National Program on Prevention and Control of Infection and Antimicrobial Resistance – PPCIRA / PORTUGAL Before 2013, Portugal had a high prevalence of hospital-acquired infections and high antimicrobial consumption compared to other EU countries. Carbapenem and quinolone use was among the highest. Through the PPCIRA program established in 2013, Portugal implemented initiatives like establishing epidemiological surveillance, antimicrobial stewardship programs, and a standard precautions campaign. These efforts led to reductions in antimicrobial consumption in both hospital and community settings, lower rates of methicillin-resistant Staphylococcus aureus, and decreases in some hospital-acquired infections like surgical site infections and infections in neonatal and adult ICUs.

1. National Program on Prevention and
Control of Infection and Antimicrobial
Resistance – PPCIRA / PORTUGAL
José Artur Paiva, Elaine Pina, Maria Goreti Silva, Paulo André
Fernandes, Anabela Coelho, José Alexandre Diniz, Francisco George
Manuela Caniça, Jorge Machado, Ana Silva

2. Where were we in 2011-2012 ?
Before PPCIRA……

3. Prevalence of HAI AM use
Portugal EU Portugal EU
Men 12,4% 7,2% 48,3% 39,2%
Women 8,8% 5,4% 42,3% 33,2%
Global
population 10,5% 6,1% 45,3% 35,8%
PPS DGH 2012
High prevalence of hospital acquired
infection and high antimicrobial consumption

4. High hospital consumption
of carbapenems
“ In 2012, consumption of carbapenems varied by a factor of 14, from
0.01 (Bulgaria) to 0.14 DDD per 1 000 inhabitants and per day (Portugal)“
“The proportion of consumption of carbapenems out of antibacterials
for systemic use ranged from 0.8% (Latvia) to 9.8% (Portugal) with an
EU/EEA population-weighted mean of 2.9%.”
2010
Carbapenems
ECDC; ESAC Net 2012

5. High antibiotic consumption in
the ambulatory setting
Insira o seu texto
ECDC; ESAC Net 2012
Global consumption
Quinolone consumption

6. 6
High ESKAPE composed index of resistance
Extracted from ECDC PPS 2011-2012

7. Growing resistance of
Staphylococcus aureus to methicillin
in Portugal (2001-2011)
ECDC – EARS Net

8. Weaknesses and threats
• Low level of integration and synergy of the several processes; no
holistic vision; too many process leaders
• Understaffing underpowerment of the central and peripheral
structures
• Absence of focus in the most relevant issues: MRSA, CRE, carbapenems,
quinolones, Standard precautions campaign
• Problems of data sharing among state institutions and of data
feedback to the providers
• Difficulties in implementing a collaborative model, increasing
capacity building and maximizing participation.
• Reimbursement system not reflecting the indicators and targets and
not boosting motivation

9. What has been done in 2013-2014?
PPCIRA initiatives

10. PROGRAM ON PREVENTION AND CONTROL OF
INFECTION AND ANTIMICROBIAL RESISTANCE
NATIONAL PROGRAM
OF INFECTION
CONTROL
NATIONAL PROGRAM ON
PREVENTION OF
ANTIMICROBIAL
RESISTANCE
+
8 Feb
2013
1999 2008
PPCIRA: one lidership

11. PPCIRA management structure:
law 15423/2013
Directorate
General of Health
(DQS)
Regional Health
Authority (RHA)
Health
Units
94% H; 25% PC
PPCIRA central
direction
PPCIRA
Regional
Coordination
Group
PPCIRA
Local
Coordination
Group
Pharmacy and Therapy
Regional Committee
RHA Administrator on
Quality
Local Comission on
Quality and Safety
Pharmacy and Therapy
Hospital Comission
Depart. Of Quality in
Health - DNH
PPCIRA Scientific
Council

12. Reduce HCAI
Reduce antimicrobial
consumption
To reduce the emergence of
antimicrobial resistance
Evict antibiotics
when there is no
infection
Reduce transmission
of antimicrobial
resistance
Shorten antibiotic
treatment duration
To reduce the incidence of resistant bacteria
STANDARD
PRECAUTIONS
CAMPAIGN
ANTIBIOTIC
STEWARDSHIP
PROGRAM
Epidemiological surveillance

13. Adhesion to the
main interventions
Launching 2012 2014
Epidemiological
surveillance of
antimcrobial resistance
(Microbiology Lab)
Guideline NRL/DGH
21 February 2013
22 70
Epidemiological
surveillance of at least one
of the HAI
Law 15423/2013
18 November 2013
85%
Antimicrobial Stewardship
Program Law 15423/2013
18 November 2013
0 40% hospitals
Standard Precautions
Campaign 5 May 2014 - 70% hospitals
24% PCC
September 2014
PPCIRA /DGH

