>> And welcome to this webinar session in honor
of World Antimicrobial Resistance Awareness Week.
Today's webinar is The Race Against Antimicrobial Resistance
in Neonates, Insights on Data,
Infection Prevention, and Stewardship.
We are excited to host the webinar and hear
from our speakers and panelists.
We will have three presentations followed by a panel discussion.
I am Katie Wilson, an epidemiologist
in the International Infection Control Branch here
at the U.S. CDC.
I will be moderating this session alongside Dr. Fernanda
Lessa, who is Chief
of the International Infection Control Branch.
A couple of notes for everyone as we get started,
French and Spanish interpretation is available
for this webinar.
In your bottom Zoom menu, click the globe icon
to access channels for Spanish and French interpretation.
If you have any questions for the presenters or panelists,
please use the Q&A, the questions and the answers button
on your bottom menu, to submit your question,
and we will be answering those live throughout the webinar.
If you would like to introduce yourself or have any questions
about interpretation, or if you are having any technical issues,
please use the chat function of this webinar.
I will now turn it over to Fernanda
to introduce our first session and speaker.
>> Good morning, everyone, good afternoon or good evening,
depending on where you are.
Thanks for joining us today for this important webinar session.
It's my pleasure to introduce our first speaker,
Dr. Amelia Keaton, who is a medical officer
within the CDC International Infection Control Branch,
where her work focuses on detection, prevention
and response to healthcare-associated infections
in low- and middle-income countries.
As a pediatric infectious diseases physician,
she has a special interest in developing resources
and guidance for neonatal care units
and other pediatric healthcare.
So Amelia, over to you.
If you are speaking, Amelia, on mute.
>> Sorry about that.
It took me a second to swap over.
Are folks able to see my screen correctly?
>> It's not on presentation view.
>> Okay, one second.
>> Perfect.
Thanks, Amelia.
>> Great. Thanks, everyone, and thank you for having me today.
My goal for the sessions -- excuse me --
for my presentation today are to provide an overview
of the unique aspects of neonatal healthcare settings.
And just for reference, a neonate, for the purposes
of this talk, is an infant who is less than 30 days of age.
I also hope to discuss global disparities
in neonatal mortality caused by infections,
and then review the epidemiology and impact
of antimicrobial-resistant infections.
So newborn infants have a lot going on.
All newborns, as soon as they're born, need to learn quickly how
to breathe independently, receive appropriate nutrition,
and fight infections with a very immature immune system
that has not seen a lot of the organisms that they're coming
in contact with when they first enter the world.
However, fortunately for all of us, most infants that are born
at term, which is on or after 37 weeks of gestation,
handle these challenges with few
or no medical interventions and do just fine.
However, infants that are born either prematurely
or with low birth weight or with other congenital health
conditions face a lot more challenges
that require many more medical interventions in some cases.
So to begin, these infants tend
to have an immature skin barrier,
and that's why we use temperature-controlled isolates,
such as the one shown in this photo.
Second, they also have incomplete lung maturation,
as well as nervous -- central nervous systems,
which impairs their ability to breathe independently,
and for these reasons, we often see infants requiring invasive
or non-invasive respiratory support.
And in some cases, they develop hemodynamic instability.
Next, we often see that infants
that are born before a certain gestational age do not
yet have the ability to feed independently,
and so often they will require feeding in G-tubes
or peripheral nutrition via a central
or peripheral venous catheter.
And then finally, these infants are often at a much higher risk
for infection, and some of this has to do with the fact
that maternal placental antibody transfer
that typically occurs during the third trimester
of pregnancy has not occurred yet, and so in addition
to having an immature system as any other newborn would,
they are also starting it a bit of a --
they have limited antibodies
that they've received from their mothers.
And so I know a lot of people who don't work in pediatrics
or in newborn medicine often walk by newborn care units
and get very intimidated, but what I try to remind people
of is that infants in these units typically have the same
risk factors for healthcare-associated infections
as older children and adults
that are also receiving medical care,
meaning that they have a weakened immune system
because of critical illness.
They typically have a compromised skin barrier.
They have a lot of different caregivers.
They typically require a long length of stay,
and they often have the presence of medical devices,
all of which increase their risk for infection.
Moving on to where these infections are most frequent,
we know that mortality and morbidity
from infections are highest in low-
and middle-income countries.
Approximately 99% of global neonatal mortality occurs
in countries that are classified as low and middle income,
with the countries in Africa
and Southeast Asia being the hardest hit.
Among infants that are born in a hospital in these settings,
healthcare-associated infections may account for anywhere from 4%
to over 55% of neonatal deaths, depending on the setting.
And when we look at the pathogens
that are causing neonatal infections and neonatal sepsis,
we also see differences by the income level of the country
in those pathogens, but also in mortality.
So on the left, we have a figure that I borrowed
from a meta-analysis of the most common pathogens indicated
in neonatal infections.
On the left-hand side is the pathogen repretation for in --
for countries that are considered high income,
and you can see from this
that the most common pathogens are E. coli,
which is typically an enteric organism that may be acquired
from a mother or the environment.
There's also representation from [inaudible] negative Staph.
and Group B streptococcus.
However, when you move to those countries that are middle income
or low income, you start to see a much larger proportion
of these infections caused by gram-negative organisms,
including Klebsiella pneumoniae.
And when you look at the pooled case fatality rates among
neonates that have these infections,
low-income countries face the highest mortality rates at 25%
which is almost double what we see
in high-income countries at 12%.
Next, I want to share some data from the NeoOBS study
on antimicrobial resistance in neonatal sepsis.
This study was a prospective,
multi-country observational study
where the researchers collected detailed daily longitudinal data
in 11 countries across Latin America,
Africa and Southeast Asia.
The figure that we see on the left is the composite or are --
is the frequency of different pathogen types in infants
with diagnosed confirmed sepsis, and how they evolve
with each day of postnatal age.
So starting on the left,
again we see a larger representation by E. coli.
We see some gram negatives, but not as large of a percentage,
but as we get -- as the infants grow older, you again start
to see a higher proportion of pathogens
such as Klebsiella pneumoniae and Acinetobacter.
Of the infants in this study,
at least 62.9% had a gram-negative organism detected
as a reason for sepsis.
And the figures on the right here demonstrate the
antimicrobial susceptibility profiles for these isolates,
and so for here, we're showing the three most common organisms
that were identified
as gram-negative infections in this study.
I'm not going to go through and try
to make you read the antibiotic names here on the x axis,
but just to note that the higher amount
of dark gray bars indicates a higher level
of resistance of that pathogen.
So obviously, Klebsiella pneumoniae
and Acinetobacter have large levels
of antimicrobial resistance in this population.
Interestingly, though, E. coli, which is something that makes
up a larger percentage of infections on the first day
of life, has -- what we can see, those isolates appear
to be somewhat more susceptible to antibiotics,
which is interesting, as these E. coli typically tend to come
from mother at the time of delivery.
