Antibiotic usage in nosocomial infections in hospitals Dr. Birgit Ross Hospital Hygiene University Hospital Essen
Infection control in healthcare settings - Isolation - Hand Hygiene - Environmental Hygiene Surveillance Antibiotic policy and guidelines - Management programmes Usage control Appropriate Use -Human -Animal -Environment Prevention IFIC Basic Concepts Reduction
A nosocomial infection also called hospital acquired infection can be defined as: 1. An infection acquired in hospital by a patient who was admitted for a reason other than that infection. 2. An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility. WHO 2002 Prevention of hospital-acquired infections - A practical guide; 2nd edition
Epidemiology of hospital acquired Infections (HAI) Benedetta Allegranzi et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis; Lancet 2011; 377: 228 41
Epidemiology of hospital acquired Infections (HAI) US: about 4,5 % HAI 1.7 million affected patients Europe: about 7.1 % HAI 4.5 million affected patients Low and middle income countries: varies between 5.7 % and 19,1 % WHO Health care associated infections FACT SHEET http://www.who.int/entity/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
Respiratory tract infection as an example for nosocomial infection (1,3 % respiratory tract infection in the study conducted by Ider et al) Ca 5.4 % of hospital admissions due to pneumonia 1,2 % of specimen tested for pathogens Cause of death 6,2 % (list of total death by cause) Prevalence of hospital-acquired infections and antibiotic use in two tertiary Mongolian hospitals B.-E. Ider et al. Journal of Hospital Infection Volume 75, Issue 3, July 2010, Pages 214 219 Prof. P.Nymadawa, MD, PhD, DSc(Med) Published online globe-network.org/.../hospital-based-pneumonia-surveillance-in-mongolia http://www.worldlifeexpectancy.com/country-health-profile/mongolia
Pneumonia is a relevant disease: Cave: Hospital environment may include other bacteria than community So in some cases you will have to treat in different ways (especially if you do not know the pathogen) Example: Community acquired pneumonia (CAP) Vs. Hospital acquired pneumonia (HAP)
What is suspected: Most common pathogens Streptococcus pneumoniae Haemophilus influenzae Others: M. pneumoniae, Enterobacteriacae, Legionella spp., S. aureus, respiratorische Viren
Antibiotic therapy 1. Empirical therapy Therapy of a probable infection. Culture of the pathogen is not available. For targeted therapy the most likely pathogens and its resistance profiles should be known. 2. Pathogen directed therapy Therapy guided by the results of a microbiological investigation. (Kind of pathogen/resistance profile) 3. Prophylaxis Use of antibiotics for prevention of infections, eg surgery The most common pathogens in the special situation should be considered
Suspected pathogen recommends therapy of that pathogen Recommended Antibiotic Therapy: Amoxicilline 3 x 1000 mg (< 70 kg 3 x 750 mg) (or Doxycycline or Azithromycine) In hospital: Cefuroxime 3 x 1,5 g i.v. Duration: 5 7 Tage, Azithromycin 3 days
Suspectec pathogens in hospital acquired pneumonia Data from Germany! Inzidenzdichte und Erregerspektrum der Beatmungsassoziierten Pneumonie nach dem Typ der Intensivstation. Daten aus 586 Intensivstationen 2005-2009 [25*]. Meyer E, Schwab F, Gastmeier P. Nosocomial methicillin resistant Staphylococcus aureus pneumonia - epidemiology and trends based on data of a network of 586 German ICUs (2005-2009). Eur J Med Res 2010; 15: 514-524
If you expect other pathogens: Cefotaxime/Cefuroxime are recommend, If you expect pseudomonas: Ciprofloxacine and/or Ceftazidime for 7 to 8 days Cave: Hospital environment depends on your antibiotic treatment Antibiotic exposure increases the risks of resistance Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106 Zaoutis TE et al. Pediatrics 2005;114:942-9 Talon D et al. Clin Microbiol Infect 2000;6:376-84
The problem of selection pressure Resistenzen susceptible less susceptible Selection Pressure of Antibiotics
About 60 % of all patients received Antibiotics, 92,1 % without sensitivity testing (similar to U.S., eg*, but big differences) Polk, Ronald E., et al., Measurement of Adult Antibacterial Drug Use in 130 US Hospitals: Comparison of Defined Daily Dose and Days of Therapy. Clin Infect Dis, 2007. 44(5): p. 664-670. de With, K., et al., Is There Significant Regional Variation in Hospital Antibiotic Consumption in Germany? Infection, 2006. 34(5): p. 274-277.
Antibiotics are misused in a variety of ways Given when they are not needed Continued when they are no longer necessary Given at the wrong dose Broad spectrum agents are used to treat very susceptible bacteria The wrong antibiotic is given to treat an infection
General Principles of Antimicrobiological Therapy 1. Obtaining an accurate Infectious Disease Diagnosis An infectious disease diagnosis is reached by determining the site of infection, defining the host (eg, immunocompromised, diabetic, of advanced age), and establishing, when possible, a microbiological diagnosis. Look at you patient 2. Timing of Initiation of Antimicrobial Therapy The timing of initial therapy should be guided by the urgency of the situation. hit hard (if urgent) get the point Anand Kumar, Optimizing antimicrobioal therapy in sepsis and septic shock, Critical Care Clinics Volume 25, Issue 4, October 2009, Pages 733 751
3. Empiric vs. Definitive Antimicrobial Therapy Initial therapy is usually empiric treat the possible pathogens If microbiological results are available: try to narrow antibiotic spectrum For example: if you find Streptococcus pneumoniae in nosocomial pneumonia, Amoxicilline may be the right choice 4. Duration of antibiotic Therapy Use the right time look at your patient again For the example of pneumonia 5 8 days are supported by most studies.
Stewardship optimizes patient safety: decreased patient-level resistance Cipro Standard Antibiotic duration LOS ICU 3 days 10 days 9 days 15 days Antibiotic resistance/ superinfection 14% 38% Singh N et al. Am J Respir Crit Care Med. 2000;162:505-11. Study terminated early because attending physicians began to treat standard care group with 3 days of therapy
5. Response to therapy Ensure that patient is better if not, this can be associated with antimicrobial resistance 6. Antibiotic Management Programme Try to initiate Antibiotic Stewardship Programme Fishman N. Am J Med. 2006;119:S53.
Prophylaxis of nosocomial pneumonia: Respiratory muscles training! Avoid Aspiration! HAND HYGIENE!
Conclusions : Nosocomial infections are common Nosocomial pneumonia (as a part of it) is common Nosocomial infections may require other treatment than community acquired infections Get the point Good hygiene is a basic tool of prophylaxis!
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