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Campaign to Prevent Antimicrobial Resistance Dialysis Patients

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Title: Campaign to Prevent Antimicrobial Resistance Dialysis Patients


1
Campaign to PreventAntimicrobial
ResistanceDialysis Patients
Campaign to Prevent Antimicrobial Resistance in
Healthcare Settings
  • Centers for Disease Control and Prevention
  • National Center for Infectious Diseases
  • Division of Healthcare Quality Promotion
  • Department of Health and Human Services
  • Link to Campaign to Prevent Antimicrobial
    Resistance Online
  • Link to Federal Action Plan to Combat
    Antimicrobial Resistance

2
Clinicians Hold the Solution!
  • Link to Campaign to Prevent Antimicrobial
    Resistance Online
  • Link to Federal Action Plan to Combat
    Antimicrobial Resistance

3
Emergence of Antimicrobial Resistance
Campaign to Prevent Antimicrobial Resistance in
Healthcare Settings
Susceptible Bacteria
4
Selection for Antimicrobial-resistant Strains
5
Antimicrobial Resistance Key Prevention
Strategies
Susceptible Pathogen
Pathogen
6
Key Prevention Strategies
  • Prevent infection
  • Diagnose and treat infection effectively
  • Use antimicrobials wisely
  • Prevent transmission

Clinicians hold the solution!
7
Campaign to Prevent Antimicrobial Resistance in
Healthcare Settings
  • General health communication strategy
  • Goals
  • - inform clinicians, patients, and other
    stakeholders
  • - raise awareness about the escalating problem of
    antimicrobial resistance in healthcare settings
  • - motivate interest and acceptance of
    interventional programs to prevent resistance

8
12 Steps To Prevent Antimicrobial Resistance
  • Targeted intervention programs for clinicians
    caring for high risk patients
  • - hospitalized adults - dialysis patients
  • - hospitalized children - surgical patients
  • long - term care residents
  • Goal Improve clinician practices prevent
    antimicrobial resistance
  • Partnership with professional societies evidence
    base published in peer-reviewed specialty
    journals
  • Educational tools web-based / didactic learning
    modules, pocket cards, slide presentations, etc.

9
12 Steps to Prevent Antimicrobial Resistance
Dialysis Patients
10
Disease Burden for Dialysis Patients
  • The number of patients with end-stage renal
    disease treated by maintenance hemodialysis in
    the US has increased during the past 30 years.¹
  • In 2001 more than 3,000 hemodialysis centers had
    greater than 250,000 chronic hemodialysis
    patients.2
  • Annual mortality rate among hemodialysis patients
    is 23 and infections are the second most common
    cause, accounting for 15 of deaths.¹
  • Hemodialysis patients are immunosuppressed and
    require frequent hospitalization and surgery,
    which increases their risk for resistant
    infections.¹
  • Vascular access infections (in hemodialysis
    patients) and peritonitis (in peritoneal dialysis
    patients) are the most common infections.¹

1 CDC, MMWR 2001 50 (5)13 2Unpublished data,
Dialysis Surveillance Network
11
Prevent Infection Step 1 Vaccinate staff and
patients
  • Fact Influenza and pneumococcal vaccine given
    to both staff and patients will help to prevent
    infections requiring antimicrobial therapy.

12
Vaccination Rates of Dialysis Patients,1999-2001
Unpublished data, Dialysis Surveillance Network
  • Link to Influenza recommendations...CDC, MMWR
    2003 52 (RR08)1-36

13
Need for Healthcare Personnel Immunization Program
s Influenza Vaccination Rates (1996-97)
Source 1997 National Health Interview
Survey Walker FJ, et al., Infect Control Hosp
Epidemiol 2000 21113
  • Link to ACIP Influenza Immunization
    Recommendations

14
Prevent Infection Step 1 Vaccinate staff
patients
Fact Influenza and pneumococcal vaccine given
to both staff and patients will help to prevent
infections requiring antimicrobial therapy.
  • Actions
  • Get influenza vaccine
  • Give influenza / pneumococcal vaccine to patients
  • in addition to routine vaccines (e.g.,
    hepatitis B)
  • Link to ACIP Influenza immunization
    recommendations
  • Link to CDC facts about influenza and
    pneumococcal vaccine
  • Link to ACIP Vaccine standing orders

