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“Attributable Cost and Length of Stay for Patients With Central Venous Catheter–Associated Bloodstream Infection in Mexico City Intensive Care Units: A Prospective, Matched Analysis”4. ([r]
(1)The Antimicrobial Stewardship Program at the ICU and Surgical antibiotic prophylaxis at Cho Ray
hospital
Pham Thi Ngoc Thao MD, PhD
(2)CONTENT
• Hospital acquired infection at ICU and surgical site infection condition
• The Antimicrobial stewardship Program (AMS) at Cho Ray hospital
• The initial results at the ICU and Surgical prophylaxis • Future plan
(3)ICU PATIENTS ARE AT RISK
• About 30% of ICU patients in developing countries have at least one hospital acquired infection (HAI) (1)
• In USA, there was 417.946 (24,6%) ICU patients had HAI by CDC (2)
• (1) WHO (2006), medical errors: The global big isse http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
(4)ICU PATIENTS ARE AT RISK
• The ICU patients have 2-5 folds of risk of infection comparing to the others(1)
• The HAI was 2-3 folds in developing countries(2)
• In Vietnam, a research done in 2012 showed that VAP was 39.4% at Cho Ray hospital and 51.6% at 103 Military hospital(3), (4)
(1), Ewans TM, Ortiz CR, LaForce FM Prevention and control of nosocomial infection in the intensive care unit
In: Irwin RS, Cerra FB, Rippe JM, editors Intensive Care Medicine 4th ed New York: Lippincot-Ravan; 1999 pp 1074–80 (2) WHO (2006), medical errors: The global big isse http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
(3)Lê Thị Anh Thư “Nhiễm khuẩn bệnh viện bệnh nhân thở máy”
(5)THE COST FOR HAI
• The cost for HAI in Argentina (1):
- For CLABSI was 4.888 USD/case - HAP: 2.255 USD /case
• In Vietnam (1):
- HAI was about 30 - 40%
- The hospital length of stay was 10-15 days longer - The cost was increased 2.9 million VND/case
(*) Francisco Higuera, et al (2015) “Attributable Cost and Length of Stay for Patients With Central Venous Catheter–Associated Bloodstream Infection in Mexico City Intensive Care Units: A Prospective, Matched Analysis”
(6)SURGICAL SITE INFECTION = SSI
• The infection in ≤ 30 days of surgery or within a year in the case of implants
(7)Jarvis, Infection Control Hospital Epidemiology 1996;17
SURGICAL SITE INFECTION
• Covers about 14 -16% of HAI • In about 2-5% operations
• There are about 40 Million operations per year in USA
• There are about 42.000 operations per year at Cho Ray hopstal
• SSI increased hospital length of stay about 7.5 days
• The cost was increased about 2.700 – 36.000 USD/ case
• The medical cost increased 130 - 845 Million USD per year in USA
(8)Case Control* Study of 255 Pairs
infection Non -infection
Readmission 41% 7%
Cost 7.531 Usd 3.844 USD
LOS 11 days days
ICU admission 29% 18%
Mortality 7.8% 3.5%
(9)RISK FACTORS
• Age
• Obesity • DM
• Malnutrition
• Long operation • Distal infection
• Corticosteroides
• Surgical site hygiene • Procedure
• Technique • Drainage
• Inappropriate Antibiotic Prophylaxis • Smoking
(10)THE CARE BUNDLE FOR SSI
1 Prophylactic antibiotic given within one hour prior to surgical incision
2 Appropriate prophylactic antibiotic selection for surgical patients
3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery)
(11)THE CARE BUNDLE FOR SSI
5 Surgery patients with appropriate hair removal
6 Surgery Patients with Perioperative Temperature Management – maintaining normothermia
7 Urinary Catheter removal on postoperative Day or with day of surgery being day zero
(12)Safe Surgery Saves Lives
(13)APPLICATION OF SURGICAL SAFETY CHECKLIST
Variables Baseline Checklist P
Number of patients 3733 3955 -Mortality 1.5% 0.8% 0.003 Complications 11.0% 7.0% <0.001
SSI 6.2% 3.4% <0.001
Re-operation 2.4% 1.8% 0.047
Haynes et al (2009) A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population New England Journal of Medicine
