WEBVTT 00:00:00.226 --> 00:00:03.186 A:middle >> And welcome to this webinar session in honor 00:00:03.186 --> 00:00:06.916 A:middle of World Antimicrobial Resistance Awareness Week. 00:00:06.916 --> 00:00:11.926 A:middle Today's webinar is The Race Against Antimicrobial Resistance 00:00:11.926 --> 00:00:14.756 A:middle in Neonates, Insights on Data, 00:00:15.276 --> 00:00:17.656 A:middle Infection Prevention, and Stewardship. 00:00:18.246 --> 00:00:20.956 A:middle We are excited to host the webinar and hear 00:00:20.956 --> 00:00:23.226 A:middle from our speakers and panelists. 00:00:23.346 --> 00:00:26.626 A:middle We will have three presentations followed by a panel discussion. 00:00:26.626 --> 00:00:31.016 A:middle I am Katie Wilson, an epidemiologist 00:00:31.016 --> 00:00:33.866 A:middle in the International Infection Control Branch here 00:00:33.866 --> 00:00:36.196 A:middle at the U.S. CDC. 00:00:36.196 --> 00:00:40.126 A:middle I will be moderating this session alongside Dr. Fernanda 00:00:40.126 --> 00:00:41.816 A:middle Lessa, who is Chief 00:00:41.816 --> 00:00:44.756 A:middle of the International Infection Control Branch. 00:00:45.226 --> 00:00:48.686 A:middle A couple of notes for everyone as we get started, 00:00:48.686 --> 00:00:53.016 A:middle French and Spanish interpretation is available 00:00:53.016 --> 00:00:53.826 A:middle for this webinar. 00:00:54.666 --> 00:00:58.346 A:middle In your bottom Zoom menu, click the globe icon 00:00:58.346 --> 00:01:02.266 A:middle to access channels for Spanish and French interpretation. 00:01:04.966 --> 00:01:09.896 A:middle If you have any questions for the presenters or panelists, 00:01:09.896 --> 00:01:13.806 A:middle please use the Q&A, the questions and the answers button 00:01:14.126 --> 00:01:17.016 A:middle on your bottom menu, to submit your question, 00:01:17.016 --> 00:01:21.406 A:middle and we will be answering those live throughout the webinar. 00:01:21.736 --> 00:01:26.116 A:middle If you would like to introduce yourself or have any questions 00:01:26.116 --> 00:01:30.346 A:middle about interpretation, or if you are having any technical issues, 00:01:30.346 --> 00:01:33.916 A:middle please use the chat function of this webinar. 00:01:33.916 --> 00:01:39.156 A:middle I will now turn it over to Fernanda 00:01:39.156 --> 00:01:41.966 A:middle to introduce our first session and speaker. 00:01:44.596 --> 00:01:48.036 A:middle >> Good morning, everyone, good afternoon or good evening, 00:01:48.036 --> 00:01:49.276 A:middle depending on where you are. 00:01:49.276 --> 00:01:56.376 A:middle Thanks for joining us today for this important webinar session. 00:01:56.696 --> 00:01:59.606 A:middle It's my pleasure to introduce our first speaker, 00:01:59.606 --> 00:02:03.596 A:middle Dr. Amelia Keaton, who is a medical officer 00:02:03.596 --> 00:02:06.666 A:middle within the CDC International Infection Control Branch, 00:02:06.956 --> 00:02:09.946 A:middle where her work focuses on detection, prevention 00:02:10.286 --> 00:02:13.756 A:middle and response to healthcare-associated infections 00:02:13.756 --> 00:02:15.836 A:middle in low- and middle-income countries. 00:02:16.186 --> 00:02:19.106 A:middle As a pediatric infectious diseases physician, 00:02:19.106 --> 00:02:22.776 A:middle she has a special interest in developing resources 00:02:22.776 --> 00:02:25.336 A:middle and guidance for neonatal care units 00:02:25.656 --> 00:02:28.226 A:middle and other pediatric healthcare. 00:02:28.726 --> 00:02:30.066 A:middle So Amelia, over to you. 00:02:40.896 --> 00:02:42.656 A:middle If you are speaking, Amelia, on mute. 00:02:42.656 --> 00:02:44.116 A:middle >> Sorry about that. 00:02:44.116 --> 00:02:46.426 A:middle It took me a second to swap over. 00:02:46.426 --> 00:02:50.896 A:middle Are folks able to see my screen correctly? 00:02:51.446 --> 00:02:53.536 A:middle >> It's not on presentation view. 00:02:53.536 --> 00:02:55.476 A:middle >> Okay, one second. 00:02:58.086 --> 00:02:59.026 A:middle >> Perfect. 00:02:59.136 --> 00:02:59.746 A:middle Thanks, Amelia. 00:03:00.396 --> 00:03:03.496 A:middle >> Great. Thanks, everyone, and thank you for having me today. 00:03:04.396 --> 00:03:08.456 A:middle My goal for the sessions -- excuse me -- 00:03:08.456 --> 00:03:11.846 A:middle for my presentation today are to provide an overview 00:03:11.846 --> 00:03:15.106 A:middle of the unique aspects of neonatal healthcare settings. 00:03:15.326 --> 00:03:17.776 A:middle And just for reference, a neonate, for the purposes 00:03:17.776 --> 00:03:23.016 A:middle of this talk, is an infant who is less than 30 days of age. 00:03:23.016 --> 00:03:25.106 A:middle I also hope to discuss global disparities 00:03:25.106 --> 00:03:27.606 A:middle in neonatal mortality caused by infections, 00:03:27.606 --> 00:03:30.086 A:middle and then review the epidemiology and impact 00:03:30.086 --> 00:03:32.496 A:middle of antimicrobial-resistant infections. 00:03:35.356 --> 00:03:38.926 A:middle So newborn infants have a lot going on. 00:03:39.646 --> 00:03:43.866 A:middle All newborns, as soon as they're born, need to learn quickly how 00:03:43.866 --> 00:03:47.846 A:middle to breathe independently, receive appropriate nutrition, 00:03:47.846 --> 00:03:51.456 A:middle and fight infections with a very immature immune system 00:03:51.546 --> 00:03:54.646 A:middle that has not seen a lot of the organisms that they're coming 00:03:54.646 --> 00:03:56.856 A:middle in contact with when they first enter the world. 00:03:56.976 --> 00:04:02.166 A:middle However, fortunately for all of us, most infants that are born 00:04:02.166 --> 00:04:06.296 A:middle at term, which is on or after 37 weeks of gestation, 00:04:06.296 --> 00:04:08.316 A:middle handle these challenges with few 00:04:08.316 --> 00:04:10.846 A:middle or no medical interventions and do just fine. 00:04:14.296 --> 00:04:17.876 A:middle However, infants that are born either prematurely 00:04:17.876 --> 00:04:20.896 A:middle or with low birth weight or with other congenital health 00:04:20.896 --> 00:04:23.826 A:middle conditions face a lot more challenges 00:04:23.826 --> 00:04:27.556 A:middle that require many more medical interventions in some cases. 00:04:27.556 --> 00:04:30.186 A:middle So to begin, these infants tend 00:04:30.186 --> 00:04:32.066 A:middle to have an immature skin barrier, 00:04:32.066 --> 00:04:35.266 A:middle and that's why we use temperature-controlled isolates, 00:04:35.376 --> 00:04:39.226 A:middle such as the one shown in this photo. 00:04:39.896 --> 00:04:43.896 A:middle Second, they also have incomplete lung maturation, 00:04:43.896 --> 00:04:46.316 A:middle as well as nervous -- central nervous systems, 00:04:46.316 --> 00:04:48.736 A:middle which impairs their ability to breathe independently, 00:04:48.736 --> 00:04:53.436 A:middle and for these reasons, we often see infants requiring invasive 00:04:53.436 --> 00:04:55.706 A:middle or non-invasive respiratory support. 00:04:55.706 --> 00:04:59.246 A:middle And in some cases, they develop hemodynamic instability. 00:05:00.886 --> 00:05:05.796 A:middle Next, we often see that infants 00:05:06.096 --> 00:05:10.306 A:middle that are born before a certain gestational age do not 00:05:10.306 --> 00:05:12.646 A:middle yet have the ability to feed independently, 00:05:12.646 --> 00:05:18.866 A:middle and so often they will require feeding in G-tubes 00:05:18.866 --> 00:05:21.766 A:middle or peripheral nutrition via a central 00:05:21.766 --> 00:05:23.486 A:middle or peripheral venous catheter. 00:05:23.696 --> 00:05:29.066 A:middle And then finally, these infants are often at a much higher risk 00:05:29.066 --> 00:05:31.566 A:middle for infection, and some of this has to do with the fact 00:05:31.566 --> 00:05:35.016 A:middle that maternal placental antibody transfer 00:05:35.016 --> 00:05:37.196 A:middle that typically occurs during the third trimester 00:05:37.196 --> 00:05:40.146 A:middle of pregnancy has not occurred yet, and so in addition 00:05:40.146 --> 00:05:45.056 A:middle to having an immature system as any other newborn would, 00:05:45.056 --> 00:05:48.656 A:middle they are also starting it a bit of a -- 00:05:48.656 --> 00:05:51.616 A:middle they have limited antibodies 00:05:51.616 --> 00:05:53.666 A:middle that they've received from their mothers. 00:05:55.086 --> 00:05:59.206 A:middle And so I know a lot of people who don't work in pediatrics 00:05:59.206 --> 00:06:02.996 A:middle or in newborn medicine often walk by newborn care units 00:06:02.996 --> 00:06:06.006 A:middle and get very intimidated, but what I try to remind people 00:06:06.006 --> 00:06:09.806 A:middle of is that infants in these units typically have the same 00:06:09.806 --> 00:06:12.166 A:middle risk factors for healthcare-associated infections 00:06:12.166 --> 00:06:13.576 A:middle as older children and adults 00:06:13.576 --> 00:06:15.346 A:middle that are also receiving medical care, 00:06:15.656 --> 00:06:19.326 A:middle meaning that they have a weakened immune system 00:06:19.326 --> 00:06:21.016 A:middle because of critical illness. 00:06:21.206 --> 00:06:23.406 A:middle They typically have a compromised skin barrier. 00:06:23.896 --> 00:06:26.046 A:middle They have a lot of different caregivers. 00:06:26.386 --> 00:06:28.976 A:middle They typically require a long length of stay, 00:06:28.976 --> 00:06:31.196 A:middle and they often have the presence of medical devices, 00:06:31.196 --> 00:06:34.186 A:middle all of which increase their risk for infection. 00:06:36.636 --> 00:06:40.166 A:middle Moving on to where these infections are most frequent, 00:06:40.436 --> 00:06:42.486 A:middle we know that mortality and morbidity 00:06:42.486 --> 00:06:44.376 A:middle from infections are highest in low- 00:06:44.376 --> 00:06:45.826 A:middle and middle-income countries. 00:06:46.586 --> 00:06:51.036 A:middle Approximately 99% of global neonatal mortality occurs 00:06:51.036 --> 00:06:54.256 A:middle in countries that are classified as low and middle income, 00:06:54.866 --> 00:06:57.506 A:middle with the countries in Africa 00:06:57.506 --> 00:06:59.656 A:middle and Southeast Asia being the hardest hit. 00:07:00.536 --> 00:07:03.406 A:middle Among infants that are born in a hospital in these settings, 00:07:03.546 --> 00:07:07.616 A:middle healthcare-associated infections may account for anywhere from 4% 00:07:07.616 --> 00:07:12.336 A:middle to over 55% of neonatal deaths, depending on the setting. 00:07:12.336 --> 00:07:16.766 A:middle And when we look at the pathogens 00:07:16.766 --> 00:07:19.966 A:middle that are causing neonatal infections and neonatal sepsis, 00:07:19.966 --> 00:07:24.756 A:middle we also see differences by the income level of the country 00:07:24.756 --> 00:07:27.626 A:middle in those pathogens, but also in mortality. 00:07:28.216 --> 00:07:32.236 A:middle So on the left, we have a figure that I borrowed 00:07:32.236 --> 00:07:35.936 A:middle from a meta-analysis of the most common pathogens indicated 00:07:35.936 --> 00:07:37.806 A:middle in neonatal infections. 00:07:38.656 --> 00:07:43.236 A:middle On the left-hand side is the pathogen repretation for in -- 00:07:43.326 --> 00:07:45.636 A:middle for countries that are considered high income, 00:07:45.846 --> 00:07:48.336 A:middle and you can see from this 00:07:48.336 --> 00:07:51.976 A:middle that the most common pathogens are E. coli, 00:07:52.066 --> 00:07:54.676 A:middle which is typically an enteric organism that may be acquired 00:07:54.676 --> 00:07:56.206 A:middle from a mother or the environment. 00:07:57.326 --> 00:08:01.296 A:middle There's also representation from [inaudible] negative Staph. 00:08:01.296 --> 00:08:03.176 A:middle and Group B streptococcus. 00:08:03.286 --> 00:08:08.476 A:middle However, when you move to those countries that are middle income 00:08:08.476 --> 00:08:11.996 A:middle or low income, you start to see a much larger proportion 00:08:11.996 --> 00:08:15.556 A:middle of these infections caused by gram-negative organisms, 00:08:15.686 --> 00:08:20.766 A:middle including Klebsiella pneumoniae. 00:08:20.766 --> 00:08:23.066 A:middle And when you look at the pooled case fatality rates among 00:08:23.066 --> 00:08:25.376 A:middle neonates that have these infections, 00:08:25.986 --> 00:08:30.686 A:middle low-income countries face the highest mortality rates at 25% 00:08:30.686 --> 00:08:32.116 A:middle which is almost double what we see 00:08:32.116 --> 00:08:34.556 A:middle in high-income countries at 12%. 00:08:37.536 --> 00:08:41.736 A:middle Next, I want to share some data from the NeoOBS study 00:08:41.736 --> 00:08:44.166 A:middle on antimicrobial resistance in neonatal sepsis. 00:08:44.166 --> 00:08:47.326 A:middle This study was a prospective, 00:08:47.326 --> 00:08:49.916 A:middle multi-country observational study 00:08:49.916 --> 00:08:55.076 A:middle where the researchers collected detailed daily longitudinal data 00:08:55.076 --> 00:08:57.196 A:middle in 11 countries across Latin America, 00:08:57.196 --> 00:08:59.876 A:middle Africa and Southeast Asia. 00:09:01.026 --> 00:09:06.196 A:middle The figure that we see on the left is the composite or are -- 00:09:06.196 --> 00:09:09.116 A:middle is the frequency of different pathogen types in infants 00:09:09.116 --> 00:09:13.266 A:middle with diagnosed confirmed sepsis, and how they evolve 00:09:13.266 --> 00:09:15.646 A:middle with each day of postnatal age. 00:09:15.976 --> 00:09:18.086 A:middle So starting on the left, 00:09:18.086 --> 00:09:22.386 A:middle again we see a larger representation by E. coli. 00:09:22.716 --> 00:09:27.326 A:middle We see some gram negatives, but not as large of a percentage, 00:09:27.916 --> 00:09:30.976 A:middle but as we get -- as the infants grow older, you again start 00:09:30.976 --> 00:09:33.276 A:middle to see a higher proportion of pathogens 00:09:33.276 --> 00:09:36.326 A:middle such as Klebsiella pneumoniae and Acinetobacter. 00:09:36.326 --> 00:09:39.196 A:middle Of the infants in this study, 00:09:39.616 --> 00:09:44.986 A:middle at least 62.9% had a gram-negative organism detected 00:09:44.986 --> 00:09:46.576 A:middle as a reason for sepsis. 00:09:46.836 --> 00:09:52.856 A:middle And the figures on the right here demonstrate the 00:09:52.856 --> 00:09:55.946 A:middle antimicrobial susceptibility profiles for these isolates, 00:09:55.946 --> 00:09:59.906 A:middle and so for here, we're showing the three most common organisms 00:09:59.906 --> 00:10:01.096 A:middle that were identified 00:10:01.096 --> 00:10:02.936 A:middle as gram-negative infections in this study. 00:10:03.076 --> 00:10:06.106 A:middle I'm not going to go through and try 00:10:06.156 --> 00:10:10.986 A:middle to make you read the antibiotic names here on the x axis, 00:10:10.986 --> 00:10:14.676 A:middle but just to note that the higher amount 00:10:14.676 --> 00:10:17.456 A:middle of dark gray bars indicates a higher level 00:10:17.456 --> 00:10:20.686 A:middle of resistance of that pathogen. 00:10:20.686 --> 00:10:22.316 A:middle So obviously, Klebsiella pneumoniae 00:10:22.316 --> 00:10:24.166 A:middle and Acinetobacter have large levels 00:10:24.166 --> 00:10:27.006 A:middle of antimicrobial resistance in this population. 