15
Prevent Infection Step 2 Get the catheters out
Fact Indwelling catheters are the single most
important factor contributing to bacteremia in
hemodialysis patients.
  • Link to NNIS Online at CDC

16
Epidemiology of Catheter Associated Infections
  • Estimated attributable mortality for
    catheter-associated bloodstream infections ranges
    from 0 to 35, depending on study design.
  • Primary risk factor for access infection is
    access type (cathetersgtgraftsgtfistulas).
  • The relative risk for bacteremia in patients with
    dialysis catheters is sevenfold the risk for
    patients with primary arteriovenous fistulas.

CDC, MMWR 2002, 51 (RR-10) p.10
17
Biofilm on Intravenous Catheter Connecter 24
Hours After Insertion
Scanning Electron Micrograph
  • Link to Biofilms and device-associated infections

18
Rates of Bacteremia Infection by Access Type -
Dialysis Surveillance Network 10/99-05/02
Tokars et al., Am J Infect Control
200230288-295.
19
Prevent Infection Step 2 Get the catheters out
  • Fact Indwelling catheters are the single most
    important factor contributing to bacteremia in
    hemodialysis patients.
  • Actions
  • Hemodialysis
  • Use catheters only when essential
  • Maximize use of fistulas/grafts
  • Remove catheters when they are no longer
    essential
  • Peritoneal Dialysis
  • Remove/replace infected catheters
  • Link to Urinary catheter infection prevention

Coming soonguidelines for preventing
catheter-associated bloodstream infections
20
Fact Careful infection control prevents
peritoneal dialysis related infections.
  • Link to NNIS Online at CDC

21
Peritoneal Catheter Insertion and Management
  • Catheter insertion should be performed under
    operating room, sterile conditions.
  • Adherence to the principles of catheter
    insertion, management, and care remain the
    cornerstone of successful peritoneal dialysis
    access.
  • Despite improvements in catheter survival over
    the last few years, catheter-related
    complications still occur, causing significant
    morbidity and often forcing the removal of the
    catheter.

Gokal et al., Peritoneal Dialysis International
19981811-33.
22
  • Fact Careful infection control prevents
    peritoneal dialysis-related infections.
  • Actions
  • Follow established guidelines for access care
  • Use proper insertion and catheter-care protocols
  • Remove access device when infected
  • Use the correct catheter
  • Link to Peritoneal Catheters and Exit-Site
    Practices 1998 Update

Guidelines for preventing catheter-associated
bloodstream infections, CDC, MMWR 2002 51 (RR10)
23
  • Fact Identifying the pathogen using
    microbiologic cultures and antimicrobial
    susceptibility testing allows for targeted
    antimicrobial therapy.

24
Importance of Utilizing Cultures and
Antimicrobial Susceptibility Testing Results
  • No. ()
    Susceptible
  • __________________________________________________
    _

  • Cefazolin Vanco Cefazolin and
    Vanco and

  • Gentamicin Gentamicin
  • __________________________________________________
    _
  • Blood Cultures 14 (78) 16 (89)
    16 (89) 17 (94)
  • (n18)
  • Clinically Significant
  • Cultures (n146) 87 (60) 100 (68) 132
    (90) 142 (97)

Fogel et al., Am J Kidney Dis 199832401-409
25
CDCs M.A.S.T.E.R. Improving Antimicrobial
Susceptibility Testing Proficiency
26
  • Fact Identifying the pathogen using
    microbiologic cultures and antimicrobial
    susceptibility testing allows for targeted
    antimicrobial therapy.
  • Actions
  • Obtain appropriate cultures
  • Target empiric therapy to likely pathogens
  • Target definitive therapy to known pathogens
  • Optimize timing,regimen,dose,route and duration
  • Link to IDSA guidelines for evaluating fever in
    critically ill adults

27
  • FactInput from infectious diseases experts
    improves the outcome of serious infections.