Next, I'll share some data from the Child Health and Mortality
and Prevention and Surveillance network,
which includes seven countries, all low and middle income.
So the initial analysis of CHAMPS data identified
that Klebsiella -- or excuse me.
Initial analysis from this study identified Klebsiella pneumoniae
as the most common pathogen in children under five,
and the second-most common pathogen causing infections
in neonates.
Of 157 of 497 isolates from children with K. pneumoniae
in the causal chain of death within this study,
84% were resistant to ceftriaxone,
which is a commonly available third-generation cephalosporin.
There's also high levels of resistance
to other antimicrobial classes,
as you can see here on the right.
Moving on to where these organisms may be acquired,
I want to highlight some work from the Burden
of Antibiotic Resistance in Neonates
from Developing Society, or BARNARDS study.
This is a very elegant network and elegant set of analyzes,
but in this particular one here, the authors were looking
at the presence of antimicrobial resistance genes
in the gut microbiota of mothers and their infants who went
on to develop neonatal sepsis.
I think what is probably most interesting to highlight
from this is that over 50% of infants studied
within this analysis were colonized
with at least one extended spectrum
beta-lactamase-producing organism.
And one in five infants was actually carrying the gene
that encodes the New Delhi metallo-beta-lactamase gene,
which confers carbapenemase resistance.
In many cases,
these antimicrobial resistance genes were actually detected
within the first 24 hours of life, and while some
of that may be connected between --
or excuse me, connected to transmission from their mothers,
they also saw a large amount of genetic relatedness
between isolates from neonates that were receiving care
in the same unit as the neonates in the study, which indicates
that there is healthcare transmission happening in many
of these cases of neonatal sepsis.
And that's important, because that's where folks
like us can step in and hopefully impact
that that high number.
Next, I wanted to show a study
that involved one large neonatal unit within a hospital in India.
These data sought to understand the relationship
between maternal rectal or vaginal colonization
and environmental gram-negative colonization
with bloodstream infection isolates among
hospitalized neonates.
So the black dots within this figure each represent a
confirmed neonatal infection
with the pathogen that's shown here at the bottom.
To better evaluate the connection
between these isolates,
the authors also collected sink isolates from sinks
within the unit, and this is important because we know
that sinks and other water sources may be great places
to -- are typically susceptible to colonization with biofilms
with antimicrobial-resistant organisms, and so they --
the authors wanted to include this as a proxy for the role
that the environment might play in these infections.
And then finally, the lines
between these dots indicate the number
of single nucleotide polymorphisms
that were identified between each isolate, and a lower number
of single-nucleotide polymorphisms indicates a higher
degree of genetic relatedness.
You'll notice here that there are no dots representing
maternal colonization isolates, and that's because the authors
of this study did not actually identify neonatal bloodstream
isolates that matched isolates obtained
from maternal specimens.
However, the clusters that we see here indicated there was a
high degree of relatedness between isolates collected
from infants within the care unit, particularly among infants
that were -- that received care within 30 days of each other.
So we see tight clustering here
with a sink isolate in the middle.
There's also connection with another cluster of isolates
that occurred among three different infants,
and then each other pair of --
or each other grouping of isolates,
represents healthcare transmission
within the unit as well.
And what all of this means, I think, for the future,
is that antimicrobial resistance is changing the way
that we approach empiric antibiotic therapy.
So as a point of reference, the World Health Organization
and many other professional organizations recommend
ampicillin and gentamicin
as the recommended empiric antibiotic treatment
for world -- for neonates that are suspected
of having infections, and the reason
for this recommendation has multiple origins.
I think one is that these antibiotics typically cover the
organisms that we see in neonatal sepsis
in high-income countries, so things like Group B Strep,
E. coli, are typically well-covered
by these antibiotics.
They're also widely available and relatively cheap.
However, a sub-analysis of data from the BANARDS network,
which I mentioned previously, sought to I look at how infants
who received broader spectrum antibiotics fared against those
who received the traditional regimen
of ampicillin and gentamicin.
And so the survival curve on the left represents the survival
of infants who received each different antimicrobial regimen
or combination.
And this, again, are data that were collected
from many hospitals across different countries
in the world, and which is why you see different antibiotic
combinations used here.
So the ampicillin --
the children that received ampicillin
and gentamicin are shown here in the red bar,
which unfortunately indicates that infants
that received either pip-tazo amikacin --
or excuse me, infants who received the combination
of CEF-TAZ and amikacin actually had a much higher rate
of survival than those who received that regimen.
A few other antibiotic regimens were tried as part
of this study, although those infants showed lower levels
of survival.
And so I think although there may be multiple factors
at play here, we are seeing a lower rate of survival now
with infants who are receiving ampicillin and gentamicin.
And the future of antimicrobial resistance is also somewhat
scary, because neonates
and children typically are underrepresented
in the antimicrobial trials that happen to try
to identify new antibiotics
that can target antimicrobial-resistant
organisms.
So in terms of new antibiotics approved since 2000,
we see that only four new antibiotics have been approved
for neonates and six antibiotics for children over the age
of one, which is in comparison to the 40 other antibiotics
that have been approved for adults.
In looking at the global spectrum of clinical trials
that are happening, there are many fewer clinical trials
that actually are enrolling children or neonates,
which means that if this doesn't change,
we're going to have very limited options if we continue
to see evolving antimicrobial resistance in this population.
So I won't go very much into the different ways
that we are trying to address neonatal antimicrobial
resistance, as we have two speakers following me
that are going to go a bit more into some of those topics,
but in terms of kind of where we're looking these days,
I think we know that we need better data
on neonatal surveillance definitions
and affordable diagnostics
so that we can better diagnose these infections
and compare data between different clinical sites
and between different countries.
Antimicrobial stewardship programs
and smarter antimicrobial use in general is also something
that I think will be important in the future.
Infection prevention and control guidance targeted specifically
for neonates so that we can interrupt
that healthcare transmission of these organisms,
a better antimicrobial toolbox with pediatric representation
in clinical trials, and evaluation
of different dosing regimens for this population,
I think, is also critical.
And then finally, I think another area
that we often forget is that we may be able to tackle some
of these infections by helping our infants develop a healthier
microbiome, so things such as kangaroo mother care,
which involves an infant spending more time skin to skin
with their mother, with the encouragement
of breastfeeding, can help with this.
We can also help with a healthier microbiome by helping
to maintain skin health in these infants
so that they are not colonized with some
of these organisms in the first place.
So in summary,
antimicrobial-resistant neonatal infections disproportionately
impact low- and middle-income countries.
Colonization
with antimicrobial-resistant organisms occurs rapidly
after birth, and organism relatedness indicates
transmission from other infants
and from the healthcare environment.
