1. Management of an outbreak of a multi-drug resistant pathogen Professor Kevin Rooney Infection Prevention & Control in the ICU Seminar 10 th November 2014

2. SBAR - Situation Director or SCN of General ICU Infection Control Potential outbreak of a carbapenem- resistant Klebsiella Pneumonia (KPC) Adjacent CTX ICU 2 new cases of KPC

3. 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

4. SBAR - Assessment KP 15% of G-ve infections Immunocompromised KPC Few options Prevent / Mitigate Hidden Killer (>50%) Silently colonises GIT Transmission Environmental Staff Both

5. SBAR - Recommendation Probable outbreak ≥2 with KPC More expected Outbreak Control Team Establish Severity HIIA Tool Prevent spread Prevent further resistance

6. Driver Diagram

7. 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)

8. 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

9. 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.

10. Mitigation ContainmentEradication

11. 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

12. 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

13. Disease Prevention Antimicrobial stewardship Risk Factor Reduction Limit Progress Limit consequences

14. 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

15. Prescription & Initiation No in the absence of clinical suspicion ✗ Sepsis Screening Tool ✓

16. Antibiotics within the hour Survival in Septic ShockSepsis Six 1.Deliver O 2 (94 -98% SpO 2 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

17. 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

18. 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

19. 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

20. 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)

21. In summary To prevent spread of an outbreak Leadership & Culture Mitigation Prevention & Antimicrobial Stewardship

22. Any questions?