360:491-9
(14)BALANCE THE RISK AND BENEFIT
Early, appropriate use to improve patients’ outcome
Inappropriate use increased risk, cost and
side effect ANTIBIOTIC USE
(15)- THE 30 PRINCIPLE IN AMS
- 30% inpatients were indicated antibiotics
- 30% inappropriate antibiotic usage - 30% Inappropriate antibiotic
surgical prophylaxis
- 30% cost for antibiotic use - AMS reduced 10-30% cost
(16)
AMS GOALS
• Appropriate, safe antibiotic use • Reduce LOS
• Reduce the cost
(17)AMS JOURNEY AT CHO RAY HOSPITAL 2009 2010 2013 2015 2016 2017 2020 Data collection 1st Guideline 2nd Guideline Pilot AMS
• All of
departments
• 3rd
(18)AMS DONE AT THE ICU, CHO RAY HOSPITAL
• Patients stratification
• The guideline compliance survey • HAI monitoring
• Antimicrobial resistance survey
(19)COMPLIANCE 95,5 96 96,5 97 97,5 98 98,5 99 99,5 100 100 97,2
Sample referral prior Antibiotics use (%)
Guideline compliance
(20)PREVALENCE OF VAP/1000 VENTILATED –DAY
MONTH
34,78 39,58
35,84 35,53
38,16
36,84
24,61
21,38 32,01
26,97
30,20
(21)PREVALENCE OF CLABSI/1000 VENOUS- DAY
3,27
5,12
2,22
3,48
7,35
3,33
0,00
2,15
1,10
6,90
2,13
1 2 3 4 5 6 7 8 9 10 11 12
(22)PREVALENCE OF UTI/1000 SONDE –DAY
3,17
1,28
3,38
4,53
2,21
0,00
6,45
1,10
1,14 1,06
1.11
1 2 3 4 5 6 7 8 9 10 11 12
(23)THE DISTRIBUTION OF MULTIDRUG RESISTANT BACTERIA
57,7
46,2 53,2 53,5 58,3
0
100 100
50 25,1 39,4 33,5 28,3 27,3
100
0
0 17,2 14,2 13,3 18,2 14,5
0 0
50
(24)CLINICAL RESULTS
86.7% well-respone (n=811)
Hết nhiễm khuẩn Giảm TT nhiễm khuẩn TT nhiễm khuẩn không thuyên giảm
Đang điều trị chưa đánh giá 59,8 26,9 12,1 1,2
Well Response Decreased infection
Not Response
(25)AMS IN SURGICAL PROPHYLAXIS
• Our guidelines in 2010, 2013 and 2016 • Training courses
• Hospital regulations in SSI classification, Antibiotic prophylasix
• Antibiotic surgical prophylasix should be done before referring patients to OR
• Randomised audit
• Review and feedback
(26)A STUDY IN 2016
• Cross sectional study : 301 clean, clean
contanminated cases in 2015 retrospectively • 311 clean, clean contanminated cases in 2016
prospectively • The outcomes
- Guideline compliance rate - Surface SSI
(27)27
THE GUIDELINE COMPLIANCE RATE INCREASED
There was significant difference in appropriate dose for surgiacal prophylaxis in 2015 and 2016 (p = 0.0028)
Dose 2015 2016
n Incidence (%) n Incidence %
Appropriate 168 58.7 214 68.8
Inappropriate 118 41.3 79 25.4
(28)There was associated bettwen inappropriate dose and SSI
(p <0,05)
Dose
Incidence of SSI in 2015 Incidence of SSI in 2016
Yes No Yes No
Appr 9 (5.3%) 160 (94.7%) 4 (1.9%) 210 (98.1%)
Inappr (6.8%) 110 (93.2%) (11.4%) 70 (88.6%) Total 17 (5.9%) 270 (94.1%) 13 (4.4%) 280 (95.6%)
(29)THE GUIDELINE COMPLIANCE IN 2015 AND 2016
P = 0.0028
(30)THE SSI
(31)Year 2015 2016 Variables N Incidenc
e (%)
N Incidence (%)
Appr 33 14.0 128 62,4
Inappr
202 86.0 77 37,6
Total 235 100.0 205 100.0
Reduced inappropriate in 48.4 % patients
Redued 30.000 - 50.000 days of antibiotic treatment
THE COST
(32)THE GUIDELINE COMPLIANCE IN 2017 BY MONTHLY
71,9
35
73,8 73,1
59,8
90,4
73,2 83,3
77,2 80,7
90,4
80,6
(33)THE GUIDELINE COMPLIANCE FOR SURGICAL PROPHYLAXIS FROM 2015 TO 2017
14
62,4
76,6
Năm 2015 Năm 2016 Năm 2017
(34)21,3%
20,4%
18,5%
17,2% 17,05%
2013 2014 USD2 M 2015 2016 2017
1 M
USD 200.000 USD
(35)Hospital acquired infection
HAI AND THE MOST COMMON MDR BACTERIA
(36)FUTURE PLAN
• AMS will be done in all clinical departments
(37)LESSONS LEARNT
• The leadership • Teamwork
• Encourage and commendation • Short term and long term goals • Use EBM with local data
(38)CONCLUSIONS
• The AMS at Cho Ray hospital has a good initial results at the ICU and Surgical prophylaxis
• The guideline compliance increased and the DDD reduced annually
• The HAI was reduced
• The MDR bacteria was well controlled
(39) http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf