Antimicrobial Resistance Symposium

The Faculty of Health Sciences, University of Malta, in collaboration with the WHO Global Leaders Group on Antimicrobial Resistance, is delighted to extend an invitation to an engaging symposium focused on raising awareness about Antimicrobial Resistance. This hybrid educational event bearing the title ‘Political advocacy and closing the knowledge gaps to address antimicrobial resistance‘ seeks to shed light on the pressing issue of Antimicrobial Resistance and its profound impact on public health.

The primary goal of this symposium is to enlighten patients and the public regarding antibiotic misuse and the critical need for effective infection prevention measures. The symposium will feature insights from members of the AMR Patient Group who will share their personal experiences in dealing with resistant bacteria. Their narratives will serve to advocate for concrete actions to combat this escalating public health threat.

This Antimicrobial Resistance Symposium is going to be held on Wednesday 22nd November 2023 from 9am till 2pm CET (Malta Time). It is going to be a hybrid event – in-person at the South Auditorium, Faculty of Health Sciences, University of Malta, and virtual.

To check what the time of event is going to be for your country please click HERE.

To register for this event please click HERE.

Register HERE to attend this antimicrobial resistance symposium in person or online.

Reference: https://www.um.edu.mt/newspoint/events/um/2023/11/amr-high-level-educational-symposium/_nocache


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Infection Prevention and Control in the Critical Care Setting

Patients in the critical care setting are more susceptible to Health Care Associated Infections (HCAIs), making infection prevention and control even more crucial within this setting. Some of the most common infection manifestations in the critically ill patient include pneumonia following intubation, bloodstream infections following IV catheterisation, and UTIs following urinary catheterisation.

Susceptibility to HCAIs within the critically ill population can be due to:

  • altered immunity – due to steroid use, surgery, anaesthesia and age
  • invasive lines – provide direct entry of bacteria into the patient’s bloodstream
  • underlying illnesses or conditions
  • broad spectrum antibiotics
  • mechanical ventilation

These risks cause an increased morbidity and mortality rate, a longer hospitalisation stay, and subsequently, higher treatment costs.

Antibiotic Use

We are currently witnessing a dramatic increase in infections by multi-drug resistant pathogens, leading to difficult infection management due to the scarcity of available antibiotics. Even more so, within the critical care setting there is an increased risk of patient-to-patient transmission, increased antibiotic use, and critically sick patients.

Multi Drug Resistant organisms (MDRO)

GRAM POSITIVES

  • VRE – Vancomycin-resistant Enterococci
  • MRSA – Methicillin-resistant Staphylococcus aureus

GRAM NEGATIVES

  • CRE – Carbapenem-resistant Enterobacterales
  • Pseudomonas aeruginosa CRE
  • ESBL-positive bacteria

OTHERS

  • Clostridium difficile
  • Neisseria meningitidis
  • Mycobacteria tuberculosis
Retrieved from https://slideplayer.com/slide/13193459/ on 28th January 2023

Infection Prevention and Control in the ICU Setting

General Preventive Techniques

  • follow the 5 moments of hand hygiene
  • alcohol hand rub should be the first hand hygiene choice – unless hands are visibly soiled
  • nails should be kept well trimmed with no gels
  • reduce jewellery use to just one plain wedding band if necessary
  • keep patients with MDRO in isolation rooms if possible
  • allocate equipment to one patient without sharing
  • screen patients for MDRO, specifically for MRSA, CRE and VRE on admission and at least weekly thereon
  • promote awareness on ANTT (aseptic non-touch technique) amongst colleagues
  • ensure disinfection of shared equipment such as monitoring lines, saturation probes, ECG leads, and blood pressure cuffs
  • promote education on infection prevention and control for staff and cleaners
  • educate patients’ relatives on infection prevention and control measures
  • ensure appropriate antibiotic use
  • ensure terminal cleaning of bed area upon patient discharge
infection prevention and control
Retrieved from https://surewash.com/news/moments-hand-hygiene/ on 28th January 2023

Glove Use

  • change gloves between procedures on the same patient when performing dirty vs aseptic tasks
  • change gloves between patients
  • don gloves immediately before contact with patient body fluid, mucous membranes, or non-intact skin
  • remove and discard immediately after a procedure and perform hand hygiene so that contamination is not transferred to another patient

Rectal screening for CRE and VRE

  • insert a charcoal swab approximately 2cn inside the rectum and rotate gently
  • ensure swab is brown-stained with faeces to ensure a good sample has been taken, as inadequate samples are not processed by the lab

