Hiệu quả của chương trình quản lý kháng sinh trong việc kiểm soát sử dụng kháng sinh tại khoa Hồi sức tích cực và dự phòng trong phẫu thuật

“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]

The Antimicrobial Stewardship

Program at the ICU and Surgical antibiotic prophylaxis at Cho Ray

hospital

Pham Thi Ngoc Thao MD, PhD

- Vice President of Vietnam National Association of Emergency,

Critical Care Medicine and Clinical Toxycology

- Head of Department of Emergency, Critical Care Medicine and

Clinical Toxycology, University of Medicine and Pharmacy at

Ho Chi Minh City, Vietnam

- Vice Director, Cho Ray hospital

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

• Conclusions

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

ICU PATIENTS ARE AT RISK

• The ICU patients have 2-5 folds of risk of infectioncomparing to the others(1).

• The HAI was 2-3 folds in developing countries(2).

• In Vietnam, a research done in 2012 showed thatVAP 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 trên các bệnh nhân thở máy”

(4) Phạm Thái Dũng, Kiều Chí Thành “Giám sát viêm phổi bệnh viện liên quan tới thở tại khoa Hồi sức cấp cứu Bệnh viện 103.”

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”

SURGICAL SITE INFECTION = SSI

• The infection in ≤ 30 days of surgery or within a year in the case of implants

Mangram (1999), “Guideline for prevention of surgical site infection, Infect Control Hosp Epidemiol

SURGICAL SITE INFECTION

• Covers about 14 -16% of HAI

Case Control* Study of 255 Pairs

SSI RESULTS

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 cardiacsurgery)

4 Cardiac surgery patients with controlled 6 A.M

postoperative serum blood glucose

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 1

or 2 with day of surgery being day zero

Safe Surgery Saves Lives

SURGICAL SAFETY CHECKLIST BY WHO

APPLICATION OF SURGICAL SAFETY CHECKLIST

Variables Baseline Checklist P

BALANCE THE RISK AND BENEFIT

Early, appropriate use to

improve patients’ outcome

Inappropriate use increased risk, cost and

side effect

ANTIBIOTIC USE

Microbial Stewardship

Anti-14

- 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

http://www.cbc.ca/news/canada/saskatoon/saskatoon-health-region-growing-antibiotic-AMS GOALS

• Appropriate, safe antibiotic use

• Reduce LOS

• Reduce the cost

• Reduce Antimicrobial resistance

AMS JOURNEY AT CHO RAY HOSPITAL

• 3 rd

Guideline

IT AP

AMS DONE AT THE ICU, CHO RAY HOSPITAL

• Patients stratification

• The guideline compliance survey

• HAI monitoring

• Antimicrobial resistance survey

• The clinical results and DDD report

PREVALENCE OF CLABSI/1000 VENOUS- DAY

THE DISTRIBUTION OF MULTIDRUG

TT nhiễm khuẩn không thuyên giảm

Đang điều trị chưa đánh

On going treatment

AMS IN SURGICAL PROPHYLAXIS

• Our guidelines in 2010, 2013 and 2016

A STUDY IN 2016

• Cross sectional study : 301 clean, clean

contanminated cases in 2015 retrospectively

• 311 clean, clean contanminated cases in 2016

THE GUIDELINE COMPLIANCE RATE INCREASED

There was significant difference in appropriate dose for surgiacal prophylaxis in 2015 and 2016 (p = 0.0028)

There was associated bettwen inappropriate dose and SSI

THE GUIDELINE COMPLIANCE

IN 2015 AND 2016

P = 0.0028

THE SSI

The SSI was reduced 2% in 2016 comparing to 2015, p<0.05

Reduced inappropriate in 48.4 % patients

Redued 30.000 - 50.000 days of antibiotic treatment

THE COST

THE GUIDELINE COMPLIANCE IN

THE GUIDELINE COMPLIANCE FOR SURGICAL

THE RATE OF ANTIBIOTIC USE

FROM 2013 TO 2017

Hospital acquired infection

HAI AND THE 5 MOST COMMON MDR

BACTERIA

5 most common MDR bacteria

FUTURE PLAN

• AMS will be done in all clinical departments

• Many interventions will be applied at the same time

• Monitor, audit and feedback with long term goals

• IT application

LESSONS LEARNT

• The leadership

• Teamwork

• Encourage and commendation

• Short term and long term goals

• Use EBM with local data

• The HAI was reduced.

• The MDR bacteria was well controlled

• AMS should be done in other hospitals including inlimited resource medical settings