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ﺑ ﺳ ﻡ ﷲ ﺍﻟﺭﺣﻣﻥ ﺍﻟﺭﺣﻳﻡIn the Name of ALLAH The most gracious, most merciful
م هللا الرحمن الرحيمسب In the Name of ALLAH
The most gracious, most merciful
Infection Control In HMC, Qatar
By: Dr. Yasser ElDeeb
A/AED Infection Prevention And Control.
A/Chairman Infection Prevention and Control Committee, Corporate.
• Objectives:
• Introduction to Hamad Medical Corporation. • The Real Life Situation (Internationally, Nationally and
Locally). • Introduction to Infection Control. • Our hospitals’ infection rates. • Discuss some of the actions to prevent & control
infection.
Qatar Map
Rumailah Hospital 362 Beds,1957
1977
Hamad General Hospital 616 Beds, 1981
Women’s hospital 334 beds, 1988
AlKhor Hospital 119 Beds, 2005
Heart Hospital 116 Beds, 2010
Al Wakra Hospital 300 Beds, 2011
Cuban Hospital 75 Beds, 2012
Hamad Medical City Complex (HMCC)
No longer profitable, new antibiotics have not been created since 1987
Drug-resistant "superbugs" represent one of the gravest threats in the history of medicine, leading experts have warned.
The end of antibiotics era– is it the ultimate consequence?
The antibiotic crisis: accelerating
resistance & little new drug
development
In the last several years, a progressive increase in resistance among bacteria specially Gram-negative pathogens that was coupled with an alarming scarcity of new antibiotic classes in the pipelines.
Overuse of antibiotics
• 22.7 million kg of antibiotics prescribed each year in the US alone!
• Unnecessary prescriptions: common cold, bronchitis, asymptomatic bacteriuria.
• Antibiotic in animal food: Avoparcin, a glycopeptide that might have raised R to vanco,
Virginiamycin, a streptogramin used widely in US in poultry probably resulted in R to streptogramins ,
Quinolones used in animal food resulted in resistant salmonella and cambylobacter.
Relationship between antibiotic use, resistance, treatment failure, and healthcare burden
Source: Academy for Infection Management
Increase in antibiotic use
Limited treatment alternatives
More antibiotics Increased mortality
Increased use of healthcare resources
Increased hospitalization
More antibiotics
Ineffective empiric therapy
Increased morbidity More antibiotics
Increase in resistant strains
MDRO (multidrug resistant organisms)
Nearly 2 million nosocomial infections / year in United States.
Of those patients, about 90,000 die as a result of their
infection.
More than 70% of these infections are duo to MDROs.
Why should we worry? • MDRO are dangerous
– More difficult to treat – May be more virulent – Increase mortality – Increase morbidity
• Resource-intensive – More expensive antibiotics – Increase length of hospitalization. – Increase demand for isolation-facilities
• Derived problems – Drug toxicity – Poorer quality of care due to single room isolation
Staph aureus (MRSA)
Pneumococci
Enterococci(VRE)
Gonococci
*Clostridium difficile
*Corynebacteria and
E. Coli (ESBL) Klebsiella (ESBL+CRE) Salmonella Pseudomonas Acinetobacter Stenotrophomonas Helicobacter …plus many others
Multi-drug resistant bacteria: a rough overview
MDR- & XDR-TB
ESBLs
ESBL producing E. coli & Klebsiella pneumoniae
http://www.salute.gov.it/imgs/C_17_pubblicazioni_1404_allegato.pdf
Prevalence and incidence of ESBLs in the G.C.C. region
Mokaddas et al 2008; Al-Zarouni et al 2008
Kuwait
Saudi Arabia
United Arab Emirates 1% 41%
31.7%
38.5%
ESBL
ESBLs E. coli in QATAR
0
10
20
30
40
50
60
70
HGH WH RH AAH AKH
2009201020112012
Source: National Nosocomial Infections Surveillance (NNIS) System
Methicillin-Resistant Staphylococcus aureus (MRSA) Among Intensive Care Unit Patients,
1995-2004
010203040506070
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Year
Perc
en
t R
esis
tan
ce
MRSA was first isolated in the United States in 1968. By the early 1990s, MRSA reached 20%-25%. In 1999, MRSA accounted for >50% of S. aureus isolates from patients in ICUs . In 2003, 60% of S. aureus isolates in ICUs were MRSA .
