Category Archives: antimicrobial resistance

Con(fused)tact precautions

Whilst “festivus”1 is generally a happy time for most of us, unfortunately people still become unwell, and our hospital beds remain occupied. One of the beds in a large Australian acute care facility has accommodated a family friend who has undergone surgery and some moderate rehab after falling at home.

Given some predisposing conditions, the family friend was at risk of acquiring a HAI, and it is disappointing to report they required treatment for various types of HAIs. They were also found to have VRE, and were promptly placed into a single room, under Contact Precautions.

Puzzled Confused Lost Signpost Showing Puzzling Problem

Whilst this family has much to be sorry and concerned about, what concerns them greatly, and what they have found most upsetting, is the inconsistent information and advice they receive on a daily basis from healthcare workers on the specific precautions that they, as family visitors, must take. Gloves, no gloves, mask, no mask, cloth gown, plastic apron… they have had almost every combination of precautions recommended. They  have even been scolded by a HCW for wearing “inappropriate” attire, whilst all the time directly observing a broad array of PPE adopted by different HCWs as they enter the room. They feel confused, angry, and upset. They lack confidence in the HCW knowledge of what is required, and feel powerless in seeking clarification of what they should be doing.

I find this troubling on several fronts. First, inconsistency. If HCWs caring for patients with MROs are giving family visitors different messages on PPE, then chances are they don’t quite understand what is required to prevent spread (evident by HCW inconsistency in their own PPE). Second, why are family visitors made to feel as though they have endangered the lives of not only their relative, but also of every other patient in the hospital when they are simply doing as they are told. And third, I don’t suspect for one minute that this situation is unique to this ward, hospital, city, or country. This scenario will likely be repeated daily in all types of facilities (see also NOTE below).

As we know, HAI prevention requires multiple interventions all being applied correctly. Whilst the momentum of antimicrobial stewardship in the fight against AMR has rightly attracted much energy, and the importance of environment is emerging , a basic understanding of precautions, and consistency of PPE messaging for HCWS and visitors is surely a simple and measureable intervention we should not lose sight of.

Phil

  1. Seinfeld 1997 – Episode 10, Season 9.

NOTE – this may be due to a lack of robust evidence and debate about Contact Precautions (see here for an example), nevertheless, messages (policy) within a facility should surely be consistent.

 

Outside the box: Infection prevention beyond the hospital walls

The recent article published in the MJA by Agostino and colleagues from the Hunter New England area provided data that could be described as not so startling, but nevertheless alarming. Their study aimed to identify groups at risk of MRSA infection, as well as the proportion of patients with MRSA but no history of recent hospitalisation (previous 12 months).

In their large cohort, they found that “young people, Indigenous Australians, and residents of aged care facilities, are disproportionally affected by CA-MRSA infections”.

Two comments in their Discussion caught my eye. The authors call for:

  • the focus of control measures to move from the healthcare setting to the community
  • national surveillance of MRSAphotodune-598972-think-outside-the-box-xl

The results of this study are not so startling because the findings are consistent with previous studies, alarming because this is another piece of evidence highlighting the deficits of our local knowledge.

This brings me to my next point. I am excited to be part of a team conducting a large study exploring infection prevention in Australian residential and aged care facilities. Led by Prof Brett Mitchell, together with Prof Ramon Shaban and Dr Deborough MacBeth, we aim to mimic a recent program of work  that generated so much rich information about infection prevention in our hospital facilities. Here are links to a sample of some of papers from this work:

This cross sectional study aims to explore governance, education, practice, surveillance and competency and capability – five key domains relating to infection prevention and control. All aged care homes in Australia are in the process of being contacted.

The findings of this study will be significant, they will:

  • further support ACIPC to refine the role and scope of practice of ICPs and better target education strategies,
  • inform decision-makers faced with accessing and planning infection control resources in settings outside hospitals.
  • guide future research priorities in this area
  • understand priorities and gaps in infection control services

If you receive an invitation to participate, I strongly encourage you to do so.

We look forward to sharing our findings with you during 2018.

Phil

What can $6m buy you?

The ability to run a children’s hospital for a year of course.Image result for angkor childrens hospital

I am in Siem Reap (Cambodia) at present and spending some time at Angkor Children’s Hospital. The hospital run entirely on donations and is the only children’s hospital in Cambodia. All services provided free. I won’t bore you with some stats, but here are some impressive figures considering the budget:

  • 27,000 ED patients a year
  • 132,000 outpatient visits
  • 880 intensive care admissions a year
  • Average cost of an ER visit $7, ICU $820 a stay.

