Dec Decisi ision on Makin Making g for P or PAP f AP for P or - PowerPoint PPT Presentation

Dec Decisi ision on Makin Making g for P or PAP f AP for P or Pacemak acemaker er Im Implan plantation tation A Model Of Success

Key Elements  Antibiotic policy versus Antibiotic Stewardship  Elements of a Successful Antimicrobial Stewardship

Problem Increased prevalence of MDR- EDR – PDR pathogen s Abuse of antibiotics

Antibiotic policy versus Antibiotic Stewardship Antibiotic Antibiotic policy Stewardship

Decision Making for Preoperative Antibiotic Prophylaxis for Pacemaker Implantation at The Cardio physiology Unit/NUH A Model of Success

 Standardized decolonization treatment consisted of :  mupirocin nasal ointment,  chlorhexidine mouth rinse,  and full-body wash with Betadine /chlorhexidine soap for 5 days.

De Deci cision sion Ma Maki king ng for or PAP AP for or Pacemak Pacemaker er Im Impla planta ntation tion Su Surger rgery y Screening For MRS (MRSA / MRCONS) 1. Nasal – Auxiliary – Ear – Perinea swabs  If candidate is + Ve positive MRS  If candidate is + Ve positive for MRS 2. Decolonization Procedure  Repeat screening for MRS (MRSA/ MRCoNS )Colonized  Decide on PAP (pre-operative antibiotic prophylaxis) based on 3. culture results.

Dec Decolon oloniza izati tion on St Stra rateg tegy y ad adop opted ted at at Th The e Ca Card rdio io ph physiol ysiology ogy Un Unit it/NUH /NUH Duration: 5days  Skin Decolonization:  Wash  Chlorhexidine or Beta dine " body wash " : Once preferably twice daily changing all clothes  Special attention to all hairy body surfaces Auxiliary – Perineum  Mupirax cream  Auxiliary – Perineum Nasal Decolonization: o Chlorhexidine Nasal rinse 5x per day o Mupirax ointment(2%) Oral Decolonization: Mouth rinse Chlorhexidine oral rinse 5x per day

Recomme ecommended Pre nded Pre-operati operative e Pr Proph ophylaxi ylaxis Pre-operative Prophylaxis Colonization State Body weight <80 kg Body weight 80-160 kg 1 Persistently Teicoplanin 400 mg Teicoplanin 800 mg colonized Or Or Vancomycin 1g Vancomycin 2g 2 Decolonized Cefazolin 1g Cefazolin 2g

Findings Total # of candidates for Pace Maker Implantation 2015 =82 2016= 46 Total= 128 Total # of Pace Maker Implant associated infections = zero

Total MRS Auxiliary& Nasal carriage among Candidates for Pace maker implantation Before & after implementation of decolonization regimen N umber of patients 128 Concomitant Auxiliary & Auxiliary Nasal carriage carriage Nasal carriage Before 72 (56.25%) 73 (57.03%) 44 (34.37%) ) ( ) ( After 24 (18.75%) 17 13.28% 5 3.91%

Aux uxiliar iliary y & N & Nasal asal c carria rriage ge o of MRS f MRS amo mong ng Ca Cand ndida idates es for or Pa Pace ce maker er implantation lantation Bef efore ore & after er impleme lementation ntation of of deco decolo loniza nization tion re regimen gimen 57.03 56.25 60 50 34.37 40 Before 30 18.75 After 13.28 20 3.91 10 0 Concomitant Axillary Nasal Axillary & Nasal carriage

MR MRS ca carri rriage age among ong ca candi dida dates es for or Pa Pace ce maker er impla plantation ntation Bef efore ore & after er impleme lementa ntation tion of of deco decolo lonization ization re regimen gimen Auxiliary and Nasal Carriage of MRS (%) + ve Auxiliary +ve Auxiliary -ve Auxiliary -ve Auxiliary + ve Nasal -ve Nasal +ve Nasal -ve Nasal Before 44 (34.37%) 28 (21.87%) 29 (22.66%) 28 (21.87%) ) ( ) ( ) ( After 5 3.91% 19 14.84% 12 9.37% 83 (64.84%) Total # of Candidates for Pace maker implantation surgery included 128

