Management of an outbreak
of a multi-drug resistant
pathogen
Professor Kevin Rooney
Infection Prevention & Control in the ICU Seminar
10th November 2014
SBAR - Situation
• Director or SCN of
General ICU
• Infection Control
• Potential outbreak of
a carbapenemresistant Klebsiella
Pneumonia (KPC)
• Adjacent CTX ICU
• 2 new cases of KPC
SBAR - Background
• 10 bedded ICU
• 650 Level 3 patients
• Level 3
• 25% Mortality
• Immunocompromised
• At risk of HAI
• Adjacent CTX ICU
• Same staff pool
• KPC patient 2 weeks
ago
SBAR - Assessment
• KP
• 15% of G-ve infections
• Immunocompromised
• KPC
•
•
•
•
•
Few options
Prevent / Mitigate
Hidden Killer (>50%)
Silently colonises GIT
Transmission
• Environmental
• Staff
• Both
SBAR - Recommendation
• Probable outbreak
• ≥2 with KPC
• More expected
• Outbreak Control
Team
• Establish Severity
• HIIA Tool
• Prevent spread
• Prevent further
resistance
Driver Diagram
Leadership & Culture
• Transparency
• Just Culture (No Blame)
Early Reporting to ICT
• Outbreak Control Team
•
•
•
•
Identify all patients
Control the outbreak
Prevent further disease
Investigate the cause & identify factors
that contributed
• Disseminate the learning
• Communication (patients, public & staff)
Severity of the Outbreak
•
•
•
•
•
•
The Hospital Infection Incident Assessment (HIIA) Tool
Impact on patients, services, public health & anxiety
Openness & Transparency
Effective Communication (case notes)
Senior Management Support
Occupational Health
•
•
•
•
Support policy implementation
Support / advise staff & OCT
Coordinate screening
Treatment & Fitness to work
Staff Screening Programme
• Beware unintended consequences
• Clearly documented in minutes of OCT
• Reasons for staff screening
• To characterise the epidemiology of the outbreak –
time, person, place.
• To identify the likely source and index case, with a
view to control.
• To assist with interrupting the chain of transmission of
an outbreak.
• To confirm eradication of the outbreak.
Mitigation
Containment
Mitigation
Eradication
Containment
• Close the ICU to all new admissions
• Discharge to cohorted areas
• Enhanced contact isolation regardless of colonisation status
• Hand hygiene, gowns & gloves for staff / visitors
• Cohort the colonised ICU & non-ICU patients (geography)
• Staff cohorting for nurses & AHP’s
• Not possible for medics, germ theory of disease
• Hand hygiene monitors 24/7
• If asymptomatic 3 x Resp & Rectal culture surveillance
• More frequent if near a colonised patient
• Trace outbreak (modes / routes of transmission)
• Patient tracking, genomic sequencing
Eradication
•
•
•
•
•
•
•
Extinction of KPC is the main aim of OCT
Dedicating equipment for single-patient use
Extensive cleaning of shared equipment with bleach
Environmental culture of surfaces prior to next patient
Increase the frequency of environmental cleaning (shift)
Daily patient baths with 2% Chlorhexidine
Double-cleaning of vacated rooms equipment with bleach or
hydrogen peroxide vapour
• Staff Education (How, Why, What)
• Modes of transmission
• Contact precautions
• Cohorting
Disease Prevention
Antimicrobial
stewardship
Limit
consequences
Disease
Prevention
Limit
Progress
Risk
Factor
Reduction
Antimicrobial Stewardship
• The aim of good antimicrobial stewardship
• Decrease in antibiotic use ✓
• Not targeting a specific antimicrobial class ✗
• Every Patient gets the Right Drug, at the Right Dose, at the
Right Time for the Right Duration
• Start Smart and Then Focus (structured response)
• Also includes clinical infection management and improving
patient outcomes ✓
• Best structure
• Prescription (initiation)
• Therapeutic Failure (dosing)
• Review
Prescription & Initiation
No in the absence of clinical
suspicion ✗
Sepsis Screening Tool ✓
Antibiotics within the hour
Survival in Septic Shock
Sepsis Six
1.
Deliver O2 (94 -98% SpO2 or 88-92%
in COPD)
2.
Take blood cultures and consider
source control
3.
Give IV antibiotics according to local
protocol
4.
Start IV fluid resuscitation (min
500ml) and reassess
5.
Check lactate & FBC
6.
Commence accurate urine output
measurement and consider urinary
catheterisation
All within one hour
Antibiotics
•
•
•
•
•
At least blood cultures x2
Consideration of cultures from other sites
Potential infective sources (PVC, CVC, CAUTI) should be sought
Source control ideally within 12 hours of diagnosis
Give for surgical prophylaxis only in cases where antibiotics
have been shown to be effective (<60 mins KTS)
• Prolonged operation or significant haemorrhage, repeat the
dose
Antimicrobial Stewardship:
Therapeutic Failure
• Antibiotic dosage
• According to the patient’s bodyweight (aminoglycosides)
• Fixed pre-determined dosage for a 60-80kg man (macrolide)
• Insufficient dosing in the obese
• Lipohilic or Hydrophilic antibiotic
• Lipophilic: dose according to actual body weight
• Hydrophilic: dose according to ideal body weight
• Insufficient concentration of drug at the site of infection
• Increased volume of distribution due to hypoalbuminaemia and
rapid administration of fluids
• Shock causing a decrease in blood supply to the infected tissues
and organs
Therapeutic Failure (contd)
• Enhanced plasma clearance of antibiotics
• Improved renal excretion from a hyperdynamic circulation
• Increased drug extraction (CVVHF)
• Therapeutic Drug monitoring
• Minimise potential unintended consequences
• Ensure optimal treatment
• Antibacterial cycling or rotation
•
•
•
•
Mitigate or limit bacterial resistance
Antibiotic heterogeneity
Limited use
Mixing classes provides greater heterogeneity
Antimicrobial Stewardship:
Therapeutic Review & Focus
• Clinical picture is an evolving process
• Daily review of diagnosis and de-escalation prevents
resistance and reduces toxicity and costs
• 4 clinical questions
• Stop, Switch, Change or Continue
• Multidisciplinary ward rounds
• Procalcitonin ( Surviving Sepsis Recommendation)
• De-escalation
• Absence of positive microbiology
• Multiresistant organisms preventing de-escalation
• Lack of bottle as still critically ill
• IV to oral switch (removal of PVC)
In summary
To prevent
spread of an
outbreak
Leadership &
Culture
Mitigation
Prevention &
Antimicrobial
Stewardship
Any questions?