ICPIC Geneva 2013

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ICPIC Geneva 2013.


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ery; or, amputate the legs before the spreading infection killed him. Mr S chose a double leg amputation. He lived. These patients serve as ‘book ends’ to the golden era of antibiotics. Both are real. Ms D’s generation lived with stories like her’s. In the battle of medicine versus fate, the balance of power lay firmly on the side of fate. Nowadays, we believe medicine can change fate. The younger among us have seen only the vaccine, not the deadly and deforming disease. It is never easy to accept the abrupt end of a young life, and the loss of Ms D still reverberates. But it may be harder for our generation to accept these sudden disappearances of life and limb because we never questioned medicine’s superiority. Yet, we must. There have been no successful discoveries of new classes of antibiotics since 1987. Meanwhile, the Center for Disease Control and Prevention recently warned of a fourfold increase in “nightmare bacteria” known as carbapenemresistant Enterobacteriaceae (CRE) in just one decade – up to half of patients who get CRE bloodstream infections die. The G8 Summit taking place now in Northern Ireland has rightly prioritized global antimicrobial resistance as a “major health security challenge.” Science ministers are calling for intensive international collaboration to achieve the goals of: avoiding the misuse of remaining antibiotics, streamlining and facilitating the development of new antibiotics, and rapid diagnostics to accelerate the identification and treatment of resistant organisms before they spread.

Superbugs, Humans and the G8.

The key to success is of course international collaboration. Microbes have been globalized along with the rest of the world. There has never been such rapid and distant spread. Thanks to mass travel, Dengue has returned to the United States and may soon become endemic in some areas. The West Nile virus, never before seen in the western hemisphere, also arrived by plane. Data sharing among infection control experts and the biotechnology and pharmaceutical industries is essential. As is facilitating the exchange of ideas for novel measures to combat this global threat.


s D was a mother of six, her youngest only two years old. She caught a cold on a Sunday, which weakened her and led to bacterial pneumonia. It was 1943, and the world was busy making war. Ms D stood at the threshold of the antibiotic era, but never crossed it – her pneumonia killed her, efficiently, by Thursday. Mr S is a twenty-eight year-old software engineer. Seventy years after the death of Ms D, he planned an adventure vacation in North Africa, where he was involved in a bus accident. His lower legs were crushed, resulting in several open fractures. He was airlifted to his home in Switzerland, but not before spending three days in a Cairo intensive care unit. By the time he arrived, several ‘superbugs’ had nested and were growing happily in his leg bones – two were fully resistant to all known antibiotics save colistin.

In Geneva, the second ICPIC conference will feature over 1,200 experts from 84 countries dedicated to infection control. Participants will exchange ideas, strategies and outcomes of recent and ongoing studies. Concrete measures will be argued and debated. In the next three days, the seedlings of collaborative efforts – from laboratory experiments to multi-center clinical studies – will be planted.

Colistin is an old drug that had all but vanished. It is toxic to the kidneys and nerves. Mr S would need high levels in his blood for at least half a year to reach the bacteria in his bones, almost certainly leading to kidney failure. He was offered a choice: try to save the legs, with a high chance of dialysis for the rest of a shortened life and an unknown chance of recov-

Though I never knew her, I would like to think Ms D would be happy. Mr S recently told me he was.

Jean-Christophe Nothias









CONTENTS 6 GLOBAL VOICES: Didier Pitter 11 ARTICLE: The Global Burden Of Healthcare-Associated Infections 12 ARTICLE: Counting The Cost Of Infection Control 13 ARTICLE: Clean Care Is Safer Care 14 ARTICLE: Clean Hands And Healthy Bodies 15 ARTICLE: Combating ‘Superbugs’ Through Rapid Diagnostic Tests 16 ARTICLE: INPIQS: Perspectives From The South 17 ARTICLE: Animals And Antibiotic Resistance


18 ARTICLE: Antimicrobial Resistance At The G8 Summit



PHONE: +41 22 917 1297





Saving Lives Through Infection Control. BY ALPHÉE LACROIX-SEPTEMBER


utbreaks of viral and bacterial infections may seem banal in light of the progress made in medical science. Yet millions of patients worldwide are affected by healthcareassociated infections every year, and thousands die. From 25-28 June, over 1,200 world experts in the prevention and control of these infections will gather in Geneva for the second International Conference on Prevention & Infection Control (ICPIC).

and debate about the prevention and control of healthcare-associated infections and antimicrobial resistance globally. The 2013 edition will include keynote lectures, interactive sessions, meet-the-expert workshops and debates on a number of issues, including SARS, the new coronavirus and H7N9, cultural differences in infection control and patient safety, antimicrobial stewardship, health economics and antibiotic resistance.