00:10:27.446 --> 00:10:30.676 A:middle Interestingly, though, E. coli, which is something that makes 00:10:30.676 --> 00:10:34.306 A:middle up a larger percentage of infections on the first day 00:10:34.306 --> 00:10:39.936 A:middle of life, has -- what we can see, those isolates appear 00:10:39.936 --> 00:10:43.026 A:middle to be somewhat more susceptible to antibiotics, 00:10:43.026 --> 00:10:47.806 A:middle which is interesting, as these E. coli typically tend to come 00:10:47.806 --> 00:10:51.356 A:middle from mother at the time of delivery. 00:10:53.076 --> 00:10:57.066 A:middle Next, I'll share some data from the Child Health and Mortality 00:10:57.066 --> 00:10:58.926 A:middle and Prevention and Surveillance network, 00:10:58.926 --> 00:11:03.486 A:middle which includes seven countries, all low and middle income. 00:11:03.486 --> 00:11:06.326 A:middle So the initial analysis of CHAMPS data identified 00:11:06.326 --> 00:11:08.836 A:middle that Klebsiella -- or excuse me. 00:11:08.836 --> 00:11:12.976 A:middle Initial analysis from this study identified Klebsiella pneumoniae 00:11:12.976 --> 00:11:16.466 A:middle as the most common pathogen in children under five, 00:11:16.466 --> 00:11:20.036 A:middle and the second-most common pathogen causing infections 00:11:20.036 --> 00:11:22.956 A:middle in neonates. 00:11:23.116 --> 00:11:28.366 A:middle Of 157 of 497 isolates from children with K. pneumoniae 00:11:28.366 --> 00:11:30.556 A:middle in the causal chain of death within this study, 00:11:31.016 --> 00:11:34.056 A:middle 84% were resistant to ceftriaxone, 00:11:34.056 --> 00:11:37.186 A:middle which is a commonly available third-generation cephalosporin. 00:11:37.666 --> 00:11:39.766 A:middle There's also high levels of resistance 00:11:39.766 --> 00:11:42.286 A:middle to other antimicrobial classes, 00:11:42.286 --> 00:11:46.746 A:middle as you can see here on the right. 00:11:46.986 --> 00:11:50.626 A:middle Moving on to where these organisms may be acquired, 00:11:50.626 --> 00:11:52.716 A:middle I want to highlight some work from the Burden 00:11:52.716 --> 00:11:56.296 A:middle of Antibiotic Resistance in Neonates 00:11:56.296 --> 00:11:59.656 A:middle from Developing Society, or BARNARDS study. 00:11:59.656 --> 00:12:04.296 A:middle This is a very elegant network and elegant set of analyzes, 00:12:04.796 --> 00:12:10.166 A:middle but in this particular one here, the authors were looking 00:12:10.166 --> 00:12:12.896 A:middle at the presence of antimicrobial resistance genes 00:12:12.896 --> 00:12:17.716 A:middle in the gut microbiota of mothers and their infants who went 00:12:17.716 --> 00:12:21.046 A:middle on to develop neonatal sepsis. 00:12:21.246 --> 00:12:23.956 A:middle I think what is probably most interesting to highlight 00:12:23.956 --> 00:12:27.276 A:middle from this is that over 50% of infants studied 00:12:27.466 --> 00:12:30.606 A:middle within this analysis were colonized 00:12:30.606 --> 00:12:32.806 A:middle with at least one extended spectrum 00:12:32.806 --> 00:12:36.166 A:middle beta-lactamase-producing organism. 00:12:36.636 --> 00:12:40.346 A:middle And one in five infants was actually carrying the gene 00:12:40.346 --> 00:12:43.536 A:middle that encodes the New Delhi metallo-beta-lactamase gene, 00:12:43.536 --> 00:12:47.216 A:middle which confers carbapenemase resistance. 00:12:47.216 --> 00:12:48.176 A:middle In many cases, 00:12:48.176 --> 00:12:51.216 A:middle these antimicrobial resistance genes were actually detected 00:12:51.216 --> 00:12:55.246 A:middle within the first 24 hours of life, and while some 00:12:55.246 --> 00:12:57.596 A:middle of that may be connected between -- 00:12:57.726 --> 00:13:01.826 A:middle or excuse me, connected to transmission from their mothers, 00:13:02.136 --> 00:13:06.456 A:middle they also saw a large amount of genetic relatedness 00:13:06.456 --> 00:13:11.066 A:middle between isolates from neonates that were receiving care 00:13:11.066 --> 00:13:15.666 A:middle in the same unit as the neonates in the study, which indicates 00:13:15.666 --> 00:13:19.216 A:middle that there is healthcare transmission happening in many 00:13:19.216 --> 00:13:21.036 A:middle of these cases of neonatal sepsis. 00:13:21.036 --> 00:13:24.346 A:middle And that's important, because that's where folks 00:13:24.346 --> 00:13:26.516 A:middle like us can step in and hopefully impact 00:13:26.826 --> 00:13:28.156 A:middle that that high number. 00:13:30.376 --> 00:13:33.916 A:middle Next, I wanted to show a study 00:13:33.916 --> 00:13:39.296 A:middle that involved one large neonatal unit within a hospital in India. 00:13:40.086 --> 00:13:44.376 A:middle These data sought to understand the relationship 00:13:44.376 --> 00:13:47.796 A:middle between maternal rectal or vaginal colonization 00:13:47.796 --> 00:13:50.496 A:middle and environmental gram-negative colonization 00:13:50.806 --> 00:13:53.296 A:middle with bloodstream infection isolates among 00:13:53.296 --> 00:13:54.726 A:middle hospitalized neonates. 00:13:55.086 --> 00:13:59.626 A:middle So the black dots within this figure each represent a 00:13:59.626 --> 00:14:02.306 A:middle confirmed neonatal infection 00:14:02.306 --> 00:14:05.106 A:middle with the pathogen that's shown here at the bottom. 00:14:05.946 --> 00:14:09.156 A:middle To better evaluate the connection 00:14:09.156 --> 00:14:10.266 A:middle between these isolates, 00:14:10.266 --> 00:14:14.216 A:middle the authors also collected sink isolates from sinks 00:14:14.216 --> 00:14:17.876 A:middle within the unit, and this is important because we know 00:14:18.126 --> 00:14:23.856 A:middle that sinks and other water sources may be great places 00:14:24.176 --> 00:14:27.996 A:middle to -- are typically susceptible to colonization with biofilms 00:14:27.996 --> 00:14:32.256 A:middle with antimicrobial-resistant organisms, and so they -- 00:14:32.256 --> 00:14:38.016 A:middle the authors wanted to include this as a proxy for the role 00:14:38.016 --> 00:14:40.896 A:middle that the environment might play in these infections. 00:14:41.106 --> 00:14:42.266 A:middle And then finally, the lines 00:14:42.266 --> 00:14:45.286 A:middle between these dots indicate the number 00:14:45.286 --> 00:14:47.746 A:middle of single nucleotide polymorphisms 00:14:47.956 --> 00:14:52.556 A:middle that were identified between each isolate, and a lower number 00:14:52.556 --> 00:14:55.666 A:middle of single-nucleotide polymorphisms indicates a higher 00:14:55.666 --> 00:14:58.296 A:middle degree of genetic relatedness. 00:14:58.296 --> 00:15:01.966 A:middle You'll notice here that there are no dots representing 00:15:01.966 --> 00:15:05.926 A:middle maternal colonization isolates, and that's because the authors 00:15:05.926 --> 00:15:09.966 A:middle of this study did not actually identify neonatal bloodstream 00:15:09.966 --> 00:15:13.246 A:middle isolates that matched isolates obtained 00:15:13.246 --> 00:15:14.706 A:middle from maternal specimens. 00:15:14.706 --> 00:15:18.666 A:middle However, the clusters that we see here indicated there was a 00:15:18.666 --> 00:15:21.666 A:middle high degree of relatedness between isolates collected 00:15:21.666 --> 00:15:26.576 A:middle from infants within the care unit, particularly among infants 00:15:26.576 --> 00:15:30.596 A:middle that were -- that received care within 30 days of each other. 00:15:30.806 --> 00:15:33.246 A:middle So we see tight clustering here 00:15:33.746 --> 00:15:35.906 A:middle with a sink isolate in the middle. 00:15:35.906 --> 00:15:39.846 A:middle There's also connection with another cluster of isolates 00:15:39.846 --> 00:15:43.456 A:middle that occurred among three different infants, 00:15:43.646 --> 00:15:46.956 A:middle and then each other pair of -- 00:15:46.956 --> 00:15:49.786 A:middle or each other grouping of isolates, 00:15:49.786 --> 00:15:51.766 A:middle represents healthcare transmission 00:15:51.766 --> 00:15:53.456 A:middle within the unit as well. 00:15:58.636 --> 00:16:02.256 A:middle And what all of this means, I think, for the future, 00:16:02.256 --> 00:16:05.156 A:middle is that antimicrobial resistance is changing the way 00:16:05.156 --> 00:16:08.276 A:middle that we approach empiric antibiotic therapy. 00:16:08.736 --> 00:16:11.766 A:middle So as a point of reference, the World Health Organization 00:16:11.766 --> 00:16:14.426 A:middle and many other professional organizations recommend 00:16:14.426 --> 00:16:15.726 A:middle ampicillin and gentamicin 00:16:15.726 --> 00:16:19.696 A:middle as the recommended empiric antibiotic treatment 00:16:19.696 --> 00:16:22.426 A:middle for world -- for neonates that are suspected 00:16:22.426 --> 00:16:24.476 A:middle of having infections, and the reason 00:16:24.476 --> 00:16:28.136 A:middle for this recommendation has multiple origins. 00:16:28.136 --> 00:16:34.406 A:middle I think one is that these antibiotics typically cover the 00:16:34.406 --> 00:16:37.086 A:middle organisms that we see in neonatal sepsis 00:16:37.086 --> 00:16:39.856 A:middle in high-income countries, so things like Group B Strep, 00:16:40.226 --> 00:16:44.406 A:middle E. coli, are typically well-covered 00:16:44.406 --> 00:16:46.276 A:middle by these antibiotics. 00:16:46.276 --> 00:16:50.146 A:middle They're also widely available and relatively cheap. 00:16:50.576 --> 00:16:54.876 A:middle However, a sub-analysis of data from the BANARDS network, 00:16:54.876 --> 00:17:01.166 A:middle which I mentioned previously, sought to I look at how infants 00:17:01.166 --> 00:17:06.426 A:middle who received broader spectrum antibiotics fared against those 00:17:06.426 --> 00:17:08.716 A:middle who received the traditional regimen 00:17:09.176 --> 00:17:12.406 A:middle of ampicillin and gentamicin. 00:17:12.406 --> 00:17:16.716 A:middle And so the survival curve on the left represents the survival 00:17:16.716 --> 00:17:22.166 A:middle of infants who received each different antimicrobial regimen 00:17:22.166 --> 00:17:23.226 A:middle or combination. 00:17:23.706 --> 00:17:27.046 A:middle And this, again, are data that were collected 00:17:27.046 --> 00:17:30.136 A:middle from many hospitals across different countries 00:17:30.136 --> 00:17:32.796 A:middle in the world, and which is why you see different antibiotic 00:17:32.796 --> 00:17:34.366 A:middle combinations used here. 00:17:35.066 --> 00:17:37.596 A:middle So the ampicillin -- 00:17:37.596 --> 00:17:39.506 A:middle the children that received ampicillin 00:17:39.506 --> 00:17:44.236 A:middle and gentamicin are shown here in the red bar, 00:17:44.576 --> 00:17:48.766 A:middle which unfortunately indicates that infants 00:17:48.766 --> 00:17:52.466 A:middle that received either pip-tazo amikacin -- 00:17:52.556 --> 00:17:59.946 A:middle or excuse me, infants who received the combination 00:17:59.946 --> 00:18:03.986 A:middle of CEF-TAZ and amikacin actually had a much higher rate 00:18:03.986 --> 00:18:07.366 A:middle of survival than those who received that regimen. 00:18:07.806 --> 00:18:09.886 A:middle A few other antibiotic regimens were tried as part 00:18:09.886 --> 00:18:13.696 A:middle of this study, although those infants showed lower levels 00:18:13.696 --> 00:18:14.696 A:middle of survival. 00:18:14.956 --> 00:18:17.846 A:middle And so I think although there may be multiple factors 00:18:17.846 --> 00:18:22.726 A:middle at play here, we are seeing a lower rate of survival now 00:18:22.726 --> 00:18:28.676 A:middle with infants who are receiving ampicillin and gentamicin. 00:18:28.676 --> 00:18:32.566 A:middle And the future of antimicrobial resistance is also somewhat 00:18:32.566 --> 00:18:35.036 A:middle scary, because neonates 00:18:35.036 --> 00:18:37.146 A:middle and children typically are underrepresented 00:18:37.146 --> 00:18:40.876 A:middle in the antimicrobial trials that happen to try 00:18:40.876 --> 00:18:44.256 A:middle to identify new antibiotics 00:18:44.256 --> 00:18:46.776 A:middle that can target antimicrobial-resistant 00:18:46.776 --> 00:18:48.086 A:middle organisms. 00:18:48.136 --> 00:18:53.656 A:middle So in terms of new antibiotics approved since 2000, 00:18:53.906 --> 00:18:57.386 A:middle we see that only four new antibiotics have been approved 00:18:57.386 --> 00:19:01.896 A:middle for neonates and six antibiotics for children over the age 00:19:01.896 --> 00:19:06.106 A:middle of one, which is in comparison to the 40 other antibiotics 00:19:06.106 --> 00:19:08.606 A:middle that have been approved for adults. 00:19:08.606 --> 00:19:12.256 A:middle In looking at the global spectrum of clinical trials 00:19:12.256 --> 00:19:15.976 A:middle that are happening, there are many fewer clinical trials 00:19:15.976 --> 00:19:18.686 A:middle that actually are enrolling children or neonates, 00:19:19.436 --> 00:19:22.196 A:middle which means that if this doesn't change, 00:19:22.196 --> 00:19:26.246 A:middle we're going to have very limited options if we continue 00:19:26.246 --> 00:19:29.806 A:middle to see evolving antimicrobial resistance in this population. 00:19:30.116 --> 00:19:35.886 A:middle So I won't go very much into the different ways 00:19:35.886 --> 00:19:39.926 A:middle that we are trying to address neonatal antimicrobial 00:19:39.926 --> 00:19:42.816 A:middle resistance, as we have two speakers following me 00:19:42.816 --> 00:19:45.746 A:middle that are going to go a bit more into some of those topics, 00:19:45.986 --> 00:19:49.746 A:middle but in terms of kind of where we're looking these days, 00:19:49.986 --> 00:19:51.986 A:middle I think we know that we need better data 00:19:51.986 --> 00:19:54.766 A:middle on neonatal surveillance definitions 00:19:54.766 --> 00:19:56.376 A:middle and affordable diagnostics 00:19:56.376 --> 00:19:58.836 A:middle so that we can better diagnose these infections 00:19:58.836 --> 00:20:01.926 A:middle and compare data between different clinical sites 00:20:01.926 --> 00:20:02.976 A:middle and between different countries. 00:20:03.066 --> 00:20:07.076 A:middle Antimicrobial stewardship programs 00:20:07.076 --> 00:20:11.286 A:middle and smarter antimicrobial use in general is also something 00:20:11.286 --> 00:20:13.186 A:middle that I think will be important in the future. 00:20:13.186 --> 00:20:19.476 A:middle Infection prevention and control guidance targeted specifically 00:20:19.476 --> 00:20:21.716 A:middle for neonates so that we can interrupt 00:20:21.716 --> 00:20:24.776 A:middle that healthcare transmission of these organisms, 00:20:24.976 --> 00:20:30.016 A:middle a better antimicrobial toolbox with pediatric representation 00:20:30.016 --> 00:20:32.776 A:middle in clinical trials, and evaluation 00:20:32.776 --> 00:20:35.026 A:middle of different dosing regimens for this population, 00:20:35.026 --> 00:20:36.526 A:middle I think, is also critical. 00:20:37.076 --> 00:20:39.486 A:middle And then finally, I think another area 00:20:39.486 --> 00:20:43.926 A:middle that we often forget is that we may be able to tackle some 00:20:43.926 --> 00:20:47.186 A:middle of these infections by helping our infants develop a healthier 00:20:47.186 --> 00:20:51.236 A:middle microbiome, so things such as kangaroo mother care, 00:20:51.446 --> 00:20:55.726 A:middle which involves an infant spending more time skin to skin 00:20:55.726 --> 00:20:58.206 A:middle with their mother, with the encouragement 00:20:58.206 --> 00:21:01.146 A:middle of breastfeeding, can help with this. 00:21:01.386 --> 00:21:04.686 A:middle We can also help with a healthier microbiome by helping 00:21:04.686 --> 00:21:06.856 A:middle to maintain skin health in these infants 00:21:07.096 --> 00:21:08.966 A:middle so that they are not colonized with some 00:21:08.966 --> 00:21:10.836 A:middle of these organisms in the first place. 