ECCMID 2014 Year in Infection Control

8/12/2019 ECCMID 2014 Year in Infection Control

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Year in Infection Control

May 2013-April 2014

Part IBarry Cookson

University College, London,

United Kingdom

Declarations: Gojo, Ecolab, Qiagen

Part II

Christina Vandenbroucke-Grauls

VU University medical center, Amsterdam,The Netherlands

Declarations: Biomerieux


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Part 1: Barry Cooksons Topics

Improving evidence base in infection control

Modelling

Surveillance including Surgical, LTCF, Costings

Typing/Tracking Organisms

MRSA

Interventions

Screening/Suppression of MRSA Hand hygiene


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Part 2: Christina Vandenbroucke-Grauls

Topics

Antimicrobial resistance & antibiotic use

ESBL and carbapenemases

Clostridium difficile

The hospital environment

Gender


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The Flos

Florence Nightingale (1820-1910)


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Pubmed & reading 12 Journals

Blogs

Twitter

Sources for Presentations

www.micro-blog.info

Otter & Yezli

http://i-prevent.blogspot.nl A.Voss

www.haicontroversies.blogspot.nlPerencevich, Diekema, Edmond
http://www.micro-blog.info/http://i-prevent.blogspot.nl/http://www.haicontroversies.blogspot.nl/http://www.haicontroversies.blogspot.nl/http://i-prevent.blogspot.nl/http://i-prevent.blogspot.nl/http://i-prevent.blogspot.nl/http://www.micro-blog.info/http://www.micro-blog.info/http://www.micro-blog.info/


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Acknowledge Colleagues help

Sheldon Stone

Olga Paniara

Modelling and Big Data

Ben Cooper, Sarah Deeny & Julie Robotham

ICPIC (Eli Perencevich & Andreas Widmer) ICAAC (Andreas Voss)

2013 ECCMID (Benedetta Allegranzi & Robert Skov)

presentations: complement, augment

Importance of ESCMID CPD library: many are

resource slides as little time to discuss in-depth


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The Flos Special Award of the Year is

Cardiff University Library, Cochrane Archive, University Hospital Llandough.


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1) Improving the quality of the infection control evidence

base: research inform guidelines/guidance

for policies for safer patient care


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Tools for improving the evidence base

of scientific literature

CONSORT for randomized controlled trials (1996)

STROBE for observational studies (2007)

ORION for intermittent time series & outbreaks (2007)

Preferred Reporting Items for Systematic Reviews &

Meta- Analyses (PRISMA) for systematic reviews &

meta analyses (2009)

EQUATOR Network (2006)

http://www.equator-network.org/resource-centre/library-

of health-research-reporting/

STROME-ID (2014)
http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/http://www.equator-network.org/resource-centre/library-of%20health-research-reporting/


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PLoS Med 10(8): e1001504.

doi:10.1371/journal.pmed.1001504

PLOS Med a champion and published previously

STROBE

Evidence that CONSORT & PRISM improved the literature

Published: August 27, 2013Studies also show that the quality of reporting overall

remains suboptimal as not all journals endorse

or enforce the use of reporting guidelines

Comment: this is certainly true for infection control

and related journals


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Reviewed outbreaks reported in So Paulo State, Brazil, &

verify compliance with mandatory outbreak notification

Explored potential for ORION to inform where need to to

improve competencies

Only 15/87 (17%) published outbreaks reported to authorities

Poor/Varied compliance with ORION categories

Background 32% , Objectives 75% , Participants 2%,

Setting 46% , Infection-Related Outcomes13%,

Interventions 52% & Culture-Typing 55%Issue:Missed opportunity to stratify by Journals requirements

for ORION (expected for authors and evaluation by referees)

Pires et al, AJIC 42 (2014) e47-e5


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PLoS Med 11(2): e1001603

doi:10.1371/

journal.pmed.1001603

Differences in:

1) Publication format

2) Work processes

3) Author team

Management

4) Statistical methods.