Bathing Patients in Critical Care Setting

  • as previously mentioned, there is a high prevalence of MDROs in the critical care setting
  • daily chlorhexidine bathing of patients in the critical care setting is encouraged since chlorhexidine helps reduce the risk of acquiring MDROs
  • washing the patient’s body with chlorhexidine has been showing effectiveness in the prevention of carriage and possibly bloodstream infections with Gram-positive MDROs (MRSA and VRE)
  • chlorhexidine washes have shown possible eradication of carriage and infection prevention of Gram-negative MDROs, however, more evidence is required in this regard

Disinfecting Isolation Rooms

  • isolation rooms should be disinfected on a daily basis
  • isolation rooms should be cleaned last using yellow cloths, disposable gloves, and chlorine-based disinfectant
  • terminal cleaning and disinfection of isolation rooms should be done following patient discharge; all surfaces need to be cleaned with detergent; mattresses and pillows should be cleaned with environmental disinfectant wipes; UV-C disinfection should be performed, by which more than 99.9% of C. difficile spores and MRSA are killed in minutes

ADVANTAGES OF USING CHLORINE-BASED DISINFECTANT:

  • inexpensive
  • low toxicity
  • rapid effect
  • broad spectrum disinfectant – bacteriocidal, tuberculocidal, fungicidal, virucidal

DISADVANTAGES OF USING CHLORINE-BASED DISINFECTANT:

  • corrosive
  • long contact time
  • employee complaints

The Nurse’s Role in Proper Antibiotic Management

  • knowledge on antibiotic resistance
  • knowledge on the most frequently used antibiotics within the critical care setting
  • knowledge on the disadvantages of using broad spectrum antibiotics – prolonged use increases risk of C. difficile
  • administer antibiotics at the recommended dosage intervals for optimal effectiveness
    • administer IV antibiotics safely and effectively, with diligence to dosage, dilution, timing and calculations
  • administer IV antibiotics to patients with sepsis within 1 hour following diagnosis to increase risk of survival
  • list reminders for antibiotic review eg. stop date, reason for prescription, change of route, etc
  • therapeutic monitoring of antibiotic levels eg. Gentamicin, Amikacin and Vancomycin require serum blood level checking for safe and effective treatment; ensure samples are taken at the appropriate time for best results
  • understand when to withold an antibiotic dose until results are available eg. in the case of Gentamicin
  • serum blood level samplings should be properly documented in both the patient’s notes and on the lab request form
  • proper handover on transfer from ICU to another ward

Ventilator Associated Pneumonia (VAP)

Pneumonia is an infection in the lung parenchyma, particularly in the bronchioles and alveoli, which is caused by pathogens such as bacteria, fungi and viruses.

Ventilated Associated Pneumonia (VAP) is pneumonia which develops 48 hours following intubation and initiation of mechanical ventilation. VAP is considered to be the 2nd most common HCAIs but the most serious one, with 25% of these patients with VAP ending up dead.

VAP happens because intubation bypasses all natural defense mechanisms within the tracheo-bronchial tree that protect the lower respiratory tract from infections.

Causative organisms, some of which are often present in the oropharyngeal cavity and the gastrointestinal system, are:

  • Gram-negative aerobes – Pseudonomas aeruginosa, Klebsiella pneumonia, Acinetobacter, Enterobacter
  • Gram-positive aerobes – Staphylococcus aureus/MRSA

There are 5 defense mechanisms which are bypassed during ventilation:

  • The Larynx and the Glottis – prevent aspiration of oral content
  • The Coughing Reflex – helps in the expelling of secretions and aspirated matter from the larger airways
  • Mucous – helps trap small particles
  • Cilia – hair-like structures which help move mucous up from the lower respiratory tract towards the larynx to be expelled
  • Phagocytic Cells – engulf bacteria if or when they manage to reach the alveoli

Aspiration of contaminated fluids and secretions into the lungs can happen in various ways:

  • colonisation of pathogenic bacteria within the oropharynx or tracheo-bronchial tree
  • the stomach, through enteral feeding, certain drugs (eg. stress ulcer prophylaxis), and supine patient positioning, may act as a source of pathogens for VAP
  • inhalation of aerosols through contaminated intubation or nebulisation equipment

Pathological development of pneumonia

  1. aspiration of contaminated fluids or secretions into the lungs
  2. initiation of the inflammatory response
  3. swelling of the mucous membranes of the alveoli and bronchi
  4. pus collects within the alveoli
  5. interference of pus with the gas exchange process
  6. development of pneumonia
infection prevention and control
Retrieved from https://www.uptodate.com/contents/pneumonia-in-adults-beyond-the-basics/print on 28th January 2023

Signs & Symptoms of VAP Pneumonia

  • temperature of >38°C
  • tachypnoea and/or dyspnoea
  • purulent sputum (off-white, yellow or green, and opaque)
  • worsening ABGs – poor SaO2 and increased ventilatory demands
  • positive sputum and/or blood cultures
  • leukocytosis >12,000 WBC/mm2
  • chest x-ray or CT scan with evidence of pneumonia

