Health Care Assiciated Infections and Antibiotic Resistance: an increasing threat to Patient Safety in Europe

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Health Care Assiciated Infections and Antibiotic
Resistance an increasing threat to Patient
Safety in Europe
Aftab Jasir, European Centre for Disease
Prevention and Control (ECDC) European public
health microbiology training program (EUPHEM)
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Objectives of the lecture

• To learn and understand about
• Basic of antibiotics and resistant among
  bacteria
• Health care associated infections
• Relevant terminologies

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Story of glory
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1945
Fleming, Florey and Chain
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Antibiotics
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Antimicrobial drugs

• Natural antibiotics
• Synthesized antibiotics

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Natural antibiotics
Penicillium notatum
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Knowledg about killing

• Do we need to use antibiotics for killing of
  pathogens?

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Modern medicine is not possible without effective
antimicrobials
Hip replacement
Organ transplants
Cancer chemotherapy
Intensive care
Care of preterm babies
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TerminologyAntiseptics

• Topical substances (e.g. skin)
• e.g. iodine or 70 alcohol
• reduce bacterial load

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Antibiotics

• Selectively toxic for bacteria
• bactericidal (killing)
• bacteriostatic (growth inhibition)
• no harm to patient (???)

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Prophylaxis
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Minimal inhibitory concentration/ minimal
bactericidal concentration (MIC/MBC)

• lowest level stopping growth/killing
• e. g. zone of inhibition around a disk

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MIC/MBC
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Most important targets in bacteria
1. Attack bacterial cell wall synthesis. 2.
Interfere with protein synthesis. 3.
Interference with nucleic acid synthesis (RNA and
DNA)4. Inhibition of an essential metabolic
pathway that exists in the bacterium but does not
exist in the host 5. Membrane inhibition or
disruption doesn't work too well because
of the similarities between and bacterial
membranes.
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Drug usage Drug resistance
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Basis of Antibiotic Resistance

• The antibiotic resistance is guided by Genomic
  changes
• Spread of R plasmids or other genetic elements
  among the Bacteria
• Do remember Antibiotics are used in veterinary
  medicine
• The discovery of antibiotic resistance was
  discovered with spread of R plasmids from animal
  sources

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Plasmids and Transposons
Tn 21
Tn 10
Tn 8
Tn 9
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Superbugs
Multi drug-resistant acquired non-susceptibility
to at least one agent in three or more
antimicrobial categories Extensively
drug-resistant non-susceptibility to at least
one agent in all but two or fewer antimicrobial
categories Pandrug-resistance (PDR) non-susceptibi
lity to all agents in all antimicrobial
categories
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Welcome to the hospital!Bugs are waiting for
you!!!
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NIIIIIICE! I am getting something good here
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Terminology

• Nosocomial
• Traditional meaning originating in hospital
• Hospital-acquired/associated
• Healthcare-acquired/associated
• HAI or NI or HCAI

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Definition
An infection occurring in a patient/staff/visitor
in a healthcare facility not present or
incubated at the time of admission. -
includes infections that do not become apparent
until after discharge and occupational infections
among staff of the facility
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Healthcare-associated infections, antimicro-bial
resistance Overlapping, but not identical
Healthcare-associated infections
Community-acquired infections
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Burden of Healthcare-Associated Infections and
Multidrug Resistance (preliminary estimate)

• Healthcare-associated infections (HCAI)
• approximately 4 million per year
• approx. 37,000 directly attributable deaths each
  year
• Multidrug-resistant bacteria
• approximately 1/2 of the deaths attributable to
  HCAI
• are due to the 7 most common multidrug-resistant
  bacteria
• in the 4 main types of HCAI bloodstream
  infection, pneumonia, skin and soft tissue
  infection, urinary tract infection
• This is an underestimate!

Source Suetens C Monnet DL, ECDC (preliminary
estimate)
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Risk factors

• External/none host
• Catheters and other invasive devices
• Surgeries
• Invasive procedures
• Antibiotic exposure
• Inadequate staff and overcrowding

• Internal/Host
• Extremes of age
• Immune status
• Illness severity
• Comorbidities
• Colonization status

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New challenges
http//ecdc.europa.eu/en/publications/Publications
/Forms/ECDC_DispForm.aspx?ID740
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Challenges in developing Case-Definitions for HAI

• Assumptions
• gt48 or gt72 hours after admission
• Not incubating at the time of admission
• Can manifest after discharge
• Acquired in healthcare setting
• Use both clinical and lab criteria

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Examples of potential for misclassification

• Case 1
• 80 y.o. patient, multiple medical problems, lives
  at home, visited by grandchildren who have colds
• 2 days later, admitted for hip fracture
• 4 days after admission she develops RSV
  (respiratory syncytial virus) pneumonia
• What you think?

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Examples of potential for misclassification

• Case 2
• 55 y.o. patient, admitted for work-up and
  management of chest pain, cared for by healthcare
  worker taking care of another patient who has
  MRSA
• Discharged after 2 days in hospital
• Develops an MRSA soft tissue infection 3 weeks
  later while in the community
• What now???

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Incubation periods

• C.difficile unknown
• MRSA unknown
• VRE unknown
• Influenza 1-4 days
• RSV 2-8 days
• Norovirus 24-48 hours

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Conclusions

• There are always outbreaks going on at the
  hospitals. However they might not be detectable
• Hospitals are a suitable place for outbreak
  investigation
• It is not always easy to define the cases
• Outbreaks agents circulating frequently.
  Therefore you need good microbiological evidence
  to confirm your cases.

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Hands are the most common public transport of
microorganisms
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18 November 2010