And multimodal interventions, including infection prevention
and control and antimicrobial stewardships, are necessary
to protect these infants.
I will stop there, and I will pass it to Fernanda
to introduce our next speaker.
Thank you.
>> Thanks so much, Amelia.
Thanks for that great presentation,
and we'll hear more from you during our panel discussion.
I am excited to introduce our next speaker.
Dr. Fahmida Chowdhury is a medical epidemiologist
with over 20 years of experience
in pediatric medicine and public health.
She is an associate scientist and Project Coordinator
at ICDDRB in Bangladesh.
Dr. Chowdhury leads research on antimicrobial resistance
and respiratory infections,
particularly among vulnerable populations
such as hospitalized patients, pregnant women and neonates.
She has spearheaded over 40 major projects,
including pivotal studies on AMR, Candida auris,
influenza, RSV, and SARS-CoV-2.
So with that, I will hand it over to you, Fahmida.
>> Hello, everyone.
I think I'm audible, right?
>> Yes, looks good, and we can hear you.
>> Okay, okay.
So good morning, good afternoon and good evening,
depending on your time zone.
I would like to thank the organizers
for giving me the opportunity to present our research findings
on critically ill neonates from Bangladesh in this webinar.
So let me say it again.
My presentation is on reductions in antimicrobial resistance
in neonates through focused infection prevention
and control interventions.
I'm sorry.
It's not moving.
Is it moving or not?
>> It's not moving.
Did you try clicking at the bottom?
>> Yeah, yeah, yeah.
>> There you go.
>> Yeah. So it is highly concerning
that antimicrobial-resistant bacteria are frequently causing
sepsis in newborns in low- and middle-income countries.
The sustainable development goal that [inaudible] aims
to reduce neonatal mortality
to at least 12 deaths per 100,000 live births by 2030.
However, these AMR infections are impeding progress
in achieving neonatal mortality targets of the SDG,
as you can see in the figure in the right-hand side.
So colonization, why we are worried
about AMR bacterial colonization,
colonization is the presence and multiplication of bacteria on
or in a host without causing disease, and is concerning
as colonization with AMR pathogens increases the risk
of future infections with these resistant organisms.
A recently published systematic review highlighted
that neonates are particularly susceptible
to becoming colonized with AMR pathogens,
especially in the setting of hospital births.
So today, I'll be presenting findings from two studies.
The first study, part of the Antibiotic Resistance
in Communities and Hospitals (that is, in short,
known as the ARCH study) focused
on antibiotic-resistant enterobacterial among
hospitalized neonates in intensive care units
of a tertiary care hospital in Dhaka City,
which is the capital of Bangladesh.
Based on the interim analysis of this study,
we conducted a second study to evaluate the impact
of an in-depth IPC intervention in the same NICU,
supported by the prevention and implementation teams
of the International Infection Control Branch of the CDC.
In my presentation, I'll be using the terms ESCRE,
which is Extended-Spectrum Cephalosporin-Resistant
Enterobacterials, and CRE,
that is Carbapenem-Resistant Enterobacterials.
So the primary of this study, primary objective
of this study is to determine the prevalence of colonization
with ESCRE and CRE on and during admission among NICU patients,
and also to estimate the incidence of infections
with ESCRE and CRE among NICU patients colonized
with ESCRE and CRE.
So this was a prospective cross-sectional study conducted
at the neonatal intensive care unit
of a tertiary medical college hospital.
Our target sample size for this study was 423,
and rectal soft samples were collected on day one, day three,
seven, and every seven days thereafter,
for neonates admitted to the NICU.
For laboratory testing, we plated rectal swabs
on selected chromagar media, and rectal swab isolates
and blood culture isolates under [inaudible] identification
and antimicrobial susceptibility testing using the Vitek
2 system.
So interim analysis from our first study revealed
that you can see here that 37%
of the 360 enrolled neonates were colonized with CRE
at enrollment, while 74% acquired colonization
after 48 hours of admission.
However, you can see here that 16%
of enrolled neonates remain CRE-colonization-free
until discharge or death.
Among the carbapenem-resistant enterobacterials,
you can see here that Klebsiella pneumoniae accounted for 73%
of the isolates, followed by E. coli, which was 33%.
So if you look back at the enrollment,
Klebsiella pneumoniae and E. coli accounted
for 82% and 51% respectively.
However, you can see here after 48 hours of admission,
this proportion increased to 92% for E. coli, and decreased
to 30% for -- sorry, 92%
for Klebsiella pneumoniae and 30% for E. coli.
So and this [inaudible] that there is a chance
of carbapenem-resistant Klebsiella pneumoniae that,
in short, known as CR-Kpn, circulating in the NICU.
So given the high burden
of CR-Kpn colonization observed 48 hours post-admission,
we further analyzed colonization trends over time.
We found a gradual increase of CR-Kpn colonization rate
that was 31% on enrollment, 57% on day three, 69% on day seven,
72% on day 14, and 73% on day 21.
And this suggests that most neonates became colonized
with CR-Kpn within the first 14 days of admission.
So we analyzed the MIC values of these CR-Kpn isolates
with different antibiotics,
and found consistent MIC patterns suggesting the spread
of same CR-Kpn spread within the NICU.
So our interim analysis
of the first study reveals a persistent high prevalence
of carbapenem-resistant Klebsiella pneumoniae
colonization that is more than 73% among neonates.
Over 58% of neonates acquire CR-Kpn colonization
after 48 hours of admission.
Clinical cultures confirmed infection with CR-Kpn,
and their consistent minimum inhibitory consideration values
were observed for various antibiotics
across the most CR-Kpn isolates,
and this finding suggests hospital-acquired transmission
and infection with the same CR-Kpn strain.
In this slide, you can see here that according to the
WHO bacterial priority pathogen, this CR-Kpn,
has risen from fifth position in 2017 to the top position
in 2024, highlighting its increasing global threat.
So based on the preliminary findings of our first study,
we conducted the second study with the primary objectives
to assess the impact of IPC interventions
that includes hand hygiene and environmental cleaning
on CRE colonization and infection among NICU patients.
And our secondary objective was to evaluate the impact
of this IPC intervention
on all-cause mortality among the NICU patients.
So this quasi-experimental study was conducted
in the same neonatal intensive care unit, enrolling 316 units
in the pre-intervention phase,
and 421 units during the IPC intervention phase.
During the pre-intervention phase, that is, from July 2023
to January 2024, rectal swab samples were collected
on days one, day two, three -- sorry, day three, day seven,
and a seven-days interval thereafter,
depending on the neonatal [inaudible].
In the post-intervention phase, that is from February
to June 2024, twice-monthly point prevalence survey were
conducted, collecting rectal swap samples,
and also biweekly evaluations of IPC practices were done.
And blood cultures were performed,
or as per physician's decision.
