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Infection Control Programmes to Contain Antimicrobial Resistance

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Infection Control Programmes to Contain Antimicrobial Resistance WHO/CDS/CSR/DRS/2001.7 Infection control programmes to contain antimicrobial resistance Lindsay E. Nicolle World Health Organization Department of Communicable Disease Surveillance and Response This document has been downloaded from the WHO/CSR Web site. The original cover pages and lists of participants are not included. See http://www.who.int/emc for more information. WHO/CDS/CSR/DRS/2001.7 ORIGINAL: ENGLISH DISTRIBUTION: GENERAL Infection control programmes to contain antimicrobial resistance Lindsay E. Nicolle Department of Internal Medicine University of Manitoba, Canada World Health Organization A BACKGROUND DOCUMENT FOR THE WHOFOR GLOBAL CONTAINMENT STRATEGY OF ANTIMICROBIALRESISTANCE Acknowledgement The World Health Organization wishes to acknowledge the support of the United States Agency for Inter- national Development (USAID) in the production of this document. © World Health Organization 2001 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organiza- tion. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. The designations employed and the presentation of the material in this document, including tables and maps, do not imply the expression of any opinion whatsoever on the part of the secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Designed by minimum graphics Printed in Switzerland WHO/CDS/CSR/DRS/2001.4 DRUG RESISTANC IN MALARIA Contents Executive Summary 1 1. Antimicrobial resistance in health care facilities 3 2. Containing antimicrobial resistance in health care facilities 4 3. Infection control programmes 5 3.1 Effectiveness of infection control programmes 5 3.2 Impact on antimicrobial resistance 5 3.3 Impact on MRSA and VRE 5 3.4 Summary 6 4. Outbreak management 7 4.1 Elements of outbreak management 7 4.2 Literature review 7 4.3 Limitations of published reports 7 4.4 Control of outbreaks caused by resistant organisms 8 4.5 Spontaneous disappearance of resistant strains 8 5. Handwashing/hand hygiene 9 5.1 Recommendations 9 5.2 Hand antiseptics 9 6. Isolation and other barrier practices 10 6.1 Practices 10 6.2 Enterobacteriaceae 10 6.3 MRSA 10 6.4 VRE 11 6.5 Summary 11 6.6 Standard barrier precautions 11 6.7 Multiply-resistant Mycobacterium tuberculosis 12 7. Environmental cleaning and sterilization 13 8. Antimicrobial interventions 14 8.1 Promotion of antimicrobial resistance 14 8.2 Systemic prophylaxis 14 8.3 Topical prophylaxis 14 8.4 Mupirocin for S. aureus 14 8.5 Antimicrobial-impregnated medical devices 15 9. Resources for infection control 16 9.1 Cost-effectiveness 16 9.2 Prioritization of infection control resources 16 10. Resource-poor countries 17 10.1 Infection control 17 10.2 Outbreaks with resistant organisms 17 10.3 Endemic antimicrobial resistance 17 iii INFECTION CONTROL PROGRAMMES TO CONTAIN ANTIMICROBIAL RESISTANCE WHO/CDS/CSR/DRS/2001.7 11. Research agenda 19 12. Discussion 20 13. Conclusions 22 14. Bibliography 23 Annex. Control of outbreaks of nosocomial antimicrobial resistant organisms 29 iv WHO/CDS/CSR/DRS/2001.7 INFECTION CONTROL PROGRAMMES TO CONTAIN ANTIMICROBIAL RESISTANCE Executive Summary 1. Health care facilities, particularly acute care cially in high-risk units, decreases transmission facilities, are important sites for the development of some resistant organisms. Barrier practices of antimicrobial resistance. The intensity of an- cannot, however, by themselves, fully prevent timicrobial use together with populations highly nor ultimately contain the progression of resist- susceptible to infection create an environment ance. which facilitates both the emergence and trans- 5. The current worldwide epidemics of MRSA and mission of resistant organisms. VRE have progressed despite intense national 2. Optimal infection control programmes in health and local infection control measures to identify care facilities decrease the frequency of nosoco- and contain the spread of these organisms. mial infection. Such programmes have been 6. The appropriate use of prophylactic anti- identified as important components of any microbials prevents some nosocomial infections. comprehensive strategy for the control of anti- However, any prophylactic antimicrobial use, microbial resistance, primarily through limiting especially in high-risk patients, contributes to transmission of resistant organisms among antimicrobial pressure and to the emergence of patients. The successful containment of antimi- antimicrobial-resistant organisms. In this case, crobial resistance in acute care facilities, how- appropriate infection control activity may ever, also requires adequate clinical microbiology actually promote antimicrobial resistance. laboratory support and a strong antimicrobial use programme. 