A Global Approach to Infection Control D.Pittet 25.02.2013 5.30Pm

ESCMID Post-graduate technical workshop

Geneva, Feb 2012 Hôpitaux Universitaires de Genève A global approach to infection control

Professor Didier Pittet, MD, MS, Infection Control Program WHO Collaborating© by Center author for Patient Safety University of Geneva Hospitals, Switzerland ESCMID Online Lecture Library Lead, 1st Global Patient Safety Challenge, World Health Organization (WHO) Patient Safety © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library

Florence Nightingale, 1820 - 1907 The very first requirement in a hospital is that it should do the © by authorsick no harm ESCMID Online Lecture Library Ignaz Philipp Semmelweis

Intervention May 15, 1847 14 16 18 1212 First Second © by author Maternal MortalityMortality Maternal Maternal

ESCMID0 2 4 6 8 10 Online Lecture Library 1841 1842 1843 1844 1845 1846 1847 1848 1849 1850 Semmelweis IP, 1861 Early times of infection control

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1863

©Recognize by author Explain ESCMID Online Lecture Library Act

Pittet D, Am J Infect Control 2005, 33:258 Does infection control

Haley RW et al. Am J Epidemiol 1985;121(2):182-205

Relative change in NI in a 5 year period (1970-1975) 30% Without infection control 26% 19% 18% 20% 14% 9% 10% LRTI SSI UTI BSI Total 0% 50%50% -10% © by author -20%

ESCMID-30% -27% Online Lecture Library -31% -32% -40% -35% -35% With infection control SENIC Study on the Efficacy of Nosocomial Infection Control per 110 beds • 1 infection control nurse per 200 to 250 beds

• 1 hospital epidemiologist per hospital (1000 beds) • Organized surveillance for nosocomial infections © by author • FeedbackESCMID of Online nosocomial Lecture infection Library rates

Haley RW et al. Am J Epidemiol 1985;121(2):182-205 Approach to infection control

1847

1863 1958

1970

1980 © by author ESCMID Online Lecture Library

Pittet D, Am J Infect Control 2005, 33:258 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

• Use and care of urinary catheters • Use and care of© vascular by author access lines • Therapy and support of pulmonary functions • SurveillanceESCMID Onlineof surgical Lecture procedures Library • Hand hygiene and standard precautions 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

• Use and care of urinary catheters • Use and care of© vascular by author access lines •Therapy and support of pulmonary functions • SurveillanceESCMID Onlineof surgical Lecture procedures Library • Hand hygiene and standard precautions Prevention of Catheter-Associated Urinary Tract Infection (CA-UTI) Two main principles

Avoid unnecessary catheterization © by author Limit the duration of catheterization ESCMID Online Lecture Library Incidence of UTI, before and after a multimodal intervention Stéphan F. et al D, Clin Infect Diseases 2006, 42:1544

Pre-intervention Post-intervention RR UTI period period (95%-CI) (n=280) (n=259) N ID* N ID* C Overall 35 27.0 13 12.0 0.44 (0.24-0.81) © by author Orthopedic surgery 29 45.8 10 18.6 0.41 (0.20-0.79) Intervention group DigestiveESCMID surgery Online6 9.0 Lecture3 5.6 Library0.62 (0.14-2.50) Control group

* ID: episodes per 1000 catheter-days Stéphan F. et al D, Reduction of UTI and antibiotic use after surgery: a controlled, prospective, before-after intervention study Clin Infect Diseases 2006, 42:1544

• Incidence density of UTI decreased by 60% after orthopedic surgery following a multimodal intervention C • Results were maintained after 2 years © by author • Less indwelling urinary catheters placed in ESCMIDthe operating Online room Lecture Library A. Cataldo on Day 2 • Decrease UTI antibiotic-related consumption 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

• Use and care of urinary catheters • Use and care of© vascular by author access lines • Therapy and support of pulmonary functions • ExESCMIDperience withOnline surgical Lecture procedures Library • Hand hygiene and standard precautions Sources of the catheter-associated bloodstream infection

Intraluminal from tubes and hubs

Hematogenous from distant sites © by author

Skin Extraluminal from ESCMID OnlineVein Lecture skinLibrary Prevention of vascular access line infection in intensive care

