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

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<b>The Antimicrobial Stewardship </b>

<b>Program at the ICU and Surgical </b>

<b>antibiotic prophylaxis at Cho Ray </b>

<b>hospital </b>

<b>Pham Thi Ngoc Thao MD, PhD</b>

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<b>CONTENT </b>

• 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

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<b>ICU PATIENTS ARE AT RISK</b>

• 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

/>

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<b>ICU PATIENTS ARE AT RISK</b>

• 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 />

(3)Lê Thị Anh Thư. “Nhiễm khuẩn bệnh viện trên các bệnh nhân thở máy”

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<b>THE COST FOR HAI </b>

• 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”

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<b>SURGICAL SITE INFECTION = SSI</b>

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

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Jarvis, Infection Control Hospital Epidemiology 1996;17

<b>SURGICAL SITE INFECTION </b>

• 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.

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<b>Case Control* Study of 255 Pairs</b>

infection Non -infection

Readmission 41% 7%

Cost 7.531 Usd 3.844 USD

 LOS 11 days 6 days

ICU admission 29% 18%

Mortality 7.8% 3.5%

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<b>RISK FACTORS </b>

• Age

• Obesity
• DM

• Malnutrition

• Long operation
• Distal infection

• Corticosteroides

• Surgical site hygiene
• Procedure

• Technique
• Drainage

• Inappropriate Antibiotic Prophylaxis
• Smoking

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<b>THE CARE BUNDLE FOR SSI </b>

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)

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<b>THE CARE BUNDLE FOR SSI </b>

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.

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<i>Safe Surgery Saves Lives</i>

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<b>APPLICATION OF SURGICAL SAFETY CHECKLIST </b>

<b>Variables </b> <b>Baseline</b> <b>Checklist</b> <b>P</b>

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. <i>New England Journal of Medicine</i>

360:491-9.

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<b>BALANCE THE RISK AND BENEFIT </b>

Early, appropriate use to
improve patients’ outcome

Inappropriate use
increased risk, cost and

side effect

<b>ANTIBIOTIC USE </b>

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-

<b>THE 30 PRINCIPLE IN AMS </b>

- 30% inpatients were indicated
antibiotics

- 30% inappropriate antibiotic usage
- 30% Inappropriate antibiotic

surgical prophylaxis .

- 30% cost for antibiotic use .
- AMS reduced 10-30% cost

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<b>AMS GOALS</b>

• Appropriate, safe antibiotic use
• Reduce LOS

• Reduce the cost

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<b>AMS JOURNEY AT CHO RAY HOSPITAL</b>

<b>2009</b>
<b>2010</b>
<b>2013</b>
<b>2015</b>
<b>2016</b>
<b>2017</b>
<b>2020</b>

<b>Data </b>
<b>collection</b>
<b>1st </b>
<b>Guideline </b>
<b>2nd </b>
<b>Guideline </b>
<b>Pilot AMS </b>

• <b>All of </b>

<b>departments</b>

• <b>3rd </b>

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<b>AMS DONE AT THE ICU, CHO RAY HOSPITAL</b>

• Patients stratification

• The guideline compliance survey.
• HAI monitoring

• Antimicrobial resistance survey

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<b>COMPLIANCE </b>

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

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<b>PREVALENCE OF VAP/1000 </b>

<b>VENTILATED –DAY</b>

<b>MONTH</b>

<b>34,78</b>
<b>39,58</b>

<b>35,84</b>
<b>35,53</b>

<b>38,16</b>

<b>36,84</b>

<b>24,61</b>

<b>21,38</b>

<b>32,01</b>

<b>26,97</b>

<b>30,20</b>

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<b>PREVALENCE OF CLABSI/1000 VENOUS- DAY</b>

<b>3,27</b>

<b>5,12</b>

<b>2,22</b>

<b>3,48</b>

<b>7,35</b>

<b>3,33</b>

<b>0,00</b>

<b>2,15</b>

<b>1,10</b>

<b>6,90</b>

<b>2,13</b>

<b>1</b> <b>2</b> <b>3</b> <b>4</b> <b>5</b> <b>6</b> <b>7</b> <b>8</b> <b>9</b> <b>10</b> <b>11</b> <b>12</b>