For data analysis for this study,
we did descriptive statistics with Pearson Chi-square test
to for the comparison.
The IPC interventions focused on training
and monitoring healthcare workers on hand hygiene,
according to the WHO recommended five moments,
and also the environmental cleaning,
along with providing counseling and motivation to mothers
on hand hygiene practices before breastfeeding.
The IPC team conducted structured
and unstructured training sessions on hand hygiene
for healthcare workers,
it was like bimonthly training sessions,
so for structured training.
And for unstructured, it was frequent training based
on the need, and also frequent training was ongoing
on the hand hygiene.
And also there was daily reminders
of hand hygiene messaging were provided.
Information, education and communication materials
as posters and [inaudible] were distributed
to healthcare workers, caregivers
and also the family members.
And also the continuous monitoring
of hand hygiene practices was implemented.
Detailed IPC training was conducted for healthcare workers
on environmental cleaning.
That is mostly for cleaning staffs.
Simple visual guides were provided to cleaning staffs,
categorizing cleaning zones into patient care areas,
shared equipment, and also the common areas.
And also the detailed cleaning schedules were developed
and implemented.
Beside that, ongoing monitoring
of cleaning practices was ensured.
This image highlights some
of the patient-relevant surface areas
for environmental cleaning.
Cleaning with detergent
and water was the essential first step before applying
any disinfectant.
And dress circuit areas are disinfected
with 5,000 PPM chlorine,
and [inaudible] circle areas were cleaned
with test screen compatible disinfectant.
These images demonstrate environmental cleaning
monitoring using Glo germ in incubator,
bed rails, and also monitors.
So coming to the results, this slide shows the improvement
in healthcare workers' compliance with hand hygiene
and environmental cleaning practices during the IPC
intervention at different time
of point prevalence survey or PPS.
Initial hand hygiene compliance was 13%
which gradually increased to 69%
by the 12-point prevalence survey.
Compliance exceeded 60% from the six-point prevalence survey.
Initial environmental cleaning compliance was 10%.
We significantly improved to 87%
by the 12-point prevalence survey,
and compliance exceeded 60%
from the four-point prevalence survey.
Hand hygiene and environmental cleaning campaigns showed a
strong correlation with both expressed a sharp increase
following the intervention,
so initial low complaints improved markedly
post-intervention, highlighting the effectiveness
of these IPC measures.
This slide showing the trend
of CRE colonization alongside improvements in hand hygiene
and environmental cleaning practices over time.
Before the IPC intervention,
you can see here the CRE colonization was high at 84%,
while CRE colonization decreased to 60% after the initiation
of IPC training, but fluctuations were observed
at different time points,
and the lowest colonization rate was 37% observed
as seven-point prevalence survey,
followed by an increase to 69% at PPS 12.
The slide highlights the significant reduction
in colonization with carbapenem-resistant organisms
after the implementation of the IPC measures.
Growth of carbapenem-resistant organism,
including enterobacterials in CHROMagar plate,
decreased from 93% to 81%,
and Vitek-confirmed CRE colonization dropped
from 84% to 61%.
If we look
to carbapenem-resistant Klebsiella pneumoniae,
it decreased from 73% before intervention,
to 52% of during the intervention.
And all reductions were significantly
statistically significant.
This slide is showing bloodstream infection
and mortality before and after IPC intervention.
Before implementing IPC measures,
the bloodstream infection rate was 23%.
While fluctuation were observed at different time points,
a notable reduction to 4% was recorded by PPS 12.
However, during PPS two, the rate increased to 24%.
Before IPC, the mortality rate per 100 admission was 17%.
Although the rate showed variation both increasing
and decreasing across time points, it ultimately dropped
to 14% by 12-point prevalence survey.
The data indicates significant reduction
in bloodstream infections
with a downward trend throughout the IPC intervention period.
However, the neonatal mortality rates did not show a
statistically significant change,
though showing a slight downward trend in mortality.
So in conclusion, IPC interventions focused
on hand hygiene
and environmental cleaning successfully reduced
colonization
with carbapenem-resistant enterobacterial
and bloodstream infections in the NICU.
Sustaining adherence to routine IPC practices is essential
to mitigate the impact of antimicrobial resistance.
However, additional strategies are necessary
to identify hidden reservoirs
and further limit the transmission
of highly resistant pathogens in NICU settings.
So this is all of our study findings.
Now, I would like to express my gratitude to the U.S. CDC
and the task force for global health
for funding these projects.
Additionally, I acknowledge the co-donors of ICDDRB
for their continuous support
which makes our research efforts possible.
Thank you.
>> Thank you so much, Fahmida.
Great presentation, really showing us the impact of IPC
and environmental cleaning and hand hygiene on reduction
of bloodstream infections among neonates.
So let's go on to our next speaker,
who is Dr. Fabio Araujo Motta.
He is a pediatrician with PhD in biotechnology applied to child
and adolescent health from the University
of Pequeno Principe in Parana, Brazil.
He is currently the Assistant Technical Director
of Quality Improvement and Research
at the Hospital Pequeno Principe,
which means in English, Little Prince Hospital.
So with that, I'm going to turn over to Fabio.
And Fabio, I'm going to share your slide.
I hope that everyone -- can people see the slide or not yet?
Can you all see the slide?
>> Yes.
>> Perfect.
Over to you, Fabio.
>> Thank you.
Okay. Good morning, everybody.
I'd like to thank CDC for this honorable invitation,
and especially for Dr. Fernanda Lessa.
Today, I will present our national strategy
for antimicrobial stewardship in neonatal
and pediatric population, and the translation into practice.
Next. Next, please.
I have no conflict of interest in this presentation,
and my agenda will be the presentation
of the five chapters of this guideline,
beginning with the scenario presentation.
Next, please.
Next. Everyone who talks
about this issue know this information published in 2016
by [inaudible] about the provision of death in 2006, 50,
if nothing is done, but the most important information was what
come later.
Please, next.
In 2022, The Lancet brought to us the following situation.
Based on prediction statistical model, it estimated
that there were almost 5 million deaths associated
with bacterial antimicrobial resistance
in 2019 including 1.27 million deaths directly attributable
to bacterial AMR.
An investigation by United Nation Environment Program
indicates that this could reduce the GDP by $3.5 billion annually
and push 24 million people
into extreme poverty over the next decade.
Next, please.
With this, AMR, is on the third place
in the deaths rank in the world.
Next. Next.
Chapter One is structure
of the antimicrobial stewardship program
in pediatric and neonatology.
Next. Here, we can see the SWOT analysis of AMS
in healthcare facility.
Specifically in Brazil, in many neonatal and pediatrics unit,
we face this challenge (next, please) about human resource,
where no dedicated healthcare professional is available
to lead the AMS team about antimicrobial use
and resistance data, where the supply
of microbiology reagents is poor and the supply
of antibiotic is poor, and about AMS activities,
where healthcare professional have competing priorities
and little time for AMS work.
