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Campaign to PreventAntimicrobial ResistanceDialysis Patients

Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare Quality Promotion

Department of Health and Human Services

Link to: Campaign to Prevent Antimicrobial Resistance Online Link to: Federal Action Plan to Combat Antimicrobial Resistance

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Link to: Campaign to Prevent Antimicrobial Resistance Online Link to: Federal Action Plan to Combat Antimicrobial Resistance


Clinicians

Hold the

Solution!

Emergence of Antimicrobial Resistance

Susceptible Bacteria


New Resistant Bacteria

Mutations

XX

Resistant Bacteria

Resistance Gene Transfer

Resistant StrainsRare

xx

Resistant Strains Dominant

xxxx

xx

xx

xxAntimicrobial Exposure

Selection for Antimicrobial-resistant Strains


Antimicrobial Resistance: Key Prevention Strategies

Optimize Use

PreventTransmission

PreventInfection

EffectiveDiagnosis& Treatment

PathogenAntimicrobial-Resistant Pathogen

Antimicrobial Resistance

Antimicrobial Use

Infection


Susceptible Pathogen

Key Prevention Strategies

Prevent infection Diagnose and treat

infection effectively

Use antimicrobials wisely

Prevent transmission


Clinicians hold the solution!


General health communication strategy Goals:

- inform clinicians, patients, and other stakeholders

- raise awareness about the escalating problem of antimicrobial resistance in healthcare settings

- motivate interest and acceptance of interventional programs to prevent resistance


12 Steps To Prevent Antimicrobial Resistance

Targeted intervention programs for clinicians caring for high risk patients- hospitalized adults - dialysis patients- hospitalized children - surgical patients- long - term care residents

Goal: Improve clinician practices & prevent antimicrobial resistance Partnership with professional societies; evidence base published in

peer-reviewed specialty journals Educational tools – web-based / didactic learning modules, pocket

cards, slide presentations, etc.


12 Steps to Prevent Antimicrobial Resistance: Dialysis Patients


Prevent Transmission

Use AntimicrobialsWisely

Diagnose & TreatEffectively

Prevent Infection

12 Partner with your patients 11 Practice hand hygiene 10 Follow infection control precautions 9 Stop antimicrobial treatment 8 Treat infection, not contamination or colonization 7 Know when to say “No” to Vanco 6 Use local data 5 Access the experts 4 Target the pathogen 3 Optimize access care 2 Get the catheters out1 Vaccinate staff and patients

Disease Burden for Dialysis Patients

The number of patients with end-stage renal disease treated by maintenance hemodialysis in the US has increased during the past 30 years.¹

In 2001 more than 3,000 hemodialysis centers had greater than 250,000 chronic hemodialysis patients.2

Annual mortality rate among hemodialysis patients is 23% and infections are the second most common cause, accounting for 15% of deaths.¹

Hemodialysis patients are immunosuppressed and require frequent hospitalization and surgery, which increases their risk for resistant infections.¹

Vascular access infections (in hemodialysis patients) and peritonitis (in peritoneal dialysis patients) are the most common infections.¹


1 CDC, MMWR 2001; 50 (5):132Unpublished data, Dialysis Surveillance Network

Fact: Influenza and pneumococcal vaccine given to both staff and patients will help to prevent infections requiring antimicrobial therapy.

Prevent InfectionStep 1: Vaccinate staff and patients


Step 1: Vaccinate staff and patients

Vaccination Rates of Dialysis Patients,1999-2001*

01020304050

60708090

100

1999 2000 2001

Influenza Vaccine

PneumococcalVaccine

Healthy People 2010Goal

Link to: Influenza recommendations...CDC, MMWR 2003; 52 (RR08):1-36

* Unpublished data, Dialysis Surveillance Network



Need for Healthcare Personnel ImmunizationPrograms: Influenza Vaccination Rates (1996-97)

34%All healthcare personnel

38%Healthcare personnel at high risk

63%All adults > 65 yrs. of age

% Vaccinated

Source: 1997 National Health Interview SurveyWalker FJ, et al., Infect Control Hosp Epidemiol 2000; 21:113

Link to: ACIP Influenza Immunization Recommendations



http://www.phppo.cdc.gov/cdcrecommends/showarticle.asp?a_artid=1361++++&TopNum=50&CallPg=Adv


Actions: Get influenza vaccine Give influenza / pneumococcal vaccine to patients in addition to routine vaccines (e.g., hepatitis B)

Prevent InfectionStep 1: Vaccinate staff & patients

Fact: Influenza and pneumococcal vaccine given to both staff and patients will help to prevent infections requiring antimicrobial therapy.