00:21:12.656 --> 00:21:13.456 A:middle So in summary, 00:21:13.456 --> 00:21:17.376 A:middle antimicrobial-resistant neonatal infections disproportionately 00:21:17.376 --> 00:21:19.316 A:middle impact low- and middle-income countries. 00:21:19.446 --> 00:21:20.746 A:middle Colonization 00:21:20.746 --> 00:21:23.886 A:middle with antimicrobial-resistant organisms occurs rapidly 00:21:23.886 --> 00:21:26.866 A:middle after birth, and organism relatedness indicates 00:21:26.866 --> 00:21:28.576 A:middle transmission from other infants 00:21:28.576 --> 00:21:30.036 A:middle and from the healthcare environment. 00:21:30.786 --> 00:21:34.286 A:middle And multimodal interventions, including infection prevention 00:21:34.286 --> 00:21:37.266 A:middle and control and antimicrobial stewardships, are necessary 00:21:37.266 --> 00:21:39.276 A:middle to protect these infants. 00:21:39.276 --> 00:21:44.986 A:middle I will stop there, and I will pass it to Fernanda 00:21:44.986 --> 00:21:46.316 A:middle to introduce our next speaker. 00:21:46.316 --> 00:21:46.776 A:middle Thank you. 00:21:47.066 --> 00:21:49.416 A:middle >> Thanks so much, Amelia. 00:21:49.416 --> 00:21:52.676 A:middle Thanks for that great presentation, 00:21:52.676 --> 00:21:55.866 A:middle and we'll hear more from you during our panel discussion. 00:21:55.866 --> 00:21:59.406 A:middle I am excited to introduce our next speaker. 00:21:59.766 --> 00:22:04.216 A:middle Dr. Fahmida Chowdhury is a medical epidemiologist 00:22:04.216 --> 00:22:06.456 A:middle with over 20 years of experience 00:22:06.456 --> 00:22:09.276 A:middle in pediatric medicine and public health. 00:22:09.276 --> 00:22:12.386 A:middle She is an associate scientist and Project Coordinator 00:22:12.386 --> 00:22:15.256 A:middle at ICDDRB in Bangladesh. 00:22:15.696 --> 00:22:19.536 A:middle Dr. Chowdhury leads research on antimicrobial resistance 00:22:19.536 --> 00:22:21.456 A:middle and respiratory infections, 00:22:21.786 --> 00:22:24.626 A:middle particularly among vulnerable populations 00:22:24.626 --> 00:22:28.846 A:middle such as hospitalized patients, pregnant women and neonates. 00:22:29.346 --> 00:22:32.646 A:middle She has spearheaded over 40 major projects, 00:22:32.646 --> 00:22:36.716 A:middle including pivotal studies on AMR, Candida auris, 00:22:36.866 --> 00:22:40.716 A:middle influenza, RSV, and SARS-CoV-2. 00:22:40.716 --> 00:22:43.876 A:middle So with that, I will hand it over to you, Fahmida. 00:22:48.836 --> 00:22:50.206 A:middle >> Hello, everyone. 00:22:50.316 --> 00:22:51.686 A:middle I think I'm audible, right? 00:22:54.146 --> 00:22:56.816 A:middle >> Yes, looks good, and we can hear you. 00:22:56.816 --> 00:22:57.626 A:middle >> Okay, okay. 00:22:57.626 --> 00:23:00.306 A:middle So good morning, good afternoon and good evening, 00:23:00.306 --> 00:23:02.036 A:middle depending on your time zone. 00:23:02.796 --> 00:23:04.876 A:middle I would like to thank the organizers 00:23:04.876 --> 00:23:08.086 A:middle for giving me the opportunity to present our research findings 00:23:08.086 --> 00:23:10.946 A:middle on critically ill neonates from Bangladesh in this webinar. 00:23:12.356 --> 00:23:14.316 A:middle So let me say it again. 00:23:14.316 --> 00:23:18.136 A:middle My presentation is on reductions in antimicrobial resistance 00:23:18.196 --> 00:23:21.056 A:middle in neonates through focused infection prevention 00:23:21.056 --> 00:23:22.526 A:middle and control interventions. 00:23:32.936 --> 00:23:33.536 A:middle I'm sorry. 00:23:33.536 --> 00:23:34.566 A:middle It's not moving. 00:23:42.396 --> 00:23:43.586 A:middle Is it moving or not? 00:23:47.446 --> 00:23:48.746 A:middle >> It's not moving. 00:23:49.276 --> 00:23:51.846 A:middle Did you try clicking at the bottom? 00:23:53.386 --> 00:23:54.186 A:middle >> Yeah, yeah, yeah. 00:23:54.186 --> 00:23:54.706 A:middle >> There you go. 00:23:55.166 --> 00:23:59.566 A:middle >> Yeah. So it is highly concerning 00:23:59.566 --> 00:24:02.796 A:middle that antimicrobial-resistant bacteria are frequently causing 00:24:02.796 --> 00:24:05.996 A:middle sepsis in newborns in low- and middle-income countries. 00:24:07.076 --> 00:24:10.196 A:middle The sustainable development goal that [inaudible] aims 00:24:10.196 --> 00:24:12.056 A:middle to reduce neonatal mortality 00:24:12.056 --> 00:24:16.526 A:middle to at least 12 deaths per 100,000 live births by 2030. 00:24:17.506 --> 00:24:21.166 A:middle However, these AMR infections are impeding progress 00:24:21.166 --> 00:24:25.246 A:middle in achieving neonatal mortality targets of the SDG, 00:24:25.246 --> 00:24:28.146 A:middle as you can see in the figure in the right-hand side. 00:24:29.546 --> 00:24:32.656 A:middle So colonization, why we are worried 00:24:32.656 --> 00:24:34.726 A:middle about AMR bacterial colonization, 00:24:35.406 --> 00:24:39.086 A:middle colonization is the presence and multiplication of bacteria on 00:24:39.086 --> 00:24:43.296 A:middle or in a host without causing disease, and is concerning 00:24:43.296 --> 00:24:46.786 A:middle as colonization with AMR pathogens increases the risk 00:24:46.786 --> 00:24:49.966 A:middle of future infections with these resistant organisms. 00:24:50.616 --> 00:24:54.036 A:middle A recently published systematic review highlighted 00:24:54.036 --> 00:24:56.636 A:middle that neonates are particularly susceptible 00:24:56.636 --> 00:24:59.636 A:middle to becoming colonized with AMR pathogens, 00:24:59.636 --> 00:25:02.496 A:middle especially in the setting of hospital births. 00:25:02.706 --> 00:25:07.426 A:middle So today, I'll be presenting findings from two studies. 00:25:07.936 --> 00:25:10.656 A:middle The first study, part of the Antibiotic Resistance 00:25:10.656 --> 00:25:13.416 A:middle in Communities and Hospitals (that is, in short, 00:25:13.416 --> 00:25:16.616 A:middle known as the ARCH study) focused 00:25:16.616 --> 00:25:19.376 A:middle on antibiotic-resistant enterobacterial among 00:25:19.376 --> 00:25:22.066 A:middle hospitalized neonates in intensive care units 00:25:22.066 --> 00:25:24.176 A:middle of a tertiary care hospital in Dhaka City, 00:25:24.476 --> 00:25:26.156 A:middle which is the capital of Bangladesh. 00:25:26.656 --> 00:25:30.026 A:middle Based on the interim analysis of this study, 00:25:30.996 --> 00:25:34.136 A:middle we conducted a second study to evaluate the impact 00:25:34.136 --> 00:25:37.446 A:middle of an in-depth IPC intervention in the same NICU, 00:25:37.716 --> 00:25:40.406 A:middle supported by the prevention and implementation teams 00:25:40.406 --> 00:25:43.406 A:middle of the International Infection Control Branch of the CDC. 00:25:48.206 --> 00:25:51.296 A:middle In my presentation, I'll be using the terms ESCRE, 00:25:51.296 --> 00:25:54.066 A:middle which is Extended-Spectrum Cephalosporin-Resistant 00:25:54.066 --> 00:25:55.966 A:middle Enterobacterials, and CRE, 00:25:55.966 --> 00:25:58.216 A:middle that is Carbapenem-Resistant Enterobacterials. 00:25:59.796 --> 00:26:03.416 A:middle So the primary of this study, primary objective 00:26:03.416 --> 00:26:06.826 A:middle of this study is to determine the prevalence of colonization 00:26:06.826 --> 00:26:13.196 A:middle with ESCRE and CRE on and during admission among NICU patients, 00:26:13.196 --> 00:26:17.096 A:middle and also to estimate the incidence of infections 00:26:17.096 --> 00:26:21.766 A:middle with ESCRE and CRE among NICU patients colonized 00:26:21.766 --> 00:26:25.806 A:middle with ESCRE and CRE. 00:26:25.806 --> 00:26:29.336 A:middle So this was a prospective cross-sectional study conducted 00:26:29.336 --> 00:26:31.476 A:middle at the neonatal intensive care unit 00:26:31.476 --> 00:26:33.486 A:middle of a tertiary medical college hospital. 00:26:34.236 --> 00:26:38.306 A:middle Our target sample size for this study was 423, 00:26:38.966 --> 00:26:43.276 A:middle and rectal soft samples were collected on day one, day three, 00:26:43.566 --> 00:26:46.096 A:middle seven, and every seven days thereafter, 00:26:46.096 --> 00:26:48.116 A:middle for neonates admitted to the NICU. 00:26:49.876 --> 00:26:52.826 A:middle For laboratory testing, we plated rectal swabs 00:26:52.826 --> 00:26:56.676 A:middle on selected chromagar media, and rectal swab isolates 00:26:56.676 --> 00:26:59.736 A:middle and blood culture isolates under [inaudible] identification 00:26:59.736 --> 00:27:02.796 A:middle and antimicrobial susceptibility testing using the Vitek 00:27:02.796 --> 00:27:03.646 A:middle 2 system. 00:27:10.136 --> 00:27:13.406 A:middle So interim analysis from our first study revealed 00:27:13.406 --> 00:27:17.846 A:middle that you can see here that 37% 00:27:17.846 --> 00:27:21.826 A:middle of the 360 enrolled neonates were colonized with CRE 00:27:21.826 --> 00:27:26.646 A:middle at enrollment, while 74% acquired colonization 00:27:26.646 --> 00:27:28.816 A:middle after 48 hours of admission. 00:27:29.286 --> 00:27:32.906 A:middle However, you can see here that 16% 00:27:32.906 --> 00:27:36.646 A:middle of enrolled neonates remain CRE-colonization-free 00:27:36.646 --> 00:27:38.146 A:middle until discharge or death. 00:27:41.736 --> 00:27:45.096 A:middle Among the carbapenem-resistant enterobacterials, 00:27:45.096 --> 00:27:49.496 A:middle you can see here that Klebsiella pneumoniae accounted for 73% 00:27:49.716 --> 00:27:53.826 A:middle of the isolates, followed by E. coli, which was 33%. 00:27:55.946 --> 00:27:58.886 A:middle So if you look back at the enrollment, 00:27:58.886 --> 00:28:01.946 A:middle Klebsiella pneumoniae and E. coli accounted 00:28:01.946 --> 00:28:06.096 A:middle for 82% and 51% respectively. 00:28:07.216 --> 00:28:10.716 A:middle However, you can see here after 48 hours of admission, 00:28:11.646 --> 00:28:15.766 A:middle this proportion increased to 92% for E. coli, and decreased 00:28:15.766 --> 00:28:18.576 A:middle to 30% for -- sorry, 92% 00:28:18.576 --> 00:28:21.246 A:middle for Klebsiella pneumoniae and 30% for E. coli. 00:28:30.166 --> 00:28:33.936 A:middle So and this [inaudible] that there is a chance 00:28:33.936 --> 00:28:36.766 A:middle of carbapenem-resistant Klebsiella pneumoniae that, 00:28:36.766 --> 00:28:39.696 A:middle in short, known as CR-Kpn, circulating in the NICU. 00:28:39.946 --> 00:28:41.666 A:middle So given the high burden 00:28:41.666 --> 00:28:45.936 A:middle of CR-Kpn colonization observed 48 hours post-admission, 00:28:45.936 --> 00:28:49.266 A:middle we further analyzed colonization trends over time. 00:28:49.846 --> 00:28:53.736 A:middle We found a gradual increase of CR-Kpn colonization rate 00:28:53.736 --> 00:29:00.566 A:middle that was 31% on enrollment, 57% on day three, 69% on day seven, 00:29:00.566 --> 00:29:06.046 A:middle 72% on day 14, and 73% on day 21. 00:29:06.626 --> 00:29:10.226 A:middle And this suggests that most neonates became colonized 00:29:10.226 --> 00:29:13.886 A:middle with CR-Kpn within the first 14 days of admission. 00:29:18.126 --> 00:29:21.856 A:middle So we analyzed the MIC values of these CR-Kpn isolates 00:29:21.856 --> 00:29:23.406 A:middle with different antibiotics, 00:29:23.406 --> 00:29:28.566 A:middle and found consistent MIC patterns suggesting the spread 00:29:28.566 --> 00:29:31.346 A:middle of same CR-Kpn spread within the NICU. 00:29:35.226 --> 00:29:37.546 A:middle So our interim analysis 00:29:37.546 --> 00:29:40.886 A:middle of the first study reveals a persistent high prevalence 00:29:40.886 --> 00:29:43.136 A:middle of carbapenem-resistant Klebsiella pneumoniae 00:29:43.136 --> 00:29:46.726 A:middle colonization that is more than 73% among neonates. 00:29:46.966 --> 00:29:52.706 A:middle Over 58% of neonates acquire CR-Kpn colonization 00:29:52.706 --> 00:29:53.976 A:middle after 48 hours of admission. 00:29:54.126 --> 00:29:59.356 A:middle Clinical cultures confirmed infection with CR-Kpn, 00:29:59.946 --> 00:30:03.066 A:middle and their consistent minimum inhibitory consideration values 00:30:03.066 --> 00:30:05.046 A:middle were observed for various antibiotics 00:30:05.046 --> 00:30:06.486 A:middle across the most CR-Kpn isolates, 00:30:06.486 --> 00:30:11.656 A:middle and this finding suggests hospital-acquired transmission 00:30:11.656 --> 00:30:14.656 A:middle and infection with the same CR-Kpn strain. 00:30:20.276 --> 00:30:23.356 A:middle In this slide, you can see here that according to the 00:30:23.356 --> 00:30:26.306 A:middle WHO bacterial priority pathogen, this CR-Kpn, 00:30:26.306 --> 00:30:32.826 A:middle has risen from fifth position in 2017 to the top position 00:30:32.826 --> 00:30:36.956 A:middle in 2024, highlighting its increasing global threat. 00:30:41.326 --> 00:30:44.356 A:middle So based on the preliminary findings of our first study, 00:30:44.356 --> 00:30:47.556 A:middle we conducted the second study with the primary objectives 00:30:47.586 --> 00:30:50.396 A:middle to assess the impact of IPC interventions 00:30:50.546 --> 00:30:53.116 A:middle that includes hand hygiene and environmental cleaning 00:30:53.116 --> 00:30:57.336 A:middle on CRE colonization and infection among NICU patients. 00:30:57.336 --> 00:30:59.846 A:middle And our secondary objective was to evaluate the impact 00:30:59.846 --> 00:31:01.426 A:middle of this IPC intervention 00:31:01.426 --> 00:31:04.366 A:middle on all-cause mortality among the NICU patients. 00:31:07.816 --> 00:31:10.876 A:middle So this quasi-experimental study was conducted 00:31:10.876 --> 00:31:15.056 A:middle in the same neonatal intensive care unit, enrolling 316 units 00:31:15.056 --> 00:31:17.006 A:middle in the pre-intervention phase, 00:31:17.006 --> 00:31:20.796 A:middle and 421 units during the IPC intervention phase. 00:31:26.896 --> 00:31:31.146 A:middle During the pre-intervention phase, that is, from July 2023 00:31:31.146 --> 00:31:35.096 A:middle to January 2024, rectal swab samples were collected 00:31:35.096 --> 00:31:40.466 A:middle on days one, day two, three -- sorry, day three, day seven, 00:31:40.466 --> 00:31:42.596 A:middle and a seven-days interval thereafter, 00:31:42.866 --> 00:31:44.176 A:middle depending on the neonatal [inaudible]. 00:31:44.176 --> 00:31:49.176 A:middle In the post-intervention phase, that is from February 00:31:49.176 --> 00:31:54.116 A:middle to June 2024, twice-monthly point prevalence survey were 00:31:54.116 --> 00:31:57.226 A:middle conducted, collecting rectal swap samples, 00:31:57.516 --> 00:32:01.376 A:middle and also biweekly evaluations of IPC practices were done. 00:32:02.926 --> 00:32:04.956 A:middle And blood cultures were performed, 00:32:04.956 --> 00:32:06.956 A:middle or as per physician's decision. 00:32:07.296 --> 00:32:10.356 A:middle For data analysis for this study, 00:32:10.356 --> 00:32:14.856 A:middle we did descriptive statistics with Pearson Chi-square test 00:32:14.856 --> 00:32:16.196 A:middle to for the comparison. 