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PREVENTION AND CONTROL OF
ANTIMICROBIAL RESISTANCEIN HOSPITAL
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Masalah resistensi di Rumah Sakit
Eksposur tinggi
terhadap antibiotika
Densitaspopulasi tinggi
Frekuensi kontak tinggi
terhadap staf RS
Risiko tinggicross infeksi
High risk
environment
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Masalah penggunaan antibiotika
Exessive/overuse
Inappropriate
Cara pemberian
Dosis
Frekuensi Lama pemberian
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100.00%32.69%-Others
3.85%CiprofloxacinCiprofloxacin
5.76%CefotaximCefotaxim
9.62%CefotaximTaxegram
23.08%CeftriaxoneTerfacef
25.00%CeftriaxoneCeftriaxone
%GenericsAntibiotics
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Relationship between antibiotic use, resistance, treatment
failure and healthcare burden
Increase inantibiotic use Increase in
resistant strains
Ineffective empirictherapy
increased morbidity
more antibiotics
Increasedhospitalisation
more antibiotics
Increaseduse ofhealthcare
resources
Limited treatmentalternatives
more antibiotics
increasedmortality
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Optimize Use
PreventTransmission
PreventInfection
EffectiveDiagnosis& Treatment
PathogenAntimicrobial-ResistantPathogen
AntimicrobialAntimicrobialResistanceResistance
Antimicrobial Use
InfectionInfection
Susceptible Pathogen
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Prevent infection
Diagnose and treatinfection effectively
Use antimicrobialswisely
Prevent transmission
Clinicians hold the solution!
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95.6 95.8
92.5
96.2
98.9 99
92.9
84.6
94
97.6
75
80
85
90
95
100
NGANJU
K
TULUNGAGUNG
TRENG
GALEK
NGAWI
BONDO
WOSO
ISPA Balita
ISPA Dewasa
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12 Steps12 Contain your contagion
11 Isolate the pathogen10 Stop treatment when cured
9 Know when to say no to vanco8 Treat infection, not colonization
7 Treat infection, not contamination6 Use local data
5 Practice antimicrobial control4 Access the experts
3 Target the pathogen2 Get the catheters out
1 Vaccinate
Prevent Transmission
Use Antimicrobials Wisely
Diagnose and Treat Effectivel
Prevent Infection
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0
10
20
30
40
50
60
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Perce
ntResistance
Methicillin (oxacillin)-resistantStaphylococcus aureus
0
5
10
15
20
25
30
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Per
centResistance Vancomycin-resistantenterococci
Non-Intensive Care Unit PatientsIntensive Care Unit Patients
Antimicrobial Resistance Among PathogensCausing Hospital-Acquired Infections
Source: National Nosocomial Infections Surveillance (NNIS) System
Link to: NNIS Online at CDC
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0
2
4
6
8
10
12
14
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Perce
ntResistance
3rd generation cephalosporin-resistant Klebsiella pneumoniae
0
5
10
15
20
25
30
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
PercentResistance
Fluoroquinolone-resistantPseudomonas aeruginosa
Non-Intensive Care Unit PatientsIntensive Care Unit Patients
Antimicrobial Resistance Among PathogensCausing Hospital-Acquired Infections
Source: National Nosocomial Infections Surveillance (NNIS) System
Link to: NNIS Online at CDC
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Link to: NNIS Online at CDC
Fact:
Catheters and other invasive devices are the #1
exogenous cause of hospital-acquired infections.
Prevent Infection
Step 2:Get the catheters out
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Biofilm on Intravenous Catheter Connecter24 Hours After Insertion
Scanning Electron Micrograph
Link to: Biofilms and device-associated infections
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Fact: Catheters and other invasive devices are the #1exogenous cause of hospital-acquired infections.
Actions:
6use catheters only when essential
6use the correct catheter
6use proper insertion and catheter-careprotocols
6remove catheters when not essential
Coming soonguidelines for preventing catheter-associated bloodstream infections Link to: Urinary catheter infection prevention
Prevent Infection
Step 2: Get the catheters out
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Fact:Appropriate antimicrobial therapy (correct
regimen, timing, dosage, route, and duration)saves lives.