Next. Next.
Because of this, it's very important to count with support
from top management and tactical level.
And what is the role of strategic level?
To give support of [inaudible] policy, invest in the program
with resource, and ensure economic sustainability.
The role of the tactical level is important
to organize management strategy, critically analyzing the carers
and communicate with senior management.
Next, please.
And yet, translate the clinical and economic result
for strategic level, and outlines
and monitors the operation with stewardship team.
And about the role of -- please return.
And about the role of operational group,
it's important to perform antimicrobial management action
and records and organize data.
Next. To reach this result is fundamental
to establish the model
of the aspect governance structure formed
by strategic tactical vision (next,
next) and operational vision.
And inside of strategical tactical vision,
we have ASP committee formed by this department,
like pharmacists, therapeutical department heads, quality
and patient safety departments.
And inside of operational vision,
we have the ASP team formed by these professional,
like microbiologist, nursing staff, pharmacist, and here,
a highlight for this kind of professional
that we call champion.
Next, please.
Next. Champion -- next.
Champion, generally -- no, sorry, return.
Yeah. Champion generally have a leadership profile
and differentiates commitments in their unit
so that they become a kind of advocate for judicious use
of antimicrobials, and the point of dialog
between the clinical unit where they work, and the professional
of the ASP teams like neonatologists,
hospital pharmacists, neonatology nurse,
or infection control nurse, for example.
Next. The Chapter Two is about the role of each service
and effective participation of the members of ASP.
Next. Here, we brought the idea of antimicrobial chain of use.
In the top of the iceberg, the action of the physician,
that is to diagnose of the infection, and selection
and indication of antimicrobial, but it's very important
to remind that the bottom part
of the iceberg contains these elements
that can make antimicrobial not work.
They are elements linked with the medication, like dose
or frequency of use or elements linked with the patients,
like diuresis, renal clearance rate,
distribution volume, for example.
Next. And to face this issue, it's very important to work
in a multi-disciplinary team.
Next. The next step is to think about the ASP team composition.
And in this document, we divide in --
we divide the team
in operational team and supporting team.
The operational teams -- inside the operational teams,
we have nurse, clinical pharmacies, infection
or pediatrician with expertise in antimicrobial therapy,
clinical microbiologist, and infection control professional.
Next. After that, we specified the role of each professional
that makes up the operational team.
For example, role of the ASP pharmacist, like suggestion
of those adjustments (next, next), record of data
for indicators (next), antibiotic treatment timing,
and have condition for doing, if well capable,
assess empirical treatment.
Next. About the role of the ASP microbiologists, it's important
to give support about clinical [inaudible] collection
and information on collection condition, for example.
Next. Next, please.
Next. About the role of the ASP nurse,
we can see (next) monitor patients (next),
plan and promote care for intravenous devices (next),
participate and mediate transition from intravenous
to oral antibiotics, for example (next), and the last
but not least, the role of the ASP physician,
like leading ASP team, coordinator activities
of ASP team (next, next), and finally,
to seek to maintain direct access
to the clinical pharmacist, microbiologist and nurse
for the discussion
and interpretation of culture results.
Next. Chapter Three is about the particularities of newborns
in the use of antimicrobials.
Next. The first particularity addressed in our guide is
about pediatric age group.
Next. This classification is directly related
to the dose to be prescribed.
Since the antimicrobial varies in those according
to age group (next), the weight parameters is the most important
variable in antimicrobial dosing,
because the prescription is given
by milligrams per kilo per day.
Next. Pediatric patients frequently undergo weight
fluctuation, especially in the neonates and infant age groups.
Next. And more frequent weight measurements are recommended
to allow for those adjustments.
Next. The next particularity is about PK of antimicrobial
in critical [inaudible] pediatric patients.
Next. And here, we brought an example of sepsis
or septic shock that leading to a serious condition,
with vasodilation, leading to an increase in capillary leak
with consequently hypo-albuminia,
with increasement of free drug and increasement of total volume
of [inaudible] (next), and decreasement
of plasma concentration of hydrophilic antibiotic.
Next. About the use of hydrophilic antibiotic,
if patients have been using this kind of hydrophilic antibiotic,
like beta lactamase, penicillins, or cephalosporins,
it's important to remind that we need to calculate the dose based
on the real weight and not the dry weight.
In opposition, if they have been using lipophilic antibiotics
like fluoroquinolones, macrolides or tetracyclines,
it's important to calculate the dose based on the dry weight.
Next. Chapter Four is about a strategy
for antimicrobial implementation and managements.
Next. The first strategy brought in this document is
about handshake antimicrobial stewardship model.
Next. Handshake is a persuasive practice
that include prospective audited education for rational use
of antimicrobial and multidisciplinary discussion
in opposition of restorative practice
that include prioritization
or treatment times control [inaudible].
Next. Handshake is an expansion
of the prospective antimicrobial audit strategy, daily review
by the infectious disease specialist
and the clinical pharmacist in 24 and 72 hours
where the performance and feedback (like intervention
on antimicrobial) are prioritized
by a stewardship team through personal communication
with the team (important to be face to face), for example,
during clinical rounds.
Next. The next strategy is about antimicrobial timeout.
Next. The origins of timeout comes from the need
for formal breaks during clinical periods, for example,
in airplane checklist, surgical checklist, and nowadays,
antimicrobial checklist.
Next. And what is timeout and how to perform it?
These are formal reevaluation of antimicrobial therapy
at intervals between 48-72 hours after the start
of empirical antibiotic therapy with strategic questions.
In a nutshell, the timeout is a structured pause
with the following question,
"Does the patient have an infection
in responding to treatment?"
Next. Are the antibiotic and dose correct and optimized?
Next. Can the antibiotic be discontinued or de-escalated?
Next. Does the patient meet the criteria
for oral antibiotic therapy?
Next. What will be the duration of the treatment?
Next. Timeout contributes to the two main goals
of the stewardship teamwork, the first, reducing treatment times
and discontinuing unnecessary antibiotics.
Next. The Strategy Three is about action
to prevent antimicrobial resistance.
It's important to remind that in 2002 the CDC published 12 steps
for prevent antimicrobial resistance,
and this publication masterfully brings together all the action
to be developed jointly by antimicrobial management team
and the infection control teams bring together
in a single scheme the importance
of the interdisciplinary role of the physician, nurse, pharmacist
and microbiologist in combating bacterial resistance.
This publication remains right and relevant
since the same problems continue to exist
within the intensive care units.
Next. This recommendation were adapted
for a neonatal intensive care unit by Patel
in 2009 aiding guidelines focus on this population,
beginning with the first step, like prevention infection,
with the use of vaccination.