http://www.salute.gov.it/imgs/C_17_pubblicazioni_1404_allegato.pdf
MRSA in Europe 2009
MRSA in QATAR
05
10152025303540
HGHIP
WHIP
RHIP
AAHIP
AKHIP
MRSA 2009MRSA 2010MRSA 2011MRSA 2012
VRE in Qatar
• 2009 total E.faecium tested 117 2010 total E.faecium tested 33 2011 total E.faecium tested 49 2012 total E.faecium tested 63
0
2
4
6
8
10
12
2009 2010 2011 2012
2009201020112012
Why the program?
• More infection, longer hospitalization • Infection breaks your procedures. • HAI even longer, more cost, worse outcome. • Dx. And treatment cost more and more • Break the chain of infection (In USA 2 million patients have HAI, cost
around 5 Billion Dollars).
GOALS
• Prevention • Education about infection control guidelines. • Analysis bundle compliance rate and monitor the
implementation of bundle elements. • Institute appropriate measures to control infections including
appropriate use of isolation techniques, P.P.Es. and immunizations.
• Screening of patients transferred to our premises. • Coordination with all hospital departments.
GOALS • Surveillance:
• Identify baseline information about the frequency and type of health care associated infections
• Report to departments and outside agencies when necessary Including Public Health.
• Monitor hand hygiene compliance of direct care staff and conduct hand hygiene campaigns.
• Device associated infection in ICUs: The following device associated infections are monitored regularly in all ICUs according to the standards of National Nosocomial surveillance system (NNIS)
» Central Line Related Blood Stream Infections. » Ventilator Associated Pneumonia. » Urinary Tract Catheter Related Infections.
– Surgical Site Infections. – Surveillance of alert organisms, like: MRSA,VRE, clostridium difficile and other
multidrug resistant organisms • Environmental surveillance: using approved check list and findings and
recommendations should be sent to the concerned unit as a feed back.
GOALS
• Control • Identify patients and/or staff with communicable or
potentially communicable infections • Advise hospital staff of control procedures indicated • Serve as an information resource for all departments on
various disinfection and cleaning products and procedures • Outbreak Investigation / Management: Outbreak investigations done whenever there will be an alert
of unusual cluster based on surveillance data or any reporting of similar cases within a hospital.
GOALS • Construction Evaluation • Product Evaluation: • The following products are examples of products we evaluation:
– Antiseptic products. – Body cleansing wash cloths (2%chlorhexidine gluconate) – Alcohol Based Hand Rub – Environmental disinfection mobile units. – Wound dressing materials. – Catheter site dressing materials. – Ventilation devices. – MedicCleanAir.
Hand Hygiene (5moments)
• 1) Before touching. • 2)Before procedure. • 3)After Procedure (hand wash). • 4)After touching. • 5)After touching surrounding.
PPE • Wear the PPE outside the room, Remove
them in the room. • Transfer a patient with MDRO only if
necessary, and wearing surgical mask. (Infection Control Policy CL7246, 2011-2014)
Care Bundles
A bundle is a set of practices when performed
collectively, reliably and continuously, have been proven to improve patient outcomes.