28
Infectious Diseases Expert Resources
Infectious Diseases Specialists
Healthcare Epidemiologists
Infection Control Professionals
Optimal Patient Care
ClinicalPharmacists
Clinical Pharmacologists
Clinical Microbiologists
Surgical Infection Experts
29
Diagnose Treat Effectively Step 5 Access the
experts
  • Fact Input from infectious diseases experts
    improves the outcome of serious infections.
  • Action
  • Consult the appropriate experts for complicated
    infections
  • Link to SHEA / IDSA Guidelines for the
    Prevention of Antimicrobial Resistance
  • in Hospitals

30
Use Antimicrobials Wisely Step 6 Use local data
  • FactThe prevalence of resistance varies by
    locale

31
Percent of S. aureus Blood Isolates Resistant to
Methicillin, by Dialysis Center
11 Centers, Canada, 101
10 Centers, Connecticut, 432
Dialysis Surveillance Network 1999-20023
1Taylor et al., Infect Control Hosp Epidemiol
200223716-720 2 Dopirak et al., Infect Control
Hosp Epidemiol 200223721-724 3 Unpublished
data, Dialysis Surveillance Network
32
Use Antimicrobials Wisely Step 6 Use local data
  • Fact The prevalence of resistance varies by
    locale.
  • Actions
  • Know your local antibiogram
  • Get previous microbiology results when patients
    transfer to your facility
  • Link to NCCLS Proposed Guidance for Antibiogram
    Development

33
  • Fact
  • Reduction of vancomycin use is one of the most
    important strategies to limit the emergence,
    selection, and spread of vancomycin resistant
    bacteria.

34
Evolution of Drug Resistance in S. aureus
Penicillin
Methicillin
Penicillin-resistant S. aureus
Methicillin-resistant S. aureus (MRSA)
1944
S. aureus
1962
Vancomycin
1997
2002
1990s
Vancomycin intermediate S. aureus (VISA)
Vancomycin-resistant enterococci (VRE)
Vancomycin- resistant S. aureus
CDC, MMWR 200251(26)565-567
35
VRE Colonization Among Dialysis Patients Who
Received Vancomycin
Received Vancomycin Developed VRE
No 0/29 (0) Yes
16/61 (26) plt.001
Atta et al., Kidney International 200159718-724
36
First Case of Vancomycin - Resistant S. aureus
(VRSA)
  • First fully vancomycin resistant clinical isolate
    of S. aureus
  • Michigan, June 2002
  • 40-year old black female with diabetes mellitus,
    peripheral vascular disease,on chronic
    hemodialysis
  • VRSA from foot ulcer and catheter exit site
  • During the 6 months preceding VRSA
  • patient experienced 6 hospitalizations, totaling
    18 days
  • patient received multiple antimicrobial therapy,
    including
  • 5.5 weeks of vancomycin

Chang S et al, New England J of Med 2003
34814,1342-3447
37
Vancomycin- Intermediate S. aureus (VISA)
  • State, Year Site PD/HD
  • Michigan, 1997 Peritonitis Chronic PD
  • New Jersey, 1997 Blood Recent PD
  • New York, 1998 Blood Chronic HD
  • Illinois, 1999 Endocarditis Chronic HD
  • Minnesota, 2000 Bone Chronic HD
  • Nevada, 2000 Liver -----
  • PDperitoneal dialysis , HDhemodialysis

Fridkin, Clin Infect Diseases 200132111
38
Guidelines for Appropriate Vancomycin Use
(HICPAC/CDC)
  • Selected situations in which the use of
    vancomycin is appropriate or acceptable
  • For treatment of serious infections caused by
    beta-lactam-resistant gram-positive
    microorganisms.
  • For treatment of infections caused by
    gram-positive microorganisms in patients who have
    serious allergies to beta-lactam agents.
  • When antibiotic-associated colitis fails to
    respond to metronidazole therapy or is severe and
    potentially life-threatening.