The first conference was convened in 2011 as a platform to foster exchange

One of the highlights of the conference will be the new Innovation Academy THEGLOBALJOURNAL.NET 5

chaired by Didier Pitter and John Conly. Fifteen finalists have been selected by the International Jury of the Academy to present their research. Each participant will provide a succinct oral summary during the course of the forum, and five will be chosen to remain in the running for three innovation awards to be presented on 28 June. The following pages showcase the vital work underway globally to reduce the burden of healthcare-associated infections – the second edition of ICPIC is a key element in this effort.




A celebrated public health expert, Didier Pittet has built a global reputation for his landmark research and pioneering efforts in the field of infection control. In particular, after leading initial observation studies showing a low compliance with basic hand hygiene practices, he has driven a worldwide uptake of the breakthrough ‘Geneva Hand Hygiene Model’ in collaboration with the World Health Organization that has contributed to a dramatic reduction in the incidence of life-threatening healthcare associated infections in rich and poor countries alike. THE GLOBAL JOURNAL + ICPIC 2013 6

GLOBAL VOICES How did you come up with the hand hygiene initiative? There were many beginnings. The first dates back to my return from the United States (US), where I studied infection prevention and observed the American method, where laboratory technicians detected infections but did not intervene. I saw their difficulty in contacting people in the tertiary sector and intervening in order to reduce the rate of infection. I then found myself in Geneva where there were no services for infection prevention. At the time, there was only a hospital hygiene service. I wondered whether there were any infection problems. In 1993, an initial survey found a relatively high rate of blood, lung and urinary infections. Preventative methods are slightly different for each type of infection, but hand hygiene is relatively universal. This led me to ask why it was so difficult to practice hand hygiene correctly. A study was conducted with the help of a team of nurses and a protocol was put in place. By going into the field and placing myself in the shoes of practitioners, I realized they simply did not have enough time. It was necessary to wash your hands with water and soap, which would take between a minute and a minute and a half. We calculated that in the intensive care unit nurses would have 22 occasions per hour to wash their hands. In other words, they spent 30 minutes per hour washing their hands. I then analyzed the data with my colleagues and we came up with a mathematical model showing the more staff had time to wash their hands, the less they would observe the protocol. People complained about a lack of time. This signified it was necessary to change the system. I thought it would be possible to use alcohol, which was already on hand in laboratories. This initial idea needed to be tested epidemiologically. A similar study had not been conducted elsewhere? It could have been, but I think our study was unique because it was a systematic epidemiological study of hand hygiene and not just an observational study. It came about from my epidemiological

experience in the US. Afterwards, we published our first paper in a very well known journal. The next step was to make staff change their practices. I was responsible for putting together an infection prevention program with the help of four nurses. According to the data, 16-18 percent of patients who arrived at the hospital were infected. The aim was to understand how to improve hospital practices. Staff found it systematically harder to disinfect their hands before treatment. I conveyed the information to doctors and nurses in a transparent and jocular way in the form of posters to show hand hygiene practices were not good. I went to see the Director of Care, the Medical Director and the General Director of the hospital to present the situation and propose alcohol dispensers. With their consent, I established a performance team that brought together the institution’s four core departments,

‘By reducing infections, we are able to reduce the length of stay and therefore expenses.’ their heads, the President of the Infection Commission, cleaners, field nurses and people from my team. Once the institution decided to support the project, about 40 people met once a month to discuss the issue. Compliance increased progressively and the rate of infection reduced. The compliance rate of practices increased from 45 to 69 percent within four years. At the same time, the infection rate in the hospital diminished by 50 percent, whereas the transmission rate of resistant germs diminished by 80 percent. In a large hospital, this amounts to between 20-24 CHF million saved each year due to interventions. By reducing infections, we are able to reduce the length of stay and therefore expenses. What did you manage to achieve after this rapid initial impact? We continued to measure compliance and conducted more precise surveys THEGLOBALJOURNAL.NET 7

to understand the specific problems in different sectors. For example, in neonatology, we determined it was not only necessary to use alcohol, but also rethink the way in which staff do to make them more consistent and reduce the number of occasions. This was very successful because we reduced infections by 40 percent. The institution followed and supported the intervention and hospital personnel were very motivated. A paper was published in The Lancet in 2000, upon which it became known as the ‘Geneva Model of Hand Hygiene Promotion.’ Between 2000-2002, dozens of experts came to Geneva to replicate our model abroad. The Center For Disease Control in the US asked us to write its guidelines on hand hygiene. The members of the National Patient Safety Agency also came and reproduced our model all over the United Kingdom (UK). Yet after examining the products available on the British market, we realized that none met required standards. The first product was developed and perfected by the Geneva hospital pharmacy. What was the outcome internationally? In the UK, infections were not measured – this was not compulsory everywhere. In Switzerland, there is no regulation but we measure infections in every hospital four times per year. The British looked at four hospitals where the campaign was carried out and also recorded a 50 percent reduction in infections. Their study targeted a type of blood infection, a multi-resistant staphylococcus that is lethal in 40 percent of cases. The health minister at the time set an objective to reduce infections by 30 percent in two years and by 40 percent in three years. This target was exceeded as infections reduced by 50 percent in two years. Is Geneva’s reputation abroad a caricature or true? It is probably true. The first time we presented our results on the reduction rate in infections to a world congress, the participants said it would not work anywhere else except in Geneva. These results were indeed a product of long-term efforts from all hospital


