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

5 Antibiotics

6 Antimicrobial drugs Natural antibiotics Synthesized antibiotics

7 Natural antibiotics Penicillium notatum

Knowledg about killing Do we need to use antibiotics for killing of pathogens? 8

Hip replacement Organ transplants Cancer chemotherapy Intensive care Care of preterm babies Modern medicine is not possible without effective antimicrobials

10 Terminology Antiseptics Topical substances (e.g. skin) Topical substances (e.g. skin) e.g. iodine or 70% alcohol e.g. iodine or 70% alcohol reduce bacterial load reduce bacterial load

12 Antibiotics Selectively toxic for bacteria bactericidal (killing) bactericidal (killing) bacteriostatic (growth inhibition) bacteriostatic (growth inhibition) no harm to patient (???) no harm to patient (???)

13 Prophylaxis

14 Minimal inhibitory concentration/ minimal bactericidal concentration (MIC/MBC) lowest level stopping growth/killing lowest level stopping growth/killing e. g. zone of inhibition around a disk

15 MIC/MBC

16 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.

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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 R determinant Tn 8 Tn 10 Tn 9 Tn 21

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 Community-acquired infections Antimicrobial resistance Healthcare-associated infections, antimicro- bial resistance: Overlapping, but not identical Antimicrobial resistance

30 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)

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

New challenges

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 Norovirus24-48 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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18 November 2010