1. Moving forward together infection prevention and control and AMR Rose Gallagher Nurse Advisor Infection Prevention and Control Royal College of Nursing

2. Learning objectives To discuss the changing nature of infection prevention and control To refresh current knowledge of current IPC strategies To discuss the relationship between IPC and AMR To highlight the implications of carbapenemase producing organisms To discuss AMR and the role of the nurse 2

3. What do we mean by IPC? Infection prevention and control is the clinical application of microbiology in practice. Infection may be caused by bacteria, fungi, viruses or prions and can result in a wide variety of infections. 3

4. Note Not all infections are transmissible, but some are and can be spread from one patient to another. IPC extends beyond transmissible infections and as nurses prevention of infection is our primary aim. 4

5. The changing face of IPC Microbiology is real time evolution - so IPC also has to be! 1950’s - Staphylococcus aureus Staphylococcus aureus – MRSA (1961) with EMRSA ++ in 1990’s Clostridium difficile 1970’s and 2006+ HIV 1983 – universal precautions vCJD 1996 SARS 2002 / novel coronavirus 2013 Pandemic influenza CPE 5

6. And of course Infection prevention is a patient safety issue Most common complication of hospitalised care Infection is an adverse event Learning from infection events using patient safety tools enhances IPC Patient safety/IPC relates to products, procedures and systems 6

7. IPC relationships 7 Community care Social care Hospitals Public Health

8. Changing health needs and considerations Increasing longevity and premature survival Long term disease patterns changing e.g. Cancer as a long term condition increase in diabetes, asthma, CHD All require contact with healthcare or are recipients of care Migration of people and workers Global warming 8

9. IPC isn’t: F Just about MRSA and C. difficile F Just about hand hygiene and dirty hospitals 9

10. IPC is: 10 All about people – patients and staff Sometimes complex Multifactorial Time consuming Easy to overlook when everything is going well (or we think it is!) In need of constant evaluation

11. What have we learnt? Isolation/separationModes of transmission 11

12. Evolving humans 12

13. Evolving society and care Simple buildingsComplex tertiary centres 13

14. Evolving bacteria Some natural resistanceAcquired resistance 14

15. HCAI variation and per speciality (source ECDC annual report 2013) 15

16. Fundamentals of IPC as we know them Infection causing microbe ReservoirPortal of exit Means of transmission Portal of entry Susceptible host 16

17. Preventing infection is a team effort

18. Corner stones of effective IPC 18

19. What we don’t know – some examples What level of hand hygiene compliance is needed to be effective? The full impact of glove use/abuse Information on rates of infection across the board The value of current educational methods What other strategies could have an impact 19

20. In an evolving world be mindful of: The law of unintended consequences 20

21. And we are running out of ammunition 21

22. We need to start thinking differently 22

23. Antibiotic resistance Evolution of acquired antibiotic resistance mechanisms is a consequence of selective pressure Or simply put Antibiotic use is driving current antibiotic resistance problems 23

24. What does this mean in practice? Infections with resistant bacteria are associated with increased morbidity and mortality Increased healthcare costs and extended length of stay Reduced antibiotic treatment options Potentially untreatable infections IPC and AMR are a public health issue 24

25. But Resistance to antibiotics is not just a hospital problem Most prescribing is done in the community Resistance is present outside hospitals We have free movement across EU borders/travel health Resistant bacteria can be passed from person to person and spread to colonise or cause infections in others 25

26. IPC and its relationship to AMR The two are inextricably linked but IPC alone cannot solve the problem 26

27. Current challenges for AMR Prescribing behaviours Development of new antibiotics Education / training Managing outbreaks differently e.g. Carbapenemase producing Enterobacteriaceae (CPE) It’s a global issue 27

28. Variation across Europe MRSAK. pneumoniae 28

29. Why are CPE so important? CPE produce an enzyme (carbapenemase) which renders the class of antibiotic (known as carbapenems) ineffective Carbapenems are our current last line of defence for some infections CPE is not one bacteria it refers to several species (E.g. Klebsiella and E. coli) CPE can share resistance mechanisms between species of bacteria 29

30. European data 2011 (source ECDC annual report 2013) 30

31. What does CPE mean for IPC? Awareness Screening and recognition of potential carriers Isolation Scrupulous IPC practices Supporting staff to think differently – outbreaks of resistance not one bacteria e.g. MRSA 31

32. Why will outbreaks be challenging? CPE will challenge the way we have previously thought of single organism outbreaks Precautions to limit spread must be strictly adhered to and potentially for longer – implications for staffing? Media and public interest/concern will need to be managed 32

33. Thinking more broadly about the nursing contribution 1. Reducing the demand for antibiotics 2. Enhancing antibiotic effectiveness 3. Providing leadership to and in support of IPC at the local, national and international level 4. Supporting whole systems approach to AMR 33

34. And finally… any questions? ‘Think flexibly to work flexibly’

35. References/resources Department of Health (2013) UK Five Year Antimicrobial Resistance strategy 2013-2015. HMSO Public Health England (2013) Acute Trust Toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae ECDC (2013) Annual epidemiological report. Reporting on 2011 surveillance data and 2012 epidemic intelligence data RCN (2013) Infection prevention and control within health and social care: commissioning, performance management and regulation arrangements (England). 35