departments. I was interested in behavioral change and ecological theories and applied them to hand hygiene. The specific characteristics of Geneva and the Swiss sense of perfection without a doubt played a role. We had the means to carry out this work and we believed in it. Posters were displayed in all units with participation from a large number of players from all levels. The approach was both ‘top down’ and ‘bottom up,’ including cleaners, nurses, logistics managers and security personnel, all the way up to management. There was an amazing ripple effect. Did you patent the alcohol dispenser system? No, never. A few years ago, we calculated that royalties of one-tenth of 1 cent for each alcohol dispenser used throughout the world would earn Geneva University Hospitals (HUG) 17 CHF billion per year. In retrospect, I don’t regret it because this allowed different countries to adapt the product to their needs. When the initiative became a World Health Organization (WHO) campaign, it exploded. During a visit to a Nairobi hospital, I found an alcohol dispenser locked up in a box. From the hospital director, I learned that he paid two and a half times more

than the average price in Europe or in the US for the alcohol. These dispensers cost around 1 CHF to produce and were sold for 7 to 8 CHF on the market at that time. This was an absolute injustice because it was essentially alcohol and glycerin, or an equivalent product. When HUG began production in large quantities, we transferred the responsibility to a company and continued to buy it at cost price. We then negotiated so that the sale price was not double the cost price. The calculation was then given to the WHO and prices dropped. In the beginning, the pharmaceutical industry was opposed to this, but today they participate in the process. Universalization was also facilitated thanks to a ‘low cost’ product. A preventative method should always be cost-free. Today, steps are underway to ensure alcohol dispensers are one of the WHO’s “medical essentials.” This is the best recognition. How did the WHO become involved? Sir Liam Donaldson – the UK’s Chief Medical Officer and member of the WHO Executive Council – proposed a World Alliance for Patient Safety to the World Assembly. This idea was THE GLOBAL JOURNAL + ICPIC 2013 8

accepted and a committee convened. Infections contracted during treatment were swiftly identified as a priority. In 2005, Lucian Leape, the ‘father’ of patient safety, referred Sir Liam to me. He asked me about the possibility of universalizing the hand hygiene campaign and it became the very first challenge for the World Alliance. I went to see Sir Iain Chalmers, the head of the Cochrane Foundation, since there was not enough evidence in scholarly literature on hand hygiene. He agreed to collaborate on the project and we were then able to focus all our energy and knowledge in this international intervention. Where was the project implemented? The WHO proposed that we engage in a worldwide campaign. Between 2005-2006, hand hygiene guidelines written for the US were re-written and internationalized by a team of around 150 people, selected according to the United Nations’ (UN) criteria of geographic representation. We held regular consensus conferences at the WHO on the ‘clean care’ program. In order to select decision makers – that is, hospital directors – we asked health ministers from different countries to sign a charter recognizing the need


to measure the rate of infection, to intervene with tools developed by the WHO and to share the results. The guidelines were only part of the solution. We developed the tools in order to put them into practice. Thanks to the WHO, 40 instruments were developed to support these guidelines. They were translated and adapted to the needs of different countries and became very popular. The WHO’s ability to mobilize, combined with expert techniques, enabled international implementation. What obligations did the WHO charter impose? The WHO cannot force governments to act, but can make suggestions. The team of experts, which developed the implementing tools, was made available to the countries involved, in order to aid staff responsible for implementation. We visited the hospitals in these countries and advised them on their practices. This was a great experience to see how each country benefited from the campaign. We also developed, with the help of companies, an excellent hand hygiene concept. Hospitals could submit a promotional program in hand hygiene to a panel of adjudicators, which would select the best hospitals for an evaluation visit.

The World Day for Hand Hygiene takes place on 5 May. It is a sister initiative created in 2009 by the UN and celebrated in hospitals and healthcare centers. Today, more than 15,000 hospitals in 100 countries take part. The promotional strategy is called ‘Five Moments for Hand Hygiene’ and identifies five moments during treatment where staff must disinfect their hands. The number five refers to these moments, to five fingers and to the date chosen to celebrate hand hygiene.

began in 2009 and pairs European hospitals speaking English, French or Portuguese, with African hospitals speaking the same languages. We assess the safety of patients in pilot hospitals and identify each hospital’s priorities. Hand safety in this way became a gateway to infection control and patient safety. Since then, other collaborations have occurred, especially in epidemiology. It has been a beautiful universal adventure. And what is the next step?

