14 HCAI Antibiotic resistance 2011

							Health Care Assiciated Infections and
Antibiotic Resistance:
 an increasing threat to Patient Safety in
Europe
Aftab Jasir, European Centre for Disease Prevention and Control (ECDC)
European public health microbiology training program (EUPHEM)
          Objectives of the lecture

To learn and understand about:

 Basic of antibiotics and resistant among
 bacteria

 Health care associated infections

 Relevant terminologies
Story of glory
1945




       Fleming, Florey and Chain
Antibiotics




              5
Antimicrobial drugs


Natural antibiotics

Synthesized antibiotics




                          6
Natural antibiotics




     Penicillium notatum
                           7
Knowledg about killing


 Do we need to use
  antibiotics for killing of
  pathogens?




                               8
Modern medicine is not possible without
effective antimicrobials


  Hip replacement

      Organ transplants

          Cancer chemotherapy


                    Intensive care

                     Care of preterm babies
         Terminology
           Antiseptics

• Topical substances (e.g. skin)
  • e.g. iodine or 70% alcohol
  • “reduce” bacterial load




                         10
Antibiotics


• Selectively toxic for bacteria
• bactericidal (killing)
• bacteriostatic (growth inhibition)

• no harm to patient (???)



                             12
Prophylaxis




              13
 Minimal inhibitory concentration/
 minimal bactericidal concentration
            (MIC/MBC)

 lowest level stopping growth/killing

e. g. zone of inhibition around a disk




                              14
MIC/MBC




          15
Most important targets in bacteria

1. Attack bacterial cell wall synthesis.

2. Interfere with protein synthesis.
3. Interference with nucleic acid synthesis (RNA and DNA)
4. Inhibition of an essential metabolic pathway that exists in the
bacterium but does not exist in the host

5. Membrane inhibition or disruption
     doesn't work too well because of the similarities between and
             bacterial membranes.




                                                       16
17
Drug usage = Drug resistance
Basis of Antibiotic Resistance

 The antibiotic resistance is guided by Genomic changes
 Spread of R plasmids or other genetic elements among the
  Bacteria

 Do remember Antibiotics are used in veterinary
 medicine

 The discovery of antibiotic resistance was discovered with
  spread of R plasmids from animal sources
Plasmids and Transposons



                           RTF

            Tn 21




    Tn 10




             Tn 9   Tn 8



        R
   determinant
Superbugs

Multi drug-resistant
acquired non-susceptibility
 to at least one agent in three
 or more antimicrobial categories
Extensively drug-resistant
non-susceptibility to at least
 one agent in all but two
 or fewer antimicrobial
 categories
Pandrug-resistance (PDR)
non-susceptibility to all agents
in all antimicrobial categories
Welcome to the hospital!
Bugs are waiting for you!!!
NIIIIIICE! I am getting something good here
                   Terminology

 Nosocomial
   • Traditional meaning “originating in hospital”

 Hospital-acquired/associated

 Healthcare-acquired/associated

 HAI   or   NI   or HCAI
                   Definition

An infection occurring in a patient/staff/visitor in a
healthcare facility not present or incubated at the
time of admission.

 - includes infections that do not become apparent until
 after discharge and occupational infections among staff
 of the facility
Healthcare-associated infections, antimicro-
bial resistance: Overlapping, but not identical

 Healthcare-
 associated
 infections




      Antimicrobial
       resistance


                                Community-acquired
                                         infections
Burden of Healthcare-Associated Infections
and Multidrug Resistance
(preliminary estimate)


      Healthcare-associated infections (HCAI)
        • approximately 4 million per year
        • approx. 37,000 directly attributable deaths each year

      Multidrug-resistant bacteria
        • approximately 1/2 of the deaths attributable to HCAI
                     are due to the 7 most common multidrug-resistant bacteria
                     in the 4 main types of HCAI: bloodstream infection,
                          pneumonia, skin and soft tissue infection, urinary tract
                          infection
                          This is an underestimate!
 Source: Suetens C & Monnet DL, ECDC
 (preliminary estimate)
30
                    Risk factors

 External/none host        Internal/Host
  • Catheters and other      •   Extremes of age
    invasive devices         •   Immune status
  • Surgeries                •   Illness severity
  • Invasive procedures      •   Comorbidities
  • Antibiotic exposure      •   Colonization status
  • Inadequate staff and
    overcrowding
New challenges




http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=740
Challenges in developing Case-Definitions for
                    HAI
Assumptions:
 >48 or >72 hours after admission
 Not incubating at the time of admission
 Can manifest after discharge
 Acquired in healthcare setting

 Use both clinical and lab criteria
Examples of potential for misclassification

Case 1
 80 y.o. patient, multiple medical problems, lives at
  home, visited by grandchildren who have colds

 2 days later, admitted for hip fracture

 4 days after admission she develops RSV (respiratory
  syncytial virus) pneumonia

                    What you think?
Examples of potential for misclassification

Case 2
 55 y.o. patient, admitted for work-up and
  management of chest pain, cared for by healthcare
  worker taking care of another patient who has MRSA
 Discharged after 2 days in hospital

 Develops an MRSA soft tissue infection 3 weeks later
  while in the community

                    What now???
                  Incubation periods

   C.difficile         unknown
    MRSA               unknown
   VRE                       unknown
   Influenza           1-4 days
   RSV                 2-8 days
   Norovirus           24-48 hours
               Conclusions
 There are always outbreaks going on at the
  hospitals. However they might not be
  detectable
 Hospitals are a suitable place for outbreak
  investigation
 It is not always easy to define the cases
 Outbreaks agents circulating frequently.
  Therefore you need good microbiological
  evidence to confirm your cases.
Hands are the most common public
transport of microorganisms
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