00:32:19.816 --> 00:32:23.806 A:middle The IPC interventions focused on training 00:32:23.806 --> 00:32:27.116 A:middle and monitoring healthcare workers on hand hygiene, 00:32:27.486 --> 00:32:30.306 A:middle according to the WHO recommended five moments, 00:32:31.016 --> 00:32:32.776 A:middle and also the environmental cleaning, 00:32:33.966 --> 00:32:37.176 A:middle along with providing counseling and motivation to mothers 00:32:37.176 --> 00:32:39.876 A:middle on hand hygiene practices before breastfeeding. 00:32:42.956 --> 00:32:45.686 A:middle The IPC team conducted structured 00:32:45.686 --> 00:32:48.956 A:middle and unstructured training sessions on hand hygiene 00:32:48.956 --> 00:32:50.146 A:middle for healthcare workers, 00:32:50.146 --> 00:32:53.656 A:middle it was like bimonthly training sessions, 00:32:53.656 --> 00:32:57.176 A:middle so for structured training. 00:32:57.176 --> 00:33:00.376 A:middle And for unstructured, it was frequent training based 00:33:00.376 --> 00:33:03.766 A:middle on the need, and also frequent training was ongoing 00:33:03.766 --> 00:33:04.796 A:middle on the hand hygiene. 00:33:05.526 --> 00:33:07.346 A:middle And also there was daily reminders 00:33:07.606 --> 00:33:09.956 A:middle of hand hygiene messaging were provided. 00:33:10.516 --> 00:33:13.046 A:middle Information, education and communication materials 00:33:13.046 --> 00:33:15.066 A:middle as posters and [inaudible] were distributed 00:33:15.066 --> 00:33:16.886 A:middle to healthcare workers, caregivers 00:33:16.886 --> 00:33:18.236 A:middle and also the family members. 00:33:19.076 --> 00:33:21.006 A:middle And also the continuous monitoring 00:33:21.006 --> 00:33:23.436 A:middle of hand hygiene practices was implemented. 00:33:28.856 --> 00:33:32.596 A:middle Detailed IPC training was conducted for healthcare workers 00:33:32.896 --> 00:33:34.466 A:middle on environmental cleaning. 00:33:34.576 --> 00:33:36.306 A:middle That is mostly for cleaning staffs. 00:33:37.506 --> 00:33:40.556 A:middle Simple visual guides were provided to cleaning staffs, 00:33:40.716 --> 00:33:43.956 A:middle categorizing cleaning zones into patient care areas, 00:33:43.956 --> 00:33:47.116 A:middle shared equipment, and also the common areas. 00:33:48.156 --> 00:33:50.876 A:middle And also the detailed cleaning schedules were developed 00:33:50.876 --> 00:33:51.866 A:middle and implemented. 00:33:53.676 --> 00:33:55.416 A:middle Beside that, ongoing monitoring 00:33:55.416 --> 00:33:57.446 A:middle of cleaning practices was ensured. 00:34:01.616 --> 00:34:04.536 A:middle This image highlights some 00:34:04.536 --> 00:34:06.646 A:middle of the patient-relevant surface areas 00:34:06.646 --> 00:34:07.996 A:middle for environmental cleaning. 00:34:09.986 --> 00:34:11.496 A:middle Cleaning with detergent 00:34:11.496 --> 00:34:14.376 A:middle and water was the essential first step before applying 00:34:14.376 --> 00:34:15.566 A:middle any disinfectant. 00:34:16.016 --> 00:34:18.566 A:middle And dress circuit areas are disinfected 00:34:18.566 --> 00:34:20.906 A:middle with 5,000 PPM chlorine, 00:34:20.906 --> 00:34:23.846 A:middle and [inaudible] circle areas were cleaned 00:34:23.846 --> 00:34:26.196 A:middle with test screen compatible disinfectant. 00:34:30.216 --> 00:34:33.266 A:middle These images demonstrate environmental cleaning 00:34:33.266 --> 00:34:36.136 A:middle monitoring using Glo germ in incubator, 00:34:36.176 --> 00:34:39.506 A:middle bed rails, and also monitors. 00:34:45.436 --> 00:34:50.376 A:middle So coming to the results, this slide shows the improvement 00:34:50.376 --> 00:34:53.336 A:middle in healthcare workers' compliance with hand hygiene 00:34:53.336 --> 00:34:56.666 A:middle and environmental cleaning practices during the IPC 00:34:56.666 --> 00:34:58.286 A:middle intervention at different time 00:34:58.286 --> 00:35:03.486 A:middle of point prevalence survey or PPS. 00:35:03.596 --> 00:35:06.766 A:middle Initial hand hygiene compliance was 13% 00:35:06.766 --> 00:35:09.336 A:middle which gradually increased to 69% 00:35:09.716 --> 00:35:12.846 A:middle by the 12-point prevalence survey. 00:35:13.526 --> 00:35:20.176 A:middle Compliance exceeded 60% from the six-point prevalence survey. 00:35:24.616 --> 00:35:27.596 A:middle Initial environmental cleaning compliance was 10%. 00:35:28.936 --> 00:35:31.266 A:middle We significantly improved to 87% 00:35:31.266 --> 00:35:32.956 A:middle by the 12-point prevalence survey, 00:35:32.956 --> 00:35:36.676 A:middle and compliance exceeded 60% 00:35:37.106 --> 00:35:40.006 A:middle from the four-point prevalence survey. 00:35:43.286 --> 00:35:45.826 A:middle Hand hygiene and environmental cleaning campaigns showed a 00:35:45.826 --> 00:35:48.946 A:middle strong correlation with both expressed a sharp increase 00:35:48.946 --> 00:35:50.286 A:middle following the intervention, 00:35:50.846 --> 00:35:53.596 A:middle so initial low complaints improved markedly 00:35:53.596 --> 00:35:55.826 A:middle post-intervention, highlighting the effectiveness 00:35:55.826 --> 00:35:57.296 A:middle of these IPC measures. 00:36:01.716 --> 00:36:03.226 A:middle This slide showing the trend 00:36:03.226 --> 00:36:07.126 A:middle of CRE colonization alongside improvements in hand hygiene 00:36:07.126 --> 00:36:09.456 A:middle and environmental cleaning practices over time. 00:36:10.326 --> 00:36:12.036 A:middle Before the IPC intervention, 00:36:12.036 --> 00:36:17.116 A:middle you can see here the CRE colonization was high at 84%, 00:36:18.366 --> 00:36:22.806 A:middle while CRE colonization decreased to 60% after the initiation 00:36:22.806 --> 00:36:27.986 A:middle of IPC training, but fluctuations were observed 00:36:27.986 --> 00:36:29.566 A:middle at different time points, 00:36:30.176 --> 00:36:34.006 A:middle and the lowest colonization rate was 37% observed 00:36:34.006 --> 00:36:35.636 A:middle as seven-point prevalence survey, 00:36:35.986 --> 00:36:40.576 A:middle followed by an increase to 69% at PPS 12. 00:36:54.706 --> 00:36:57.346 A:middle The slide highlights the significant reduction 00:36:57.346 --> 00:37:00.146 A:middle in colonization with carbapenem-resistant organisms 00:37:00.146 --> 00:37:02.976 A:middle after the implementation of the IPC measures. 00:37:04.246 --> 00:37:06.646 A:middle Growth of carbapenem-resistant organism, 00:37:06.646 --> 00:37:09.546 A:middle including enterobacterials in CHROMagar plate, 00:37:09.546 --> 00:37:12.626 A:middle decreased from 93% to 81%, 00:37:13.856 --> 00:37:17.456 A:middle and Vitek-confirmed CRE colonization dropped 00:37:17.456 --> 00:37:19.786 A:middle from 84% to 61%. 00:37:22.726 --> 00:37:23.306 A:middle If we look 00:37:23.306 --> 00:37:25.566 A:middle to carbapenem-resistant Klebsiella pneumoniae, 00:37:25.806 --> 00:37:29.276 A:middle it decreased from 73% before intervention, 00:37:29.276 --> 00:37:32.276 A:middle to 52% of during the intervention. 00:37:34.626 --> 00:37:36.956 A:middle And all reductions were significantly 00:37:36.956 --> 00:37:38.676 A:middle statistically significant. 00:37:43.966 --> 00:37:46.676 A:middle This slide is showing bloodstream infection 00:37:46.676 --> 00:37:49.756 A:middle and mortality before and after IPC intervention. 00:37:50.006 --> 00:37:52.856 A:middle Before implementing IPC measures, 00:37:52.856 --> 00:37:57.626 A:middle the bloodstream infection rate was 23%. 00:37:57.626 --> 00:38:01.326 A:middle While fluctuation were observed at different time points, 00:38:01.326 --> 00:38:06.336 A:middle a notable reduction to 4% was recorded by PPS 12. 00:38:07.496 --> 00:38:13.626 A:middle However, during PPS two, the rate increased to 24%. 00:38:17.116 --> 00:38:22.136 A:middle Before IPC, the mortality rate per 100 admission was 17%. 00:38:23.196 --> 00:38:26.246 A:middle Although the rate showed variation both increasing 00:38:26.246 --> 00:38:29.376 A:middle and decreasing across time points, it ultimately dropped 00:38:29.376 --> 00:38:33.866 A:middle to 14% by 12-point prevalence survey. 00:38:36.536 --> 00:38:38.936 A:middle The data indicates significant reduction 00:38:38.936 --> 00:38:40.736 A:middle in bloodstream infections 00:38:41.576 --> 00:38:44.666 A:middle with a downward trend throughout the IPC intervention period. 00:38:45.876 --> 00:38:49.766 A:middle However, the neonatal mortality rates did not show a 00:38:49.896 --> 00:38:51.876 A:middle statistically significant change, 00:38:51.876 --> 00:38:54.836 A:middle though showing a slight downward trend in mortality. 00:39:00.936 --> 00:39:03.936 A:middle So in conclusion, IPC interventions focused 00:39:03.936 --> 00:39:04.856 A:middle on hand hygiene 00:39:04.856 --> 00:39:08.246 A:middle and environmental cleaning successfully reduced 00:39:08.246 --> 00:39:09.686 A:middle colonization 00:39:09.686 --> 00:39:11.886 A:middle with carbapenem-resistant enterobacterial 00:39:11.886 --> 00:39:14.596 A:middle and bloodstream infections in the NICU. 00:39:15.816 --> 00:39:20.236 A:middle Sustaining adherence to routine IPC practices is essential 00:39:20.236 --> 00:39:23.256 A:middle to mitigate the impact of antimicrobial resistance. 00:39:24.426 --> 00:39:26.836 A:middle However, additional strategies are necessary 00:39:26.836 --> 00:39:28.646 A:middle to identify hidden reservoirs 00:39:28.646 --> 00:39:30.436 A:middle and further limit the transmission 00:39:30.436 --> 00:39:33.086 A:middle of highly resistant pathogens in NICU settings. 00:39:36.166 --> 00:39:38.836 A:middle So this is all of our study findings. 00:39:39.966 --> 00:39:43.896 A:middle Now, I would like to express my gratitude to the U.S. CDC 00:39:43.896 --> 00:39:46.286 A:middle and the task force for global health 00:39:46.286 --> 00:39:47.736 A:middle for funding these projects. 00:39:48.476 --> 00:39:51.326 A:middle Additionally, I acknowledge the co-donors of ICDDRB 00:39:51.326 --> 00:39:52.786 A:middle for their continuous support 00:39:52.786 --> 00:39:54.876 A:middle which makes our research efforts possible. 00:39:54.876 --> 00:39:55.206 A:middle Thank you. 00:39:56.556 --> 00:39:59.886 A:middle >> Thank you so much, Fahmida. 00:40:00.006 --> 00:40:04.406 A:middle Great presentation, really showing us the impact of IPC 00:40:04.406 --> 00:40:08.646 A:middle and environmental cleaning and hand hygiene on reduction 00:40:08.646 --> 00:40:10.826 A:middle of bloodstream infections among neonates. 00:40:10.826 --> 00:40:13.286 A:middle So let's go on to our next speaker, 00:40:13.286 --> 00:40:16.826 A:middle who is Dr. Fabio Araujo Motta. 00:40:17.176 --> 00:40:23.126 A:middle He is a pediatrician with PhD in biotechnology applied to child 00:40:23.456 --> 00:40:27.026 A:middle and adolescent health from the University 00:40:27.026 --> 00:40:30.276 A:middle of Pequeno Principe in Parana, Brazil. 00:40:30.576 --> 00:40:34.096 A:middle He is currently the Assistant Technical Director 00:40:34.126 --> 00:40:37.226 A:middle of Quality Improvement and Research 00:40:37.226 --> 00:40:41.156 A:middle at the Hospital Pequeno Principe, 00:40:41.316 --> 00:40:45.466 A:middle which means in English, Little Prince Hospital. 00:40:45.466 --> 00:40:49.016 A:middle So with that, I'm going to turn over to Fabio. 00:40:49.016 --> 00:40:52.956 A:middle And Fabio, I'm going to share your slide. 00:40:53.956 --> 00:41:01.066 A:middle I hope that everyone -- can people see the slide or not yet? 00:41:03.236 --> 00:41:04.666 A:middle Can you all see the slide? 00:41:05.806 --> 00:41:06.276 A:middle >> Yes. 00:41:07.296 --> 00:41:07.796 A:middle >> Perfect. 00:41:08.136 --> 00:41:08.966 A:middle Over to you, Fabio. 00:41:08.966 --> 00:41:09.336 A:middle >> Thank you. 00:41:09.336 --> 00:41:11.986 A:middle Okay. Good morning, everybody. 00:41:11.986 --> 00:41:15.836 A:middle I'd like to thank CDC for this honorable invitation, 00:41:16.346 --> 00:41:19.026 A:middle and especially for Dr. Fernanda Lessa. 00:41:19.706 --> 00:41:22.666 A:middle Today, I will present our national strategy 00:41:22.666 --> 00:41:25.526 A:middle for antimicrobial stewardship in neonatal 00:41:25.526 --> 00:41:29.556 A:middle and pediatric population, and the translation into practice. 00:41:29.846 --> 00:41:34.156 A:middle Next. Next, please. 00:41:34.156 --> 00:41:37.726 A:middle I have no conflict of interest in this presentation, 00:41:37.846 --> 00:41:40.716 A:middle and my agenda will be the presentation 00:41:40.716 --> 00:41:45.116 A:middle of the five chapters of this guideline, 00:41:45.406 --> 00:41:48.186 A:middle beginning with the scenario presentation. 00:41:48.246 --> 00:41:49.186 A:middle Next, please. 00:41:52.436 --> 00:41:55.316 A:middle Next. Everyone who talks 00:41:55.316 --> 00:42:00.686 A:middle about this issue know this information published in 2016 00:42:00.686 --> 00:42:06.186 A:middle by [inaudible] about the provision of death in 2006, 50, 00:42:06.566 --> 00:42:12.176 A:middle if nothing is done, but the most important information was what 00:42:12.176 --> 00:42:13.026 A:middle come later. 00:42:13.636 --> 00:42:14.786 A:middle Please, next. 00:42:14.786 --> 00:42:21.416 A:middle In 2022, The Lancet brought to us the following situation. 00:42:22.086 --> 00:42:25.646 A:middle Based on prediction statistical model, it estimated 00:42:25.646 --> 00:42:29.536 A:middle that there were almost 5 million deaths associated 00:42:29.536 --> 00:42:32.056 A:middle with bacterial antimicrobial resistance 00:42:32.376 --> 00:42:42.606 A:middle in 2019 including 1.27 million deaths directly attributable 00:42:42.606 --> 00:42:44.156 A:middle to bacterial AMR. 00:42:44.556 --> 00:42:48.376 A:middle An investigation by United Nation Environment Program 00:42:48.726 --> 00:42:54.896 A:middle indicates that this could reduce the GDP by $3.5 billion annually 00:42:54.896 --> 00:42:57.406 A:middle and push 24 million people 00:42:57.406 --> 00:43:01.636 A:middle into extreme poverty over the next decade. 00:43:02.366 --> 00:43:05.336 A:middle Next, please. 00:43:05.506 --> 00:43:08.826 A:middle With this, AMR, is on the third place 00:43:08.826 --> 00:43:10.836 A:middle in the deaths rank in the world. 00:43:10.836 --> 00:43:15.346 A:middle Next. Next. 00:43:16.036 --> 00:43:18.186 A:middle Chapter One is structure 00:43:18.186 --> 00:43:21.236 A:middle of the antimicrobial stewardship program 00:43:21.236 --> 00:43:24.176 A:middle in pediatric and neonatology. 00:43:24.486 --> 00:43:31.386 A:middle Next. Here, we can see the SWOT analysis of AMS 00:43:31.486 --> 00:43:33.066 A:middle in healthcare facility. 00:43:33.906 --> 00:43:38.556 A:middle Specifically in Brazil, in many neonatal and pediatrics unit, 00:43:38.826 --> 00:43:45.876 A:middle we face this challenge (next, please) about human resource, 00:43:46.116 --> 00:43:49.826 A:middle where no dedicated healthcare professional is available 00:43:49.826 --> 00:43:54.236 A:middle to lead the AMS team about antimicrobial use 00:43:54.236 --> 00:43:57.066 A:middle and resistance data, where the supply 00:43:57.066 --> 00:44:01.296 A:middle of microbiology reagents is poor and the supply 00:44:01.296 --> 00:44:06.076 A:middle of antibiotic is poor, and about AMS activities, 00:44:06.116 --> 00:44:10.576 A:middle where healthcare professional have competing priorities 00:44:10.696 --> 00:44:13.416 A:middle and little time for AMS work. 00:44:13.556 --> 00:44:16.296 A:middle Next. Next. 00:44:18.116 --> 00:44:22.926 A:middle Because of this, it's very important to count with support 00:44:23.016 --> 00:44:25.756 A:middle from top management and tactical level. 