic patients
November intensive cleaning of ICU surfaces commenced
2006
February MRSA screening extended hospital wide
2007
March 2007 circular issued mandating ID consultation when restricted
antibiotics used beyond 48hrs
August 2007 tigecycline, vancomycin, teicoplanin added to restricted
antibiotics
January 2008 chlorhexidine bathing for all patients in ICU and oral
decontamination for ventilated patients introduced
August 2008 -elimination of white coats and recommendation against
long sleeves, ties and wrist watches
-teicoplanin and vancomycin removed, polymyxins added
to restricted antibiotics list

36.  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

40.  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

45. Infectivity Prevention Perceived
after stick threat
Hepatitis B 30% Vaccine Low
Hepatitis C 3% None None
HIV 0.3% Post exposure High
prophylaxis

46.  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

47.  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

48.  Standard precautions
 Isolation (syndrome and disease specific)
◦ Contact
 MRSA
 Resistant non-fermenters
 VRE
◦ Droplet
◦ Airborne

49.  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

51.  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

52.  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

53.  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

55. 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

56. Ventilator Associated Pneumonia
Semi recumbent posture
Avoid routine stress ulcer prophylaxis;
sucralfate is better (when needed)
Subglottic suctioning
Avoid tubing change q 24 hours
Selective decontamination of the digestive
tract
Avoid nasal intubation
Ref: N Engl J Med 1999;340:627-34

57. Catheter Related Bloodstream Infection:
(CRBSI)
Clinical catheter site infection (or)
Systemic signs of sepsis (c no other source)
AND
Positive catheter culture
(quantitative / semi quantitative)
AND
Same organism cultured in peripheral blood

58. Hand hygiene
Full Sterile barrier @ placement
Chlorhexidine is better than
povidone iodine site prep
Prefer subclavian site, avoid femoral
Antibiotic-impregnated catheters
Remove catheter when not required
MMWR 2002; 51: RR-10
N Engl J Med 2003;348:1123-33.
N Engl J Med 2006;355:2725

60.  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

61.  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

62.  Clinical
 Culture based
 Outpatient follow-up
 Feedback
 Can reduce SSI rates by 35-50%
 Stratify monitoring to high risk group

63.  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

65.  Prospective
audit,
intervention and
feedback is the
cornerstone
 Antibiotic forms
introduced
 Special focus on
surgical
prophylaxis

68.  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

69.  Motion-activated video cameras were
strategically located throughout a medical
intensive care unit
Clin Infect Dis 2012 54: 1-7