The second steps about removed catheters,
with when they are no longer needed.
Next, please.
The third steps about target therapy to the pathogen.
The fourth steps about consult a specialist,
concert experience professional in treating infection
in children's and neonates.
The fifth steps (next) about the use antibiotics correctly,
practice correct use of antimicrobials.
The sixth steps about using local data,
know the overall antibiogram of its unit for empirical therapy.
The seventh steps about treat the infection,
not the contamination.
Next, please.
Next. And the eighth steps
about treat the infection, not the colonization.
Here, is important to remind the importance of treat pneumonia,
not the tracheal aspirate, for example.
Treat bacteremia, not the tip of the CVC connector, and remember
that coagulase negative staphylococcus
in a single blood culture sample with growth more
than 48 hours may be contamination.
Assess if the blood culture sample
from the CVC is colonization
when the peripheral blood culture is negative.
Next. The ninth steps about use antibiotics correctly,
and know when to say no to vancomycin,
cephalosporin and carbapenems.
The 10th steps is
about discontinuing antimicrobial treatment,
for example, in surgical antimicrobial prophylaxis.
Eleventh steps about isolated de pathogens, and 12th steps
about the break the chain of transmission.
Do not allow sick visitors in the ICU and the NICU.
Next. The last chapter is Chapter Five about indicators.
Next. Here we brought a new indicators about classification
of antimicrobial problems named PRAT.
PRAT tool means Problem Relate Antimicrobial Therapy.
Is a tool created by our group at Pequeno Principe Hospital,
and there was no specific classification for problems
with antimicrobials, so far.
These two seek to map the epidemiology
of antimicrobials problems, provide opportunity
for harmonizing records,
and comparing hospitals, if possible.
Next. And these two include 17 primary problems domains
and six nine subdomains, for example.
Next. Here we can see the systemization
of these two (next) with primary domain, for example,
a prescribed dose with its subcategory,
like underdose based on literature or protocol,
or overdose according to serum level.
And its suggesting off-pharmacotherapeutic
intervention.
In case of underdose, we need to increase dose,
or in case of overdose, we need to decrease dose.
The next example is about the necessary drug (next,
please) with its subcategory, patient without infection
and use antimicrobial or extend antimicrobial time
without indication, with its suggestion
of pharma therapeutic intervention
like suspend antimicrobial, for example.
Next. And here, our last slide about the process
and outcome indicators.
In this guideline, we bring some suggestions
about some process indicators, like days of therapy or length
of therapy, or some quality indicator
like empirical antibiotic therapy consistent
with local protocol, or those adjustments for renal function,
for example, and about some examples
for about outcome indicators
like clinical multi-drug resistance or cost indicator
like cost savings or cost avoidance or days
of therapy, for example.
Next. These are our colleagues in the workgroup,
and I'd like to thank for the opportunity to work
with these amazing people here, Vanessa, Roseli, Mara, Beatriz,
Marinei, Bianca and Luiza, and Camilla and [inaudible].
Okay, next.
Thank you very much for this opportunity.
>> Thanks so much, Fabio, for the great presentation.
It's nice to see the antimicrobial shift program
guideline and all the indicators that you showed today
for Brazil, but also more broadly, for Latin America.
So now I would like all the speakers
and panelists should be on camera.
We are going to start our discussion panel,
and I have the honor to introduce our panelists.
We have, as part of the panel, [inaudible] Patel,
who is a PharmD, the BCI GP is infectious disease pharmacist
at the CDC's International Infection Control Branch,
where she focuses on her work on developing
and strengthening antimicrobial [inaudible] programs globally.
We also have a part of our panel, Dr. Angela Dramowski,
who is a Professor of Pediatric Infectious Diseases
at Stellenbosch University and the head of clinical unit
for the general pediatrics at Tygerberg Hospital
in Cape Town, South Africa.
She's passionate about patient safety with a focus
on the prevention and treatment
of neonatal sepsis in African hospital.
Last but not least, we also have Dr. Deborah Tong,
who is a registered pharmacist with postgraduate qualification
in pharmacy practice and global health policy.
She has a background infectious diseases clinical pharmacy,
and is currently a technical officer working
on microbial stewardship
in the antimicrobial resistance division
of the World Health Organization.
So thanks all of you for joining today,
and my first question is going to go to Dr. Deborah Tong.
Can you talk about, based on the presentation and,
you know that the AWARE book, the recommendation in terms
of treatment for neonatal sepsis from the community is ampicillin
and gentamicin, with the second choice being cephalosporin
of third-generation plus aminoglycosides,
and we are seeing this increase in resistance
in neonatal sepsis coming from the community.
So is there a plan to update the AWARE book
for the neonatal sepsis, given the current epidemiology?
And also, can you talk about the WHO plans in terms
of updating the [inaudible] toolkit?
>> Thank you very much, Fernanda, and thank you
for all the presentations earlier today.
As you mentioned the AWARE book and WHO guidelines
for neonatal sepsis are currently recommending
ampicillin and gentamicin as first choice,
or second choice being a third-generation cephalosporin
with amikacin or another aminoglycoside.
So as an update,
WHO is currently reviewing these guidelines.
But for the time being, ampicillin
and gentamicin still remain as first-choice therapy,
and the second choice still remains a third-generation
cephalosporin and amikacin.
And the reason for this is
because there's still not enough good quality evidence
on the optimum antibiotic regimen to recommend,
particularly in low-resource settings in low-
and middle-income countries.
So our first speaker, Amelia,
mentioned the NeoOBS prospective observational study
that was conducted by [inaudible] et al.
So this was done in more than 3,000 babies in 11 countries
over three years, and she did show some of the data
from this study, but basically, some key findings of that was
that more than one-third of the babies that they had enrolled
in this study had a history
of previous intravenous antibiotic exposure,
with many of them being exposed
in the last 24 hours before enrolling in the study.
And throughout this study, they also saw that more
than 200 different combinations
of empiric antibiotics were started in infants,
showing that there's a huge variation
in antibiotic prescribing practices globally
and across different regions of the world.
And basically there was a lot of switching
between different regimens, as well as escalation
from narrower spectrum to broader spectrum antibiotics
within the first few days
and throughout the infant's treatment.
And what we saw from that study and various others,
that the most common pathogen was Klebsiella pneumoniae,
and this was not only resistant to ampicillin
and third-generation cephalosporins,
but also to [inaudible] and beta lactamase inhibitors,
as well as to carbapenem, so this makes it really difficult
to actually formulate recommendations based
on the antibiotics that we currently have
and that many countries have access to.
There's still very little data about the impact of AMR
on mortality in neonates, and little information about how
to account for all these confounding factors,
as well as the heterogeneity in the studies that have been done
and the consistent switching between different regimens
of antibiotic therapy.