University of Geneva Hospitals Education-based, multimodal prevention strategy of CRI

Eggimann and Pittet Sepsis Monitor 2000 Prevention of vascular access line infection Medical intensive care unit

Incidence density episodes/1’000 patient-days

12 11.3 10 9.2 1997 reduction 8 8.2 19981999 6 © by3.8* author-67% primary BSI% 4 3.3* -68% clinical sepsis 3.1 2.6* -63% microbiologically doc. BSI 2ESCMID Online1.2* Lecture-64% insertion Library site infection 0 74% 1996 1997 1999 Eggimann et al. Lancet 2000; 355:1864 * P < 0.05 Education-based prevention of vascular catheter-associated bloodstream infection

12 Primary bacteremia / 1000 CVC-days Sherertz Ann Intern Med 2000 10

8 112 MICUs (NNIS) Coopersmith et al. CCM 2002 6 146 SICUs (NNIS) Warren et al. CCM 2003 4 © by author 2 Eggimann et al. Lancet 2000 0 ESCMID Online Lecture Library Eggimann et al. 1995 1996 1997 1998 1999 2000 2001 2002Ann Intern Med NNIS Am J Infect Control 1999 2005 Multimodal intervention strategies to reduce catheter-associated bloodstream infections:

- Hand hygiene - Maximal sterile barrier precaution at insertion - Skin antisepsis with alcohol-based chlorhexidine- containing products - Subclavian access as the preferred insertion site - Daily review of line necessity - Standardized catheter© careby usingauthor a non-touch technique - Respecting the recommendations for dressing change ESCMID Online Lecture Library Eggimann P. Lancet 2000; 35: 290 Pronovost P. N Engl J Med 2006; 355: 26 Zingg W. Crit Care Med 2009; 37: 2167 Efficacy of multimodal intervention strategies:

Baseline Intervention

Eggimann 3.1/1000 catheter-days 1.2/1000 catheter-days Lancet 2000 Ann Intern Med 2005

Pronovost *7.7/1000 catheter-days *1.4/1000 catheter-days NEJM 2006

Zingg 3.1/1000 catheter-days 1.1/1000 catheter-days Crit Care Med 2009 © by author *mean pooled CRBSI-episodes per 1’000 catheter-days ESCMIDE ggimannOnline P. Lancet Lecture2000; 35: 290 Library Eggimann P. Ann Intern Med 2005; 142: 875 – 5 year follow-up Pronovost P. N Engl J Med 2006; 355: 26 Zingg W. Crit Care Med 2009; 37: 2167 Could we do better ?

Chlorhexidine gluconate- impregnated sponge

1.40 per 1000 catheter-days Control dressings HR = 0.39; p=0.03 ChG dressings Cumulative RiskRisk Cumulative Cumulative

ESCMID Catheter-daysOnline Lecture Library

Timsit JF. JAMA 2009; 301: 1231 Efficacy of multimodal intervention strategies:

Baseline Intervention

Eggimann 3.1/1000 catheter-days 1.2/1000 catheter-days

Pronovost *7.7/1000 catheter-days *1.4/1000 catheter-days

Zingg 3.1/1000 catheter-days 1.1/1000 catheter-days

Timsit 1.4/1000© catheter-days by author0.6/1000 catheter-days

*mean pooled CRBSI-episodes per 1’000 catheter-days ESCMID Online Lecture Library Eggimann P. Lancet 2000; 35: 290 Pronovost P. N Engl J Med 2006; 355: 26 Zingg W. Crit Care Med 2009; 37: 2167 Timsit JF. JAMA 2009; 301: 1231 Could we do even better ? Could we do better ?

