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My name is Karen Burns. I'm a consultant clinical microbiologist and I work in Dublin and Ireland. Um In part one of the talk, I talked about the problem of A R epidemiology. And um so I'm just going to give a few slides in part two, just to recap on that and then focus on the infection prevention, control considerations and communication. Um OK. So in part one, I was talking about the bacteria of concern, the Enterobacter alley such as E coli and klebsiella. Many other species exist and pseudomonas, aeruginosa and acinetobacter baumannii and the antimicrobial class that we're worried about developing resistance to the Beatle lactams ranging from very narrow spectrum agents like amoxicillin to the widest spectrum last resort agents like carb penin. And I discussed how resistance mechanisms can be inherent to the bacterium or they can be acquired through communication and exchange of genetic material with other bacter. And as a one example of an acquired resistance mechanism, the ability to pick up genes that encode enzymes such as Betty lactoses. And then um as a, as a, as an example of a Betty lactamase, the carbapenemase enzymes that are most of concern to us because they can destroy our last resort antimicrobials. The carbapenems within the carbapenemases. I looked at the non metallo lactamase producers, OX and K PC and the metal lactamase or MBL such as DMV. And I, and we were more worried about the most worried should I say about the MBL? Because they tend to have even fewer treatment options when they are causing infection than the non MBL. We have different caras types depending if you're enterobacterales, pseudomonas or acinetobacter and the distribution of those types varies worldwide. We know that these bacteria are distributed in humans, animals, food and the environment such as soil and water. And we're seeing increasing incidence of infections caused by these bacteria that contribute to and cause mortality and they have limited or costly treatment options. It is a complex public health issue requiring a one health coordinated strategy to tackle it. But individual and organizational actions are also really important and regardless of the bacteria, the carbapenemase or the country, the objectives are the same. And one of our control measures that I focused on in the first part of the talk was antimicrobial stewardship with the aim of minimizing the risk of AMR from spreading so that we can preserve antimicrobials for future generations. And I think we all have a vested interest in this because we are going to be the patients in 20 years time. So we want to make sure there's something left if, if we develop an infection. And we also obviously have the outcome, objective of treating infections effectively and also preventing them from happening in the first place by using infection control measures. And recognizing the importance of vaccination because you know, vaccinated against somebody against influenza might actually result in them not needing to go into hospital from influenza infection, and then not consequently picking up a hospital card infection due to an A or a bacterium. And we really want to keep our patients safe at all times. But most, especially when they're at most at risk of developing invasive infections such as in an intensive care unit or after surgery as and the public as partners in achieving these aims. So, II, the alphabet soup and all of these aros discussed in part one for this presentation. I'm going to use CPO and when I use it, it, I'm talking about all of the enterobacterales, pseudomonas and acinetobacter that produce carbenin Mees. So I showed you this, these two maps in, in, in, in, in part one and the global distribution of the MBL producing carbapenemase organisms. And you might ask yourself, you know, is this a sinking ship? And is there any point in us trying to control this problem? Well, well, yes, it is. And I think you really need to know what your local epidemiology is. What are the CPO of most concern where you are? Is it enterobacterales or pseudomonas? Acinetobacter? What is the most prevalent carbapenemase. Is it MBL type or non MBL type? How extensive is the local problem? Are you seeing infections in high risk patients? Are you seeing infections in patients coming in from the community who don't have healthcare exposure? Are you picking it up when you're screening on, on admission to high risk areas or are you picking it up in, in, in, in only in patients who are transferred from hospitals abroad? For example? and how frequently are these scenarios occurring? Is it daily or is it very rarely? So, you know, it, it's really important to know this because if you have a, an oxy enterobacterales problem in your hospital, you do not want to import a pseudomonas DM problem or an acinetobacter bowmannii DM problem in on top of that. So there's always a a really good reason that, that we should try and control these, these organisms from spreading. And so we talked about A MS and now I'm gonna talk more about infection prevention and control. And so these measures are aimed to protect our patients from picking up CPO and then if they happen to have CPO from developing infections caused by CPO. Um But, but the good news is is that if you implement these measures that they can protect any patient from infection due to any bacteria, be it antimicrobial resistant or antimicrobial susceptible? Because obviously, there's a huge burden of infection due to a bacteria that are susceptible to antimicrobials. And and they still harm and kill patients. So it's well worthwhile implementing these measures too. Um Think about where infection can arise. It can arise in the community and patients go to their GP or they end up coming into hospital through the emergency department. It can arise in a healthcare facility be that in a nursing home. Um or in the acute hospital, it can arise on a general ward or in a high risk area like an ICU or a transplant or hematology ward. Um And infections can be acquired in the community. They can be acquired in the healthcare