Central line bundle
Insersion Maintenence • Optimal site • Hand hygiene • Full body droop, sterile area • Sterile gloves, gown and
towel • Surgical masks & cap
• Hand wash B4 accessing • Standard dressing
techniques • Change I.V. bags Q24 hrs • Change tubing Q72hrs
CENTRAL LINE BUNDLE
1.Hand hygiene 2.Maximal Barrier precautions upon insertion 3.Chlorehexidine Skin antisepsis (Chloroprep) 4.Optimal catheter site selection, with subclavian vein as the
preferred site for Non –Tunneled catheters. 5.Daily Review of line Necessity with prompt removal of
Unnecessary Lines
The key components of the Ventilator Bundle
1.Elevation of the Head of the Bed to between 30 and 45 degrees
2.Daily "Sedation Vacations" and Assessment of Readiness to Extubate.
3.Daily oral care with Chlorhexidine. 4.Peptic Ulcer Disease Prophylaxis (PUD). 5.Deep Venous Thrombosis Prophylaxis(DVT).
Indwelling Urinary Catheters Bundle
• Perform a daily review of the need for the urinary catheter. • Check the catheter has been continuously connected to the
drainage system. • Ensure patients are aware of their role in preventing urinary
tract infection. (Alternative bundle criterion - if the patient is unable to be made aware, Perform routine daily meatal hygiene).
• Regularly empty urinary drainage bags as separate
procedures, each into a clean container. • Perform hand hygiene, gloves and apron prior to each
catheter care procedure; on procedure completion, remove gloves and apron and perform hand hygiene again.
Blood & Body Fluid Exposure • Needle stick injury • Bite • Splash on M.M. • Cut
Role • Prevention: avoid recap, use appropriate barrier, Hand
hygiene • Wash • Eye splash station • Ova, Form • Staff clinic, or ED
Antimicrobial stewardship program
• Automatic stop order for antibiotic prophylaxis. • The pharmacy software.
Surveillance
• Ongoing collection of data Analysis & Interpretation Dissemination.
• Targeted. (area, service, procedure, organism,
site).
Purposes of Surveillance • Improve patient outcomes.
• Obtain “baseline” data. • Identify problems. • Evaluate and control interventions. • Monitor quality of infection control practices. • Educate health-care providers. • Determine research / study. • Convince the administration. • Satisfy regulatory / accreditation requirements.
How to compare?
National Healthcare Safety Network (NHSN)
Benchmarking In percentile-10th,25th,50th,75th and 90th
Prevention of Antimicrobial Resistance
Clinicians hold the solution!
Antimicrobial Resistance: Key Prevention Strategies
Optimize Use
Prevent Transmission Prevent
Infection
Effective Diagnosis & Treatment
Pathogen
Antimicrobial Resistance
Antimicrobial Use
Infection
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
1. Vaccinate 2. Get the catheters out 3. Target the pathogen 4. Access the experts
5. Practice antimicrobial control 6. Use local data 7. Treat infection, not contamination 8. Treat infection, not colonization 9. Know when to say “no” to
Vacomycine 10. Stop treatment when infection is
cured or unlikely 11. Isolate the pathogen 12. Break the chain of Infection
Diagnose and Treat Infection Effectively
Prevent Infection
Use Antimicrobials Wisely
Prevent Transmission
Actions: give influenza / pneumococcal vaccine to at-
risk patients before discharge get influenza vaccine annually
Prevent Infection Step 1: Vaccinate
Fact: Pre-discharge influenza and pneumococcal vaccination of at-risk hospital patients and influenza vaccination of healthcare personnel will prevent infections.