YES But will be reported © by author to you by Walter Zingg and at ICPIC 2013 ESCMID Online Lecture Libraryin Geneva Prevention of vascular access line infection

© by author ESCMID Online Lecture Library W. Zingg on Day 2 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

Patient Devices • Age • Invasive ventilation • Burns • Duration of invasive • Coma ventilation • Lung disease • Reintubation • Immunosuppression© by author• Medication • Malnutrition • Prior antiobiotic •ESCMID Blunt trauma Online Lecturetreatment Library • Sedation General precautions

• Staff education, hand hygiene, isolation precautions (I)

• Surveillance of infection and resistance with© timely by author feedback (II) ESCMID Online Lecture Library • Adequate staffing levels (II)

ATS Guidelines 2005 © by author ESCMID Online Lecture Library Crit Care Med 2010: volume 38 in Press 1. Adherence to hand hygiene 2. Adherence to2 gloveyear andintervention gown use study: 3.Compliance Backrest elevation with preventivemaintenance measures increased 4. Correct tracheal-cuff maintenance VAP prevalence© by rate author decreased by 51% 5. Orogastric tube use 6.ESCMID Gastric overdistention Online avoidance Lecture Library 7. Good oral hygiene 8. Elimination of non-essential tracheal suction VAP Prevention

1. Hand hygiene before and after patient contact, preferably using alcohol-based handrubbing 2. Avoid endotracheal intubation if possible 3. Use of oral, rather than nasal, endotracheal tubes 4. Minimize the duration© by of author mechanical ventilation 5. Promote tracheostomy when ventilation is needed ESCMIDfor a longer Online term Lecture Library 6. Glove and gown use for endotracheal tube manip VAP Prevention (con’t)

7. Avoid non-essential tracheal suction 8. Oral hygiene with chlorhexidine 9. Backrest elevation 30-45o 10. Maintain tracheal tube cuff pressures (>20) to prevent regurgitation from the stomach 11. Avoid gastric overdistension© by author 12. Promote enteral feeding 13.ESCMID Careful blood Online sugar control Lecture in patients Library with diabetes 14. SDD in selected cases L. Brochard on Day 3 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

• Use and care of urinary catheters • Use and care of© vascular by author access lines • Therapy and support of pulmonary functions • ExperienceESCMID withOnline surgical Lecture procedures Library • Hand hygiene and standard precautions Strategies to prevent SSI • Objectives – Reduce the inoculum of bacteria at the surgical site • Surgical Site Preparation • Antibiotic Prophylaxis Strategies – Optimize the microenvironment of the surgical site – Enhance the physiology of the host (host defenses)

• In relation to risk ©factors, by author classified as – Patient-related (intrinsic) – Pre-operative ESCMID– Operative Online Lecture Library Patient-related factors • Diabetes - Recommendation (IDSA/SHEA) – Preoperative • Control serum blood glucose; reduce HbA1C levels to <7% before surgery if possible (A-II) – Post-operative (cardiac surgery patients only) • Maintain the postoperative blood glucose level at less than 200 mg/dL (A-I) • Smoking - Rationale – Nicotine delays wound© healingby author – Cigarette smoking = independent RF for SSI after cardiac surgery ESCMID- Studies: None Online Lecture Library - Recommendation – Encourage smoking cessation within 30 days before procedure Surgeon Skill and Technique

• Excellent surgical technique reduces the risk of SSI (A-III)

• Includes – Gentle traction and handling of tissues – Effective hemostasis – Removal of devitalized tissues – Obliteration of dead spaces – Irrigation of tissues with saline during long procedures – Use of fine, non-absorbed monofilament suture material © by author – Wound closure without tension ESCMID– Adherence to principles Online of asepsis Lecture Library Procedure-related risk factors

– Hair removal technique – Preoperative infections – Surgical scrub – Skin preparation – Antimicrobial prophylaxis – Surgeon skill/technique – Asepsis © by author ESCMID– Operative time Online Lecture Library – Operating room characteristics © by author ESCMID Online Lecture Library Active surveillance

Courtesy: Astagneau, SFHH 2007 Summary: Relative SSI reduction

- Active surveillance 38% Haley et al, Am J Epidemiol 1985

55% Rioux et al, J Hosp Infect 2007

- Multimodal intervention 27% 100k lives campaign

57% Trussel et al, Am J Surg 2008

- Correct and timely 18% Saxer et al, Ann Surg 2009 antibiotic prophylaxis

- Normothermia 13% Kurz et al, NEJM 1996

- Chlorhexdidine-alcohol? 41% Darouiche et al, NEJM 2010 -ESCMID Suppl. oxygen? Online 25%LectureQadan Library et al, Arch Surg 2009 G. De Angelis on Day 3 - Nasal mupirocin for MSSA? 58% Bode et al, NEJM 2010 - Surgical hand antisepsis no data no random Widmer et al, J Hosp Infect 2010 1st principle of infection prevention at least 35-50% of all nosocomial infections are associated with patient care practices:

