Management of an outbreak of a multi-drug resistant pathogenProfessor Kevin RooneyInfection Prevention & Control in the ICU Seminar10th November 2014

SBAR - Situation• Director or SCN of

General ICU• Infection Control• Potential outbreak of

a carbapenem-resistant Klebsiella Pneumonia (KPC) • Adjacent CTX ICU• 2 new cases of KPC

SBAR - Background• 10 bedded ICU• 650 Level 3 patients• Level 3• 25% Mortality• Immunocompromised• At risk of HAI• Adjacent CTX ICU• Same staff pool• KPC patient 2 weeks

ago

SBAR - Assessment• KP • 15% of G-ve infections• Immunocompromised

• KPC• Few options• Prevent / Mitigate• Hidden Killer (>50%)• Silently colonises GIT• Transmission• Environmental• Staff• Both

SBAR - Recommendation• Probable outbreak• ≥2 with KPC• More expected• Outbreak Control

Team• Establish Severity• HIIA Tool

• Prevent spread• Prevent further

resistance

Driver Diagram

Leadership & Culture

• Transparency• Just Culture (No Blame) Early Reporting to ICT

• Outbreak Control Team• Identify all patients• Control the outbreak• Prevent further disease• Investigate the cause & identify factors

that contributed• Disseminate the learning • Communication (patients, public & staff)

Severity of the Outbreak• The Hospital Infection Incident Assessment (HIIA) Tool• Impact on patients, services, public health & anxiety• Openness & Transparency• Effective Communication (case notes)• Senior Management Support• Occupational Health• Support policy implementation• Support / advise staff & OCT• Coordinate screening• Treatment & Fitness to work

Staff Screening Programme

• Beware unintended consequences• Clearly documented in minutes of OCT

• Reasons for staff screening• To characterise the epidemiology of the outbreak –

time, person, place.• To identify the likely source and index case, with a

view to control.• To assist with interrupting the chain of transmission of

an outbreak.• To confirm eradication of the outbreak.

Mitigation

Mitigation

Containment

Eradication

Containment• Close the ICU to all new admissions• Discharge to cohorted areas

• Enhanced contact isolation regardless of colonisation status• Hand hygiene, gowns & gloves for staff / visitors

• Cohort the colonised ICU & non-ICU patients (geography)• Staff cohorting for nurses & AHP’s• Not possible for medics, germ theory of disease

• Hand hygiene monitors 24/7• If asymptomatic 3 x Resp & Rectal culture surveillance• More frequent if near a colonised patient

• Trace outbreak (modes / routes of transmission)• Patient tracking, genomic sequencing

Eradication• Extinction of KPC is the main aim of OCT• Dedicating equipment for single-patient use • Extensive cleaning of shared equipment with bleach• Environmental culture of surfaces prior to next patient• Increase the frequency of environmental cleaning (shift)• Daily patient baths with 2% Chlorhexidine• Double-cleaning of vacated rooms equipment with bleach or

hydrogen peroxide vapour • Staff Education (How, Why, What)• Modes of transmission• Contact precautions• Cohorting

Disease Prevention

Antimicrobial Stewardship • The aim of good antimicrobial stewardship• Decrease in antibiotic use ✓• Not targeting a specific antimicrobial class ✗

• Every Patient gets the Right Drug, at the Right Dose, at the Right Time for the Right Duration

• Start Smart and Then Focus (structured response)• Also includes clinical infection management and improving

patient outcomes ✓• Best structure• Prescription (initiation)• Therapeutic Failure (dosing)• Review

Prescription & InitiationNo in the absence of clinical

suspicion ✗Sepsis Screening Tool ✓

Antibiotics within the hourSurvival in Septic Shock Sepsis Six

1. Deliver O2 (94 -98% SpO2 or 88-92% in COPD)

2. Take blood cultures and consider source control

3. Give IV antibiotics according to local protocol

4. Start IV fluid resuscitation (min 500ml) and reassess

5. Check lactate & FBC

6. Commence accurate urine output measurement and consider urinary catheterisation

All within one hour

Antibiotics• At least blood cultures x2• Consideration of cultures from other sites • Potential infective sources (PVC, CVC, CAUTI) should be sought

• Source control ideally within 12 hours of diagnosis • Give for surgical prophylaxis only in cases where antibiotics

have been shown to be effective (<60 mins KTS)• Prolonged operation or significant haemorrhage, repeat the

dose

Antimicrobial Stewardship: Therapeutic Failure• Antibiotic dosage• According to the patient’s bodyweight (aminoglycosides)• Fixed pre-determined dosage for a 60-80kg man (macrolide)• Insufficient dosing in the obese

• Lipohilic or Hydrophilic antibiotic• Lipophilic: dose according to actual body weight • Hydrophilic: dose according to ideal body weight

• Insufficient concentration of drug at the site of infection • Increased volume of distribution due to hypoalbuminaemia and

rapid administration of fluids • Shock causing a decrease in blood supply to the infected tissues

and organs

Therapeutic Failure (contd)• Enhanced plasma clearance of antibiotics • Improved renal excretion from a hyperdynamic circulation• Increased drug extraction (CVVHF)

• Therapeutic Drug monitoring • Minimise potential unintended consequences • Ensure optimal treatment

• Antibacterial cycling or rotation• Mitigate or limit bacterial resistance • Antibiotic heterogeneity• Limited use• Mixing classes provides greater heterogeneity

Antimicrobial Stewardship: Therapeutic Review & Focus• Clinical picture is an evolving process• Daily review of diagnosis and de-escalation prevents

resistance and reduces toxicity and costs • 4 clinical questions• Stop, Switch, Change or Continue

• Multidisciplinary ward rounds• Procalcitonin ( Surviving Sepsis Recommendation)• De-escalation • Absence of positive microbiology• Multiresistant organisms preventing de-escalation• Lack of bottle as still critically ill

• IV to oral switch (removal of PVC)

In summary

To prevent spread of an

outbreak

Leadership & Culture Mitigation

Prevention & Antimicrobial Stewardship

Any questions?