Link to: ACIP Influenza immunization recommendations Link to: CDC facts about influenza and pneumococcal vaccine Link to: ACIP: Vaccine standing orders





Link to: NNIS Online at CDC

Fact: Indwelling catheters are the single most important factor contributing to bacteremia in hemodialysis patients.

Prevent InfectionStep 2: Get the catheters out


Step 2: Get the catheters out

http://www.cdc.gov/ncidod/hip/surveill/nnis.htm

Epidemiology of Catheter Associated Infections

Estimated attributable mortality for catheter-associated bloodstream infections ranges from 0% to 35%, depending on study design.

Primary risk factor for access infection is access type (catheters>grafts>fistulas).

The relative risk for bacteremia in patients with dialysis catheters is sevenfold the risk for patients with primary arteriovenous fistulas.



CDC, MMWR 2002, 51 (RR-10); p.10

Biofilm on Intravenous Catheter Connecter 24 Hours After Insertion

Scanning Electron Micrograph

Link to: Biofilms and device-associated infections



http://www.cdc.gov/ncidod/eid/vol7no2/donlan.htm

Rates of Bacteremia Infection by Access Type - Dialysis Surveillance Network 10/99-05/02

0.3 0.5

4.8

8.7

0.0

2.0

4.0

6.0

8.0

10.0

Fistula Graft CuffedCatheter

NoncuffedCatheter

Rat

e p

er 1

00 p

atie

nt-

mo

nth

s

Tokars et al., Am J Infect Control 2002;30:288-295.



Fact: Indwelling catheters are the single most important factor contributing to bacteremia in hemodialysis patients.

Actions: Hemodialysis:

Use catheters only when essential Maximize use of fistulas/grafts Remove catheters when they are no longer essentialPeritoneal Dialysis: Remove/replace infected catheters

Coming soon…guidelines for preventing catheter-associated bloodstream infections Link to: Urinary catheter infection prevention

Prevent InfectionStep 2: Get the catheters out



http://www.cdc.gov/ncidod/hip/default.htm

http://www.cdc.gov/ncidod/eid/vol7no2/maki.htm

Link to: NNIS Online at CDC

Fact: Careful infection control prevents peritoneal dialysis related infections.

Prevent InfectionStep 3: Optimize access care


Step 3: Optimize access care

Peritoneal Catheter Insertion and Management

Catheter insertion should be performed under operating room, sterile conditions.

Adherence to the principles of catheter insertion, management, and care remain the cornerstone of successful peritoneal dialysis access.

Despite improvements in catheter survival over the last few years, catheter-related complications still occur, causing significant morbidity and often forcing the removal of the catheter.



Gokal et al., Peritoneal Dialysis International 1998;18:11-33.

Fact: Careful infection control prevents peritoneal dialysis-related infections.

Actions: Follow established guidelines for access care Use proper insertion and catheter-care protocols Remove access device when infected Use the correct catheter

Guidelines for preventing catheter-associated bloodstream infections, CDC, MMWR 2002 51 (RR10) Link to: Peritoneal Catheters and Exit-Site Practices 1998 Update

Prevent InfectionStep 3: Optimize access care



Fact: Identifying the pathogen using microbiologic cultures and antimicrobial susceptibility testing allows for targeted antimicrobial therapy.

Diagnose & Treat EffectivelyStep 4:Target the pathogen


Step 4: Target the pathogen

Importance of Utilizing Cultures and Antimicrobial Susceptibility Testing Results

No. (%) Susceptible___________________________________________________ Cefazolin Vanco Cefazolin and Vanco and

Gentamicin Gentamicin

___________________________________________________Blood Cultures 14 (78) 16 (89) 16 (89) 17 (94)(n=18)

Clinically SignificantCultures (n=146) 87 (60) 100 (68) 132 (90) 142 (97)

Fogel et al., Am J Kidney Dis 1998;32:401-409



CDC’s M.A.S.T.E.R. Improving Antimicrobial Susceptibility Testing Proficiency

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults


Fact: Identifying the pathogen using microbiologic cultures and antimicrobial susceptibility testing allows for targeted antimicrobial therapy.

