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

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

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

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

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

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 12.7 100%)

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

General paediatric wards

P I C U

Preintervention 12 mo Intervention 4 mo Postintervention 12 mo Dec 2010- Nov 2011 Nov 2011- Feb 2012 March 2012- 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

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

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

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

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) > 12 60 months 371 (30.4) 362 (25.7) > 60 120 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 (34.5 492 (34.6) Community 758 (61.7) 835 (58.8)

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

Nosocomial infection (n=1227) n patients % patients (95% CI) Culture positive 117 9.5 (8.0-11.3) bloodstream infection Culture negative likely 50 4.1 (3.1-5.3) bloodstream infection VAP/pneumonia 39 3.2 (2.3-4.3) CAUTI/UTI 65 5.3 (4.2-6.7) Surgical site infection 19 1.5 (0.9-2.3) Gastroenteritis 22 1.8 (1.2-2.7) Phlebitis 31 2.5 (1.8-3.6) Upper respiratory infection 13 1.1 (0.6-1.8) Total 277 22.6 (20.3-24.9)

Patients used antibiotics Patients exposed to irrational antibiotics PICU n=228 (%) Infectious ward n=466 (%) Non-infectious ward n=553(%) 212 345 223 118 (55.7) 135 (39.1) 83 (37.2)

Numbers of hand hygiene opportunities Hand hygiene compliance PICU (%) Infectious ward (%) Non-infectious ward (%) 596 576 518 70 (11.7) 124 (21.5) 125 (24.1)

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

The effectiveness of a multifaceted intervention

Total numbers of patients with nosocomial infections Total numbers of patients recruited Overall proportion of patients with nosocomial infections Preintervention Postintervention 277 123 1227 1419 RR (95% CI) 22.5% 8.4% 0.32 (0.26-0.41)

Intervention started in Dec 2011

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

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 0.16 0.31)

Total numbers of patients exposed to irrational antibiotics Preintervention Postintervention 336 182 RR (95% CI) Total numbers of patients used antibiotics Overall proportion of patients with irrational antibiotics 780 882 43% 20.6% 0.46 (0.40-0.55)

Total of hand hygiene moments Total of hand hygiene opportunities Overall hand hygiene compliance Pre-intervention Postintervention 319 1125 1690 1789 RR (95% CI) 18.9% 62.9% 3.33 (2.99-3.70)

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 (0.61-0.97) 68/277 (25) 47/121 (38.8) 1.55 (1.14-2.11)

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 (0.61-0.97) 68/277 (25) 47/121 (38.8) 1.55 (1.14-2.11) 309/4369 (7) 328/5454 (6) 0.85 (0.73-0.98)

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

After adjusting for factors potentially associate with mortality: Nosocomial infections was associated with mortality with adjusted OR 4.6 (95% CI 3.0 7.1)

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

Antibiotic resistance of nosocomial bloodstream pathogens

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

Incidence of MDR infections was 6.4% MDR increased the risk of death by 17.5 (95% CI 5.1-59.2)

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

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

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

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

Thank you