Reducing nosocomial infections and improving rational use of antibiotics in children in Indonesia

Transcription

1 Yemeni International Congress on Infectious Disease (YICID), 2014 Reducing nosocomial infections and improving rational use of antibiotics in children in Indonesia

2 Background and rationale Study of a multifaceted intervention to reduce nosocomial infections in Yogyakarta, Indonesia Conclusion and implication

3 25% 20% 15% 10% 5% NICU PICU Perinatology ward Pediatric ward 0%

4 Hospitalized Children Infection Antibiotic Use Direct Contact NosocomiaI Infection Antibiotic Resistance Cost >> Hospital stay >> Death >>

5 Hospitalized Children Infection Antibiotic Use Direct Contact NosocomiaI Infection Antibiotic Resistance Cost >> Hospital stay >> Death >>

6 Pediatrics and International Child Health 2013;33(2):61-78 Hand-hygiene campaigns as part of multifaceted interventions showed the strongest effectiveness for reducing NI rates (median effect 49%, effect range %)

7 Setting: Dr Sardjito Hospital, Yogyakarta A teaching hospital (adults and children) Number of beds: Paediatric wards: 113 beds including private paediatric wards, paediatric hematology-oncology wards, and general paediatric wards Paediatric ICU: 9 beds. Number of admitted patients each year: Paediatric wards: 4500 patients Paediatric ICU: 320 patients

8 General paediatric wards

9 P I C U

10 Preintervention 12 mo Intervention 4 mo Postintervention 12 mo Dec Nov 2011 Nov Feb 2012 March Feb 2013 S U B J E C T INTERVENTION Infection control antibiotic stewardship Lectures, trainings, outreach visit Reminders (antibiotic chart and checklists) Audit and performance feedback S U B J E C T A N A L Y S I S Proportions of nosocomial infection, Rational antibiotic use, Hand hygiene compliance Mortality Proportions of nosocomial infection, Rational antibiotic use, Hand hygiene compliance Mortality

11 Nosocomial infection surveillance CDC criteria: bloodstream infection, pneumonia, urinary tract infection, surgical site infection, others Audit of care practices Rational antibiotic use WHO Pocketbook of Hospital Care for Children Dose, duration and spectrum of antibiotic Hand hygiene practice My five moments for hand hygiene Direct observation

12 A MODULE BOOK, CD and AN ANTIBIOTIC CHART BASED ON WHO POCKETBOOK HOSPITAL CARE FOR CHILDREN

13

14

15 1. Baseline data for nosocomial infection, irrational antibiotic use, hand hygiene compliance, and mortality in the preintervention period 2. The effectiveness of the multifaceted intervention on the nosocomial infection, irrational antibiotic use, hand hygiene compliance 3. Impact of the intervention on mortality 4. Antibiotic resistance of nosocomial bloodstream infection and empirical antibiotic choices

16 Baseline characteristics Pre-intervention n=1227 (%) Post-intervention n=1419 (%) Male sex no. (%) 683 (55.6) 797 (56.1) Age no. (%) < 12 months 281 (22.9) 340 (23.9) > months 371 (30.4) 362 (25.7) > months 247 (20.3) 327 (23.3) > 120 months 318 (26.1) 375 (26.7) Ward of origin no. (%) PICU 228 (18.5) 281 (19.8) Infectious ward 466 (38) 450 (31.7) Non-infectious ward 533 (43.4) 688 (48.4) Source of patients Referral 424 ( (34.6) Community 758 (61.7) 835 (58.8)

17 Baseline pre-intervention data: Nosocomial infection Irrational antibiotic use Hand hygiene compliance Mortality

18 Nosocomial infection (n=1227) n patients % patients (95% CI) Culture positive ( ) bloodstream infection Culture negative likely ( ) bloodstream infection VAP/pneumonia ( ) CAUTI/UTI ( ) Surgical site infection ( ) Gastroenteritis ( ) Phlebitis ( ) Upper respiratory infection ( ) Total ( )

19

20 Patients used antibiotics Patients exposed to irrational antibiotics PICU n=228 (%) Infectious ward n=466 (%) Non-infectious ward n=553(%) (55.7) 135 (39.1) 83 (37.2)