Diagnose and TreatInfection Effectively
Step 3:Target the pathogen
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Inappropriate Antimicrobial Therapy:Prevalence Among Intensive Care Patients
Source: Kollef M, et al: Chest 1999;115:462-74
0%
10%
20%
30%
40%
50%
Community-acquired infectionHospital-acquired infection
Hospital-acquired infection afterinitial community-acquired infection
InappropriateAntimicrobial Therapy(n = 655 ICU patients with infection)
Patient GroupPercentIn
a
ppro
priate
17.1%
34.3%
45.2%
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Inappropriate Antimicrobial Therapy:Impact on Mortality
Source: Kollef M, et al: Chest 1999;115:462-74
0
100
200
300
400
500
600
No
.In
fe c
te d
Pa
t i e n
ts
42.0% mortality
17.7% mortality Relative Risk = 2.37(95% C.I. 1.83-3.08; P< .001)
# Deaths
# Survivors
Inappropriate
Therapy
Appropriate
Therapy
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Fact: Appropriate antimicrobial therapy saves lives.
Actions:6 culture the patient
6 target empiric therapy to likely pathogens and
local antibiogram6 target definitive therapy to known pathogens
and antimicrobial susceptibility test results
Link to: IDSA guidelines for evaluating fever in critically ill adults
Diagnose and Treat Infection Effectively
Step 3: Target the pathogen
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Nosocomial infections
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Fact:
Infectious diseases expert input improves
the outcome of serious infections.
Diagnose and TreatInfection Effectively
Step 4:Access the experts
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Infectious Diseases Expert Resources
Infectious Diseases
Specialists
OptimalPatient CareOptimalPatient Care
Infection ControlProfessionals
HealthcareEpidemiologists
ClinicalPharmacists
ClinicalPharmacologists
Surgical InfectionExperts
ClinicalMicrobiologists
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 4: Access the experts
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Fact: Infectious diseases expert input improves the
outcome of serious infections.
Action:
6 consult infectious diseases expertsabout patients with serious infections
Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistancein Hospitals
Diagnose and Treat Infection Effectively
Step 4: Access the experts
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Fact:
Programs to improve antimicrobial use
are effective.
Use Antimicrobials Wisely
Step 5: Practiceantimicrobial control
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Methods to Improve Antimicrobial Use
Passive prescriber education
Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue
Pharmacy substitution or switch Multidisciplinary drug utilization evaluation (DUE) Interactive prescriber education
Provider/unit performance feedback Computerized decision support/online ordering
Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals
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Computerized Antimicrobial Decision Support Local clinician-derived consensus guidelines embedded in
computer-assisted decision support programs
62,759 patients receiving antimicrobials over 7 years
1988 1994
Medicare case-mix index 1.7481 2.0520Hospital mortality 3.65% 2.65%
Antimicrobial cost per treated patient $122.66 $51.90
Properly timed preoperative antimicrobial 40% 99.1%
Stable antimicrobial resistance
Adverse drug events decreased by 30%
Source: Pestotnik SL, et al: Ann Intern Med 1996;124:884-90
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Use Antimicrobials Wisely
Step 5: Practice antimicrobial control
Fact: Programs to improve antimicrobial use are effective.
Action:6 engage in local antimicrobial use quality
improvement efforts
Link to: Methods to improve antimicrobial use and prevent resistance
Source: Schiff GD, et al: Jt Comm J Qual Improv 2001;27:387-402
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Fact:The prevalence of resistance can vary
by time, locale, patient population,hospital unit, and length of stay.
Use Antimicrobials Wisely
Step 6: Use local data
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Trimethoprim/Sulfamethoxazole (TMP/SMX)Resistance Among Bacterial Patient Isolates*
San Francisco General HospitalMartin JN, et al: J Infect Dis 1999;180:1809-18
* 30,886 patient isolatesStaphylococcus aureusEscherichia coli
Enterobacterspp.Klebsiella pneumoniae
Morganellaspp.Proteusspp.Serratiaspp.Citrobacterspp.
0
10
20
30
40
50
60
1988 1989 1990 1991 1992 1993 1994 1995Percen
tResistantP
atientIsolates Non-HIV units (n = 28,966 patient isolates)
HIV units (n = 1,920 patient isolates)
Prevalence of TMP/SMX useamong AIDS patients
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 6: Use local data
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Prevalence of Fluoroquinolone-ResistantEscherichia coli: Variability Among PatientPopulations
0
10
20
30
40
50
HIV/AIDS
Trauma
COP
D
Diabetes
Dialy
sis
Homeless
InjectionDrugUse
Pediatric
Patient Characteristics
Percen
tResistant
Patien
tIsolates
San Francisco General Hospital 1996-1997
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 6: Use local data
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Use Antimicrobials Wisely
Step 6: Use local data
Fact: The prevalence of resistance can vary by locale, patient
population, hospital unit, and length of stay.
Actions:
6know your local antibiogram6know your patient population
Link to: NCCLS Proposed Guidance for Antibiogram Development
p p
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12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Interpreting a Positive Blood Culture
True Bacteremia:
Unlikely Uncertain Likely
S. aureus
S. pneumoniae
Enterobacteriaceae P. aeruginosa
Candida albicans
Corynebacteriumspp.
