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<b>Pham Thi Ngoc Thao MD, PhD</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
• 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
• 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”
• 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.
(*) 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”
• The infection in <i>≤ 30 days of surgery or within a </i>
<i>year in the case of implants</i>
Jarvis, Infection Control Hospital Epidemiology 1996;17
• 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
<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%
• Age
• Obesity
• DM
• Malnutrition
• Long operation
• Distal infection
• Corticosteroides
• Surgical site hygiene
• Procedure
• Technique
• Drainage
• Inappropriate Antibiotic Prophylaxis
• Smoking
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)
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.
<i>Safe Surgery Saves Lives</i>
<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.
<b>BALANCE THE RISK AND BENEFIT </b>
Early, appropriate use to
improve patients’ outcome
Inappropriate use
increased risk, cost and
side effect
- 30% inpatients were indicated
antibiotics
- 30% inappropriate antibiotic usage
- 30% Inappropriate antibiotic
surgical prophylaxis .
- 30% cost for antibiotic use .
- AMS reduced 10-30% cost
• Appropriate, safe antibiotic use
• Reduce LOS
• Reduce the cost
• <b>All of </b>
<b>departments</b>
• <b>3rd </b>
<b>AMS DONE AT THE ICU, CHO RAY HOSPITAL</b>
• Patients stratification
• The guideline compliance survey.
• HAI monitoring
• Antimicrobial resistance survey
Sample referral prior
Antibiotics use (%)
Guideline compliance
<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>26,97</b>
<b>30,20</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>
<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>
57,7
46,2 53,2 53,5 58,3
0
100 100
50
25,1 <sub>39,4</sub> 33,5 <sub>28,3</sub> 27,3
100
0 0
0
17,2 14,2 13,3 18,2 14,5
0 0 0
50
86.7% well-respone (n=811)
Hết nhiễm
khuẩn
Giảm TT
nhiễm khuẩn
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>
• 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
• 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
<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 <sub>168</sub> <b><sub>58.7</sub></b> <sub>214</sub> <b><sub>68.8</sub></b>
Inappropriate <sub>118</sub> <sub>41.3</sub> <sub>79</sub> <sub>25.4</sub>
<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%)
<b>P = 0.0028</b>
<b>Year</b> <b>2015</b> <b>2016</b>
<b>Variables</b> N Incidenc
e (%)
N Incidence
(%)
<b>Appr</b> <sub>33</sub> <b><sub>14.0</sub></b> <sub>128</sub> <b><sub>62,4</sub></b>
<b>Inappr</b>
202 86.0 77 37,6
<b>Total</b> <sub>235</sub> <sub>100.0</sub> <sub>205</sub> <sub>100.0</sub>
Reduced inappropriate in 48.4 % patients
Redued <b>30.000 - 50.000 days of antibiotic treatment</b>
<b>71,9</b>
<b>35</b>
<b>73,8</b> <b><sub>73,1</sub></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>
<b>14</b>
<b>62,4</b>
<b>76,6</b>
Năm 2015 Năm 2016 Năm 2017
<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><sub>USD</sub>2 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>
<b>Hospital acquired infection </b>
• AMS will be done in all clinical departments
• The leadership
• Teamwork
• Encourage and commendation
• Short term and long term goals
• Use EBM with local data
• 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.