Moving forward together infection prevention and control and AMR

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Moving forward together infection prevention
and control and AMR

• Rose Gallagher
• Nurse Advisor Infection Prevention and Control
• Royal College of Nursing

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Learning objectives

• To discuss the changing nature of infection
  prevention and control
• To refresh current knowledge of current IPC
  strategies
• To discuss the relationship between IPC and AMR
• To highlight the implications of carbapenemase
  producing organisms
• To discuss AMR and the role of the nurse

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What do we mean by IPC?

• Infection prevention and control is the
• clinical application of microbiology in
• practice. Infection may be caused by
• bacteria, fungi, viruses or prions and can
• result in a wide variety of infections.

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Note

• Not all infections are transmissible, but some
  are and can be spread from one patient to
  another. IPC extends beyond transmissible
  infections and as nurses prevention of infection
  is our primary aim.

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The changing face of IPC

• Microbiology is real time evolution - so IPC
  also has to be!
• 1950s - Staphylococcus aureus
• Staphylococcus aureus MRSA (1961) with EMRSA
  in 1990s
• Clostridium difficile 1970s and 2006
• HIV 1983 universal precautions
• vCJD 1996
• SARS 2002 / novel coronavirus 2013
• Pandemic influenza
• CPE

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And of course Infection prevention is a patient
safety issue

• Most common complication of hospitalised care
• Infection is an adverse event
• Learning from infection events using patient
  safety tools enhances IPC
• Patient safety/IPC relates to products,
  procedures and systems

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IPC relationships
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Changing health needs and considerations

• Increasing longevity and premature survival
• Long term disease patterns changing e.g. Cancer
  as a long term condition increase in diabetes,
  asthma, CHD
• All require contact with healthcare or are
  recipients of care
• Migration of people and workers
• Global warming

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IPC isnt

• Just about MRSA and C. difficile
• Just about hand hygiene and dirty hospitals

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IPC is

• All about people patients and staff
• Sometimes complex
• Multifactorial
• Time consuming
• Easy to overlook when everything is going well
  (or we think it is!)
• In need of constant evaluation

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What have we learnt?

• Isolation/separation

• Modes of transmission

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Evolving humans
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Evolving society and care

• Simple buildings

• Complex tertiary centres

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Evolving bacteria

• Some natural resistance

• Acquired resistance

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HCAI variation and per speciality (source ECDC
annual report 2013)
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Fundamentals of IPC as we know them
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Preventing infection is a team effort
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Corner stones of effective IPC
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What we dont know some examples

• What level of hand hygiene compliance is needed
  to be effective?
• The full impact of glove use/abuse
• Information on rates of infection across the
  board
• The value of current educational methods
• What other strategies could have an impact

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In an evolving world be mindful of

• The law of unintended consequences

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And we are running out of ammunition
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We need to start thinking differently
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Antibiotic resistance

• Evolution of acquired antibiotic resistance
  mechanisms is a consequence of selective pressure
• Or simply put
• Antibiotic use is driving current antibiotic
  resistance problems

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What does this mean in practice?

• Infections with resistant bacteria are associated
  with increased morbidity and mortality
• Increased healthcare costs and extended length of
  stay
• Reduced antibiotic treatment options
• Potentially untreatable infections
• IPC and AMR are a public health issue

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But

• Resistance to antibiotics is not just a hospital
  problem
• Most prescribing is done in the community
• Resistance is present outside hospitals
• We have free movement across EU borders/travel
  health
• Resistant bacteria can be passed from person to
  person and spread to colonise or cause infections
  in others

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IPC and its relationship to AMR

• The two are inextricably linked but IPC alone
  cannot solve the problem

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Current challenges for AMR

• Prescribing behaviours
• Development of new antibiotics
• Education / training
• Managing outbreaks differently e.g. Carbapenemase
  producing Enterobacteriaceae (CPE)
• Its a global issue

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Variation across Europe

• MRSA

• K. pneumoniae

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Why are CPE so important?

• CPE produce an enzyme (carbapenemase) which
  renders the class of antibiotic (known as
  carbapenems) ineffective
• Carbapenems are our current last line of defence
  for some infections
• CPE is not one bacteria it refers to several
  species (E.g. Klebsiella and E. coli)
• CPE can share resistance mechanisms between
  species of bacteria

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European data 2011 (source ECDC annual report
2013)
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What does CPE mean for IPC?

• Awareness
• Screening and recognition of potential carriers
• Isolation
• Scrupulous IPC practices
• Supporting staff to think differently outbreaks
  of resistance not one bacteria e.g. MRSA

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Why will outbreaks be challenging?

• CPE will challenge the way we have previously
  thought of single organism outbreaks
• Precautions to limit spread must be strictly
  adhered to and potentially for longer
  implications for staffing?
• Media and public interest/concern will need to be
  managed

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Thinking more broadly about the nursing
contribution

• Reducing the demand for antibiotics
• Enhancing antibiotic effectiveness
• Providing leadership to and in support of IPC at
  the local, national and international level
• Supporting whole systems approach to AMR

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And finally any questions?
Think flexibly to work flexibly
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References/resources

• Department of Health (2013) UK Five Year
  Antimicrobial Resistance strategy 2013-2015.
  HMSO
• Public Health England (2013) Acute Trust Toolkit
  for the early detection, management and control
  of carbapenemase-producing Enterobacteriaceae
• ECDC (2013) Annual epidemiological report.
  Reporting on 2011 surveillance data and 2012
  epidemic intelligence data
• RCN (2013) Infection prevention and control
  within health and social care commissioning,
  performance management and regulation
  arrangements (England).