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José Artur Paiva Elaine Pina, Maria Goreti Silva, Paulo Nogueira
Anabela Coelho, José Alexandre Diniz, Francisco George
Directorate National of Health - DGS
An update on the Portuguese Program on
Prevention and Control of Infection
and Antimicrobial Resistance
PPCIRA: priority program
…..
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NATIONAL PROGRAM FOR PREVENTION AND CONTROL OF INFECTION
AND OF ANTIMICROBIAL RESISTANCE
INFECTION CONTROL NATIONAL PROGRAM
ANTIMICROBIAL RESISTANCE NATIONAL
PROGRAM +
Feb 2013
1999 2008
PPCIRA: one leadership
To reduce HCAI To reduce AM consumption
To reduce emergence of antimicrobial resistance
One only problem, not four
To reduce transmission of antimicrobial resistance
Creating PPCIRA managemet structure
DQS – DGS (DNH)
Regional Health AuthoritiesARS
Local Health Units
PPCIRA Management Structure
DQS – DGS (NDH)
ARS (RHA)
Local health Units
PPCIRA
Direction
PPCIRA
Regional
Coordination
Group
PPCIRA
Local
Coordination
Group
RHA Pharmacy and Therapy Comission
DC member for Quality in Health
Quality and Safety Local Comission
Hospital Pharmacy and Therapy Comission
Quality in Health Department - NDH
PPCIRA Scientific Council
Número de ETC enfermeiros de controlo de infeção por 250 camas hospitalares
ECDC PPS 2011-2012
Número de ETC médicos de controlo de infeção por 250 camas hospitalares
ECDC PPS 2011-2012
PPCIRA
Local Coordinating Group
a) At least, 40 hours per week of MEDICAL ACTIVITY, in hospitals,
ULS, ACES,
b) In hospitals or ULS with more than 250 beds or more than 250 000
inhabitants, one of the doctors must give at least 28 hours per
week to this task;
b) In hospitals or ULS with more than 750 beds or more than 500 000
inhabitants, at least 80 hours per week of MEDICAL ACTIVITY and
one of the doctors must give at least 28 hours per week to this
task;
c) At least one full time NURSE for the task in hospitals, ULS, ACES
and one more nurse per each additional 250 hospital beds
Multidisciplinary: Doctors (including one microbiologist, if Micro Lab
in the hospital), nurses, pharmacists, other health professionals
Questionnaire on the activities of the hospital comissions
• Have information on antimicrobial resistance in…….69%
• Have information on antimicrobial consumption in..49%
• Analyses consumption and resistances in……………….44%
• Regulates antimicrobial prescription in……………………24%
• Feedbacks data to the services in……………………………27%
• Feedbacks data to the prescribers in……………………….11%
PPCIRA DGS 2012
PPCIRA Structure and Mission Law nº 15423/2013
PPCIRA management structure, in three levels: Direction, RCG and LCG
Extension to primary care and long-term care
More human resources in RCG and LCG
Higher empowerment of these structures
Mandatory epidemiological surveillance
Mandatory antimicrobial stewardship
Possible Strategies
• Education, education, education
• Education but please also create
A DEDICATED PROCESS
ANTIMICROBIAL
STEWARDSHIP
PROGRAMME
Driver Diagram
• Identify clinical providers as champions to be
thought leaders about AS
• Work with administrators to ensure that they
understand rationale, interventions and goals
and that they provide support
• Engage a physician champion and core team
• Bring different disciplines together to improve
collaboration and communication
• Identify priority areas and targets for intervention
Interventions
• Reduce carbapenem use
• Reduce quinolone use
• Reduce duration of antibiotic therapy
• Limit prophylaxis to no more than 24 hours
•Promote amox/clav and pip/taz use in some infections caused by ESBL+ Enterobactereaceae
•Promote de-escalation
Guidelines
precauções básicas e isolamento
“bundle” anti-MRSA
prevenção da infeção do local cirúrgico
profilaxia antibiótica cirúrgica
duração de terapêutica antibiótica
“bundle” hospitalar PPCIRA
uso de carbapenemes
tratamento de infeção intra-abdominal
prevenção de infeção associada a dispositivos invasivos, incluindo “bundle” do CVC
política de antisséticos e desinfetantes
