We have received a conference report from Muchaneta Mugabe, Medical Laboratory Scientist,National Microbiology Reference Laboratory, Harare, Zimbabwe following recent attendance at ICPIC 2017, Geneva, Switzerland.

Introduction.

Infection prevention and control has become an established entity in the health field. A lot of health problems can be solved by introducing infection control practices and antimicrobial stewardship in health facilities. Hand hygiene has been considered the most important tool in combating  transmission of infections while antimicrobial stewardship helps in controlling and preventing transmission and the rapid development of multi drug resistant  infections. Different studies done in different countries have proved the importance of infection control practices in fighting against mortality and morbidity and reducing the health economic costs which have become a burden in most countries ` economies.  This has given rise to the need of countries to meet and share information, experiences and strategies to work together to help fight the emerging diseases posing public health threats such as EBOLA, ZIKA, gram negative multidrug resistant organisms and Hospital Acquired infections (HAI).

This conference was organized by experts from different societies such as the European Society of Clinical Microbiology (ESCMID), the Infection Control African Network (ICAN), World Health Organisation, the Asia Pacific Society of Infection Control (APSIC) and Society of Health Epidemiology of America (SHEA). The conference scientific programme was fully packed with informative activities such as ICPIC key notes symposia pro-con debates, free papers and meet the expert sessions.

The International conference on Prevention and infection control (ICPIC) had the main objective of providing a platform or forum for the exchange of knowledge and experience in the prevention of health care associated infections and the control of antimicrobial resistance around the world.

Summary of activities

There were 6 rooms in which different presentations took place on different topics (rooms 1,2,3,4,15 and 16).

From 8am-8:50am everyday, it was the meet the expert session. In these sessions, I benefited from the experiences shared by experts in the field of antimicrobial stewardship and infection control in hospitals. This was an enlightening experience that brought to the mind a lot of possible ways that can be used in hospitals to combat the threat of antimicrobial resistance.  There were also discussions on Multidrug resistant organisms mainly the Gram negative organisms and the MRSA and how infection control practices can help dramatically to reduce the spread of those infections in the hospital. There were also calls for health workers to have infection control committee so as to work as a unit sharing ideas and helping each other in antimicrobial stewardship to avoid misuse of antibiotics.

 Hospital based surveillance of infection was said to be the important tool that will indicate as a dash board where we identify problematic infections. This will also indicate the working and nonworking strategies. There is need to avoid outbreaks than fire fight whilst lives have been lost.

It was difficult for me to decide which room to attend as there would be areas of interest being presented at the same time in different rooms.

 My main areas of interest were antimicrobial resistance and surveillance and HAI.

Sessions on antimicrobial stewardship and costs of resistance and surveillance. These presentations where done in different auditoriums.

Lessons learned:

Antibiotics pressure was explained as the pressure caused by some antibiotics when they kill susceptible organisms and let the resistant one thrive. This selective pressure was linked to antibiotics misuse.

Microbiology laboratories need to be capacitated and be recognized in infection prevention control and antimicrobial stewardship. There is a need to have standardized procedures and work to be divided among laboratories. Laboratories should have levels, those who perform clinical and general tests, then higher levels which specialise in certain tests. And that each country should have referral laboratories which should be research oriented and can be the source of standard for lower level laboratories.

Investments to be done as we forge the fight of disease spread

  • Lab infra-structure enhancement
  • Surveillance system strengthening
  • Building foundation for AMR surveillance Data
  • Antimicrobial stewardship (AMR)

Reduce emergency and interrupt the spread: this call enlightened us on how infection control is the backbone of reducing infections. To fulfill this health care workers should have passion for their work and have standardised protocols and be visible in planning programmes that can be aired out on media such as newspapers and television. The infection control people should be visible to the world using all kinds of media that will make them known in the community.

Surgical site infection: surveillance of surgical site infections should be carried out in hospitals. During surveillance, there is need for accurate data collection and reporting. Phone call proved to be a better intervention in getting correct surgical site infection data than log books. Studies have shown that surgical preoperative prophylaxis is better than post-operative antibiotics.

General hands, janitors, drivers, and lab assistants have been generally left out in Infection control training. Theses have a large part to play in infection control or infection spread.  They are to be involved all training as they have a large part to play in safety of the environment.

Sterility effectiveness using any method of sterilization has not yet been evaluated, there seem to be as nothing published on how effective is sterilization. In the meantime healthcare facilities should use the document on sterilization found on WHO website.

Fleming fund: Fleming`s fund uses Taxpayer`s money. Therefore this money should be used wisely to the satisfaction of the tax payer. $265 million has been set aside for the AMR project worldwide. The fund aims to ensure that laboratories are functional from the lower level laboratory to the higher level (referral Laboratories). This fund is already working in more than 100 countries where project proposals are underway and at different stages of development or implementation. The GLASS document is an ambitious document difficult to implement, time consuming and has personnel challenges whereas Fleming  fund want baseline visibility.

