Keeping multiresistant pathogens under control

In the last two years SARS-CoV-2 has dominated activity at healthcare facilities. Other challenges, such as preventing and controlling multidrug-resistant organisms (MDRO) and monitoring newly emerging pathogens such as Candida auris, have taken a back seat. Swissnoso has recently published new guidelines for hospitals on these matters.

As part of the Swiss Strategy on Antibiotic Resistance (StAR), Swissnoso, with the support of the Federal Office of Public Health (FOPH), has formulated harmonised national recommendations on the prevention and control of multiresistant pathogens (MRPs). Two new guidelines on this were recently published.

Early detection of pathogens
The first guideline (Prävention und Kontrolle von MRE im Nicht-Ausbruch-Setting; prevention and control of MRPs in non-outbreak settings) places a particular emphasis on early detection and initiation of measures – a strategy that has proven to be effective when it comes to preventing the spread of multiresistant pathogens and avoiding outbreaks. There is a presentation of general principles on infection prevention and the control of multiresistant pathogens, plus specific recommendations for different MRPs. The guidelines define which patient groups should be screened for MRPs, for example after a stay abroad or prior hospitalisation. Given that a not insignificant proportion of MRE infections are imported, in addition to the appropriate use of antibiotics, screening is a core measure in the StAR strategy. If a multiresistant pathogen is diagnosed, it is crucial to isolate the patients affected rapidly to avoid an outbreak. Accordingly the guideline also contains recommendations on how to isolate correctly.

What to do in the event of an outbreak
The second guideline (Management von Ausbrüchen mit MRE; managing MRP outbreaks) contains a concise presentation of control measures to be taken in the event of an outbreak. They are designed to help acute hospitals manage MDRO-outbreaks that have occurred several times in the last few decades in Switzerland. In the event of an outbreak caused by MRPs, it is often difficult to find the patient who was infected first, as in most cases the pathogen has already spread unnoticed before it is first detected. This means that it is crucial to detect cases early on and respond rapidly to control the spread and prevent the colonisation and/or infection of other patients. For this reason the guideline describes concrete steps to be taken in the event of an outbreak, from forming a team charged with managing the outbreak, providing the necessary communications and information, complying with the reporting requirement, isolating the people affected, tracking and tracing contacts to adequate cleaning and disinfection of the patient environment.

Basis for hospitals to create their own guidelines
These national guidelines are intended as the basis for acute hospitals to prepare their own guidelines adapted to the local situation. Formulating hospital-specific guidelines of this sort is part of the minimum structural requirements for the prevention and management of healthcare-associated infections (HAIs) in Swiss acute hospitals (Strukturelle Mindestanforderungen für die Prävention und Bekämpfung von healthcare-assoziierten Infektionen (HAI) in Schweizer Akutspitälern). A special diagnosis-related group (DRG) also gives hospitals a financial incentive to formulate and consistently implement such guidelines.

Candida auris: a treacherous yeast fungus
There is a new problem in the form of the yeast fungus Candida auris, discovered a few years ago. Multiple outbreaks have been reported in hospitals all over the world, primarily in intensive care units. In February 2022, the European Centre for Disease Prevention and Control (ECDC) published a report on 277 reported cases in eight different hospitals in northern Italy. In Switzerland the first case was described in 2018. So far only a few sporadic cases have been documented in patients who were repatriated from abroad. The fact that Candida auris survives particularly well on surfaces makes it a highly transmissible pathogen in healthcare facilities. This means that vigilance and stringent measures to prevent and control infection are of crucial importance. As well as being easily transmitted, however, Candida auris is often resistant to antimycotics. Finally, it is crucial to use validated diagnostic methods, otherwise Candida auris can be misidentified, as has already been reported. Swissnoso recently published national recommendations (available in german or french) on the prevention and control of Candida auris infections.