Hospital-acquired (nosocomial) infections occur in developed as well as and resource poor countries. They cause increased morbidity and are a major cause of death among hospitalized patients. Prevalence surveys in Lithuania, Latvia, Estonia and Sweden show that 4-11% of hospitalized patients acquire a nosocomial infection. The most frequent are infections of surgical wounds, the urinary tract and the lower respiratory tract.
The intensity of antibiotic use in a population highly susceptible to infections creates an environment that facilitates the development as well as transmission of resistant organisms. Optimal infection control programs in health care facilities decrease the frequency of nosocomial infections. Such programs have been identified as important components of comprehensive strategies for the control of antimicrobial resistance, primarily by limiting the spread of resistant organisms among patients. Infection control is a quality standard and is essential for the well-being and safety of patients, staff and of the general population. It affects most departments of the hospital and involves issues of quality, risk management, clinical governance, health and safety.
WHO Global Strategy for Containment of Antimicrobial Resistance announced in 2001 addresses the challenge of emerging antibiotic resistance. In November 2001 an EU recommendation was adopted in which every member state was asked to put in place specific strategies on the prudent use of antimicrobial agents. Revised recommendations on Prevention of Hospital-acquired Infections were released by the WHO in 2002.
The Council of Baltic Sea States (CBSS) established a Task Force on Communicable Disease Control in the Baltic Sea Region during a meeting in Denmark in April 2000. Several areas related to communicable diseases were identified for action, among them antimicrobial resistance and hospital infection control.
Two Task Force projects funded by Sida (Swedish International Development Cooperation Agency) in Sweden, Surveillance of antibiotic resistance in the Baltic Region (AB12) and Creating templates for education in infection control (AB 24), joined forces and held a seminar entitled Infection Control and Containment of Antibiotic Resistance in Riga, 20 -24 March, 2004. The purpose of this seminar was to bring microbiologists and infection control professionals into closer contact and improve communication.
Forty selected experts representing microbiology and infection control from nine countries were invited to participate in the seminar. Participants were selected by steering group members to bring the best available expertise from Estonia, Latvia, Lithuania and Northwest Russia. Lecturers were invited from four European countries. Conference participants were considered members of the newly formed BALTICCARE network.
Nine workshops were arranged during the seminar. In each workshop identification of problems and possible solutions were discussed. Issues where a solution could not be suggested were noted as unresolved. Actions that could be taken through the BALTICCARE network were identified.
Surveillance of antibiotic resistance
It was generally noted that national data on surveillance of antibiotic resistance were not available in the Baltic countries or in Russia. Methods for detecting antibiotic resistance varied greatly both within and between countries. Small reports and observations indicated that among outpatients resistance levels were not very high and were comparable to average European levels. One case of community-acquired MRSA (Methicillin-Resistant Staphyllococcus aureus) had been reported from Latvia. A high level of resistance among nosocomial pathogens was recorded in all countries. Some hospitals were using WHONET 5 for their microbiological laboratory register. Larger laboratories in Estonia are already participating in the European network for surveillance of antibiotic resistance (EARSS), Latvia is planning to participate with six laboratories and Lithuania is preparing to introduce the EARSS protocol.
An unresolved issue was the establishment of a reference laboratory/center in each of the participating countries. Centers intended, through government agencies, for this purpose were malfunctioning due to lack of trained staff and necessary equipment.
Antibiotic resistance markers
Most laboratories used NCCLS (The National Committee for Clinical Laboaratory Standards) standards and guidelines for susceptibility testing, but these were usually not updated. In Russia a national standard is used. There was a wide variety of screening methods and verification methods, e.g. for the detection of MRSA and ESBL (Ekstended spectrum betalaktamase) -producing gram-negative bacteria. Funding was generally not available for central laboratories to receive and analyze resistant strains using molecular methods.
The conclusion was to appoint a working group to identify current methodologies in each country and to define standard procedures and/or adopt internationally accepted standards (e.g. EARSS protocol) for routine antibiotic susceptibility testing. External quality control programs could also be organized within the network. Networking on national and regional levels for the implementation of molecular methods in reference/referral laboratories seemed necessary.
Surveillance of nosocomial infections
Some surveillance activities were already established in countries represented at the seminar. National prevalence studies were performed in Latvia and Lithuania, and in Estonia one prevalence survey at Tartu University Hospital had taken place. In Lithuania prospective surveillance has been introduced in selected ICUs (Intensive care unit) and surgical departments using HELICS (Hospitals in Europe Links for Infection Control Through Surveillance) protocols. In Russia, SSI (Surgical site infection) surveillance had been initiated in several institutions. Results of these surveys have been published in internationally recognized scientific journals.
