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1. Hospital Associated Infections & Antibiotic Stewardship

2. Definition by CDC: Infections that the patients acquire during the course of receiving treatments for other conditions, or acquired by the healthcare workers while performing their duties in the healthcare settings World Health Organization (WHO) defines HCAI as:- “An infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the hospital, but appearing after discharge, and also occupational infections among staff of the facility”

3. Introduction Definition: Healthcare-associated infections (HCAIs) , Nosocomial or Hospital Acquired Infections(HAIs) are not present or incubating at the time of admission to the healthcare facility. Among HAIs, device-associated infections pose the greatest threat to patient safety, particularly in ICUs, with higher rates observed in low and middle income countries Although estimates vary regarding the proportion of nosocomial infections which are preventable, it may be as high as 20% in developed countries and as high as 40% or more in developing countries. Limited, often low quality data are available from low and middle-income countries for HAIs Healthcare-associated infections are one of the most common adverse events in the care delivery system

4. Studies have shown that HAI prevalence varies from 3.8% to 19.6% depending on the population surveyed with a pooled global prevalence of 10.1%. At any given time, out of every 100 hospitalized patients, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. The fight against HCAI as a public health priority was promoted through the World Health Organization's 'Clean Care is Safer Care' campaign. HCAIs are multi-factorial, which are related to healthcare systems and procedures as well as behavioral practices. Although eradication of HAI is impossible, a well-conducted prospective surveillance is the gold standard and may significantly reduce HAI and associated costs. However, this approach requires comprehensive resources and well coordinated prevention programs.

5. In 1854, during the Crimean War Florence Nightingale demonstrated that hygiene could make a difference. demonstrated that cleaning up the military hospital with fresh linens, rat poisons and scrub–brushed floors would result in a reduction of the combat wounded death rates from 40% to 2% in a matter of six months.  Historical Background

6. At the same time Joseph Lister, a British Surgeon also demonstrated that limb amputations became infected 47% of the time before hand washing and carbolic acid antisepsis, and only 15% of the time after this ritual was introduced.

7. HAI in 20 th and 21 st Century The present era of healthcare- associated infections (HAI) started with the Center for Disease Control and Prevention (CDC) in the USA. It started the National Nosocomial Infection Surveillance System (NNIS) in 1950s and the SENIC project in 1974. It was observed that one-third of healthcare- associated infections were preventable through effective infection control . Many guidelines were produced by Healthcare Infection Control Practices Advisory Committee (HICPAC).

8. Since 2005, various member countries of the world have signed the pledge of WHO’s First Global Patient Safety Challenge. Introducing low-cost measures, such as hand hygiene, staff education and inclusion of basic principles of infection control in medical and paramedical curricula can reduce health care associated infections.

9. Sources of Infection Sources of Infection: The source of HAI may be either endogenous or exogenous. Endogenous Source: The majority of infections are endogenous in origin, i.e. they involve patient’s own microbial flora which may invade the patients body during some surgical or instrumental manipulations. Exogenous: From another patient/ staff member/ environment in the hospital Environmental sources: Intimate objects, air, water, food Cross infection/ Healthcare Workers from: other patients, hospital staff (suffering from infections or asymptomatic carriers)

10. Microorganism Implicated Most of HAI causing pathogens are multi drug resistance. This is due to increased antibiotic usage in the hospital environment, which leads to the minor population of resistance organisms present initially to flourish under the influence of contact and selective antibiotic pressure. These drug resistant bugs slowly replace the susceptible strains. ESKAPE Pathogens: The vast majority of HAI are caused by ESKAPE pathogens. This is an acronym proposed by the Infectious Disease Society of America (IDSA), which represent a list of the pathogens that are capable of “escaping” the biocidal action of antibiotics and mutually representing new paradigms in pathogenesis And resistance: E nterococcus faecium S taphylococcus aureus K lebsiella Pneumoniae A cinetobacter baumannii P seudomonas aeruginosa E nterobacter species

11. Mode Of transmission There are five main modes of transmission Contact Vector borne Air borne Droplet Common vehicle

12. Contact Transmission : 1) Direct: Skin to skin contact and thereby physical transfer of microorganisms between a susceptible host and an infected or colonized person( usually by healthcare workers, rarely other patients) 2) Indirect: This involves contact of a susceptible host with contaminated inanimate objects such as: Dressings, or gloves, instruments, (e.g. stethoscope) Parenteral transmission through: Needle or sharp prick injuries Splash's of body fluids or excretions Contaminated saline flush, syringes, etc. Inhalation mode: 1) Droplets generated from the infected person while coughing, sneezing and talking are propelled for a short distance through the air and deposited on the hosts body 2) Airborne Transmission : This refers to droplet or dust particles that remain suspended in the for long time and can travel longer distance 3) Vector Borne Transmission : Transmission via vectors such as mosquitoes, flies, etc. carrying the microorganisms. This is rare mode of transmission in the hospital.