setting. They can be acquired in the hospital and they can be acquired in, in a unit within the hospital. So those distinctions are important. And in Europe in 2022 and 2023 28 countries performed third European point prevalence survey which is a snapshot looking at healthcare associated infections in acute hospitals. And this is a very highly powered survey because it had captured almost 300,000 inpatients across 1250 hospitals in 28 eu or EE countries. And they found that on the day of the PPS or the point prevalence survey, about 7.1% of inpatients met a case definition for an active healthcare associated infection which extrapolates to about 93,305 inpatients in Europe with an active HCI on any given day or 4.8 million episodes of healthcare associated infections in Europe in a single year. So the burden of this is, is quite high. Um And in the PPS, they found uh reported almost 23,000 healthcare associated infections. Um respiratory tract followed by urinary tract, followed by skin and or surgical site infection followed by bloodstream infection were, were the top four categories. And 60% of those episodes had positive microbiology. Results associated with them were and the causative pathogens. Um The, the, the, the, the the 3 g negative groups were, were high on, on, on the list of causes. Um And of the enterobacterales, almost 10% of them were resistant to carbapenems. About 30% of the pseudomonas were resistant and frighteningly, um Almost 83% of the acinetobacter were carbapenem resistant. So these, these bulbs are here, they're now they're causing problems in our hospitals in Europe. And I'm sure this situation is the same around the world. Um So wh O produced guidance on, on, on this issue in 2017. And in the same year, I was involved in a group that produced um guidance from the European Center for Disease Control that was mainly focusing on trying to prevent these from getting into healthcare set. So, trying to prevent importation of um cure, it was the specific focus of that guidance document but um you know, keeping them out and not letting or having control measures to, to, to, to detect them on arrival and stop them from spreading. And in my country, we have um infection prevention and control guidance, which is published in May 2023 and it is freely available and we also have guidance for producing for CPE, which is the main issue in Ireland um which is fairly recent too. And, and, and so all of these documents are are freely available for, for you to have a look at if you want some more information. So before we start, I think it's really important to recognize the the the importance of the chain of infection in this, in this scenario, the the causative pathogen is CP and the reservoir where it is found, it's found in the patient, it's found in the patient zone. So that's the bed space. The patient is in or the single room that the patient is in, it's found in the wider healthcare environment in the clinical area in the ward. It's found in the equipment. Um it's found on the hands of healthcare workers. And so all of these reservoirs are or means of transmission as well and we have portals of entry. So how does this bug get on to a patient? Um either by direct contact of that patient with contaminated hands of healthcare workers environment or equipment through breaches in the normal skin barrier, such as those surgical wounds or pressure injuries or device exit site infections, et et cetera. Um And so then you have a patient now who is either colonized with CPO or develops infection with it, there's a susceptible host. And so they're going to start shedding that cpo into their environment um either through their contaminated hands um and also um through, through their, through feces as well. So if patient has diarrhea, the environment around them is going to be very heavily contaminated with CPO. But the important thing that we have at our disposal are standard precautions because these are designed to break the chain of infection. And and I also want to say because patients are who are colonized with any bacterium. It's really important that we facilitate our patients to clean their hands on an airplane and have a meal, you'll be given a hand wipe and equally if you're a patient in the hospital and you can't get out of your bed to get to a sink, to wash your hands. It's really important that we support you and facilitate you and help you if you need it to, to clean your hands after using the toilet or commode before you eat. And so we have our who five moments for hand hygiene, standard precautions are the standard. We should be using them for every patient every time. No exceptions. And when we talk about hand hygiene, we talk about our five moments. But we also talk about our technique. It's really important that we can do proper hand hygiene by being be below the elbows, no hand jewelry no wrist jewelry, no fingernail enhancements because these bacteria love to live under false nails and nail varnish and in, in the crevices of rings and watches. So we, we have to be very below the elbows and have correct technique. Um So moment one, don't bring CP to the patient, clean your hands before you touch a patient. Moment two, before you do an aseptic procedure, like put in an IV line on that patient don't bring CPO to the patient on your hand. So you've cleaned your hands and, and don't, you know, make sure they don't contaminate the patient's sterile site that, that IV line with CPE may be that the patient is carrying. Um So, so that's really important. Um And then if you've been exposed to the patient's body fluid such as changing a urinary catheter or, or, or emptying a catheter bag, um don't contaminate yourself. So, clean your hands after that. And then once you have touched the patient and you're leaving the patient's zone, the patient's zone is this dotted line here. So this is the bed space, the patient is in or the room that they're in and all of this environment around that patient is heavily contaminated with CP. So, so once you touch the patient, don't bring it to the next patient and clean your hands. But if, if