VRE outbreak at ICAN Harare, Zimbabwe

1. VRE
05-­‐11-­‐14
Andreas
Voss,
MD,
PhD
¤
Controlling
the
spread
of
VRE
and
especially
other
MDRO
may
cause
serious
harm
to
my
job
security
¤ Advisory
board,
speaker
fees
&
grants
from
3M,
bioMerieux,
JD,
Deb,
AspeMx,
Astra
Zeneca,
Milenium
bioscience,
…
¤ Everyone
harbours
enterococci
in
his/
her
GI-­‐tract
¤ Resistant
to
cephalosporines
¤ Most
prevalent
species:
E.
faecalis
¤ Low
virulence
– UTI
– Abdominal
infecMons
– CLA-­‐BSI
and
endocardiMs
• “Big/resistant
brother”
of
E.
faecalis
– Amoxicillin/ampicillin-­‐resistant
– Recent
shiY:
E.
faecalis
à
E.
faecium
• LocaMon
(GI)
unchanged
• Virulence
unchanged
• SuscepMble
to
vancomycin
• E.
faecium
and
(less
frequent)
E.
faecalis
–
other
species
less
important
• It’s
all
about
vanA
en
vanB,
the
other
van-­‐gens
are
generally
less
important
• Certain
clonal
complex’s
(CCs)
trend
to
be
more
epidemic
e.g.
CC17
• VRE
does
not
equal
VRE
ICAN
2014
1

2. VRE
05-­‐11-­‐14
Ears
june
2011
Meningitis
Neonatal infection
sepsis
pneumonia
UTI
Surgical infection
sepsis
meningitis
endocarditis
UTI
Intra-abd. infections
Wound infections
Patient: underlying diseases, antibiotics, veel co-morbidity
¤
Contact
isolaMon
²
(preferably)
single
room
²
own
toilet/bed-­‐pan,
…
²
gloves
and
gown
²
hand
hygiëne
²
disinfec<on
of
environment
¤
Not
one
reason,
but
the
consequence
of
mulMple,
small
factors
à
Swiss-­‐Cheese-­‐Accident
Model
ICAN
2014
2

3. VRE
05-­‐11-­‐14
(hand)hygiene
antibiotics
cleaning
Maintenance
Werk pressure
Bad luck
(Hand) hygiene
antibiotics
cleaning
Maintenance
Work pressure
Bad luck
(Hand) hygiene
antibiotics
cleaning
Maintenance
Work pressure
Bad luck
VRE
outbreak
¤
Bad
luck
²
virulent
clone
¤
High
Work
pressure
²
mixing
personnel
from
different
wards,
trainees
¤
Cleaning/disinfecMon
²
vacant
responsibiliMes
¤
Maintenance/technique
²
bed-­‐pan
washers
not
sufficient
¤
Discipline
en
behaviour
²
basic
infecMon
control
(contact
isolaMon/flagging)
²
hand
hygiene
¤
Microbiology
¤
Epidemiology
¤
InfecMon
control
¤
PoliMcs
&
communicaMon
¤
AnMbioMc
stewardship
¤
DecolonizaMon
¤
Chrome-­‐agar
versus
standard
media
¤
“Added
value”
Ampicillin-­‐MH-­‐boullion
¤
MulMplex
PCR
on
clinical
materials
¤
Determine
A0
value
of
the
outbreak
strain
¤
Compare/evaluate
typingmethods
²
MLST,
AFLP
ICAN
2014
3

4. VRE
05-­‐11-­‐14
¤ Up
to
50%
of
ward
HCWs
=
trainees
¤ Faulty
contact
isolaMon
¤ Bad
hand
hygiene
&
lacking
adherence
to
basic
infecMon
control
measures
¤ Flagged
paMents
not
isolated/cohorted
¤ Bed-­‐pans
and
commodes
frequently
VRE+
¤ High-­‐touch
surfaces
VRE+
¤
Bedpan
VRE+
despite
washers
were
tested
and
validqted
!
Not
our
model
¤
Combined
value
of
temperature
and
Mme
Z
=
10C
(thermal
destrucMon
factor)
T
=
measured
temperature
=
Mme
for
disinfecMon
(sec)
¤
Bed-­‐pan
washers
according
to
EU
norm
A60
²
A60
=
the
effect
of
1
min
80°C
¤
The
A0
values
A0
>
60
cleaning,
contact
with
intact
skin
A0
>600
semi
criMcal,
in
contact
with
non-­‐intact
skin
or
mucous
membranes
A0
>
A0
>3000
criMcal,
in
contact
with
sterile
Mssue,
high-­‐level
disinfecMon
¤
Range
of
values!
²
CWZ
A0
80
to
5000
(too
much
variaMon)
¤ TesMng
did
not
follow
the
norms
²
No
cold
start
tesMng
¤
ValidaMon
of
measurements?
²
detailed
knowledge
no
longer
present
in
service
company
ICAN
2014
4