It was agreed that before starting new projects objectives of the surveillance should be clearly defined. Antibiotic use, laboratory results or active case surveillance could be used as methods. Introduction of HELICS protocols, definitions and coding system would be helpful in order to facilitate local and international comparisons, and participation should be encouraged. However, such participation would require significant intellectual and financial resources, and it must be clarified at the local level how hospitals will benefit from these activities.
The unresolved issue was the definition of nosocomial infections. Implementation of CDC (Center for Disease Control and Prevention) definitions for certain infections (e.g. UTI (Urine tract infection)) is difficult in settings with limited resources. Establishment of a working group within the network for modification or simplification of CDC definitions would be helpful.
Outbreak investigation including molecular epidemiology methods
Outbreaks of multiresistant nosocomial pathogens such as MRSA, multiresistant Pseudomonas aeruginosa, Acinetobacter baumanii, Enterobacter and other Gram-negative rods were being recognized as a serious problem in all participating countries. Early detection of outbreaks was considered problematic due to poor communication between clinicians and laboratories.
Antibiograms should be used as the first tool for phenotypic outbreak analysis, with molecular methods if available as a complement. PCR based methods (e.g. ERIC) were considered applicable for Gram-negative pathogens and might be introduced in large hospitals. The relatively labor intensive and expensive PFGE method for epidemiological typing should be used retrospectively and only in reference laboratories where databases should be created. Hospitals should be able to perform outbreak investigations within their own resources, and with the assistance of external experts only in very serious situations.
Creation of the system of link nurses in every department who should report to the infection control service was suggested. A training course addressing outbreak investigations with international experts could be organized within the network.
Unsolved problems were the shortage in most of the hospitals of relevant staff that could perform outbreak investigations and the lack of molecular epidemiology tools that required additional financial investments.
Clinical microbiology is a sub-specialty of laboratory medicine in the Baltic States and Russia with no special training in Lithuania and Latvia. There was insufficient access to new international standards for identification and verification of microorganisms and detection of antibiotic resistance. Most of the hospitals had sampling guidelines. Lists of antibiotics for susceptibility testing and laboratory methods were not harmonized at the national level. Many laboratories still lacked computers.
It was concluded that clinical microbiology should be recognized as a separate specialty. There is a need for national clinical microbiology societies with close connection to international societies. Clinical microbiology should be included in the curriculum of universities and postgraduate training.
It was suggested that a Baltic Society of Clinical Microbiology could be created to achieve more influence.
There was a significant absence of proper guidelines in all participating countries. Adherence to proper hand hygiene procedures was insufficient due to high workload, lack of suitable hygiene products and low compliance. Some hospitals in the Baltic States had local MRSA containment protocols. There was a universal lack of isolation rooms and cohort staff.
It was generally agreed upon that standard precautions should be used for all patients. Isolation of the patients should be added in special situations: MRSA, diarrhoea, tuberculosis.
Precautions should preferably be ranked in order of importance. Written evidence based national guidelines for the health care community should be ratified at the governmental level.
Common guidelines for the Baltic States could be an issue of discussion. The network could facilitate exchange of educational materials, templates and scientific literature.
Unresolved issues were the efficient implementation of guidelines, the lack of financial resources and the shortage of rooms for patients in need of isolation.
General knowledge among medical staff on infection control measures such as hand hygiene, was low. Implementation of prudent antibiotic use was a problem. Lack of qualified infection control and clinical microbiology staff in the Baltic States and Russia is a problem. The existing infection control specialists had varying academic backgrounds in the respective countries except Estonia. Little or no information on the prudent use of antibiotics and on the threat of antibiotic resistance was offered to the general public.
It was concluded that there is an urgent need to increase educational activities in infection control and clinical microbiology. Establishment of postgraduate education on national and/or international level is essential. Continuous postgraduate education programs for every medical specialty should include infection control. All levels of the health care system including health care providers and administrators need to get additional education in this field. Targeted education for different groups was suggested as a more effective approach. The role of the network in educational activities could be significant. International education seminars could be organized on subjects where the local expertise was insufficient e.g. in education for infection control nurses or in outbreak investigations.
Strategies for containment of antibiotic resistance
Hospital administrators and governments often do not understand the extent of the problem of antimicrobial resistance, and patients and the general population do not get sufficient information. Surveillance systems using the best international standards would need significant additional resources which governments are not ready to supply. Marketing of antibiotics is not restricted in any of the participant countries and in Russia no prescription is needed to by antibiotics.
Regular collection and analysis of validated data on antibiotic resistance should be performed in every country. Information should be given to authorities, medical care providers and general population with additional explanations. The general population should be educated about antimicrobial resistance and importance of proper antibiotic use with involvement of mass media and other available resources. National and hospital guidelines for antibiotic use are recommended only if they are based on local resistance data and evidence-based principles.
Data on total antibiotic consumption is difficult to obtain and the problem of unrestricted marketing of antibiotics will probably remain unresolved.
How to network intellectually and physically
Interaction between clinical microbiologists and infection control staff is paramount for infection control. This interaction was not always present and varied greatly between hospitals and between countries. There is currently no formal network of microbiologists and infection control specialists in the Baltic States and Russia.
Teams (committees) of interested specialists including hospital administrators should be created in every hospital to address infection control and antibiotic use problems. An infection control physician with a background in infectious diseases or clinical microbiology should preferably replace current hospital epidemiologists. Creation of strong national and international networks should be encouraged. The BALTICCARE discussion forum provided by the Swedish Institute for Infectious Disease Control could help in getting to know each other better and to develop collaborative projects. Common educational programs with invited experts could be introduced. Experience from participation in External Quality Control programs could be shared. An international approach to governments, state agencies and mass media could be used to achieve better recognition.
One unresolved issue was how to promote interest in networking without financial incentives.
The problem of antimicrobial resistance and hospital-acquired infections has been largely neglected in the Baltic States and Russia during last twenty years. New diagnostic and therapeutic approaches have changed the patient population. Increasing problems are also associated with the rise in bacterial resistance, a problem rooted in the widespread, uncontrolled and, in many cases, erroneous use of antibiotics, coupled with inadequate hospital hygiene procedures and the lack of relevant regulations and guidelines. An initiative was taken to create a network between leading infection control specialists and clinical microbiologists from Estonia, Latvia, Lithuania and Russia BALTICCARE. Laboratories and clinics were chosen for collaboration within BALTICCARE network with the expectation to become centres of national networks from which continual education will take place.
The Riga seminar, being the first main activity of this network, was organized by Stradins University Hospital, a leading local centre for research on antimicrobial resistance and hospital-acquired infections in Latvia. The Latvian Ministry of Health supported the seminar. A press conference was held at the end of the seminar. A report was shown on the TV3 news channel and abstracts published in main Latvian newspapers and medical journals.
The participants in the seminar agreed on three major strategies in the battle against emerging antibiotic resistance:
The first is to improve infection control where a major component is to ensure that all hospitals have an infection control team sufficiently staffed to support a hospital wide infection control program.
The second strategy comprises rational antibiotic prescribing which will reduce the selection pressure that encourages the emergence of resistant organisms. Hospital microbiology laboratories and infectious disease/infection control teams need to be resourced to tackle the problem in co-operation with their clinical colleagues.
The third important strategy is safe delivery of healthcare. There is currently a remorseless drive to reduce waiting lists and treat more and more patients whilst reducing the costs of healthcare by reducing bed numbers. The way we deliver healthcare today is almost guaranteed to spread resistant organisms such as MRSA.
It is clear that the health care professionals alone cannot solve these problems. Politicians, policy makers, hospital managers and other care givers need to consider the problem and implement a long term strategy on containment of antibiotic resistance and reduction of hospital infections. It is a common concern for all of us to see to that patients may rest assured that everything is being done to minimize the risk of acquiring an infection through the spread of antimicrobial resistant pathogens within the hospital.
The seminar workshops identified a number of issues where actions are needed and which would benefit from being handled within a network. Problems identified in several of the workshops were:
Available scientific data on antibiotic resistance and on hospital-acquired infections are insufficient.
Official report systems are not scientifically structured and validated and therefore give unreliable figures.
Optimal external quality control is not provided to all laboratories.
Molecular typing of outbreak microorganisms is rarely performed and usually only for scientific reasons.
Clinical microbiologists and infection control professionals with sufficient training are lacking.
Communication between microbiologists and clinicians needs to be improved.
It is obvious that to improve the situation actions on a national level are needed, e.g. establishment of a multidisciplinary reference group to coordinate resistance detection protocols, implement software (WHONET 5) and analyze the data, and of a reference center for surveillance of resistance. Participation in international activities (EARSS: European Antimicrobial Resistance Surveillance System, EUCAST: European Working Party on Antibiotic Susceptibility Testing) was recommended as was exchange of information on resistance patterns between countries. Joining international surveillance projects would provide better scientific data and also raise the profile and qualification of researchers involved. Coordinated action within the local Baltic Sea region network could attract additional attention from politicians.
The network participants will continue to work in collaboration on projects defined after the workshop discussions. Results from this collaboration will be presented during a second seminar in the autumn of 2005.