Can we really halve GNBSIs? GNBSI Jon Otter,

Can we really halve GNBSIs? GNBSI Jon Otter, PhD FRCPath Imperial College London [email protected] @jonotter Blog: www.ReflectionsIPC.com You can download these slides from www.jonotter.net Starters for 10 1.Whats the problem with GNBSI? 2.What is behind the MRSA / CDI reductions? 3.Why have these not been effective against MSSA and E. coli? 4.(How) can we reduce GNBSIs? THE END OF ANTIBIOTICS IS NIGH Rising threat from AMR-GNR

% of all HAI caused by GNRs. % of ICU HAI caused by GNRs. Non-fermenters Acinetobacter baumannii Pseudomonas aeruginosa Stenotrophomonas maltophilia Enterobacteriaceae Klebsiella pneumoniae Escherichia coli Enterobacter cloacae Hidron et al. Infect Control Hosp Epidemiol 2008;29:966-1011. Peleg & Hooper. N Engl J Med 2010;362:1804-1813. CPE

CPO Creating a monster Extended-spectrum beta-lactams Enterobacteriaceae Carbapenems ESBLs CPE Whats the problem? Antibiotic resistance +++ Courtesy of Pat Cattini Whats the problem? Poor clinical outcome

Enterobacteriaceae Organism Attributable mortality Non fermenters AmpC / ESBL CPE A. baumannii Moderate Massive (>50%) Minimal Shorr et al. Crit Care Med 2009;37:1463-1469. Patel et al. Iinfect Control Hosp Epidemiol 2008;29:1099-1106.

Whats the problem? Rapid spread Clonal expansion Rapid spread Horizontal gene transfer GI carriage Whats the problem? Error bars represent range Elective surgical missed revenue Staff time Additional length of stay Screening Bed / bay / ward closures

Contact precautions Anti-infective costs HPV decontamination Ward-based monitors 0 100000 Cost / Otter et al. Clin Microbiol Infect 2017;23:188-196. 200000 300000 400000 60,000 50,000 40,000 MRSA BSI

MSSA BSI E. coli BSI C. difficile 30,000 20,000 2015/16 2014/15 2013/14 2012/13 2011/12 2010/11 2009/10

0 2008/09 10,000 2007/08 Number of cases National trends: mandatory surveillance ESPAUR 2016 report highlights Increasing prevalence of E. coli and K. pneumoniae BSI, with something in the region of a 20-30% increase in both between 2010 and 2015. Pip/tazo resistance is on the rise in E. coli and K. pneumoniae, with resistance rates now approaching 12% for E. coli BSIs, and 20% for K. pneumoniae BSIs. Carbapenem-resistance in Gram-negative BSIs remains low although the number of cases reported nationally is increasing and almost certainly at least a 10-fold under-estimate of actual prevalence.

There is skewed geographical distribution, and higher rates in both the very young and very old, both in terms of prevalence and resistance for Gram-negative bacteria. The overall use of antimicrobials has declined across the healthcare sector for the first time, although hospital use of key agents (pip/tazo, carbapenems, and colistin) continues to increase. CQUIN programmes have been launched to try to address this in hospitals. ESPAUR 2016. Carbapenem-resistant organisms, Europe 24.0 Carbapenem-resistant P. aeruginosa 22.0 20.0 Carbapenem-resistant K. pneumoniae Multidrug-resistant K. pneumoniae 18.0 % Resistant

16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2005 EARS-Net 2006 2007 2008 2009

2010 2011 2012 2013 2014 Emergence of CPE in the UK PHE. The emerging threat of AMR GNR! Pathogen Resistance Resistance genes Species HA vs CA

At-risk pts Virulence Environment GNR +++ Multiple Multiple HA & CA All +++ +/- MRSA + Single Single HA Unwell ++ +

VRE + Single Single HA Unwell +/++ C. difficile +/n/a Single HA Old + +++ Enterobacteriaceae vs. non-fermenters Share Gram stain reaction Concerning AMR

Differ Risk factors & at-risk population Potential for epidemic spread Infection profile & mortality Prevalence Colonisation site & duration Transmission routes Resistance profile & mechanisms Acronym minefield CPC CRE MDR-GNR CRO MDR-GNB

ESBL CPE CRC NDM KPC CRAB Number of MRSA bacteraemias MRSA bacteraemia, England 2001-2013 2,500 1 2

3 4 5 6 7 8 9 10 2,000 11 1,500 12 1. 2.

