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

1. 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)

2. Objectives of the lecture To learn and understand about: • Basic of antibiotics and resistant among bacteria • Health care associated infections • Relevant terminologies

3. Story of glory

4. 1945 Fleming, Florey and Chain

5. Antibiotics 5

6. Antimicrobial drugs • Natural antibiotics • Synthesized antibiotics

7. Natural antibiotics Penicillium notatum 7

8. Knowledg about killing • Do we need to use antibiotics for killing of pathogens? 8

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

10. TerminologyAntiseptics • Topical substances (e.g. skin) • e.g. iodine or 70% alcohol • “reduce” bacterial load 10

12. Antibiotics • Selectively toxic for bacteria • bactericidal (killing) • bacteriostatic (growth inhibition) • no harm to patient (???) 12

13. Prophylaxis 13

14. Minimal inhibitory concentration/ minimal bactericidal concentration (MIC/MBC) • lowest level stopping growth/killing e. g. zone of inhibition around a disk 14

15. MIC/MBC 15

16. 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. 16

18. Drug usage = Drug resistance

21. 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

22. RTF R determinant Plasmids and Transposons Tn 21 Tn 10 Tn 8 Tn 9

23. 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-susceptibility to all agents in all antimicrobial categories

25. Welcome to the hospital!Bugs are waiting for you!!!

26. NIIIIIICE! I am getting something good here

27. Terminology • Nosocomial • Traditional meaning “originating in hospital” • Hospital-acquired/associated • Healthcare-acquired/associated • HAI or NI or HCAI

28. 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

29. Antimicrobial resistance Antimicrobial resistance Healthcare-associated infections, antimicro-bial resistance: Overlapping, but not identical Healthcare-associated infections Community-acquired infections

30. 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) 30

31. 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

32. New challenges http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=740

33. Challenges in developing Case-Definitions for HAI Assumptions: • >48 or >72 hours after admission • Not incubating at the time of admission • Can manifest after discharge • Acquired in healthcare setting • Use both clinical and lab criteria

34. 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?

35. 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???

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

37. 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.

38. Hands are the most common public transport of microorganisms

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40. 18 November 2010