1. ECDC Programme on Antimicrobial Resistance & Healthcare-Associated Infections
Carl Suetens, Senior Expert, Deputy Programme Coordinator European Centre for Disease Prevention and Control

2. Role of the European Centre for Disease Prevention and Control (ECDC)
Identify, assess and communicate current and emerging health threats to human health from communicable diseases.
— ECDC Founding Regulation (851/2004), Article 3
ECDC provides:
EU-level surveillance of communicable diseases
Scientific opinions and studies;
Early Warning System and response;
Technical assistance and training;
Epidemic intelligence;
Communication
to the scientific community,
to the public.

3. Marc Sprenger, Director
ECDC
Organisational Chart
June 2010
Office of the Director
Chief Scientist
Preparedness
and Response Unit (PRU)
Surveillance Unit (SUN)
Scientific Advice Unit (SAU)
Communication and Country Cooperation Unit (CCU)
Administrative Services Unit (ADMIN)
EOC and Preparedness Section
ARHAI Section (SUN)
ARHAI Section (SAU)
Knowledge and Resource Centre on Health Communication
Legal and Procurement Section
Epidemic Intelligence and Response Section
FWD Section (SUN)
FWD and EVD Section (SAU)
Scientific Communication Section
Internal Control Coordination
Training Section
HASH Section (SUN)
HASH Section (SAU)
Public Communication and Media Section
Human Resources Section
RTI Section (SUN), incl. FLU and TB subsections
RTI Section (SAU), incl. FLU and TB subsections
Web Services Section
Finance Section
VPD Section (SUN)
VPD Section (SAU)
ICT and Project Support Section
Data Management and General Surveillance Section
Future Threats and Determinants Section
Missions, Meetings
and Logistics Section
Unit
Section
Scientific and Technical Advice and Knowledge Services SE
Special Entitiy under Deputy Head of Unit
DSP
Core of Disease Specific Programme (DSP) (supported by other units) 3

4. Antimicrobial resistance Antimicrobial resistance
Healthcare-associated infections, antimicro- bial resistance: Overlapping, but not identical
Healthcare- associated infections
Antimicrobial resistance
Antimicrobial resistance
Nosocomial infections and antimicrobial resistance are two special health issues listed in Annex 1 of Commission Decision 2000/96/EC.
The term ”healthcare-associated infections” is now preferred to nosocomial infections because it includes not only infections acquired in hospitals, but also in other settings where healthcare is provided.
Although, for historical and professional reasons, the issues of healthcare-associated infections and antimicrobial resistance are often dealt with together, they represent two separate, though overlapping issues.
Healthcare-associated infections are often, but not always caused by resistant microorganisms
Conversely, antimicrobial resistance can affect microorganisms in hospitals, but also outside hospitals.
PRESS SPACE BAR
So far, the European Antibiotic Awareness Day that I mentioned previously addresses antimicrobials and antimicrobial resistance in patients outside hospitals
- The topic chosen by the Czech Presidency of the EU, however, is patient safety, healthcare-associated infections as well as antimicrobial resistance issues in hospitals and other healthcare settings and my presentation will now focus on these issues.
Community-acquired infections

5. Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) at ECDC
Antimcirobial resistance (AMR)
Healthcare-associated infect. (HAI)
Alcohol hand rub consumption
Antimcirobial consumtpion
Antimicrobial stewardship
Infection control (IC)
Surveillance of outcomes
Guidance & risk assessments
Ad-hoc studies
Surveillance of determinants
Coordination & capacity building
Communication
Training

6. Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) at ECDC
Antimcirobial resistance (AMR)
Healthcare-associated infect. (HAI)
Alcohol hand rub consumption
Antimcirobial consumtpion
Antimicrobial stewardship
Infection control (IC)
Surveillance of outcomes
Guidance & risk assessments
Ad-hoc studies
Surveillance of determinants
Coordination & capacity building
Communication
Training
EARS-Net
Formerly IPSE + PPS
ESAC + PPS
Indicators
C. difficile survey (ECDIS)
ECDC-EMA Joint Report
Review of national hand hygiene campaigns
C. difficile, MRSA, KPC&XDR
Guidance on prevention and control of HAI Guidance on antimicrobial stewardship
Meetings of National Focal Points & Country visits
MRSA typing
Meetings of Surveillance Contact Points & Country visits (training)
European Antibiotic Awareness Day
Collaboration with WHO on hand hygiene
Short course on prevention and control of MDRO
Assessment of IC training needs Short course on PPS Short course on HAI epidemiology