Cambodia is a very poor country with a neonatal mortality of 18 per 1000 live births. 32% of children under 5 are stunted, 24% are underweight. Just $500 will is enough to provide weekly lectures to nurses for year; $5000 enough to buy medication for all ICU patients for 6 weeks.Image result for angkor childrens hospital

The most common hospital diagnosis are respiratory infections, asthma, gastro and sepsis. Over the next few days, I am meeting the Cambodia Oxford Medical Research Unit team, spending some time looking at infection control issues and challenges and similarly with nursing education and development. On infection control, the issues are significant, Gram negative resistance is a real problem (more on that to come in another blog).

If you want to know more about Angkor Children’s hospital, try this Angkor Hospital Video

More to come on infection control successes and challenges.

Brett

(Note: Pictures were not taken by me, rather publicly available)

 

Making antimicrobial resistance and the control of communicable disease, like infection control, is really everyone’s business.

As I reflect on another year, there have been many headline issues in infection control and communicable diseases. One headline was arguably the brightest, loudest and most prominent—antimicrobial resistance. In many respects 2016 was the year for antimicrobial resistance (AMR). The march of resistance and the grave concerns therein, particularly with the spread of carbapenem-resistant Enterobacteriaceae or CRE, have focused the attention of many. Global recognition and focus came via the United Nations as well as multi-national whole of government emphasis of AMR as a priority in the United Kingdom, the United States and other countries around the world. The year also saw a much-needed corrective global focus and attention on access and excess rather than overuse and misuse. All made for interesting times for clinicians, patients and consumers, and society in general. It also makes for interesting times for what comes next. In considering the priorities for research and innovation, the following seem to me to be some of the important focal areas for the future:

One priority focal point should be the formal designation of the control of communicable diseases, the spread of infection and antimicrobial resistance as societal, political, health and research priorities within a One Health approach. As we have seen, the United Nations declared AMR as a global health priority, only forth health priority to be so declared. The WHO and its many divisions applied renewed focus of AMR around the world. The United States and United Kingdom has posited AMR squarely as a whole-of-government and whole of society issue. Others have followed suit in various forms. Doing so matters. Such declarations matter. They transact change. Such designations focus the efforts and attention turn of governments, NGO, researchers, funding bodies, industry, clinicians, educators and society more broadly. Some doubt the significant and weight of such declarations as declared health and/or research priorities. To those I say try de-designate an existing health or research priority that has unfinished business and see what happens. For example removing cancer from Australia’s list of national health and research priorities would never be entertained, and any attempt would attract unanimous condemnation. The new and impressive Australian Medical Research Future Fund and Australian Medical Research and Innovation Priorities 2016-2018 have AMR and the control of communicable diseases as core priorities. Such designation is commended, but more is needed. AMR should be a national designated national health priority, as it is one issue that underpins so many health areas. It also underpins the fabric of society.

Another focus should be the acceleration and expansion of infection-excluding diagnostics and technology. While technology and resources for rapid and definitive diagnosis is the ultimate goal, excluding infection attributable injury and disease that has a reliance on antibiotics would go a long way to reducing our use of antibiotics. 

Closely related to this is the need for intense and considered focus on new and renewed countermeasures. This should include, but is not limited to, One Health vaccine development for conditions that have reliance on antimicrobials, drug discovery, rapid definitive diagnostics at both bench and bedside, utility of non-classic pharmacological interventions such as bacteriophages, and the standardisation of laboratory testing.

Moreover, we should focus on extending the evidence and practice base that is we know works (or not as the case may be) in human health and non-health related context into animal, agricultural and environment sectors for a truly One Health approach. Is it not time equivalent of the Five Moments for Hand Hygiene for veterinarians?

Finally, and not before time, it’s time cast of the armoury of own specialist professions and embrace the many in non-clinical professions, and call upon them to join be part of the solution to AMR. It is high time we harnessed existing and new knowledge into human factors and behaviour modification to bring about whole of societal change within a One Health approach. This should focus on existing evidence base for non-infection control and non-health to effect changes in human factors for reliance on antibiotics for all populations across the lifespan and across One Health. So much is known about behaviour change in the non-health areas, as marketing and behavioural sciences. It is difficult to see how these cannot be applicable (or relevant in some form) to AMR. What we can learn from our non-clinical peers about changing people behaviours from the commercial work is enormous. Moreover, such focus must be across the spectrum of disease and illness including prevention, treatment, rehabilitation and coalescence.

AMR is not, and can no longer be considered, a problem for just for clinicians both human and veterinary, and industry to solve. It is a whole of society challenge, and many of the solutions are non-clinical. It, like infection control, is everyone’s business.

 

What do we know about antimicrobial use in Australian residential aged care facilities?

The National Centre for Antimicrobial Stewardship (NCAS) is a multidisciplinary collaborative funded by the NHMRC with a strong track record of innovation and Capturesuccessful translation into clinical practice. We asked Dr Noleen Bennett from NCAS to write about a national antimicobial prescribing survey in aged care. It has brought up some interesting findings.