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Current

Emerging

Health Knowledge Ecosystems

Modelling!

PLoS Med 11(2): e1001603

doi:10.1371/

journal.pmed.1001603

o e ng


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o e ngA previous ECCMID Debate (2012)

Audience split on utility!

Everything should bemade as simple as possible,

but not simplerAlbert Einstein


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We argue that usability & stability of a model is an outcome

of the negotiation that occurs within the networks &

discourses surrounding it.

PLoS ONE 8(10): e76277.

doi:10.1371/journal.pone.0076277

PLoS Med 10(10): e1001540.

doi:10.1371/journal.pmed.1001540

We have found evidence to suggest that identification of

uncertainties, combined with their deproblematisation

can act to stabilise the role of scientific modelling in

decision-making


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Clin Microbiol Infect 2013; 19: 993998

Mathematical models play an important role in helpinghealthcare systems to respond to ongoing epidemics or

plan the logistics of various theoretical scenarios

Prediction & model-based management of

epidemics in their early phase are quite unlikely tobecome the norm. far too complex to be predictable

BC: so do we guess: sometimes nothing else is available?

Flu: pnas.org/content/early/2011/10/24/1103002108.short

Internetbiosurveillance systems can detect an outbreak

of an infection more rapidly than ever before.

BC : this may be a bit premature?


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The Flos Honorary Award of the Year goes to Prof Tim Berners-Lee

Inventor of the World Wide Web

25thAnniversary


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3) Surveillance


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Lancet Infect Dis 2014;14: 16068

Dengue & Influenza reviewed

Complement not replace existing systems

Many issues described e.g. Lack of access to internet

Populations vary in internet use and Health-seeking

behaviour (BC: sample migration e.g. Facebook?)

USA poor sensitivity and spatial resolutionnecessary to detect small, localised flu outbreaks

Also see Big Data FT article


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Big data: are we making a big mistake?

FT Magazine: March 28, 2014: Tim Harford

Googles estimates of the spread of flu-like illnesses

were overstated by almost a factor of two. Google cared

about correlation rather than causation

The End of Theory: with enough data, the numbersspeak for themselves .. hopelessly naive where

spurious patterns vastly outnumber genuine discoveries.

When it comes to data, size isnt everything.

Non random.. sampling error USA twittersare disproportionately young, urban/suburban & black

(Sample migration; Super tweeters?)


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Cape Town Sunday Times

Lancet Infect Dis 2014;14: 16068


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Journal of Hospital Infection


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(2014) 34e41

Referral to:

Observed rate

Supra Regiona

specialistHospitals

Created

Same

Collective


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Murchan et al,EMRSA-16 spread in

England and Wales.

J Clin Microbiol

2004; 57: 345-346.

HAI results, ECDC PPS 2011-2012


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HAI results, ECDC PPS 2011 2012

HAI prevalence:

Overall: 13829/231459patients with 1 HAI

HAI prevalence: 6.0%

Country range: 2.3%-10.8%

15000 HAIs; 1.1 HAI/patient

HAI present at admission: 23%

Same hospital: 55%

33% surgical site infection

HAI during current hospitalisation: 76% of HAIs, prevalence: 4.5%

Median time to onset of HAI: 12 days

Microorganism reported: 45.9%

Prevalence antimicrobial use for treatment of hospitalinfection: 6.4%

95% of patients with HAI received >=1 antimicrobial onday of survey

Source: ECDC PPS, 2011-2012

(1) incl. C. difficileinfections 3.6%

(2) incl. clinical sepsis 5.3%

23%

19%

20%

11%

8%

6%4%

10%

Pneumonia/LRTI

Urinary tract

Surgical site infection

Bloodstream

Gastrointestinal (1)

Systemic (2)

Skin/Soft tissue

Other/unspecified

Type of HAI

30 countries (29 EU/EEA countries+ Croatia), 33 PPSs (networks)