7. In some facilities, reallocation of infection con- trol resources to comply with recommendations 3. Infection control interventions are effective in for control of colonization of MRSA and VRE controlling some outbreaks of colonization and has compromised other infection control func- infection with antimicrobial-resistant organisms tions, potentially increasing the frequency of in health care facilities. In fact, antimicrobial nosocomial infection. resistance frequently is a phenotypic marker for the outbreak organism which facilitates identi- 8. Overall, infection control programmes have fication and early initiation of interventions to some efficacy in containing antimicrobial resist- control the outbreak. The application of infec- ance, particularly when an outbreak with a tion control measures, however, is not uniformly resistant strain is identified. Other infection con- successful in limiting outbreaks with resistant trol practices decrease transmission of both organisms. resistant and susceptible organisms among patients, and intensification of these practices 4. Barrier practices including patient isolation and to limit transmission of resistant organisms likely the use of gloves, gowns, or masks, are widely has some short-term efficacy in decreasing en- recommended for the control of endemic anti- demic resistance. Ultimately, however, limiting microbial resistance. The effectiveness of these antimicrobial resistance rests primarily with practices is controversial, and studies evaluating antimicrobial use rather than infection control. their efficacy are contradictory. The extent to which these practices decrease resistance likely 9. If the infection control responsibility is expanded varies with other determinants, such as preva- to incorporate control of transmission and colo- lence of antimicrobial-resistant organisms in the nization with resistant organisms, rather than facility, characteristics of the patient population, decreasing infections, additional resources to staffing ratio and expertise, and patient volumes. support the increased activity must be allocated. New implementation of these practices, espe- 1 INFECTION CONTROL PROGRAMMES TO CONTAIN ANTIMICROBIAL RESISTANCE WHO/CDS/CSR/DRS/2001.7 10. Further systematic evaluation of infection con- trol interventions in containing endemic anti- microbial resistance in acute care facilities, as well as other health care settings, is needed. This should include studies of the natural history and impacts of antimicrobial-resistant organisms in facilities as well as effectiveness, feasibility, and costs of specific infection control interventions. 2 WHO/CDS/CSR/DRS/2001.7 INFECTION CONTROL PROGRAMMES TO CONTAIN ANTIMICROBIAL RESISTANCE 1. Antimicrobial resistance in health care facilities Antimicrobial resistance is a predictable outcome munity infections in Brazil (9). The flow of resist- of antimicrobial use. The rapidity with which re- ant organisms is not, however, unidirectional. Re- sistance emerges and its extent are proportional to sistant strains have emerged in the community, such the intensity of antimicrobial use (1). Resistance as penicillin-resistant Streptococcus pneumoniae (10) first emerges in populations with a high frequency and resistant Salmonella spp (11,12), and been in- of infection, due to either underlying patient troduced into acute care facilities with resulting status or interventions compromising host defences, nosocomial infections. resulting in a high rate of antimicrobial use. Where patients at risk are in close proximity, the transmis- TABLE I. ANTIMICROBIAL-RESISTANT ORGANISMS OF sion of organisms between patients will be facili- CONCERN IN HEALTH CARE FACILITIES tated, and the opportunity for a single strain to Organism Resistant to disseminate widely is enhanced. All these features are present in health care facilities, particularly acute Staphylococcus aureus methicillin care facilities and areas such as intensive care units vancomycin Staphylococcus epidermidis vancomycin
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