Challenges in controlling infection for the 21st century

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Eugene Athan, Chair of the Australasian Society for Infection Disease Healthcare Infection Control Special Interest Group (HICSIG) discusses the priority areas for research and advocacy in infection control in Australia and New Zealand.
The 20^th century has seen many of the greatest advances in healthcare in human history. Advances such as the discovery of antibiotics, cancer chemotherapy, transplantation and prosthetic joint replacement have significantly enhanced the quality and quantity of human lives. Unfortunately in the 21st century we now face great challenges and are in some ways victims of our own success. Antimicrobial resistance through bacterial evolution now poses a major threat to human health and has rendered many recent advances potentially hazardous. Both the WHO and CDC have recently declared antimicrobial resistance an urgent threat to human health and called for urgent public health responses.
Closer to home the Australasian Society for Infectious Disease (ASID) and in particular the Healthcare Infection Control Special Interest Group (HICSIG) has established several key priority areas for future research and advocacy in Australia and New Zealand

1. 
   Clostridium difficile is a bacterium associated with widespread gastrointestinal disease in humans.
   C. difficile is an opportunistic pathogen, whose spores germinate to colonise the gut where the normal microbiota has been compromised by antibiotics. The spores can survive in the hospital environment for many months and have been attributed with an increase in C. difficile infection (CDI) in healthcare settings. C. difficile is responsible for diseases such as antibiotic-associated diarrhoea and pseudomembranous colitis. More serious diseases include toxic megacolon and bowel perforations, which are life-threatening conditions that require surgical intervention.C. difficile associated diarrhoea (CDAD) is a major problem in healthcare facilities worldwide as the number of cases reported each year is increasing, along with the severity of related diseases. A recent study analysed the additional cost of hospital-acquired conditions found that CDI was one of the most expensive and estimated the additional costs of CDAD for Victoria and Queensland to be AUD $4,600,000 per annum. There are reports of increased occurrence, virulence and antimicrobial resistance of CDAD in the United States and Europe. Hypervirulent strains have been associated with more severe disease and a greater risk of death.
   CDAD often occurs after antibiotics eliminate other gastrointestinal flora, allowing C. difficile to overpopulate the gut. The primary mode of transmission is the faecal-oral via spores, and the incubation period is usually 2-3 days. Other risk factors for CDAD include: advanced age, prolonged hospitalisation, gastric acid suppression and immunosuppression. Antibiotic exposure is attributed as a causal factor in approximately 90% of hospital-acquired CDAD. Community acquired CDAD (CACDAD) is increasingly recognised and surveillance definitions have been developed to classify the mode of acquisition so that cases of community acquired CDAD can be stratified using any associated healthcare facility visits.
   

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   “The HICSIG and Australasian College of Infection Prevention and Control,is currently discussing ways to improve our National surveillance systems through laboratory testing methods and collection of epidemiologic information.”
   

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   The HICSIG and Australasian College of Infection Prevention and Control, is currently discussing ways to improve our National surveillance systems through laboratory testing methods and collection of epidemiologic information. We are also updating therapeutic guidelines to assist clinical care for refractory cases.


2. Staphylococcus aureus (“golden staph.”) remains the most important cause of healthcare associated infection. Staphylococcus aureus bacteremia (SAB) carries a significant morbidity, mortality and excess cost burden. SAB is strongly associated with the presence of intravascular devices both peripheral and central and these are commonplace in the care of patients in modern healthcare. Healthcare associated SAB is now a KPI for all healthcare organisations and surveillance systems are in place. There is an increased awareness of the insertion technique and care of intravascular devices. These include close attention to asepsis, use 2% chlorhexidine for skin preparation, early removal of devices not needed and routine inspection of insertion sites for any signs of inflammation. The challenge will be to implement these improvements systematically across all healthcare organisations for all health care workers managing these devices in a sustainable way and to monitor the outcome. Fortunately the focus afforded by the new National Health care Standards developed by the Australian Commission on Safety and Quality in Health care should enable service providers to provide the necessary resources and training tools to achieve these improvements. The HICSIG is are currently discussing ways to improve reporting and feedback of SAB to clinical teams and exploring methods to implement best practice of intravascular device care.


3. Multidrug resistant gram negative bacteria have emerged as a global human health threat. In particular Carbapenem ( a last resort antibiotic) resistant enterobacteracae (CRE) pose a major challenge. These bacteria can form part of the normal bowel flora and then act as a reservoir for drug resistant genetic mutations which are readily exchanged between bacterial strains and can be transmitted between individuals or contaminate the environment. When CRE cause infection they place patients at greater risk of potentially untreatable infection and increased mortality. Patients in residential aged care facilities are also potentially at increased risk. Multi-drug resistant Gram-negative organisms have been isolated more frequently overseas. Over the past 2 years there have been an increasing number of cases of CRE in Australian patients. Some patients contracted the infection overseas and unfortunately some within Australia. In November 2011, the National Healthcare Associated Infection Advisory Committee of the Australian Commission on Safety and Quality in Health Care discussed the potential implications of CRE in Australian hospitals. A taskforce was established in partnership with the Australasian Society Infectious Diseases, Australasian College of Infection Prevention and Control, Public Health Laboratory Network and Australasian Society of Antimicrobials to develop recommendations for the infection control management and testing algorithms of patients with CRE.

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“Both the WHO and CDC have recently declared antimicrobial resistance an urgent threat to human health and called for urgent public health responses.”

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Eugene Athan is Associate Professor of Medicine at University of Melbourne and Deakin University and is Chair of the Healthcare Infection Control Special Interest Group at the Australasian Society for Infection Disease. He is also Director of the Department of Infectious Diseases and Infection Prevention at Barwon Health, Geelong.
Eugene has extensive experience in clinical and epidemiologic research in areas of emerging infectious diseases including Mycobacteria ulcerans, Infective endocarditis including the multinational collaboration for endocarditis research (ICE), device infections and multi-resistant bacteria. He has contributed to or co-authored more than 100 peer-reviewed publications and has been recognised for his contribution as a public health specialist with awards including the Sir Richard Stawell memorial prize for 2007 and Certificate of Honour from the Federal Minister of Health 2006 for humanitarian medical service in Aceh, Indonesia post tsunami.
He has served and contributed to several government and scientific technical advisory panels and committees including Ministerial advisory bodies in areas of infection control, secual health, HIV and viral hepatitis, CJD and Mycobacteria ulcerans.
References
1. www.cdc.gov/drugresistance/threatreport- 2013/
2. Bauer MP, Notermans DW, van Benthem BH, et al. Clostridium difficile infection in Europe: a hospital-based survey. Lancet. 2011 Jan 1;377(9759):63-73. 211
3. McDonald LC, Coignard B, Dubberke E, et al. Recommendations for surveillance of 217 Clostridium difficile-associated disease. Infect Control Hosp Epidemiol. 2007 Feb;28(2):140- 218.
4. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium 219 difficile infections. Clin Microbiol Rev. 2010 Jul;23(3):529-49. 220.
5. Cheng AC, Ferguson JK, Richards MJ et al. Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection. MJA 2011; 194: 353–358.
6. Turnidge JD, Kotsanas D, Munckhof W et al (2009) Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand. Med J Aust 191(7):368–373.
7. Stuart RL, Cameron D, Scott C et al. Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services. Med J Aust 2013; 198 (10): 551-553.
8. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-32.
9. http://www.safetyandquality.gov.au/our-work/clinical-care-standards
10. http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/mrgn-guide/