Another sister initiative was to produce a disinfectant in Africa from sugar cane or potatoes. In September 2008, a meeting between African health ministers took place, where I met Lord Patel, head of the National Patient Safety Agency. At a hospital in Yaounde, I presented our strategy against infections and the minister from Mali explained how alcohol could be produced locally from sugar cane. Twenty-seven ministers signed an agreement and today there are training seminars for francophone countries in Mali to produce alcohol this way. A few months later, Lord Patel presented the project to the House of Lords and raised funds to create a partnership program between European and African countries. This program THEGLOBALJOURNAL.NET 9

The next step is to ensure the adventure continues. We cannot simply settle for a change in practices – we have to constantly improve. In order to assess practices, we require adequate tools within everyone’s means and available in different languages. One day, there will be automatic measuring devices enabling individual performance reviews of each doctor instead of a global review. All institutions must identify their problems and establish their own strategies. Eventually, we want all hospitals to participate in the worldwide campaign. Over 1.4 million patients are infected every day in hospitals. Thanks to action from the WHO and an institutionalization in healthcare, we have been able to reduce this figure by 20-30 percent.

Stories From ICPIC 2013. As befits a gathering of experts from more than 80 countries, the second edition of the International Conference on Prevention & Infection Control will foster debate and facilitate the sharing of critical knowledge on a wide and deep range of topics constituting the key elements of a global public health challenge touching all countries and health systems. The special feature that follows explores only a handful of these issues, but in doing so aims to shine a light on the important work being done on a larger scale to alleviate the global burden of infection.


The Global Burden Of Infection.

of these infections is sometimes poor, and known evidence based prevention strategies could be enforced more effectively. The main factors placing patients at risk are prolonged and inappropriate use of invasive devices and antibiotics, high-risk and sophisticated procedures, immunosuppression and other severe underlying patient conditions, and insufficient application of isolation procedures.

In Europe alone, healthcare-associated infections are the cause of 16 million extra days of hospital stay and 37,000 deaths every year. Associated costs are estimated to exceed $9 billion annually. These infections are acquired by patients while receiving treatment in a healthcare setting, from in-patient care hospitals, to ambulatory surgical centers and nursing homes. They are caused by infectious agents – most commonly, bacteria, fungi and viruses. Risk factors include contamination of the healthcare environment, transmission of communicable diseases between patients and staff, over or improper use of antibiotics, surgical procedures, injections and in-dwelling medical devices such as urinary catheters. National and multi-center studies on endemic healthcare-associated infections from 1995-2010 showed their prevalence in mixed patient populations averaged over 7 percent in high-income countries. Although data is very fragmented, it is estimated that infection rates in low-income countries varied from 5-19 percent. In high-income countries, healthcareassociated infections are mostly the result of healthcare delivery system failures. Awareness and knowledge

In developing countries, additional factors – such as poor hygiene and sanitation, lack of basic equipment, inadequate infrastructure, overcrowding and pervasive malnutrition and disease – play an important role in increasing the risk of infection. Dr Benedetta Allegranzi, Technical Lead for Patient Safety at the World Health Organization, suggests multiple use of syringes in settings with limited resources is an aggravating factor. Newborns are also a high-risk population, with neonatal infection rates three to 20 times worse than in high-income countries. Similarly, up to one-third of operated patients are affected by surgical site infections, while in intensive-care units infection rates can be up to 20 times higher than in developed country hospitals. The global impact, however, goes beyond the costs and health consequences for patients and their families. It entails the need for more complex medical treatments, longer hospital stays delaying bed availability and the prescribing of additional, expensive antibiotics. Encouragingly, research suggests most healthcare-associated infections are preventable and can be reduced by as much as 50 percent or more. Because the ability of hospitalized patients to fight infection is often diminished by a pre-existing disease, it is essential that healthcare facilities comply with safety standards to prevent and control THEGLOBALJOURNAL.NET 11

infections. Prevention strategies must combine the efforts of clinicians, scientists, public health leaders and patients themselves. Surveillance systems for healthcareassociated infections exist in several high-income countries, but are virtually non-existent elsewhere, says Allegranzi. Prevention measures include isolation, cleaning, sterilization and disinfection, infectious waste disposal and specific procedures for injection safety. Another important factor is antimicrobial resistance, as pathogens often carry patterns of multi-drug resistance known to bring more virulence. In a majority of cases, the spread of healthcareassociated infections is connected to the hand contamination of healthcare workers – still a problem in modern hospitals. In March, the European Center for Disease Prevention and Control published a technical report with core competencies to be adopted by infection control and hospital hygiene professionals in the European Union. The report was aimed at standardizing competencies through training courses tailored to different national contexts, while also facilitating the mutual recognition of competencies across member state systems. Risks of infection at a global level are also exacerbated by increasing travel, medical tourism and shared healthcare. “Inter-country” patients have emerged as a distinct group including military and civilian medical evacuees, medical tourists and those whose medical care is divided between countries for a variety of social, familial or financial reasons. Travellers and migrants also act as vectors (and victims) of healthcare-associated infections. On a daily basis, medical practitioners are faced with patients who may have been hospitalized in any part of the world in the preceding days.


