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www.healthcare-in-europe.com 7NEWS & MANAGEMENT Antimicrobial stewardship strategies Antibiotics tend to be given too often and used for too long A diagnostic marker reduces antibiotics use Carrying home a nosocomial infection Report: Mark Nicholls Since 2009, as part of diagnostic and antimicrobial stewardship strat- egies, Hampshire Hospitals National Health Service (NHS) Trust has used serum procalcitonin (PCT) – an innovative and highly specific mark- er to diagnose clinically relevant bacterial infections and sepsis. Consultant Clinical Microbiologist and the Director of Infection Prevention and Control, Dr Kordo Saeed, explained: ‘In our experi- ence, the integration of the PCT assay to our clinical practice, has not only led to safe reduction in unnec- essary antibiotic usage and costs in our Trust, but has also potentially resulted in reduction of selective pressure on antibiotics and on hos- pital beds.’ In early June, Dr Saeed outlined his hospital’s success in ‘rapid proc- alcitonin assay in diagnosis and mon- itoring of sepsis’ during the nation- al meeting of the Association for Clinical Chemistry and Laboratory As the trend for ambulatory care grows, patients may acquire an infection during their hospital stay but will actually develop a noso- comial infection when back home. For instance, chemotherapy patients, who tend not to be hospitalised any more, may develop an infection a few days after receiving treatment. ‘The number of ambulatory patients in healthcare is increas- ing. Therefore we prefer to use the term healthcare-associated rath- er than nosocomial infections, as the latter only refers to hospital- ised patients,’ said Dr Juan Pablo Horcajada, Head of the Department of Infectious Diseases at Hospital del Mar, Barcelona. Two of the most frequent health- care associated-infections (HAIs) are urinary infections and pneumonia. Surgery patients, who are increas- ingly send home a few hours after the procedure, may also develop post surgery infections. Another area doctors are particularly vigilant with is bacteraemia, i.e. the presence of bacteria in the blood, which can develop after placing catheters in the circulatory system as part of treatment. Dedicated commissions regroup- ing doctors from every specialty are put in place at every hospital across Spain to monitor infection develop- ment within the structure. The Spanish Ministry of Health is pushing for homogenisation through the National Hospital Infections Vigilance Plan, with the goal of gath- ering the data acquired at every site. However, in a country torn between distinct autonomous regions, systems differ hugely and collecting informa- tion on the national scale remains a challenge. Steps must be taken accordingly, Horcajada believes. ‘We need to unify our approach. Some communities have excellent initia- tives to recompile infection data, but others don’t. If vigilance systems are not the same, you can’t have a global and rapid overview of what’s going on in the country; instead, you lose time trying to collect the data in every region, and sometimes their systems and codifications differ greatly,’ he said. Infections decline However complex their extraction, national data show a decline in the occurrence of HAIs. The propor- tion of patients suffering from these infections dropped from 11-12% to 6-8% in just a few years, thanks to improved vigilance and greater respect of preventive steps, such as systematic medical and patient hand washing, as well as better equipment hygiene. However, Horcajada believes more could be done in this regard, starting with more appropriate antibiotics use. ‘This is really an open ques- tion in Spain; antibiotics tend to be used too often and too long, both in hospitals and primary assistance centres. As a result, bacteria are increasingly drug-resistant. This is one of the most serious problems in infection management nowadays and we really have to deal with it.’ The SEIMC is addressing the issue, notably with a nationwide strategic plan to reduce the risk of selec- tion and dissemination of antibiotics resistance. Despite all their efforts, however, healthcare providers will never be able to prevent all patients from developing HAIs, especially as peo- ple are not as healthy as they used to be. ‘HAIs will always be around; they are a normal part of healthcare,’ he observed. ‘Modern healthcare solved many problems and patients increasingly survive, but they are weaker and their immune defences are down. As a result, some infec- tions are more common than they used to be.’ In Spain, the number of legal actions taken against doctors for HAI cases is rising, a phenomenon spreading from the USA. Instead, patients should acknowledge that every procedure carries a risk, which doctors can only try to minimise, Horcajada believes. ‘Maybe our problem is lack of communication. If patients were well informed about the risks and took greater part in their treatment, they would not think of suing their doctors. Somehow, the doctor-patient relationship was lost and we need to get it back. The moment it’s back, I don’t think we’ll have a problem anymore.’ Horcajada deplores the short time doctors can spend with patients under the current scheme, and warned against the impact of money- saving policies on healthcare quality. His wish is for the establishment of a proper infectious diseases spe- cialty in Spain. ‘Currently infectious diseases are a subspecialisation of internal medicine, whilst they are a proper specialty in many other countries. If this were the same in Spain, HAIs management would cer- tainly improve.’ Medicine in Cardiff, Wales. There he examined the ‘potential impact and the usefulness of a rapid “quantita- tive” point of care (POCT) testing’ in the context of reconfigurations and mergers of diagnostic laboratories. Procalcitonin has been around since mid-1980s and is interests clinicians because it appears to be more specific for bacterial infection, particularly when there are systemic features or sepsis. This has proved advantageous because it enables clinicians and hospitals to make more informed decisions on treatment, particularly when clinical presentations of some viral infections, inflammatory condi- tions and bacterial infections can be similar, making a clinical diagnosis and appropriate treatment of infec- tion challenging. ‘Additionally,’ Dr Saeed said, ‘clini- cal signs and laboratory findings may be subtle in the early stages of infection. There is a tenden- cy among many clinicians to treat for potential infection if they have doubts, just in case the cause is infective. This in turn leads to inap- propriate antibiotic use and higher costs.’ PCT also has other advantag- es because, apart from being more specific for bacterial infections than other biomarkers, it is quicker, sta- ble and relatively easy to measure. ‘Anything that can complement our clinical findings in a timely manner and support differentiating bacte- rial infection from non-infection can help to improve not only patient management, but also the appropri- ate use of antibiotics. In this context and in our experience PCT appears to be an effective marker,’ he said. Research published by Dr Saeed and colleagues has suggested that in about 50% of those ‘just in case’ cases, PCT has resulted in either withholding and/or stopping antibi- otics without adverse effect in those patients, whilst continuing antibiot- ics in cases of patients who need antibiotics. ‘Overall by introducing PCT, there were around 17% reduc- tions in antibiotic use and, based on us with additional armaments to achieve this. However, he stressed procalci- tonin is NOT a magic bullet and, like other clinical tests, PCT results must not be acted upon as an individual marker or without considering full history, physical exam and other investigational findings. ‘It is,’ he said, ‘part of a jigsaw and can be used to complement clinical judg- ments and physical examinations.’ British National Formulary prices, this has resulted in direct savings in antibiotic usage of around £14,450 (€20,000) for every six months,’ he added. There are additional sav- ings from hidden costs associated with giving antibiotics such as IV sets, pharmacy time, nursing time and storage. PCT has helped the clinicians to make clearer decisions on giving antibiotics to patients who need them, but also prevent- ing patients unnecessarily receiv- ing antibiotics or suffering adverse effects of antibiotics. In the case of sepsis, PCT has been a major benefit. Dr Saeed concluded: ‘Diagnosis of Sepsis can be challenging and we need biomarkers that can assist doc- tors to diagnose sepsis in a timely manner in order to achieve the best outcome for patients. Real life evalu- ations of the newer and more rapid point of care PCT test in Emergency Departments, General Practice and/ or inside ambulances may provide About 6-8% of Spanish patients will develop an infection during or after a hospital stay. Can these infections be avoided? How is Spain facing up to the challenge? Dr Juan Pablo Horcajada, Head of the Department of Infectious Diseases at Hospital del Mar, Barcelona, and spokesperson of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), assessed the situation and insisted on the creation of a dedicated specialty in an exclusive interview for EH by Mélisande Rouger. Kordo Saeed is Consultant Clinical Microbiologist and the Director of Infection Prevention and Control at Hampshire Hospitals NHS Foundation Trust and also an Honorary Senior Lecturer Southampton University Medical School. His specific areas of interest are clinical microbiology and infection prevention; biomarkers and antimicrobial stewardship; management of orthopaedic-related infections; educa- tion, research and clinical evaluations; and health promotion and education in devel- oping countries. Juan Pablo Horcajada heads the Department of Infectious Diseases at Hospital del Mar in Barcelona, Spain

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