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<b>PREVALENCE OF UTI/1000</b>

<b>SONDE –DAY </b>

<b>3,17</b>

<b>1,28</b>

<b>3,38</b>

<b>4,53</b>

<b>2,21</b>

<b>0,00</b>

<b>6,45</b>

<b>1,10</b>

<b>1,14</b> <b>1,06</b>

<b>1.11</b>

<b>1</b> <b>2</b> <b>3</b> <b>4</b> <b>5</b> <b>6</b> <b>7</b> <b>8</b> <b>9</b> <b>10</b> <b>11</b> <b>12</b>

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<b>THE DISTRIBUTION OF MULTIDRUG </b>

<b>RESISTANT BACTERIA </b>

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

0
17,2 14,2 13,3 18,2 14,5

0 0 0

50

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<b>CLINICAL RESULTS </b>

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

<b>Well Response Decreased </b>
<b>infection </b>

<b>Not </b>
<b>Response</b>

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<b>AMS IN SURGICAL PROPHYLAXIS </b>

• 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

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<b>A STUDY IN 2016 </b>

• 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

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<b>THE GUIDELINE COMPLIANCE RATE INCREASED</b>

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

Dose 2015 2016

n Incidence (%) n Incidence %

Appropriate ₁₆₈ <b>_58.7</b> ₂₁₄ <b>_68.8</b>

Inappropriate ₁₁₈ _41.3 ₇₉ _25.4

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<i>There was associated bettwen inappropriate dose and SSI </i>

<i>(</i>p <0,05)

Dose

<b>Incidence of SSI in 2015 </b> <b>Incidence of SSI in 2016 </b>

Yes No Yes No

<b>Appr</b> <b>9 (5.3%)</b> 160 (94.7%) <b>4 (1.9%)</b> 210 (98.1%)

Inappr 8 (6.8%) 110 (93.2%) 9 (11.4%) 70 (88.6%)
Total <b>17 (5.9%)</b> 270 (94.1%) <b>13 (4.4%)</b> 280 (95.6%)

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<b>THE GUIDELINE COMPLIANCE </b>

<b>IN 2015 AND 2016 </b>

<b>P = 0.0028</b>

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<b>THE SSI </b>

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<b>Year</b> <b>2015</b> <b>2016</b>
<b>Variables</b> N Incidenc

e (%)

N Incidence
(%)

<b>Appr</b> ₃₃ <b>_14.0</b> ₁₂₈ <b>_62,4</b>

<b>Inappr</b>

202 86.0 77 37,6

<b>Total</b> ₂₃₅ _100.0 ₂₀₅ _100.0

Reduced inappropriate in 48.4 % patients

Redued <b>30.000 - 50.000 days of antibiotic treatment</b>

<b>THE COST </b>

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<b>THE GUIDELINE COMPLIANCE IN </b>

<b>2017 BY MONTHLY</b>

<b>71,9</b>

<b>35</b>

<b>73,8</b> <b>_73,1</b>

<b>59,8</b>

<b>90,4</b>

<b>73,2</b>
<b>83,3</b>

<b>77,2</b> <b>80,7</b>

<b>90,4</b>

<b>80,6</b>

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<b>THE GUIDELINE COMPLIANCE FOR SURGICAL </b>

<b>PROPHYLAXIS FROM 2015 TO 2017</b>

<b>14</b>

<b>62,4</b>

<b>76,6</b>

Năm 2015 Năm 2016 Năm 2017

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<b>21,3%</b>

<b>20,4%</b>

<b>18,5%</b>

<b>17,2%</b> <b>17,05%</b>

<b>2013</b> <b>2014</b> <b>_USD2 M </b> <b>2015</b> <b>2016</b> <b>2017</b>

<b>1 M </b>

<b>USD </b> <b>200.000 </b>
<b>USD</b>

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<b>Hospital acquired infection </b>

<b>HAI AND THE 5 MOST COMMON MDR </b>

<b>BACTERIA </b>

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<b>FUTURE PLAN </b>

• AMS will be done in all clinical departments

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<b>LESSONS LEARNT </b>

• The leadership
• Teamwork

• Encourage and commendation
• Short term and long term goals
• Use EBM with local data

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<b>CONCLUSIONS</b>

• 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.

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