Counting The Cost Of Infection Control.

pneumonia increases the length of stay in ICUs. By contrast, the additional impact of antimicrobial resistance on these patient outcomes was low. In other words, in the ICU context, infection must be prevented regardless of whether it is due to a resistant bacteria or not.

Estimating the cost of healthcareassociated infections and the costeffectiveness of infection prevention strategies is a challenging endeavor. Most studies estimate the burden of nosocomial infections by looking at the cost of extra days in hospital due to the infection, or costs directly attributable to treatment of the infection – antibiotics or surgery. Estimating the socio-economic impact, however, is far more complex. The 1988 SENIC (Study on the Efficacy of Nosocomial Infection Control) project in the United States was a landmark project establishing the importance of infection control. Researchers estimated that 32 percent of nosocomial infections occurring in hospitals without an effective infection control team could be avoided. Key conditions identified were surveillance and control efforts, one infection nurse for 250 beds, the presence of a trained hospital epidemiologist and feedback of surgical wounds infection rates to practicing surgeons.

A recent European study indicated that infection with methicillin-resistant or methicillin susceptible Staphylococcus aureus (MRSA or MSSA) carries a significant health economic cost. Bloodstream infection with either of these bacteria is associated with excess length of stay and mortality. In 2007, 27,711 episodes of MRSA were associated with 5,503 excess deaths and 255,683 excess hospital days in participating countries. The total costs attributable to excess hospital stays for MRSA topped $63 million. Other bacteria are threatening patient safety. Based on prevailing trends, the number of infections caused by third generation cephalosporin resistant E.coli is likely to increase rapidly, outnumbering MRSA infections in the near future. Another study looking only at patients in European intensive care units (ICUs) found healthcare-associated bloodstream infections and pneumonia both increase mortality, while THE GLOBAL JOURNAL + ICPIC 2013 12

Some experts have suggested projections regarding the cost of antimicrobial resistance grossly underestimate the ‘true cost’ by focusing on excess costs of hospitalization. According to Professor Richard Smith from the World Health Organization’s Collaborating Center on Global Change and Health, “the real human cost will be felt when we can no longer treat infections because we have no effective antibiotics.” As antimicrobial resistance spreads worldwide and increasingly affects patients with little buying power, drug companies are reluctant to invest in the development of cheap antibiotics that patients take for a short time, as opposed to drugs treating longer-term chronic conditions like arthritis or heart disease. Dr Andrew Stewardson, Research Fellow at the University of Geneva Hospitals, notes that “in addition to costs associated with healthcare provision and patient health, estimates of the societal impact of antimicrobial resistance should take into account the current trajectory, which leads towards a future with limited access to effective antibiotics.” On the bright side, a recent German study identified the use of alcohol based hand rub and antimicrobial stewardship programs as “positive externalities,” associating hand hygiene and the reduction of antibiotic use with cost saving. Similarly, a recent American study suggested 100,000-200,000 central line-associated bloodstream infections have been prevented since 1990 through the use of evidence-based prevention practices.


Clean Care Is Safer Care.

Engaging patients and healthcare professionals as partners is critical to the prevention and control of healthcare-associated infections globally. Patient information brochures and training for healthcare personnel have become standard practice in many hospitals around the world. But some healthcare institutions are going the extra mile and introducing new initiatives to prevent, control and raise awareness of these infections. Dr Ling Moi Lin, Director of Infection Control at Singapore General Hospital, says more and more healthcare facilities are using e-modules to train healthcare professionals in infection prevention and control. These modules are mostly directed at intensive care unit (ICU) staff for the prevention of the most commonly diagnosed infections in these settings – mainly ventilator-associated pneumonia, catheter-associated urinary tract infections and central lineassociated blood stream infections. Singapore’s General Hospital – a 1,600 bed acute tertiary care facility – uses innovative teaching methods to promote infection prevention and control. Evidence-based best care practices are compiled as educational bundles and convenient pocket-sized cards are then produced and circulated to all staff for easy reference. Similarly, quality improvement teams have also been established to help implement these policies more effectively in ICUs, where creative use of video teaching and checklists has helped to ensure that best practices are complied with at all times. These initiatives have proven to be a great success, as the hospital has been able to eradicate totally ventilatorassociated pneumonia and central line-associated blood stream infections in its ICUs. In 2001, the World Health Organization released a Global Strategy for Containment of Antimicrobial Resistance,