2014:12;7|

Observed vs predicted HAI prevalence by country


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Observed vs predicted HAI prevalence by country,

ECDC PPS 2011-2012

0 2 4 6 8 10 12 14 16 18 20

LatviaRomania

LithuaniaSlovakiaBulgaria

UK-WalesUK-N. Ireland

MaltaHungary

Czech RepublicUK-Scotland

FranceGermany

IrelandLuxembourg

EstoniaCroatia

UK-EnglandAustria

ItalySlovenia

PolandCyprus

BelgiumSweden

NetherlandsFinlandNorway

Spain

GreeceDenmark*

IcelandPortugal

Patients with HAI (%)

Observed HAI prevalence (%)(with 95% confidence interval)

Predicted HAI prevalence (%)(based on case-mix)

http://www.ecdc.europa.eu/en/publications/Publication

althcare-associated-infections-antimicrobial-use-PPS.

Structure & process indicators:


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ppercentage of single room beds

Single room beds in participating hospitals (%): median = 11.1%

Source: ECDC, 2012 (ECDC PPS data as of 23/11/2012)

0 20 40 60 80 100

N of single room beds*100 /Total beds

UK-WalesUK-Scotland

UK-Northern IrelandUK-England

SwedenSpain

SloveniaSlovakiaRomaniaPortugal

PolandNorway

NetherlandsMalta

LuxembourgLithuania

LatviaItaly

IrelandIceland

HungaryGreece

GermanyFranceFinlandEstonia

DenmarkCzech Republic

CyprusCroatia

BulgariaBelgiumAustria

*Poor data representativeness

Alcohol hand rub consumption in acute care


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p

hospitals, ECDC PPS 2011-2012


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HAI PPS 4600 trained

Susan Hopkins lead, HP Agency & HP Scotland

HALT 2 PPS 1700 LTCFs staff trained.Fidelma Fitzpatrick & Tracey Dillane,

HSE & HP Surveillance Centre


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2013:

http://www.ecdc.europa.eu/en/

publications/Publications/infect

ion-control-core-

competencies.pdf2014-15: TRICE-Implementation Strategy includes

IC Course assessments IC/HH WIKI : ESCMID SGs to be involved

Revisiting TRICE IC Resources

Awaiting clearance fo

ECDC-Funded SIGHT Project


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ECDC-Funded SIGHT Project

Should be in Lancet ID (Zing et al)


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Increasing Healthcare Delivery in the Community Increasingly aged populations

Decreasing lengths of hospital stay: HAIs

presenting in the community

Increasing numbers of step-down from hospital andhybrid (Step-Down/Residential) facilities

Issues

with definitions of names of facilities

Lack of surveillance, infection control standards,

guidelines and audit .

LOW PRIORITY IN MANY COUNTRIES

See: Moro et al, ICHE 2010; 31 (suppl. 1); 559-62 (IPSE WP7)

Cookson et al, J Hosp Infect 2013; 85: 45-53 (HALT 1)


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Carl Suetens

ECDC

Championed HALT

Antoon Gijsens

DG SANCO

Bea Jans

HALT Lead

LTCF a late addition


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Cookson et al, J Hosp Infect 2013; 85: 45-53.


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HALT-1 & 2 Reports

Katrien Latour, Abstract No ECCMI-4351

http://www.ecdc.europa.eu/en/Pages/home.aspx

5thMay 2014
http://www.ecdc.europa.eu/en/Pages/home.aspxhttp://www.ecdc.europa.eu/en/Pages/home.aspx


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Additional & increasing burden of AMR organisms

Main increases are in AMR organisms MSSA continuing increases

MRSA increases 7.6%/Y then decreases 4.8%/Y 200


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Surgical Site Infections

(SSIs)


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Korol et al, PLoS ONE 8(12): e83743. doi:10.1371/journal.pone.0083743

1) Challenging:

very rich literature


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very rich literature

many study designs,

settings,

categorizations &

definitions

2) Despite this

they consistently

found associated

SSI risk factors

3) Risk Factors

relate to:

reduced fitness,

patient frailty,

surgery duration,

& complexityBC: Body warming,

glucose control,

triclosan stitches?