Thanks for Noleen for this blog – Phil, Brett and Ramon.

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The short answer is we know antimicrobial use in Australian residential aged care facilities (RACFs) needs to be improved. The unacceptable risk otherwise is the emergence of multi drug resistant infections and other adverse consequences in this vulnerable population.

In 2015, 186 RACFs participated in the pilot Aged Care National Antimicrobial Prescribing Survey. Key areas for improvement were identified and included:

  • inadequate documentation
    • 31.6% of prescriptions did not have an indication justifying their use
    • 65.0% of prescriptions did not have a review or stop date documented.
  • the use of antimicrobials for unspecified skin infections
    • 17.5% of antimicrobials were being used for unspecified skin infections.
  • prolonged duration of prescriptions.
    • 31.4% of prescriptions had been prescribed for longer than six months.

All Australian RACFs and multi-purpose services are now strongly encouraged each year to participate in acNAPS. Participation assists in ensuring compliance with national guidelines and targeting local and national actions to support appropriate antimicrobial use.

For further information, the friendly NAPS team can be contacted via email support@nasp.org.au or phone (03) 9342 9415. The data collection period for the 2016 acNAPS has been extended. Data can now be collected and entered prior to Friday 9th September.

Declaration: Dr Noleen Bennett is employed at the National Centre for Antimicrobial Stewardship and is the Project Officer for the Aged Care National Antimicrobial Prescribing Survey

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Brett: For those interested in other Australian data in residential and aged care (infection and antimicrobials related) here are some links to articles. (This is not an exhaustive list)

 

 

The ‘I’ and the ‘We’ of antimicrobial resistance

 

Not a day goes by where there isn’t a report somewhere about the threat of antimicrobial resistance. Our media is awash with grim stories about ‘superbugs’ emerging in patients and hospitals, with dire predictions about the future of healthcare and even humanity and the planet as we know it. There is much that we know about antimicrobial resistance. We know that antimicrobial resistance is a significant global health and security threat. We know that it is something that is increasingly the focus of the work of busy infection control professionals, ID physicians and pharmacists. We know that governments, non-government organisations and all manner of other organisations and groups around the world are marshalling resources, and launching campaigns and strategies to slow the pace and spread of antimicrobial resistance. We know that use of antimicrobials is the primary driver of resistance, and we know that this is accelerated by what is commonly described as overuse, misuse or inappropriate use.  We also know that there is considerable international evidence demonstrating the relationship between antibiotic overuse, misuse or inappropriate use of antibiotics and resistance, and we know the kinds of very many problems that arise from this. Recently here in Australia the First Australian Report on Antimicrobial Use and Resistance in Human Health[1] by the Australian Commission on Safety and Quality in Health Care documented the extent to which Australia has contributed to the rise of global problem. The news this report brought was mixed: in some areas it was cause for celebration; in others our worst fears were realised. We know there is much, much more work to be done.

There are other aspects to this, however, that are not well known to all. There are aspects of this that ‘we’ don’t know well or appreciate. We tend of overlook, forget, and even not appreciate that for millions of people around the world the concepts of antibiotic overuse, misuse or inappropriate use are completely alien.  For millions and millions of people around there world there is no access, or very limited access, to antibiotics. Antibiotics are precious commodities that many only dream of having. In their recent commentary in The Lancet Pamela Das and Richard Horton argued that focusing on resistance in terms of misuse or overuse fails to take a global perspective on the needs of the many for whom antibiotics are a precious resource.[2] As they rightly point out, we tend to overlook, or lack an appreciation for, the fact that many more people die from the lack of access, or delayed access,to antimicrobials than from resistant organisms. While this stark reminder should of course in no way serve to discourage efforts to more prudent use of antibiotics in settings where overuse, misuse or inappropriate use occurs, we must also turn our minds to how we can bring about both sustainable access and sustainable effectiveness for all. We must enhance non antimicrobial-based initiatives to reduce the burden of disease, such as immunisation to improve health outcomes with a system of Universal Health Coverage. We know that this is but one critical intervention to realising the efforts for our wider goal to conserve antibiotics and reduce selection pressure that drives resistance. Moreover, we must all think long and hard about who we actually are when it comes to antimicrobial resistance. In doing so we must all work just as hard to ensure fair access to antibiotics as we do to tackling excess.

Ramon

 

 

[1] Declaration of Interest: Professor Shaban was the project leader of a research consortium at Griffith University contracted by Australian Commission on Safety and Quality in Health Care to contribute to this report. No other interests to declare.

[2] Das P & Horton R. (2015) Antibiotics: achieving the balance between access and excess. The Lancet, Vol 387, Issue 10014, p102-104.