Actions: Obtain appropriate cultures Target empiric therapy to likely pathogens Target definitive therapy to known pathogens Optimize timing,regimen,dose,route and duration

Link to: IDSA guidelines for evaluating fever in critically ill adults

Diagnose & Treat Effectively Step 4: Target the pathogen



http://www.journals.uchicago.edu/CID/journal/issues/v26n5/my56_1042/my56_1042.web.pdf

Fact:Input from infectious diseases experts improves the outcome of serious infections.


Step 5: Access the experts

Diagnose & Treat EffectivelyStep 5:Access the experts

Infectious Diseases Expert Resources

Infectious Diseases Specialists

Optimal Patient Care

Optimal Patient Care

Infection Control Professionals

Healthcare Epidemiologists

ClinicalPharmacists

Clinical Pharmacologists

Surgical InfectionExperts

ClinicalMicrobiologists



Fact: Input from infectious diseases experts improves the outcome of serious infections.

Action: Consult the appropriate experts for

complicated infections

Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistancein Hospitals

Diagnose & Treat Effectively Step 5: Access the experts



Fact:The prevalence of resistance varies by locale

Use Antimicrobials WiselyStep 6: Use local data


Step 6: Use local data

Percent of S. aureus Blood Isolates Resistant to Methicillin, by Dialysis Center

0

2

4

6

8

10

10 20 30 40 50 60 70 90

Percent Resistant to Methicillin

Nu

mb

er o

f D

ialy

sis

Cen

ters

Dialysis Surveillance Network 1999-20023

11 Centers, Canada, 10%1

10 Centers, Connecticut, 43%2

1Taylor et al., Infect Control Hosp Epidemiol 2002;23:716-7202 Dopirak et al., Infect Control Hosp Epidemiol 2002;23:721-7243 Unpublished data, Dialysis Surveillance Network



Use Antimicrobials Wisely Step 6: Use local data

Fact: The prevalence of resistance varies by locale.

Actions: Know your local antibiogram Get previous microbiology results when

patients transfer to your facility

Link to: NCCLS Proposed Guidance for Antibiogram Development



Fact: Reduction of vancomycin use is one of the most important strategies to limit the emergence, selection, and spread of vancomycin resistant bacteria.

Use Antimicrobials WiselyStep 7: Know when to say “No” to vanco


Step 7: Know when to say “No” to Vanco

S. aureus

Penicillin

[1944] Penicillin-resistantS. aureus

Evolution of Drug Resistance in S. aureus

Methicillin

[1962]

Methicillin-resistantS. aureus (MRSA)

Vancomycin-resistantenterococci (VRE)

Vancomycin

[1990s]

[1997]

Vancomycinintermediate

S. aureus(VISA)

[2002]

Vancomycin-resistantS. aureus


Step 7: Know when to say “ No” to Vanco

CDC, MMWR 2002;51(26):565-567

VRE Colonization Among Dialysis Patients Who Received Vancomycin


Step 7: Know when to say “ No” to Vanco

Received Vancomycin Developed VRE

No 0/29 (0%)

Yes 16/61 (26%)

p<.001

Atta et al., Kidney International 2001;59:718-724

First Case of Vancomycin - Resistant S. aureus (VRSA)

First fully vancomycin resistant clinical isolate of S. aureus Michigan, June 2002 40-year old black female with diabetes mellitus, peripheral

vascular disease,on chronic hemodialysis VRSA from foot ulcer and catheter exit site During the 6 months preceding VRSA:

patient experienced 6 hospitalizations, totaling 18 days patient received multiple antimicrobial therapy, including 5.5 weeks of vancomycin

Chang S et al, New England J of Med 2003; 348:14,1342-3447



Vancomycin- Intermediate S. aureus (VISA)

State, Year Site PD/HD*Michigan, 1997 Peritonitis Chronic PDNew Jersey, 1997 Blood Recent PDNew York, 1998 Blood Chronic HDIllinois, 1999 Endocarditis Chronic HDMinnesota, 2000 Bone Chronic HDNevada, 2000 Liver -----

PD=peritoneal dialysis , HD=hemodialysis

Fridkin, Clin Infect Diseases 2001;32:111



Guidelines for Appropriate Vancomycin Use (HICPAC/CDC)

Selected situations in which the use of vancomycin is appropriate or acceptable: For treatment of serious infections caused by beta-

lactam-resistant gram-positive microorganisms. For treatment of infections caused by gram-positive

microorganisms in patients who have serious allergies to beta-lactam agents.