13. 4) Common vehicle transmission: This mode includes food, water, medications, devices and equipment's Types of HAIS CAUTI (Catheter-associated urinary tract infections) VAP(Ventilator Associated Pneumonia) SSI( Surgical Site Infections) CLABSI( Central line-associated blood stream infections)

14. Catheter Related Blood Stream Infections Blood stream Infections (BSI) in hospitalized patient may either develop directly or without any secondary source or may occur in secondary site infection. Primary BSI may or may not be associated with central line known as central venous catheter or CVC are of two types: CRBSI: This is the definition used for the purpose of clinical diagnosis and treatment, which requires definite laboratory evidence that CVC is a source of BSI. CLABSI: This terminology is used for surveillance purposes only. Epidemiology: According to CDC NHSN 2013 report, the pooled mean incidence of CLABSI per 1000 CL days was found as 0.29% in critical units and 0-1.2% in inpatient wards.

15. What is a central line-associated bloodstream infection? A central line-associated bloodstream infection (CLABSI) is a laboratory confirmed bloodstream infection not related to an infection at another site develops within 48 hours of central line placement. Patients who get a CLABSI have a fever, and might also have red skin and soreness around the central line. If this happens, healthcare providers can do tests to learn if there is an infection present. Centers for Disease Control and Prevention (CDC) definition : CLABSI is a surveillance definition used by the CDC and defined as the recovery of a pathogen from a blood culture (a single blood culture for an organism not commonly present on the skin and two or more blood cultures for organism commonly present on the skin) in a patient who had a central line at the time of infection or within 48 hours before the development of infection. The infection cannot be related to any other infection the patient might have and must not have been present or incubating when the patient was admitted to

16. NHSN surveillance definition: A laboratory confirmed infection where a CVC is in place for >2 calendar days prior to a positive culture and is also in place the day of or day prior to culture RISK FACTORS: 1) Intrinsic Factors: Age, gender and underlying health categories CLABSI Rates are higher among children, particularly neonates, and highest in Pediatric ICU’s and Critical Care Units Hematological and immunological deficient patients have higher risk of CLABSI as well as underlying gastrointestinal and cardiac diseases 2) Extrinsic Factors: Prolonged hospital stay prior to insertion of CVC multiple catheters, duration of Cather, CVC site. Femoral and internal Juglar access sites have higher rates. Insertion procedure of central venous catheter plays a large role in CLABSI Lack of maximum sterile barrier.

17. Insertion Bundle Maintenance Bundle Hand Hygiene Daily aseptic CL care during bundling Hand Hygiene Alcohol Rub Decontamination Sterile PPE Daily decontamination of local sign of infection Site of insertion- subclavian preferred, avid femoral Change of dressing with 2% chlorhexidine Chlorhexidine skin preparation Daily assessment of rediness of removal Skin must be completely after use of antiseptics Use semipermeable dressing Hand wash after procedure Bundle Care

18. CATHETER ASSOCIATED URINARY TRACT INFECTION (CAUTI ) Catheter associated bacteriuria has been defined as presence of significant bacteriuria in a catharized or recently catheterized patient, with or without symptoms or signs referable to the urinary tract. Accordingly it can be classified as: Catheter-associated (CAUTI): symptoms and signs referable to the urinary tract infection Cather associated asymptomatic Bacteriuria: without symptoms or signs referable to the urinary tract. A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.

19. Microbiology: In-short term catharized patients, most CA-bacteriuria is monomicrobial such as gram negative bacilli or enterococci. Escherichia coli, Enterobacteriaceae, Funguria In long-term catheterized patients Epidemiology: According to CDC NHSN 2013 report, the pooled mean incidence CAUTI per 100 catheterized days were found as 0-5.3% in critical care unit and 0-3.1% in Inpatient wards. Risks: A) Type of catheterization: Indwelling catheterization, intermittent catheterization, Suprapubic catheterization B) Patient-related risk factors: Female gender, fatal underlying illness, older age, diabetes mellitus, elevated serum creatinine, poor personal hygiene C) Failure of adherence to aseptic technique, emergency catheter insertion outside the operating room. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.

20. Insertion Bundle Maintenance Bundle Insert only when appropriate indication is present Daily Catheter care Sterile Items Properly secured Non touch technique Drainage bag must be above the floor and below the bladder level Closed drainage system Hand Hygiene and change of gloves between patients, separate jug for each bag, alcohol swabs for outlet-while emptying urine Appropriate size Catheter Daily assessment of readiness of removal Secured after placement Bundle Care

21. Ventilator Associated Pneumonia(VAP) Pneumonia that occurs that occurs 48-72 hours or thereafter, following endotracheal intubation or mechanical ventilation, characterized by: The presence of new or progressive infiltrate Signs of systemic infection Worsening of oxygenation Changes in sputum characteristics Microbiological Detections

22. RISKS Device related: Reintubation Frequent change of ventilator circuit Intervention Related: Irrational use of antibiotics Sedation Tracheostomy Patient Related: Advanced Age Male sex Duration of hospitalization prior to development of VAP Patient supine position Poor nutrition Immobilization Sinusitis Healthcare worker-related: Improper adherence to aseptic techniques Contaminated environmental sources