So what we do need, and what is ongoing at this point,
is more large-scale prospective trials that incorporate
and allow for different study arms,
not just comparing one to another.
So there are some trials ongoing, like the neocept trial,
which is evaluating the impact and efficacy
of three different combinations of antibiotic therapy,
including fosfomycin amikacin, flomoxef amikacin,
and flomoxef Fosfomycin.
So while there's still probably not good enough good quality
data to recommend something different,
we do risk exacerbating the problem of AMR just
by recommending broad spectrum antibiotics from the get-go,
which are not backed by evidence, so we do look forward
to the results of these new studies that are coming
through in the next couple of years to inform new
and updated recommendations for neonatal sepsis.
Would you like me to continue with the toolkit update now,
or would you like other members of the panel to go
for their question first?
>> Yeah, so let's go back to the AMS toolkit, then later,
and then go to the next question.
So Katie, over to you.
>> Yeah. So our next question, we're going to ask Angela
to talk to us a bit more about strategies
and advice you would recommend to colleagues in NICUs
when thinking about IPC and AMR.
Over to you, Angela.
>> Thanks, Katie.
Good afternoon, good morning, everybody.
Thank you very much.
So I really enjoyed all the talks, but especially Fahmida's
and congratulations to all the work that they did
in the unit in the [inaudible].
I think the challenges are very familiar to anybody working
in a low-, middle-income neonatal unit.
I wanted to take a step back just to conceptualize
at what point pathogens
and antimicrobial resistance elements are transferred
to neonates to help shape how we think
about preventing these infections.
And so, clearly, it all starts with a pregnant mum.
Often we think about infections in the neonatal unit
as very polarized early onset neonatal sepsis,
typically thought of to be transmitted vertically
from mother to child in labor and delivery,
and then hospital-acquired infection,
horizontal transmission, from the healthcare environment,
workers, equipment, surfaces,
etc. I think what shocked me a little bit
about Fahmida's data is that on day one of life,
almost 40% of babies were already colonized
with carbapenem-resistant enterobacteriales,
so anything you do on the neonatal unit in terms
of cleaning and hand hygiene is already too late.
We need to be looking further upstream
in our prevention efforts to make sure
that we protect babies during pregnancy and delivery
in those first 24 hours after birth.
And there, we need a whole package of care that speaks
to prevention of preterm birth, maternal nutrition,
careful management of maternal infections and antibiotic use,
etc., and then, really importantly, environmental
and hand hygiene and device cleaning
for a safe labor and delivery.
Then once the baby is delivered and admitted
onto your newborn unit, infections and pathogens
that have been transmitted then colonize the surface
of the baby, and then we need to move to measures that are going
to protect the baby from colonization going
to invasive infection, and this is
where all the traditional IPC measures come into place,
as well as specific baby measures that some
of the speakers mentioned to maintain a really strong barrier
of the skin and the gut,
which are the two biggest surface areas
where bacterial pathogens can then invade
into the bloodstream.
And by the time you get to established infection,
sepsis and multiorgan failure, it's too late,
and we've lost most of our babies at that point.
So it doesn't matter, the best antibiotics in the world,
the most kind of appropriately tailored
for your situation may be too late for many babies,
so prevention will always be our first prized goal.
And then just conceptually,
to think about where do we need to put our efforts?
So the study that Fahmida described really is looking
at that traditional package
of infection prevention control measures which try
to prevent colonization of a baby with pathogens,
but there are three other important areas I just want
to highlight.
So if you look at the top left, starting right at the beginning,
we want to promote colonization with normal flora
to outcompete the pathogens, and we can do this
by doing really good, essential newborn care with as early
as possible institution of skin-to-skin care, or KMC,
ensuring that we give breast milk
to as many babies as possible.
There is an increasingly important emerging role
for probiotics for gut integrity.
And then what Fabio spoke to, so important,
babies that don't need antibiotics should not be
receiving them, and those that need it, we need to try
and stop them as soon as possible.
And then again, moving on, looking at maintenance
of skin integrity, there's many studies looking
at emollient therapy as a way to improve the skin barrier,
but we as clinicians need to do much better
to prevent skin breaches and injuries,
so thinking of non-invasive testing for things
like jaundice, and doing better at securing IV devices.
And then lastly, thinking specifically back
to data, data is power.
So if you know your own neonatal unit,
what pathogens are circulating and you work with,
as Fabio mentioned, your microbiologists
if you have them, or your surveillance teams
at national level, you can look
and decide what antibiotics are most appropriate based
on your profile of pathogens,
and then critically feed this information back
to your neonatal unit staff and managers and parents,
because only through working together
as a big multi-disciplinary team can we do better
to prevent infections in hospitalized newborns.
Thanks so much.
>> Thanks, Angela.
I just want to take the opportunity, because I'm looking
at the questions are coming on the Q&A box,
and I do think that's important.
Maybe we can talk about two of the questions,
because I do think that's something that we see often.
It is hospitals' NICUs being overcrowded, so sometimes three
to five babies per bed.
And I think one of the colleagues put on the
on the chat, on the Q&A, what would be the recommendations
when you have those overcrowded units and in [inaudible] role?
And I think then the second question
that maybe whomever wants to answer, if you can talk
about what do you do in your NICU, if you have a neonate
with CRE, when do you discontinue contact precautions
for that patient.
So open to Fabio, Fahmida, or Angela, if you want to talk
about your experience on your NICU.
>> Should I start?
>> Go ahead.
>> Okay. Just briefly, I can say what is going on in our NICU
in Bangladesh, the study hospital
where we conducted our study.
As you have mentioned, that our NICU is overcrowded,
and sometimes it's occasional
for at Dhaka Medical College NICU, we have to sometimes,
you know, have two or three bed
for neonates phototherapy mission,
even for incubation as well.
And if there is any CRE colonization,
CRE infection is identified for a patient, nowadays,
after we started our study, we have just have a separate --
it's not a separate corner, I would say,
just they separate the baby from the other babies,
but still there is chance of contamination,
having the transmission of the infection from that baby,
because we can't separate --
isolate the baby in a separate room, because it's
in the same room, but a bit different place.
So this is the scenery in brief in our hospital, study hospital.
>> Thanks, Fahmida.
Angela, I'm going to turn over to you if you want to talk
about any strategies in this overcrowded setting, and also,
when do you discontinue contact precaution for CRE-infected
or -colonized neonate?
>> Sure. I'll take the last question first.
So there's not good evidence to guide,
but we look at at least 12 months,
so we try to flag the record of that baby, because inevitably,
pre-terms get readmitted many times in the first year of life,
and so we encourage, once a baby is readmitted,
to re-institute contact precautions for up to 12 months,
and then we re-screen beyond 12 months to see
if there's persistent carriage where possible,
but I know that CRE screening is not widely available
across most African hospitals.