14. PPCIRA “bundles”
 Hand hygiene
 Adequate use of gloves
• Patient/clinical environmental hygiene
 “Anti-MRSA” policy
 Surgical antibiotic prophylaxis for no more than 24 h
 Duration of antibiotic duration limited to 7 days (with exceptions)
• Reduction of quinolone and carbapenem prescription
 Antimicrobial stewardship program in the first 96 h
 Hand hygiene
 Adequate use of gloves
• Patient/Clinical environmental hygiene
 Compliance with the vaccination program
• Adquate tretment of wounds
• Reduction in the prescription of quinolones
• Guideline for the treatment of RTI
 Guideline for the treatment of UTI
 Antimicrobial stewardship program
Hospital
Bundle
Comunity
Bundle

15. Education and Pedagogy
• “Train the trainers” course
• In all RHA (7 health regions)
• Topics: strategy, implementation and science
• Two modules, hospital and ambulatory, in two
consecutive days
• 4 trainers per course; a total of 8 trainers
• In October 2014, more than 600 doctors and
nurses were trained as trainers

16. Citizen’s awareness
Winter 2013

17. What has been achieved ?
PPCIRA results

18. Reduction of large spectrum antibiotic
consumption in the ambulatory setting
Quinolones:
 Higher consumption among ECDC
countries in 2010
 Improvement to 7th place in 2013
 European median= 1,81
GUIDELINES:
- Duration of antibiotic
therapy
- Treatment of UTI
INFARMED, 2014
Quinolone consumption
Large spectrum over small
spectrum antbiotic consumption

19. Reduction of antibiotic consumption
in the hospital setting
GUIDELINES:
- Duration of antibiotic treatment
- Treatment of UTI
- Surgical antibiotic prophylaxis
INFARMED, 2014
Feedbacking
data to
hospitals
Hospital antibiotic consumption in
the 1st semester of the year

20. Reduction of the rate of
Staphylococcus aureus
resistance to methicillin (MRSA)
ECDC / EARS Net
% of the invasive Staph aureus isolates
resistant to methicillin

21. CRE alert surveillance system
1.8% of all Enterobacteriaceae
Mechanisms of carbapenem resistance Number of isolates (%)
Production of acquired carbapenemase
GES-type 5
KPC-type 195
VIM-type 9
KPC-type, GES-type 2
NDM-type 1
Subtotal 212 (40%)
Other mechanisms
ESBL and/or AmpC production associated with
impermeability mechanism
214
Imipenem resistance mechanism inherent to te species 23
Probable impermeability mechanism 3
Subtotal 240 (45,3%)
Isolates susceptible to the carbapenems 76
Non-viable isolates 2
Subtotal 78 (14,7%)
TOTAL 530

22. CR-BSI (per 1000 CVC days):
2003-2013
3.1
3.0
2.5
2.1 1.9
1.9
0.9
1.4
1.9
2.4
2.9
3.4
2002-2004 2005-2007 2010 2011 2012 2013
Variação da taxa de INCS associada a CVC
Linear (Variação da taxa de INCS associada a CVC)

23. Reduction of some of the HAI
Density of nosocomial BSI due to Staphylococcus aureus and by MRSA
Infections in Adult ICUs

24. Reduction of some of the HAI
Infections in Neonatal ICUs
Surgical
site
infections

25. HCAI in
long term care institutions
GUIDELINES:
- Standard
precautions
- Prevention of
surgical site
infection
- Prevention of
chronic wound
infection

26. Next months……..

27. Strategy
1. Structure consolidation: 4 instead of 3 at DNH
2. Standard precautions campaign
3. Mandatory epidemiological surveillance
4. Mandatory antimicrobial stewardship program
5. Guidelines
6. Education of citizens and professionals
7. Intersectorial Alliance (joint effort)
8. Finantial motivation / Contract-programs
Keep the momentum

28. PPCIRA
institutional assessment
1. To have PPCIRA-Local Coordinating Group in accordance with 15423/2013 law
2. To participate in the epidemiollogical surveillance of antimicrobial resisitance,
through LCG and Microbiology Labs.
3. To participate in the 4 epidemiological surveillance programs on HAI
4. To analyse institution’s data on antimicrobial consumption,
relating them to antimicrobial resistance patterns
5. To have a Antimicrobial Stewardship Program
6. To participate in the Standard Precautions Campaign
7. To reduce mean duration of antibiotic treatment course
8. To reduce to zero surgical antibiotic prophylaxis > 24h
9. To increase antibiotic free days
10. To reduce carbapenem consumption in hospitals
11. To reduce % patients that acquire colonization or infection by MDR in hospitals
12. To reduce hospital MRSA rate
13. To avoid increase in CRE rate
14. To reduce % of patients on antibiotic treatment for chronic wound
15. To reduce quinolone consumption in the ambulatory setting

29. ppcira@dgs.pt
Thanks !