NOTE: Diagnosing VAP can be difficult!

infection prevention and control
Chest X-rays and CT-scan of a 65-year-old man who developed ventilator-associated pneumonia. Chest X-ray performed the day VAP was suspected seems normal (a), whereas the CT-scan performed the same day showed consolidation of the left inferior lobe (b, d). Bronchoalveolar lavage yielded 105Enterobacter aerogenes. The next day, chest X-ray showed progression of pulmonary infiltrates (c). VAP diagnosis based on chest X-ray would have been delayed – Retrieved from https://link.springer.com/article/10.1007/s00134-020-05980-0 on 28th January 2023

VAP Risk Factors

  • length of time in which the patient is exposed to the healthcare environment
  • predisposing host-related factors such as age, malnutrition etc
  • treatment factors eg. endotracheal intubation, prolonged exposure to antibiotics

VAP Consequences

  • increased mortality
  • prolonged mechanical ventilation
  • increased antibiotic use
  • prolonged stay at the ITU and hospital
  • increased medical cost

VAP Infection Prevention and Control

  • do not intubate patient unless necessary
  • choose non-invasive ventilation over invasive ventilation where possible
  • elevate head of bed 30-45° especially for patients receiving enteral feeding
  • minimise aspiration of contaminated oropharyngeal and tracheal secretions
  • suction subglottic secretions
  • avoid gastric over distention
  • avoid unplanned extubation
  • maintain correct ETT cuff pressure (20cm H2O)
  • provide frequent oral hygiene – suctioning, toothbrushing, and using chlorhexidine mouthwashes
  • use HME filters rather than heated humidifiers
  • remove condensate from ventilatory circuits periodically
  • extubate as soon as possible

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Antibiotic Resistance and Antimicrobial Stewardship

Antibiotics are medicines that can treat bacterial infections, but at the same time upset microbial ecology, causing an alteration in the normal bacterial flora of the patient. Antibiotics cannot treat viral infections such as the common cold or the flu. Some organisms are sensitive or resistant to a given antibiotic, whilst others acquire resistance. How? If antibiotics are taken when they are not truly needed or beneficial to the individual, they can stop working. This is referred to as antibiotic resistance.

antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.publichealthpost.org/databyte/antibiotic-resistant-bacteria/ on 10th June 2022
antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.streetinsider.com/PRNewswire/CDC+releases+2019+AR+Threats+Report/16129462.html on 10th June 2022

Antibiotic Resistance

Antibiotics may be:

  • Broad Spectrum Antibiotics: active against both gram +ve and gram -ve bacteria
  • Narrow Spectrum Antibiotics: active against gram -ve bacteria only
  • Bacteriocidal – kill bacteria in a direct way
  • Bacteriostatic – slow the reproduction of bacteria
antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.pinterest.com/AliciaKlepeis/antibiotics/ on 10th June 2022

Antibiotic resistance happens when an antibiotic loses its ability to kill or control bacterial growth in an effective way, thus leading to bacterial growth within the presence of therapeutic levels of the antibiotic.

Similarly, bacteria may undergo structural changes in its DNA, with different bacteria exchanging DNA information, leading to further antibiotic resistance.

Retrieved from https://www.zmescience.com/science/breastmilk-protects-antibiotic-resistance-836533/ on 10th June 2022

Antibiotic Pressure in Hospitals

Antibiotic use is concentrated in hospitals, making it easy for resistant bacteria to proliferate in the hospital setting as well as in the patients themselves. Unresponsive therapy for resistant organisms leads to an increase in treatment time, making cross-infections more likely to occur. This causes increased antibiotic-resistant hospital infections.

Nosocomial pathogens include bacteria, viruses and fungal parasites. WHO estimates that approximately 15% of all hospitalised patients suffer from such infections. During hospitalisation, the patient is exposed to pathogens found in the surrounding environment, healthcare staff, and other infected patients. Nosocomial pathogens, which are often resistant to the antibiotics in current use, include:

  • Staphylococcus aureus (S. aureus / MRSA)
  • Enterococci
  • Klebsiella / Enterobacter / Serratia
  • Pseudonomas Aeruginosa / Acinetobacter
Retrieved from https://courses.cdc.train.org/Module6B_Principles_Transmission-BasedPrecautions_LTC/mod_6b_principles_of_transmission_based_precautions_lesson_2_33_multidrug_resistant_organisms.html on 10th June 2022

Carbapenem-Resistant Enterobacteriaceae (CRE)

Carbapenem-Resistant Enterobacteriaceae (CRE) are strains of bacteria which are resistant to carpabenem – an antibiotic class, which is used to treat severe infections. CRE are also resistant to most other commonly used antibiotics, and in some cases, to all available antibiotics.