CDC, MMWR 199544(RR12)1-13
39
Guidelines for Appropriate Vancomycin Use
(HICPAC/CDC)
  • Selected situations in which the use of
    vancomycin should be discouraged
  • Treatment in response to a single blood culture
    positive for coagulase-negative staphylococcus,
    if other blood cultures taken during the same
    time frame are negative.
  • Continued empiric use for presumed infections in
    patients whose cultures are negative for
    beta-lactam resistant gram-positive
    microorganisms.
  • Eradication of MRSA colonization.
  • Systemic or local prophylaxis for infection or
    colonization of indwelling central or peripheral
    intravascular catheters.
  • Primary treatment of antibiotic-associated
    colitis.
  • Routine prophylaxis for patients on continuous
    ambulatory peritoneal dialysis or hemodialysis.
  • Treatment (chosen for dosing convenience) of
    infections caused by beta-lactam-sensitive
    gram-positive microorganisms in patients who have
    renal failure.

40
Use Antimicrobials WiselyStep 7 Know when to
say No to vanco
  • Fact Reduction of vancomycin use is one of the
    most
  • important strategies to limit the emergence,
    selection, and
  • spread of vancomycin resistant bacteria.
  • Action
  • Follow CDC guidelines for vancomycin use
  • Consider 1st generation cephalosporins instead of
    vancomycin
  • Link to Methods to improve antimicrobial use and
    prevent resistance

41
  • Fact
  • A major cause of antimicrobial overuse is
    treatment of contamination or colonization.

42
Interpreting a Positive Blood Culture
  • True Bacteremia
  • Unlikely Uncertain
    Likely
  • S. aureus
  • S. pneumoniae
  • Enterobacteriaceae
  • P. aeruginosa
  • C. albicans
  • Corynebacterium spp.
  • Non-anthracis Bacillus spp.
  • Propioniobacterium acnes
  • coagulase-negative
  • staphylococci

43
Use Antimicrobials Wisely Step 8 Treat
infection, not contamination or colonization
  • Fact A major cause of antimicrobial overuse is
    treatment of contamination or colonization.
  • Actions
  • Use proper antisepsis for drawing blood cultures
  • Get one peripheral vein blood culture, if
    possible
  • Avoid culturing vascular catheter tips
  • Treat bacteremia, not the catheter tip
  • Culture the blood, not the skin or catheter hub
  • Link to CAP standards for specimen collection
    and management

44
Use Antimicrobials Wisely Step 9 Stop
antimicrobial treatment
  • Fact
  • Stopping empiric therapy when cultures are
    negative can significantly reduce antimicrobial
    use.

45
Short-course Antimicrobial Treatment of New
Pulmonary Infiltrates in an ICU
  • Standard Experimental
  • Variable Therapy (n42) Therapy (n39)
  • Regimen clinician discretion ciprofloxacin 400mg
  • (all treated 18 drugs) (IV bid x 3 days)
  • Treatment gt 3 days 97 28
  • Antimicrobial resistance 35 15
  • Length of stay
  • mean/median 14.7/9 days 9.4/4 days
  • Mortality (30 day) 31 13
  • Antimicrobial cost
  • mean/total 640/16,004 259/6,484
  • Link to Singh N, et al.,Am J Respir Crit Care
    Med 2000162505-511

46
Use Antimicrobials WiselyStep 9 Stop
antimicrobial treatment
  • Fact Stopping empiric therapy when cultures are
    negative can significantly reduce antimicrobial
    use.
  • Actions
  • Stop when infection is treated
  • Stop when clinical and laboratory data rule out
    infection
  • Link to IDSA guideline for evaluating fever in
    critically ill adults

47
Prevent Transmission Step 10 Follow infection
control precautions
  • Fact
  • Following the recommended infection control
    precautions for hemodialysis patients can prevent
    transmission of infections from patient to
    patient.