Na Nasa sal l & ax & axillar illary y Carr rriage iage of of MR MRS among mong C Candi andida dates es for or Pace Pace maker er implantation lantation Bef efore ore & after er impleme lementation ntation of of dec decol olon onization ization re regimen gimen in per erce cent nt 64.84 70 60 50 34.37 40 Before After 22.66 30 21.87 21.87 14.84 20 9.37 3.91 10 0 A+/N+ A+/N- A-/N+ A-/N-

MR MRSA A & MR MRCoNS oNS ca carri rriage ge a among ong C Candid didates es for or Pa Pace ce maker er implantation lantation Bef efore ore & after er impleme lementation ntation of of deco decolo lonization nization re regime gimen MRSA +ve CoNS +ve Before 23 (17.97%) 86 (67.19%) After 3 (2.34%) 36 (28.13 %)

Per ercentage centage of of T Total tal MR MRSA A & MR & MRCoNS oNS ca carria rriage ge a among mong Ca Cand ndida idates es for or Pa Pace ce maker er impla plantation ntation Bef efore ore & af after er implementation plementation of of dec decol olon onization ization re regimen gimen 67.19 70 60 50 40 Before 28.13 After 30 17.97 20 2.34 10 0 CoNS +ve MRSA +ve

MRS MRSA A an and MR d MRCoNS CoNS ca carri rriage age amon among g Cand Candid idat ates es for or Pace Pace ma maker er im impla plant ntation ation su surger rgery y Be Before ore an and a d after er Decoloniz De colonization ation MRSA+ve MRSA +ve MRSA - ve MRSA - ve MRCoNS+ve MRCoNS-ve MRCoNS + ve MRCoNS -ve Primary 6 6 52 18 culture (4.69%) (4.69%) (40.63%) (14.06 % ) results After - 3 25 54 Decoloniz (2.34%) ( 30.5%) (65.8%) ation Total # of Candidates for Pace maker implantation surgery included 128

% of % of T Total tal ca carria rriage ge of of Me Meth thicillin cillin Res esistant istant Sta taphylococ ylococci ci amon ong C Candid didates es for or Pa Pace ce maker er impla plantation ntation surger urgery y Bef efore ore and d after er implementation plementation of of D Dec ecolon olonization ization 65.8 70 60 50 40.6 40 30.5 30 20 14.1 10 4.69 4.69 2.34 0 0 MRSA+/MRCONS+ MRSA+/MRCONS- MRSA-/MRCONS+ MRSA-/MRCONS- Before After

Cum Cumul ulativ ative e MR MRS S – Ve Candidat e Candidates es for or Pace Pace maker mak er im implantation plantation  Cumulative MRS – Ve Candidates for Pace maker implantation = Out come The need for Vancomycin / Teichoplanin PAP dropped from 100 (78.13% )out of 128 patients To 45 (35.16%) patients

In Conclusion Decolonization regimens are successful tools to lower carriage rates of Methicillin resistant Staphylococci It can lower the need for Vancomycin/Teicoplanin in Peri- operative antibiotic prophylaxis (PAP)

Finally The joint effort of IP&C UNIT, Microbiology Lab Antimicrobial Stewardship & The CardioPhysiology Unit set an example of a successful Antibiotic Stewardship Program to limit the abuse of Vancomycin/ Teicoplanin in Pre-operative antibiotic prophylaxis (PAP) while ensuring Safe Pace Maker Implant Surgery

Special Thanks To Prof Dr Moustapha Nawar  For advising & supporting the decolonization /Safe Implant Surgery Program at Alexandria NUH

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