Blantyre Institute of Neurological Sciences BINS

OVERCOMING HOSPITAL ACQUIRED INFECTIONS, AND ANTIMICROBIAL RESISTANCE IN OPERATED PATIENTS AND THE SURGICAL DISCIPLINES AT QUEEN ELIZABETH CENTRAL HOSPITAL: SYMPOSIUM REPORT

Reported by: Kamalo PD, Feasey N, Chafewa N

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A conference was convened on the 11th of January 2019, at Queen Elizabeth Central Hospital (QECH) in Blantyre, with the aim of understanding the burden of surgery associated infections in the hospital, the factors driving them and strategizing to control such infections. The meeting was held at the John Hopkins Research Project Conference Room, sanctioned by the Quality Control Committee at QECH and the collaborating partners were QECH, Malawi-Liverpool Wellcome Trust, John Hopkins Research Project, College of Medicine, Central Medical Stores Trust and the Blantyre Institute of Neurological Sciences. The composition of participants was multidisciplinary, with a total of 57 participants, which included surgeons, gynaecologists, microbiologists, pharmacists, paediatricians, physicians, intensivists, nurse specialists and students, among others.

The background to the meeting was an observation in several surgical departments (surgery, obstetrics and gynaecology, paediatric intensive care unit and the main intensive care unit) of increasing incidence of postoperative infections, which were resistant to our commonly available antibiotics, including the very antibiotic currently in use for surgical prophylaxis - ceftriaxone. The increasing incidence of multidrug resistant gram negative bacteraemia had been demonstrated in most surgical units and, in the absence of strict guidelines on antibiotic use in surgery, there was a push to using more potent antibiotics with gram negative cover like meropenem, thereby risking development of resistance as well. There is suspicion that antimicrobial resistant pathogens are likely circulating in the hospital environment (wards, operating theatres, on healthcare workers), as well as in the community.

Appreciating the need for a multidisciplinary approach in order to properly address these problems, this symposium was convened and the following is a summary of the proceedings and resolutions.

1. The Evidence

Three presentations were made from the Paediatric Intensive Care Unit (PICU), the Orthopedics Unit in the Department of Surgery and the Obstetrics and Gynaecology department. These presented research findings on infections in the respective departments. The highlights included

  1. Increasing incidence of gram negative sepsis in very young infants in the PICU. This required scaling down of admissions (hence operations) in the unit in order to clear and control contamination in the unit. Strict guidelines on the use of high potent antibiotics including meropenem were instituted. Sensitivity to ceftriaxone was almost non-existent in PICU
  2. In orthopaedics the rate of infection in patients treated for traumatic fractures ranged between 5 and 9% in a period of 5 years. Although this infection rate was within international standards, the Orthopedic unit preferred antibiotic for surgical prophylaxis other than ceftriaxone was not available in pharmacy.
  3. In obstetrics and gynaecology department (The Chatinkha Unit), a study was reported in which they cultured swabs from the environment in the Unit to detect the spectrum of bacterial contamination. These included ward walls, doors, beds, equipment, sinks etc. Findings were a wide spectrum of organisms which were mainly sensitive to tetracycline and only occasionally to ceftriaxone. These contaminants were not collaborated in the organisms causing sepsis in the unit but the study highlighted the highly toxic nature of the environment

Of note in all these studies was the lack of capacity of the Main Laboratory at QECH to carry out microbiological sensitivity tests, most of these assessments were done in outside laboratories. A few other surgical units presented their anecdotal data and all were in line with the above observations.

2. Factors Driving Development of Resistance

We then discussed factors that contribute to infections and development of resistance. We had a key presentation from the PhD work of Dr Chimwemwe Mula of Kamuzu College of Nursing on the role and challenges of nurses on antimicrobial stewardship. This work was conducted at the Emergency Department and the acute medical wards of QECH. Important findings from her study included delays in administration of the initial dose of antibiotics prescribed in the emergency unit where antibiotics were administered more than an hour after the prescription; also, in the wards, nurses engaged in practices which encourage development of resistance through untimely delivery of antibiotics and improper preparation of antibiotics prior to administration. This work has been published and it was agreed that the nursing department should look at these issues in order to deliver antibiotics appropriately, enhance the efficiency to the medications in the patients and reduce development of resistance.

The importance of developing and adhering to guidelines was discussed. The Department of Medicine presented the process of developing antibiotic guidelines for QECH incorporated in the application MicroGuide. The presenter demonstrated that the introduction of these guidelines reduced the prescriptions of ceftriaxone in the department of medicine by 26% and that the guideline to review whether a prescribed antibiotic was still necessary at 48 hours and at any other time was increasingly being followed. It was noted that the epidemiology of organisms causing infections and their susceptibility to available antibiotics in the unit should be known in order to develop such guidelines. Noting that systematic bacterial cultures have not been done in the surgical departments, it was agreed that such surveillance should be instituted which will guide the development of guidelines for surgical patients.