00:44:26.246 --> 00:44:30.876 A:middle And what is the role of strategic level? 00:44:31.486 --> 00:44:36.006 A:middle To give support of [inaudible] policy, invest in the program 00:44:36.006 --> 00:44:40.246 A:middle with resource, and ensure economic sustainability. 00:44:41.506 --> 00:44:46.376 A:middle The role of the tactical level is important 00:44:46.376 --> 00:44:51.316 A:middle to organize management strategy, critically analyzing the carers 00:44:51.776 --> 00:44:54.376 A:middle and communicate with senior management. 00:44:54.556 --> 00:44:55.406 A:middle Next, please. 00:44:57.216 --> 00:45:00.836 A:middle And yet, translate the clinical and economic result 00:45:00.836 --> 00:45:03.986 A:middle for strategic level, and outlines 00:45:03.986 --> 00:45:07.566 A:middle and monitors the operation with stewardship team. 00:45:07.766 --> 00:45:11.276 A:middle And about the role of -- please return. 00:45:11.416 --> 00:45:13.856 A:middle And about the role of operational group, 00:45:14.136 --> 00:45:17.866 A:middle it's important to perform antimicrobial management action 00:45:17.986 --> 00:45:20.486 A:middle and records and organize data. 00:45:21.536 --> 00:45:26.176 A:middle Next. To reach this result is fundamental 00:45:26.176 --> 00:45:28.236 A:middle to establish the model 00:45:28.236 --> 00:45:31.616 A:middle of the aspect governance structure formed 00:45:31.616 --> 00:45:35.146 A:middle by strategic tactical vision (next, 00:45:38.156 --> 00:45:41.316 A:middle next) and operational vision. 00:45:42.376 --> 00:45:45.516 A:middle And inside of strategical tactical vision, 00:45:45.966 --> 00:45:50.896 A:middle we have ASP committee formed by this department, 00:45:50.896 --> 00:45:55.346 A:middle like pharmacists, therapeutical department heads, quality 00:45:55.346 --> 00:45:57.246 A:middle and patient safety departments. 00:45:57.556 --> 00:46:00.336 A:middle And inside of operational vision, 00:46:00.786 --> 00:46:04.806 A:middle we have the ASP team formed by these professional, 00:46:04.806 --> 00:46:10.166 A:middle like microbiologist, nursing staff, pharmacist, and here, 00:46:10.166 --> 00:46:12.986 A:middle a highlight for this kind of professional 00:46:12.986 --> 00:46:14.346 A:middle that we call champion. 00:46:14.346 --> 00:46:15.206 A:middle Next, please. 00:46:16.336 --> 00:46:18.986 A:middle Next. Champion -- next. 00:46:19.266 --> 00:46:22.946 A:middle Champion, generally -- no, sorry, return. 00:46:23.906 --> 00:46:27.396 A:middle Yeah. Champion generally have a leadership profile 00:46:27.396 --> 00:46:30.326 A:middle and differentiates commitments in their unit 00:46:30.686 --> 00:46:35.026 A:middle so that they become a kind of advocate for judicious use 00:46:35.026 --> 00:46:38.446 A:middle of antimicrobials, and the point of dialog 00:46:38.446 --> 00:46:43.216 A:middle between the clinical unit where they work, and the professional 00:46:43.216 --> 00:46:46.446 A:middle of the ASP teams like neonatologists, 00:46:46.446 --> 00:46:50.116 A:middle hospital pharmacists, neonatology nurse, 00:46:50.376 --> 00:46:53.276 A:middle or infection control nurse, for example. 00:46:54.206 --> 00:47:00.756 A:middle Next. The Chapter Two is about the role of each service 00:47:00.836 --> 00:47:05.676 A:middle and effective participation of the members of ASP. 00:47:05.676 --> 00:47:12.696 A:middle Next. Here, we brought the idea of antimicrobial chain of use. 00:47:13.166 --> 00:47:17.476 A:middle In the top of the iceberg, the action of the physician, 00:47:17.476 --> 00:47:21.936 A:middle that is to diagnose of the infection, and selection 00:47:21.936 --> 00:47:26.566 A:middle and indication of antimicrobial, but it's very important 00:47:26.566 --> 00:47:29.296 A:middle to remind that the bottom part 00:47:29.296 --> 00:47:32.516 A:middle of the iceberg contains these elements 00:47:32.866 --> 00:47:35.976 A:middle that can make antimicrobial not work. 00:47:36.716 --> 00:47:41.716 A:middle They are elements linked with the medication, like dose 00:47:42.166 --> 00:47:46.966 A:middle or frequency of use or elements linked with the patients, 00:47:47.246 --> 00:47:50.546 A:middle like diuresis, renal clearance rate, 00:47:50.816 --> 00:47:53.046 A:middle distribution volume, for example. 00:47:53.226 --> 00:48:01.686 A:middle Next. And to face this issue, it's very important to work 00:48:01.686 --> 00:48:03.496 A:middle in a multi-disciplinary team. 00:48:03.836 --> 00:48:11.816 A:middle Next. The next step is to think about the ASP team composition. 00:48:11.816 --> 00:48:15.636 A:middle And in this document, we divide in -- 00:48:15.906 --> 00:48:17.866 A:middle we divide the team 00:48:17.866 --> 00:48:21.066 A:middle in operational team and supporting team. 00:48:21.756 --> 00:48:25.836 A:middle The operational teams -- inside the operational teams, 00:48:25.836 --> 00:48:29.666 A:middle we have nurse, clinical pharmacies, infection 00:48:29.666 --> 00:48:34.416 A:middle or pediatrician with expertise in antimicrobial therapy, 00:48:34.636 --> 00:48:38.716 A:middle clinical microbiologist, and infection control professional. 00:48:39.026 --> 00:48:45.876 A:middle Next. After that, we specified the role of each professional 00:48:45.876 --> 00:48:48.666 A:middle that makes up the operational team. 00:48:49.206 --> 00:48:54.296 A:middle For example, role of the ASP pharmacist, like suggestion 00:48:54.296 --> 00:49:01.916 A:middle of those adjustments (next, next), record of data 00:49:01.916 --> 00:49:07.216 A:middle for indicators (next), antibiotic treatment timing, 00:49:07.906 --> 00:49:12.356 A:middle and have condition for doing, if well capable, 00:49:12.356 --> 00:49:14.376 A:middle assess empirical treatment. 00:49:14.646 --> 00:49:21.346 A:middle Next. About the role of the ASP microbiologists, it's important 00:49:21.346 --> 00:49:24.846 A:middle to give support about clinical [inaudible] collection 00:49:24.846 --> 00:49:28.626 A:middle and information on collection condition, for example. 00:49:28.626 --> 00:49:32.566 A:middle Next. Next, please. 00:49:32.566 --> 00:49:37.996 A:middle Next. About the role of the ASP nurse, 00:49:38.246 --> 00:49:43.916 A:middle we can see (next) monitor patients (next), 00:49:45.266 --> 00:49:50.086 A:middle plan and promote care for intravenous devices (next), 00:49:50.366 --> 00:49:54.596 A:middle participate and mediate transition from intravenous 00:49:54.676 --> 00:50:00.466 A:middle to oral antibiotics, for example (next), and the last 00:50:00.466 --> 00:50:04.166 A:middle but not least, the role of the ASP physician, 00:50:04.386 --> 00:50:09.496 A:middle like leading ASP team, coordinator activities 00:50:09.496 --> 00:50:15.706 A:middle of ASP team (next, next), and finally, 00:50:15.706 --> 00:50:18.226 A:middle to seek to maintain direct access 00:50:18.316 --> 00:50:21.806 A:middle to the clinical pharmacist, microbiologist and nurse 00:50:22.336 --> 00:50:23.886 A:middle for the discussion 00:50:24.086 --> 00:50:25.856 A:middle and interpretation of culture results. 00:50:26.046 --> 00:50:33.576 A:middle Next. Chapter Three is about the particularities of newborns 00:50:33.766 --> 00:50:36.066 A:middle in the use of antimicrobials. 00:50:36.136 --> 00:50:40.386 A:middle Next. The first particularity addressed in our guide is 00:50:40.386 --> 00:50:42.306 A:middle about pediatric age group. 00:50:42.696 --> 00:50:47.156 A:middle Next. This classification is directly related 00:50:47.156 --> 00:50:49.056 A:middle to the dose to be prescribed. 00:50:49.436 --> 00:50:53.216 A:middle Since the antimicrobial varies in those according 00:50:53.216 --> 00:50:58.546 A:middle to age group (next), the weight parameters is the most important 00:50:58.546 --> 00:51:01.146 A:middle variable in antimicrobial dosing, 00:51:01.586 --> 00:51:03.796 A:middle because the prescription is given 00:51:03.796 --> 00:51:05.816 A:middle by milligrams per kilo per day. 00:51:06.326 --> 00:51:11.026 A:middle Next. Pediatric patients frequently undergo weight 00:51:11.026 --> 00:51:16.256 A:middle fluctuation, especially in the neonates and infant age groups. 00:51:16.366 --> 00:51:21.216 A:middle Next. And more frequent weight measurements are recommended 00:51:21.216 --> 00:51:23.596 A:middle to allow for those adjustments. 00:51:24.196 --> 00:51:30.336 A:middle Next. The next particularity is about PK of antimicrobial 00:51:30.336 --> 00:51:32.856 A:middle in critical [inaudible] pediatric patients. 00:51:33.096 --> 00:51:38.666 A:middle Next. And here, we brought an example of sepsis 00:51:38.666 --> 00:51:43.366 A:middle or septic shock that leading to a serious condition, 00:51:43.366 --> 00:51:48.066 A:middle with vasodilation, leading to an increase in capillary leak 00:51:48.596 --> 00:51:51.706 A:middle with consequently hypo-albuminia, 00:51:52.186 --> 00:51:59.386 A:middle with increasement of free drug and increasement of total volume 00:51:59.386 --> 00:52:02.636 A:middle of [inaudible] (next), and decreasement 00:52:02.636 --> 00:52:07.266 A:middle of plasma concentration of hydrophilic antibiotic. 00:52:07.626 --> 00:52:14.266 A:middle Next. About the use of hydrophilic antibiotic, 00:52:14.496 --> 00:52:19.056 A:middle if patients have been using this kind of hydrophilic antibiotic, 00:52:19.056 --> 00:52:22.576 A:middle like beta lactamase, penicillins, or cephalosporins, 00:52:23.416 --> 00:52:28.516 A:middle it's important to remind that we need to calculate the dose based 00:52:28.516 --> 00:52:31.716 A:middle on the real weight and not the dry weight. 00:52:32.356 --> 00:52:38.266 A:middle In opposition, if they have been using lipophilic antibiotics 00:52:38.266 --> 00:52:42.256 A:middle like fluoroquinolones, macrolides or tetracyclines, 00:52:42.636 --> 00:52:47.026 A:middle it's important to calculate the dose based on the dry weight. 00:52:47.336 --> 00:52:52.606 A:middle Next. Chapter Four is about a strategy 00:52:52.606 --> 00:52:56.866 A:middle for antimicrobial implementation and managements. 00:52:57.326 --> 00:53:02.626 A:middle Next. The first strategy brought in this document is 00:53:02.626 --> 00:53:05.876 A:middle about handshake antimicrobial stewardship model. 00:53:06.066 --> 00:53:11.516 A:middle Next. Handshake is a persuasive practice 00:53:11.626 --> 00:53:16.776 A:middle that include prospective audited education for rational use 00:53:16.776 --> 00:53:20.876 A:middle of antimicrobial and multidisciplinary discussion 00:53:21.236 --> 00:53:23.916 A:middle in opposition of restorative practice 00:53:23.916 --> 00:53:25.756 A:middle that include prioritization 00:53:26.066 --> 00:53:28.776 A:middle or treatment times control [inaudible]. 00:53:29.276 --> 00:53:33.556 A:middle Next. Handshake is an expansion 00:53:33.556 --> 00:53:39.376 A:middle of the prospective antimicrobial audit strategy, daily review 00:53:39.376 --> 00:53:41.766 A:middle by the infectious disease specialist 00:53:41.766 --> 00:53:45.946 A:middle and the clinical pharmacist in 24 and 72 hours 00:53:46.356 --> 00:53:50.376 A:middle where the performance and feedback (like intervention 00:53:50.376 --> 00:53:53.156 A:middle on antimicrobial) are prioritized 00:53:53.156 --> 00:53:56.826 A:middle by a stewardship team through personal communication 00:53:56.876 --> 00:54:01.266 A:middle with the team (important to be face to face), for example, 00:54:01.266 --> 00:54:02.906 A:middle during clinical rounds. 00:54:03.276 --> 00:54:08.476 A:middle Next. The next strategy is about antimicrobial timeout. 00:54:08.756 --> 00:54:14.556 A:middle Next. The origins of timeout comes from the need 00:54:14.556 --> 00:54:19.066 A:middle for formal breaks during clinical periods, for example, 00:54:19.066 --> 00:54:23.516 A:middle in airplane checklist, surgical checklist, and nowadays, 00:54:24.206 --> 00:54:26.886 A:middle antimicrobial checklist. 00:54:27.296 --> 00:54:33.206 A:middle Next. And what is timeout and how to perform it? 00:54:33.546 --> 00:54:38.986 A:middle These are formal reevaluation of antimicrobial therapy 00:54:38.986 --> 00:54:43.676 A:middle at intervals between 48-72 hours after the start 00:54:43.676 --> 00:54:47.926 A:middle of empirical antibiotic therapy with strategic questions. 00:54:48.286 --> 00:54:51.856 A:middle In a nutshell, the timeout is a structured pause 00:54:52.446 --> 00:54:54.186 A:middle with the following question, 00:54:54.696 --> 00:54:57.036 A:middle "Does the patient have an infection 00:54:57.036 --> 00:54:58.696 A:middle in responding to treatment?" 00:54:58.746 --> 00:55:06.616 A:middle Next. Are the antibiotic and dose correct and optimized? 00:55:06.936 --> 00:55:11.836 A:middle Next. Can the antibiotic be discontinued or de-escalated? 00:55:11.836 --> 00:55:16.606 A:middle Next. Does the patient meet the criteria 00:55:16.606 --> 00:55:18.696 A:middle for oral antibiotic therapy? 00:55:18.836 --> 00:55:23.356 A:middle Next. What will be the duration of the treatment? 00:55:23.526 --> 00:55:29.006 A:middle Next. Timeout contributes to the two main goals 00:55:29.156 --> 00:55:33.646 A:middle of the stewardship teamwork, the first, reducing treatment times 00:55:33.796 --> 00:55:37.456 A:middle and discontinuing unnecessary antibiotics. 00:55:37.786 --> 00:55:42.886 A:middle Next. The Strategy Three is about action 00:55:42.886 --> 00:55:45.316 A:middle to prevent antimicrobial resistance. 00:55:46.166 --> 00:55:51.256 A:middle It's important to remind that in 2002 the CDC published 12 steps 00:55:51.256 --> 00:55:53.426 A:middle for prevent antimicrobial resistance, 00:55:53.886 --> 00:55:58.496 A:middle and this publication masterfully brings together all the action 00:55:58.496 --> 00:56:02.956 A:middle to be developed jointly by antimicrobial management team 00:56:03.156 --> 00:56:06.956 A:middle and the infection control teams bring together 00:56:06.956 --> 00:56:09.806 A:middle in a single scheme the importance 00:56:09.806 --> 00:56:14.686 A:middle of the interdisciplinary role of the physician, nurse, pharmacist 00:56:14.686 --> 00:56:17.846 A:middle and microbiologist in combating bacterial resistance. 00:56:18.446 --> 00:56:20.706 A:middle This publication remains right and relevant 00:56:21.226 --> 00:56:24.016 A:middle since the same problems continue to exist 00:56:24.086 --> 00:56:26.506 A:middle within the intensive care units. 00:56:26.896 --> 00:56:30.216 A:middle Next. This recommendation were adapted 00:56:30.306 --> 00:56:34.546 A:middle for a neonatal intensive care unit by Patel 00:56:34.546 --> 00:56:39.336 A:middle in 2009 aiding guidelines focus on this population, 00:56:39.756 --> 00:56:45.316 A:middle beginning with the first step, like prevention infection, 00:56:45.316 --> 00:56:47.476 A:middle with the use of vaccination. 00:56:47.856 --> 00:56:51.796 A:middle The second steps about removed catheters, 00:56:52.166 --> 00:56:55.296 A:middle with when they are no longer needed. 00:56:55.456 --> 00:56:56.366 A:middle Next, please. 