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AMR: Implementing the National Plan for Healthcare

This article explores the implementation of the national plan for antimicrobial resistance (AMR) in the healthcare setting, highlighting the prevalence of healthcare-associated infections (HCAIs) and the need for effective infection prevention and control measures. It also discusses the emerging threats of multi-drug resistant bacteria and the importance of appropriate antibiotic use.

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AMR: Implementing the National Plan for Healthcare

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  1. AMR – Where we stand, how we implement the national plan, and how this translates to the healthcare setting. • 03 September 2019 • Jon Otter, PhD FRCPath • Imperial College London • j.otter@imperial.ac.uk • @jonotter • Blog: www.ReflectionsIPC.com • Slides: www.jonotter.net

  2. ReAct.

  3. But I would like to sound one note of warning…There may be a danger, though, in underdosage. The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant. Here is a hypothetical illustration. Mr X has a sore throat. He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails. Mrs X dies. Who is primarily responsible for Mrs X’s death? Why Mr X whose negligent use of penicillin changed the nature of the microbe. Moral: If you use penicillin, use enough. Alexander Fleming, Nobel Lecture, December 11 1945.

  4. ReAct.

  5. Prevalence of HCAI • The 2016 national PPS was a huge undertaking that included 48,312 patients from 88 NHS Trusts and 6 private hospitals. • 7% of patients had an HCAI and 33% were on an antimicrobial.. • Pneumonia was the most common HCAI (29%) followed by UTI (17%) then SSI (15). • Prevalence of peripheral vascular cannula (43%), central venous catheters (7%), urinary catheters (20%), and intubation (2%). HCAI and antimicrobial use by speciality. ESPAUR Report 2017.

  6. Source: ESPAUR 2017. Source: DMAP.

  7. HCAIs are expensive Cassini et al. Plos Med 2016.

  8. AMR bacteria

  9. MRSA

  10. MRSA bacteraemia, England 1990-2012 Duerden et al. Open Forum Infect Dis 2015.

  11. MRSA bacteraemia, England 2001-2013 4 5 6 8 9 10 • Mandatory reporting, 2001 • ‘Gettting ahead of the curve’, 2002 • ‘Winning ways’, 2003 • ‘Towards cleaner hospitals’, 2004 • ‘Cleanyourhands’, 2004 • Targets introduced, 2004 • Cleanliness improvement, 2005 • ‘Going further faster’, 2006 • Root cause analysis, 2006 • Revised national guidelines, 2006 • Deep clean, 2007 • Screening elective admissions, 2008 • Universal screening, 2010 3 7 1 2 11 12 13

  12. Does hand hygiene explain the reductions? ‘The Cleanyourhands campaign was associated with sustained increases in hospital procurement of alcohol rub and soap, which the results suggest has an important role in reducing rates of some healthcare associated infections.’ Stone et al. BMJ 2012;344:e3005.

  13. Spurious correlations http://www.tylervigen.com/spurious-correlations

  14. Spurious correlations http://www.tylervigen.com/spurious-correlations

  15. Spurious correlations http://www.tylervigen.com/spurious-correlations

  16. What’s driving increases in MSSA BSI?

  17. Why antibiotic susceptible bacteria are resistant to hospital-based IPC intervention • Mathematical model to investigate transmission in hospitals and their surrounding catchment area. • Included a competitive advantage for resistant bacteria in hospitals and sensitive bacteria in the community. • Modelling the impact of improving hand hygiene by 10%. • Antibiotic-resistant bacteria were disproportionately affected in hospitals! van Kleef et al. BMC Infect Dis 2013;13:294.

  18. Why antibiotic susceptible bacteria are resistant to hospital-based IPC intervention van Kleef et al. BMC Infect Dis 2013;13:294.

  19. MRSA bacteraemia, England 2001-2013 4 5 6 8 9 10 • Mandatory reporting, 2001 • ‘Gettting ahead of the curve’, 2002 • ‘Winning ways’, 2003 • ‘Towards cleaner hospitals’, 2004 • ‘Cleanyourhands’, 2004 • Targets introduced, 2004 • Cleanliness improvement, 2005 • ‘Going further faster’, 2006 • Root cause analysis, 2006 • Revised national guidelines, 2006 • Deep clean, 2007 • Screening elective admissions, 2008 • Universal screening, 2010 3 7 1 2 11 12 13

  20. MRSA in Europe, 2016 % invasive S. aureus isolates resistant to meticillin. EARS-Net 2018.

  21. MRSA in Europe, 2000 to 2016 % invasive S. aureus isolates resistant to meticillin. EARS-Net 2018.

  22. CPE

  23. National trends: mandatory surveillance in England

  24. The emerging threat of CPE

  25. Rising threat from MDR-GNR % of all HAI caused by GNRs. % of ICU HAI caused by GNRs. CPO CPE Hidron et al. Infect Control Hosp Epidemiol 2008;29:966-1011. Peleg & Hooper. N Engl J Med 2010;362:1804-1813.

  26. Creating a monster Extended-spectrum beta-lactams Carbapenems

  27. CRE in Europe, 2016 % invasive K. pneumoniae isolates resistant to carbapenems EARS-Net 2018.

  28. Emergence of CRE in Europe, 2005-2016 EARS-Net 2018.

  29. What drives the European ‘north-south divide’? Antibiotic use Infection control staffing Single room availability National debt 1. ECDC Point Prevalence Survey, 2013. 2, National debt as a percentage of GDP. "Eurostat public debt GDP" by Eurostat. Licensed under Attribution via Wikimedia Commons.

  30. Social and material deprivation • We performed a risk factor analysis, which included both individual-level variables (such as overseas travel, antibiotic exposure, and age) and were also able to include community-level variables (such as markers of household overcrowding, deprivation, immigration, and ethnicity). • We found that risk factors for ESBL were travel to Asia (OR 4.4, CI 2.5-7.6), or Africa (OR 2.4, CI 1.2-4.8) in the 12 months prior to admission, two or more courses of antibiotics in the 6 months prior to admission (OR 2.0, CI 1.3-3.0), and residence in a district with a higher than average prevalence of overcrowded households (OR 1.5, CI 1.05-2.2). The global prevalence of ESBL in the community, from Woerther et al. Otter et al. ClinMicrobiolInfect 2019.

  31. Drivers of Gram-negative BSI

  32. Emergence of CRE in the UK ESPAUR 2017.

  33. The tip of the iceberg… 0.5%1 x 186,393 = 932 (!) 0.1%2 x 186,393 = 186 0.1% x 15.892m* = 15,892 * Admissions to NHS acute hospitals, Financial Year 14/15. NHS Confederation, Key Statistics on the NHS, Mookerjee et al. ECCMID2016. Otter et al. J AntimicrobChemother2016;71:3556-356.

  34. CRE in the USA NHSN / NNIS data; MMWR 2013;62:165-170.

  35. A framework for the 5 year National Action Plan on AMR: 2019-2024.

  36. Key points

  37. Promotion of better public engagement in AMR

  38. Other points

  39. Will it work? Survey on www.reflectionsipc.com; Jan 2019.

  40. AMR – Where we stand, how we implement the national plan, and how this translates to the healthcare setting. • 03 September 2019 • Jon Otter, PhD FRCPath • Imperial College London • j.otter@imperial.ac.uk • @jonotter • Blog: www.ReflectionsIPC.com • Slides: www.jonotter.net

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