recommending the establishment of infection prevention and control programs in all hospitals and stressing the need for coordination of these activities and the education of staff. Moi Lin notes, however, that “the main challenge lies with allocating adequate resources to education and training of all healthcare workers. Most healthcare institutions have an inadequate number of trained Infection control professionals who need to balance their time with surveillance, outbreak management, administrative matters and education.” Some healthcare institutions are attempting to manage this problem with creative solutions. The annual celebration of key promotional events has been used widely to raise awareness and bolster education efforts. Every year, thousands of hospitals worldwide THEGLOBALJOURNAL.NET 13

celebrate Hand Hygiene Day on 5 May and Infection Control Week in November. Other innovative strategies include skits, wall poster competitions, debates and game booths to educate patients and medical staff alike on the issue of infection prevention and control. Singapore General Hospital’s hand hygiene program has helped achieve hand hygiene compliance of 60-70 percent for the last two years amongst hospital staff. Patients are also taught to use antiseptic bath solutions before surgical procedures, which has led to a significant reduction in surgical site infections. According to Moi Lin, “patients have the right to enjoy safe care whilst in our facilities. Their awareness and understanding of infection prevention and control is part of the excellent care we deliver.”


Clean Hands And Healthy Bodies.

the field, and WHO experts regularly visit healthcare facilities worldwide to provide support and monitor implementation. Prevention strategies include blood and injection safety, sound clinical procedures and water, sanitation and waste management.

Every year, hundreds of millions of patients around the world die or are affected by heathcare-associated infections acquired during stays in hospitals or other healthcare settings. By cleaning their hands, staff can contribute to reducing the global burden of infection by up to 50 percent. While the impact and causes differ between developed and developing countries, lack of compliance with hand hygiene by medical practitioners is a general, systemic issue faced by all healthcare facilities worldwide.

A task force of more than 150 public health experts was formed to draft Guidelines on Hand Hygiene in Healthcare. These provide healthcare workers, hospital managers and authorities with the best scientific evidence and recommendations to improve practices and reduce infections. Pilot tests in each of the six WHO regions were conducted to provide local data on resources required to carry out the recommendations and gather information on feasibility, reliability and cost effectiveness.

In 2005, the World Health Organization (WHO) in partnership with the University of Geneva Hospitals (HUG) launched the first Global Patient Safety Challenge, Clean Care is Safer Care. Didier Pittet, Director of the Infection Control Program at HUG, led this global campaign to promote hand hygiene regardless of the level of development and the availability of resources. The campaign is also in line with the United Nations (UN) Millennium Development Goals.

Since the launch of the initiative, more than 130 health ministries have pledged commitment to Clean Care is Safer Care, representing over 93 percent of the world population. In addition, over 15,700 healthcare facilities and approximately 9 million healthcare workers in 169 of the 194 UN member states participate each year in Hand Hygiene Day on 5 May. A range of tools and materials were developed to improve hand hygiene in THE GLOBAL JOURNAL + ICPIC 2013 14

In 2007, WHO CleanHandsNet commenced as an informal network of national, sub-national and regional hand hygiene programs. Regional focal points gather information from areas with large scale activities with the aim of sharing experiences and learning. Innovative campaigns include a Hospital Key Performance Indicator in Malaysia, a web-based training program on hand hygiene in Denmark, an iPAD/iPhone compatible performance monitoring tablet used nationwide in Australia and the local production of alcohol-based hand rub in Mali. Other initiatives such as education and selfassessment tools, media campaigns and the accreditation of facilities further contribute to reducing infection rates. Dr Benedetta Allegranzi, Technical Lead, Patient Safety at the WHO, notes the efficiency of hand hygiene campaigns largely depends on practicality and the engagement of patients and staff. “Religion, culture and education were major factors in the implementation of our pilot projects,” says Allegranzi. “In countries such as Mali, alcohol-based hand rub was often not available or too expensive. And it was sometimes not used for religious reasons. Experts on the ground had to find tailored solutions for every case.” The impact of hand hygiene campaigns is particularly significant in low-income countries, where average compliance rose from 51 to 67 percent since the launch of Clean Care is Safer Care. The prevention of healthcare-associated infections has since been placed among the top health priorities in 116 UN member states.


Combating ‘Superbugs’ Via Rapid Diagnostic Tests. Traditionally, the detection of microbes such as bacteria and viruses has required their growth in a laboratory, then a lengthy process of identification through straining techniques and, sometimes, tests of their resistance to certain antimicrobial agents. Meanwhile, patients newly admitted to hospital are not universally isolated from other patients due to the cost, logistics and psychological implications. For resistant microbes, this diagnostic lag time is a boon – it creates a window allowing for their spread to surfaces, hospital personnel and other patients before identification triggers isolation of their host. Fortunately, a parallel track of rapid diagnostic testing has emerged in recent decades. Rapid diagnostic tests bypass culturing and staining, targeting instead traces of the unique DNA or other ‘blueprint’ material inherent in all microbes. While early identification of a harmful micro-organism is of obvious benefit to an individual patient whose physicians can more quickly initiate the right therapy, “the benefit to the general public cannot be underestimated” suggests Dr Angela Huttner of the Geneva University Hospitals. A rapid diagnosis narrows the window period during which resistant organisms can spread. It also allows physicians to avoid the overuse of the ‘big guns’ of broad-spectrum antibiotics, which itself drives the emergence of resistance organisms – so-called ‘superbugs.’ Rapid tests have become a key component in the overall effort to reduce the spread of resistant organisms. They are now used with regularity in some countries to detect methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and other bacteria. According to Huttner, the significant clinical impact of rapid diagnostic tests is becoming apparent in the outpatient