00:56:56.716 --> 00:57:01.756 A:middle The third steps about target therapy to the pathogen. 00:57:02.116 --> 00:57:05.026 A:middle The fourth steps about consult a specialist, 00:57:05.636 --> 00:57:08.866 A:middle concert experience professional in treating infection 00:57:08.866 --> 00:57:10.886 A:middle in children's and neonates. 00:57:11.556 --> 00:57:18.786 A:middle The fifth steps (next) about the use antibiotics correctly, 00:57:19.326 --> 00:57:23.046 A:middle practice correct use of antimicrobials. 00:57:23.316 --> 00:57:26.806 A:middle The sixth steps about using local data, 00:57:26.846 --> 00:57:31.616 A:middle know the overall antibiogram of its unit for empirical therapy. 00:57:32.176 --> 00:57:35.446 A:middle The seventh steps about treat the infection, 00:57:35.446 --> 00:57:36.906 A:middle not the contamination. 00:57:37.026 --> 00:57:37.936 A:middle Next, please. 00:57:39.306 --> 00:57:43.626 A:middle Next. And the eighth steps 00:57:43.626 --> 00:57:47.306 A:middle about treat the infection, not the colonization. 00:57:47.466 --> 00:57:53.166 A:middle Here, is important to remind the importance of treat pneumonia, 00:57:53.346 --> 00:57:56.146 A:middle not the tracheal aspirate, for example. 00:57:56.376 --> 00:58:02.426 A:middle Treat bacteremia, not the tip of the CVC connector, and remember 00:58:02.426 --> 00:58:05.206 A:middle that coagulase negative staphylococcus 00:58:05.206 --> 00:58:08.956 A:middle in a single blood culture sample with growth more 00:58:08.956 --> 00:58:12.376 A:middle than 48 hours may be contamination. 00:58:12.996 --> 00:58:15.246 A:middle Assess if the blood culture sample 00:58:15.246 --> 00:58:17.616 A:middle from the CVC is colonization 00:58:17.916 --> 00:58:21.326 A:middle when the peripheral blood culture is negative. 00:58:21.776 --> 00:58:28.706 A:middle Next. The ninth steps about use antibiotics correctly, 00:58:29.046 --> 00:58:32.356 A:middle and know when to say no to vancomycin, 00:58:32.356 --> 00:58:34.506 A:middle cephalosporin and carbapenems. 00:58:35.476 --> 00:58:36.976 A:middle The 10th steps is 00:58:36.976 --> 00:58:39.606 A:middle about discontinuing antimicrobial treatment, 00:58:39.606 --> 00:58:42.796 A:middle for example, in surgical antimicrobial prophylaxis. 00:58:43.356 --> 00:58:48.046 A:middle Eleventh steps about isolated de pathogens, and 12th steps 00:58:48.046 --> 00:58:51.256 A:middle about the break the chain of transmission. 00:58:51.556 --> 00:58:55.666 A:middle Do not allow sick visitors in the ICU and the NICU. 00:58:56.366 --> 00:59:03.196 A:middle Next. The last chapter is Chapter Five about indicators. 00:59:03.296 --> 00:59:09.816 A:middle Next. Here we brought a new indicators about classification 00:59:09.816 --> 00:59:13.296 A:middle of antimicrobial problems named PRAT. 00:59:13.296 --> 00:59:17.736 A:middle PRAT tool means Problem Relate Antimicrobial Therapy. 00:59:18.296 --> 00:59:22.666 A:middle Is a tool created by our group at Pequeno Principe Hospital, 00:59:23.186 --> 00:59:26.896 A:middle and there was no specific classification for problems 00:59:26.896 --> 00:59:28.986 A:middle with antimicrobials, so far. 00:59:29.576 --> 00:59:32.236 A:middle These two seek to map the epidemiology 00:59:32.236 --> 00:59:36.246 A:middle of antimicrobials problems, provide opportunity 00:59:36.246 --> 00:59:38.176 A:middle for harmonizing records, 00:59:38.486 --> 00:59:41.156 A:middle and comparing hospitals, if possible. 00:59:41.486 --> 00:59:48.226 A:middle Next. And these two include 17 primary problems domains 00:59:48.226 --> 00:59:50.466 A:middle and six nine subdomains, for example. 00:59:51.046 --> 00:59:54.856 A:middle Next. Here we can see the systemization 00:59:55.016 --> 01:00:00.236 A:middle of these two (next) with primary domain, for example, 01:00:00.236 --> 01:00:04.326 A:middle a prescribed dose with its subcategory, 01:00:04.936 --> 01:00:09.366 A:middle like underdose based on literature or protocol, 01:00:09.396 --> 01:00:12.496 A:middle or overdose according to serum level. 01:00:13.066 --> 01:00:16.106 A:middle And its suggesting off-pharmacotherapeutic 01:00:16.106 --> 01:00:16.916 A:middle intervention. 01:00:17.166 --> 01:00:20.566 A:middle In case of underdose, we need to increase dose, 01:00:20.906 --> 01:00:24.716 A:middle or in case of overdose, we need to decrease dose. 01:00:25.246 --> 01:00:28.746 A:middle The next example is about the necessary drug (next, 01:00:28.746 --> 01:00:34.586 A:middle please) with its subcategory, patient without infection 01:00:34.586 --> 01:00:39.106 A:middle and use antimicrobial or extend antimicrobial time 01:00:39.146 --> 01:00:42.596 A:middle without indication, with its suggestion 01:00:42.596 --> 01:00:44.796 A:middle of pharma therapeutic intervention 01:00:45.096 --> 01:00:47.886 A:middle like suspend antimicrobial, for example. 01:00:48.406 --> 01:00:55.066 A:middle Next. And here, our last slide about the process 01:00:55.066 --> 01:00:57.316 A:middle and outcome indicators. 01:00:57.686 --> 01:01:00.726 A:middle In this guideline, we bring some suggestions 01:01:00.726 --> 01:01:07.156 A:middle about some process indicators, like days of therapy or length 01:01:07.156 --> 01:01:10.856 A:middle of therapy, or some quality indicator 01:01:11.266 --> 01:01:15.386 A:middle like empirical antibiotic therapy consistent 01:01:15.386 --> 01:01:19.836 A:middle with local protocol, or those adjustments for renal function, 01:01:19.836 --> 01:01:23.006 A:middle for example, and about some examples 01:01:23.056 --> 01:01:25.986 A:middle for about outcome indicators 01:01:25.986 --> 01:01:31.746 A:middle like clinical multi-drug resistance or cost indicator 01:01:31.746 --> 01:01:36.796 A:middle like cost savings or cost avoidance or days 01:01:36.796 --> 01:01:38.286 A:middle of therapy, for example. 01:01:39.536 --> 01:01:45.536 A:middle Next. These are our colleagues in the workgroup, 01:01:45.536 --> 01:01:49.716 A:middle and I'd like to thank for the opportunity to work 01:01:49.716 --> 01:01:57.596 A:middle with these amazing people here, Vanessa, Roseli, Mara, Beatriz, 01:01:57.596 --> 01:02:03.266 A:middle Marinei, Bianca and Luiza, and Camilla and [inaudible]. 01:02:03.816 --> 01:02:05.686 A:middle Okay, next. 01:02:08.296 --> 01:02:11.036 A:middle Thank you very much for this opportunity. 01:02:13.616 --> 01:02:17.526 A:middle >> Thanks so much, Fabio, for the great presentation. 01:02:17.526 --> 01:02:23.386 A:middle It's nice to see the antimicrobial shift program 01:02:23.386 --> 01:02:26.496 A:middle guideline and all the indicators that you showed today 01:02:26.916 --> 01:02:29.436 A:middle for Brazil, but also more broadly, for Latin America. 01:02:30.006 --> 01:02:32.276 A:middle So now I would like all the speakers 01:02:32.276 --> 01:02:34.156 A:middle and panelists should be on camera. 01:02:34.156 --> 01:02:38.826 A:middle We are going to start our discussion panel, 01:02:38.996 --> 01:02:46.346 A:middle and I have the honor to introduce our panelists. 01:02:46.516 --> 01:02:52.096 A:middle We have, as part of the panel, [inaudible] Patel, 01:02:52.096 --> 01:02:58.756 A:middle who is a PharmD, the BCI GP is infectious disease pharmacist 01:02:58.756 --> 01:03:01.516 A:middle at the CDC's International Infection Control Branch, 01:03:01.626 --> 01:03:04.616 A:middle where she focuses on her work on developing 01:03:04.616 --> 01:03:07.656 A:middle and strengthening antimicrobial [inaudible] programs globally. 01:03:08.326 --> 01:03:12.796 A:middle We also have a part of our panel, Dr. Angela Dramowski, 01:03:12.796 --> 01:03:17.146 A:middle who is a Professor of Pediatric Infectious Diseases 01:03:17.406 --> 01:03:21.856 A:middle at Stellenbosch University and the head of clinical unit 01:03:21.856 --> 01:03:25.956 A:middle for the general pediatrics at Tygerberg Hospital 01:03:25.956 --> 01:03:27.766 A:middle in Cape Town, South Africa. 01:03:28.496 --> 01:03:31.806 A:middle She's passionate about patient safety with a focus 01:03:31.806 --> 01:03:33.466 A:middle on the prevention and treatment 01:03:33.776 --> 01:03:37.226 A:middle of neonatal sepsis in African hospital. 01:03:37.976 --> 01:03:41.986 A:middle Last but not least, we also have Dr. Deborah Tong, 01:03:42.296 --> 01:03:46.176 A:middle who is a registered pharmacist with postgraduate qualification 01:03:46.176 --> 01:03:49.506 A:middle in pharmacy practice and global health policy. 01:03:49.886 --> 01:03:53.126 A:middle She has a background infectious diseases clinical pharmacy, 01:03:53.436 --> 01:03:56.386 A:middle and is currently a technical officer working 01:03:56.386 --> 01:03:58.226 A:middle on microbial stewardship 01:03:58.606 --> 01:04:02.226 A:middle in the antimicrobial resistance division 01:04:02.436 --> 01:04:04.706 A:middle of the World Health Organization. 01:04:04.706 --> 01:04:08.916 A:middle So thanks all of you for joining today, 01:04:09.356 --> 01:04:16.426 A:middle and my first question is going to go to Dr. Deborah Tong. 01:04:17.606 --> 01:04:22.696 A:middle Can you talk about, based on the presentation and, 01:04:22.696 --> 01:04:28.066 A:middle you know that the AWARE book, the recommendation in terms 01:04:28.066 --> 01:04:33.626 A:middle of treatment for neonatal sepsis from the community is ampicillin 01:04:33.626 --> 01:04:37.656 A:middle and gentamicin, with the second choice being cephalosporin 01:04:37.656 --> 01:04:40.606 A:middle of third-generation plus aminoglycosides, 01:04:41.226 --> 01:04:44.426 A:middle and we are seeing this increase in resistance 01:04:44.776 --> 01:04:50.026 A:middle in neonatal sepsis coming from the community. 01:04:50.076 --> 01:04:53.356 A:middle So is there a plan to update the AWARE book 01:04:53.356 --> 01:04:56.526 A:middle for the neonatal sepsis, given the current epidemiology? 01:04:56.866 --> 01:05:00.456 A:middle And also, can you talk about the WHO plans in terms 01:05:00.456 --> 01:05:03.576 A:middle of updating the [inaudible] toolkit? 01:05:03.886 --> 01:05:08.116 A:middle >> Thank you very much, Fernanda, and thank you 01:05:08.116 --> 01:05:12.416 A:middle for all the presentations earlier today. 01:05:12.776 --> 01:05:17.296 A:middle As you mentioned the AWARE book and WHO guidelines 01:05:17.296 --> 01:05:21.206 A:middle for neonatal sepsis are currently recommending 01:05:21.206 --> 01:05:23.776 A:middle ampicillin and gentamicin as first choice, 01:05:23.776 --> 01:05:27.326 A:middle or second choice being a third-generation cephalosporin 01:05:27.326 --> 01:05:30.246 A:middle with amikacin or another aminoglycoside. 01:05:30.286 --> 01:05:32.316 A:middle So as an update, 01:05:32.316 --> 01:05:35.866 A:middle WHO is currently reviewing these guidelines. 01:05:35.866 --> 01:05:38.466 A:middle But for the time being, ampicillin 01:05:38.466 --> 01:05:43.006 A:middle and gentamicin still remain as first-choice therapy, 01:05:43.006 --> 01:05:45.856 A:middle and the second choice still remains a third-generation 01:05:45.856 --> 01:05:47.336 A:middle cephalosporin and amikacin. 01:05:47.336 --> 01:05:48.856 A:middle And the reason for this is 01:05:48.856 --> 01:05:52.766 A:middle because there's still not enough good quality evidence 01:05:52.766 --> 01:05:55.246 A:middle on the optimum antibiotic regimen to recommend, 01:05:55.246 --> 01:05:58.166 A:middle particularly in low-resource settings in low- 01:05:58.166 --> 01:05:59.836 A:middle and middle-income countries. 01:05:59.896 --> 01:06:01.216 A:middle So our first speaker, Amelia, 01:06:01.356 --> 01:06:05.736 A:middle mentioned the NeoOBS prospective observational study 01:06:05.736 --> 01:06:07.976 A:middle that was conducted by [inaudible] et al. 01:06:07.976 --> 01:06:11.496 A:middle So this was done in more than 3,000 babies in 11 countries 01:06:11.496 --> 01:06:15.316 A:middle over three years, and she did show some of the data 01:06:15.316 --> 01:06:19.996 A:middle from this study, but basically, some key findings of that was 01:06:19.996 --> 01:06:23.256 A:middle that more than one-third of the babies that they had enrolled 01:06:23.256 --> 01:06:25.466 A:middle in this study had a history 01:06:25.466 --> 01:06:28.176 A:middle of previous intravenous antibiotic exposure, 01:06:28.176 --> 01:06:29.956 A:middle with many of them being exposed 01:06:29.956 --> 01:06:34.186 A:middle in the last 24 hours before enrolling in the study. 01:06:34.286 --> 01:06:36.636 A:middle And throughout this study, they also saw that more 01:06:36.636 --> 01:06:38.666 A:middle than 200 different combinations 01:06:38.666 --> 01:06:41.666 A:middle of empiric antibiotics were started in infants, 01:06:41.666 --> 01:06:43.496 A:middle showing that there's a huge variation 01:06:43.496 --> 01:06:45.916 A:middle in antibiotic prescribing practices globally 01:06:45.916 --> 01:06:49.466 A:middle and across different regions of the world. 01:06:49.466 --> 01:06:52.586 A:middle And basically there was a lot of switching 01:06:52.586 --> 01:06:55.126 A:middle between different regimens, as well as escalation 01:06:55.126 --> 01:06:58.586 A:middle from narrower spectrum to broader spectrum antibiotics 01:06:58.586 --> 01:06:59.906 A:middle within the first few days 01:06:59.906 --> 01:07:03.666 A:middle and throughout the infant's treatment. 01:07:03.876 --> 01:07:07.006 A:middle And what we saw from that study and various others, 01:07:07.006 --> 01:07:09.796 A:middle that the most common pathogen was Klebsiella pneumoniae, 01:07:09.796 --> 01:07:12.816 A:middle and this was not only resistant to ampicillin 01:07:12.816 --> 01:07:14.546 A:middle and third-generation cephalosporins, 01:07:14.546 --> 01:07:20.966 A:middle but also to [inaudible] and beta lactamase inhibitors, 01:07:20.966 --> 01:07:33.516 A:middle as well as to carbapenem, so this makes it really difficult 01:07:33.516 --> 01:07:43.006 A:middle to actually formulate recommendations based 01:07:43.006 --> 01:07:46.636 A:middle on the antibiotics that we currently have 01:07:46.636 --> 01:07:50.036 A:middle and that many countries have access to. 01:07:50.036 --> 01:07:54.326 A:middle There's still very little data about the impact of AMR 01:07:54.326 --> 01:08:02.866 A:middle on mortality in neonates, and little information about how 01:08:02.866 --> 01:08:05.716 A:middle to account for all these confounding factors, 01:08:05.716 --> 01:08:11.976 A:middle as well as the heterogeneity in the studies that have been done 01:08:11.976 --> 01:08:23.096 A:middle and the consistent switching between different regimens 01:08:23.226 --> 01:08:26.426 A:middle of antibiotic therapy. 01:08:26.426 --> 01:08:35.126 A:middle So what we do need, and what is ongoing at this point, 01:08:35.126 --> 01:08:42.366 A:middle is more large-scale prospective trials that incorporate 01:08:42.366 --> 01:08:49.066 A:middle and allow for different study arms, 01:08:49.066 --> 01:08:52.836 A:middle not just comparing one to another. 01:08:52.836 --> 01:08:56.776 A:middle So there are some trials ongoing, like the neocept trial, 01:08:56.776 --> 01:09:01.316 A:middle which is evaluating the impact and efficacy 01:09:01.316 --> 01:09:06.426 A:middle of three different combinations of antibiotic therapy, 01:09:06.536 --> 01:09:09.986 A:middle including fosfomycin amikacin, flomoxef amikacin, 01:09:09.986 --> 01:09:12.066 A:middle and flomoxef Fosfomycin. 