Swedish situation - facilitators and barriers for guidelines concerning infection control and AMR

Swedish situation - facilitators and barriers for guidelines concerning infection control and AMR Birgitta Lytsy, MD, PhD Departmen of Clinical Microbiology and Infection Control Uppsala University Hospital

Sweden 10 university hospitals 80 regional hospitals Regions and counties Municipalities Majority of hospitals is public and funded by taxes

What are the facilitators?

Good surveillance of HAI-Health-care associated infections Antibiotic presciption Antibiotic resistance

Point-prevalence studies of HAIs 5 Since 2008 8,7% 9,0% 8,9% 8,9% 9,3% 9,2% 9,4% 9,6% 8,9% 11,0% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% HT1 3 VT1 3 HT1 2 VT12 HT1 1 VT 11 HT 10 VT 10 HT 09 VT 09 9,7% HT0 8 8,9% VT14 Källa: PPM-VRI

Infections 1 Surgical site infections 2 Drug related infections (C difficile) 3 Other HAI related to devices 4 Other 5 Riskfactors: mechanical ventilation, urinary tract infection, surgery, immunosuppression, central lines, antibiotic therapy 6

Point-prevalence studies University hospitals in Sweden Förekomst av vårdrelaterade infektioner, Regionssjukhus (somatik) 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Akademiska sjukhuset Karolinska Universitetssjukhuset Linköping Norrlands Universitetssjukhus S:t Eriks Ögonsjukhus Sahlgrenska Universitetssjukhuset Skånes Universitetssjukhus SUS Lund SUS Malmö Universitetssjukhuset Örebro HT 08 HT 09 HT 10 HT11 HT12 VT13 HT13 Uppsala University Hospital 11 %

Prevalence of riskfactors 8 2016-

Since 2013: Incidence of HAI Infection tool : [Infektioner] fördelat på [Vård/Samhälle], avgränsad till [Tidsperiod: Senaste året (2015-02-16-2016-02-15)], [Organisatorisk enhet: Akademiska sjukhuset, Affektiva sjukdomar, Akut- och konsultpsykiatri]

Healthcare-associated infections at UUH 2015 : [Infektioner] fördelat på [Infektion], avgränsad till [Tidsperiod: Senaste året (2015-02-16-2016-02-15)], [Organisatorisk enhet: Akademiska sjukhuset, Affektiva sjukdomar, Akut- och konsultpsykiatri], [Vård/Samhälle: Vårdrelaterad]

Ward level Medical ward : [Infektioner] fördelat på [Vård/Samhälle], avgränsad till [Tidsperiod: Förra året (2014-01-01-2014-12-31)], [Organisatorisk enhet: Medicinavdelning 30 E, Uppsala]

CA-infections in the medical ward 2014 : [Vårdtillfällen] fördelat på [Infektion], avgränsad till [Tidsperiod: Förra året (2014-01-01-2014-12-31)], [Organisatorisk enhet: Medicinavdelning 30 E, Uppsala], [Infektion: Lunginflammation - samhälle, Exacerbation av KOL, Urinvägsinfektion med feber - samhälle, ]

Typ av SFI 30E : [Vårdtillfällen] fördelat på [Infektion], avgränsad till [Tidsperiod: Förra året (2014-01-01-2014-12-31)], [Organisatorisk enhet: Medicinavdelning 30 E, Uppsala], [Infektion: Lunginflammation - samhälle, Exacerbation av KOL, Urinvägsinfektion med feber - samhälle, ]

Typ av VRI 30E : [Vårdtillfällen] fördelat på [Infektion], avgränsad till [Tidsperiod: Förra året (2014-01-01-2014-12-31)], [Organisatorisk enhet: Medicinavdelning 30 E, Uppsala], [Infektion: Lunginflammation - vård, Urinvägsinfektion med feber - vård, ]

Typ av VRI 30E : [Vårdtillfällen] fördelat på [Infektion], avgränsad till [Tidsperiod: Förra året (2014-01-01-2014-12-31)], [Organisatorisk enhet: Medicinavdelning 30 E, Uppsala], [Infektion: Lunginflammation - vård, Urinvägsinfektion med feber - vård, ]

C difficile 2014 30F 2014 30E 2014

SWEDRES SVARM 2013 Yearly national report on antibiotic use and resistance in human and veterinary medicine

Quarterly reports AB prescription

Quarterly reports AB prescription

DDD/1000 inhabitants and day 18 16 14 12 10 8 6 4 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Outpatent care Hospital care Källa: Folkhälsomyndigheten 2014 Antibiotic sale