When antibiotic-associated colitis fails to respond to metronidazole therapy or is severe and potentially life-threatening.



CDC, MMWR 1995;44(RR12):1-13

Guidelines for Appropriate Vancomycin Use (HICPAC/CDC)

Selected situations in which the use of vancomycin should be discouraged: Treatment in response to a single blood culture positive for coagulase-negative

staphylococcus, if other blood cultures taken during the same time frame are negative.

Continued empiric use for presumed infections in patients whose cultures are negative for beta-lactam resistant gram-positive microorganisms.

Eradication of MRSA colonization. Systemic or local prophylaxis for infection or colonization of indwelling central or

peripheral intravascular catheters. Primary treatment of antibiotic-associated colitis. Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or

hemodialysis. Treatment (chosen for dosing convenience) of infections caused by beta-lactam-

sensitive gram-positive microorganisms in patients who have renal failure.



Use Antimicrobials WiselyStep 7: Know when to say “No” to vanco

Fact: Reduction of vancomycin use is one of the most important strategies to limit the emergence, selection, and spread of vancomycin resistant bacteria.

Action: Follow CDC guidelines for vancomycin use Consider 1st generation cephalosporins instead of

vancomycin

Link to: Methods to improve antimicrobial use and prevent resistance



Fact: A major cause of antimicrobial overuse is treatment of contamination or colonization.

Use Antimicrobials WiselyStep 8: Treat infection,not contamination or colonization


Step 8: Treat infection, not contamination or colonization

Interpreting a Positive Blood CultureTrue Bacteremia: Unlikely Uncertain Likely

• S. aureus• S. pneumoniae• Enterobacteriaceae• P. aeruginosa• C. albicans

• Corynebacterium spp.• Non-anthracis Bacillus spp.• Propioniobacterium acnes

• coagulase-negative staphylococci

Kim SD, et al., Infect Control Hosp Epidemiol 2000;21:213-217

pre-test probabilitypatient risk factorsprosthetic devicesclinical evidence

post-test probability# positive / # cultures compare antibiograms compare genotypes


Step 8: Treat infection, not contamination or colinization

Use Antimicrobials Wisely Step 8: Treat infection, not contamination or colonization

Fact: A major cause of antimicrobial overuse is treatment of contamination or colonization.

Actions: Use proper antisepsis for drawing blood cultures Get one peripheral vein blood culture, if possible Avoid culturing vascular catheter tips Treat bacteremia, not the catheter tip Culture the blood, not the skin or catheter hub

Link to: CAP standards for specimen collection and management


Step 8: Treat infection, not contamination or colonization

Fact: Stopping empiric therapy when cultures are negative can significantly reduce antimicrobial use.

Use Antimicrobials WiselyStep 9: Stop antimicrobial treatment


Step 9: Stop antimicrobial treatment

Short-course Antimicrobial Treatment of New Pulmonary Infiltrates in an ICU

Standard Experimental

Variable Therapy (n=42) Therapy (n=39)Regimen clinician discretion ciprofloxacin 400mg

(all treated; 18 drugs) (IV bid x 3 days)Treatment > 3 days 97% 28%

Antimicrobial resistance 35% 15%

Length of stay mean/median 14.7/9 days 9.4/4 days

Mortality (30 day) 31% 13%

Antimicrobial cost mean/total $640/$16,004 $259/$6,484

Link to: Singh N, et al.,Am J Respir Crit Care Med 2000;162:505-511



Use Antimicrobials WiselyStep 9: Stop antimicrobial treatment

Fact: Stopping empiric therapy when cultures are negative can significantly reduce antimicrobial use.