So, you know, standard precautions should apply
to every baby in every facility,
and doing excellent hand hygiene, environmental cleaning,
will go a long way, even if you can't screen
for particular resistant infections.
And then the issue of overcrowding is a political,
managerial and a crying shame, because this is not something
that clinicians and nurses
at the coalface can do anything about.
We try to provide the best care for the baby in front of us,
and we absolutely acknowledge that overcrowding is detrimental
to individual babies' health, and there is ample data globally
to show that overcrowded neonatal units
and under-resourced neonatal units, particularly
with high patient-to-staff ratios, have poorer outcomes.
That's non-negotiable.
That is the truth.
So we have to do much better advocacy as global bodies
and as clinicians caring for these vulnerable moms
and babies to demand the same.
You would never put three adults in a bed.
Why do you do it to neonates?
Thank you.
Over.
>> Great points, Angela.
So let me go to [inaudible]
with a question [inaudible] microbial stewardship.
If you can talk about the CDC global effort
to launch microbial stewardship, and as you talk
about the global efforts, if you can address one of the questions
on the chat was about monitoring the antibiotics
that are classified as reserve antibiotics.
Over to you.
>> Yeah, thanks.
Thanks so much, Fernanda.
So I would say one thing that we very quickly noticed
when starting to dedicate work towards advancing antibiotic
stewardship globally is
that there are many guidance documents that exist.
There are many at the national level.
There are many at the regional level as well, and so one thing
that we wanted to do is not recreate, you know,
existing guidance, but instead create some resources
that really allow you to sort
of take the guidance documents to the next step.
And so I'm going to share my screen quickly
to show you some of these resources.
So first, of course, the -- we have our core elements document
that gives a little bit different perspective in terms
of key principles towards developing a sustainable
antibiotic stewardship program.
This document has been around for many years,
and it is available in both English and Spanish.
And so like I mentioned, you know, we didn't want to recreate
yet another document that is like this, and instead,
we've created something,
something that accompanies our core elements document,
as well as WHO resources,
and developed this global antibiotic stewardship
evaluation tool.
And this tool allows you to customize an action plan
for your individual healthcare facility, and so it is organized
by different domains,
five different domains you can see here,
and essentially there are 66 questions, again organized
into five different domains.
And there's a scoring system that we've developed
to go alongside this tool,
and what that scoring system allows you
to do is really identify
which domain your facility needs the most work to advance.
And also, as many other presenters have mentioned,
that communication from your healthcare workers
to hospital administration, as we advocate
for more resources, etc., is important.
And so the scoring system will also allow you to sort
of share those data with hospital administrators
at a higher level to, again,
indicate where resources are needed.
The other thing is that they're very detailed questions.
So in, you know, very low-resource settings,
we expect many of the answers to be no.
And intentionally, we have created this document
to be all-encompassing, so that not to get discouraged,
but to be able to identify where specifically you may be able
to make improvements based off of your level
of resources available.
And then also the scoring will allow you to sort
of track progress over time, so again, the tool is not intended
to benchmark a healthcare facility.
Instead, it is intended for the healthcare facility
to advance their own stewardship program.
So let's say the healthcare facility takes this at baseline.
They identify many opportunities for advancement.
They work on that in the coming year.
They retake the tool.
They should see an improvement in their score, again,
an easy way for them to track progress, as well as for them
to communicate that with their hospital leadership.
Again, we know in antibiotic stewardship
that the more success we show
and the more data-driven we can be,
the more resources potentially will be allocated to building,
again, a sustainable program.
Part of this tool is monitoring and evaluation.
And so, remember, when we think about monitoring
of antibiotic stewardship, we do think beyond antibiotics, right?
So we also want to monitor use of various interventions
and reporting to key players in the hospital.
That may be to hospital administration,
as I've mentioned, but also to microbiology
and other healthcare workers across the institution,
and so you'll see Domain 5 is solely dedicated to monitoring
and reporting of various metrics.
And one of the metrics that was mentioned in the chat,
I believe, was related to monitoring, specifically
of restricted antibiotics.
There are two key antibiotic stewardship interventions
that have the most evidence base to do this.
The first is creating a restriction policy
where prior authorization of use
of those antimicrobials is necessary.
So what this means is let's say a clinician would
like to prescribe meropenem.
Prior to prescribing meropenem, there is a direct consultation
with a member of the antibiotic stewardship team,
and a discussion is had about the appropriateness of use
of that agent, and that is what we call a prior authorization.
And so the clinician, the prescribing clinicians,
needs approval before being able to prescribe that drug.
Now, this is very -- can be very resource intensive, right,
because you need somebody that is able
to answer the questions real time.
And the other evidence-based intervention is called
prospective audit with feedback.
And so in this scenario,
the antibiotic stewardship team reviews a list of patients
that are prescribed a target antibiotic.
And then they review the clinical case
as if they were managing the patient and decide whether
or not meropenem is appropriate --
again, meropenem as an example in this case --
is appropriate for use, and then has a discussion
with the clinical care team about alternatives,
about duration, about dosing, combination therapy
that may be necessary, etc. And so these are two practical ways
to implement a restriction policy around the use
of reserved antibiotics,
sometimes the easiest antibiotics to target,
given that we expect the use of those antibiotics to be lower
in the general population.
>> Thanks so much, Tricia.
I see that we have some attendees
with their hands raised, but we are towards the end
of the session, but I do want just
to ask a question that's coming up a lot on the chat.
It relates to MRSA colonization, and I'm wondering if one
of you can talk about, in your NICU, what's your policy once --
do you screen for MRSA colonization, and if you do,
do you try decolonization with mupirocin?
>> I can answer that from the South African perspective.
So over the last 15 years in our neonatal unit,
we've seen quite a change in the epidemiology
of invasive Staph aureus infection.
Initially, very high rates.
It was our second most common pathogen
after Klebsiella pneumoniae, and over 70% were MRSA.
In the last five to 10 years, we've seen a shift
with much lower rates of Staph aureus invasive infection,
probably now our fifth-most-common pathogen,
and a reversion to majority methicillin-susceptible staph.
We have not changed our policy in terms of screening
for colonization, so we don't do screening unless there is a
large outbreak of MRSA, and we don't routinely decolonize.
Only if we find an index baby
who has a MRSA bloodstream infection, we decolonize
that patient, and in the past,
we did decolonize immediate contacts
with both mupirocin nasally twice a day for a week,
and chlorhexidine gluconate body washes for a week,
but in recent years, we focused only on the index patient,
good isolation in an incubator with contact precautions.
Thank you.
>> This is wonderful.
Okay, so we are at the end of our webinar.
I really want to thank all the panelists and speakers as well
as all the audience who joined us today.
Thanks so much everyone,
and hope that everyone has a good [inaudible] AMR Awareness
Week and [inaudible] to combat antimicrobial
resistance globally.
Thanks, everyone.