7. European Antibiotic Awareness Day
2008
Materials for general public
32 countries participated
2009
Materials for primary care prescribers
Website translated in all EU languages
TV spots developed
Match with Get Smart week in the United States
2010: Focus on hospital prescribers
Finally, ECDC is coordinating an EU health initiative to promote prudent use of antibiotics and support Member States and other European countries in their efforts in this area.
The European Antibiotic Awareness Day is a recurrent event that takes place throughout Europe on 18 November each year since 2008.
In 2008,...
THEN MAKE SENTENCES FROM BULLET POINTS
For more information: Earnshaw S, et al. Euro Surveill 2009;14(30) &

8. Outpatient antibiotic (J01) use , 2008 (ESAC)

9. Antimicrobial Resistance and Healthcare-Associated Infections Team
Scientific Advice
Dominique L. Monnet, Senior Expert AMR & HAI, Coordinator
Marc Struelens , Senior Expert AMR & HAI
Anna-Pelagia Magiorakos, Expert AMR & HAI
Scientific Officer AMR & HAI
J. Todd Weber, CDC liaison to ECDC (part time)
Elmira Khazeva, Secretary (part time)
Surveillance Unit
Carl Suetens, Senior Expert HAI, Deputy Coordinator
Ole E. Heuer, Senior Expert AMR
Klaus Weist, Seconded National Expert HAI
Carlo Gagliotti, Expert AMR
Jolanta Griškevičienė, Expert HAI
Eva Liljestedt, Secretary (part time)
Senior Expert Antimicrobial Consumption (2010)
Health Communication Unit Preparedness and Response
- Sarah Earnshaw, Information Officer Unit - Jas Mantero, Expert
(part time) Carmen Valera, Vladimir P.

10. ECDC Healthcare-Associated Infection Surveillance: overview of activities
Carl Suetens
Surveillance Unit European Centre for Disease Prevention and Control

11. Burden of healthcare-associated infections and multidrug-resistant bacteria in EU*
(preliminary estimate)
Healthcare-associated infections (HAI)
approximately 4 million per year
Directly attributable deaths: approx. 37,000 each year
Extra hospital days: approx. 16 million each year
Direct costs: approx. €5.5 billion per year (average €334 per day)
Multidrug-resistant bacteria
approximately 1/2 of the deaths attributable to HCAI are due to the 7 most common multidrug-resistant bacteria ...
... and in the four main types of HCAI: bloodstream infection, pneumonia, skin and soft tissue infection, urinary tract infection
"This is a very conservative estimate!"
Source: ECDC Annual Epidemiological Report 2008 and Monnet DL, ECDC (preliminary estimate)

12.
Decision 2119/98 of the European Parliament and Council, 24/09/1998: network for epidemiological surveillance and control of communicable diseases in Europe

14. Languages of the European Union
Knowledge of English
Source: Europeans and their language, Special Eurobarometer 243. European Commission, February 2006.

15. History of standardized surveillance of healthcare-associated infections in the EU
HELICS (Hospitals in Europe Link for infection control through surveillance) = collaboration of national/regional surveillance networks: first initiative in 1994, funding discontinued
1998: Decision 2119/98 EC: epidemiological surveillance and control of communicable diseases in Europe
: Helics (EC DG-Sanco funded project): surveillance of Surgical Site Infections and ICU-acquired infections
: Continued Helics surveillance support as one of workpackages of IPSE (Improving Patient Safety in Europe)
1/7/2008: transition IPSE & HAI surveillance coordination to ECDC Stockholm

16. Basis for European Healthcare-Associated Infection surveillance activities
Decision 2119/98 of the European Parliament and Council, 24/09/1998: network for epidemiological surveillance in Europe
ECDC Founding Regulation (851/2004)
IPSE evaluation & transition plan
Council Recommendation 2009/C 151/01 of 9 June 2009 on patient safety, including the prevention and control of healthcare associated infections
ECDC Advisory Forum, HAI surveillance Coordination Group