Actions: Stop when infection is treated Stop when clinical and laboratory data

rule out infection

Link to: IDSA guideline for evaluating fever in critically ill adults



Fact: Following the recommended infection control precautions for hemodialysis patients can prevent transmission of infections from patient to patient.

Prevent TransmissionStep 10: Follow infection control precautions


Step 10: Follow infection control precautions

Infection Control Precautions for Hemodialysis Patients

In the hemodialysis setting, contact transmission plays a major role in

transmission of bloodborne and other pathogens. Infection Control Precautions for hemodialysis patients include:

Strict attention to hand hygiene using gloves for patient care and when handling patients medical equipment and

devices. Dedicating nondisposable items for use on a single patient. Cleaning and disinfection of items taken into a dialysis station that will be used for

more than one patient. For patients at increased risk for transmission of pathogenic bacteria,

including antimicrobial-resistant strains, additional precautions also might be necessary in some circumstances. For example, staff treating the patient should a) wear a separate gown over their usual clothing and b) dialyze the patient at a station with as few adjacent stations as possible.


Step 10: Follow infection control precautions

Prevent Transmission Step 10: Follow infection control procedures

Fact: Following recommended infection control precautions for hemodialysis patients can prevent transmission of infections from patient to patient.

Actions: Use standard infection control precautions

for dialysis centers Consult local infection control experts

Link to: A VRE prevention success story Link to: CDC isolation guidelines and recommendations


Step 11: Practice hand hygiene

Fact:

Hand hygiene is the single most important infection control measure for preventing the spread of antimicrobial resistant organisms.

Prevent TransmissionStep 11: Practice hand hygiene



Hand Hygiene Adherence in Hospitals

1. Gould D, J Hosp Infect 1994;28:15-30 2. Larson E, J Hosp Infect 1995;30:88-1063. Slaughter S, Ann Intern Med 1996;3:360-365 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860 5. Pittet D, Lancet 2000;356:1307-1312

Year of Study Adherence Rate Hospital Area

1994 (1) 29% General and ICU

1995 (2) 41% General

1996 (3) 41% ICU

1998 (4) 30% General

2000 (5) 48% General



Effectiveness of Hand Hygiene Agents in Reducing Bacteria on Hands

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, Philadelphia: Lippincott & Williams,1999.

Time after disinfection

Bac

teri

al R

edu

ctio

n

Plain soap

Antimicrobial soap(4% Chlorhexidine)

Alcohol-based handrub (70% Isopropanol)

Baseline

0 60 180 minutes

%

99.9

99.0

90.0

0.0

log

3.0

2.0

1.0

0.0



Fact: Hand hygiene is the single most important infection control measure for preventing the spread of antimicrobial resistant organisms.Actions:

Wash your hands or use alcohol-based handrub

Set an example!

Link to: Health guidelines for healthcare personnel Coming soon…new guidelines for hand hygiene



Prevent TransmissionStep 11: Practice hand hygiene

Fact:

Dialysis patients share in the responsibility for preventing access-related infections

Prevent TransmissionStep 12: Partner with your patients


Step 12: Partner with your patients

Poor Patient Hygiene is a Risk Factor for Infection

No.(%) with Poor Hygiene

Patients Patients not p-value

Infected Infected

All Infections 17/23 (74%) 12/48 (25%) 0.0004

Access siteInfections 8/9 (89%) 21/62 (34%) 0.002

Kaplowitz et al., Infect Control Hosp Epidemiol 1988;9:534-541



Educating Patients About Infection Control Practices

• Patients should be educated about the importance of their role in infection control upon admission to a dialysis center/hospital and at least annually thereafter.

• Educational materials should include personal hygiene, hand hygiene, proper care of access lines, and recognition of signs of infection.

CDC, MMWR 2001;50 (5): 31



Fact: Dialysis patients share in the responsibility for preventing access-related infections.

Actions: Educate patients about proper access care

and infection control measures Re-educate regularly

Link to: Health guidelines for healthcare personnel Coming soon…new guidelines for hand hygiene

Prevent TransmissionStep 12: Partner with your patients



PREVENTION IS PRIMARY!

Protect patients…protect healthcare personnel…

promote quality healthcare!


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