5. VRE
05-­‐11-­‐14
¤
A0
value
of
outbreak
strain:
=
160
(2
min,
80C)
¤
Bed-­‐pans
visible
dirty:
A0
is
not
a
statement
about
being
clean
¤
Roomservice
¤
Roomservice-­‐plus
¤
Registered
nurse
¤
Nurse
asistant
¤
Cleaning
Even
if
you
think
you
know
it,
are
they
actually
doing
it?
ICAN
2014
5

6. VRE
05-­‐11-­‐14
¤
Do
certain
anMbioMcs
select
for
VRE?
¤
Which
anMbioMcs
are
used
in
your
paMent
populaMon?
Antibiotics (AB):
• chephalosporines, vancomycin, cipro
Selective Digestive tract Decontamination (SDD)
• no proof that SDD increases prevalence of VRE ↑
•
NL: 10 of 14 (71%) of VRE+ hospitals use SDD
CWZ:
• 93% ≥ 1 AB in the 3 months before first VRE+ culture
• 54% was on AB at the time of their first VRE+ culture
• On average VRE+ patient received 2.85 (range 0-10)
different ABs before their first VRE+ culture
0.9%
=
close
to
nothing
¤
Does
your
hospital
has
an
A-­‐team?
¤
Nothing
in
the
literature
¤
Possible
intervenMons?
²
probioMcs
²
feces-­‐transplantaMon
²
ban
of
certain
food
(eg.
no
chicken)
ICAN
2014
6

7. VRE
05-­‐11-­‐14
• Weekly audits including feedback
• Are screening cultures* negative
• Are bed pans visible clean à later dropped when
switch to disposable bed-pans
• Do HCWs regard HH-rules and show no mistakes
during observation of contact isolation
• Are all flagged patients actually in isolation (SR or
cohort)
• Only trained nurses taking care of VRE patients
* Weekly microbiological screening of the environment and all patients in affected units (n=8)
Ward
Cultures
(pats
&
en.)
Cleaning
HH-­‐rules
&
isola<on
Flagging/
sor<ng
Trained
HCWs
A
B
C
D
E
Reported
to
medical
head,
unit
manger,
head
nurse,
CEO
….
cleaning
flagging
cleaning
Week
Cultures
(pats
&
en.)
Cleaning
HH-­‐rules
&
isola<on
Flagging/
sor<ng
Trained
HCWs
1
2
3
4
5
6
7
….
A
long
<me
Twee
week
meeMng
with
CEO,
IC,
medical
head
and
unit
manager
!
¤ VRE tiredness after a few months
¤ BC to get the disposable system (VernaCare)
¤ Continuing merging of units
¤ Financial pressure – no closure of wards
¤ Too much work – to little trained HCWs
ICAN
2014
7

8. VRE
05-­‐11-­‐14
AYer
14
months,
450+
cases,
20.000
PCRs,
extra
cleaners,
new
products,
and
endless
audits
International Society of Chemotherapy
for Infection and Cancer
www.ischemo.org
…..…..to
advance
the
educa.on
and
the
science
of
therapy
of
infec.on
• AnM-­‐infecMve
pharmacology
• AnMmicrobials
of
the
Future
• AnMmicrobial
Stewardship
• AnMsepMcs
• Bone,
Skin
and
SoY
Tissue
InfecMons
• Clostridium
difficile
InfecMon
• Collateral
Effects
of
AnM-­‐infecMves
• Controlling
AnMmicrobial
Resistance
• Device
Related
InfecMons
and
Biofilm
• EndocardiMs
&
Blood
Stream
InfecMons
• Fungal
InfecMons
• HepaMMs
• Human-­‐Animal
Interface
in
AnMmicrobial
Resistance
• ImmunisaMons
and
Vaccines
• Infec<on
Control
• InfecMons
in
Catastrophic
Areas
• InfecMons
in
the
ICU
and
Sepsis
• Intra-­‐abdominal
InfecMon
• MRSA
• OPAT
• Streptococcal
InfecMons
• Tuberculosis
• Urinary
Tract
InfecMons
• Zoonoses
• AnMmicrobial
Stewardship
&
InfecMon
Control
African
Network
hOps://www.surveymonkey.com/r/2XG8LV6
ICAN
2014
8