17. IPSE-ECDC transition overview
WP1
Infection Control Training
WP2
Standards & Indicators
WP3
Nosocomial Event Warning
WP4
HELICS-SSI & HELICS-ICU
WP5
CARE-ICU (AMR & antibiotics)
WP6
ICU tools (molecular typing)
WP7
HCAI in Nursing Homes
ECDC HCAI surveillance :
1 ICU-module in TESSy
SSI surveillance
+ HELICSwin support, TESSy training
ECDC EPIS
ECDC - SPI surveillance
ECDC CfT MRSA typing
2 ECDC CfT:
IC training needs assessment
PPS training curriculum
ECDC CfP HCAI surveillance in LTCF (HALT)
ECDC:
EU PPS of HCAI (& AB use) in hospitals
Call concordance study HAI case definitions

18. ECDC support to the Council Recommendation on Patient Safety & HCAI
Programme, measures, guidelines
Guidance development
Country visits
EU PPS
Surveillance: SSI, ICU
Structure and process indicators
Epidemic Intelligence (EPIS)
Surveillance
Needs assessment IC training & core competencies (IPSE-WP1)
Training modules: PPS, AMR control
Infection Control Training
Patient information, Research
Annual Report, Web development
E-bug, HH workshop at EU conference

19. The Council Recommendation recommends that Member States …
Establish/strengthen active surveillance systems
National/regional level:
Prevalence surveys at regular intervals, as appropriate
Surveillance of targeted infection types + process/structure indicators to evaluate strategy
Timely detection/reporting alert organisms/clusters of HAIs
Reporting of clusters/infection types of international relevance
At level of healthcare institutions
Surveillance of targeted infection types + process/structure indicators to evaluate implementation of measures
Surveillance for timely detection alert organisms/clusters of HAIs
High quality microbiological documentation/patient records
Use surveillance methods/indicators as recommended by ECDC and case definitions agreed at Community level.

20. Participation to HAI surveillance, status in 2010
SIRO
NOIS
SSHAIP
INST HYG
HISC
PREZIES
NHS
HPA
NSIH
KISS
ANIS
RAISIN
NNSR
ASR
ENVIN
ISC III
HELICS
SPIN-UTI

21. EU HAI surveillance integrated in TESSy in October 2010
Pre-TESSY
TESSy = “The European Surveillance System” = ECDC’s online database, upload and reporting system for all communicable diseases under surveillance
Integration of all dedicated surveillance networks
June, : 2nd annual HAI surveillance meeting, final adjustments to SSI and ICU protocols
October (4-8/10): HAI TESSy training for national surveillance coordinators and data managers

22. EU-PPS for HAI/Antimicrobial use in acute care hospitals
Pilot PPS: June-September 2010: 25 countries subscribed (at least 1 hospital per country)
2 levels: full (patient-based + risk factors), light (aggregated denominators for each ward)
Full PPS ( ): representative systematic sample of hospitals per country

23. ECDC support to Point Prevalence Survey
Training: Outsourced (HPA, UK) development of standardized training material for Point Prevalence Survey (Jan-Nov 2010):
1-day training for large audience
5-day course in-depth epidemiological concepts and PPS data analysis
Training of trainers
Pilot PPS support project (Univ of Antwerp, BE, InVS, FR, IPH, BXL):
Helpdesk during pilot
Feasibility analysis
WebPPS tool test
Full collaboration with ECDC ARHAI team
Software (HELICSwin or adapted ESAC WebPPS)
Helpdesk
On-site workshops

24. Infection control structure- and process indicators (SPIs)
Integrated in Point Prevalence Survey (hospital and national level), ICU surveillance (integration IPSE WP5) and SSI surveillance (no separate protocol)
Will be further developed as a function of development of ECDC guidance on healthcare-associated infections and antimicrobial stewardship
Survey of SPIs currently in place in Member States in 2010

25. Healthcare-Associated infections in European LongTerm care facilities (HALT)
Follow-up of WP7 of IPSE
Outsourced (Jan 2009 – Feb 2011) to consortium coordinated by former IPSE hub (Lyon, Univ Claude Bernard) + ex-IPSE WP7 + Esac-nursing homes
Repeated prevalence surveys
Integration HAI, SPIs, AMR markers and antimicrobial use through collaboration ESAC
Discussed at ECDC Advisory Forum (Feb 2010) => light and full protocol
Future: one HALT PPS month/year