Non-anthracis Bacillusspp.
Propionibacterium acnes
Coagulase-negative
staphylococci
Source: Kim SD, et al: Infect Control Hosp Epidemiol 2000;21:213-7
Pre-test probabilitypatient risk factorsprosthetic devicesclinical evidence
Post-test probability# positive/# culturescompare antibiogramscompare genotypes
Step 7: Treat infection, not contamination
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12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Fact:
A major cause of antimicrobial overuseis treatment of colonization.
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Use Antimicrobials Wisely
Step 8: Treat infection,not colonization
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Fact:
Vancomycin overuse promotes
emergence, selection, and spreadof resistant pathogens.
Steps to e e t t c ob a es sta ce osp ta ed du ts
Use Antimicrobials Wisely
Step 9: Know when tosay no to vanco
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
St 9 K h t t
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S. aureus
Penicillin
[1950s]
Penicillin-resistant
S. aureus
Evolution of Drug Resistance in S. aureus
Link to: CDC Facts about VISA Link to: CDC Facts about VRE
Methicillin
[1970s]
Methicillin-resistant
S. aureus(MRSA)
Vancomycin-resistant
enterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin
intermediate-
resistantS. aureus(VISA)
Vancomycin-
resistant
S. aureus
Step 9: Know when to say no to vanco
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
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Use Antimicrobials Wisely
Step 9: Know when to say no to vanco
Fact: Vancomycin overuse promotes emergence, selection, andspread of resistant pathogens.
Actions:
6treat infection, not contaminants or colonization
6fever in a patient with an intravenous catheteris not a routine indication for vancomycin
Link to: CDC guidelines to prevent vancomycin resistance
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US $ 17 Milyar
25%
32%
33%
10%
25%
27%
28%
20%
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Fact:
Failure to stop unnecessaryantimicrobial treatment contributesto overuse and resistance.
Use AntimicrobialsWisely
Step 10: Stop treatmentwhen infection is cured
or unlikely
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Fact: Failure to stop unnecessary antimicrobial treatmentcontributes to overuse and resistance.
Actions:6when infection is cured
6when cultures are negative and infection
is unlikely6when infection is not diagnosed
Use Antimicrobials Wisely
Step 10: Stop antimicrobial treatment
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Fact:
Patient-to-patient spread ofpathogens can be prevented.
Prevent Transmission
Step 11:Isolate the pathogen
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Prevent Transmission
Step 11: Isolate the pathogen
Fact: Patient-to-patient spread of pathogens can beprevented.
Actions:
6use standard infection control precautions6contain infectious body fluids (use approved
airborne/droplet/contact isolation precautions)
6when in doubt, consult infection controlexperts
Link to: A VRE prevention success story
Link to: CDC isolation guidelines and recommendations
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Fact:
Healthcare personnel can spread
antimicrobial-resistant pathogens frompatient to patient.
Prevent Transmission
Step 12:Contain your contagion
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Improved Patient Outcomes AssociatedWith Proper Hand Hygiene
Ignaz Philipp Semmelweis(1818-1865)
Chlorinated lime hand antisepsis
Link to: Ignaz Semmelweis
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Impact of Hand Hygiene on HospitalInfections
Year Author Setting Impact on Infection Rates
1977 Casewell adult ICU Klebsielladecreased1982 Maki adult ICU decreased
1984 Massanari adult ICU decreased
1990 Simmons adult ICU no effect1992 Doebbeling adult ICU decreased with one versus
another hand hygiene product
1994 Webster NICU MRSA eliminated
1995 Zafar nursery MRSA eliminated1999 Pittet hospital MRSA decreasedICU = intensive care unit; NICU = neonatal ICU
MRSA = methicillin-resistant Staphylococcus aureus.
Link to: Improving hand hygiene
Source: Pittet D: Emerg Infect Dis 2001;7:234-240
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How are Patients Exposed to HospitalWater?
Handwashing (cross-contamination) Bedpans
Enteral feedings
Respiratory equipment
Drinking
Showering Bed bathing
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Prevent TransmissionStep 12: Break the chain of contagion
Fact: Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient.
Actions:
6stay home when you are sick
6contain your contagion
6keep your hands clean6set an example!
Link to: Health guidelines for healthcare personnel Coming soonnew guidelines for hand hygiene
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Hypodermic syringeswith Self-Sheathing safetyf t
Hypodermic syringes with RetractableTechnology safety feature
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feature
Self-sheathedprotected position
gy y
Retracted protected position
Phlebotomy needle withSelf-Blunting safety feature
Blunted protected position
Attached to syringe needle
Attached to blood tube holder
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