setting as well. For example, officebased diagnostic test kits that quickly rule out the presence of Streptococcus in patients with sore throats – symptoms that may simply be due to a passing viral infection – allow for a reduction in unnecessary antibiotic consumption. An earlier lack of rapid testing capabilities for sexually transmitted diseases led to the widespread and ‘blind’ use of antibiotics in the attempt to treat all possible infections, which in turn led to the development of antibiotic-resistant gonorrhea. The advent of rapid tests in this domain has also led to a decrease in unwarranted antibiotic consumption. THEGLOBALJOURNAL.NET 15

However, “rapid diagnostic tests remain a work in progress” cautions Huttner. “Many have not yet been rigorously tested and validated in clinical specimens. In some cases, they can be too sensitive, identifying contaminating organisms that are not ultimately important clinically. Some platforms are unwieldy and require advanced training to operate.” Turnaround times can also be much longer than expected and costs prohibitively high, as specialized staff are required to run the machines used in the testing process. As a result of these limitations, while promising, rapid diagnostic tests continue to be used in parallel for now with traditional diagnostic methods.


INPIQS: Perspectives From The South.

Acting in a consulting capacity, the participants analyzed the cost of producing the solution locally, as well as other economic and political aspects of implementing the plan. Since its creation, INPIQS has built a large network comprising national and regional associations as well as international and regional organizations. International partners include the World Health Organization, the West African Health Organization and the World Bank.

The International Network for Planning and Improving Quality and Security in Health Systems in Africa (INPIQS) is a non-profit organization founded in 2006. A pool of national and international experts specialized in the evaluation of health systems are working to reform and develop national health policies in sub-Saharan Africa. They aim to harmonize professional practices, develop technical standards of healthcare and support ministries of health and African universities in the definition of health policies. The rate of healthcare-associated infections (HAIs) in Africa is estimated to be between 35 and 60 percent due to a general lack of prevention and control measures in healthcare facilities. National health authorities often fail to adopt the necessary policies due to a lack of awareness and information regarding the burden of these infections in healthcare settings. A staggering consequence of this is that “HAIs are the third cause of maternal mortality, the second cause of infant mortality and

the first cause of post-surgical mortality in Africa,” says Dr Mansour Adéoti, Secretary General of INPIQS. One of the main goals of INPIQS is to bridge the gap between health professionals and policy makers, while building partnerships to improve patient safety. Specific functions of INPIQS include assessing local healthcare facilities, fostering medical know-how and skills, crafting tailored solutions for specific health systems, promoting south-south cooperation among healthcare institutions and advocating for infection prevention and control policies at the governmental level. The activities of INPIQS span a large part of sub-Saharan Africa. In 2011, the network oversaw the creation of national policies in Guinea-Bissau and Côte d’Ivoire on community health and risk management in healthcare settings respectively. In 2012, INPIQS assessed Mali’s strategy for the local production, distribution and use of alcohol-based hand rub solutions. THE GLOBAL JOURNAL + ICPIC 2013 16

According to Mansour, the main achievements of INPIQS have been its collaboration with African health ministries to develop national policies for patient safety, the adoption of an African charter on the quality of healthcare and patient safety and the creation of national and regional platforms to allow patients, researchers and institutional actors to exchange information and knowledge about patient safety. At the same time, there are still many challenges to face. “The mobilization of decision-makers at the governmental level and in healthcare facilities remains insufficient” according to Mansour, and efforts to build capacity are frustrated by the “frequent transfer of qualified, trained staff and senior officials.” Another issue is the lack of funding allocated by states and regional organizations to patient safety and quality care. Future activities of INPIQS include an international conference on blood safety and safety surveillance in Abidjan (Côte d’Ivoire) in October and a joint session between INPIQS and IPCAN (Infection Prevention & Control Africa Network) on the theme “Contribution of Community-Based Interventions in the Fight Against Infection for Achieving the MDGs in the Health Sector in Africa” in November.


Animals And Antibiotic Resistance.