01:09:12.066 --> 01:09:16.676 A:middle So while there's still probably not good enough good quality 01:09:16.676 --> 01:09:18.366 A:middle data to recommend something different, 01:09:18.366 --> 01:09:21.396 A:middle we do risk exacerbating the problem of AMR just 01:09:21.396 --> 01:09:24.096 A:middle by recommending broad spectrum antibiotics from the get-go, 01:09:24.126 --> 01:09:25.506 A:middle which are not backed by evidence, so we do look forward 01:09:25.536 --> 01:09:26.826 A:middle to the results of these new studies that are coming 01:09:26.856 --> 01:09:28.116 A:middle through in the next couple of years to inform new 01:09:28.146 --> 01:09:29.496 A:middle and updated recommendations for neonatal sepsis. 01:09:29.526 --> 01:09:30.966 A:middle Would you like me to continue with the toolkit update now, 01:09:30.996 --> 01:09:32.256 A:middle or would you like other members of the panel to go 01:09:32.286 --> 01:09:32.886 A:middle for their question first? 01:09:32.916 --> 01:09:34.206 A:middle >> Yeah, so let's go back to the AMS toolkit, then later, 01:09:34.236 --> 01:09:35.136 A:middle and then go to the next question. 01:09:35.166 --> 01:09:35.676 A:middle So Katie, over to you. 01:09:35.706 --> 01:09:37.056 A:middle >> Yeah. So our next question, we're going to ask Angela 01:09:37.086 --> 01:09:38.196 A:middle to talk to us a bit more about strategies 01:09:38.226 --> 01:09:39.546 A:middle and advice you would recommend to colleagues in NICUs 01:09:39.576 --> 01:09:40.386 A:middle when thinking about IPC and AMR. 01:09:40.416 --> 01:09:40.896 A:middle Over to you, Angela. 01:09:40.926 --> 01:09:41.226 A:middle >> Thanks, Katie. 01:09:41.256 --> 01:09:42.186 A:middle Good afternoon, good morning, everybody. 01:09:42.216 --> 01:09:42.696 A:middle Thank you very much. 01:09:42.726 --> 01:09:44.106 A:middle So I really enjoyed all the talks, but especially Fahmida's 01:09:44.136 --> 01:09:45.396 A:middle and congratulations to all the work that they did 01:09:45.426 --> 01:09:45.936 A:middle in the unit in the [inaudible]. 01:09:45.966 --> 01:09:47.496 A:middle I think the challenges are very familiar to anybody working 01:09:47.526 --> 01:09:48.546 A:middle in a low-, middle-income neonatal unit. 01:09:48.576 --> 01:09:49.986 A:middle I wanted to take a step back just to conceptualize 01:09:50.016 --> 01:09:50.616 A:middle at what point pathogens 01:09:50.646 --> 01:09:52.086 A:middle and antimicrobial resistance elements are transferred 01:09:52.116 --> 01:09:53.106 A:middle to neonates to help shape how we think 01:09:53.136 --> 01:09:53.976 A:middle about preventing these infections. 01:09:54.066 --> 01:10:00.246 A:middle And so, clearly, it all starts with a pregnant mum. 01:10:00.246 --> 01:10:03.656 A:middle Often we think about infections in the neonatal unit 01:10:03.656 --> 01:10:07.636 A:middle as very polarized early onset neonatal sepsis, 01:10:07.726 --> 01:10:10.636 A:middle typically thought of to be transmitted vertically 01:10:10.636 --> 01:10:13.396 A:middle from mother to child in labor and delivery, 01:10:13.476 --> 01:10:15.676 A:middle and then hospital-acquired infection, 01:10:15.676 --> 01:10:19.286 A:middle horizontal transmission, from the healthcare environment, 01:10:19.566 --> 01:10:21.456 A:middle workers, equipment, surfaces, 01:10:21.456 --> 01:10:24.606 A:middle etc. I think what shocked me a little bit 01:10:24.606 --> 01:10:29.466 A:middle about Fahmida's data is that on day one of life, 01:10:29.466 --> 01:10:32.616 A:middle almost 40% of babies were already colonized 01:10:32.616 --> 01:10:35.756 A:middle with carbapenem-resistant enterobacteriales, 01:10:35.836 --> 01:10:38.436 A:middle so anything you do on the neonatal unit in terms 01:10:38.436 --> 01:10:41.346 A:middle of cleaning and hand hygiene is already too late. 01:10:41.616 --> 01:10:43.986 A:middle We need to be looking further upstream 01:10:43.986 --> 01:10:46.466 A:middle in our prevention efforts to make sure 01:10:46.466 --> 01:10:50.256 A:middle that we protect babies during pregnancy and delivery 01:10:50.256 --> 01:10:53.116 A:middle in those first 24 hours after birth. 01:10:53.116 --> 01:10:56.546 A:middle And there, we need a whole package of care that speaks 01:10:56.546 --> 01:11:00.286 A:middle to prevention of preterm birth, maternal nutrition, 01:11:00.556 --> 01:11:05.826 A:middle careful management of maternal infections and antibiotic use, 01:11:05.826 --> 01:11:10.746 A:middle etc., and then, really importantly, environmental 01:11:10.746 --> 01:11:13.936 A:middle and hand hygiene and device cleaning 01:11:14.026 --> 01:11:16.576 A:middle for a safe labor and delivery. 01:11:17.116 --> 01:11:20.836 A:middle Then once the baby is delivered and admitted 01:11:20.836 --> 01:11:23.956 A:middle onto your newborn unit, infections and pathogens 01:11:23.956 --> 01:11:26.806 A:middle that have been transmitted then colonize the surface 01:11:26.806 --> 01:11:30.246 A:middle of the baby, and then we need to move to measures that are going 01:11:30.246 --> 01:11:33.606 A:middle to protect the baby from colonization going 01:11:33.606 --> 01:11:35.646 A:middle to invasive infection, and this is 01:11:35.646 --> 01:11:39.086 A:middle where all the traditional IPC measures come into place, 01:11:39.086 --> 01:11:42.206 A:middle as well as specific baby measures that some 01:11:42.206 --> 01:11:45.776 A:middle of the speakers mentioned to maintain a really strong barrier 01:11:45.776 --> 01:11:47.406 A:middle of the skin and the gut, 01:11:47.786 --> 01:11:50.456 A:middle which are the two biggest surface areas 01:11:50.706 --> 01:11:53.556 A:middle where bacterial pathogens can then invade 01:11:53.556 --> 01:11:54.526 A:middle into the bloodstream. 01:11:55.076 --> 01:11:58.526 A:middle And by the time you get to established infection, 01:11:58.526 --> 01:12:00.586 A:middle sepsis and multiorgan failure, it's too late, 01:12:00.586 --> 01:12:02.896 A:middle and we've lost most of our babies at that point. 01:12:02.896 --> 01:12:05.966 A:middle So it doesn't matter, the best antibiotics in the world, 01:12:06.126 --> 01:12:09.886 A:middle the most kind of appropriately tailored 01:12:09.886 --> 01:12:12.656 A:middle for your situation may be too late for many babies, 01:12:12.656 --> 01:12:16.616 A:middle so prevention will always be our first prized goal. 01:12:16.616 --> 01:12:19.186 A:middle And then just conceptually, 01:12:19.366 --> 01:12:22.696 A:middle to think about where do we need to put our efforts? 01:12:22.696 --> 01:12:26.096 A:middle So the study that Fahmida described really is looking 01:12:26.096 --> 01:12:27.466 A:middle at that traditional package 01:12:27.466 --> 01:12:30.646 A:middle of infection prevention control measures which try 01:12:30.646 --> 01:12:34.216 A:middle to prevent colonization of a baby with pathogens, 01:12:34.216 --> 01:12:36.826 A:middle but there are three other important areas I just want 01:12:36.826 --> 01:12:37.496 A:middle to highlight. 01:12:37.496 --> 01:12:40.926 A:middle So if you look at the top left, starting right at the beginning, 01:12:40.926 --> 01:12:44.036 A:middle we want to promote colonization with normal flora 01:12:44.496 --> 01:12:47.526 A:middle to outcompete the pathogens, and we can do this 01:12:47.526 --> 01:12:51.906 A:middle by doing really good, essential newborn care with as early 01:12:51.906 --> 01:12:56.016 A:middle as possible institution of skin-to-skin care, or KMC, 01:12:56.016 --> 01:12:57.546 A:middle ensuring that we give breast milk 01:12:57.546 --> 01:12:59.106 A:middle to as many babies as possible. 01:12:59.106 --> 01:13:02.046 A:middle There is an increasingly important emerging role 01:13:02.046 --> 01:13:04.936 A:middle for probiotics for gut integrity. 01:13:05.186 --> 01:13:07.496 A:middle And then what Fabio spoke to, so important, 01:13:07.496 --> 01:13:10.496 A:middle babies that don't need antibiotics should not be 01:13:10.496 --> 01:13:13.266 A:middle receiving them, and those that need it, we need to try 01:13:13.266 --> 01:13:15.086 A:middle and stop them as soon as possible. 01:13:15.566 --> 01:13:18.386 A:middle And then again, moving on, looking at maintenance 01:13:18.386 --> 01:13:20.876 A:middle of skin integrity, there's many studies looking 01:13:20.876 --> 01:13:23.886 A:middle at emollient therapy as a way to improve the skin barrier, 01:13:23.886 --> 01:13:26.826 A:middle but we as clinicians need to do much better 01:13:27.056 --> 01:13:29.286 A:middle to prevent skin breaches and injuries, 01:13:29.286 --> 01:13:32.476 A:middle so thinking of non-invasive testing for things 01:13:32.476 --> 01:13:36.456 A:middle like jaundice, and doing better at securing IV devices. 01:13:36.876 --> 01:13:39.196 A:middle And then lastly, thinking specifically back 01:13:39.196 --> 01:13:41.466 A:middle to data, data is power. 01:13:41.466 --> 01:13:43.576 A:middle So if you know your own neonatal unit, 01:13:43.576 --> 01:13:46.766 A:middle what pathogens are circulating and you work with, 01:13:46.766 --> 01:13:48.846 A:middle as Fabio mentioned, your microbiologists 01:13:48.846 --> 01:13:51.286 A:middle if you have them, or your surveillance teams 01:13:51.286 --> 01:13:53.326 A:middle at national level, you can look 01:13:53.326 --> 01:13:56.146 A:middle and decide what antibiotics are most appropriate based 01:13:56.146 --> 01:13:58.146 A:middle on your profile of pathogens, 01:13:58.146 --> 01:14:00.966 A:middle and then critically feed this information back 01:14:01.246 --> 01:14:05.056 A:middle to your neonatal unit staff and managers and parents, 01:14:05.056 --> 01:14:07.186 A:middle because only through working together 01:14:07.186 --> 01:14:10.856 A:middle as a big multi-disciplinary team can we do better 01:14:10.856 --> 01:14:13.686 A:middle to prevent infections in hospitalized newborns. 01:14:13.996 --> 01:14:15.006 A:middle Thanks so much. 01:14:17.066 --> 01:14:17.846 A:middle >> Thanks, Angela. 01:14:17.846 --> 01:14:21.476 A:middle I just want to take the opportunity, because I'm looking 01:14:21.476 --> 01:14:24.636 A:middle at the questions are coming on the Q&A box, 01:14:24.636 --> 01:14:26.206 A:middle and I do think that's important. 01:14:26.206 --> 01:14:30.326 A:middle Maybe we can talk about two of the questions, 01:14:30.326 --> 01:14:35.146 A:middle because I do think that's something that we see often. 01:14:35.146 --> 01:14:40.566 A:middle It is hospitals' NICUs being overcrowded, so sometimes three 01:14:40.566 --> 01:14:44.246 A:middle to five babies per bed. 01:14:44.246 --> 01:14:47.976 A:middle And I think one of the colleagues put on the 01:14:47.976 --> 01:14:51.946 A:middle on the chat, on the Q&A, what would be the recommendations 01:14:51.946 --> 01:14:57.726 A:middle when you have those overcrowded units and in [inaudible] role? 01:14:58.276 --> 01:15:00.396 A:middle And I think then the second question 01:15:00.396 --> 01:15:04.116 A:middle that maybe whomever wants to answer, if you can talk 01:15:04.116 --> 01:15:10.036 A:middle about what do you do in your NICU, if you have a neonate 01:15:10.036 --> 01:15:14.186 A:middle with CRE, when do you discontinue contact precautions 01:15:14.186 --> 01:15:16.366 A:middle for that patient. 01:15:16.366 --> 01:15:24.186 A:middle So open to Fabio, Fahmida, or Angela, if you want to talk 01:15:24.186 --> 01:15:26.796 A:middle about your experience on your NICU. 01:15:32.096 --> 01:15:34.376 A:middle >> Should I start? 01:15:34.486 --> 01:15:35.026 A:middle >> Go ahead. 01:15:35.626 --> 01:15:39.446 A:middle >> Okay. Just briefly, I can say what is going on in our NICU 01:15:39.446 --> 01:15:42.926 A:middle in Bangladesh, the study hospital 01:15:42.956 --> 01:15:44.286 A:middle where we conducted our study. 01:15:44.286 --> 01:15:49.356 A:middle As you have mentioned, that our NICU is overcrowded, 01:15:49.796 --> 01:15:51.726 A:middle and sometimes it's occasional 01:15:51.726 --> 01:15:54.656 A:middle for at Dhaka Medical College NICU, we have to sometimes, 01:15:54.656 --> 01:15:56.866 A:middle you know, have two or three bed 01:15:56.866 --> 01:15:59.746 A:middle for neonates phototherapy mission, 01:16:00.196 --> 01:16:01.846 A:middle even for incubation as well. 01:16:01.846 --> 01:16:05.666 A:middle And if there is any CRE colonization, 01:16:05.786 --> 01:16:08.556 A:middle CRE infection is identified for a patient, nowadays, 01:16:08.556 --> 01:16:13.516 A:middle after we started our study, we have just have a separate -- 01:16:13.516 --> 01:16:16.936 A:middle it's not a separate corner, I would say, 01:16:16.976 --> 01:16:21.006 A:middle just they separate the baby from the other babies, 01:16:21.116 --> 01:16:24.816 A:middle but still there is chance of contamination, 01:16:24.816 --> 01:16:27.916 A:middle having the transmission of the infection from that baby, 01:16:27.916 --> 01:16:29.676 A:middle because we can't separate -- 01:16:29.676 --> 01:16:32.836 A:middle isolate the baby in a separate room, because it's 01:16:32.836 --> 01:16:35.686 A:middle in the same room, but a bit different place. 01:16:36.056 --> 01:16:40.876 A:middle So this is the scenery in brief in our hospital, study hospital. 01:16:41.276 --> 01:16:43.016 A:middle >> Thanks, Fahmida. 01:16:43.016 --> 01:16:45.506 A:middle Angela, I'm going to turn over to you if you want to talk 01:16:45.506 --> 01:16:52.136 A:middle about any strategies in this overcrowded setting, and also, 01:16:52.416 --> 01:16:56.636 A:middle when do you discontinue contact precaution for CRE-infected 01:16:56.636 --> 01:16:58.016 A:middle or -colonized neonate? 01:16:58.426 --> 01:17:00.336 A:middle >> Sure. I'll take the last question first. 01:17:00.336 --> 01:17:02.526 A:middle So there's not good evidence to guide, 01:17:02.586 --> 01:17:04.996 A:middle but we look at at least 12 months, 01:17:05.066 --> 01:17:09.016 A:middle so we try to flag the record of that baby, because inevitably, 01:17:09.016 --> 01:17:12.766 A:middle pre-terms get readmitted many times in the first year of life, 01:17:12.956 --> 01:17:16.086 A:middle and so we encourage, once a baby is readmitted, 01:17:16.086 --> 01:17:20.356 A:middle to re-institute contact precautions for up to 12 months, 01:17:20.356 --> 01:17:23.106 A:middle and then we re-screen beyond 12 months to see 01:17:23.106 --> 01:17:25.556 A:middle if there's persistent carriage where possible, 01:17:25.876 --> 01:17:29.016 A:middle but I know that CRE screening is not widely available 01:17:29.016 --> 01:17:30.776 A:middle across most African hospitals. 01:17:30.776 --> 01:17:34.496 A:middle So, you know, standard precautions should apply 01:17:34.496 --> 01:17:36.666 A:middle to every baby in every facility, 01:17:36.666 --> 01:17:39.836 A:middle and doing excellent hand hygiene, environmental cleaning, 01:17:39.836 --> 01:17:42.296 A:middle will go a long way, even if you can't screen 01:17:42.296 --> 01:17:45.566 A:middle for particular resistant infections. 01:17:45.566 --> 01:17:49.036 A:middle And then the issue of overcrowding is a political, 01:17:49.036 --> 01:17:52.926 A:middle managerial and a crying shame, because this is not something 01:17:52.926 --> 01:17:54.516 A:middle that clinicians and nurses 01:17:54.516 --> 01:17:56.996 A:middle at the coalface can do anything about. 