0102030405060708090
100
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Pnumonia patient65 yrs and aboveand recievedppneumobenchmark
Flu vaccination Campaign 2013 S/N Hospital Doctors Nurses Para Med & Other Total
1 HGH 168 335 1038 1541
2 WH 13 206 418 637
3 NCCCR 15 124 173 312
5 RH 38 265 435 738
6 ED 61 192 213 466
7 Al -Wakra Hospital 5 73 531 609
8 Staff Clinic M C 5 162 319 486
9 Al-Khoor Hospital 55 214 435 704
10 Fahad bin Jassim & Al -Wakra Dialysis unite 0 60 297 357
11 PEC Al-Saad 42 104 264 410
12 PEC (Rayyan ,Daayen ,Airport & Shammal) 18 34 189 241
13 OPD Annex 4 37 47 88
14 Psychiatric 4 26 73 103
15 Cuban Hospital 56 172 327 555
16 Heart Hospital 29 490 142 661
17 Residential Compound Complex 2 40 47 89
TOTAL 515 2534 4948 7997
Fact: Catheters and other invasive devices are the # 1 exogenous cause of hospital-onset infections. Actions:
use catheters only when essential use the correct catheter use proper insertion & catheter-care protocols remove catheters when not essential
Prevent Infection Step 2: Get the catheters out
Link to:IDSA Guidelnes for the Prevention of Intravascular Catheter-related Infections
Fact: Appropriate antimicrobial therapy saves lives. Actions:
Culture the patient Target empiric therapy to likely pathogens
and local antibiogram Target definitive therapy to known
pathogens and antimicrobial susceptibility test results
Diagnose & Treat Infection Effectively Step 3: Target the pathogen
Inappropriate Antimicrobial Therapy: Impact on Mortality
Step 3: Target the pathogen
Fact: Infectious diseases expert input improves the outcome of serious infections.
Diagnose & Treat Infection Effectively Step 4: Access the experts
Step 4: Access the experts
Fact: Programs to improve antimicrobial use are effective.
Use Antimicrobials Wisely Step 5: Practice Antimicrobial Control
A direct relationship between antibiotic consumption and antibiotic resistance
Bronzwaer et al. Emerg Infect Dis 2002; 8: 278-82
Fact: The prevalence of resistance can vary by time, locality, patient population, hospital unit, and length of stay.
Use Antimicrobials Wisely Step 6: Use local data
Use Antimicrobials Wisely Step 7: Treat infection, not
contamination Fact: A major cause of antimicrobial overuse is
“treatment” of contaminated cultures. Actions:
use proper antisepsis for blood & other cultures culture the blood, not the skin or catheter hub use proper methods to obtain & process all
cultures
Link to: CAP standards for specimen collection and management
Use Antimicrobials Wisely Step 8: Treat infection, not colonization
Fact: A major cause of antimicrobial overuse is treatment of colonization.
Actions:
treat bactraemia, not the catheter tip or hub treat pneumonia, not the tracheal aspirate treat urinary tract infection, not the indwelling
catheter
Link to: IDSA guideline for evaluating fever in critically ill adults
Fact: e.g.Vancomycin overuse promotes emergence, selection,and spread of resistant pathogens.
Use Antimicrobials Wisely Step 9: Know when to say “no” to vancomycin
Fact: Failure to stop unnecessary antimicrobial
treatment contributes to overuse and resistance.
Actions:
when infection is cured when cultures are negative and
infection is unlikely when infection is not diagnosed
Use Antimicrobials Wisely Step 10: Stop antimicrobial treatment
Prevent Transmission Step 11: Isolate the pathogen
Fact: Patient-to-patient spread of pathogens can be
prevented. Actions:
use standard infection control precautions contain infectious body fluids (use APPROPRIATE airborne/droplet/contact isolation
precautions)
when in doubt, consult infection control experts
Fact: Healthcare personnel can spread antimicrobial-resistant pathogens from patient-to-patient.
Prevent Transmission Step 12: Break the chain of
infection
Our Program • Policies & Procedures • Surveillance • Isolation • Construction • Education • Sterilization • Hand hygiene • Environment • Occupational Health • Outbreaks
Acknowledgement
• Dr.Mohammed Abu Khattab, Consultant I.D. • Rida AlKhodour, Infection Control Team Head
, Alkhor Hospital. • Manal AlMalkawi, Infection Control Team
Head, Rumailah Hospital • All The Infectious Diseases Team, Infection
Control Chairmen, And above all the infection control practitioners who do the real work behind the scenes!
Let us work together to maintain a clean, safe and possibly an infection-free
environment.