prevenção e controlo de Clostridium difficile
prevenção e tratamento de infeção em feridas crónicas
Scientific Council 25 experts
Situações em que se justifica
terapêutica antibiótica > 7 dias
Cistite ou pielonefrite complicada com resolução clínica lenta 10 dias IIb B
Prostatite 4-6 semanas IIa C
Pneumonia por Legionella spp 10-14 dias I A
Pneumonia por bacilos Gram negativos não fermentadores 7-14 dias IIa B
Pneumonia a Pneumocystis jiroveci 21 dias IIa B
Pneumonia necrotizante 10-14 dias IIa C
Abcesso pulmonar 4-6 semanas IIa C
Empiema 2-6 semanas IIb C
Foco intra-abdominal persistente 10-14 dias IIa B
Colite pseudomembranosa 10 dias I A
Bacteriémia por Staphylococcus aureus 14-21 dias I A
Meningite por Streptococcus pneumoniae 10 dias I C
Meningite por bacilos Gram negativo, Streptococcus agalactiae ou Listeria spp 14-21 dias I C
Abcesso cerebral 4-8 semanas IIa B
Osteomielite hematogénea 4-8 semanas IIa B
Artrite séptica 2-4 semanas II A
Artrite séptica em prótese 2-3 meses II A
Fasceite necrotizante/Gangrena gasosa variável I C
Pericardite bacteriana 4 semanas IIa C
Endocardite não complicada de válvula nativa* 4 semanas I A
Pós operatório de endocardite 2 semanas I A
Brucelose ≥ 6 semanas I A
Doença de Lyme 14-28 dias I C
PPCIRA Structure and Mission Law nº 15423/2013
PPCIRA management structure, in three levels: Direction, RCG and LCG
Extension to primary care and long-term care
More human resources in RCG and LCG
Higher empowerment of these structures
Mandatory epidemiological surveillance
Mandatory antimicrobial stewardship
Epidemiological surveillance systems
ANTIMICROBIAL RESISTANCE
- Problem micorganisms
- Alert microrganisms
- EARS Net
ANTIMICROBIAL
CONSUMPTION
- Comunity
- Hospital
- ESAC Net
- Veterinary
HOSPITALACQUIRED
INFECTION
- HELICS ICU
- HELICS SSI
- INF NeoNatal ICU
- INCS
- UCC
- IPI
Prevalence of antimicrobial use (% of patients on at least
one antibiotic) in european hospitals, per country,
ECDC PPS 2011–2012
ECDC PPS 2011–2012
45,3%
EU: 35,8%
Antibiotic abuse:
Portuguese data
AM use in hospitals
Portugal EU
Men 48,3% 39,2%
Women 42,3% 33,2%
Global
population
45,3%
35,8%
IPI DGS 2012
Uma dose 24 horas Mais de 24 h
Surgical prophylaxis
64%
Prevalence of carbapenem use in hospitals
ECDC PPS 2011-2012
Comunity quinolones consumption, 2010, as DDD per 1000 habitants per dia
Epidemiological surveillance systems
ANTIMICROBIAL RESISTANCE
- Problem micorganisms
- Alert microrganisms
- EARS Net
ANTIMICROBIAL
CONSUMPTION
- Comunity
- Hospital
- ESAC Net
- Veterinary
HOSPITALACQUIRED
INFECTION
- HELICS ICU
- HELICS SSI
- INF NeoNatal ICU
- INCS
- UCC
- IPI
Mixed index of antimicrobial resistance extracted from ECDC PPS 201-2012
Methicilin resistant Staphylococcus aureus
in Portugal (2001-2011)
ECDC – EARS Net
Carbapenem resistant Enterobacteriaceae
ECDC PPS 2011-2012
CENTRO BACTERIA MECANISMO
PT 064 1 E coli Amp C + impermeabilidade
PT 062 1 K pneumoniae Carbapenemase + ESBL
PT 053 3 E coli; 3 Klebsiella pneumoniae
2 Enterob cloacae; 1 Citrobacter
ESBL + impermeabilidade; Amp C+impermeabilidade
ESBL + Amp C + impermeabilidade; ESBL + Amp C
Amp C + impermeabilidade; Amp C
PT 042 1 E coli ; 37 Klebsiella pneumoniae
1 Enterobacter cloacae; 1 Serratia
Carbapenemase + ESBL; Carbapenemase + Amp C
Carbapenemase; Carbapenemase +Amp C + ESBL
Amp C + impermeabilidade
PT 041 4 Klebsiella ESBL + Amp C + impermeabilidade; Metalobetalactamase
PT 035 3 Klebsiella pneumonia; 8 Enterobacter ESBL + Amp C + impermeabilidade; Amp C + impermeabilidade; Carbapenemase
PT 032 2 E coli ; 2 K pneumoniae
8 Enterobacter
ESBL + Amp C; Amp C + impermeabilidade; ESBL + AmpC + impermeabilidade
PT 031 3 E coli; 15 Klebsiella
20 Enterobacter; 1 Staph aureus
Amp C + impermeabilidade; ESBL + Amp C + impermeabilidade
ESBL + impermeabilidade; Carbapenemase + ESBL; Carbapenemase
Carbapanemese + Amp C
PT 027 5 Klebsiella pneumoniae Carbapenemase + ESBL
PT 059 14 Klebsiella pneumoniae
1 Enterob cloacae
Carbapenemase + ESBL; Carbapenemase; Amp C + impermeabilidade