WHO on AMR: the World Bank has set aside 9 billion dollars yearly for AMR to avoid the crisis of incurable infections by 2050.  The one health approach programme will be used in which partners such as FAO, WHO, OIE have come together tow work on this project. Some countries are still doing situational analysis and some are on preliminary stages of implementation. The one health approach includes the state on animal, human and agriculture in antimicrobial resistance. One health awareness campaign should be carried out to bring visibility of knowledge of this programme to everyone. Countries to select sites that commit to send surveillance data. In the beginning the data can be monitoring just one organism per site. WHO has a model in trying to reduce antibiotic misuse: the list of essential medicines and has classified them under

  • Access Antibiotics that should be available for use
  • Watch: antibiotics that are recommended for second choice
  • Reserve antibiotics

Controlling misuse of antibiotics: the carrot and stick procedure in Australian programmes:

Carrot:This is when antimicrobial stewardship is encouraged. The stick is when it is enforced/ there should be auditing of prescribed antibiotics. If the drugs that have been prescribed have been released by the pharmacist without approval, its  illegal and punishable. If the Nurse in the ward goes on to administer antibiotics not approved they should also be penalised. Checking outpatients’ records of prescription against what is allowed to be prescribed. Medical AID societies to be advised not to reimburse antibiotics used without evidence of bacterial infection.

Antimicrobial resistance

 Hospital acquired infections and antimicrobial misuse are at a rise. Countries should have National infection prevention policies (IPC) in place. MRSA, ESBL, CRE and MDRGNO are frighteningly causing mortality and morbidity and the only best way to controlling by implementation of IPC.  There is work being done to try and produce new antibiotics which are to be expected between2018-2020. So far new antibiotics in the making are organisms targeted. Specific  antibiotics e.g Delafloxacin for Gram positive, Plazomicin for Enterobacteriaceae and Murepavidin   for Pseudomonas.

A study was done to compare incidence of ESBL transmission in hospitals by control isolation versus the standard procedure methods for all patience identified to be ESBL carriers. Single bedroom treatment was compared to multiple room treatment in reducing Hospital acquired infection spread. The rate of transmission was measured over a period of time. The result was that there was no significant difference in incidence of ESBL transmission in both environments. Therefore the conclusion was ESBL carriage or acquisition does not mean transmission. There are noted disadvantages for the single room isolation method, which are social isolation and reduced quality care and that it is expensive to implement. Some arguments were that there is no need to isolate patients whilst they use the same toilet. Finally the conclusion agreed was that IPC at every stage makes a great difference whether using single approach or multimodal approach. Hospitals need to improve on COMPLIANCE!. Many compliance studies and posters have shown a great difference and improvement in ESBL transmission as long as infection control practices are being adhered to.

Hand hygiene

Hand hygiene is practiced in most country hospitals now than before but has not yet been implemented to the expected levels.  The gathered information from presenters and poster presentation show that there has been low compliance to hand hygiene in hospitals implementing it due to the tedious steps that need to be done before the clinicians go to the next patient. The introduced 6 steps in most countries and 7 in France are taking about 30sec long. Therefore 3 step methods which takes 15 seconds has been evaluated in other studies and have been seen to take lesser time and is as effective as the 6/7 step procedure. Some hospitals are already implementing the 3 steps and they have seen improvement in hand hygiene compliance. The three steps   are 1)mix 2)fingers 3)thumbs and they advise to start with fingers as they are the main areas that get contaminated. The effectiveness of the 3 or 6 steps depend on the size of the hand, volume of handrub and scrubbing of important parts (.especially the fingers)

There are questions still unanswered on hand hygiene: what threshold of l og reduction of bacteria in the health care workers is acceptable?  Is there a clinically meaningful threshold to evaluate hand rub? There is need for evidence based evaluation of hand rub.

 Bathing and HAI prevention: daily bathing with 1% chlorhexidine in ICU led to prevention of MDRO in 24 weeks

Use of gloves substantially reduces infections but there is need to practice hand hygiene before and after use of gloves. The use of gloves affects hand hygiene adherence and gives HCW complacency and a false sense of security. There is need to enforce hand hygiene even when gloves prove to reduce infection there is still risk of infection

Exhibition

There was range of infection control products being marketed and advertised. These products if they would be afforded would go a long way in eradicating infection transmission. The main drawback is that most hospitals are economically challenged and might not be able to sustain procurement and use of such product. There are some hospitals which are using those products and they are able to procure through funders. But the disadvantage is as soon as funders pull out sustainability becomes a problem. Amazing products such bed pans and urinaries which have absorbents which will ensure non-leakages were also exhibited by different companies, and a variety of alcohol hand rubs. Antimicrobial resistance and Infection Control journal (ARIC)& BMC journal stand providing guidelines for publishing papers.

Poster viewing, guided poster tours and visiting of exhibitions were done during the lunch hour. Most countries are carrying out studies and bringing out evidence based facts on the importance of hand hygiene and antimicrobial stewardship. These all are the right-hand man of the infection control. They cannot be separated, as long as infection control practices are adhered to, antimicrobial resistance and transmission of super bugs will be controlled or even eliminated. There was also evidence of guidelines put in place and some researches done but no implementation.

 Throughout the tours and poster viewing what came out as the main limiting factors to progress of infection control in most countries or hospitals in the lack of unity among health care professional. Very few testified of unity in purposes and understanding of the great success that can be achieved in saving lives if all departments work together in infection control committees to fight against MDRO.

IT was an exciting conference where knowledge was indeed shared fulfilling the main objective of the conference to provide a platform for knowledge exchange. I feel motivated to keep pursuing the goal of finally having a functional infection control committee through providing evidence of the need in our hospital setting.

My Participation: I had the privilege of participating on the guided tour poster presentation. My presentation was entitled: Approaches To Detecting Gram-Negative Bacteria In The Hospital Environment And On Hands In An African Hospital Setting.

 Acknowledgement

I would like to greatly appreciate the funding provided by ICAN, ICPIC and the academy of Medical science (UK) and the support offered by ICAZ in ensuring my conference attendance.

 Report compiled by Muchaneta Mugabe