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Risk score gauged independent influence of each risk factor

New logistic regression approach of quantifying the influence of

different operative types on SSIs

Model used 181 894 operations for derivation, 181 146 for validation

SSIRS captured 89.7% of the validation population

Web based system available significantly better discrimination than NNIS

Basic Risk SSI Index

Also a simpler SSIRS index permits 30-day SSI risk bedside estimation

without computational aids

BC: Needs external validation. ECDC interested?

van Walraven C, Musselman R. PLoS ONE 2013;8:e67167


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Owens et al, JAMA. 2014;311:709-716

Retrospective analysis: 284, 098 ambulatory surgical procedure

Databases of 1/3 US population in 8 dispersed USA states

Needed postsurgical acute care visits

General, orthopaedic, neuro, gynae, & urologic surgeryLength of stay less than 2 days

SSIs at 14days 3.09 /1000 ambulatory surgical procedures

30days 4.84 /1000 ambulatory surgical procedures

63.7% within 14 days of the surgery: limited risk factor analys 93.2% needed inpatient treatment

Low relative to all causes but significant adverse events

The Post Discharge SurveillanceAn Elephant in the Room!


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An Elephant in the Room!

http://en.wikipedia.org/wiki/Elephant

Difficult to compare studies as

differences in e.g.

Lengths of stay

Operative categories

Definitions of infections

Methods of data collection:

Re-admissions only! Telephone or Patient or

Healthcare worker reporti

If staff/patients are trained

Lack detail so work canbe repeated


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American Journal of Infection Control 41 (2013) 591-6

Journal of Hospital Infection 86 (2014) 127e132

American Journal of Infection Control 41 (2013) 549-53

Ann Intern Med. 2013;159:447-455.

Post Discharge Surveillance (PDS)


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J Hospital Infect 2013; 84: 267

(& refs to two previous letters)

Disputes including English HPA (PHE) SSI system do not

bench mark PDS data

Brisbane group supported English HPA responding:

Until a valid & cost-effective solutionPDS is found donot bench mark.

Hospitals are required to undertake PDS, so the data can

be used for internal (i.e. local) quality improvement

Should not be required to submit PDS data for publicscrutiny or be penalized for not doing so.


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Raschka et al, AJIC 2013;41: 773-7

19% less selected HAIs over 4 years

Cost avoidance of at least $9 million

80% in last two years!

(so enormous potential: useful to quote internationally)

Interesting methodology Vancouver regional

Canadian Inf. control

programme

Standardized policies,

procedures, and initiatives(including hand hygiene

campaign)

Th Fl E t di A i f th Y


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The Flos Extraordinary Anniversary of the Year

60 years since description

of DNAs structure

Watson, Crick,

(Franklin and Wilkins)

http://www.chemheritage.org/discover/online-resources/chemistry-in-history/themes/biomolecules/dna/watson-crick-wilkins-franklin.aspx

4) Typing & Tracking HAI Organisms


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Lancet Infect Dis 2014; 14: 34152


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Medline database

searches with terms

Infection

&

Molecular Epidemiology

No papers/100K/year


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20 items added to 22 item STROBE checklist

Should advance the quality & transparency of

scientific reporting, with clear benefits for

evidence reviews & health-policy decision making




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Optimisation of NGS information for Infection Control TeamsSee also :Humphries & Coleman Letter: http://dx.doi.org/10.1016/j.jhin.2013.05.002


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Educate users (STROME-ID) e.g. strengths and limitations

Clear objectives to ensure optimises patient care/safety

Interpretation needs detailed epidemiological data

Golden fleece TIMELY automatic appropriate simplified

discriminant data : (TATs not stated in many papers!)

Dialogue with reference laboratories and others with expertise

this area to optimize its potential.