ESBL + Amp C; Amp C
PT 007 4 Klebsiella pneumoniae
1 Enterobacter cloacae; 1 Proteus
Carbapenemase + ESBL; Amp C + impermeabilidade
ESBL + Am pC + impermeabilidade
PT 033 4 Klebsiella pneumoniae ESBL + carbapenemase; Carbapenemase + Amp C
PT 030 2 E coli; 11 Klebsiella pneumoniae
2 Enterobacter
Carbapenemase (5 com ESBL); Amp C + ESBL; Amp C + ESBL + impermeabilidade
ESBL + impermeabilidade; ESBL + Carbapenemase
PT 026 2 E coli; 1 Klebsiella pneumoniae Carbapenemase; ESBL + impermeabilidade; ESBL + carbapenemase
PT 016 1 Enterobacter cloacae ESBL + Amp C + impermeabilidade
PT 011 8 Klebsiella pneumoniae Carbapenemase + ESBL; ESBL + Amp C + impermeabilidade
PT 092 1 Klebsiella pneumoniae ESBL + impermeabilidade
PT 056 1 Klebsiella pneumoniae ESBL + impermeabilidade
PT 043 5 Klebsiella pneumoniae
3 Enterobacter cloacae; 1 Citrobacter
Amp C + impermeabilidade; Amp C
PT 036 1 Citrobacter freundii Metalobetalactamase
PT 003 1 Klebsiella pneumoniae Carbapenemase + ESBL
PT 052 1 Klebsiella pneumoniae Carbapenemase + ESBL
PT 045 1 Klebsiella pneumoniae Amp C + impermeabilidade
PT 005 3 Klebsiella pneumonia; 1 Enterobacter Amp C + impermeabilidade (1ESBL); Amp C
114
carbapenem R
Klebsiella
Resistance to carbapenem in
Enterobacteriaceae
1-Mecanismos que implicam resistência
aos carbapenemes (carbapenemase positivos) Total
GES-tipo 3
KPC-tipo 111
OXA-48-tipo 3
VIM-tipo 2
Total Geral 119
2- Mecanismos que implicam resistência aos carbapenemes
(carbapenemase negativos) Total
Produção de AmpC associada a eventual mecanismo de impermeabilidade
(sobretudo Enterobacter spp.) 102
Produção de ESBL associada a eventual mecanismo de impermeabilidade
(sobretudo E. coli) 22
Eventual mecanismo de impermeabilidade 5
Familía Proteaceae (resistência ao imipenem por mecanismo intrínseco) 23
Total Geral 152
Epidemiological surveillance systems
ANTIMICROBIAL RESISTANCE
- Problem micorganisms
- Alert microrganisms
- EARS Net
ANTIMICROBIAL
CONSUMPTION
- Comunity
- Hospital
- ESAC Net
- Veterinary
HOSPITALACQUIRED
INFECTION
- HELICS ICU
- HELICS SSI
- INF NeoNatal ICU
- INCS
- UCC
- IPI
Correlation between expected and real
prevalence of infection, per country,
ECDC PPS 2011-2012
Ob
se
rve
d H
AI
pre
va
len
ce
%
ECDC SURVEILLANCE REPORT 2011-12
EU: 6,1%
Tipo/Local de infeção hospitalar
IPI 1988-2012
Conclusions
Combining strategies
creates synergies
Valiquette L et al. Clin Infect Dis 2007; 45: S112-S121
Strategy
1. Structure definition
2. Mandatory epidemiological surveillance
3. Antimicrobial stewardship
4. Guidelines
5. Information/Education
6. Finantial motivation / Contract-program
The PPCIRA hospital “bundle”
• Hand hygiene
• Adequate use of gloves
• Hygiene of surfaces around patients
• Surgical antibiotic prophylaxis for not longer than 24 h
• Antibiotic stop orders at day 7
• Antimicrobial stewardship in the first 96 h
The PPCIRA comunity bundle
• Hand hygiene
• Vaccination compliance
• Adequate treatment of wounds
• Reduction of quinolone prescription
• Guideline for the treatment of respiratory infections
• Antibiotic stewrdship
Education
• Bimodular course in 2 consecutive days – hospital and primary care
• Based in RHA and RCG
• 5 teachers
• Around 40 students
• Reproducible and replicating
• Will occur from April to June 2014
Indicators and goals
• Number of hospitals participating in the national network of antimicrobial
resistance 2014/ Number of hospital in the Portugal ≥ 50%.
• Hospital consumption of carbapenems in DDD per 1000 habitants in 2015
/ Hospital consumption of carbapenems in DDD per 1000 habitants in
2011 ≤ 95%
• Comunity consumption of quinolones in DDD per 1000 habitants in 2015 /
Comunity consumption of quinolones in DDD per 1000 habitants in 2011
≤ 95%
• Number of MRSA bacteremias per 1000 patient days in 2015 / Number of
MRSA bacteremias per 1000 patient days in 2012 ≤ 90%
• Rate of MRSA bacteremias over the total SA bacteremias in 2015 / Rate
of MRSA bacteremias over the total SA bacteremias in 2012 ≤ 90%