3. Understanding best practices in Infection Prevention

A presentation was made from the theatre nursing department on principles of infection prevention. It was noted that the best way to prevent infections is to maintain a clean and aseptic environment starting from the wards and then in the theatres themselves. The aim is to ensure that patients, staff, equipment and floors are not a source of infection. Contamination of the operating theatre remains the major cause of nosocomial infection and as such good hygiene practice in hospitals and in operating theatres is mandatory to minimize nosocomial postoperative infections. To this end it was noted that due to high turn-over of patients, most of our theatres are not thoroughly and properly scrubbed thereby harbouring blood, dust, soil, debris, trash, insects /spider webs which encourage contamination of wounds and infections. Another concern was the poor and ancient design of most of our theatres which brings outside traffic too close to operating theatres. In some theatres, theatre personnel cross sterile areas in order to access changing rooms, all these contravening infection prevention measures.

The meeting concluded that there is need to redesign our theatres, so that the flow of traffic meets contemporary standards of infection prevention.

Hygiene in the wards was also a cause if great concern where there are many guardians to one patient, at the same time or serially, thereby making it difficult to teach the guardians on infection prevention measures. The increasing numbers of visitors but also many visiting hours also create major problems with infection prevention, whereby the wards are left very dirty after each visiting hour.
Participants suggested that the number of guardians should be limited, guardians should be given ward gowns so that they are properly identified and that they cannot just change anyhow, limit visiting times to hospital but also to limit access of visitors into the wards.

Antibiotic prophylaxis was also considered as one of the best practices in infection prevention, whose scientific basis is clear. It was stressed that antibiotic prophylaxis on its own cannot tackle infections, the hygiene measures discussed above should be the mainstay of our infection prevention strategy. The use of ceftriaxone for both prophylaxis and therapeutic purposes was declared an anomaly to principles of prophylaxis, and, coupled with the increasing rate of resistance to ceftriaxone in the hospital, the meeting unanimously agreed to shift from ceftriaxone to cefazolin as the main drug in surgical prophylaxis. It was noted that cefazolin has a wide enough cover for most gram positive and gram negative bacteria responsible for wound infections.

It was noted that cefazolin is a first generation cephalosporin with no activity against MRSA or ESBL which are important offenders in implant surgery. It was agreed that the microbiologists should have discussions with relevant departments to make special considerations for prophylaxis for patients in orthopaedics and neonates in paediatric surgery where cefazolin may not be sufficient cover to expected offending organisms in these two subspecialties.
It was agreed that cefazolin shall only be used as a drug of prophylaxis, only accessible to anaesthetists who administer surgical prophylaxis in our hospital and that cefazolin shall not be given after surgery in the wards.
A guideline was to be made and incorporated in MicroGuide to help in deciding which patients need prophylaxis, and which ones have dirty or contaminated wounds requiring treatment with ceftriaxone. A representative for Central Medical Stores Trust was tasked to explore the availability of cefazolin in Malawi.

4. Implementation of Resolutions prevention of infections in postoperative patients and scaling down abuse of antibiotics

The meeting discussed possible challenges to implementing the resolutions from this meeting. Those identified included lack of buy-in of suggested ideas from Hospital management, misallocation of funds to treating infections other than investing in measures to prevent the infections, lack of research on infections in surgery which leaves to base for making decisions and guidelines on antibiotic choices, lack of buy-in from the community with the proposed changes to the culture of hospital visitations. Several strengths were also identified. By the end of the meeting the following summarises the resolutions made.

  1. Establish an Infection Control Directorate at a management level, which will look at how to operationalize the strategies (in bold and italics above) and mobilise resources and give guidance to the infection Prevention Committee. This committee can also look at the hospital build environment, hospital facilities, hospital linen, etc
  2. There is need to re-introduce the Infection Prevention Team which will be given powers to implement resolutions made in this meeting, in the various departments with guidance from the Infection Control Directorate. The team shall consist of a Microbiologist, a pharmacist and a senior nurse and they shall work with Charge nurses in the wards, empowering them to enforce infection prevention strategies in staff, guardians and visitors. This committee will concentrate local (ward level) implementation of the resolutions
  3. Approach researchers, to work with the various departments in research on surgical site infection swabs. In this work the laboratory at QECH, in collaboration with the Department of Microbiology at The College of Medicine, will play a leading role in order to ensure sustainability. The information gathered through this exercise will be used in the creation of surgical antibiotic stewardship guidelines.
  4. Institute measures which will lead to changing surgical prophylaxis from ceftriaxone to cefazolin as soon as possible
  5. Engage the community and community leaders to create demand for better infection prevention measures and encourage the public to adopt a new culture which will reduce contamination of the hospitals.