you're in the zone and you haven't touched the patient, but you've touched the environment, you still have to clean your hands because you've got CP all over this place in the environment and you want to make sure you don't bring it to the next patient. So that's hand hygiene to prevent CP transmitting very cheap, safe, effective way to to control. Um It I II decontamination, obviously reusable invasive medical devices that we use in theaters, endoscopy, cardiac intervention suites, radiology, endoscopes, ultrasound probes, they have to be decontaminated properly. There are well described outbreaks of CP organisms associated with gi endoscopes that were not properly decontaminated. Um And so it's, it's critical that these, these, these procedures are done properly and that they're audited and monitored. And I can't emphasize how important it is that the environment is clean. Um It needs to be physically clean and, and, and that includes, um, that's the entire ward. It's where the patients are accommodated. It's the bathrooms, it's the communal areas, it's the furniture, it's the mattresses, it's the pillows, it's the curtains, it's everything and we need to focus on the dry areas and also on the moist areas. Um, our patient care equipment has to be clean. Um, even if it's used by a single patient, we have to clean it to prevent, you know, kind of build up of bacteria on it and shared equipment obviously has to be decontaminated before it's ever brought to the next patient. And, and that's all of these bits and pieces of equipment that we have on the ward that they all have to be cleaned. Um, waste management. A lot of these bugs are carried in the bowels so we have to make sure toilets are properly cleaned that their seats are intact, that they're not broken. Um, that our fecal management systems like macerator, bedpan washers or pulp disposal units are working properly, reaching the right temperature, achieving the temperature that's needed to, to clean them properly. Um, bacteria like CPE and uh uh Pseudomonas love moist environments. They love biofilm and they love being down drains and outlets of sinks. And what's really important is that a clinical hand hygiene sink should only be used for hand hygiene and we should never allow body fluids to be disposed down those hand hygiene sinks, patients shouldn't be washing their teeth in them. We shouldn't be putting enteral feed down those sink drains because we're feeding the bugs and the biofilm if we do so. Um And so it's really important that they are cleaned and maintained and used appropriately. And obviously your use linen has to be managed appropriately as well. Acinetobacter will survive very nicely in, in, in dry um environments or, or on, on linens. So you really need governance and assurance around this. So you gotta be asking yourself who's cleaning this bit of equipment? Do they know what they're doing? Can they clean it properly? Is it actually clean when they say it's cleaned? And how do I know it's clean? And so all of that involves ongoing training and supervision and documentation and maintenance and repair and replacement of equipment underpinned by policies, procedures and guidelines and assured by audit and feedback. So that's all really integral. This is standard, this should be happening every, every day and every clinical area. Um A and consistent use of standard precautions by all healthcare workers in all settings will protect your patient and you as the healthcare worker from picking up transmissible pathogens. Um because patients don't, in my experience come into the emergency department with I have CPE Coli and my blood stamped on their forehead. Um You, you know, they come in with a clinical syndrome and infection may be part of the differential diagnosis. So you have to assume all patients are potentially infectious un until, until you've ruled it out. And what we're aiming to do here is to ensure that any person environment or equipment that comes into contact with the patient is as free from pathogens as is practically possible. So, standard precautions, great transmission based precautions are added on where standard precautions alone are not enough to prevent cross transmission. So when we're talking about CPS, the transmission based precautions that we recommend are contact precautions because these bugs are transmitted by contact hands, environment, etc. So, um that essentially means adding PPE when you're in contact with the patient or their environment, personal protective equipment, um segregating patients that we know to have the same CPO from those who are not known to have that CPO and that may be in a, putting a patient in a single room or if you have more patients with CPO than you have single rooms, you might cohort them together in a bay or a section of the ward. Or if you have more uh patients with, with CPO than you would like, you might actually need to designate a specific ward for the patients that you know to have CPO. But you also want to keep a designated toilet or a commode or bathroom for use of CPO patients. So because we know these organisms are carried in about and I just would avoid cohorting patients who have different carbapenemases or who have carbapenemases in different pathogen groups. So you don't want to cohort an N DM Aines Bacter patient with an N DM CBS patient, for example. So as I said, contact precautions mean personal protective equipment. And what is recommended here is disposable gloves and disposable long sleeve gowns that are put on while you're in the patient zone. So while you're in the, remember the dotted line here, while you're in the the bed space of the patient or while you are in the patient room, because the environment around this patient, as I said, is going to be heavily contaminated with the CPO that the patient is shedding into the environment and the long sleeve gown and gloves will protect your hands and your clothing from becoming contaminated with CP. Um And because you don't want to be bringing it out of the room inadvertently into another part of the more and it PPE is great, but it's really important