According to some recent estimates, antibiotic usage amongst animals is almost double that of usage amongst humans. Because antibiotic misuse is the major cause of antimicrobial resistance, food-producing animals have become an important reservoir of bacteria such as E. coli and Salmonella spp that are resistant to third generation antibiotics. There is growing concern regarding the possible consequences on human health. In 2006, the use of antibiotics as growth promoters was banned in Europe. Yet, this practice continues in many countries as much antibiotics use on animals is for growth promotion and infection prevention rather than to treat infections. Transmission of bacteria from animals to humans can occur via direct contact, environmental contamination, or via the food chain. International trade in food products means contaminated food is a very efficient mode for the transmission of antibiotic resistance. In the Netherlands, 44 percent of veterinarians are colonized by livestockassociated methicillin-resistant Staphylococcus aureus (also known as MRSA), a bacterium critical to human health. A recent study from the Netherlands demonstrated significant similarity in E.coli strains found in retail chicken meat and humans. This provides strong evidence of the link between antibiotic resistance in animals and human health. Approximately 90 percent of retail chicken samples were contaminated with the bacteria. A similar proportion has been found in retail meat in Spain and Switzerland. Recent reports from several European countries have demonstrated that raw retail chicken meat is commonly contaminated with E.coli resistant to third generation cephalosporins. But there are alternatives. In Denmark, strict policies to control the use of

antibiotics have resulted in a 60 percent reduction of contaminations over the period 1994 to 2001. At the same time, the number of pigs bred for human consumption increased. Dr Andrew Stewardson, a Research Fellow at the University of Geneva Hospitals, says “successful initiatives regarding the rational use of antibiotics… such as those introduced in Denmark, have demonstrated that substantive change is possible without a major negative impact on the foodproduction industry.” The E.coli strain responsible for the outbreak of haemolytic uraemic THEGLOBALJOURNAL.NET 17

syndrome in Europe in 2011 is thought to have been spread in contaminated sprouts, affecting 36 facilities. The same year, the European Food Safety Authority released a report about the public health risk posed by certain types of antibiotics in food and animals intended for human consumption. The report concluded that “prioritisation is complex, but it is considered that a highly effective control option would be to stop all uses of cephalosporins, or to restrict their use to specific circumstances. As co-resistance is an important issue, it is also of high priority to decrease the total antimicrobial use in animal production in the EU.”


Antimicrobial Resistance At The G8 Summit.

treatments, organ transplants and implants, where antibiotics are crucial to ensure patient safety. Yet, at the same time as antibiotic resistance continues to grow, development of new antibiotics is declining. More than a dozen new classes of antibiotics were developed in the 1930s through to the 1960s. Since then, however, there have only been two new classes developed. Currently, antibacterial drugs constitute only 1.6 percent of all drugs in development. Apart from new drugs, there is also a lack of efficient and affordable testing equipment with high sensitivity to distinguish bacterial from viral diseases, and to identify resistant patterns in bacteria.

For the first time in five years, G8 science ministers met on 12 June in London to discuss new and emerging global challenges. Antimicrobial resistance topped the agenda. On the eve of the meeting, the United Kingdom’s (UK) Science Minister, David Willetts, announced, “I want to discuss with my G8 counterparts how we can better address the issue of antibiotic resistance, drawing on the expertise of our science and research bases to speed up the introduction of new drugs. Open data and open access to research are also important international issues that I want to see progress on.” In March, the UK’s Chief Medical Officer, Dame Sally Davies, warned untreatable infections pose a “catastrophic threat” to the population.

She urged health ministers in other countries to prioritize the problem of antimicrobial resistance. “We can’t tackle the problem on our own and urgently need coordinated international action,” she said ahead of the G8 meeting. Afterwards, Willetts reported that “some of us were shocked to find that antibiotics are being put into marine paints to stop barnacles growing on boats.” The consequences of antibiotic resistance for rich and poor countries alike are not just worrying, but potentially devastating. Some fear a return to the conditions of the preantibiotic era. For example, that child mortality from respiratory tract infections – already high in developing countries – could substantially increase. Resistance also jeopardizes advanced medical procedures, such as cancer THE GLOBAL JOURNAL + ICPIC 2013 18

Factors influencing use and misuse of antibiotics include patient demands, poor testing facilities, lack of training among health staff and pharmacists and aggressive marketing by industry to prescribers, consumers and providers. Indeed, it is estimated that 50 percent of antibiotics worldwide are purchased privately without prescriptions. In addition, counterfeit and substandard drugs also contribute to the problem of resistance. The G8 ministers released a joint statement on 14 June, identifying antimicrobial drug resistance as a “major health security challenge of the 21st century.” According to the statement, concrete actions will include coordinated efforts to rein in the use of existing antimicrobials, the development of rapid diagnostics to inform antimicrobial use, incentives for the development of new antimicrobials, international cooperation and surveillance data on drug resistance and theoretical and applied research to better understand the origin, spread, evolution and development of resistance and the role of the innate immune system.


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