Consider accreditation requirements for Reference labs

National information considered National funding ref Public Health aspects

See also :Humphries & Coleman Letter: http://dx.doi.org/10.1016/j.jhin.2013.05.002


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Ehrlich & Post JAMA Internal Medicine 2013;173: 1406-06

Struelens and Brisse. Euro Surveill. 2013;18(4):pii=20386.

Editorialand several very useful papers in issuealso look at: Price et al, CID 2014;58:60918

Invited paper: interesting analysis of potential

MRSA


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MRSA

Melo Christino et al Lancet 2013;382:205 (20 July 2013)


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Melo-Christino et al, Lancet 2013;382:205 (20 July 2013)

vanA +MRSA strain in Europe from Portuguese patient USA MRSA type (ST105, SCCmectype II: common

HAI strain in Portugal)

No epidemiological links to USA

vanA source may a wound VRE

Treatment progressing and no spread thus far


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Emerged in Brazil following multiple vancomycin courses

No spread so far: died with GNR BSI

Related to community USA 300 strain: has bsa CA MRSA

operon PVL negative

Perhaps element originated from a GRE in another patient

in the same room: patient also positive (late)

Transferable to other S aureus (WOW!!!!!) Worrying : USA 300 clades common globally

Rossi et al, N Engl J Med 2014;370:1524-31

Strommenger et al J Antimicrob Chemoth


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174 SA and MRSA of CC8 (including CA USA300) from 5 Continents

1957-2008 Phylogeny explored at 112 genetic housekeeping loci, AMR and

diverse mobile genetic elements

9 clades: 8 independent SCCmec acquisitions : started in mid-1970s.

88% carried plasmidic rep gene sequences (5 rep genes and eight repfamilies)

Increasing and stable AMR (9 classes) during the evolution of several

lineages, including USA300. (Comment: check pedigree of different

strains.)

Diverse virulence determinants

Perhaps WILL become a multiple resistant MRSA?

(USA300 now a hospital MRSA)

Strommenger et al, J Antimicrob Chemoth

2014; 69: 616622


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4 new MRSA mecA/C negative from 3 ST types from

Scottish patients

Perhaps due to identified amino acid substitutions in

their endogenous PBPs 1, 2 & 3?

Not BORSA strains, as resistant to both oxacillin &

cefoxitin

Need for vigilance ref molecular MRSA assays &

possible new drug target resistance MUST NOT ABANDON PHENOTYPIC TESTING

Xiaoliang et al, J Antimicrob Chemother 2014; 69: 594597


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A 55-pound or greater Hog producesat least 10 gallons of manure a day (!)

Manure spread on surrounding Iowan

fields

MRSA can be aerosolized from thismanure to human food or water

sources.

Carrel et al, Infect Control Hosp Epidemiol 2014;35(2):190-192

BetterPho

McKinnell et al, ICHE 2013; 34(: 161170


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McKinnell et al, ICHE2013; 34(: 161 170

Often ignored in studies & national screening programmes

Systematic review 1966-2012: 23 papers: 39,497 patients

Few studies looked at >1 such extra nasal site!

ICU admission: detects ~1/3 more

Hospital admission: >6% MRSA incidence: extra 37%


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CDC EIP-ABCs sentinel laboratory-based MRSA casefinding identified MRSA cultures in 9 US metropolitan areas

from 2005 through 2011

Detailed risk factor analyses for HA- & CA-MRSA

In 2011 invasive MRSA infections (80 461) 31% lower than in

2005

Dantes et al, JAMA Intern Med. 2013;173(21):1970-1978.