that there's the correct sequence of putting it on and taking it off. And we learned a lot about this during COVID. Um because if you take off PPE in the wrong sequence, then you run the risk of contaminating yourself. And, and so you've kind of, you missed the opportunity to prevent transmission. Um, invasive devices in wounds are so it's so important that we care for them because if we don't, then if a patient is carrying CPO or if we're carrying CPO in our hands to a patient, they are going to be a portal of entry of CPO. So our, our IV lines, our urinary catheters are tubes or tracheostomies um are enteral feeding like our entry tube or our peg tube. We, we have to have a system of minding those devices. We use insertion checklists, maintenance care bundles and very important to evaluate them every day. And can we get them out? Do we need them anymore? Don't leave them in any longer than they're required. Um, a surgical wound care. This is this portal of entry for surgical site infections. So we have to be absolutely diligent about minding our surgical wounds and preventing patients from getting wounds, avoidable wounds like pressure injuries, which can go on. Then to become a source of infection. Uh I'll point to you in the direction of this, this useful um open access document, which is a compendium of strategies to prevent the following healthcare associated infections, published by the Society for Healthcare Epidemiology in America. And it just kind of gives you a kind of a, a summary of the evidence based recommendations within each of these infection types. And it's, it's very useful, particularly if you're considering developing a local policy or procedure um for prevention of SSI for example. So screening um screening for carriage of CP. So for CPE, you can use a rectal swab or a sample of feces. Um The WH O guidance in 2017 was of the view that screening systematically for things like acinetobacter and pseudomonas were not underpinned with evidence and didn't routinely recommend it. It, it may be undertaken in the setting of an outbreak or in high risk ward, for example. Um But you, you have the options of of screening patients on admission to the hospital. Um and that could be to screen everyone coming in the door or to adopt a risk factor based approach. Um you could screen on admission to high risk areas um and you could screen weekly thereafter to make sure patients hadn't picked up CP as part of their stay. And so in my hospital, we use risk factor based screening. Um And so there is a list of, of risk factors that we would look for. Um And if a patient met those criteria, they will be screened on, on admission to the hospital. And you can also detect CPO from clinical specimens that are taken from patients who are being investigated for suspected infection such as blood cultures or urine. Um And uh in a case of a urine or a wound swab or a respiratory specimen, you do have to ask yourself, is this colonization with CPO or is it a CPO infection? And again, that risk assessment, do I need to give an antimicrobial? Can we observe? And what can we prescribe if infection is, is, is the problem here? So when we have a positive laboratory result for CP, we need to act on it. And so we will communicate with the ward, the admitting team with the patient and with the patient's primary care doctor or GP. Um and, and always trying to assess a potential significance if we're growing the CP from a clinical specimen to provide antimicrobial stewardship advice and to, to give the patient information and counseling. So when we're talking to patients about CPO, I think it's really important that, that, that the patient knows that they have had a positive result for CPO. And that's open disclosure. And I think that should happen from a senior team member. I don't think it's fair to leave it to the most junior team member who may not be as experienced and may not have all of the information because we don't want to frighten the patient. Um We don't want to, to, to scare them unnecessarily and, and we want to provide them with very clear and factual information and avoiding all of the acronyms and medical jargon that I'm talking about in this talk. So it really needs to be very clear layman's terms, um verbal information and then supplement it with additional information, you know, because it's a lot for the patient to take on board. So in my hospital, we have a variety of patient information, leaflets um that explain to patients, you know why they're being screened for CP if they become a positive result or if they're found to be in contact with somebody who's been ACP patient. Um So, so verbal is really important and then back it up with written information that they can go back to when, when they have had time to digest it. So the key points are that the bacteria are the problem. The patient is never ever the problem. Um You need to reassure your patient that most people who carry CPO will never go on to develop infection by CPO. Um And if they ever go on to develop an infection in the future, it's much more likely it's going to be due to bacteria that are easily treated with common antibiotics. Um And if this is a case of CPO that you're dealing with now, or if you're worried about CPO infection arising in the future. We're actually in a good space here because we know what antibiotics are likely to work best to treat it because we've grown it and we, we've done those tests and the patient needs to know that the measures that staff are taking while they're in hospital, such as putting them in a single room or staff putting on PPE are intended to prevent the CPO spreading around the ward to other patients who might be more prone to infection. And patient care or transfer of care should never be compromised because of CPO status. That's why we have transmission based precautions. So every healthcare provider should be in a position to use these transmission based precautions. And so patients care should never ever be delayed. And if a patient knows they have CP, then they've been empowered to communicate their status. If they come to a healthcare