DDD/1000 inhabitants and day 4 3,5 3 2,5 2 1,5 1 0,5 0 Outpatient care Hospital care Källa: Folkhälsomyndigheten 2014 AB prescribed for ambulatory care

Prescriptions Antibiotics commonly used to treat respiratory tract infections Antibiotics commonly used to treat skin and soft tissue infections Antibiotics commonly used to treat urinary tract infections Antibiotics commonly used to treat acne 300000 250000 200000 150000 100000 50000 0 0-4 years 5-9 years 10-14 years 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50-54 years 55-59 years 60-64 years 65-69 years 70-74 75-79 80-84 85-89 90 - years years years years years Källa: Folkhälsomyndigheten 2014 AB prescribed for respiratory infections

Number of cases per 100 000 inhabitants Ecoli, women Ecoli, men Kpneumoniae, women Kpneumoniae, men 300 250 200 150 100 50 0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 >85 Källa: Folkhälsomyndigheten 2014 ESBL-producers by age

Number of cases Domestic Imported Other/missing 45 40 35 30 Origin of ESBL 25 20 15 10 5 0 2007 2008 2009 2010 2011 2012 2013 Källa: Folkhälsomyndigheten 2014 Figure 23 2

Number of cases Domestic Imported Domestic/Imported Imported/Domestic No data 3000 2500 Origin of MRSA 2000 1500 1000 500 0 2006 2007 2008 2009 2010 2011 2012 2013 Källa: Folkhälsomyndigheten 2014 Figure 25 2 2016-

Guidelines in place HAI-Health-care associated infections Antibiotic presciption

Medical Protection Agency Care programmes to control prescription and AMR Examples: Antibiotic prophylaxis dental care Antibiotic use pregnancy Tonsillitis, mediaotitis children Pneumonia Urinary tract infection women and men STI

SE: Regulation on Basic hygiene 2007 All staff shall during examination, care and treatment or other direct contact with patients observe this regulation Includes: Dresscode Handhygiene Gloves Apron

Hands Alcohol-based disinfectant Before and after tending to a patient

Access to disinfectants everywhere

Uniform code Short sleeves No rings No wristwatches No bracelets Makes proper desinfection of hands possible

All cathegories of staff clothes gets contaminated change every day

Gowns or aprons for close contacts With bed and patients

Gloves only when risk of touching secretions, excretions risk and contaminated and dirty equipment

Alerts patients visitors staff

What are the barriers?

Gap There is a gap between what we DO and what we KNOW Some existing knowledge is not applied sufficiently 3 2016-

The traditional approaches

Overcorowded hospitals

UUH Uppsala University Hospital All wards have 2-3 extra beds Staff is not dimensioned to care for them but have to In corridors, treatment rooms, storage rooms and showers

Consequences 1 pat could be moved within and between wards up to 6 times during a few days stay due to overcrowding Risk of transmission of pathogens and resistant bacteria between patients Nurses flee the hospitals

320 patients ESBL-producing Klebsiella pneumoniae 2007: 30 billion SEK ESBL- K pneumoniae 30 25 20 15 Screening odling Klin odl 10 5 0 Maj Juni Juli Aug Sept Okt Nov Dec Jan Feb Mars April Maj Juni Juli Aug Sept Okt Nov Dec Jan Feb Mars April Maj Juni Juli Aug Sept Okt Nov Dec Jan Feb Mars April Maj Juni Juli Aug Sept 2005 2006 2007 2008 Ransjö, Lytsy, Aspevall et al Journal of Hospital Infection 2010

Investigation by Infection and Prevention Control Team Severe underlying disesases Several risk factors for transmission Lack of single rooms Permanent extra beds (2-3/day) Insufficient cleaning of rooms between patients

Clements et al Lancet Inf Dis 2008

Zingg et al Lancet Inf Dis 2014;

Compliance to hand hygiene decreases due to tiredness Dai, H et al J Appl Psychol 2015; 100:846-62 Compliance hand hygiene decreases over time from 40,2 ->34,8% after 12 hours work (p < 0,0001)

Risk tiredness Every 1 % decrease in compliance to hand hygiene increases the risk of HAI by 3,9/1000 pat Pittet, D Lancet 2000; 356:1307-1312

Swedish situation 2015 Summary Excellent surveillance Less actions and interventions Health-care system is overcrowded and understaffed