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Antimicrobial and infection control: international challenges, trends and guidelines

European Centre for Disease Prevention and Control. Antimicrobial and infection control: international challenges, trends and guidelines. Dominique L. Monnet , ECDC Improving infection control practice: Hungarian and international trends and potentials, Budapest, 6 March 2019.

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Antimicrobial and infection control: international challenges, trends and guidelines

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  1. European Centre for Disease Prevention and Control Antimicrobial and infection control:international challenges, trends and guidelines Dominique L. Monnet, ECDC Improving infection control practice: Hungarian and international trends and potentials, Budapest, 6 March 2019

  2. ECDC – European Centre for Disease Prevention and Control An agency of the European Union, located in Stockholm, Sweden Founded in 2005; nearly 300 employees Mandate to ‘identify, assess and communicate current and emerging threats to human health from communicable diseases’ European Union (EU) (28) and European Economic Area (EEA) (3) = 31 countrieswith a total of more than 500 million people www.ecdc.europa.eu

  3. Six sigma quality comparisons defect rates Healthcare-associated infections (ECDC PPS, 2016-2017)  Adapted from: Perl T, 2007.

  4. Antimicrobial resistance(AMR) Antimicrobial resistance Healthcare-associated infections, antimicrobial resistance: Overlapping, but not identical Healthcare-associated infections Community-acquired infections

  5. New data from ECDC and the European Commission, November 2018 https://www.ecdc.europa.eu/sites/portal/files/documents/AMR-surveillance-EARS-Net-2017.pdf https://www.ecdc.europa.eu/sites/portal/files/documents/ESAC-NET-reportAER-2017-updated.pdf https://ec.europa.eu/health/amr/action_eu_en Cassini A, et al. The Lancet Infectious Diseases 5 November 2018; Plachouras D, et al.; Ricchizzi E, et al.; Suetens C, et al. Eurosurveillance15 November 2018.

  6. Staphylococcus aureus: % of invasive isolates with resistance to meticillin(MRSA), EU/EEA, 2006 & 2016 2006 2016 Source: EARS/EARS-Net, 2017 (https://atlas.ecdc.europa.eu).

  7. Escherichia coli:% of invasive isolates with resistance to third-generation cephalosporins*, EU/EEA, 1999-2016 2003 2001 2002 2004 1999 2000 2010 2009 2008 2005 2007 2006 2012 2016 2011 2014 2013 2015 * cefotaxime, ceftriaxone or ceftazidime Source: EARS/EARS-Net, 2017 (https://atlas.ecdc.europa.eu).

  8. Klebsiella pneumoniae: % of invasive isolates with resistance to carbapenems,EU/EEA, 2006 & 2016 2006 2016 Source: EARS/EARS-Net, 2017 (https://atlas.ecdc.europa.eu).

  9. Enterococcus faecium: % of invasive isolates with resistance to vancomycin,EU/EEA, 2006 & 2016 2006 2016 Source: EARS/EARS-Net, 2017 (https://atlas.ecdc.europa.eu).

  10. Acinetobacter spp.: % of invasive isolates with combined resistance*,EU/EEA, 2012 & 2016 *Fluoroquinolones, aminoglycosides and carbapenems 2012 2016 Source: EARS/EARS-Net, 2017 (https://atlas.ecdc.europa.eu).

  11. Burden of infections with antibiotic-resistant bacteria is comparable to burden of influenza, TB & HIV/AIDS combined • 671 689 infections with antibiotic-resistant bacteria, 63% were healthcare-associated infections • 33 110 attributable deaths • 170 DALYs* per 100 000 population, • 75% due to healthcare-associated infections • 70% due to 4 top-ranking antibiotic-resistant bacteria • 39% due to carbapenem- and/or colistin resistance *DALYS, Disability-adjusted life years Adapted from: Cassini A, et al. Eurosurveillance 2018;23(16):pii=17-00454; Cassini A, et al. Lancet Infectious Diseases. 5 November 2018.

  12. Estimated burden of infections with antibiotic-resistant bacteria, age-group standardised, EU/EEA, 2015 Source: Cassini A, et al. Lancet Infectious Diseases. 5 November 2018.

  13. AMR costs 3.5B USD PPPs per year to the healthcare systems of EU/EEA and other OECD countries Source: OECD. Stemming the Superbug Tide: just a few dollars more. 2018. oe.cd/amr-2018

  14. Economic assessment* of a ‘mixed-intervention’ package†Just a few dollars more lead to substantial savings in healthcare expenditure • †’Mixed-intervention’ package: • Improve hospital hygiene(starting with hand hygiene) • Antimicrobial stewardship • Rapid diagnostic tests(bacterial vs. viral infection) • Delayed prescription • Public awareness campaigns Implementation cost Impact on healthcare expenditure Source: OECD. Stemming the Superbug Tide: just a few dollars more. 2018. oe.cd/amr-2018 *Including effect on susceptible infections.

  15. Humans + Animals + Environment = One Health Prudent use of antibiotics. Everyone is responsible!

  16. H Cross-border transfer of patients Imported animalsImported foods International travel Antimicrobial consumption and AMR: a continuum of risks in our societies ICU & Haem./bone marrow transplant (BMT) 124 mg/kg (country range: 50 – 182 mg/kg) 152 mg/kg(country range: 3 – 419 mg/kg) ~ 10% DDDs ~ 90% DDDs 35% (21-55%) patients on a given day 2% (1-4%) populationon a given day 59% patients MDR* MDR MDR,XDR,PDR MDR . *MDR, multidrug-resistant; XDR, extensively drug-resistant; PDR, pandrug-resistant Source: ECDC/EFSA/EMA JIACRA report, 2017; ECDC ESAC-Net 2016; ECDC PPS, 2013.

  17. Many initiatives… AMC AMR HAI ESAC-Net EARS-Net HAI-Net ECDC EC/DG SANTE Joint Actions with Member States(e.g. EU-JAMRAI) Crisis management & preparedness in health (SANTE/C3)(includes projects under EU Health Programme) Country audits (SANTE/F5) Performance of national health systems(SANTE/B) European One Health Action Plan against AMR (includes ECDC, EFSA and EMA) EC/DG RTD Horizon 2020, many projects under IMI, JPIAMR CAESAR AMCsurveillance WHO/Europe WHO Headquarters Implementation of theGlobal Action Plan on AMR (incl. GLASS, WAAW) Transatlantic Task Force on AMR (TATFAR)(EU, US, Canada, Norway) International collaborationsand initiatives United Nations, G7, G20GHSA, NDPHS Source: ECDC, 2018.

  18. Member States’ progress on national action plans, 2017 Country-self assessmentsas reported to WHO for 2017. Countries in alphabetical order within each category. Countries with * did not report to WHO in the latest wave and 2016 data was used instead. Source: WHO (2018). https://amrcountryprogress.org/; OECD (2018). Stemming the Superbug Tide: just a few dollars more. 2018. oe.cd/amr-2018(adapted).

  19. Challenge = local implementation Global European National Regional Local

  20. ECDC point prevalence surveys 2016-2017: healthcare-associated infections and antimicrobial use in acute care hospitals and long-term care facilities Complete reports: 3 May 2019 Plachouras D, et al. Eurosurveillance 15 November 2018; Ricchizzi E, et al. Eurosurveillance 15 November 2018; Suetens C, et al. Eurosurveillance15 November 2018.

  21. Composite index* of antimicrobial resistance (AMR) in healthcare-associated infections from acute care hospitals, EU/EEA countries and Serbia, 2016-2017 * Bulgaria and the Netherlands: poor national representativeness of acute care hospital sample; ** Norway: national protocol; Norway and UK-Scotland did not collect microbiological data.. *Percentage of isolates resistant to first-level antimicrobial resistance markers in healthcare-associated infections, i.e.: Staphylococcus aureus resistant to meticillin(MRSA), Enterococcus faecium and Enterococcus faecalis resistant to vancomycin, Enterobacteriaceaeresistant to third-generation cephalosporins, Pseudomonas aeruginosa and Acinetobacter baumanniiresistant to carbapenems. Adapted from: Suetens C, et al. Eurosurveillance 15 November 2018.

  22. Main actions to prevent and control antimicrobial resistance Prudent use of antimicrobial agents(only when needed, correct dose, correct dose intervals, correct duration) Infection prevention and control(hand hygiene, screening, isolation) New antimicrobial agents(with a novel mechanism of action, research, development)

  23. Prevalence of antimicrobial use in acute care hospitals, EU/EEA and Serbia, 2016-2017 1 in 3 patients in acute care hospitalsin EU/EEA countries received at least one antimicrobialon any given day * Bulgaria, the Netherlands: poor national representativeness of acute care hospital sample; ** Norway: national protocol. Plachouras D, et al. Eurosurveillance 15 November 2018

  24. Countries with a higher prevalence of antibiotic use have a higher composite index of AMR, but countries with more frequent review and change of antibiotic prescriptions have a lower composite index of AMR Preliminary results Preliminary results r = 0.51p = 0.004 r = –0.67p = 0.0001 Patients with at least one antibiotic* (%) Antibiotic* prescriptions reviewed and changed during treatment (%) *Antibacterials for systemic use (ATC J01) Source: ECDC point prevalence survey in European acute care hospitals, 2016-2017 (preliminary, unpublished results).

  25. Proportion of broad-spectrum antibiotics in acute care hospitals, EU/EEA countries & Serbia, 2016–2017 EU/EEA Proportion of broad-spectrum antibiotics (%) Source: Plachouras D, et al. Eurosurveillance 15 November 2018.

  26. Surgical antibiotic prophylaxis in acute care hospitals, by duration (single dose, one day, more than one day), EU/EEA countries and Serbia, 2016-2017 1 dose 1 day more than 1 day 54% surgical antibiotic prophylaxiscourses in EU/EEA countries were prescribed formore than one day EU/EEA Source: Plachouras D, et al. Eurosurveillance 15 November 2018.

  27. Countries with more resources for infection prevention and control have a lower composite index of AMR Preliminary results r = –0.58p = 0.004 Preliminary results r = –0.57p = 0.003 Beds with alcohol hand rub dispenser at point of care (%) Beds in single rooms (mean %) Additional result: Hospitals with at least 0.4 FTE infection prevention and control nurse for 250 beds (r = –0.35, p = 0.04) Source: ECDC point prevalence survey in European acute care hospitals, 2016-2017 (preliminary, unpublished results).

  28. Assessment of infection control/hospital hygiene capacity and training needs in the European Union Availability of a curriculum or programme for training doctors and nurses as infection control/hospital hygiene professionals https://ecdc.europa.eu/sites/portal/files/documents/Assessment-infection-control-training-in-EU.pdf

  29. https://ecdc.europa.eu/en/publications-data/directory-online-resources-prevention-and-control-antimicrobial-resistance-amrhttps://ecdc.europa.eu/en/publications-data/directory-online-resources-prevention-and-control-antimicrobial-resistance-amr

  30. https://ecdc.europa.eu/en/publications-datadirectory-guidance-prevention-and-controltraining/training-courses-infectionhttps://ecdc.europa.eu/en/publications-datadirectory-guidance-prevention-and-controltraining/training-courses-infection

  31. https://ecdc.europa.eu/en/publications-data/directory-online-resources-prevention-and-control-antimicrobial-resistance-amrhttps://ecdc.europa.eu/en/publications-data/directory-online-resources-prevention-and-control-antimicrobial-resistance-amr

  32. Epidemiological situation of carbapenemase-producing Enterobacteriaceae, assessment by national experts in European countries, July 2018 Source: Brolund A, et al. Eurosurveillance (28 February 2019). Simulation exercise on antimicrobial resistance (AMR SimEx), Bucharest, 1st March 2019

  33. Comparison of epidemiological stages of carbapenemase-producing Enterobacteriaceae, assessment by national experts in European countries, 2010–2018 Source: Brolund A, et al. Eurosurveillance (28 February 2019). Simulation exercise on antimicrobial resistance (AMR SimEx), Bucharest, 1st March 2019

  34. National capacity for surveillance and containment of carbapenem-resistant and carbapenemase-producing Enterobacteriaceae, July 2018 Source: Brolund A, et al. Eurosurveillance (28 February 2019). Simulation exercise on antimicrobial resistance (AMR SimEx), Bucharest, 1st March 2019

  35. Infection prevention and control measures and tools to prevent entry of carbapenem-resistant Enterobacteriaceae (CRE) into healthcare settings: ECDC guidance (2017) • Core measures • Profile for ”at risk” patients who require supplemental measures • Preliminary supplemental measures (at admission, for ”at risk” patients) • Supplemental measures (for confirmed CRE-positive patients) Source: Magiorakos et al. Antimicrob Resist Infect Control (15 November 2017).

  36. Preventing outbreaks of carbapenem-resistant Enterobacteriaceae(CRE) and glycopeptide-resistant Enterococcus faecium(GRE) following introductions by admitted patients, Paris, France, 2010-2015 Proportion of outbreaks among CPE or GRE introductions (%) CPE and GRE introductions (No.) CPE, carbapenemase-producing Enterobacteriaceae; GRE, glycopeptide-resistant Enterococcus faecium. GRE introductions CPE introductions Proportion of outbreaks among CPE or GRE introductions Adapted from: Fournier S, et al. Eurosurveillance (22 February 2018). Simulation exercise on antimicrobial resistance (AMR SimEx), Bucharest, 1st March 2019

  37. Preventing outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) and glycopeptide-resistant Enterococcus faecium(GRE) following introductions by admitted patients, according to measures implemented within the first two days around an index case, Paris, France, 2010-2015 Proportion of outbreaks (n=103) among CPE or GRE introductions (n=901) Proportion of secondary cases (n=427) among CPE or GRE cases (n=1,328) CPE or GRE introductions (index cases) Secondary cases CPE or GRE introductions without outbreaks Outbreaks CPE, carbapenemase-producing Enterobacteriaceae; GRE, glycopeptide-resistant Enterococcus faecium. Adapted from: Fournier S, et al. Eurosurveillance (22 February 2018). Simulation exercise on antimicrobial resistance (AMR SimEx), Bucharest, 1st March 2019

  38. https://ewrs.ecdc.europa.eu/

  39. https://antibiotic.ecdc.europa.eu

  40. 18 November 2019 18-24 NOVEMBER 2018

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