21 Numbers of hand hygiene opportunities Hand hygiene compliance PICU (%) Infectious ward (%) Non-infectious ward (%) (11.7) 124 (21.5) 125 (24.1)

22 Mortality (%) Mortality in children in the study 127/1227 (10.4) Mortality in children with nosocomial infection 68/277 (24.5)

23 The effectiveness of a multifaceted intervention

24

25 Total numbers of patients with nosocomial infections Total numbers of patients recruited Overall proportion of patients with nosocomial infections Preintervention Postintervention RR (95% CI) 22.5% 8.4% 0.32 ( )

26 Intervention started in Dec 2011

27 Identical data collection in the pre-and-post intervention periods Similar proportions of culture taken from sterile sites Cultures only taken when there was signs and symptoms of infection No changes in laboratory procedures Adjustment for that might be associated with nosocomial infections

28 After adjusting for patient characteristics, independent risk factors of nosocomial infection and independent risk factors of mortality: The multifaceted intervention reduced nosocomial infections with RR 0.21 (95% CI )

29

30 Total numbers of patients exposed to irrational antibiotics Preintervention Postintervention RR (95% CI) Total numbers of patients used antibiotics Overall proportion of patients with irrational antibiotics % 20.6% 0.46 ( )

31

32 Total of hand hygiene moments Total of hand hygiene opportunities Overall hand hygiene compliance Pre-intervention Postintervention RR (95% CI) 18.9% 62.9% 3.33 ( )

33 Pre-intervention n= 1227 (%) Post-intervention n= 1419 (%) RR (95% CI) Mortality in children in the study Mortality in children with nosocomial infections 127/1227 (10.4) 114/1419 (8) 0.78 ( ) 68/277 (25) 47/121 (38.8) 1.55 ( )

34 Pre-intervention n= 1227 (%) Post-intervention n= 1419 (%) RR (95% CI) Mortality in children in the study Mortality in children with nosocomial infections Mortality in overall hospitalized children 127/1227 (10.4) 114/1419 (8) 0.78 ( ) 68/277 (25) 47/121 (38.8) 1.55 ( ) 309/4369 (7) 328/5454 (6) 0.85 ( )

35 After adjusting for differences in patient characteristics and treatment: The multifaceted intervention reduced mortality by 28% (95% CI 6% 46%)

36 After adjusting for factors potentially associate with mortality: Nosocomial infections was associated with mortality with adjusted OR 4.6 (95% CI )

37 Nosocomial bloodstream infection (BSI): Antibiotic resistance Mortality in multidrug resistance (MDR) infections Empiric antibiotic choices

38 Antibiotic resistance of nosocomial bloodstream pathogens

39 Antibiotic resistance of nosocomial bloodstream pathogens Around 46% patients with nosocomial BSI were resistant to at least an antibiotic.

40

41 Incidence of MDR infections was 6.4% MDR increased the risk of death by 17.5 (95% CI )

42

43 The multi-faceted intervention (infection control and antibiotic stewardship programs): reduce nosocomial infections improve rational use of antibiotics increase hand hygiene compliance reduce mortality

44 Antibiotic resistance was emerging Empiric antibiotics for nosocomial BSI: amikacin, ciprofloxacin, imipenem, and ceftazidime

45 Alerting policy makers on the significant burden of nosocomial infections and this can be reduced with low cost interventions Determining empirical antibiotic recommendations for nosocomial BSI based on local antibiotic sensitivity tests provides rational antibiotic choices

46 Prof. Trevor Duke Dr Sharon Kinney Assoc. Prof. Andrew Daley Prof. Yati Soenarto Department of Paediatrics, Dr Sardjito Hospital, Yogyakarta Infection Control Team, Dr Sardjito Hospital, Yogyakarta Antibiotic Resistance Control Committee, Dr Sardjito Hospital, Yogyakarta Centre for International Child Health, the Royal Children s Hospital Melbourne, the University of Melbourne Infection Control Team, the Royal Children s Hospital Melbourne Research team

47 The multi-faceted intervention (infection control and antibiotic stewardship programs): reduce nosocomial infections improve rational use of antibiotics increase hand hygiene compliance reduce mortality

48 Thank you