Dantes et al, JAMA Intern Med. 2013;173(21):1970-1978


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CA MRSA Stable: epidemiology

incomplete e.g. home/LTCF

Interventions


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Culture, Organisational &Behavioural Aspects


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Behavioural AspectsCulture

Excellent reviews: De Bono et al,J Hosp Infect.2014; 86:

1-6 and Borg,J Hosp Infect 2014; 86:161-68

Essential www site of Geert Hofstede

http://geerthofstede.com/dimensions-of-national-cultures

Hand Hygiene Studies Utilizing Shared Accountability and Financial Incentives

Talbot et al, ICHE2013; 34: 1129-1136

Positive deviance study: Marra et al,AJIC2013;41:984-8

Real-time assessment practice using a TheoreticalBehavioural Domains Framework. Fuller et al,AJIC

2014;42:106-10

Hot Topics!

U i l MRSA S i
http://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultureshttp://geerthofstede.com/dimensions-of-national-cultures


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Universal MRSA Screening

Universal MRSA Decolonisation/Suppression

Hammers to crack walnuts?

See posts on:

http://haicontroversies.blogspot.com

&

NEJM Letters

English Universal MRSA Screening
http://haicontroversies.blogspot.com/http://haicontroversies.blogspot.com/


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1) NOW Audit: Fuller et, al PLoS ONE 8(9): e74219

Implementation of universal screening was poor

Admission Screening performed on:

Emergency admissions 61% (median 67.3%)

Electives 81% (median 59.4%)

Very low MRSA admission prevalence:

Emergencies 1%: Electives 0.6%

Inpatient MRSA prevalence 3.3% (6% for original model)

2) Modelling

Consultation underway suggesting stopping universalscreening

Universal Decolonisation/SuppressionA Horizontal Strategy


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gy

Lee et al, 2013 doi 10.11.36/bmjopen-2013-003126

Derde et al,Lancet Infect Dis

2014; 14: 3139

Huang et al, N Engl J Med 2013. DOI: 10.1056/NEJMoa1207290

First RCT

Universal Antiseptic Use Risks

(Horizontal Strategies)


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( Horizontal Strategies )

At what rates of resistant organisms is it cost effective?

Mupirocin needed: how effective is it in reducing infections?

Increasing side effects?

How and how often used, rotate them?

What is best antiseptic to use e.g. octenidine? Inactive chlorhexidine/soap formulations?

Increasing disinfectant/antiseptic resistance

Increased quantities used

Sumps of bacteria e.g. leaking abscesses, suppurating

tracheostomies

Universal Antiseptic Use Risks


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(Horizontal Strategies)

Surveillance issues

Locally: short lengths of stay, not detect damaged

organisms

Nationally: no surveillance

Resistance cut-off agreements review?

Maillard et al,Microb. Drug Res., 2013

doi:10.1089/mdr.2013.0039

Morissey et al, PLoS One. 2014; 9: e86669.

doi:10.1371/journal.pone.0086669

Universal versus Targeted MRSA Screening?


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g gDeeny et al, JHI 2013

More efficient use of resources

Less potential for resistance to antiseptics

J Hosp Infect 2013; 85: 33-44

Hand hygiene


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Schweizer, et.al, Clinical Infectious Diseases 2014;58:24859


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Only 39 quasi-experimental & 4 cluster & 2 RCTs /8,148 studies

over 12 years

Insufficient studies to assess single interventions!How can we design bundles?

No of bundle components was not associated with greater effect:

Include one or two interventions tripled compliance

Include >two produced doubling of compliance

Two bundles effective and Three studies of each:

Education, Reminders, Feedback: OR (pooled) : 1.45 (1.12, 1.94)

If add Administrative Support, & alcoholic handrubs :

OR (pooled): 1.82 (1.69-1.97)

Rock et al, American Journal of Infection Control 41 (2013) 994-6


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Conclusion: HH before donning nonsterile gloves does not decrease

already low bacterial counts on gloves. HH before donning nonsterile

gloves may be unnecessary?

Comment: Saves time: will HCWs confuse with sterile glove usage

especially when stressed?

Use of scents in training1/3 increase in complianceComment: Effectiveness for: different staff? Sustained?

In real workplace? Pavlovian approach ethical? Own life.

Birnbach et al J Hosp Infect 2013;85: 79-81.

ECCMID 2014 Year in Infection Control

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