26. HALT: Pilot results of HAI in nursing homes
Median % % (min. 0 - max. 26.7)
Mean % [95% CI: ]

27. Surveillance of Clostridium difficile infections (CDI)
2006: ESGCD/ECDC case definitions on CDI
2007: ECDC launched the European C. difficile survey (ECDIS, ) (Scientific Advice Unit)
2008: Guidance on measures to limit spread of CDI
Sep 2009: ECDC CDI expert meeting, Advisory Forum discussion
2010: Call for Tender “Laboratory support for CDI surveillance”:
Enhance the laboratory capacity for surveillance, and maintenance of a ribotyping nomenclature reference database for Clostridium difficile
Development of a European enhanced CDI surveillance protocol with case-based epidemiological data.

28. Concordance study of HAI dase definitions

29. Concordance study: Results
*CDC/NHSN PNU1 and HELICS/IPSE PN2, PN4, PN5
**CDC/NHSN PNU2 and HELICS/IPSE PN1, PN3
***CDC/NHSN LCBI and HELICS/IPSE BSI-A with origin “Catheter” and origin “Unknown”

30. The Council Recommendation recommends that Member States … (3)
Adopt and implement a strategy, pursuing (cont’d):
Foster education and training of healthcare workers
National/regional level:
Specialised infection control training/education programmes
Education on prevention and control of HCAIs for all healthcare workers
At level of healthcare institutions
Regular training for all healthcare personnel
Regular advanced training for specialised infection control staff

31. Needs assessment of (hospital) infection control training in EU (TRICE)
Follow-up of IPSE WP1
Call for Tender (June 2009)
Awarded to University of Udine (Italy):
12/ /2010 (TRICE project)
Objectives:
To assess current infection control capacities and infection control training status in EU Member States (Questionnaire, update of IPSE WP1 Q 2006)
To define a procedure for endorsement of the IPSE core competency document
To propose future EU and national activities in the area of infection control training
Meeting in Udine, June 2010: country representatives identified by Competent Bodies for training on ECDC’s request

32. Presence of National Curriculum or Programme for training IC/HH Nurses
Yes (at national or professional level) No
Not respondent
(IPSE 2006)
(TRICE 2010)
54.8%
(17/31)
63.6% (21/33)

33. Other ECDC ARHAI training activities, 2010
On-site HAI surveillance workshops:
Technical support visit, 2 x ½ day workshop
Including case studies of HAI case definitions and computer exercises (HELICSwin)
Call for Tender ”Curriculum and training materials for the first course on ‘Control of multidrug-resistant micro-organisms in health care settings’” – deadline 10/9/2010
HAI surveillance workshop, Sofia, Nov 2009

34. Overview HAI surveillance workplan 2010
Surveillance of Healthcare-Associated Infections (HAI): Surgical Site Infections (SSI), ICU-acquired infections (ICU)
European Point Prevalence Survey of HAI and Antimicrobial Use in acute care hospitals (PPS)
Structure and process indicators for infection control: integrated in Point Prevalence Survey and ICU/SSI surveillance
Surveillance/rPPS of HAI in long-term care facilities (outsourced)(HALT)
Surveillance of Clostridium difficile infections (CDI) (Call for tender)
Case definitions of HAI: Concordance Study (outsourced)
Training (PRU/SUN/SAU):
Needs Assessment of Infection Control Training in EU (outsourced)
PPS training material (outsourced)
Country support: HELICSwin support (outsourced), on-site HAI surveillance training courses, PPS pilot support project (outsourced)
EPIS: ARHAI alerts

35. Thank you! Takk Kiitos Takk Tack Tänan Tak Paldies Spasibo/ Спасибо
Go raibh maith agaibh
Tak
Paldies
Spasibo/
Спасибо
Thank you!
Ačiū
Dank u
Danke
Dziekuje
Merci
Dăkujem vám
Děkuji vám
Köszönöm
Hvala
Mulţumesc
Grazie
Blagodarya/Благодаря
Gracias
Obrigado
Efharisó/
ευχαριστώ
Grazzi
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