Networks of hospitals: building a common strategy for HAI prevention and control and antimicrobial policy Tomasz Ozorowski, M.D. University of Medical Sciences, Poznan, Poland National Programme Of Antibiotic Protection

National Programme Of Antibiotic Protection for more rational antibiotic usage in Poland supported by Ministry of Health Medicine Veterinary Agriculture Primary Care Secondary care Guidelines for ABS ICU branch pilot hospitals Network of hospitals Implementing ABS Collecting data Exchanging experience

National Programme of Antibiotic Protection Pilot hospitals Initial requirements: Acute hospital > 400 beds with ICU Support from hospital administration Antimicrobial team Ability to conduct PPS 31 acute hospitals Mean number of beds = 573 Mean numbres of beds in ICU = 8 Mean time of hospital stay = 5.3 days Mean time of ICU stay = 10 days

Pilot hospitals: 3-stage cooperation 1. Collection of entrance data (2008-10) retrospectivelly: antibiotic consumption, bloodstream infection prospectivelly: PPS study 2. Implementation of ABS programme cooperation with antimicrobial team workshops for administration and physicans at the hospital and department level 3. Observe and analyze the results Practical conclusions Less scientific Examples for other hospitals Probably not possible to Correction of the programme find relation with mortality rate and change in resistance

Pilot hospitals antibiotic consumption, one-year period, ATC class J01, DDD/100 BD ICU The results were compared with ARPAC and CARE-ICU European studies: (1) MacKenie F., Monnet D., Gould I.: Relationship between the number of different antibiotics used and the total use of antibiotics in european hospitals, J Antimicrob Chemother 2006;58:657-60. (2) Hanberger H., Arman D., Gill H., et al.: Surveillance of microbial resistance in European Intensive Care Units: a first report from the Care-ICU programme for improved infection control, Intensive Care Med 2009; 35:91-100 (35 ICU)

Top 10 ten antibiotics in Polish hospitals number of DDD (>1 mln)

Top 10 antibiotics in Polish ICU number of DDD

Pilot hospitals – incidence of HA bloodstream infection diagnosed in hospitals/1000 admissions one-year period, 525266 pts, 906 infections The results were compared with the following studies: Finland :4 hospitals Lyytikäinen Clin Infect Dis 2002; 35:e14-19 Estonia: 3 hospitals , Mitt: J Hosp Infect 2009;71:365-70 Belgium : 117 hospitals, Ronveaux Eur J Clin Microbiol Infect Dis 1998;17:695-700. USA: 49 hospitals, Wisplinghhoff Clin Infect Dis 2004;39:309-17.

Pilot hospitals: etiology of HA bloodstream infection

Incidence and etiology of HA bloodstream infection acquired in ICU 27 ICU, 4641 pts, 39125BD , 294 infection 16% HELICS=2,3% (1) ECDC: Annual epidemiological report on communicable diseases in Europe, 2010.

Point Prevalence Survey Results of pilot study in 31 Polish hospitals

PPS –data collection Risk factor for HAI HAI Community acquired infections Antibiotic use as surgical prophylaxis Antibiotic use for other reason than infection and surgical prophylaxis Exclusion: day centre, and day-case patients, no psychiatric departments 1 day = one unit Two education sessions about conducting PPS for hospital teams

PPS – main results, 9288 patients

PPS results 536 HAI in 9288 patients (5.8%) Etiology identified in 60% of HAI : 1. E.coli, 2 A.baumanii, 3. S.aureus (33% MRSA), no VRE , no CRE , only 2 cases of C.difficile

PPS results prevalence of risk factors for HAI prevalence of the use of central venous catheter The results were compared with the following studies: Slovenia: 19 acute care hospitals,6695 pts; Klavs J Hosp Infect 2003;54:149-57 Greece : 14 hospitals academic / regional, 3925 pts; Gikas J Hosp Infect 2002;50:269-75 Italy: 21 acute care hospitals ; Pellizerr Infection 2008;36:112-9 USA: 6 academic centers,2459 pts; Climo ICHE 2003;24:942-5

PPS results prevalence of risk factors for HAI % of ICU patients - day of the study The results were compared with the following studies: UK: 4 country study; Smyth J Hosp Infect 2008;69:230-48 Slovenia: 19 acute care hospitals,6695 pts, Klavs J Hosp Infect 2003;54:149-57 Nosocomial infections in Belgium part I: national prevalence study. KCE reports 92C. ,2008 Greece : 14 hospitals academic/regional, 3925 pts, Gikas J Hosp Infect 2002;50:269-75 Italy: 21 acute care hospitals Pellizerr Infection 2008;36:112-9

PPS-results antibiotic prescribed: no infection and surgical prophylaxis: 7,7% pts Group of reasons Specific reasons Respiratory tract Lung edema, pleuritis, unspecific X ray abnormalities Urinary tract Renal stones, catheter Digestiv tract Pancreatitis, liver cirrhosis, colon cancer Neonates CRP, mother risk factor for infection, results of superficial cultures Skin and soft tissue Chronic wound CNS Cerebral haemorrhage Other Fever, cancer, neutropenia, high CRP PPS as a useful tool for antibiotic overuse identification → analysis and proposes→ feedback to physicians

Pilot hospital: main conclusion from the results Antibiotic consumption similar to other countries but high domination of iv amoxicllin with clavulanate, even in ICU Acinetobacter baumanii: very frequent Gram negative as a cause of HAI, probably as a result of low organization level and insufficient education of cleaning services Significantly higher incidence of bloodstream infection in polish ICU than in HELICS study Prevalence of HAI (5.8%) approximates the average from 7 main European studies (6.8%) but significantly lower prevalence of the main risk factor for HAI, probably as a result of different organization of health care system