23. Care Compliance Policy Based or Structured Measures Elevate the head between 30-45 degrees to prevent aspiration of gastric contents and secretions. Perform Hand Hygiene Daily Assessment of readiness to extubate with the use of sedation medicine Avoid supine position Use of endotracheal tubes for patients ventilated more than 72 hrs. Use standard precaution while suctioning Critically ill patient requiring mechanical ventilation are at higher risk of peptic ulcers or gastrointestinal bleedings Use orotracheal route, not nasotracheal route for elective intubation Oral Care Use close suctioning method Provide easy access to non-invasive ventilation equipment Bundle Care

24. Surgical Site Infections Surgical Site Infections are defined as infections that develop at the surgical site within 30 days of surgery ( or within 90 days ) Source: Endogenous source: Skin, Mucosa Exogenous source: Hygiene Epidemiology: According to CDC NHSN 2019 , SSIs remain a substantial cause of morbidity, prolonged hospitalization and death SSI is most costly HAI. SSI affects One third of patients who have undergone surgical procedure The SSI is the most frequent cause of unplanned re-admissions after surgery Risks: 1) Patient related: Malnutrition, age, diabetes, duration of pre or post stay, smoking, obesity, hypoxemia 2) Procedure related: Improper surgical scrub, inadequate skin antiseptic, prolonged operative type, Poor operative glycemic control 3) Procedure related: Presence of blood or clot or suture material and crushed muscle, necrotic tissue, dead space, hematoma and foreign bodies at the surgical sites

25. Pre operative Intra operative Post operative Preoperative bath with soap or an antiseptic During surgery glycemic control should be implemented Daily wound dressing Application of mupirocin 2% ointment Normothermia should be maintained Surgical antibiotic prophylaxis is not recommended Antimicrobial prophylaxis should be administered only when indicated (colorectal surgery) Normovolemia should be maintained Skin preparation in the operating room should be performed surgical site preparation with alcohol based chlorhexidine antiseptic solution Surgical hand disinfection BUNDLE CARE

26. INTRODUCTION Anti-biotic:- A Drug Used To Treat Infections Caused By Bacteria And Other Microorganisms. Stewardship:- Supervising, or managing of something. Or the careful and responsible management of something. Antibiotic Stewardship:- It is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Antibiotic stewardship program (ASP ) Antibiotic stewardship program is a coordinated program that promotes the appropriate use of antibiotics, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. Definition:- The antibiotic stewardship is A collective set of methodologies used in order to enhance the appropriate antibiotic use & reduce the deleterious effects of antibiotic use and also includes the awareness of the related aspects like antibiotic resistance, toxicity & economic burden.

27. The Centers for Disease Control and Prevention has defined antimicrobial stewardship as use of the right antibiotic, for the right patient , at the right time, with the right dose, route, and frequency, causing least harm to the patient and future patients. Why do we need AMSP? Antimicrobial Resistance Misuse or over use of antibiotics Widespread use of antibiotics in other sector Poor Antibiotic research

28. Purposes Of Antibiotic Stewardship Program (ASP):- The First aim of ASP is the optimization of proper use of antibiotics in order to ensure better clinical implications & reduction of harmful effects the Second aim is to make the antibiotic usage cost-effective the Third aim is to maintain it’s quality in patient care the Fourth aim is to reduction of any collateral damage in case of multidrug resistant microbial infections the Fifth aim is to prevent the generation and spread of antimicrobial resistance (AMR) or anti-biotic resistance (ABR). [the more antimicrobials we use, the higher the resistance

29. Goal Of AMSP Combat antimicrobial resistance: Restricting antibiotic use results in reduction of antibiotic pressure, which in turn development of antimicrobial resistance Restricting antibiotic use can reduce colonization or infection with gram positive or gram negative resistant bacteria 2) Improve pt outcomes: Improve infection cure rates Reduce SSI rates Reduce mortality and morbidity 3) Reduce Healthcare cost

30. The 5 R Approach To Antibiotic Stewardship Program (ASP):- To foster A culture of continuous improvement, experts have recommended ‘ the 5 R approach to ASP’ . 1. Responsibility:- everyone who uses antimicrobials acknowledges that use can cause harm. When we do use an antimicrobial, we should take actions that reduce the risk for future public’s health. 2. Reduction:- whenever we can, we need to look for ways to reduce our reliance on antimicrobials

31. 3. Refinement:- when we use antimicrobials, we should ensure that we are using the right drug, at the right dose, at the right time, treating the right bug, for the correct length of time. 4. Replacement:- consider non-antimicrobial products that could be used to promote good health and prevent disease. 5. Review:- we should be critical of every an antimicrobial was used and decide on A specific strategy for making further improvements and reductions in use .

32. IMPORTANCE OF ANTIBIOTIC STEWARDSHIP PROGRAM (ASP):- Patient care:- the quality of the care of patient improves if antibiotic stewardship program (ASP) is being practiced in A hospital environment. Safety:- the safety of the patient enhances due to the implementation of the antibiotic stewardship program (asp). Treatment failure reduction:- the antibiotic stewardship program (asp) implementation reduces the treatment anomalies as less antibiotic resistance is observed .

33. Thank You