01:17:56.996 --> 01:18:01.196 A:middle We try to provide the best care for the baby in front of us, 01:18:01.416 --> 01:18:05.586 A:middle and we absolutely acknowledge that overcrowding is detrimental 01:18:05.586 --> 01:18:10.746 A:middle to individual babies' health, and there is ample data globally 01:18:10.746 --> 01:18:14.536 A:middle to show that overcrowded neonatal units 01:18:14.536 --> 01:18:17.116 A:middle and under-resourced neonatal units, particularly 01:18:17.116 --> 01:18:20.876 A:middle with high patient-to-staff ratios, have poorer outcomes. 01:18:21.236 --> 01:18:22.356 A:middle That's non-negotiable. 01:18:22.356 --> 01:18:23.186 A:middle That is the truth. 01:18:23.186 --> 01:18:27.846 A:middle So we have to do much better advocacy as global bodies 01:18:27.846 --> 01:18:31.416 A:middle and as clinicians caring for these vulnerable moms 01:18:31.416 --> 01:18:34.046 A:middle and babies to demand the same. 01:18:34.046 --> 01:18:35.966 A:middle You would never put three adults in a bed. 01:18:35.966 --> 01:18:37.636 A:middle Why do you do it to neonates? 01:18:37.776 --> 01:18:38.306 A:middle Thank you. 01:18:38.306 --> 01:18:38.746 A:middle Over. 01:18:40.226 --> 01:18:41.156 A:middle >> Great points, Angela. 01:18:41.536 --> 01:18:43.616 A:middle So let me go to [inaudible] 01:18:43.616 --> 01:18:45.996 A:middle with a question [inaudible] microbial stewardship. 01:18:46.086 --> 01:18:48.876 A:middle If you can talk about the CDC global effort 01:18:48.876 --> 01:18:52.766 A:middle to launch microbial stewardship, and as you talk 01:18:52.766 --> 01:18:58.616 A:middle about the global efforts, if you can address one of the questions 01:18:58.616 --> 01:19:05.676 A:middle on the chat was about monitoring the antibiotics 01:19:05.676 --> 01:19:10.086 A:middle that are classified as reserve antibiotics. 01:19:10.086 --> 01:19:10.446 A:middle Over to you. 01:19:10.446 --> 01:19:12.346 A:middle >> Yeah, thanks. 01:19:12.346 --> 01:19:14.106 A:middle Thanks so much, Fernanda. 01:19:14.156 --> 01:19:18.616 A:middle So I would say one thing that we very quickly noticed 01:19:18.616 --> 01:19:24.716 A:middle when starting to dedicate work towards advancing antibiotic 01:19:24.716 --> 01:19:26.746 A:middle stewardship globally is 01:19:26.746 --> 01:19:29.916 A:middle that there are many guidance documents that exist. 01:19:29.916 --> 01:19:32.056 A:middle There are many at the national level. 01:19:32.056 --> 01:19:37.046 A:middle There are many at the regional level as well, and so one thing 01:19:37.046 --> 01:19:41.536 A:middle that we wanted to do is not recreate, you know, 01:19:41.676 --> 01:19:46.726 A:middle existing guidance, but instead create some resources 01:19:46.726 --> 01:19:48.226 A:middle that really allow you to sort 01:19:48.226 --> 01:19:50.746 A:middle of take the guidance documents to the next step. 01:19:50.836 --> 01:19:53.646 A:middle And so I'm going to share my screen quickly 01:19:54.486 --> 01:19:55.956 A:middle to show you some of these resources. 01:19:56.056 --> 01:20:01.616 A:middle So first, of course, the -- we have our core elements document 01:20:01.916 --> 01:20:05.996 A:middle that gives a little bit different perspective in terms 01:20:05.996 --> 01:20:10.816 A:middle of key principles towards developing a sustainable 01:20:10.816 --> 01:20:12.426 A:middle antibiotic stewardship program. 01:20:12.816 --> 01:20:16.156 A:middle This document has been around for many years, 01:20:16.316 --> 01:20:20.086 A:middle and it is available in both English and Spanish. 01:20:21.076 --> 01:20:25.076 A:middle And so like I mentioned, you know, we didn't want to recreate 01:20:25.076 --> 01:20:28.466 A:middle yet another document that is like this, and instead, 01:20:28.466 --> 01:20:29.686 A:middle we've created something, 01:20:29.686 --> 01:20:34.636 A:middle something that accompanies our core elements document, 01:20:34.636 --> 01:20:36.186 A:middle as well as WHO resources, 01:20:36.306 --> 01:20:40.156 A:middle and developed this global antibiotic stewardship 01:20:40.156 --> 01:20:41.406 A:middle evaluation tool. 01:20:41.406 --> 01:20:48.946 A:middle And this tool allows you to customize an action plan 01:20:48.946 --> 01:20:55.506 A:middle for your individual healthcare facility, and so it is organized 01:20:55.506 --> 01:20:59.006 A:middle by different domains, 01:20:59.156 --> 01:21:03.296 A:middle five different domains you can see here, 01:21:03.296 --> 01:21:08.076 A:middle and essentially there are 66 questions, again organized 01:21:08.076 --> 01:21:10.266 A:middle into five different domains. 01:21:10.266 --> 01:21:12.556 A:middle And there's a scoring system that we've developed 01:21:12.556 --> 01:21:14.496 A:middle to go alongside this tool, 01:21:14.496 --> 01:21:17.366 A:middle and what that scoring system allows you 01:21:17.366 --> 01:21:19.586 A:middle to do is really identify 01:21:19.586 --> 01:21:25.466 A:middle which domain your facility needs the most work to advance. 01:21:25.686 --> 01:21:29.906 A:middle And also, as many other presenters have mentioned, 01:21:29.906 --> 01:21:34.146 A:middle that communication from your healthcare workers 01:21:34.146 --> 01:21:37.156 A:middle to hospital administration, as we advocate 01:21:37.156 --> 01:21:40.706 A:middle for more resources, etc., is important. 01:21:40.706 --> 01:21:44.466 A:middle And so the scoring system will also allow you to sort 01:21:44.466 --> 01:21:47.936 A:middle of share those data with hospital administrators 01:21:47.936 --> 01:21:50.346 A:middle at a higher level to, again, 01:21:50.346 --> 01:21:52.336 A:middle indicate where resources are needed. 01:21:52.336 --> 01:21:58.206 A:middle The other thing is that they're very detailed questions. 01:21:58.206 --> 01:22:01.886 A:middle So in, you know, very low-resource settings, 01:22:01.886 --> 01:22:04.566 A:middle we expect many of the answers to be no. 01:22:05.126 --> 01:22:08.746 A:middle And intentionally, we have created this document 01:22:08.746 --> 01:22:14.606 A:middle to be all-encompassing, so that not to get discouraged, 01:22:14.606 --> 01:22:18.426 A:middle but to be able to identify where specifically you may be able 01:22:18.426 --> 01:22:20.976 A:middle to make improvements based off of your level 01:22:20.976 --> 01:22:22.456 A:middle of resources available. 01:22:23.736 --> 01:22:26.326 A:middle And then also the scoring will allow you to sort 01:22:26.326 --> 01:22:29.956 A:middle of track progress over time, so again, the tool is not intended 01:22:29.956 --> 01:22:32.986 A:middle to benchmark a healthcare facility. 01:22:32.986 --> 01:22:36.426 A:middle Instead, it is intended for the healthcare facility 01:22:36.426 --> 01:22:40.126 A:middle to advance their own stewardship program. 01:22:40.126 --> 01:22:44.106 A:middle So let's say the healthcare facility takes this at baseline. 01:22:44.106 --> 01:22:49.506 A:middle They identify many opportunities for advancement. 01:22:49.506 --> 01:22:51.936 A:middle They work on that in the coming year. 01:22:52.226 --> 01:22:53.776 A:middle They retake the tool. 01:22:53.776 --> 01:22:56.506 A:middle They should see an improvement in their score, again, 01:22:56.506 --> 01:23:00.296 A:middle an easy way for them to track progress, as well as for them 01:23:00.296 --> 01:23:03.846 A:middle to communicate that with their hospital leadership. 01:23:03.946 --> 01:23:07.026 A:middle Again, we know in antibiotic stewardship 01:23:07.026 --> 01:23:09.996 A:middle that the more success we show 01:23:09.996 --> 01:23:11.926 A:middle and the more data-driven we can be, 01:23:11.926 --> 01:23:16.466 A:middle the more resources potentially will be allocated to building, 01:23:16.466 --> 01:23:18.626 A:middle again, a sustainable program. 01:23:20.066 --> 01:23:25.016 A:middle Part of this tool is monitoring and evaluation. 01:23:25.266 --> 01:23:27.466 A:middle And so, remember, when we think about monitoring 01:23:27.466 --> 01:23:32.716 A:middle of antibiotic stewardship, we do think beyond antibiotics, right? 01:23:32.716 --> 01:23:37.916 A:middle So we also want to monitor use of various interventions 01:23:38.666 --> 01:23:42.316 A:middle and reporting to key players in the hospital. 01:23:42.316 --> 01:23:44.256 A:middle That may be to hospital administration, 01:23:44.256 --> 01:23:47.256 A:middle as I've mentioned, but also to microbiology 01:23:47.256 --> 01:23:51.016 A:middle and other healthcare workers across the institution, 01:23:51.016 --> 01:23:55.586 A:middle and so you'll see Domain 5 is solely dedicated to monitoring 01:23:56.356 --> 01:23:59.876 A:middle and reporting of various metrics. 01:24:00.726 --> 01:24:03.976 A:middle And one of the metrics that was mentioned in the chat, 01:24:03.976 --> 01:24:07.836 A:middle I believe, was related to monitoring, specifically 01:24:07.836 --> 01:24:09.186 A:middle of restricted antibiotics. 01:24:09.186 --> 01:24:15.346 A:middle There are two key antibiotic stewardship interventions 01:24:15.346 --> 01:24:18.936 A:middle that have the most evidence base to do this. 01:24:18.936 --> 01:24:22.206 A:middle The first is creating a restriction policy 01:24:23.056 --> 01:24:26.176 A:middle where prior authorization of use 01:24:26.176 --> 01:24:30.076 A:middle of those antimicrobials is necessary. 01:24:30.076 --> 01:24:36.026 A:middle So what this means is let's say a clinician would 01:24:36.026 --> 01:24:38.706 A:middle like to prescribe meropenem. 01:24:39.396 --> 01:24:43.436 A:middle Prior to prescribing meropenem, there is a direct consultation 01:24:43.436 --> 01:24:46.166 A:middle with a member of the antibiotic stewardship team, 01:24:46.166 --> 01:24:50.636 A:middle and a discussion is had about the appropriateness of use 01:24:50.636 --> 01:24:55.716 A:middle of that agent, and that is what we call a prior authorization. 01:24:55.886 --> 01:24:58.566 A:middle And so the clinician, the prescribing clinicians, 01:24:58.566 --> 01:25:02.476 A:middle needs approval before being able to prescribe that drug. 01:25:03.276 --> 01:25:06.326 A:middle Now, this is very -- can be very resource intensive, right, 01:25:06.326 --> 01:25:08.756 A:middle because you need somebody that is able 01:25:08.756 --> 01:25:12.196 A:middle to answer the questions real time. 01:25:12.196 --> 01:25:17.256 A:middle And the other evidence-based intervention is called 01:25:17.256 --> 01:25:19.956 A:middle prospective audit with feedback. 01:25:19.956 --> 01:25:21.506 A:middle And so in this scenario, 01:25:21.506 --> 01:25:25.886 A:middle the antibiotic stewardship team reviews a list of patients 01:25:25.886 --> 01:25:30.216 A:middle that are prescribed a target antibiotic. 01:25:30.216 --> 01:25:32.806 A:middle And then they review the clinical case 01:25:32.806 --> 01:25:35.966 A:middle as if they were managing the patient and decide whether 01:25:35.966 --> 01:25:38.036 A:middle or not meropenem is appropriate -- 01:25:38.036 --> 01:25:41.316 A:middle again, meropenem as an example in this case -- 01:25:41.316 --> 01:25:45.876 A:middle is appropriate for use, and then has a discussion 01:25:45.876 --> 01:25:49.176 A:middle with the clinical care team about alternatives, 01:25:49.176 --> 01:25:53.946 A:middle about duration, about dosing, combination therapy 01:25:53.946 --> 01:25:58.856 A:middle that may be necessary, etc. And so these are two practical ways 01:25:58.856 --> 01:26:02.456 A:middle to implement a restriction policy around the use 01:26:02.456 --> 01:26:04.506 A:middle of reserved antibiotics, 01:26:04.506 --> 01:26:08.546 A:middle sometimes the easiest antibiotics to target, 01:26:08.546 --> 01:26:13.486 A:middle given that we expect the use of those antibiotics to be lower 01:26:13.486 --> 01:26:15.516 A:middle in the general population. 01:26:18.936 --> 01:26:20.916 A:middle >> Thanks so much, Tricia. 01:26:21.216 --> 01:26:24.426 A:middle I see that we have some attendees 01:26:24.426 --> 01:26:30.196 A:middle with their hands raised, but we are towards the end 01:26:30.196 --> 01:26:32.346 A:middle of the session, but I do want just 01:26:32.346 --> 01:26:35.766 A:middle to ask a question that's coming up a lot on the chat. 01:26:35.766 --> 01:26:41.086 A:middle It relates to MRSA colonization, and I'm wondering if one 01:26:41.086 --> 01:26:46.736 A:middle of you can talk about, in your NICU, what's your policy once -- 01:26:46.736 --> 01:26:53.036 A:middle do you screen for MRSA colonization, and if you do, 01:26:53.296 --> 01:26:56.226 A:middle do you try decolonization with mupirocin? 01:27:02.006 --> 01:27:05.396 A:middle >> I can answer that from the South African perspective. 01:27:05.396 --> 01:27:09.766 A:middle So over the last 15 years in our neonatal unit, 01:27:09.766 --> 01:27:12.886 A:middle we've seen quite a change in the epidemiology 01:27:12.886 --> 01:27:15.556 A:middle of invasive Staph aureus infection. 01:27:15.746 --> 01:27:17.186 A:middle Initially, very high rates. 01:27:17.186 --> 01:27:19.256 A:middle It was our second most common pathogen 01:27:19.256 --> 01:27:22.846 A:middle after Klebsiella pneumoniae, and over 70% were MRSA. 01:27:22.846 --> 01:27:27.646 A:middle In the last five to 10 years, we've seen a shift 01:27:27.646 --> 01:27:31.466 A:middle with much lower rates of Staph aureus invasive infection, 01:27:31.466 --> 01:27:34.586 A:middle probably now our fifth-most-common pathogen, 01:27:34.586 --> 01:27:38.956 A:middle and a reversion to majority methicillin-susceptible staph. 01:27:39.496 --> 01:27:44.146 A:middle We have not changed our policy in terms of screening 01:27:44.146 --> 01:27:47.546 A:middle for colonization, so we don't do screening unless there is a 01:27:47.546 --> 01:27:52.206 A:middle large outbreak of MRSA, and we don't routinely decolonize. 01:27:52.206 --> 01:27:54.886 A:middle Only if we find an index baby 01:27:55.116 --> 01:27:58.676 A:middle who has a MRSA bloodstream infection, we decolonize 01:27:58.676 --> 01:28:01.676 A:middle that patient, and in the past, 01:28:01.676 --> 01:28:04.566 A:middle we did decolonize immediate contacts 01:28:04.826 --> 01:28:08.796 A:middle with both mupirocin nasally twice a day for a week, 01:28:08.796 --> 01:28:11.836 A:middle and chlorhexidine gluconate body washes for a week, 01:28:12.136 --> 01:28:16.366 A:middle but in recent years, we focused only on the index patient, 01:28:16.756 --> 01:28:20.376 A:middle good isolation in an incubator with contact precautions. 01:28:20.846 --> 01:28:21.426 A:middle Thank you. 01:28:24.146 --> 01:28:25.516 A:middle >> This is wonderful. 01:28:25.546 --> 01:28:27.506 A:middle Okay, so we are at the end of our webinar. 01:28:27.506 --> 01:28:31.886 A:middle I really want to thank all the panelists and speakers as well 01:28:31.886 --> 01:28:35.576 A:middle as all the audience who joined us today. 01:28:35.576 --> 01:28:37.606 A:middle Thanks so much everyone, 01:28:37.606 --> 01:28:43.456 A:middle and hope that everyone has a good [inaudible] AMR Awareness 01:28:43.456 --> 01:28:46.766 A:middle Week and [inaudible] to combat antimicrobial 01:28:46.766 --> 01:28:47.956 A:middle resistance globally. 01:28:47.956 --> 01:28:48.846 A:middle Thanks, everyone.