CRE can spread and share their antibiotic-resistant qualities with healthy bacteria in the body, possibly causing infections in the bladder, blood, or other areas. Unfortunately, when such infections happens, it’s very hard and at times impossible to treat effectively.

Retrieved from https://apic.org/monthly_alerts/cre-the-nightmare-bacteria/ on 10th June 2022

Methicillin-Resistant Staphylococcus Aureus (MRSA)

MRSA is a type of bacteria resistant to widely used antibiotics, making infections with MRSA harder to treat than other bacterial infections.

Retrieved from https://www.ukm.my/umbi/news/mrsa-the-superbug/ on 10th June 2022

Antimicrobial Resistance (AMR)

Antimicrobial resistance can be reduced through prudent and rational antibiotic use. This can be achieved through programmes aimed at preventing and containing healthcare associated infections and antimicrobial resistant organisms.

antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.pinterest.com/pin/653936808368459544/ on 10th June 2022

Global Action Plan on Antimicrobial Resistance (WHO)

Antibiotics are life-saving. However, they are only effective when working against the organism causing the infection. Antibiotics should be prescribed and used with responsibility, so as not to contribute to the ever-increasing antimicrobial resistance.

Antibiotic resistance causes:

  • slower response to therapy
  • increased risk of infection
  • additional investigations
  • unnecessary treatments
  • use of broad-spectrum antimicrobials which increase cost and may lead to potential adverse reactions
  • increased morbidity and mortality
  • increased risk of infection spreading across the hospital and the community
  • longer hospital stay
  • longer absence from work
antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.europarl.europa.eu/cmsdata/133622/IPOL_STU%282017%29614187_EN.pdf on 10th June 2022

Antimicrobial Stewardship (AMS)

Through Antimicrobial Stewardship, we can do our part in ensuring we use antibiotics correctly so that they remain active for future generations.

Question everything…

  • Is an antibiotic really necessary to treat the patient?
  • If yes, does the choice of antibiotic follow the hospital antibiotic prescribing guidelines?
  • Have microbiology samples been taken and sent to the lab and the results reviewed?
  • Is the antibiotic of choice being administered through the correct route, for the correct duration, and at the correct dose?
  • Is a daily review on antibiotic use being performed so as to see if it can be stepped down from IV to oral or stopped?
antibiotic resistance and antimicrobial stewardship
Retrieved from https://infectionsinsurgery.org/core-elements-of-antibiotic-stewardship/ on 10th June 2022

The Role of the Nurse in Antimicrobial Stewardship

  • nurses make up a big part of the healthcare workforce
  • nurses are the ones mostly present around the patients
  • nurses are patient advocates
  • nurses are involved in patient education, infection prevention and control, monitoring of antibiotic use, and medication prescription and management of the patient
  • nurses are a part of the multidisciplinary team that sees to the patient’s needs
  • nurses work within multiple levels in local clinical settings
  • nurses have a key role in safeguarding the effectiveness of antibiotics fur future generations

Thus…

Nurses NEED to be recognised as influential members of the multidisciplinary team in the fight against antimicrobial resistance whilst assuring antimicrobial stewardship.

Through leadership skills, nurses can support infection prevention and control, antimicrobial stewardship and public health.

Patient Management

  • understand the difference between colonisation and infection
  • perform hand hygiene before and after touching a patient and surroundings
  • ensure environmental cleaning procedures are complete and consistent
  • assess patients for risk of acquiring and transmitting an infection
  • ensure correct collection of microbiological specimens if clinical need is indicated
  • encourage targeted interventions to reduce unnecessary use of antibiotics
  • ensure the use of most narrow-spectrum antibiotics are used to treat a patient’s infection
  • review and recognise if treatment is not in line with microbiological result
  • document findings
  • facilitate discharge planning

Medication management

  • recognise if patients are able to tolerate oral intake and so could change from IV to oral antimicrobials
  • ensure timely administration of antimicrobials at the right rate and follow up on missed doses
  • ensure that antimicrobials which perform optimally within a specific therapeutic level are in line with recommendations
  • monitor patient to ensure intended therapeutic effect of antimicrobial
  • recognise allergies and side effects
  • document clearly and accurately the generic name, dose, time, route, reason for administration, review, and stop date, as well as each administration
  • dispose of unused antimicrobials correctly
antibiotic resistance and antimicrobial stewardship
Retrieved from https://twitter.com/who/status/799155457415909376 on 11th June 2022
antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.who.int/europe/home?v=welcome on 11th June 2022
antibiotic resistance and antimicrobial stewardship
Retrieved from https://www.semanticscholar.org/paper/Covering-more-territory-to-fight-resistance%3A-role-Edwards-Drumright/a5ce54ee643a82e100bd48afa62d1d54cef5bda9 on 11th June 2022

Antibiotic Allergies


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