provide in the future. Um And if as a healthcare staff, staff member, you feel you need help or advice in communicating this, I would urge you to talk to your local IPC team or your infection specialist. And I'll be glad to, I'm certainly glad to talk to my colleagues about how best to, to discuss these things with their patients. But we don't want to frighten the patient and the patient should never ever feel like they're the problem. And this is some feedback that patients in the hospital in, in my country had given, um, after ACP outbreak and, and it's really awful to think that any patient felt that they felt like a leper that nobody was coming into their room and that they had to ask for food. And, and, you know, I just think it's so sad to think that somebody who's in hospital with problem A picks up CPE and, and then ends up feeling like this and we have to make absolutely every effort to make sure no patient has ever felt like that their care has been compromised because of this um contact tracing is something that you can do. If you find a case, you might ask yourself well, who shared that bay or toilet facilities with the CPO colonized patient. And for how long because it's an opportunity to screen those contacts for c um while they're in the hospital because they might also be carrying it in the source of onward transmission to other patients. Um And in my hospital, we flag those contacts so that when they ever represent a hospital, it's an opportunity to screen them for carriage. So obviously, you're getting all this laboratory data, you've got to be doing something with it. So you can do that on a daily basis all the way up to an annual basis, looking at CPO detections from screening or from clinical specimens, trying to determine where your patients are picking up cpo or are they coming in from the community with us from other hospitals or are they picking it up in your hospital? And are there particular wards of concern? Um And you cannot manage if you're not measuring and it needs to be timely. Um because you want to identify cross transmission early to prevent clusters or outbreaks from occurring and to be able to implement your enhanced control measures in a very timely fashion. So, you know, obviously low hanging fruit as if you don't know somebody who's already had CP, that you can detect them easily if they come back to the hospital. And so that can be done in a passive way, you can tell the patient's GP or obviously, you should tell the patient's GP so that they know um if the patient develops infection in the community that they need to ask for help. Um But you know, you can ask the patient to tell their healthcare provider um on presentation, but that path of it, it, it's not a very reliable method because if a patient needs to come back to hospital with an acute problem, the CPO might be the last thing on their mind and they might forget to tell you. So it's important to have active methods such as electronic flags or flags on healthcare records or mechanisms and transfer documentation that that the receiving healthcare facility or ward knows that this patient has a AAA colonized with the antimicrobial resistant organism for which precautions are required. Um And the reasons as I say is that if they know about it, they can apply transmission based precautions on arrival and prevent armor transmission. If the patient goes on to develop infection and CP is a potential pathogen to get the right antibiotics on board early. Um And if the patient needs to have surgery where ACP could potentially be a cause of POSTOP infections such as an abdominal surgery or organ transplant surgery, that the surgical prophylaxis for that procedure is appropriate and covers the CP. And it doesn't rely on that passive method of relying on the patient or their GP to remember to tell you when they come back to hospital. So education and training, I I'm hoping that this is going some way towards that um that we're, you know, he healthcare workers continuously are developing professionally and that we are understand about this problem, how it's transmitted, how we can break the chain of infection, how to do hand hygiene, how to put on and take off PPE properly, how to make sure that everything in the environment and the equipment is properly cleaned and how to prescribe antimicrobials sensibly using the start smart and then focus approach. And as I say in World Health Organizations, Antibiotic Awareness Week, education is, is part of, of the key message here. Um and governance is extremely important are the roles and responsibilities purely defined within an organization and within a team and within a ward, our staff trained and educated on this because we can't talk to patients about this problem if we don't understand it ourselves. And I think that's sometimes the problem is that because we're not confident in discussing the problem, we kind of put it on the long finger or we try and avoid having to have those, those discussions with patients, but they're so important because patients are frightened when we don't talk to them about things and they want to know why have I been put into a single room? What's wrong? So we have to talk to our patients um audit and feedback surveillance using it as information for action to prevent outbreaks from happening. And when we have outbreaks to be able to pick them up early and manage them effectively and also to learn from outbreaks, what went wrong, what went well, what would we do differently? Um And, and that importance of communicating internally and when patients are going to transfer of care to other facilities or back to their GP and the patients and their families. So I think patient care is central to everything that we do and carriage of these antimicrobial resistant bacteria must never compromise or delay that um CPO is a complicated problem and it requires multimodal strategies. But back to basics is effective standard precautions, transmission based precautions for people who we know to have CPO antimicrobial stewardship and effective communication. So thank you very much for your attention.