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Mandatory reporting, 2001 Getting ahead of the curve, 2002 Winning ways, 2003 Towards cleaner hospitals, 2004 Cleanyourhands, 2004 Targets introduced, 2004 Cleanliness improvement, 2005 Going further faster, 2006 Root cause analysis, 2006

Revised national guidelines, 2006 Deep clean, 2007 Screening elective admissions, 2008 Universal screening, 2010 1,000 All cases 500 0 Trust apportioned 13 C . difficile infe ction (C D I)I case s C. difficileCDI infection cases,

(CDI),2004-2013 England 2004-2013 3 1. National Antimicrobial Stewardship Group (ASG) formed in England, 2003 2. Mandatory reporting, 2004 3. Targets, 2007 4. Revised national guidelines, 2009 5. Start Smart Then Focus lauchned 6. ESPAUR formed 18,000 16,000 12 14,000 4

12,000 10,000 5 8,000 6,000 4,000 2,000 0 6 All cases Trust apportioned Does hand hygiene explain the reductions? The Cleanyourhands campaign was associated with sustained increases in hospital procurement of alcohol rub and soap, which the results suggest has an important

role in reducing rates of some healthcare associated infections. Stone et al. BMJ 2012;344:e3005. Does antimicrobial stewardship explain the reduction? Dingle et al. Lancet Infect Dis 2017 in press. 60,000 50,000 40,000 MRSA BSI MSSA BSI E. coli BSI C. difficile 30,000 20,000 2015/16

2014/15 2013/14 2012/13 2011/12 2010/11 2009/10 0 2008/09 10,000 2007/08

Number of cases Why no reduction in MSSA or E. coli bacteraemia? Spurious correlation? Correlation between national chocolate consumption and rate of Nobel prize winners. Messerli FH. New Engl J Med 2012;367:1562-4. Number of MRSA bacteraemias MRSA bacteraemia, England 2001-2013 2,500 1 2 3 4

5 6 7 8 9 10 2,000 11 1,500 12 1. 2. 3. 4. 5.

6. 7. 8. 9. 10. 11. 12. 13. Mandatory reporting, 2001 Getting ahead of the curve, 2002 Winning ways, 2003 Towards cleaner hospitals, 2004 Cleanyourhands, 2004 Targets introduced, 2004 Cleanliness improvement, 2005 Going further faster, 2006 Root cause analysis, 2006 Revised national guidelines, 2006 Deep clean, 2007 Screening elective admissions, 2008

Universal screening, 2010 1,000 All cases 500 0 Trust apportioned 13 Targeted approach to MRSA infection prevention Reduction targets introduced in 2004 and reinforced in 2006 High impact interventions launched in 2006 Root cause analysis launched in 2006 Revised national guidelines launched in 2006 (including screening, isolation, and suppression for carriers)

Going further faster (2006) Key challenge Specific Focus Challenge 1 Engage the board and use performance management at every level Challenge 2 Ensure clinical ownership across organisation Challenge 3 Screen and/or decontaminate according to risk assessment Challenge 4 Use HIIs* to monitor and increase compliance

Challenge 5 Integrate with risk and clinical governance framework Challenge 6 Ensure infection control is part of induction and ongoing training Challenge 7 Effectively coordinate bed management with infection control input Challenge 8 Clean and decontaminate Challenge 9 Proactively manage your reputation, engage all staff and local community

* HII = high impact interventions: Central venous catheter care bundle; Peripheral intravenous cannula care bundle; Renal catheter care bundle; Care bundle to prevent surgical site infection; Care bundle for ventilated patients; Urinary catheter care bundle; Care bundle to reduce the risk from Clostridium difficile. From Going further faster From Going further faster, 2006 MRSA invasive infections, Europe EARS-Net Explanatory correlations in Europe? Antibiotic stewardship Hand hygiene HCW

screening Cleaning / disinfection Active screening Decol. GNR Toolbox Contact precautions Cohorting staff / patients Env. screening

Education Otter et al. Clin Microbiol Infect 2015 2015;21:10571066. Note flagging Understanding and preventing E. coli BSI Devices High risk patients SSI / wounds AMR E. coli BSI

UTI NHS improvement: plans to reduce GNBSI ambition to halve healthcare-associated GNBSI by 2021 exemplifying and sharing best practice across the health system improving training on infection prevention for NHS staff showing the figures for E. coli cases on wards, making them visible to patients and visitors in the same way that MRSA and C. difficile cases are currently displayed improving incentives to promote the reduction in infection rates e.g. with a 45 million quality premium working with the Care Quality Commission (CQC) to encourage a focus on infection prevention during inspections Ruth May letter, 15/07/2017.

NHS improvement: resources to reduce GNBSI an improvement resource of good practice, co-produced with Public Health England (PHE) and colleagues across the NHS, which will continue evolve as we understand the most effective interventions regular Performance Improvement Network events throughout the year for the NHS to share examples of good practice, successes and challenges visits to healthcare economies to understand and share good practice across the country further analysis based on the data that PHE publishes to help organisations make rapid progress Ruth May letter, 15/07/2017. Can we really halve GNBSIs? GNBSI Jon Otter, PhD FRCPath Imperial College London [email protected]

@jonotter Blog: www.ReflectionsIPC.com You can download these slides from www.jonotter.net

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