Compliance 40% < Compliance ESCMID Online Lecture Library Library Lecture Online ESCMID Handwashing … an action of the past (except when hands are visibly soiled)

1. Recognized 2. Explained © by author 3. Act Alcohol-based ESCMID Online handLecture rub Library is standard of care Alcohol-based hand rub at the point of The University care of Geneva Hospitals, 1995

50%50%

1. Recognize 2. Explain 3. Act 4. …and Convince your administrator Change© by theauthor culture ESCMID Online Lecture Library … and contributes to cost-savings « Success story – Key Parameters »

• System change • Education of healthcare workers • Monitoring and feedback of performance • Administrative© by support author • Leadership and culture change • AssociatedESCMID Online with reductionLecture Library in cross- transmission and infection rates 1. System change

Alcohol-based Access to safe, handrub at point of continuous water care supply, soap and • The 5 core towels

components of the + WHO Multimodal 2. Training and Education Hand Hygiene + Improvement 3. Observation and feedback Strategy © by author + 4. Reminders in the hospital ESCMID Online Lecture Library + 5. Hospital safety climate © by author Implementation ESCMID Online Lecture toolkittoolkitLibrary “My 5 Moments for Hand Hygiene”

Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. J Hosp Infect 2007;67:9-21 A multimodal strategy

System change EducationEducation Monitoring© by author performance + feedback+ feedback ESCMID Online LectureRemindersReminders Library Safety culture Pittet D. Clean hands reduce the burden of disease Lancet ; 366 : 185-86, 2005

ESCMID OnlineTo reduce Lecture Library health care-associated infections Hand hygiene as the cornerstone Countries committed to addressing HAI Launch of the 1st Global Patient Safety Challenge WHO HQ, 13 October 2005

Countries committed in 2005-2006

Countries planning to commit in 2006 Objectives of the Challenge

At the global level 1. Awareness

ForESCMID health care Online Lecture3. Technical Library settings guidelines and tools Saudi Arabia Singapore Kenya

Northern Ireland Russia Republic of Ireland 130 countries committed to address HAI 93 % world population coverage

© by author ESCMID Online Lecture Library > 15 300 registered health-care facilities from 159 countries ~ 13 million health-care staff and ~ 3.8 million patient beds Infection Control and Quality Healthcare in the New Millenium Multidisciplinary team approach

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1970

ESCMID1990 Online Lecture Library 2000

Pittet D, Am J Infect Control 2005, 33:258 Evolving to new challenges in infection control and patient safety

- Team and multidisciplinary team work - Successful interventions - Adaptability of© actions by author - Scaling up ESCMID Online Lecture Library - Sustainability of actions / interventions - Leadership commitment / Governance Infection prevention: toward zero risk

Only team and multidisciplinary team work will result in successful interventions Adaptability of actions is critical to ensure sustainability© by authorof interventions LESCMIDeadership Onlinecommitment Lecture is key Libraryto success Zero risk is an illusion, but toward very limited risk and significant reduction is evidence Infection Control and Quality Healthcare in the New Millenium Where are we going ? Multidisciplinary team approach

1. Recognize 1847 2. Explain Healthcare system: 3. Act1863 1958 -Hospitals 1970 -Ambulatory services 1980 -Nursing homes 1990 -Long-term care facilities 2000 -Home care delivery systems © by author Patient safety State/country International Financing promotion epidemiologyESCMIDsurveillance Onlinebodies Lecture Library program systems

Pittet & Sax, Infectious Diseases. Cohen textbook (2nd ed.), chap.85, 2004 ryryry © by author ESCMID Online Lecture Library ICPIC 2011 ~1300 participants 86 countries (33 low income countries) all continents