48
Infection Control Precautions for Hemodialysis
Patients
  • In the hemodialysis setting, contact transmission
    plays a major role in transmission of bloodborne
    and other pathogens.
  • Infection Control Precautions for hemodialysis
    patients include
  • Strict attention to hand hygiene
  • using gloves for patient care and when handling
    patients medical equipment and devices.
  • Dedicating nondisposable items for use on a
    single patient.
  • Cleaning and disinfection of items taken into a
    dialysis station that will be used for more than
    one patient.
  • For patients at increased risk for transmission
    of pathogenic bacteria, including
    antimicrobial-resistant strains, additional
    precautions also might be necessary in some
    circumstances. For example, staff treating the
    patient should a) wear a separate gown over their
    usual clothing and b) dialyze the patient at a
    station with as few adjacent stations as
    possible.

49
Prevent Transmission Step 10 Follow infection
control procedures
  • Fact Following recommended infection control
    precautions for hemodialysis patients can prevent
    transmission of infections from patient to
    patient.
  • Actions
  • Use standard infection control precautions for
    dialysis centers
  • Consult local infection control experts
  • Link to A VRE prevention success story
  • Link to CDC isolation guidelines and
    recommendations

50
Prevent Transmission Step 11 Practice hand
hygiene
  • Fact
  • Hand hygiene is the single most important
    infection control measure for preventing the
    spread of antimicrobial resistant organisms.

51
Hand Hygiene Adherence in Hospitals
  • Year of Study Adherence Rate Hospital Area
  • (1) 29 General and ICU
  • 1995 (2) 41 General
  • 1996 (3) 41 ICU
  • 1998 (4) 30 General
  • (5) 48 General

1. Gould D, J Hosp Infect 19942815-30 2.
Larson E, J Hosp Infect 19953088-106 3.
Slaughter S, Ann Intern Med 19963360-365 4.
Watanakunakorn C, Infect Control Hosp Epidemiol
199819858-860 5. Pittet D, Lancet
20003561307-1312
52
log 3.0
99.9
Time after disinfection
180 minutes
60
0
Effectiveness of Hand Hygiene Agents in Reducing
Bacteria on Hands
99.0
2.0
Alcohol-based handrub (70 Isopropanol)
Bacterial Reduction
90.0
1.0
Antimicrobial soap(4 Chlorhexidine)
0.0
0.0
Plain soap
Baseline
Adapted from Hosp Epidemiol Infect Control, 2nd
Edition, Philadelphia Lippincott
Williams,1999.
53
Prevent Transmission Step 11 Practice hand
hygiene
  • Fact Hand hygiene is the single most important
    infection control measure for preventing the
    spread of antimicrobial resistant organisms.
  • Actions
  • Wash your hands or use alcohol-based handrub
  • Set an example!
  • Link to Health guidelines for healthcare
    personnel
  • Coming soonnew guidelines for hand hygiene

54
Prevent Transmission Step 12 Partner with your
patients
  • Fact
  • Dialysis patients share in the responsibility for
    preventing access-related infections

55
Poor Patient Hygiene is a Risk Factor for
Infection
  • No.() with Poor Hygiene
  • Patients Patients not p-value
  • Infected
    Infected
  • All Infections 17/23 (74)
    12/48 (25) 0.0004
  • Access site
  • Infections 8/9 (89)
    21/62 (34) 0.002

Kaplowitz et al., Infect Control Hosp Epidemiol
19889534-541
56
Educating Patients About Infection Control
Practices
  • Patients should be educated about the importance
    of their role in infection control upon admission
    to a dialysis center/hospital and at least
    annually thereafter.
  • Educational materials should include personal
    hygiene, hand hygiene, proper care of access
    lines, and recognition of signs of infection.

CDC, MMWR 200150 (5) 31
57
Prevent Transmission Step 12 Partner with your
patients
  • Fact Dialysis patients share in the
    responsibility for preventing access-related
    infections.
  • Actions
  • Educate patients about proper access care and
    infection control measures
  • Re-educate regularly
  • Link to Health guidelines for healthcare
    personnel
  • Coming soonnew guidelines for hand hygiene

58
Campaign to Prevent Antimicrobial Resistance in
Healthcare Settings
PREVENTION IS PRIMARY!
Protect patientsprotect healthcare
personnel promote quality healthcare!
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